Raus Respiratory Care Pharmacology 9th Edition By Gardenhire – Test Bank

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Raus Respiratory Care Pharmacology 9th Edition By Gardenhire – Test Bank

Chapter 02: Principles of Drug Action

Gardenhire: Rau’s Respiratory Care Pharmacology, 9th Edition

 

MULTIPLE CHOICE

 

  1. During which phase of drug action is a drug made available to the body?
a. Administration
b. Pharmacokinetic
c. Pharmacodynamic
d. Pharmacogenetic

 

 

ANS:  A

A drug dose is made available to the body during the drug administration phase. The pharmacokinetic phase involves the time course and disposition of a drug in the body, based on its absorption, distribution, metabolism, and elimination. The pharmacodynamic phase involves the mechanisms of drug action by which a drug molecule causes its effect on the body. Pharmacogenetics is the study of variations among patients in their responses to drugs that are caused by hereditary differences.

 

REF:   p. 12

 

  1. A drug’s portal of entry into the body is known as the
a. formulation.
b. dosage.
c. route of administration.
d. additive.

 

 

ANS:  C

Formulation involves the physical state of the drug in association with nondrug components (e.g., the vehicle). Dosage involves the amount of active drug being administered. The route of administration is the portal of entry for the drug into the body, such as by oral (enteral) administration, injection, or inhalation. Additives are agents that help deliver the drug. For example, a metered dose inhaler (MDI) uses propellants to move the drug, a dry powder inhaler (DPI) uses bulking agents to improve dispersion of the drug, and capsules use a gelatinous material on the outside to allow the drug to be swallowed more easily.

 

REF:   p. 12

 

  1. Which of the following are routes of drug administration?
  2. Enteral
  3. Parenteral
  4. Ointment
  5. Inhalation

 

a. 1 and 4 only
b. 1, 2, and 3 only
c. 1, 2, and 4 only
d. 1, 2, 3, and 4

 

 

ANS:  C

Enteral (gastrointestinally), parenteral (other than gastrointestinally, generally injected), and inhalation are three of the five broad categories of drug administration (the other two are transdermal and topical). Ointment describes the formulation of a drug that may be administered topically.

 

REF:   p. 13

 

  1. Which of the following methods of drug delivery are commonly considered parenteral?
  2. Intravenous
  3. Intramuscular
  4. Paste
  5. Aerosol

 

a. 1 and 4 only
b. 1 and 2 only
c. 3 and 4 only
d. 1, 2, 3, and 4

 

 

ANS:  B

Technically, the term parenteral means “besides the intestine,” which implies any route of administration other than enteral. However, the parenteral route is commonly taken to mean injection of a drug. Various options are available for injection of a drug, the most common of which are the following:

Intravenous (IV): Injected directly into the vein, allowing nearly instantaneous access to the systemic circulation. Drugs can be given as a bolus, in which case the entire dose is given rapidly, leading to a sharp increase in the plasma concentration, or as a steady infusion to avoid this precipitous increase.

(IM): Injected deep into a skeletal muscle. Because the drug must be absorbed from the muscle into the systemic circulation, the drug effects occur more gradually than with intravenous injection, although typically more rapidly than by the oral route.

Subcutaneous (SC): Injected into the subcutaneous tissue beneath the epidermis and dermis.

Intraosseous (IO): Injected into the marrow of the bone.

 

REF:   p. 13

 

  1. Which of the following methods of drug administration requires a needle?
  2. Transdermal
  3. Inhalation
  4. Subcutaneous
  5. Intravenous

 

a. 1 and 3 only
b. 2 and 4 only
c. 1 and 2 only
d. 3 and 4 only

 

 

ANS:  D

Subcutaneous administration involves the use of a needle to inject drug into the tissue beneath the epidermis and dermis. Intravenous administration involves the use of a needle to inject drug directly into a vein or via a catheter put in place for this purpose. With transdermal administration, drug is absorbed percutaneously, obviating the need for a hypodermic needle and decreasing the fluctuations in plasma drug levels that can occur with repeated oral administration. Inhalation involves administering the drug in an aerosolized form directly to the lung.

 

REF:   p. 13

 

  1. Which of the following is not a part of the pharmacokinetic phase of a drug?
a. Absorption
b. Receptor site
c. Metabolism
d. Elimination

 

 

ANS:  B

Absorption, distribution, metabolism, and speed and method of elimination are factors that influence the course of a drug after it is introduced in the body. Receptors participate in the pharmacodynamic phase of drug action.

 

REF:   p. 14

 

  1. The process of incorporating a substance into a cell by engulfment and transport to the cell interior in vesicles is termed
a. aqueous diffusion.
b. lipid diffusion.
c. bioavailability.
d. pinocytosis.

 

 

ANS:  D

Aqueous diffusion describes the absorption of a substance into the aqueous compartments of the body, such as the interstitial spaces. Lipid diffusion describes the movement of a drug across lipid membranes en route to its place of action. Bioavailability indicates the portion of a drug that reaches the systemic circulation. Pinocytosis describes the incorporation of a substance into a cell by a process of membrane engulfment and transport of the substance to the cell interior in vesicles, allowing translocation across a membrane barrier.

 

REF:   p. 15

 

  1. Which of the following factors may have an effect on drug absorption?
  2. Route of administration
  3. Metabolic degradation
  4. Inactivation by stomach acids
  5. Blood flow to absorption site
a. 1 only
b. 1 and 2 only
c. 1 and 4 only
d. 1, 2, 3, and 4

 

 

ANS:  D

The route of administration determines which barriers to absorption must be crossed by a drug. Such barriers can affect the drug’s time to onset and time to peak effect. Intravenous administration bypasses the need for absorption from the gastrointestinal tract seen with oral administration, generally gives a very rapid onset and peak effect, and provides 100% availability of the drug in the bloodstream. The amount of drug in the bloodstream (its bioavailability) is influenced not only by absorption but also by inactivation caused by stomach acids and by metabolic degradation, which can occur before the drug reaches the main systemic compartment. Another important variable governing absorption and bioavailability is blood flow to the site of absorption.

 

REF:   p. 15

 

  1. Which of the four major body compartments contains the smallest average volume in liters?
a. Intracellular fluid
b. Vascular space
c. Interstitial fluid
d. Fat

 

 

ANS:  B

Intracellular fluid accounts for an average of 20 L of volume. Blood accounts for an average of 5 L of volume. Interstitial fluid accounts for an average of 10 L of volume. Fat accounts for an average of 14 to 25 L of volume.

 

REF:   p. 16

 

  1. The principal organ for drug metabolism is the
a. brain.
b. liver.
c. stomach.
d. lung.

 

 

ANS:  B

Other tissues, such as the lung, intestinal wall, and endothelial vascular wall, can transform or metabolize drugs; however, the liver is the principal organ for drug metabolism.

 

REF:   p. 17

 

  1. Which of the following routes of drug administration help to reduce the first-pass effect?
  2. Oral administration
  3. Injection
  4. Sublingual tablets
  5. Rectal administration

 

a. 1 and 3 only
b. 2 and 4 only
c. 2, 3, and 4 only
d. 1, 2, and 4 only

 

 

ANS:  C

Oral administration allows the drug to travel from the stomach or intestine to the branches of the portal vein, which drain directly into the liver, allowing for a large portion of the drug to be terminated before reaching the systemic circulation. The following routes avoid first-pass circulation through the liver: injection, buccal or sublingual tablets, transdermal (e.g., patch) or rectal (e.g., suppositories) administration, and inhalation. These routes of administration bypass the portal venous circulation of the liver, allowing drugs to be generally distributed in the body before being circulated through the liver and ultimately metabolized. They also bypass metabolic degradation occurring in the gut as a result of specific metabolic enzymes (e.g., cytochrome P450 family 3 [CYP3]) or bacterial flora.

 

REF:   p. 17

 

  1. Which of the following organs is considered the primary site of drug excretion?
a. Kidney
b. Liver
c. Small intestine
d. Stomach

 

 

ANS:  A

The primary site of drug excretion in the body is the kidney. The liver is the site of much drug metabolism, and the kidney is important for removing drug metabolites produced by the liver. Some drugs are not metabolized and are eliminated from the circulation entirely by the kidney. The small intestine and stomach are potential sites for drug absorption.

