Chapter 12 - Administer Medications and Specialty Gases Flashcards Preview

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Flashcards in Chapter 12 - Administer Medications and Specialty Gases Deck (20)
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1

A physician orders a 70% He/30% O2 mixture to be delivered to a patient having an acute asthmatic attack. Which of the following systems would be most appropriate to deliver this mixture?

  1. nebulizer set at 100% oxygen with aerosol mask
  2. tight-fitting nonrebreathing mask with competent valving
  3. simple oxygen mask set to deliver 15 L/min oxygen
  4. tight-fitting partial rebreathing mask at 12 L/min

2

Because a tight-fitting nonrebreathing mask with competent valving and set at the appropriate flow rate can deliver close to 100% source gas, it approximates the characteristics of a fixed-performance delivery system. For this reason, the well-designed nonrebreather is the system of choice for short-term administration of high concentrations of O2, as well as other premixed therapeutic gases. Alternatively, a high flow nasal cannula can be used to deliver heliox.

2

A physician orders 2.5 mL (1.0 mg/mL) dornase alpha (Pulmozyme) via aerosol once per day for a 12-year-old cystic fibrosis patient with purulent secretions. Which of the following methods would you use to deliver this drug?

  1. standard drug nebulizer with aerosol mask
  2. breath-actuated drug nebulizer with mouthpiece
  3. standard drug nebulizer with mouthpiece
  4. breath-actuated drug nebulizer with aerosol mask

2

Only certain drug nebulizers are FDA approved for administration of dornase alpha (Pulmozyme). These include breath-actuated nebulizers (e.g., the Pari LC Plus or Star) or specialized jet nebulizers (e.g., the Sidestream or Acorn II nebulizer) driven by compressors capable of generating at least 35 to 45 psig. Due to the high cost of dornase alpha and the need to minimize its wastage, masks are not used for delivery of this drug, except to babies.

3

A physician has ordered albuterol (Proventil) and deoxyribonuclease (DNase) by aerosol for a cystic fibrosis patient who also receives postural drainage TID. You should administer these therapies in which of the following sequences?

  1. deoxyribonuclease (DNase), postural drainage, albuterol (Proventil)
  2. albuterol (Proventil), deoxyribonuclease (DNase), postural drainage
  3. postural drainage, albuterol (Proventil), deoxyribonuclease (DNase)
  4. deoxyribonuclease (DNase), albuterol (Proventil), postural drainage

2

When a doctor orders a combination of therapies aimed at either getting drugs (steroids, antibiotics) in or getting secretions out of the airway, you should generally perform them in the follow order: (1) therapies to open the airways; (2) therapies to thin or break down the secretions, and (3) therapies to help mobilize and remove the secretions. In this case that would mean given the bronchodilator first (Proventil), followed by the mucolytic agent (DNase), followed by the clearance procedure (postural drainage).

4

An adult patient is prescribed steroid administration via an MDI formulation. To help minimize pharyngeal deposition of the drug, which of the following would you recommend?

  1. have the patient use a holding chamber with the MDI
  2. have the patient use the closed mouth technique
  3. have the patient inhale the mist as rapidly as possible
  4. have the patient use a breath-actuated MDI with mask

1

Patients prescribed steroids by MDI should use either a spacer or valved holding chamber in order to minimize pharyngeal deposition. This can help reduce the risk of topical side effects such as thrush.

5

The recommended initial dose of inhaled nitric oxide (INO) is:

  1. 2 ppm
  2. 20 ppm
  3. 200 ppm
  4. 0.02

2

INO is approved for the treatment of term and near-term (>34 weeks) neonates with hypoxemic respiratory failure associated with persistent pulmonary hypertension of the newborn (PPHN). The recommended initial dose of inhaled nitric oxide is 20 parts per million, ppm but can often be quickly reduced to 5–6 ppm.

6

A doctor prescribes heliox therapy for a patient admitted to the Emergency Department with an acute exacerbation of asthma. A full cylinder of 70% helium and 30% O2 is at the bedside with a standard nasal cannula attached. You should:

  1. administer the therapy with the cannula as ordered
  2. administer the therapy and then draw an ABG
  3. obtain a nonrebreathing mask and administer the therapy
  4. obtain a venturi mask and administer the therapy

3

Because helium is so highly diffusible, helium/oxygen mixtures must be administered via closed or semi-closed systems. Administration of helium/oxygen mixtures via a low-flow system like a standard nasal cannula will cause significant air dilution and make the therapy ineffective. A specialized high-flow cannula can prevent most air dilution and is a good alternative to a nonrebreathing mask if available.

