Exam Instructions
• Each question has FOUR answer choices. Select the ONE BEST answer.
• Correct answer and rationale appear below each question for self-study review.
• Chapters covered: 48, 49, 64, 67, 68, 71, 79 (Lehne's Pharmacotherapeutics).
Question 1. A patient with persistent asthma asks why the provider prescribed an
inhaled glucocorticoid rather than a short-acting beta-2 agonist (SABA) for daily use.
Which response by the nurse practitioner is most accurate?
A. SABAs are more expensive and therefore avoided for long-term use.
B. Inhaled glucocorticoids address the underlying airway inflammation that drives asthma
symptoms and are first-line therapy for persistent asthma.
C. SABAs cause permanent bronchial remodeling when used daily.
D. Inhaled glucocorticoids also act as rescue inhalers for acute attacks.
✔Correct Answer: B. Inhaled glucocorticoids address the underlying airway inflammation
that drives asthma symptoms and are first-line therapy for persistent asthma.
Rationale: Inhaled glucocorticoids are the cornerstone of long-term asthma management because
they suppress airway inflammation, the underlying pathology. SABAs provide bronchodilation for
quick relief but do not alter the inflammatory process. Cost and remodeling are not primary reasons
for choosing glucocorticoids over SABAs for maintenance.
Question 2. Which adverse effect is MOST commonly associated with inhaled
glucocorticoids used for asthma management?
A. Adrenal suppression requiring hospitalization.
B. Oropharyngeal candidiasis and dysphonia.
C. Significant bone loss within the first month of treatment.
D. Hyperglycemia requiring insulin therapy.
✔Correct Answer: B. Oropharyngeal candidiasis and dysphonia.
Rationale: The most common adverse effects of inhaled glucocorticoids are oropharyngeal
candidiasis (thrush) and dysphonia (hoarseness), both resulting from local deposition of steroid in the
oropharynx. Patients should rinse the mouth and gargle after each use. Adrenal suppression and
bone loss can occur with long-term, high-dose therapy but are not the most common effects.
Question 3. A patient using an MDI is told to use a spacer device. What is the
PRIMARY benefit of adding a spacer to an MDI?
A. The spacer converts the drug to a dry powder, which is better absorbed.
B. Spacers store medication doses, allowing administration without the inhaler present.
1
, C. Spacers increase drug delivery to the lungs and decrease deposition on the oropharyngeal
mucosa.
D. Spacers eliminate the need for the patient to inhale slowly and deeply.
✔Correct Answer: C. Spacers increase drug delivery to the lungs and decrease deposition
on the oropharyngeal mucosa.
Rationale: Spacer devices attach directly to the MDI and improve delivery by slowing the aerosol
cloud, allowing smaller particles to reach the lungs (increasing lung deposition from ~9% to ~21%)
while decreasing oropharyngeal deposition from ~81% to ~22%. They also reduce the need for
perfect hand-breath coordination.
Question 4. A prescriber orders salmeterol (Serevent Diskus) for a patient with asthma
who is not adequately controlled on an inhaled glucocorticoid alone. Which statement
about salmeterol use in asthma is correct?
A. Salmeterol can replace inhaled glucocorticoids in patients with mild persistent asthma.
B. Salmeterol is preferred over SABAs for quick relief of acute bronchospasm.
C. When used for asthma, salmeterol must always be combined with an inhaled glucocorticoid.
D. Salmeterol is first-line bronchodilator therapy for newly diagnosed asthma.
✔Correct Answer: C. When used for asthma, salmeterol must always be combined with an
inhaled glucocorticoid.
Rationale: Long-acting beta-2 agonists (LABAs) such as salmeterol carry a black box warning:
monotherapy in asthma has been associated with increased asthma-related deaths. Therefore, when
used in asthma, LABAs must always be combined with an inhaled glucocorticoid, ideally in the same
inhaler device. They are not for acute attacks and are not first-line therapy.
Question 5. Montelukast (Singulair) is prescribed for a 10-year-old child with mild
persistent asthma. Which neuropsychiatric adverse effect requires monitoring with this
drug?
A. Tardive dyskinesia and extrapyramidal symptoms.
B. Suicidal ideation, depression, and abnormal dreams.
C. Opioid-like sedation and respiratory depression.
D. Hallucinations exclusively associated with zileuton but not montelukast.
✔Correct Answer: B. Suicidal ideation, depression, and abnormal dreams.
