Karch PrepU Chapter 55: Drugs Acting on the Lower Respiratory Tract

When evaluating an asthmatic client's knowledge of self-care, the nurse recognizes that additional instructions are needed when the client makes which of the following statements?

"When I am short of breath, I will increase the use of my fluticasone." Fluticasone is an inhaled steroid and should not be used during acute asthmatic attacks. Washing linens weekly will decrease the incidence of dust mites. When clients can participate in some, but not all of usual activities, they are in the yellow zone. Once medication is inhaled, the client should hold his or her breath for 10 seconds so that medication can reach deep into the lungs. (less)

A client is receiving ipratropium as maintenance therapy for chronic obstructive pulmonary disease. The nurse would caution the client that up to how many inhalations may be used in 24 hours if needed?

12 With ipratropium, the usual dosage is 2 inhalations four times/day for a total of 8 inhalations. However, the client can use up to 12 inhalations if needed in 1 day.

The nurse assesses the serum theophylline of a patient. Which finding would the nurse identify as being therapeutic?

15 mcg/mL Therapeutic theophylline levels range from 10 to 20 mcg/mL. A value of 15 mcg/mL would be considered therapeutic.

A client is using an inhaled bronchodilator as treatment for exercise-induced asthma. The nurse would instruct the client to use the inhaler at which time?

15 minutes before engaging in exercise The client should use the inhaler approximately 15 minutes before exercising to achieve the maximum therapeutic effects.

A client who is experiencing anaphylaxis with severe wheezing receives a dose of epinephrine intravenously. The nurse would expect the drug to exert it full effects within which time frame?

20 minutes When given intravenously, epinephrine peaks in approximately 20 minutes. It would be at this time that the drug is most effective.

A client is receiving theophylline intravenously. The nurse reviews the results of his serum drug levels and notifies the physician for which result?

25 mcg/mL A serum theophylline level greater than 20 mcg/mL is considered toxic.

A male client presents with symptoms of bronchospasm that occurred during a birthday party for his grandson. What medication would the nurse expect the physician to give him?

Albuterol A selective, short-acting, inhaled beta2-adrenergic agonist (e.g., albuterol) is the initial rescue drug of choice for acute bronchospasm; subcutaneous epinephrine may also be considered. (less)

The parents of a 7-year-old boy who has just been diagnosed with allergic asthma are being taught about their son's medication regimen by the nurse. The nurse is currently teaching the parent's about the appropriate use of a "rescue drug" for acute exacerbations of their son's asthma. What drug should the nurse suggests the parents to use in these situations?

Albuterol Albuterol is a rescue drug that should be used first for all acute symptoms of shortness of breath or wheezing. Theophylline does not produce rapid symptom relief and beclomethasone is a maintenance drug. Acetylcysteine is not used in the treatment of asthma because it is used to manage secretions, which are not associated with asthma. (less)

Mr. Ashum is prescribed an albuterol inhaler as part of his treatment regimen for asthma. What is the mechanism of action for this medication?

Albuterol causes relaxation of the bronchial smooth muscles. The main result of albuterol binding to beta-2 receptors in the lungs is relaxation of bronchial smooth muscles. This relaxation of bronchial smooth muscle relieves bronchospasm, reduces airway resistance, facilitates mucous drainage, and increases vital capacity. (less)

Which of the following would a nurse identify as a surfactant?

Beractant Beractant is a lung surfactant. Cromolyn is a mast cell stabilizer. Zileuton is a leukotriene receptor antagonist. Theophylline is a xanthine.

A client is experiencing an acute asthmatic attack. Which agent would be most effective?

Beta-2 selective adrenergic agonist A beta-2 selective adrenergic agonist or sympathomimetic would be most appropriate because these agents are rapidly distributed after injection and rapidly absorbed after inhalation. An inhaled steroid would require 2 to 3 weeks to reach effective levels. Leukotriene receptor antagonists and mast cell stabilizers do not have immediate effects. (less)

A nurse would expect to increase the dosage of theophylline if the client has a current history of which of the following?