 

REF:   p. 17

 

  1. Inhaled aerosols may have which types of intended effects on the body?
  2. Enteral
  3. Local
  4. Systemic
  5. Oral

 

a. 1 and 3 only
b. 2 and 4 only
c. 2 and 3 only
d. 1, 2, 3, and 4

 

 

ANS:  C

Enteral and oral describe possible routes of drug administration. Inhaled aerosols are deposited on the surface of the upper or lower airway and are a form of topically administered drug. As topically deposited agents, inhaled aerosols can be intended for either a local effect in the upper or lower airway or a systemic effect as the drug is absorbed and distributed in the blood.

 

REF:   p. 19 | p. 20

 

  1. Approximately what percentage of an inhaled aerosol reaches the lower respiratory tract with current delivery devices?
a. 0% to 10%
b. 10% to 30%
c. 50% to 60%
d. 90% to 100%

 

 

ANS:  B

Although 10% is the generally accepted amount of drug that actually reaches the lower respiratory tract, this number may range from 10% to 30% based on the delivery device and patient technique.

 

REF:   p. 21

 

  1. Out of the total systemically available drug, the proportion of drug available from the lung is known as the
a. TI
b. VD
c. L/T ratio
d. T1/2

 

 

ANS:  C

The therapeutic index (TI) is the difference between the minimal therapeutic and toxic concentrations of a drug. The volume of distribution (VD) is the ratio of the amount of drug administered versus the plasma concentration of the drug. For an aerosol drug (bronchodilator, corticosteroid, mediator antagonist) that targets the respiratory tract, the L/T ratio is defined as the proportion of drug available from the lung out of the total systemically available drug. Plasma half-life (T1/2) describes the amount of time required for the plasma concentration of a drug to decrease by one-half.

 

REF:   p. 21 | p. 22

 

  1. The mechanism of drug action by which a drug molecule causes its effect in the body is known as the
a. pharmacodynamic phase.
b. elimination phase.
c. pharmacokinetic phase.
d. administration phase.

 

 

ANS:  A

Pharmacokinetics describes what the body does to a drug, and pharmacodynamics describes what the drug does to the body. Elimination describes the removal of a drug from the body; the kidney is the primary site of drug elimination. The pharmacokinetic phase describes the time course and deposition of a drug in the body. The administration phase describes the method by which a drug dose is made available to the body.

 

REF:   p. 23

 

  1. The relationship between a drug’s chemical structure and its clinical activity is known as
a. bioavailability.
b. biotransformation.
c. pharmacokinetics.
d. structure-activity relationship.

 

 

ANS:  D

Bioavailability refers to the amount of a drug that reaches the systemic circulation. Biotransformation is the transformation of a drug into a metabolite or inactive form. Pharmacokinetics describes the time course and disposition of a drug in the body. The relationship between a drug’s chemical structure and its clinical effect or outcome on the body is termed the structure-activity relationship (SAR).

 

REF:   p. 23

 

  1. Given the following information, which drug is most potent?
Drug ED50
A 10 mg
B 5 mg
C 1 mg
D 15 mg

 

a. Drug A
b. Drug B
c. Drug C
d. Drug D

 

 

ANS:  C

The dose at which 50% of the response to the drug occurs is indicated in Figure 2-13 and is referred to as the ED50, the dose of drug that produces 50% of the maximal effect. This may also be denoted as the EC50, for effective concentration giving 50% of the maximal response. Potency refers to the concentration (EC50) or dose (ED50) of a drug producing 50% of that drug’s maximal response. The potency of two drugs, A and B, can be compared on the basis of the ED50 values of the two drugs: relative potency, A and B = ED50 (B)/ED50 (A).

 

REF:   p. 27

 

  1. Which of the following drugs has the greatest potential of crossing over from a therapeutic effect to a toxic effect?
Drug TI
A 2
B 20
C 5
D 15

 

a. Drug A
b. Drug B
c. Drug C
d. Drug D

 

 

ANS:  A

The ratio of the dose that is toxic to 50% of test subjects (LD50) to the dose that provides relief to 50% of subjects (ED50) is the clinical therapeutic index (TI). This index represents the safety margin of the drug. The smaller the TI, the greater the possibility of crossing from a therapeutic effect to a toxic effect. Drug A has the narrowest TI.

 

REF:   p. 27

 

  1. The drug albuterol binds to its corresponding receptor to initiate its intended response of bronchodilation. By definition, albuterol is known as a(n)
a. agonist.
b. antagonist.
c. both A and B.
d. neither A nor B.

 

 

ANS:  A

An agonist is a drug or chemical that binds to a corresponding receptor (has affinity) and initiates a cellular effect or response (has efficacy). An antagonist is a drug or chemical that is able to bind to a receptor (has affinity) but causes no response (zero efficacy).

 

REF:   p. 28

 

  1. Two different drugs (each with its own mechanism of action) are administered to a patient in an attempt to relieve bronchoconstriction. The ordering physician hopes that the effect of the drug pair will be greater than the sum of the separate effects of each individual drug. If successful, this would be an example of
a. potentiation.
b. synergism.
c. additivity.
d. tolerance.

 

 

ANS:  B

Potentiation is a special case of synergism in which one drug has no effect but can increase the activity of another drug. Synergism occurs when two drugs act on a target organ by different mechanisms of action and the effect of the drug pair is greater than the sum of the separate effects of the drugs. Additivity occurs when two drugs act on the same receptors and the combined effect is the simple linear sum of the effects of the two drugs, up to a maximal effect. Tolerance describes a decreasing intensity of response to a drug over time.

 

REF:   p. 28

 

  1. Mrs. Johnson is a 37-year-old woman who has been taking medication for lower back pain for the last 18 months. She reports to her physician that although the medication initially rendered her pain-free, she now receives very little relief from her daily dose. This situation is described by which of the following terms used to refer to drug responsiveness (assuming that her condition has not actually worsened)?
a. Hypersensitivity
b. Idiosyncratic effect
c. Tolerance
d. Tachyphylaxis

 

 

ANS:  C

Hypersensitivity describes an allergic or immune-mediated response to a drug, which can be serious, requiring airway maintenance or ventilatory assistance. An idiosyncratic effect is one that is unusual, opposite to, or has no effect compared with the predicted usual effect in an individual. Tolerance describes a decreasing intensity of response to a drug over time. Tachyphylaxis describes a rapid decrease in response to a drug.

 

REF:   p. 29

 

  1. A perfectly efficient aerosol delivery device would theoretically have an L/T ratio of which of the following?
a. 0
b. 0.5
c. 0.75
d. 1.0

 

 

ANS:  D

For an aerosol drug that targets the respiratory tract, the L/T ratio can be defined as the proportion of drug available from the lung, out of the total systemically available drug. Theoretically, if a 10-mg dose was administered, and a resulting 10 mg was available systemically, the L/T ratio would be 10 divided by 10, which equals 1.

 

REF:   p. 21

 

  1. Which of the following factors can increase the lung availability/total systemic availability ratio of inhaled drugs?
  2. Efficient delivery devices
  3. Inhaled drugs with a high first-pass metabolism rate
  4. Mouth washing
  5. Use of a reservoir device

 

a. 1 and 2 only
b. 1 and 3 only
c. 1, 2, and 3 only
d. 1, 2, 3, and 4

 

 

ANS:  D

Any action that reduces the swallowed portion of the inhaled drug can increase the L/T ratio; a high first-pass metabolism rate can also increase the L/T ratio.

 

REF:   p. 21 | p. 22

 

  1. The drug methacholine can stimulate parasympathetic receptors in the airways, causing bronchoconstriction. Epinephrine can stimulate b2 receptors in the airways, causing bronchodilation. These two opposing effects that cancel each other out are an example of
a. chemical antagonism.
b. functional antagonism.
c. competitive antagonism.
d. synergism.

 

 

ANS:  B

Chemical antagonism is a direct chemical interaction between a drug and a biologic mediator, which inactivates the drug. Functional antagonism occurs when two drugs each produce an effect and the effects cancel each other out. Competitive antagonism occurs when a drug has an affinity for a receptor but no efficacy and at the same time blocks the active agonist from binding to and stimulating the receptor. Synergism occurs when two drugs act on a target organ by different mechanisms of action and the effect of the drug pair is greater than the sum of the separate effects of the drugs.