Rationale: Postmarketing reports link leukotriene modifiers — including montelukast, zafirlukast, and
zileuton — to neuropsychiatric effects such as depression, mood changes, suicidal thinking, abnormal
dreams, and agitation. Parents and patients should be counseled to report any behavioral changes.
These effects are rare but important.
Question 6. A patient with COPD is being started on tiotropium (Spiriva). Which
pharmacologic classification does tiotropium belong to?
A. Short-acting beta-2 agonist (SABA).
B. Inhaled glucocorticoid.
C. Long-acting muscarinic antagonist (LAMA).
D. Phosphodiesterase-4 inhibitor.
✔Correct Answer: C. Long-acting muscarinic antagonist (LAMA).
2
, Rationale: Tiotropium is a long-acting muscarinic antagonist (LAMA), also classified as a long-acting
anticholinergic. It blocks muscarinic receptors in the bronchi, reducing bronchoconstriction. LAMAs
are preferred for stable COPD management. Ipratropium is the short-acting anticholinergic equivalent.
Question 7. Which inhaled device is breath-activated, requires no hand-breath
coordination, and delivers a higher percentage of drug to the lungs compared with a
standard MDI?
A. Soft mist inhaler (SMI).
B. Dry powder inhaler (DPI).
C. Metered-dose inhaler (MDI) with spacer.
D. Traditional jet nebulizer.
✔Correct Answer: B. Dry powder inhaler (DPI).
Rationale: Dry powder inhalers (DPIs) are breath-activated, eliminating the need for hand-breath
coordination required by MDIs. DPIs deliver approximately 20% of the total dose to the lungs versus
~10% for MDIs. However, they require the patient to inhale quickly and deeply, which can be
challenging for very young children or patients with advanced disease.
Question 8. A patient taking zileuton (Zyflo) for asthma is also prescribed theophylline.
Which drug interaction concern is MOST important to address?
A. Zileuton accelerates theophylline metabolism, causing subtherapeutic levels.
B. Zileuton inhibits CYP1A2, slowing theophylline metabolism and potentially causing toxic
theophylline levels.
C. Combined use increases the risk for oropharyngeal candidiasis.
D. Theophylline blocks the leukotriene-synthesis inhibition of zileuton.
✔Correct Answer: B. Zileuton inhibits CYP1A2, slowing theophylline metabolism and
potentially causing toxic theophylline levels.
Rationale: Zileuton inhibits CYP1A2 isoenzymes. Because theophylline is a CYP1A2 substrate,
concurrent use with zileuton can markedly increase theophylline plasma levels, raising the risk for
theophylline toxicity (nausea, vomiting, seizures, dysrhythmias). Theophylline dosage should be
reduced when zileuton is added.
Question 9. Omalizumab (Xolair) is prescribed for a 16-year-old with moderate-to-
severe allergic asthma. Which action MUST be taken before initiating omalizumab
therapy?
A. Obtain a baseline chest radiograph to rule out COPD.
B. Perform a skin or blood test to confirm allergen reactivity, as the drug only benefits patients with
allergen-driven asthma.
C. Start an oral glucocorticoid course for 10 days to reduce baseline inflammation.
D. Administer a test dose of ipratropium to assess anticholinergic tolerance.
✔Correct Answer: B. Perform a skin or blood test to confirm allergen reactivity, as the drug
only benefits patients with allergen-driven asthma.
Rationale: Omalizumab works by antagonizing IgE and is effective only in patients whose asthma is
driven by a specific allergen. Therefore, allergen reactivity must be confirmed via skin testing or blood
test before initiating therapy. The drug cannot benefit patients without demonstrable allergen-
mediated disease.
3
, Question 10. A patient is transitioning from oral prednisone to an inhaled
glucocorticoid for asthma management. The nurse practitioner explains that the
transition must be done gradually. Why is this important?
A. Abrupt cessation of inhaled glucocorticoids causes rebound bronchospasm.
B. Prolonged systemic glucocorticoid use suppresses adrenocortical function, and abrupt
discontinuation can be life-threatening due to adrenal insufficiency.
C. Oral prednisone has antiviral properties that the inhaled steroid lacks, requiring overlap.
D. Inhaled glucocorticoids take 6 months to begin working and require oral steroid bridging.
✔Correct Answer: B. Prolonged systemic glucocorticoid use suppresses adrenocortical
function, and abrupt discontinuation can be life-threatening due to adrenal insufficiency.