Cigarette smoking Nicotine increases the metabolism of xanthines; therefore, an increased dosage would be necessary. Hyperthyroidism, gastrointestinal, upset or alcohol intake requires cautious use of the drug because these conditions may be exacerbated by the systemic effects of the drug. The drug dosage may need to be decreased in these situations. (less)

The client's theophylline levels are increased. The nurse questions the client about his intake of which of the following?

Coffee Xanthines are found in colas, coffee, chocolate, and charcoal-prepared foods. This could cause the client's theophylline levels to increase. Neither tea, carrots, nor cheese affect theophylline levels. (less)

A group of students are reviewing the various drugs that affect inflammation. The students demonstrate understanding when they identify which agent as a mast cell stabilizer?

Cromolyn Cromolyn is a mast cell stabilizer. Montelukast is a leukotriene receptor antagonist. Calfactant is a lung surfactant. Triamcinolone is an inhaled steroid.

A client who smokes is receiving theophylline orally. Because of his history of smoking, the nurse expects the health care provider to do what with the theophylline dosing?

Increase Nicotine from smoking interferes with the ability of the body to metabolize theophylline. Due to decreased metabolism, the dosage of theophylline would be increased.

A patient with asthma is administered zileuton along with theophylline. Which of the following drug interactions should the nurse monitor the patient for?

Increased serum theophylline When administering zileuton along with theophylline, the nurse should monitor for increased serum theophylline. Serum zileuton levels and pulse rate are not increased when zileuton is administered along with theophylline. Increased prothrombin time is seen when warfarin, and not theophylline, is given along with zileuton. (less)

A patient is prescribed salmeterol. The nurse would expect this drug to be administered by which route?

Inhalation Salmeterol is administered via inhalation.

A neonate is receiving beractant. The nurse understands that this agent is administered by which route?

Intratracheal Beractant is administered intratracheally.

Which agents would the nurse identify as selectively and competitively blocking the receptors for the production of two substances that are components of SRSA?

Leukotriene receptor antagonists Leukotriene receptor antagonists selectively and competitively block or antagonize receptors for the production of leukotrienes D4 and E4, components of SRSA. Xanthines are thought to work by directly affecting the mobilization of calcium within the cell by stimulating two prostaglandins, resulting in smooth muscle relaxation. Xanthines also inhibit the release of slow-reacting substance of anaphylaxis (SRSA) and histamine. Mast cell stabilizers work at the cellular level to inhibit the release of histamine (released from mast cells in response to inflammation or irritation) and inhibits the release of SRSA. Anticholinergics are used as bronchodilators because of their effect on the vagus nerve, which is to block or antagonize the action of the neurotransmitter acetylcholine at vagal-mediated receptor sites. (less)

A client with COPD takes theophylline. The nurse identifies that the client is still experiencing severe dyspnea. Upon review of labs, the theophylline level remains nontherapeutic. The nurse evaluates the client for which of the following drugs that may cause decreased theophylline levels?

Nicotine When combined with nicotine, theophylline levels are decreased. Allopurinol, cimetidine, and corticosteroids can increase theophylline levels.

While reviewing a client's history, an allergy to which of the following would alert the nurse to a possible problem with the use of ipratropium?

Peanuts The use of ipratropium is contraindicated in the presence of known allergy to the drug or to peanuts or soy products because the vehicle used to make ipratropium, an aerosol, contains a protein associated with peanut allergies. (less)

A therapeutic theophylline level ranges from 10 to 20 mcg/mL.

True

A nurse is providing education to a 56-year-old man who is admitted to the emergency department with an acute asthma attack. The nurse's initial assessment reveals that the patient has a history of pneumonia, drinks large quantities of coffee, and eats a high-calorie diet. Albuterol is prescribed for him. The important consideration when the nurse is preparing a teaching plan will be that the patient

has a high coffee intake. Caffeine has sympathomimetic effects that may increase the risk for adverse effects with albuterol. The nurse should assess the patient's intake of caffeine through coffee, tea, soda, cocoa, candy, and chocolate. The patient's age, history of pneumonia, and preference for high-calorie food would not have important implications for his albuterol drug therapy. (less)

You have just finished teaching your 15-year-old patient how to use his inhaler to treat his asthma. What statement, made by your patient, suggests that he understands what you've taught him?