 

REF:   p. 28

 

  1. The lining of the lower respiratory tract presents barriers to drug absorption and includes which of the following elements?
  2. Airway surface liquid
  3. Capillary vascular network
  4. Epithelial cells
  5. Interstitium

 

a. 1 and 2 only
b. 1 and 3 only
c. 1, 2, and 3 only
d. 1, 2, 3, and 4

 

 

ANS:  D

The lining of the lower respiratory tract presents barriers to drug absorption. This mucosal barrier consists of the following five identifiable elements: airway surface liquid, epithelial cells, basement membrane, interstitium, and capillary vascular network.

 

REF:   p. 14

 

  1. The study of genetic factors and their influence on drug response is termed
a. pharmacogenetics.
b. functional antagonism.
c. competitive antagonism.
d. pharmacokinetics.

 

 

ANS:  A

Functional antagonism occurs when two drugs each produce an effect and the effects cancel each other out. Competitive antagonism occurs when a drug has an affinity for a receptor but no efficacy and at the same time blocks the active agonist from binding to and stimulating the receptor. Pharmacokinetics is the time course and disposition of a drug in the body, based on its absorption, distribution, metabolism, and elimination.

 

REF:   p. 29

 

  1. The difference between the minimal therapeutic and toxic concentrations of a drug is known as the
a. TI.
b. VD.
c. L/T ratio.
d. T1/2.

 

 

ANS:  A

The therapeutic index (TI) is the difference between the minimal therapeutic and toxic concentrations of a drug. The volume of distribution (VD) is the ratio of the amount of drug administered versus the plasma concentration of the drug. For an aerosol drug (bronchodilator, corticosteroid, mediator antagonist) that targets the respiratory tract, the L/T ratio is defined as the proportion of drug available from the lung out of the total systemically available drug. Plasma half-life (T1/2) describes the amount of time required for the plasma concentration of a drug to decrease by one-half.

 

REF:   p. 18

 

  1. A measure of how quickly a drug is eliminated from the body is known as the
a. TI.
b. VD.
c. L/T ratio.
d. T1/2.

 

 

ANS:  D

The therapeutic index (TI) is the difference between the minimal therapeutic and toxic concentrations of a drug. The volume of distribution (VD) is the ratio of the amount of drug administered versus the plasma concentration of the drug. For an aerosol drug (bronchodilator, corticosteroid, mediator antagonist) that targets the respiratory tract, the L/T ratio is defined as the proportion of drug available from the lung out of the total systemically available drug. Plasma half-life (T1/2) describes the amount of time required for the plasma concentration of a drug to decrease by one-half.

 

REF:   p. 18

 

  1. Mr. Ashoor is a 29-year-old asthmatic patient who takes MDI albuterol for wheezing and typically gets quick relief following two puffs. After he mowed the lawn today, he realized he was having a rapid decrease in responsiveness to his albuterol. He tried taking it again but still had no relief. This situation is described by which of the following terms used to refer to drug responsiveness?
a. Hypersensitivity
b. Idiosyncratic effect
c. Tolerance
d. Tachyphylaxis

 

 

ANS:  D

Hypersensitivity describes an allergic or immune-mediated response to a drug, which can be serious, requiring airway maintenance or ventilatory assistance. An idiosyncratic effect is one that is unusual, opposite to, or has no effect compared with the predicted usual effect in an individual. Tolerance describes a decreasing intensity of response to a drug over time. Tachyphylaxis describes a rapid decrease in response to a drug.

 

REF:   p. 29

 

  1. Which is the term that refers to the concentration (EC50) or dose (ED50) of a drug producing 50% of the maximal response of the drug?
a. Potency
b. Hypersensitivity
c. Potentiation
d. Additivity

 

 

ANS:  A

Hypersensitivity describes an allergic or immune-mediated response to a drug, which can be serious, requiring airway maintenance or ventilatory assistance. Potency refers to the concentration (EC50) or dose (ED50) of a drug producing 50% of the maximal response of the drug. Additivity occurs when two drugs act on the same receptors and the combined effect is the simple linear sum of the effects of the two drugs, up to a maximal effect. Potentiation is a special case of synergism in which one drug has no effect but can increase the activity of another drug.

 

REF:   p. 27 | p. 28

 

  1. An allergic or immune-mediated reaction to a drug, which can be serious, requiring airway maintenance or ventilatory assistance is called
a. potency.
b. hypersensitivity.
c. potentiation.
d. additivity.

 

 

ANS:  B

Hypersensitivity describes an allergic or immune-mediated response to a drug, which can be serious, requiring airway maintenance or ventilatory assistance. Potency refers to the concentration (EC50) or dose (ED50) of a drug producing 50% of the maximal response of the drug. Additivity occurs when two drugs act on the same receptors and the combined effect is the simple linear sum of the effects of the two drugs, up to a maximal effect. Potentiation is a special case of synergism in which one drug has no effect but can increase the activity of another drug.

 

REF:   p. 29

 

  1. A special case of synergism in which one drug has no effect but can increase the activity of another drug is known as
a. potency.
b. hypersensitivity.
c. potentiation.
d. additivity.

 

 

ANS:  C

Hypersensitivity describes an allergic or immune-mediated response to a drug, which can be serious, requiring airway maintenance or ventilatory assistance. Potency refers to the concentration (EC50) or dose (ED50) of a drug producing 50% of the maximal response of the drug. Additivity occurs when two drugs act on the same receptors and the combined effect is the simple linear sum of the effects of the two drugs, up to a maximal effect. Potentiation is a special case of synergism in which one drug has no effect but can increase the activity of another drug.

 

REF:   p. 28

 

  1. This term is used to describe when two drugs act on the same receptors and the combined effect is the simple linear sum of the effects of the two drugs, up to a maximal effect.
a. Potency
b. Hypersensitivity
c. Potentiation
d. Additivity

 

 

ANS:  D

Hypersensitivity describes an allergic or immune-mediated response to a drug, which can be serious, requiring airway maintenance or ventilatory assistance. Potency refers to the concentration (EC50) or dose (ED50) of a drug producing 50% of the maximal response of the drug. Additivity occurs when two drugs act on the same receptors and the combined effect is the simple linear sum of the effects of the two drugs, up to a maximal effect. Potentiation is a special case of synergism in which one drug has no effect but can increase the activity of another drug.

 

REF:   p. 28

 

  1. Why is lipid diffusion an important mechanism for drug absorption?
a. Many epithelial membranes must be crossed if a drug is to distribute in the body and reach its target organ.
b. Epithelial cells do not have lipid membranes, so a drug must be water-soluble to diffuse across such a membrane.
c. It is directly related to the proportion of a drug that reaches the systemic circulation.
d. Lipid diffusion has no importance in drug absorption because the body has very few epithelial membranes drugs must cross.

 

 

ANS:  A

Lipid diffusion is an important mechanism for drug absorption because many epithelial membranes must be crossed if a drug is to distribute in the body and reach its target organ.

 

REF:   p. 15

 

  1. The term used to indicate the proportion of a drug that reaches the systemic circulation is
a. bioavailability.
b. biotransformation.
c. pharmacokinetics.
d. structure-activity relationship.

 

 

ANS:  A

Bioavailability refers to the amount of a drug that reaches the systemic circulation. Biotransformation is the transformation of a drug into a metabolite or inactive form. Pharmacokinetics describes the time course and disposition of a drug in the body. The relationship between a drug’s chemical structure and its clinical effect or outcome on the body is termed the structure-activity relationship (SAR).

 

REF:   p. 11

 

  1. The process by which a drug is transported to its sites of action, eliminated, or stored is referred to as
a. bioavailability.
b. biotransformation.
c. drug distribution.
d. plasma half-life.

 

 

ANS:  C

Bioavailability refers to the amount of a drug that reaches the systemic circulation. Biotransformation is the transformation of a drug into a metabolite or inactive form. Drug distribution is the process by which a drug is transported to its sites of action, eliminated, or stored. Plasma half-life (T1/2) is the time required for the plasma concentration of a drug to decrease by one-half.

 

REF:   p. 15 | p. 16

 

  1. The time required for the plasma concentration of a drug to decrease by one-half is referred to as
a. bioavailability.
b. biotransformation.
c. drug distribution.
d. plasma half-life.

 

 

ANS:  D

Bioavailability refers to the amount of a drug that reaches the systemic circulation. Biotransformation is the transformation of a drug into a metabolite or inactive form. Drug distribution is the process by which a drug is transported to its sites of action, eliminated, or stored. Plasma half-life (T1/2) is the time required for the plasma concentration of a drug to decrease by one-half.