Rationale: Prolonged systemic glucocorticoid therapy suppresses endogenous glucocorticoid
production by the adrenal cortex (adrenal suppression). Abruptly stopping oral glucocorticoids — such
as when switching to an inhaled route — can precipitate adrenal crisis because the adrenal glands
cannot immediately resume endogenous production. The oral dose must be tapered gradually.
Several months are needed for adrenocortical recovery.
Question 11. A patient with COPD is prescribed roflumilast (Daliresp). Which statement
about this drug is correct?
A. Roflumilast is a first-line bronchodilator approved for both asthma and COPD.
B. Roflumilast is a phosphodiesterase-4 inhibitor approved only for COPD, used to reduce
exacerbations in severe disease with chronic bronchitis.
C. Roflumilast is a LABA that must be combined with an inhaled steroid.
D. Roflumilast is contraindicated in patients with depression because it causes euphoria.
✔Correct Answer: B. Roflumilast is a phosphodiesterase-4 inhibitor approved only for
COPD, used to reduce exacerbations in severe disease with chronic bronchitis.
Rationale: Roflumilast (Daliresp) is a selective PDE4 inhibitor approved only for COPD — not
asthma. It is used as add-on therapy to reduce exacerbation risk in patients with severe COPD with a
primary chronic bronchitis component and a history of frequent exacerbations. It should be used with
caution in patients with depression, as it may worsen mood.
Question 12. Which criterion confirms a diagnosis of COPD using spirometry?
A. FEV1 less than 80% of predicted, measured before bronchodilator administration.
B. Post-bronchodilator FEV1/FVC ratio less than 0.70.
C. Peak expiratory flow less than 60% of personal best.
D. Total lung capacity greater than 120% of predicted.
✔Correct Answer: B. Post-bronchodilator FEV1/FVC ratio less than 0.70.
Rationale: A diagnosis of COPD requires a post-bronchodilator FEV1/FVC ratio of less than 0.70.
This confirms the presence of persistent airflow obstruction. The FEV1 percentage of predicted is
used to classify severity once the diagnosis is established but is not itself the diagnostic criterion.
Question 13. A patient using albuterol (ProAir HFA) requires the SABA more than twice
a week to control symptoms. What is the appropriate clinical action?
A. Increase the albuterol dose to 4 inhalations per use.
B. Step up therapy, as needing a rescue inhaler more than twice a week indicates inadequate
asthma control.
4
• Each question has FOUR answer choices. Select the ONE BEST answer.
• Correct answer and rationale appear below each question for self-study review.
• Chapters covered: 48, 49, 64, 67, 68, 71, 79 (Lehne's Pharmacotherapeutics).
Question 1. A patient with persistent asthma asks why the provider prescribed an
inhaled glucocorticoid rather than a short-acting beta-2 agonist (SABA) for daily use.
Which response by the nurse practitioner is most accurate?
A. SABAs are more expensive and therefore avoided for long-term use.
B. Inhaled glucocorticoids address the underlying airway inflammation that drives asthma
symptoms and are first-line therapy for persistent asthma.
C. SABAs cause permanent bronchial remodeling when used daily.
D. Inhaled glucocorticoids also act as rescue inhalers for acute attacks.
✔Correct Answer: B. Inhaled glucocorticoids address the underlying airway inflammation
that drives asthma symptoms and are first-line therapy for persistent asthma.
Rationale: Inhaled glucocorticoids are the cornerstone of long-term asthma management because
they suppress airway inflammation, the underlying pathology. SABAs provide bronchodilation for
quick relief but do not alter the inflammatory process. Cost and remodeling are not primary reasons
for choosing glucocorticoids over SABAs for maintenance.
Question 2. Which adverse effect is MOST commonly associated with inhaled
glucocorticoids used for asthma management?
A. Adrenal suppression requiring hospitalization.
B. Oropharyngeal candidiasis and dysphonia.
C. Significant bone loss within the first month of treatment.
D. Hyperglycemia requiring insulin therapy.
✔Correct Answer: B. Oropharyngeal candidiasis and dysphonia.
Rationale: The most common adverse effects of inhaled glucocorticoids are oropharyngeal
candidiasis (thrush) and dysphonia (hoarseness), both resulting from local deposition of steroid in the
oropharynx. Patients should rinse the mouth and gargle after each use. Adrenal suppression and
bone loss can occur with long-term, high-dose therapy but are not the most common effects.
Question 3. A patient using an MDI is told to use a spacer device. What is the
PRIMARY benefit of adding a spacer to an MDI?
