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When and why would patients using a SABA for rescue symptoms need to be started on an ICS?

When: Frequent use of SABA (>2 times/week) indicates poor control.

Why: ICS helps reduce underlying inflammation, improving control and reducing exacerbations.

Mechanism of action of SABAs

Stimulate beta-2 receptors, causing bronchodilation.

Mechanism of action of LABAs

Stimulate beta-2 receptors for prolonged bronchodilation.

Meds for acute exacerbations vs chronic therapy?

Acute exacerbations: SABAs, oral steroids.

Chronic therapy: ICS, LABAs, LAMAs.

Why are LABAs NEVER given to patients with asthma without an ICS? What are its common side effects?

Why: Increased risk of asthma-related death.

Side effects: Tremor, restlessness, tachycardia

Mechanism of action of Montelukast (Singulair) for treatment of asthma?

Leukotriene receptor antagonist, reducing inflammation and bronchoconstriction.

Theophylline therapeutic uses and why no longer used as frequently?

Uses: Bronchodilator for asthma and COPD.

Less use: Narrow therapeutic index, side effects, drug interactions.

Most useful test of lung function?

Spirometry.

What is considered the safest anti-asthma medication – that can also be used with exercise-induced asthma?

SABAs (e.g., albuterol) take 30 min prior to exercise

Which is better – SABA as a nebulizer or inhaler?

Inhaler, for convenience and ease of use.

What are the major side-effects of ICS meds? What can be done to minimize bone loss?

Side effects: Oral thrush, dysphonia, bone loss.

Minimize bone loss: Use lowest effective dose, adequate calcium and vitamin D, weight-bearing exercise.

Should antihistamines be taken regularly or PRN for allergy symptoms?

Regularly for persistent symptoms, PRN for intermittent symptoms.

Cromolyn – counseling patients on when to expect a response.

Takes 1-2 weeks for full effect.

What patient s/s would benefit from administration of a sympathomimetic med?

Nasal congestion.

Why to avoid prolonged use of topical sympathomimetic agents?

Risk of rebound congestion.

What populations and/or conditions to avoid giving cough/cold meds to?

Children under 4-6 years, those with specific chronic conditions without consulting a healthcare provider.

What meds and/or conditions increase the risk of PUD and why?

Meds/Conditions: NSAIDs, H. pylori infection, smoking.

Why: They damage the mucosal lining or increase acid production.

Risk factors and management of NSAID induced ulcers?

Risk factors: Long-term use, high doses, previous history of ulcers, over 60 y/o.

Management: Use of PPIs, H2 blockers, or misoprostol for prophylaxis.

What meds can be given for prophylaxis for ulcers?

PPIs, H2 receptor antagonists, misoprostol.

Best test for h. pylori?

Urea breath test.

What would an appropriate treatment regimen be for h. pylori?

Triple therapy with PPI, clarithromycin, and amoxicillin or metronidazole.

Most common side effects of clarithromycin?

Nausea, diarrhea, abnormal taste.

Why don’t we use tetracyclines in pregnant patients or younger children?

Risk of tooth discoloration and inhibition of bone growth.

Remember NO alcohol with metronidazole use (or within 72 hours of it).

Risk of severe nausea, vomiting, and other reactions.

Cimetidine – know food/drug interactions.

Inhibits hepatic metabolism of warfarin, phenytoin, theophylline, and others. Can be affected by antacids.

What are the adverse effects of PPIs and mechanism of action?

Increased risk of fractures, pneumonia, C. difficile infection, hypomagnesemia. Mechanism: Low gastric acidity alters GI flora and reduces calcium absorption.

Patient teaching points for different laxatives?

Use as directed, stay hydrated, avoid overuse to prevent dependency.

Laxative abuse – causes, consequences, and treatment.

Causes: Misconceptions about normal bowel function.

Consequences: Dehydration, electrolyte imbalance, dependence.

Treatment: Education, dietary changes, psychological support.