 

REF:   p. 18

 

  1. After inhalation of an aerosol by a spontaneously breathing patient with no artificial airway, a proportion of the aerosol does which of the following?
  2. Impacts in the oropharynx
  3. Is swallowed
  4. Is absorbed by the lungs
  5. Is exhaled

 

a. 1 and 2 only
b. 1 and 3 only
c. 1, 2, and 3 only
d. 1, 2, 3, and 4

 

 

ANS:  C

After inhalation of an aerosol by a spontaneously breathing patient with no artificial airway, a proportion of the aerosol impacts in the oropharynx and is swallowed, and a proportion is inhaled into the airway. Because a portion of an inhaled aerosol is swallowed, the inhalation route leads to gastrointestinal absorption, as well as lung absorption of the drug. The traditional percentages given for stomach and airway proportions, based on Stephen Newman’s classic measures in 1981 with an MDI, are approximately 90% and 10%, respectively.

 

REF:   p. 20 | p. 21

 

Chapter 12: Nonsteroidal Antiasthma Agents

Gardenhire: Rau’s Respiratory Care Pharmacology, 9th Edition

 

MULTIPLE CHOICE

 

  1. The general indication for clinical use of nonsteroidal antiasthma agents is
a. short-term control of bronchospasm.
b. prophylactic management of mild persistent asthma.
c. long-term control of bronchospasm.
d. control of severe asthma attack.

 

 

ANS:  B

The general indication for clinical use of nonsteroidal antiasthma agents is prophylactic management, or control, of mild persistent asthma as put forth in the 2007 National Asthma Education and Prevention Program (NAEPP) Guidelines for the Diagnosis and Management of Asthma. These agents are not designed for short-term control or to reverse active bronchospasm.

 

REF:   p. 203

 

  1. Nonsteroidal antiasthma drugs are
a. relievers.
b. â2 antagonists.
c. antiinfectives.
d. controllers.

 

 

ANS:  D

All the drugs described in Chapter 12 are controllers, not relievers, and are used in asthma requiring antiinflammatory drug therapy.

 

REF:   p. 203

 

  1. Accolate is the brand name for which medication?
a. Zafirlukast
b. Montelukast
c. Zileuton
d. Omalizumab

 

 

ANS:  A

Accolate is the brand name for zafirlukast. Singulair is the brand name for montelukast, Zyflo is the brand name for zileuton, and Xolair is the brand name for omalizumab.

 

REF:   p. 204

 

  1. Cromolyn sodium is available in what form?
a. Nebulizer solution
b. Tablet
c. MDI
d. Nasal spray

 

 

ANS:  A

Cromolyn sodium is available only as a small volume nebulizer (SVN) formulation. The antileukotriene drugs zafirlukast, montelukast, and zileuton are available in tablet form.

 

REF:   p. 204

 

  1. Which type of asthma is associated with allergic reactions?
a. Chronic
b. Intrinsic
c. Acute
d. Extrinsic

 

 

ANS:  D

Extrinsic asthma is dependent on allergy, or atopy, whereas intrinsic asthma shows no evidence of sensitization to common inhaled allergens.

 

REF:   p. 203

 

  1. Which of the following are antileukotriene agents?
  2. Zafirlukast
  3. Zileuton
  4. Cromolyn sodium
  5. Montelukast

 

a. 1, 2, and 4 only
b. 3 and 4 only
c. 1, 2, and 3 only
d. 2, 3, and 4 only

 

 

ANS:  A

Cromolyn sodium is a mast cell stabilizer, whereas zafirlukast, montelukast, and zileuton are considered antileukotrienes.

 

REF:   p. 204

 

  1. Cromolyn sodium is effective in preventing bronchospasm by
a. inhibiting mast cell degranulation.
b. blocking cholinergic receptor sites.
c. enhancing mast cell degranulation.
d. stimulating â2-adrenergic sites.

 

 

ANS:  A

As a mast cell stabilizer, cromolyn sodium works to prevent bronchospasm by inhibiting the degranulation of mast cells, blocking release of the chemical mediators of inflammation. It has no bronchodilatory effects.

 

REF:   p. 207

 

  1. The most commonly reported side effect of cromolyn sodium is
a. diarrhea.
b. pneumonia.
c. nasal congestion.
d. headache.

 

 

ANS:  C

Nasal congestion may be seen after beginning cromolyn sodium use. Dermatitis, myositis, and gastroenteritis have occurred in a very few patients.

 

REF:   p. 208

 

  1. After a patient begins using cromolyn sodium, how long may it take before clinical improvement in the patient’s symptoms is seen?
a. 24 hours
b. 4 to 6 days
c. 2 to 4 weeks
d. 1 to 3 months

 

 

ANS:  C

It may take 2 to 4 weeks for improvement in the patient’s symptoms, enabling a decrease in concomitant therapy such as bronchodilator or steroid use.

 

REF:   p. 208

 

  1. The usual dose of nebulized cromolyn sodium is
a. 10 mg four times per day.
b. 20 mg four times per day.
c. 30 mg three times per day.
d. 80 mg three times per day.

 

 

ANS:  B

The usual dose of 20 mg qid (80 mg/day) in some cases can be reduced to a maintenance dose of 40 to 60 mg/day after the patient is stabilized for 1 or 2 months.

 

REF:   p. 208

 

  1. Zileuton is administered by
a. DPI.
b. tablet.
c. MDI.
d. nebulizer.

 

 

ANS:  B

Zileuton is marketed as Zyflo in a tablet formulation.

 

REF:   p. 211

 

  1. Singulair can be administered to which of the following patient populations?
  2. Adults and adolescents 15 years or older
  3. Pediatric patients 6 to 14 years
  4. Pediatric patients 2 to 5 years
  5. Pediatric patients 12 to 23 months
  6. Pediatric patients 6 to 23 months

 

a. 1 and 2 only
b. 1 only
c. 1, 2, and 3 only
d. 1, 2, 3, 4, and 5

 

 

ANS:  D

Montelukast is available as a 10-mg tablet, as 4-mg and 5-mg chewable cherry-flavored tablets, and as a 4-mg packet of granules.

Adults and adolescents 15 years or older: One 10-mg tablet daily, taken daily.

Pediatric patients 6 to 14 years: One 5-mg chewable tablet daily, taken daily.

Pediatric patients 2 to 5 years: One 4-mg chewable tablet daily, or one 4-mg packet of oral granules daily.

Pediatric patients 12 to 23 months: One 4-mg packet of oral granules taken every evening.

Pediatric patients 6 to 23 months: One 4-mg packet of oral granules taken daily for allergic rhinitis.

 

REF:   p. 213

 

  1. Mast cells are
a. chemical mediators that cause inflammation.
b. agents that block the inflammatory response in asthma.
c. agents used prophylactically to treat the inflammatory response in asthma.
d. connective tissue cells that contain heparin and histamine.

 

 

ANS:  D

Mast cells are connective tissue cells that contain heparin and histamine. Antileukotrienes agents block the inflammatory response in asthma.

Leukotrienes are chemical mediators that cause inflammation.

Mast cell stabilizers are agents used prophylactically to treat the inflammatory response in asthma.

 

REF:   p. 202

 

  1. Leukotrienes exhibit which of the following effects?
  2. Increased mucus secretion
  3. Inhibition of normal ciliary action
  4. Increased airway edema
  5. Bronchoconstriction
  6. Recruitment of other inflammatory cells into airways

 

a. 4 only
b. 1, 2, and 4 only
c. 3, 4, and 5 only
d. 1, 2, 3, 4, and 5

 

 

ANS:  D

Leukotrienes are potent bronchoconstrictors and stimulate other cells to cause airway edema, mucus secretion, ciliary beat inhibition, and recruitment of other inflammatory cells into the airway.

 

REF:   p. 209 | p. 210

 

  1. Zileuton interacts with which of the following respiratory care drugs?
  2. Theophylline
  3. Albuterol
  4. Warfarin
  5. Ipratropium bromide
  6. Beclomethasone

 

a. 1 and 3 only
b. 2 and 4 only
c. 3 and 5 only
d. 1 and 5 only

 

 

ANS:  A

Zileuton interacts with two important drugs in respiratory care: theophylline and warfarin. It may cause an increase in serum theophylline concentrations and can increase prothrombin time when given concomitantly with warfarin.