"I need to shake the inhaler well before taking the medication." Just before each use, the patient should shake the inhaler well. After shaking, proper technique involves exhaling before placing the inhaler in the mouth; taking a slow, deep breath while delivering the medication into the mouth; and holding the breath for approximately ten seconds before exhaling slowly. A subsequent dose can be administered within a few minutes of the first. (less)

A female client is prescribed systemic corticosteroids for her asthma. The nurse knows that the client is at risk for what problem?

Adrenal insufficiency Adrenal insufficiency is most likely to occur with systemic or high doses of inhaled corticosteroids.

After teaching a group of students about leukotriene receptor antagonists, the instructor determines a need for additional teaching when the students identify which agent as an example?

Fluticasone Fluticasone is an inhaled steroid. Montelukast is a leukotriene receptor antagonist. Zileuton is a leukotriene receptor antagonist. Zafirkulast is a leukotriene receptor antagonist. (less)

An 8-year-old client comes to see you reporting shortness of breath, cough, and chest tightness when participating in gym class. The client is seen by the physician in the clinic and diagnosed with exercise-induced asthma. What inhaled drug therapy is the physician most likely to prescribe?

Formoterol (Foradil), a highly selective beta-2 agonist Formoterol is used primarily to prevent exercise-induced asthma, although it may also be used in patients with emphysema or chronic bronchitis. Epinephrine induces multiple adverse reactions, while terbutaline's main pharmacotherapeutic effect is the prevention of bronchospasm, and it is also clinically used to abort premature labor. Theophylline is administered orally or intravenously. (less)

A patient is instructed on the administration of inhaled corticosteroid agents to treat asthma. How do inhaled corticosteroid agents assist in the treatment of asthma?

Inhaled corticosteroid agents will reduce airway inflammation. Inhaled corticosteroid agents suppress the release of inflammatory mediators, block the generations of cytokines, and decrease the recruitment of airway eosinophils. Inhaled corticosteroid agents do not depress the central nervous system. Inhaled corticosteroid agents do not affect bronchodilation or constriction. (less)

Mark, 8 years old, is prescribed flunisolide. The physician advises Mark and his parents to use a spacer when administering this medication. What is the benefit of such use?

It helps decrease systemic absorption. Spacers help decrease systemic absorption, because less flunisolide is swallowed. Spacers may also help alleviate dysphonia by filtering larger aerosol particles that ordinarily deposit in the oropharynx and extrathoracic airways (this precaution also reduces the risk for oropharyngeal candidiasis). The use of a spacer does not prevent intrapulmonary delivery of the drug; nor does it reduce the risk of tachycardia and sinusitis. (less)

The nurse is evaluating the education of a client that uses albuterol for an acute asthma attack. The nurse knows that the lesson has been effective when the client states that albuterol is which of the following types of medication?

SABA Albuterol is a short-acting beta-2 agonist (SABA). It is used to treat and prevent bronchospasm.

A patient is started on albuterol (Proventil). What reaction should the patient be instructed on?

Tachycardia will occur. The symptoms of cardiac stimulation, including tachycardia, are noted with the administration of albuterol. The patient will not experience polydipsia, hypotension, or diarrhea.

Leukotriene receptor antagonists are administered orally.

True

A patient is being assessed by the home care nurse on the administration of the inhalers. Which of the following will assist in proper administration of the inhaler?

Use of a spacer The patient should be instructed to use a spacer to increase compliance and accuracy of administration. The corticosteroid should be administered after the bronchodilator. The increase in fluids will not affect the administration of the inhaler. The patient should hold his breath for several seconds after administration of the inhaler. (less)

Chronic obstructive pulmonary disease (COPD) encompasses which of the following? Select all that apply:

• Chronic bronchitis • Asthma Explanation: COPD encompasses asthma, chronic bronchitis, chronic obstructive bronchitis, emphysema, or a combination of the conditions.

The nurse instructs a patient who is using albuterol for exercise-induced bronchospasm to use the inhaler at which time?

15 minutes prior to exercising Albuterol for exercise induced bronchospasm should be administered 15 minutes prior to exercising.

A patient who is prescribed ipratropium administers the drug at 9:15 AM. The patient should begin to notice the drug beginning to act at which time?