7

A patient is prescribed Triamcinolone acetonide (Azmacort) via MDI 2 puffs TID. To decrease the likelihood of oral candidiasis, you would recommend that the patient:

  1. be prescribed an appropriate antibiotic
  2. decrease the frequency of inhalations to BID
  3. rinse her mouth and gargle with water after inhalation
  4. receive concurrent bronchodilator therapy

3

Oral candidiasis (thrush) is a potential adverse effect of aerosolized steroids. This problem can be easily avoided by having the patient thoroughly rinse his or her mouth and gargling with water following MDI inhalation.

8

The administration of what drug is most appropriate to thin secretions and help in the removal of a mucous plug?

  1. albuterol
  2. ipratropium bromide
  3. acetylcysteine
  4. racemic epinephrine

3

Acetylcysteine (Mucomyst) breaks the disulfide bonds in mucous, thereby helping thin and mobilize secretions in patients with mucous plugs. It can be administered by aerosol or by direct instillation via a bronchoscope. Albuterol and racemic epinephrine are adrenergic agents that cause bronchodilation (albuterol) or vasoconstriction (racemic epi). Ipratropium bromide is an anticholinergic drug, also used to promote bronchodilation.

9

The most important property of helium with respect to its use in helium-oxygen therapy is its:

  1. density
  2. viscosity
  3. flammability
  4. specific gravity

1

The most important property of helium with respect to its use in helium-oxygen therapy is its density. The low density of helium-oxygen mixtures lowers the pressure difference needed to move gas through narrowed air passages (large airways), thus decreasing the work of breathing.

10

You are instructing an 8-year-old boy with asthma on the use of an albuterol MDI. What can be done to increase the deposition of the bronchodilator?

  1. Add a spacer or holding chamber to the MDI
  2. Have the child inhale the as quickly as possible
  3. Switch from an MDI to a small volume nebulizer
  4. Remove the mouthpiece from the MDI

1

Spacers and holding chambers can help increase MDI pulmonary drug deposition. Deposition is improved because (1) less patient coordination is required, (2) particle velocity and size (MMD) decrease (large particles impact in the spacer/holding chamber), and (3) less drug deposits occurs in the pharynx.

11

When given a physician’s order to administer 2.0 mL of 0.5% albuterol (Proventil) to an adult via SVN, you should do which of the following?

  1. check the patient's ID band and then deliver the treatment
  2. substitute levalbuterol (Xopenex) for the albuterol (Proventil)
  3. monitor the patient's pulse and then deliver the treatment
  4. contact the physician and clarify the order

4

First, all therapy orders should be verified before administration. Second, this order is questionable since the dosage is 4x the normal for albuterol by SVN. For these reasons it would be mandatory to contact the physician's and clarify the order.

12

After withdrawal from inhaled nitric oxide (NO) therapy, an infant suddenly becomes hemodynamically unstable. You should:

  1. return the infant to the prior NO dosage
  2. recommend administration of vasodilators
  3. decrease to FIO2 to the lowest level tolerable
  4. initiate rapid chest compressions

1

During weaning or immediately after withdrawing NO, some patients can becomes hemodynamically unstable and/or develop severe hypoxemia. The best solution in these cases is to restore the NO therapy at the level previously being administered. Additional hemodynamic support (e.g., vasopressors) and supplemental oxygen may also be necessary, as well as close patient monitoring.

13

Before giving your patient an aerosol treatment with racemic epinephrine for laryngeal edema, you check his vital signs. His pulse rate is 85/min and respiratory rate is 16/min. Five minutes into the treatment, his pulse rate climbs to 135/min and his respiratory rate rises to 29/min. What is the best action in this case?

  1. continue the treatment as ordered to completion
  2. switch to albuterol (Proventil) and continue the treatment
  3. stop the treatment, monitor the patient, and contact the physician
  4. ask the patient’s nurse what action she would recommend

3

The significant rise in heart rate (over 50%) suggests that the patient is experiencing an adverse reaction to the racemic epinephrine. For this reason, the therapy should be stopped, the patient stabilized and the physician contacted.