 

REF:   p. 212

 

  1. Zafirlukast is a
a. leukotriene receptor stimulator.
b. leukotriene receptor antagonist.
c. b adrenergic.
d. corticosteroid.

 

 

ANS:  B

Zafirlukast and montelukast are both leukotriene receptor antagonists and block the inflammatory effects of leukotrienes. Specifically, zafirlukast binds to the cysteinyl leukotriene 1 receptors, with no agonist effect.

 

REF:   p. 212

 

  1. The only antileukotriene agent currently approved for use in patients younger than 5 years of age is
a. zafirlukast.
b. Singulair.
c. Accolate.
d. Xolair.

 

 

ANS:  B

Montelukast is the only one of the three currently available antileukotriene agents that is approved for use in children younger than 5 years. To date, no safety issues have appeared with pediatric use, and the drug has been proven safe and effective in infants 6 months old.

 

REF:   p. 213

 

  1. What is the clinical indication for use of antileukotriene drug therapy, such as montelukast, in asthma?
a. As a rescue bronchodilator in step 1 asthma
b. As a long-acting bronchodilator in step 3 asthma
c. As an alternative to inhaled steroids
d. As a mast cell stabilizer

 

 

ANS:  C

The following points summarize the current understanding of the role of antileukotriene drug therapy in asthma:

  • Antileukotriene agents are prophylactic, controller drugs used in persistent asthma, including mild, moderate, and severe states; they are not indicated for acute relief or rescue therapy.
  • Antileukotrienes can be tried as an alternative to inhaled corticosteroids or cromolynlike agents in mild persistent asthma requiring more than as-needed b2 agonists.
  • Antileukotrienes may not be optimal as monotherapy in persistent asthma.
  • Antileukotrienes may allow reduction of high-dose inhaled corticosteroids or prevent an increase in the dose of inhaled corticosteroids, and they reduce or prevent the need for oral corticosteroids.
  • Evidence to date shows these agents as safe and often effective choices in managing a wide range of asthma severity.

 

REF:   p. 213 | p. 214

 

  1. Which of the following agents is considered a mast cell stabilizer?
a. Montelukast
b. Zafirlukast
c. Cromolyn sodium
d. Zileuton

 

 

ANS:  C

Montelukast, zafirlukast, and zileuton all are antileukotriene agents. Cromolyn sodium, also known as Intal, is a mast cell–stabilizing agent used as a prophylactic in the treatment of asthma. Although it may not be used as often in clinical practice today as it was previously, the agent is an alternative in mild persistent asthma. The antiinflammatory mast cell–stabilizing effect of cromolyn has led to uses other than asthma prophylaxis, including the following:

  • Allergic rhinitis (nasal solution)
  • Mastocytosis, to improve diarrhea, abdominal pain, headaches, nausea, and itching (oral)

 

REF:   p. 204

 

  1. Which of the following nonsteroidal antiasthma agents is formulated as a subcutaneous injection?
a. Zileuton
b. Xolair
c. Montelukast
d. Zafirlukast

 

 

ANS:  B

Xolair is the trade name for omalizumab. It is formulated as a subcutaneous injection every 4 weeks; dose depends on weight and serum IgE level. The other drugs listed are available only for oral administration.

 

REF:   p. 215

 

  1. Which of the following is a monoclonal antibody used to treat asthma?
a. Omalizumab
b. Zileuton
c. Zafirlukast
d. Montelukast

 

 

ANS:  A

Omalizumab (Xolair) is a subcutaneously injected monoclonal antibody. This drug is indicated for the treatment of moderate to severe asthma in adults and adolescents 12 years and older who have a positive skin test or in vitro reactivity to a perennial aeroallergen. Zileuton, zafirlukast, and montelukast are antileukotrienes.

 

REF:   p. 215

 

  1. Which of the following is an advantage to the use of antileukotriene agents?
a. Multiple ways of administration
b. No interaction with inhaled steroids
c. Effective in more than 90% of patients
d. All formulations are available for pediatric use

 

 

ANS:  C

Antileukotriene drug therapy is effective in approximately 50% of patients (although this proportion is higher in aspirin-sensitive individuals), but there is no method to predict which patients will be responders. Oral administration, additive effect with inhaled steroids, and available pediatric formulation all are advantages of antileukotriene agents.

 

REF:   p. 214

 

  1. Allergic inflammation of the airway is the product of an immune response, and the ________________ plays a central role in attracting mast cells and eosinophils.
a. T lymphocyte
b. B lymphocyte
c. A and B
d. Neither A nor B

 

 

ANS:  A

Allergic inflammation of the airway is the product of an immune response, and the T lymphocyte plays a central role in attracting mast cells and eosinophils, which release mediators that attract other cells and damage epithelial cells. Antibodies are serum globulins (proteins) modified specifically to combine and react with an antigen (substance capable of provoking antibodies or cellular immunity). B lymphocytes are antibody-producing plasma cells, memory cells for later antibody production.

 

REF:   p. 204

 

  1. A 22-year-old patient is experiencing an acute exacerbation of her asthma and is complaining of wheezing and shortness of breath. Which is the most appropriate medication to help relieve her symptoms?
a. Omalizumab
b. Zileuton
c. Cromolyn sodium
d. Albuterol

 

 

ANS:  D

Omalizumab is a prophylactic agent used in uncontrolled moderate to severe persistent asthma; it is not indicated for acute relief or rescue therapy. Zileuton is an antileukotriene. Antileukotriene agents are prophylactic controller drugs used in persistent asthma, including mild, moderate, and severe states; they are not indicated for acute relief or rescue therapy. Cromolyn is used only as a prophylactic agent and should not be used during acute bronchospasm; this is based on its mode of action because the drug must already be present to prevent mast cell degranulation. It has no bronchodilating action and may cause further bronchial irritation as an aerosol.

 

REF:   p. 203

 

  1. What is the mechanism of action for Singulair?
a. 5-LO inhibitor
b. Leukotriene receptor antagonist
c. Leukotriene receptor agonist
d. Monoclonal antibodies

 

 

ANS:  B

Montelukast (Singulair) is a competitive antagonist for the Cysteinyl leukotrienes LTC4, LTD4, and LTE4.

 

REF:   p. 213

 

  1. Zach is a 14 year old with complaints of shortness of breath and wheezing when working out. He currently takes albuterol and theophylline. What medication may help with his symptoms?
a. Xolair
b. Cromolyn
c. Singulair
d. Accolate

 

 

ANS:  C

Exercise-induced asthma: In exercise-induced asthma, cooling and drying of the airway promotes the generation of leuko-trienes, resulting in bronchoconstriction. Although protection varies from complete to very little, the antileukotrienes develop no tolerance and may benefit patients who want to exercise or whose jobs require exercise under cold, dry conditions without the use of short-acting rescue b agonists. Accolate may interact with his theophylline.

 

REF:   p. 213

 

  1. Bobby is in a sickle cell crisis. Along with his pain medications, he received a medication via inhalation. His mother asks you if you know what the medication was. What is one possibility?
a. Albuterol
b. Cromolyn
c. Combivent
d. Relenza

 

 

ANS:  B

Anti-sickle cell effects. Both the intranasal solution and the 20-mg inhaled powder capsule of cromolyn given as a single dose were observed to cause a striking decrease in sickle cell percentage in nine African children with severe sickle cell disease. Improvement was seen 24 hours after administration of the single dose. The reduction in sickling is hypothesized to be due to the blocking of calcium-activated potassium channels, which play a major part in water loss and erythrocyte dehydration.

 

REF:   p. 206 | p. 207

 

Chapter 22: Drugs Affecting Circulation: Antihypertensives, Antianginals, Antithrombotics

Gardenhire: Rau’s Respiratory Care Pharmacology, 9th Edition

 

MULTIPLE CHOICE

 

  1. Damage to vital body organs resulting from hypertension is called
a. congestive heart failure.
b. multiple organ/system failure.
c. cardiovascular disease.
d. chronic obstructive pulmonary disease.

 

 

ANS:  C

Hypertension adversely affects numerous body organs, including the heart, brain, kidney, and eye. Damage to these organ systems resulting from hypertension is termed cardiovascular disease. Uncontrolled hypertension increases cardiovascular disease morbidity and mortality by increasing the risk of developing left ventricular hypertrophy, angina, myocardial infarction, heart failure, stroke, peripheral arterial disease, retinopathy, and renal failure.