9:30 AM Inhaled ipratropium has an onset of action of 15 minutes, so the patient should begin to feel the effects of the drug at 9:30 AM.

A patient has been admitted to a healthcare facility with asthma. The nurse is advised to administer theophylline to the patient. To which of the following patients can the nurse safely administer theophylline?

A 65-year-old male patient with asthma The nurse can safely administer theophylline to the patient who is 65 years of age. It needs to be administered cautiously in patients above 69 years of age, or with hepatic disease, cardiac disease, and hypertension. (less)

During the summer, a female client experiences increased periods of acute symptoms of her asthma. The physician increases the dose frequency of which of her medications?

Albuterol Albuterol is the initial drug of choice for acute bronchospasm.

The asthmatic client is being treated with two inhalers, albuterol and flunisolide. The nurse teaches the client that the two medications should be administered in what order?

Albuterol first, wait five minutes and then follow with flunisolide Albuterol is a bronchodilator and should be used first, given time to open the airways, and then the inhaled corticosteroid is administered.

A patient is experiencing an acute asthma attack. What is the first-line therapy for relief of an acute asthma attack?

Beta2-adrenergic agonist A patient experiencing an acute asthma attack should be administered a beta2-adrenergic agonist. The patient can receive an inhaled steroid, but it is not the first-line therapy. Leukotriene modifiers are used for maintenance in asthma, not during acute exacerbation. Xanthines are not the drug of choice in acute asthma attack. (less)

A patient is given theophylline to treat acute asthma symptoms. Which of the following foods should the patient avoid?

Chocolate Chocolate contains caffeine and is also a xanthine; thus chocolate should be avoided when the patient is taking theophylline. Restriction of bananas, orange juice, and cranberry juice is not required. (less)

A nurse is providing discharge planning for a 45-year-old woman who has a prescription for oral albuterol. The nurse will question the patient about her intake of which of the following?

Coffee The nurse should assess the patient's intake of caffeine, including coffee, tea, soda, cocoa, candy, and chocolate. Caffeine has sympathomimetic effects that may increase the risk for adverse effects. Alcohol, salt, and vitamin C intake is important to assess, but does not potentiate the effects of albuterol. (less)

A patient is experiencing an acute asthma attack. Which of the following medications are contraindicated for the treatment of acute asthma?

Cromolyn (Intal) Cromolyn stabilizes mast cells and is not used in acute bronchospasm. Aminophylline is used in limited cases, but is administered for acute asthma attack. Albuterol is used for acute asthma attack. Corticosteroids are administered for acute asthma attack to decrease inflammation. (less)

The first step in treating obstructive pulmonary disorders involves medication therapy.

False Reducing environmental exposure to irritants and avoiding exposure to known irritants and allergens is the first step in treatment.

A nurse is required to educate a patient prescribed albuterol on the adverse effects associated with the drug. Which of the following symptoms, if experienced, should the nurse instruct the patient to report to the health care provider?

Headache and flushing The nurse should instruct the patient to contact the health care provider if palpitations, tachycardia, chest pain, muscle tremors, dizziness, headache, flushing, or difficulty with urination or breathing occur. Fall in blood pressure, increased nighttime urination, or hearing impairment are not adverse effects associated with a sympathomimetic bronchodilator. (less)

When teaching a patient to use a dry powder inhaler, which of the following is true? Select all that apply:

Hold breath for 10 seconds. • Inhale quickly. Explanation: To properly use a dry powder inhaler prepare the medication for inhalation, place mouthpiece to lips, inhale quickly, hold your breath for 10 seconds, do not swallow capsules provided, and do not place inhaler in water. (less)

An 8-year-old child with an acute asthmatic attack is receiving metaproterenol via nebulizer. Which of the following would be most appropriate?

Mix the drug with saline. Metaproterenol is mixed with saline in the nebulizer chamber for administration. The child should sit upright or be in a semi-Fowler's position. He should breathe slowly and deeply during the treatment. The treatment is completed when all of the solution (liquid) is gone from the chamber. (less)

The client uses his sympathomimetic inhaler frequently. The nurse evaluates the client for which of the following symptoms related to frequent use of the sympathomimetic inhaler?