14

A physician has ordered administration of a steroid available only in a metered dose (MDI) preparation. In training the patient in its use, you cannot get her to coordinate MDI discharge with her breathing. Which of the following actions would be appropriate?

  1. recommend discontinuing the treatments
  2. add a spacer or holding chamber to the MDI
  3. suggest an oral steroid instead of the MDI preparation
  4. recommend a bronchodilator via SVN

2

Two techniques can be used to aid proper application of MDI aerosols: extension devices (spacers and holding chambers) and breath-triggered systems. Extension devices minimize aerosol loss and maximize propellant evaporation, thereby increasing stability and penetration. Breath-triggered systems synchronize MDI discharge with the patient's inspiration, thereby requiring less patient coordination.

15

 

Which of the following gas concentrations must be monitored during inhaled nitric oxide (NO) therapy

 


                NO                 NO2                      O2

A             Yes                 Yes                   No

B             Yes                 No                    Yes

C             No                  Yes                   Yes

D             Yes                Yes                    No

  1. A
  2. B
  3. C
  4. D

4

When nitric oxide (NO) comes in contact with oxygen, the toxic gas nitrogen dioxide (NO2) is produced. NO2 levels should not exceed 2-3 ppm. For this reasons, Nitric oxide therapy systems must continuously monitor not only NO and O2 levels, but also NO2 levels. Alarms are used to detect excessive levels of nitric oxide and NO2, or undesired changes in FIO2.

16

Which of the following measurements done before and after treatment would best determine the effectiveness of an aerosolized albuterol (Proventil) administered to an asthmatic patient?

  1. arterial blood gas analysis
  2. maximum inspiratory pressure (MIP)
  3. forced expiratory volume (FEV) 
  4. vital capacity

3

When monitoring the effectiveness of a bronchodilator treatment pre- and post-FEV1 measurements should be obtained. The highest pre/post results should be use to calculate percent change (%Δ) or percent improvement. A change of at least 12% indicates a significant improvement in airway caliber. If no improvement is seen, you may want to recommend a change in bronchodilator, or its dose or frequency of administration.

17

You are working with a confused elderly patient who has atelectasis and is ordered to receive an aerosolized bronchodilator for bronchospasm. Which of the following delivery methods would you choose?

  1. use a small volume nebulizer + mask
  2. use a dry powder inhaler (DPI)
  3. use an MDI + incentive spirometry
  4. use a small volume nebulizer + CPAP

4

This patient's confused state suggests that cooperation is unlikely (ruling out the DPI and the incentive spirometry). Although a small volume nebulizer + mask would be acceptable for bronchodilator deliver to this patient, he also has atelectasis. The best way to treat both the atelectasis and the bronchospasm is to combine bronchodilator therapy with lung expansion therapy, such as CPAP or BiPAP. Among these options CPAP is a good choice since it would require the least patient cooperation.

18

Which of the following would be the most important data utilized to assess a patient's ability to perform metered dose inhaler (MDI) aerosol therapy?

  1. overall general appearance
  2. stable vital signs
  3. exercise tolerance
  4. capacity to follow instructions

4

To perform complex tasks such as using an MDI correctly, a patient must be fully oriented and able to follow instructions.

19

The only medical indication for the use of helium/oxygen mixtures is in the management of:

  1. small airway obstruction
  2. restrictive diseases
  3. large airway obstruction
  4. diffusion defects

3

Wherever the flow pattern is turbulent (mainly in the large airways), substituting a low density helium mixture for higher density air or O2 encourages laminar flow. Because less pressure is required to move a gas at a given velocity under conditions of laminar flow, breathing a helium mixture will reduce the work of breathing associated with obstruction in the large airways.

20

A doctor prescribes heliox therapy for a patient admitted to the Emergency Department with an acute exacerbation of asthma. A full cylinder of 70% helium and 30% O2 is at the bedside with a standard nasal cannula attached. You should:

  1. administer the therapy with the cannula as ordered
  2. administer the therapy and then draw an ABG
  3. obtain a nonrebreathing mask and administer the therapy
  4. obtain a venturi mask and administer the therapy

3

Because helium is so highly diffusible, helium/oxygen mixtures must be administered via closed or semi-closed systems (such as a non-rebreather mask). Administration of helium/oxygen mixtures via a low-flow system like a standard nasal cannula will cause significant air dilution and make the therapy ineffective. A specialized high-flow cannula can prevent most air dilution and is a good alternative to a nonrebreathing mask if available.