 

REF:   p. 371

 

  1. Uncontrolled hypertension increases the risk of which of the following?
  2. Myocardial infarction
  3. Peripheral arterial disease
  4. Angina
  5. Stroke
  6. Renal failure

 

a. 1 and 3 only
b. 2 and 4 only
c. 1, 4, and 5 only
d. 1, 2, 3, 4, and 5

 

 

ANS:  D

Uncontrolled hypertension increases cardiovascular disease morbidity and mortality by increasing the risk of developing left ventricular hypertrophy, angina, myocardial infarction, heart failure, stroke, peripheral arterial disease, retinopathy, and renal failure.

 

REF:   p. 371

 

  1. What agents act to lower blood pressure by stopping the conversion of angiotensin I to angiotensin II?
a. Angiotensin-converting enzyme inhibitors (ACEIs)
b. Angiotensin II receptor blockers
c. Diuretics
d. b blockers

 

 

ANS:  A

ACEIs act primarily through suppression of the renin–angiotensin–aldosterone system. Because of a lack of renal blood flow, renin is released into the circulation, where it acts on angiotensinogen to produce angiotensin I. In the pulmonary vasculature, angiotensin I is converted by angiotensin-converting enzyme to angiotensin II. Angiotensin II is a highly potent endogenous vasoconstrictor that also stimulates aldosterone secretion from the zona glomerulosa cells of the adrenal cortex, contributing to sodium and water retention. Angiotensin II also stimulates the release of catecholamines from the adrenergic nerve endings and mediates the release of central sympathetic outflow. Angiotensin-converting enzyme is abundant in the endothelial cells of blood vessels and to a lesser extent in the kidneys. ACEIs block the conversion of angiotensin I to angiotensin II by competing with the physiologic substrate angiotensin I for the active site of angiotensin-converting enzyme.

 

REF:   p. 372

 

  1. The product of cardiac output and total peripheral resistance defines
a. arterial blood pressure.
b. central venous pressure.
c. afterload.
d. preload.

 

 

ANS:  A

Arterial blood pressure, termed blood pressure, is generated by the interplay between blood flow and the resistance to blood flow. Arterial blood pressure reaches a peak during cardiac systole and a nadir at the end of diastole. Arterial blood pressure is defined hemodynamically as the product of cardiac output (heart rate ´ stroke volume) and total peripheral resistance.

 

REF:   p. 374

 

  1. Hypertension in adults is defined as a blood pressure greater than
a. 120/80 mm Hg.
b. 130/85 mm Hg.
c. 140/90 mm Hg.
d. 160/100 mm Hg.

 

 

ANS:  C

More than 1 billion people worldwide and 1 in every 4 Americans have high blood pressure (=140/90 mm Hg).

 

REF:   p. 372

 

  1. First-line agents for treatment of uncomplicated hypertension include
a. diuretics only.
b. thiazide diuretics, ACEIs, ARBs, and CCBs.
c. ACEIs and a-blocking agents.
d. ACEIs, b blockers, and ARBs.

 

 

ANS:  B

First-line agents for the treatment of uncomplicated hypertension are thiazide-type diuretics, or angiotensin-converting enzyme inhibitors (ACEIs), angiotensin II receptor blockers (ARBs), and calcium channel blockers (CCBs).

 

REF:   p. 372

 

  1. Angiotensin-converting enzyme inhibitors (ACEIs) produce which of the following effects?
  2. Decrease in renal blood flow
  3. Reduction of peripheral arterial pressure
  4. Increase in renal blood flow
  5. Significant increase in heart rate
  6. Increase in cardiac output

 

a. 2, 4, and 5 only
b. 1, 2, and 4 only
c. 2, 3, and 5 only
d. 1, 2, 3, 4, and 5

 

 

ANS:  C

The hemodynamic effects of ACEIs are a reduction of peripheral arterial resistance, an increase in cardiac output, little or no change in heart rate, an increase in renal blood flow, and unchanged glomerular filtration rate. ACEIs have mild antihyperlipidemic effects.

 

REF:   p. 372

 

  1. Angiotensin-converting enzyme inhibitors (ACEIs) are indicated for which of the following?
  2. Heart failure
  3. Systolic dysfunction
  4. Post–myocardial infarction
  5. Hypertension
  6. Proteinuric kidney disease

 

a. 4 only
b. 1, 2, and 4 only
c. 1, 2, 3, and 4 only
d. 1, 2, 3, 4, and 5

 

 

ANS:  D

There are 10 ACEIs available in the U.S. market. ACEIs are the preferred antihypertensives in the setting of systolic dysfunction heart failure, proteinuric kidney disease (diabetic and nondiabetic), and post–myocardial infarction. ACEIs generally decrease systolic and diastolic blood pressure by 15% to 25%. ACEIs are most effective in normal-renin or high-renin hypertension; however, they are also effective in low-renin hypertension, especially when used at maximal doses. ACEIs are effective alone and in combination with other antihypertensive agents, especially thiazide-type diuretics.

 

REF:   p. 372 | p. 373

 

  1. The most common side effect of angiotensin-converting enzyme inhibitors (ACEIs) is
a. persistent dry cough.
b. loss of taste.
c. rash.
d. orthostatic hypotension.

 

 

ANS:  A

The most common ACEI-induced adverse effect is a persistent nonproductive dry cough (20% to 30%). The cough may be due to ACEI-induced accumulation of kinins, prostaglandins, or substance P in the respiratory tract. The cough may develop within days to 1 year after the start of therapy.

 

REF:   p. 375 | p. 376

 

  1. A significant drug interaction occurs between angiotensin-converting enzyme inhibitors (ACEIs) and
a. corticosteroids.
b. loop diuretics.
c. NSAIDs.
d. antibiotics.

 

 

ANS:  C

A significant drug interaction occurs when combining ACEIs with nonsteroidal antiinflammatory drugs (NSAIDs). NSAIDs increase renin release by inhibiting renal vasodilating prostaglandins (PGE2 and PGI2), blunting or negating the antihypertensive effects of ACEIs. NSAIDs less likely to reduce renal prostaglandins and to minimize or circumvent the interaction with ACEIs are sulindac (Clinoril), nabumetone (Relafen), etodolac (Lodine), salsalate (Disalcid), and choline magnesium trisalicylate (Trilisate). ACEIs may increase lithium concentrations and have been associated with life-threatening lithium toxicity. ACEI-induced renal sodium depletion may increase lithium renal tubule reabsorption. Patients receiving this combination should be monitored for symptoms of lithium toxicity, such as nausea, vomiting, diarrhea, tremor, and mental status changes.

 

REF:   p. 375 | p. 376

 

  1. The classes of diuretics include which of the following?
  2. Loops
  3. Potassium-sparing
  4. Osmotics
  5. Thiazides
  6. Carbonic anhydrase inhibitors

 

a. 1 and 4 only
b. 2, 3, and 5 only
c. 1, 2, 4, and 5 only
d. 1, 2, 3, 4, and 5

 

 

ANS:  D

Diuretics are divided into five classes: thiazides and thiazidelike agents, loop diuretics, potassium-sparing agents, carbonic anhydrase inhibitors (e.g., acetazolamide [Diamox]), and osmotics (e.g., mannitol). Thiazides and potassium-sparing agents are the only two classes that are primarily used for the management of hypertension.

 

REF:   p. 381

 

  1. Thiazide diuretics increase excretion of
  2. sodium.
  3. chloride.
  4. calcium.
  5. potassium.
  6. magnesium.

 

a. 1 and 2 only
b. 3, 4, and 5 only
c. 1, 2, 4, and 5 only
d. 1, 2, 3, 4, and 5

 

 

ANS:  C

Thiazide diuretics increase sodium and chloride excretion by interfering with their reabsorption in the distal tubule; a mild diuresis of slightly concentrated urine results. Excretion of potassium, bicarbonate, magnesium, phosphate, and iodide is also increased, and calcium excretion is decreased. Although thiazides decrease extracellular fluid volume, antihypertensive activity is primarily caused by direct vasodilation.

 

REF:   p. 382

 

  1. Lasix and Bumex are
a. thiazide diuretics.
b. loop diuretics.
c. osmotic diuretics.
d. potassium-sparing diuretics.

 

 

ANS:  B

Furosemide (Lasix) and bumetanide (Bumex) are loop diuretics that act principally at the thick ascending limb of the loop of Henle, where they decrease sodium reabsorption by competing for the chloride site on the Na+-K+-2Cl symporter (a transport molecule).