Mechanism of action/adverse effects (or potential) of ondansetron (Zofran)?

Mechanism: Serotonin receptor antagonist.

Adverse effects: Headache, constipation, QT prolongation.

Non-drug measures to help with morning sickness?

Ginger, acupressure, small frequent meals, avoiding triggers.

Motion sickness treatments?

Scopolamine, antihistamines (e.g., dimenhydrinate, meclizine).

Antidiarrheal agents and common pathogens and treatments for traveler’s diarrhea?

Agents: Loperamide, bismuth subsalicylate.

Pathogens: E. coli

Treatments: antibiotics like ciprofloxacin or rifaximin / Azithromycin for children/pregnancy

Vitamin K forms (i.e., K1 or K2), sources, and deficiencies.

Forms: K1 (phylloquinone), K2 (menaquinone).

Sources: Green leafy vegetables, fermented foods.

Deficiencies: Bleeding disorders.

All of the Vitamin B vitamins, their names, uses and preparations, and adverse effects along with the manifestations of their deficiencies.

Vitamins: Thiamin (B1), riboflavin (B2), niacin (B3), pyridoxine (B6), folic acid (B9), cyanocobalamin (B12), pantothenic acid, biotin.

Uses: Energy metabolism, red blood cell formation, nerve function.

Deficiencies: Beriberi (B1), ariboflavinosis (B2), pellagra (B3), anemia (B6, B12, folic acid).

Adverse effects: Varies per vitamin, generally minimal.

Vitamin C uses, deficiencies, and preparations.

Uses: Antioxidant, collagen synthesis, immune support.

Deficiencies: Scurvy.

Preparations: Supplements, dietary intake (fruits and vegetables).

Mechanism of action for orlistat.

Inhibits pancreatic lipase, reducing fat absorption.

Mechanism of action for phentermine.

Sympathomimetic amine, suppresses appetite.

Mechanism of action for GLP-1.

Increases insulin secretion, slows gastric emptying.

Mechanism of action for Lorcaserin.

Selective serotonin 2C receptor agonist, reduces appetite.

Which medications are also used for diabetes?

GLP-1 receptor agonists (e.g., liraglutide).

Flaxseed uses and administration recommendations.

Uses: Laxative, cholesterol-lowering.

Administration: Ground flaxseed or flaxseed oil.

Kava indications for use and adverse effects.

Indications: Anxiety, stress relief.

Adverse effects: Hepatotoxicity.

St. John’s Wort mechanism of action and drug interactions.

Mechanism: Inhibits reuptake of serotonin, norepinephrine, and dopamine.

Interactions: Reduces effectiveness of many drugs (e.g., oral contraceptives, warfarin).

Cranberry juice mechanism of action and uses.

Mechanism: Inhibits bacterial adhesion to urinary tract walls.

Uses: Prevents urinary tract infections.

Which supplements can affect platelet aggregation?

Garlic, ginger, ginkgo biloba, ginseng.

What are low potency and high potency steroids?

Low potency: Hydrocortisone.

High potency: Betamethasone.

A patient with asthma is admitted to an emergency department with a respiratory rate of 22 breaths/minute, a prolonged expiratory phase, tight wheezes, and an oxygen saturation of 90% on room air. The patient reports using fluticasone [Flovent HFA] 110 μg twice daily and has used 2 puffs of albuterol [Proventil HFA] 90 mcg/puff every 4 hours for 2 days. The nurse will expect to administer which drug?

Intravenous glucocorticoids, nebulized albuterol and ipratropium, and oxygen.

A patient with stable COPD is prescribed a bronchodilator medication. Which type of bronchodilator is preferred for this patient?

A long-acting inhaled beta2 agonist.

A patient with COPD is prescribed tiotropium [Spiriva]. After the initial dose, the patient reports only mild relief within 30 minutes. What will the nurse tell the patient?

“You should see improved effects within the next week.”