A. The spacer converts the drug to a dry powder, which is better absorbed.
B. Spacers store medication doses, allowing administration without the inhaler present.
1
, C. Spacers increase drug delivery to the lungs and decrease deposition on the oropharyngeal
mucosa.
D. Spacers eliminate the need for the patient to inhale slowly and deeply.
✔Correct Answer: C. Spacers increase drug delivery to the lungs and decrease deposition
on the oropharyngeal mucosa.
Rationale: Spacer devices attach directly to the MDI and improve delivery by slowing the aerosol
cloud, allowing smaller particles to reach the lungs (increasing lung deposition from ~9% to ~21%)
while decreasing oropharyngeal deposition from ~81% to ~22%. They also reduce the need for
perfect hand-breath coordination.
Question 4. A prescriber orders salmeterol (Serevent Diskus) for a patient with asthma
who is not adequately controlled on an inhaled glucocorticoid alone. Which statement
about salmeterol use in asthma is correct?
A. Salmeterol can replace inhaled glucocorticoids in patients with mild persistent asthma.
B. Salmeterol is preferred over SABAs for quick relief of acute bronchospasm.
C. When used for asthma, salmeterol must always be combined with an inhaled glucocorticoid.
D. Salmeterol is first-line bronchodilator therapy for newly diagnosed asthma.
✔Correct Answer: C. When used for asthma, salmeterol must always be combined with an
inhaled glucocorticoid.
Rationale: Long-acting beta-2 agonists (LABAs) such as salmeterol carry a black box warning:
monotherapy in asthma has been associated with increased asthma-related deaths. Therefore, when
used in asthma, LABAs must always be combined with an inhaled glucocorticoid, ideally in the same
inhaler device. They are not for acute attacks and are not first-line therapy.
Question 5. Montelukast (Singulair) is prescribed for a 10-year-old child with mild
persistent asthma. Which neuropsychiatric adverse effect requires monitoring with this
drug?
A. Tardive dyskinesia and extrapyramidal symptoms.
B. Suicidal ideation, depression, and abnormal dreams.
C. Opioid-like sedation and respiratory depression.
D. Hallucinations exclusively associated with zileuton but not montelukast.
✔Correct Answer: B. Suicidal ideation, depression, and abnormal dreams.
Rationale: Postmarketing reports link leukotriene modifiers — including montelukast, zafirlukast, and
zileuton — to neuropsychiatric effects such as depression, mood changes, suicidal thinking, abnormal
dreams, and agitation. Parents and patients should be counseled to report any behavioral changes.
These effects are rare but important.
Question 6. A patient with COPD is being started on tiotropium (Spiriva). Which
pharmacologic classification does tiotropium belong to?
A. Short-acting beta-2 agonist (SABA).
B. Inhaled glucocorticoid.
C. Long-acting muscarinic antagonist (LAMA).
D. Phosphodiesterase-4 inhibitor.
✔Correct Answer: C. Long-acting muscarinic antagonist (LAMA).
2
, Rationale: Tiotropium is a long-acting muscarinic antagonist (LAMA), also classified as a long-acting
anticholinergic. It blocks muscarinic receptors in the bronchi, reducing bronchoconstriction. LAMAs
are preferred for stable COPD management. Ipratropium is the short-acting anticholinergic equivalent.
Question 7. Which inhaled device is breath-activated, requires no hand-breath
coordination, and delivers a higher percentage of drug to the lungs compared with a
standard MDI?
A. Soft mist inhaler (SMI).
B. Dry powder inhaler (DPI).
C. Metered-dose inhaler (MDI) with spacer.
D. Traditional jet nebulizer.
✔Correct Answer: B. Dry powder inhaler (DPI).
Rationale: Dry powder inhalers (DPIs) are breath-activated, eliminating the need for hand-breath
coordination required by MDIs. DPIs deliver approximately 20% of the total dose to the lungs versus
~10% for MDIs. However, they require the patient to inhale quickly and deeply, which can be
challenging for very young children or patients with advanced disease.
Question 8. A patient taking zileuton (Zyflo) for asthma is also prescribed theophylline.
Which drug interaction concern is MOST important to address?
A. Zileuton accelerates theophylline metabolism, causing subtherapeutic levels.
B. Zileuton inhibits CYP1A2, slowing theophylline metabolism and potentially causing toxic
theophylline levels.
C. Combined use increases the risk for oropharyngeal candidiasis.
D. Theophylline blocks the leukotriene-synthesis inhibition of zileuton.
✔Correct Answer: B. Zileuton inhibits CYP1A2, slowing theophylline metabolism and
potentially causing toxic theophylline levels.