 

REF:   p. 382

 

  1. Which of the following agents reduce total peripheral resistance by a direct action on vascular smooth muscle?
a. Angiotensin blockers
b. Vasodilators
c. Angiotensin-converting enzyme inhibitors
d. Calcium channel blockers

 

 

ANS:  B

The two common vasodilators used in the management of hypertension are hydralazine (Apresoline) and minoxidil (Rogaine, Loniten). Because of their adverse-effect profile, vasodilators are second-line antihypertensive agents. Hydralazine is also indicated for heart failure and has been used for angina. These agents reduce total peripheral resistance by a direct action on vascular smooth muscle, increasing intracellular concentrations of cyclic guanosine 3′,5′-monophosphate (cGMP).

 

REF:   p. 385

 

  1. ________ is a symptom of myocardial ischemia.
a. Peripheral swelling
b. Angina
c. Low oxygen saturation
d. Headache

 

 

ANS:  B

Ischemic heart disease has many clinical variants, such as stable exertional angina; unstable (rest, preinfarction, crescendo) angina; coronary vasomotion; vasospasm associated with atypical, variant, or Prinzmetal’s angina; silent myocardial ischemia; or myocardial infarction. Angina pectoris (chest pain) is a symptom or marker of myocardial ischemia. Ischemia is defined as a lack of oxygen and decreased or no blood flow to the myocardium.

 

REF:   p. 385

 

  1. Nitroglycerin relieves chest pain by
a. decreasing heart rate.
b. increasing force of heart contractions.
c. dilating coronary arteries.
d. constricting coronary arteries.

 

 

ANS:  C

Nitroglycerin reduces myocardial oxygen demand by causing dilation of coronary arteries and collaterals, resulting in decreased end-diastolic pressures.

 

REF:   p. 386

 

  1. Nitrates can be administered by which of the following routes?
  2. Transdermal
  3. Inhalation
  4. Oral
  5. Intravenous
  6. Sublingual

 

a. 1 and 5 only
b. 2 and 3 only
c. 1, 3, 4, and 5 only
d. 1, 2, 3, and 5 only

 

 

ANS:  C

Nitrates may be administered by various routes and are readily available in multiple preparations, including oral, intravenous, ointment, transdermal, translingual, and sublingual tablets.

 

REF:   p. 386

 

  1. All patients with angina should receive what drug for prophylaxis of a myocardial infarction?
a. Heparin
b. Dopamine
c. Lidocaine
d. Aspirin

 

 

ANS:  D

All patients with angina should receive daily aspirin to prevent a myocardial infarction.

 

REF:   p. 386

 

  1. Anticoagulants work by
a. preventing the formation of the fibrin clot.
b. lysing thrombi by degrading fibrin.
c. dilating vessels so that clots are less likely to form.
d. inhibiting the action of platelets.

 

 

ANS:  A

Anticoagulants work by preventing the formation of the fibrin clot and preventing further clot formation in already existing thrombi. Antiplatelet agents inhibit the action of platelets in the initial stage of the clotting process. Thrombolytics break up thrombi by degrading fibrin.

 

REF:   p. 389 | p. 390

 

  1. The most commonly used anticoagulant is
a. warfarin.
b. aspirin.
c. heparin.
d. protamine sulfate.

 

 

ANS:  C

Heparin is commonly used in the treatment or prevention of venous thromboembolism or pulmonary embolism, the treatment of atrial fibrillation with embolization, the diagnosis and treatment of disseminated intravascular coagulation, and the prophylaxis and treatment of peripheral arterial embolism. Dipyridamole and aspirin are antiplatelet agents, and protamine sulfate is the antidote for heparin.

 

REF:   p. 389

 

  1. Aspirin is
a. an anticoagulant.
b. an antiplatelet agent.
c. an analgesic.
d. a thrombolytic.

 

 

ANS:  B

Aspirin is hydrolyzed to salicylic acid and inhibits prostaglandin production by acetylating cyclooxygenase, the initial enzyme in the prostaglandin biosynthesis pathway. This inhibition of platelet aggregation lasts for the life of the platelet, which is approximately 7 to 10 days. By inhibiting platelet aggregation, aspirin increases bleeding times. Low doses of aspirin inhibit platelet aggregation, whereas larger doses inhibit cyclooxygenase in arterial walls, which interferes with prostacyclin production. Prostacyclin is a potent vasodilator and inhibitor of platelet aggregation. Lower doses plausibly may be more effective than higher doses in preventing coronary heart disease; however, this has not been proven clinically.

 

REF:   p. 386

 

  1. Thrombolytic agents should be given ________ in relation to the onset of symptoms.
a. within 12 hours
b. within 2 days
c. within minutes
d. within 1 to 2 weeks

 

 

ANS:  A

Eligible patients should receive thrombolytic therapy within 12 hours of symptom onset; however, benefit can be realized for up to 24 hours. Fibrinolytics are preferred to primary percutaneous coronary intervention (PCI) when patients present within 3 hours of symptom onset and the time to primary PCI will be greater than 90 minutes.

 

REF:   p. 403

 

  1. Thrombolytics restore coronary blood flow by
a. dilating the artery.
b. preventing fibrin clot formation.
c. preventing platelet aggregation.
d. dissolving the thrombus.

 

 

ANS:  D

Thrombolytics reduce the incidence of heart failure and death associated with an acute myocardial infarction and restore coronary blood flow by dissolving the thrombus, limiting the extent of ischemia and necrosis.

 

REF:   p. 403

 

  1. Your 37-year-old patient has an initial blood pressure reading of 160/98 mm Hg. No other readings have been taken since this time. Should he be diagnosed as having hypertension?
a. Yes
b. No

 

 

ANS:  B

Hypertension is diagnosed by the mean of two or more separate seated blood pressure determinations on different days.

 

REF:   p. 372 | p. 373

 

  1. Your 74-year-old patient has a recorded blood pressure of 185/125 mm Hg. He is not currently showing any signs or symptoms of acute organ complications. You would label his condition a
a. hypertensive urgency.
b. hypertensive emergency.
c. hypertensive crisis.
d. both A and C.

 

 

ANS:  D

A patient with blood pressure greater than 180/120 mm Hg is considered to be in a hypertensive crisis. A hypertensive crisis represents either a hypertensive urgency or a hypertensive emergency. Hypertensive urgencies usually signify high blood pressures without signs or symptoms of acute target organ complications, but patients may present with severe headaches, shortness of breath, nosebleeds, or severe anxiety. In these situations, reduction in blood pressure may proceed safely to a stage 1 value with oral antihypertensives over several hours to several days. Oral captopril, clonidine, and labetalol are routinely used to manage hypertensive urgencies. A hypertensive emergency exists when the elevation of blood pressure is accompanied by acute, chronic, or progressing target organ injury.

 

REF:   p. 374

 

  1. Antihypertensive effects of b blockers include
  2. blockade of b receptors on the renal juxtaglomerular cells.
  3. blockade of b receptors in the lungs.
  4. blockade of myocardial b receptors.
  5. blockade of Na+ channels in the luminal membrane of the cells in the distal tubules.
  6. blockade of central nervous system b receptors.

 

a. 1 and 2 only
b. 1, 3, and 5 only
c. 1, 2, 4, and 5 only
d. 1, 2, 3, 4, and 5

 

 

ANS:  B

The antihypertensive effects of b blockers are multimechanistic and are as follows:

  • Blockade of b receptors on the renal juxtaglomerular cells, leading to renin blockade and decreased angiotensin II concentrations.
  • Blockade of myocardial b receptors, leading to decreased cardiac contractility and heart rate, diminishing cardiac output.
  • Blockade of central nervous system b receptors, leading to decreased sympathetic output from the central nervous system and possibly blockade of peripheral b receptors, decreasing norepinephrine concentrations.

 

REF:   p. 380

 

  1. Centrally acting adrenergic agents lower blood pressure by
a. affecting cardiac output.
b. affecting peripheral resistance.
c. neither A nor B.
d. both A and B.