A parent asks a nurse about growth suppression resulting from the use of an inhaled glucocorticoid in children. What will the nurse tell the parent?

Growth may be slowed, but eventual adult height will not be reduced.

A patient who uses an inhaled glucocorticoid for chronic asthma calls the nurse to report hoarseness. What will the nurse do?

Ask whether the patient is rinsing the mouth after each dose.

A young adult woman will begin using an inhaled glucocorticoid to treat asthma. The nurse will teach this patient about the importance of which action?

Participating in weight-bearing exercises on a regular basis.

A 7-year-old child with asthma uses a daily inhaled glucocorticoid and an albuterol MDI as needed. The provider has added montelukast [Singulair] to the child’s regimen. Which statement by the child’s parent indicates understanding of this medication?

“I may notice mood changes in my child.”

A child is receiving a combination albuterol/ipratropium [DuoNeb] inhalation treatment. The patient complains of a dry mouth and sore throat. What will the nurse do?

Reassure the patient that these are expected side effects.

A patient with severe chronic COPD uses an inhaled LABA/glucocorticoid but continues to have frequent exacerbation of symptoms. The nurse will contact the provider to discuss:

Adding roflumilast [Daliresp] once daily.

A nurse provides teaching to a patient with allergic rhinitis who will begin using an intranasal glucocorticoid. Which statement by the patient indicates understanding of the teaching?

“I should use a decongestant if necessary before using the glucocorticoid.”

A patient with asthma comes to a clinic for treatment of an asthma exacerbation. The patient’s medication history lists an inhaled glucocorticoid, montelukast [Singulair], and a SABA as needed via MDI. The nurse assesses the patient and notes a respiratory rate of 18 breaths/minute, a heart rate of 96 beats/minute, and an oxygen saturation of 95%. The nurse auscultates mild expiratory wheezes and equal breath sounds bilaterally. What will the nurse do?

Question the patient about how much albuterol has been used.

A patient with stable COPD receives prescriptions for an inhaled glucocorticoid and an inhaled beta2-adrenergic agonist. Which statement by the patient indicates understanding of this medication regimen?

“The glucocorticoid is used as prophylaxis to prevent exacerbations.”

Which medication should be used for asthma patients as part of step 1 management?

Short-acting beta2 agonists. (SABA)

A nurse is teaching a group of nursing students about the different formulations of beta2-adrenergic agonist medications. Which statement by a student indicates understanding of the teaching?

“Oral beta2 agonists are not useful for short-term treatment.”

A nurse and a nursing student are reviewing the care of a 30-kg patient who will receive intravenous aminophylline. Which statement by the student indicates an understanding of the administration of this medication?

“Dosing is titrated based on the serum theophylline levels.”

A patient with persistent frequent asthma exacerbations asks a nurse about a long-acting beta2-agonist medication. What will the nurse tell this patient?

LABAs should be combined with an inhaled glucocorticoid.

A patient who has been newly diagnosed with asthma is referred to an asthma clinic. The patient reports daily symptoms requiring short-acting beta2-agonist treatments for relief. The patient has used oral glucocorticoids three times in the past 3 months and reports awakening at night with symptoms about once a week. The patient’s forced expiratory volume in 1 second (FEV1) is 75% of predicted values. The nurse will expect this patient to be started on which regimen?

Daily low-dose inhaled glucocorticoid/LABA with a SABA as needed.

A patient has just received a prescription for fluticasone/salmeterol [Advair Diskus]. What will the nurse include as part of the teaching for this patient about the use of this device?

“You do not need good hand–lung coordination to use this device.”

A patient with asthma will be using a metered-dose inhaler (MDI) for delivery of an inhaled medication. The provider has ordered 2 puffs to be given twice daily. It is important for the nurse to teach this patient that:

The patient should wait 1 minute between puffs.

A patient who takes oral theophylline [Theochron] twice daily for chronic stable asthma develops an infection and will take ciprofloxacin. The nurse will contact the provider to discuss:

Reducing the theophylline dose.