Rationale: Zileuton inhibits CYP1A2 isoenzymes. Because theophylline is a CYP1A2 substrate,
concurrent use with zileuton can markedly increase theophylline plasma levels, raising the risk for
theophylline toxicity (nausea, vomiting, seizures, dysrhythmias). Theophylline dosage should be
reduced when zileuton is added.
Question 9. Omalizumab (Xolair) is prescribed for a 16-year-old with moderate-to-
severe allergic asthma. Which action MUST be taken before initiating omalizumab
therapy?
A. Obtain a baseline chest radiograph to rule out COPD.
B. Perform a skin or blood test to confirm allergen reactivity, as the drug only benefits patients with
allergen-driven asthma.
C. Start an oral glucocorticoid course for 10 days to reduce baseline inflammation.
D. Administer a test dose of ipratropium to assess anticholinergic tolerance.
✔Correct Answer: B. Perform a skin or blood test to confirm allergen reactivity, as the drug
only benefits patients with allergen-driven asthma.
Rationale: Omalizumab works by antagonizing IgE and is effective only in patients whose asthma is
driven by a specific allergen. Therefore, allergen reactivity must be confirmed via skin testing or blood
test before initiating therapy. The drug cannot benefit patients without demonstrable allergen-
mediated disease.
3
, Question 10. A patient is transitioning from oral prednisone to an inhaled
glucocorticoid for asthma management. The nurse practitioner explains that the
transition must be done gradually. Why is this important?
A. Abrupt cessation of inhaled glucocorticoids causes rebound bronchospasm.
B. Prolonged systemic glucocorticoid use suppresses adrenocortical function, and abrupt
discontinuation can be life-threatening due to adrenal insufficiency.
C. Oral prednisone has antiviral properties that the inhaled steroid lacks, requiring overlap.
D. Inhaled glucocorticoids take 6 months to begin working and require oral steroid bridging.
✔Correct Answer: B. Prolonged systemic glucocorticoid use suppresses adrenocortical
function, and abrupt discontinuation can be life-threatening due to adrenal insufficiency.
Rationale: Prolonged systemic glucocorticoid therapy suppresses endogenous glucocorticoid
production by the adrenal cortex (adrenal suppression). Abruptly stopping oral glucocorticoids — such
as when switching to an inhaled route — can precipitate adrenal crisis because the adrenal glands
cannot immediately resume endogenous production. The oral dose must be tapered gradually.
Several months are needed for adrenocortical recovery.
Question 11. A patient with COPD is prescribed roflumilast (Daliresp). Which statement
about this drug is correct?
A. Roflumilast is a first-line bronchodilator approved for both asthma and COPD.
B. Roflumilast is a phosphodiesterase-4 inhibitor approved only for COPD, used to reduce
exacerbations in severe disease with chronic bronchitis.
C. Roflumilast is a LABA that must be combined with an inhaled steroid.
D. Roflumilast is contraindicated in patients with depression because it causes euphoria.
✔Correct Answer: B. Roflumilast is a phosphodiesterase-4 inhibitor approved only for
COPD, used to reduce exacerbations in severe disease with chronic bronchitis.
Rationale: Roflumilast (Daliresp) is a selective PDE4 inhibitor approved only for COPD — not
asthma. It is used as add-on therapy to reduce exacerbation risk in patients with severe COPD with a
primary chronic bronchitis component and a history of frequent exacerbations. It should be used with
caution in patients with depression, as it may worsen mood.
Question 12. Which criterion confirms a diagnosis of COPD using spirometry?
A. FEV1 less than 80% of predicted, measured before bronchodilator administration.
B. Post-bronchodilator FEV1/FVC ratio less than 0.70.
C. Peak expiratory flow less than 60% of personal best.
D. Total lung capacity greater than 120% of predicted.
✔Correct Answer: B. Post-bronchodilator FEV1/FVC ratio less than 0.70.
Rationale: A diagnosis of COPD requires a post-bronchodilator FEV1/FVC ratio of less than 0.70.
This confirms the presence of persistent airflow obstruction. The FEV1 percentage of predicted is
used to classify severity once the diagnosis is established but is not itself the diagnostic criterion.
Question 13. A patient using albuterol (ProAir HFA) requires the SABA more than twice
a week to control symptoms. What is the appropriate clinical action?
A. Increase the albuterol dose to 4 inhalations per use.
B. Step up therapy, as needing a rescue inhaler more than twice a week indicates inadequate
asthma control.
4