 

 

ANS:  D

Centrally acting adrenergic agents, or a2 agonists, lower blood pressure by affecting both cardiac output and peripheral resistance; they are negative inotropes and chronotropes. a2 agonists stimulate brainstem a2 receptors, resulting in a decrease in sympathetic outflow from the central nervous system. a2 agonists are very effective antihypertensives; however, they are not considered first-line therapy because of their side-effect profile.

 

REF:   p. 383 | p. 384

 

  1. Side effects of centrally acting adrenergic agents include
  2. dry mouth.
  3. constipation.
  4. urinary retention.
  5. blurred vision.
  6. central nervous system side effects.

 

a. 5 only
b. 1, 3, and 5 only
c. 1, 2, 4, and 5 only
d. 1, 2, 3, 4, and 5

 

 

ANS:  D

a2 agonists are very effective antihypertensives; however, they are not considered first-line therapy because of their side-effect profile. They have a high incidence of anticholinergiclike side effects, such as sedation, blurred vision, dry mouth, constipation, and urinary retention, and central nervous system side effects, such as drowsiness, fatigue, headaches, depression, psychosis, and nightmares. Long-term use of these agents results in sodium and fluid retention and almost always necessitates the use of concomitant diuretics; this is especially seen with methyldopa.

 

REF:   p. 384

 

  1. The unmonitored dosing for unfractionated heparin for deep vein thrombosis and pulmonary embolism is
a. bolus of 60 U/kg (maximum 400 U) and then 12 U/kg/hr.
b. 175 U/kg every 24 hours.
c. initial 333 U/kg and then 250 U/kg every 12 hours.
d. 1 mg/kg subcutaneously every 12 hours.

 

 

ANS:  C

The pharmacokinetic properties and dosing parameters for all heparins are depicted in Table 22-12.

 

REF:   p. 389 | p. 390

 

  1. The dose of aspirin for prevention of myocardial infarction is
a. 325 to 650 mg every 4 hours.
b. 50 to 325 mg daily.
c. 81 to 325 mg daily.
d. 500 to 1.5 g daily.

 

 

ANS:  C

The dose of aspirin for its analgesic, antiinflammatory, and antipyretic effects is considered high dose and may be 325 to 650 mg up to every 4 hours daily as needed. The dose of aspirin for its antithrombotic indications is considered low dose; the range for prevention of myocardial infarction is 81 to 325 mg daily, and for prevention of transient ischemic attack/stroke, it is 50 to 325 mg daily. Up to 25% of patients taking aspirin as an antithrombotic may be genetically prone to aspirin resistance, and higher doses may be necessary to overcome resistance (e.g., 500 mg to 1.5 g daily).

 

REF:   p. 399

 

  1. Delayed-onset heparin-induced thrombocytopenia type 2 (HIT-2) is due to
a. congestive heart failure.
b. multiple organ/system failure.
c. cardiovascular disease.
d. formation of antiplatelet antibodies.

 

 

ANS:  D

Early-onset heparin-induced thrombocytopenia type 1 (HIT-1) manifests with a decrease in platelets of approximately 50,000/mm3. The decrease in platelets is transient and inconsequential. Delayed-onset HIT-2 is due to the formation of antiplatelet antibodies between days 6 and 12. If a patient has heparin-dependent antibodies present in plasma from previous heparin exposure, HIT-2 may occur at any time. HIT-2 is dependent on platelet factor 4 binding. These platelet antibodies aggregate and form the basis for the paradoxical heparin-induced white clot syndrome.

 

REF:   p. 392

 

  1. The standard for monitoring warfarin therapy is
a. international normalized ratio (INR).
b. complete blood count.
c. prothrombin time (PT).
d. pulmonary function testing.

 

 

ANS:  A

INR is the standard for monitoring warfarin therapy. PT as a tool for monitoring warfarin therapy is problematic because thromboplastin reagents vary in their responsiveness to warfarin-induced reduction in clotting factors, a variability that depends on their method of preparation. INR is a mathematical correction of the results of the one-stage PT that standardizes the reporting of PT determinations worldwide. INR takes into account the sensitivity of the thromboplastin used in each specific laboratory to determine PT. The target INR range for warfarin in most clinical scenarios is 2 to 3. INR should be used exclusively to dose warfarin clinically; however, PT should be reviewed in conjunction with INR to aid in detecting laboratory errors in calculation or assay methodology.

 

REF:   p. 396

 

  1. Glycoprotein (GP) inhibitors are indicated for the treatment of
  2. acute coronary syndromes.
  3. unstable angina.
  4. deep vein thrombosis.
  5. hypertension.
  6. patients undergoing percutaneous coronary intervention (PCI).

 

a. 5 only
b. 1, 2, and 5 only
c. 1, 2, 4, and 5 only
d. 1, 2, 3, 4, and 5

 

 

ANS:  B

GP IIb/IIIa inhibitors are indicated for the treatment of patients with acute coronary syndromes (unstable angina or non–ST segment elevation acute myocardial infarction), patients who are medically managed, and patients undergoing PCI. Abciximab (ReoPro) is the GP IIb/IIIa inhibitor of choice for PCI. The management of unstable angina or non–ST segment elevation acute myocardial infarction includes the use of aspirin, heparin, and a GP IIb/IIIa inhibitor.

 

REF:   p. 397

 

  1. The most common adverse effect associated with thrombolytic agents is
a. dry mouth.
b. heparin-induced thrombocytopenia type 2.
c. cardiovascular disease.
d. bleeding.

 

 

ANS:  D

The most common adverse effects associated with thrombolytic agents are major and minor bleeding. Sites of major bleeding include gastrointestinal, genitourinary, respiratory tract, retroperitoneal, and intracranial hemorrhage. Minor bleeding often manifests as superficial or surface bleeding as a result of arterial punctures and surgical intervention.

 

REF:   p. 404

 

  1. Novo Seven initiates thrombin generation by activating factor
a. V.
b. VII.
c. VIII.
d. X.

 

 

ANS:  D

Recombinant factor VIIa (Novo Seven) initiates thrombin generation by activating factor X, thus promulgating the coagulation cascade. PCCs are concentrated pooled plasma products that typically contain clotting factors. These factors are generally not activated and will require activation via the coagulation cascade.

 

REF:   p. 390

 

  1. What is Kcentra indicated for?
a. Diuresis
b. Urgent reversal of warfarin
c. Hypertensive crisis
d. Angina

 

 

ANS:  B

In 2013, the U.S. FDA approved the four-factor PCC (Kcentra) for the urgent reversal of warfarin anticoagulation in adults with acute major bleeding. Like plasma, Kcentra is used in conjunction with the administration of vitamin K to reverse the anticoagulation effect and stop the bleeding. Unlike the plasma counterpart, Kcentra does not require blood group typing or thawing, adding the additional advantage for dosing convenience and ease. Kcentra dosing is individualized based on the pretreatment INR.

 

REF:   p. 397

 

  1. Disease conditions and medications that cause hypertension include which of the following?
  2. Cushing’s syndrome
  3. Hypothyroidism
  4. Pheochromocytoma
  5. Amphetamines
  6. Pseudoephedrine

 

a. 1, 2, and 5 only
b. 1, 4, and 5 only
c. 1, 3, 4, and 5 only
d. 1, 2, 3, 4, and 5

 

 

ANS:  C

Disease-induced causes of hypertension include Cushing syndrome, hyperparathyroidism, hyperthyroidism, pheochromocytoma, primary aldosteronism, and kidney disease. Drug-induced causes of hypertension include amphetamines, corticosteroids, cyclosporine, erythropoietin, estrogens, nonsteroidal antiinflammatory drugs (NSAIDs) including cyclooxygenase-1 inhibitors (e.g., ibuprofen and naproxen) and cyclooxygenase-2 inhibitors (e.g., celecoxib), pseudoephedrine, sibutramine, tacrolimus, venlafaxine, high sodium–containing over-the-counter (OTC) products (e.g., Alka-Seltzer effervescent antacid tablets), OTC weight loss products (e.g., ephedrine-containing diet pills), and chronic alcohol ingestion.

 

REF:   p. 374

 

  1. Vascular smooth muscle and cardiac cell contraction is dependent on
a. the free extracellular calcium ion concentration.
b. the free intracellular calcium ion concentration.
c. the free extracellular potassium ion concentration.
d. the free intracellular potassium ion concentration.

 

 

ANS:  B

Vascular smooth muscle and cardiac cell contraction is dependent on the free intracellular calcium ion concentration.

 

REF:   p. 378

 

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