A patient admitted to the hospital has been using phenylephrine nasal spray [Neo-Synephrine] 2 sprays every 4 hours for a week. The patient complains that the medication is not working because the nasal congestion has increased. What will the nurse do?

Request an order for an intranasal glucocorticoid to be used while the phenylephrine is withdrawn.

A patient who has a viral upper respiratory infection reports having a runny nose and a cough that prevents sleep and asks the nurse to recommend an over-the-counter medication. Which medication will the nurse recommend?

Diphenhydramine [Benadryl].

A parent asks a nurse to recommend an intranasal decongestant for a 6-year-old child. Which response by the nurse is correct?

“Decongestant drops are recommended instead of decongestant sprays.”

A 7-year-old child has a cough, runny nose, congestion, and fever, and the parents ask the nurse to recommend an over-the-counter product. Which response by the nurse is correct?

“It is best to use single-agent medications to treat individual symptoms.”

Which medication used for asthma has off-label uses to treat allergic rhinitis?

Omalizumab [Xolair].

A patient with a cough has been advised to use guaifenesin. The patient asks the nurse to explain the purpose of the drug. The nurse will explain that guaifenesin:

Helps stimulate the flow of secretions to increase cough productivity.

A parent asks a nurse about giving diphenhydramine [Benadryl] to a child to relieve cold symptoms. Which response by the nurse is correct?

“Because histamine does not cause cold symptoms, Benadryl would not be effective.”

A patient asks the nurse what type of medications would be most effective for treating seasonal and perennial rhinitis. Which response by the nurse is correct?

Fluticasone propionate [Flovent HFA, Flovent Diskus, Ticanase].

What is ipratropium bromide [Atrovent]?

An anticholinergic used for allergic rhinitis and colds.

A patient stops taking a proton pump inhibitor (PPI) after 6 weeks of therapy for treatment of peptic ulcer disease. The patient reports symptoms of dyspepsia to the nurse. The nurse will tell this patient to:

Try an antacid to see whether it relieves these symptoms.

When metronidazole [Flagyl] is a component of the H. pylori treatment regimen, the patient must be instructed to do what?

Avoid any alcoholic beverages.

A patient is diagnosed with Zollinger-Ellison syndrome. Which medication does the nurse expect the provider to order for this patient?

Ranitidine [Zantac].

A patient who has gastroesophageal reflux disease (GERD) receives a prescription for a proton pump inhibitor (PPI) medication. What will the nurse include when teaching the patient about this drug?

“You should report any fever and cough to your provider.”

An older adult patient with severe gastroesophageal reflux disease (GERD) has had only minimal relief using a histamine2-receptor antagonist (H2RA). The patient is to begin taking omeprazole [Prilosec]. What will the nurse teach this patient?

Long-term therapy may be needed.

A patient admitted to the hospital has a history of peptic ulcer disease. The patient takes ranitidine [Zantac] and sucralfate [Carafate]. The patient tells the nurse that discomfort is usually controlled but that symptoms occasionally flare up. What will the nurse do?

Contact the provider to discuss serologic testing and an antibiotic.

The nurse is providing education to a patient who has been prescribed both an antacid and cimetidine [Tagamet]. Which instruction should the nurse give the patient about taking the medications?

“Take the antacid 1 hour after the ranitidine.”

A patient is diagnosed with peptic ulcer disease. The patient is otherwise healthy. The nurse learns that the patient does not smoke and that he drinks 1 or 2 glasses of wine with meals each week. The nurse anticipates that the provider will prescribe which drugs?

Amoxicillin [Amoxil], clarithromycin, and omeprazole [Prilosec].

A nursing student is caring for a patient who is taking sucralfate [Carafate] and ciprofloxacin [Cipro] to treat peptic ulcer disease. The student asks the nurse about the pharmacokinetics of sucralfate. Which statement by the student indicates a need for further teaching?

