Question 1

A 50-year-old patient who recently quit smoking reports a frequent morning cough productive of yellow sputum.A chest x-ray is clear,and the patient's FEV₁ is 80% of predicted.Pulse oximetry reveals an oxygen saturation of 97%.The primary care NP auscultates clear breath sounds.The NP should:

A) reassure the patient that these symptoms will subside.
B) prescribe a moderate-dose ICS twice daily.
C) order a long-acting anticholinergic with albuterol twice daily.
D) prescribe an albuterol metered-dose-inhaler, 2 puffs every 4 hours as needed.

Accepted Answer

For patients with stable COPD having respiratory symptoms with FEV1 between 60% and 80% of predicted,inhaled bronchodilators may be used.COPD is not reversible,and the symptoms will not subside.ICS therapy or long-acting anticholinergics are recommended when FEV₁ is less than 60%.

Question 2

A patient who was recently diagnosed with COPD comes to the clinic for a follow-up evaluation after beginning therapy with a SABA as needed for dyspnea.The patient reports occasional mild exertional dyspnea but is able to sleep well.The patient's FEV₁ in the clinic is 85% of predicted,and oxygen saturation is 96%.The primary care NP should recommend:

A) a combination LABA/ICS twice daily.
B) influenza and pneumococcal vaccines.
C) ipratropium bromide (Atrovent) twice daily.
D) home oxygen therapy as needed for dyspnea.

influenza and pneumococcal vaccines.

Accepted Answer

Influenza and pneumococcal immunizations are recommended to help reduce comorbidity that will affect respiratory status.This patient is stable with the prescribed medications,so no additional medications are needed at this time.Home oxygen therapy is used for patients with severe resting hypoxemia.

Question 3

A primary care NP is evaluating a patient who has COPD.The patient uses a LABA twice daily.The patient reports having increased exertional dyspnea,a frequent cough,and poor sleep.The patient also uses a short-acting b-adrenergic agonist (SABA)five or six times each day.Pulse oximetry reveals an oxygen saturation of 92%.The patient's FEV₁/forced vital capacity is 65,and FEV1 is 55% of predicted.The NP should prescribe a(n):

A) oral corticosteroid.
B) long-acting anticholinergic.
C) long-acting oral theophylline.
D) combination ICS/LABA inhaler.

combination ICS/LABA inhaler.

Accepted Answer

Providers should administer combination inhaled therapies for symptomatic patients with stable COPD and FEV₁ less than 60%.Oral corticosteroids have not been shown to be effective,even in severe cases of COPD.Long-acting anticholinergic medications may be used as monotherapy in early stages of COPD.Long-acting theophylline is poorly tolerated because of side effects.

Question 4

A 75-year-old patient requires frequent use of corticosteroids to control COPD exacerbations.To monitor adverse drug effects in this patient,the primary care NP should:&#10;A) order a bone density study.&#10;B) monitor the patient's renal function at every visit.&#10;C) order an electrocardiogram to assess for arrhythmias.&#10;D) order routine chest radiographs to watch for pneumonia.

Accepted Answer

High-dose ICSs and oral corticosteroids that are often used in COPD may cause or worsen osteoporosis in an older adult.The NP should order a bone density study.

Question 5

A patient with asthma is given an asthma action plan and returns to the clinic in 2 weeks to follow up on symptoms.Which statement by the patient indicates a need for further teaching?&#10;A) &#34;I use the ICS as needed when I am wheezing.&#34;&#10;B) &#34;A side effect of albuterol may be shortness of breath.&#34;&#10;C) &#34;I should rinse my mouth thoroughly after using an ICS.&#34;&#10;D) &#34;I put the albuterol metered-dose inhaler in my mouth with my lips sealed around it.&#34;

Accepted Answer

ICSs are controller medications and are not used as needed for symptoms,so this statement by the patient indicates a need for further teaching.The other statements are true.

Question 6

A primary care NP sees an adolescent patient for a hospitalization follow-up after an asthma exacerbation.The patient reports having daily symptoms with nighttime awakening 4 or 5 nights per week and misses school several days each month.The patient currently uses a salmeterol/fluticasone LABA twice daily and albuterol as needed.The patient requires a refill of the albuterol prescription once a month.The patient does not have any known allergies.The NP should:

A) order a high-dose ICS plus a LABA twice daily.
B) consider adding theophylline to this patient's regimen.
C) continue the current regimen and add omalizumab daily.
D) order a combination product with ipratropium and albuterol.

Accepted Answer

The patient has moderate persistent asthma not well controlled with the current regimen.The next step is to prescribe a high-dose ICS to be taken along with the LABA and to refer to an asthma specialist.Theophylline is recommended in the 5- to 11-year age group.Omalizumab is indicated if the patient has allergies.Ipratropium is used during acute exacerbations.

Question 7

A primary care nurse practitioner (NP)is evaluating a patient with asthma who reports having wheezing and coughing 1 or 2 days each week and awakening from sleep three or four times each month with asthma symptoms.The patient's forced expiratory volume in 1 second (FEV₁)is 80% of the predicted value.The patient's current medication regimen is an albuterol metered-dose inhaler,2 puffs every 4 hours as needed.The NP should prescribe:

A) montelukast (Singulair) po daily.
B) ipratropium bromide bid with albuterol.
C) a low-dose inhaled corticosteroid (ICS), 2 puffs bid.
D) a long-acting b-adrenergic agonist (LABA), 1 puff bid.

Accepted Answer

This patient has symptoms of mild,persistent asthma.The preferred controller medication in adults and children with persistent asthma is a low-dose ICS.Montelukast is a leukotriene modifier,which may be considered as an alternative to a low-dose ICS but is not the first option to try.Ipratropium is often used during an acute exacerbation but not for long-term control.LABA medications are used in patients with moderate persistent symptoms.

Question 8

A primary care NP sees a child with asthma to evaluate the child's response to the prescribed therapy.The child uses an ICS twice daily and an albuterol metered-dose inhaler as needed.The child's symptoms are well controlled.The NP notes slowing of the child's linear growth on a standardized growth chart.The NP should change this child's medication regimen to a:

A) combination ICS/LABA inhaler twice daily.
B) short-acting b2-agonist (SABA) with oral corticosteroids when symptomatic.
C) combination ipratropium/albuterol inhaler twice daily.
D) SABA as needed plus a leukotriene modifier once daily.

Accepted Answer

A leukotriene modifier may be used as an alternative to ICS for children who experience systemic side effects of the ICS.This child's symptoms are well controlled,so there is no need to step up therapy to include a LABA.Oral corticosteroids should be used only for severe exacerbations.Ipratropium and albuterol are used for severe exacerbations.

Question 9

A 70-year-old patient who has COPD takes theophylline daily and uses a SABA for exacerbation of symptoms.The patient reports using the SABA three or four times each week when short of breath.The patient reports feeling jittery and nauseated and having trouble sleeping.The primary care NP should:

A) obtain a serum theophylline level.
B) order a creatinine clearance level.
C) prescribe a leukotriene modifier instead of theophylline.
D) discontinue the SABA and change to ipratropium bromide.

Accepted Answer

Nausea,vomiting,insomnia,jitteriness,and other symptoms may indicate theophylline toxicity.Serum concentration monitoring should be done whenever signs of toxicity are suspected.A serum creatinine clearance level is not indicated.Leukotriene modifiers are not used for COPD.Ipratropium is used as an adjunct to the SABA during acute exacerbations.

Deck 16: Asthma and Chronic Obstructive Pulmonary Disease Medications