Nervousness Frequent use of sympathomimetic inhalers can cause nervousness, hypertension, tachycardia, and anxiety.

The nurse is teaching a client how to prevent Candida infections. Which of the following would the nurse include in the instructions?

Rinse mouth with water after each use. The client should be taught to rinse his mouth out with water after using oral inhalers to prevent a Candida oral infection.

A female client presents to the emergency department with acutely deteriorating asthma. Her husband shows the nurse salmeterol when the nurse asks what medications his wife takes at home. He then tells the nurse that he gave her three extra puffs when she became ill. What statement is correct in this situation?

Salmeterol is contraindicated based on his wife's condition. The FDA has issued a black box warning that initiating salmeterol in people with significantly worsening or acutely deteriorating asthma may be life threatening.

Xanthine derivatives elicit their effect by which of the following mechanisms? (Choose one)

Stimulation of the central nervous system Stimulation of the central nervous system is the mechanism of action for xanthine derivatives. Stimulation of beta-adrenergic receptors is the mechanism of action for beta 2 agonists. Reduction of airway hyper-responsiveness is the mechanism of action for inhaled corticosteroids. Stabilization of mast cell membranes is the mechanism of action for mast cell stabilizers. (less)

A patient is using an albuterol (Proventil) inhaler, which is a bronchodilator. Which of the following patient teaching interventions is important for the patient who is experiencing shortness of breath related to constriction of airways?

Stop smoking due to the bronchoconstriction Cigarette smoking will increase bronchoconstriction, so the patient should be encouraged to stop. The albuterol causes hand shaking. Insulin will not decrease hand shaking. The patient will not require ibuprofen (Advil). The patient should be encouraged to exercise, and it should not be limited to one time per week. (less)

After teaching a group of students about inhaled steroids, the instructor determines that the teaching was successful when the students state which of the following?

The drugs are not for use during an acute attack. The drugs are not for emergency use or use during an acute attack because their onset of action is slow. Systemic absorption is not typical with inhalation unless the patient did not administer the drug properly or has lesions that allowed absorption of the drug. Inhalation decreases the effectiveness of the inflammatory cells leading to decreased swelling and promotion of beta adrenergic receptor activity. The drugs are rapidly absorbed, but take 2 to 3 weeks to reach effective levels. (less)

A man who smokes one pack of cigarettes daily has been diagnosed with chronic bronchitis. He has been prescribed theophylline by his family doctor. What effect will the patient's smoking status have on the therapeutic use of theophylline?

The patient may require higher doses of theophylline than a nonsmoker Smoking cigarettes may decrease serum theophylline levels. In fact, some patients who smoke require an increase in theophylline dosage of up to 50%. Theophylline is not associated with a risk of anaphylactoid reaction. Theophylline doses do not need to be concurrent with the use of bronchodilators. (less)

A client was using nicotine patch to stop smoking when he was started on theophylline for emphysema. He has successfully stop smoking and has stopped using his nicotine patch. Which of following would be warranted? (Choose one)

Theophylline dose should be decreased Nicotine decreases theophylline levels. If a client is no longer using nicotine his/her theophylline levels will increase warranting a decrease in theophylline dose.

Cromolyn should not be used during an acute asthmatic attack.

True Cromolyn is the only mast cell stabilizer still available and is available only in an OTC form. It is no longer considered part of the treatment standards because of the availability of more specific and safer drugs. (less)

A high school student was diagnosed with asthma when he was in elementary school and has become accustomed to carrying and using his "puffers". In recent months, he has become more involved in sports and has developed a habit of administering albuterol up to 10 times daily. The nurse should teach the student that overuse of albuterol can lead to

rebound bronchoconstriction. Patients who self-administer albuterol may use their MDIs more frequently than recommended. This practice can result in rebound bronchoconstriction, which may motivate the patient to increase MDI use, stimulating the cycle of rebound congestion. Overuse of albuterol is not linked to pneumonia or hepatotoxicity. Albuterol is not an anticholinergic drug. (less)

A 5-year-old boy is brought to the ED with an asthma exacerbation, including wheezing (a high-pitched, whistling sound caused by turbulent airflow through an obstructed airway). Those who have asthma chronically present with what signs, even when they may appear symptom free? Select all that apply.