“Sucralfate has a moderate acid-neutralizing capacity.”

A 30-year-old male patient will begin a three-drug regimen to treat peptic ulcer disease. The regimen will consist of bismuth subsalicylate, tetracycline, and cimetidine [Tagamet]. The nurse will include which information when teaching this patient about this drug regimen?

Decreased libido, impotence, and gynecomastia are reversible side effects.

A patient who takes nonsteroidal anti-inflammatory drugs (NSAIDs) for arthritis asks a nurse what can be done to prevent ulcers. The nurse will recommend asking the provider about using which medication?

Proton pump inhibitors.

A patient newly diagnosed with PUD reports taking low-dose aspirin (ASA) for prevention of cardiovascular disease. The nurse learns that the patient drinks 2 to 3 cups of coffee each day and has a glass of wine with dinner 3 or 4 nights per week. The patient eats three meals a day. The nurse will counsel this patient to:

Change the meal pattern to five or six smaller meals per day.

A patient is admitted with lower abdominal pain and nausea. The nurse performing the initial assessment notes that the patient’s abdomen is distended and firm, and hypoactive bowel sounds are present. The patient has not had a stool for 3 days. The nurse will contact the provider who will:

Perform diagnostic tests.

A patient reports taking an oral bisacodyl laxative [Dulcolax] for several years. The provider has suggested discontinuing the laxative, but the patient is unsure how to do this. The nurse will tell the patient to:

Stop taking the laxative immediately and expect no stool for several days.

A patient with renal disease is scheduled for a colonoscopy. Before the procedure, the nurse will anticipate administering:

Polyethylene glycol and electrolytes.

The parent of a child with cerebral palsy reports that the child has pebble-like stools most of the time and seems uncomfortable if several days have passed between stools. The nurse will suggest that the parent discuss which medication with the child’s provider?

Polyethylene glycol [MiraLax].

A patient will undergo a colonoscopy and the provider has ordered sodium phosphate as a bowel cleanser before the procedure. The nurse reviews the patient’s chart and notes that the patient’s creatinine clearance and blood urea nitrogen are both elevated. What will the nurse do?

Request an order to give polyethylene glycol and electrolytes (PEG-ELS) instead.

The nurse is caring for an older adult patient after a right hip open reduction internal fixation (ORIF). The patient is taking an opioid every 6 hours as needed for pain. The nurse discusses obtaining an order from the prescriber for which medication?

Docusate sodium [Colace].

A nurse is taking a history on a clinic patient who reports being constipated. Upon further questioning, the nurse learns that the patient’s last stool was 4 days ago, that it was of normal soft consistency, and that the patient defecated without straining. The patient’s abdomen is not distended and bowel sounds are present. The patient reports usually having a stool every 1 to 2 days. What will the nurse do?

Ask about recent food and fluid intake.

A nurse receives an order to administer castor oil to a patient. Which action by the nurse is correct?

Chill the medication and mix it with fruit juice.

Which condition would cause the nurse to withhold a PRN order for magnesium hydroxide?

Chronic renal failure.

A patient has been taking senna [Senokot] for several days and the nurse notes that the urine is yellowish-brown. What does the nurse know about this symptom?

It is an expected harmless effect of senna.

A patient with a history of chronic alcohol abuse has been admitted to the unit with cirrhosis. Upon review of the patient’s laboratory test results, the nurse notes that the patient’s ammonia level is elevated at 218 μg/dL. What medication should the nurse prepare to administer?

Lactulose.

A patient’s provider has recommended a bulk-forming laxative for occasional constipation. Which statement by the patient indicates understanding of the teaching about this agent?

“I should take each dose with a full glass of water.”

A patient has been taking psyllium [Metamucil] two to three times daily for several days. The patient complains of stomach pain but has not had a stool. What will the nurse do?

Palpate the patient’s abdomen and auscultate for bowel sounds.