• Airway inflammation • Damaged airway mucosa Explanation: Inflammation and damaged airway mucosa are chronically present in asthma, even when clients appear symptom free.

The nurse should complete which of the following during acute breathing distress before initiation of a broncodilator? Select all that apply:

• Check blood pressure. • Check pulse. • Check respiratory rate Explanation: Prior to initiation of a bronchodilator during acute breathing distress, the nurse needs to take a blood pressure, pulse, and respiratory rate.

When describing the action of xanthines, which of the following would the nurse include? Select all that apply.

• Direct effect on the mobilization of calcium within the cell • Stimulation of 2 prostaglandins leading to smooth muscle relaxation • Inhibition of release of slow-reacting substance of anaphylaxis Explanation: Although the exact action is unknown, it is thought that xanthines work by directly affecting the mobilization of calcium within the cell by stimulating two prostaglandins, resulting in smooth muscle relaxation. Xanthines also inhibit the release of slow-reacting substance of anaphylaxis (SRSA) and histamine. (less)

After teaching a group of students about antiasthmatic agents, the students demonstrate understanding of the information when they identify which of the following as sympathomimetics? Select all that apply.

• Epinephrine • Terbutaline • Formoterol Explanation: Epinephrine is a sympathomimetic. Terbutaline is a sympathomimetic. Formoterol is a sympathomimetic. Budesonide is an inhaled steroid. Tiotropium is an anticholinergic. Cromolyn is a mast cell stabilizer. (less)

A client with exercise-induced bronchospasm calls the physician's office to obtain a refill for his breathing medication. Which of the following should the nurse ask the physician to refill? Select all that apply:

• Levalbuterol (Xopenex) • Bitolterol (Tornalate)

After teaching a group of students about zafirlukast, the students demonstrate understanding when they identify which of the following as possible adverse effects? Select all that apply.

• Myalgia • Dizziness • Vomiting Explanation: Myalgia is a possible adverse effect of zafirkulast. Dizziness is a possible adverse effect of zafirkulast. Vomiting is a possible adverse effect of zafirkulast. Constipation is not associated with zafirlukast. Chills are not associated with zafirkulast. (less)

Which of the following would be most important to assess before administering calfactant? (Select all that apply.)

• Oxygen saturation levels • Lung sounds • Endotracheal tube placement Correct Explanation: Before administering calfactant, it would be important to ensure proper endotracheal tube placement because the drug is instilled directly into the trachea. In addition, lung sounds and oxygen saturation levels would be important as a baseline to evaluate effectiveness of the drug. (less)

Your patient, a 27-year-old athlete with newly diagnosed asthma, presents at your office for patient education regarding situations that could precipitate an asthma attack. Your teaching includes that acute episodes of asthma may last minutes to hours. In your teaching, which of the following precipitants do you state may cause the asthma? Select all that apply.

• Pollutants • Exercise • Allergens Precipitants may include allergens (eg, pollens, molds), airway irritants and pollutants (eg, chemical fumes, cigarette smoke, automobile exhaust), cold air, and exercise.

The client is 73 years of age and has a history of coronary artery disease and COPD. She is being started on formoterol (Foradil). The nurse would assess the client for which of the following conditions? Select all that apply.

• Tachycardia • Hypertension Explanation: Older adults taking adrenergic bronchodilators are at increased risk for adverse reactions related to the cardiovascular system, such as tachycardia (not bradycardia), arrhythmias, palpitations, and hypertension (not hypotension). Lethargy is not related to taking adrenergic bronchodilators. (less)

Aerosols are often the drugs of choice to treat asthma because of what characteristics? (Select all that apply.)

• They act directly on the airways. • They relieve symptoms quickly. • They can usually be given in smaller doses. • They produce fewer adverse effects than oral or parenteral drugs. Correct Explanation: Because aerosol products act directly on the airways, drugs given by inhalation can usually be given in smaller doses and produce fewer adverse effects than oral or parenteral drugs. Aerosol products also produce a relief of asthma symptoms in a quick fashion. (less)