A 44 year old man has a long standing history of moderate persistent asthma that is normally well controlled by fluticasone with salmeterol (Advair) via MDI, one puff twice a day, and the use of albuterol 1-2 times a week PRN wheezing. Three days ago he developed a sore throat, clear nasal discharge, body aches, and a dry cough.
In the past 24 hours, he has had intermittent wheezing that needed albuterol use, two puffs every 3 hours, which produced partial relief.
Your next most appropriate action is to obtain a:

A. chest radiograph
B. measure O2
C. spirometry measurement
D. sputum smear for WBC
You examine jane, a 24 yr old woman who has an acute asthma flare following a 3 day history of upper respiratory tract symptoms (clear nasal discharge, dry cough, no fever).She has hx of moderate persistent asthma that is in good control and an acceptable peak expiratory flow (PEF). She is using budesnide (Pulmicort) and albuterol as directed and continues to have difficulty with coughing and wheezing. At home, PEF is 55% of personal best. In office, her FEV1 is 65% of predicted. Her medication regiment should be adjusted to include:
A. theophylline
B. salmeterol
C. prednisone
D. montelukast

For Jane in previous question, you also prescribe:

A. amoxicillin
B. azithromycin
C. levofloxacin
D. no antimicrobial therapy

   D. no antimicrobial therapy

Peak expiratory flow meters:

A. should only be used in the presence of a medical professions
B. provide a convenient method to check lung function at home
C. are as accurate as spirometry
D. should not be used more than once daily

Which of the following is most likely to appear on a chest radiograph of a person during an acute severe asthma attack?

A. hydrochlorothiazide
B. propranolol
C. amlodipine
D. enalapril

Which of the following is inconsistent with the presentation of asthma that is not well controlled?

A. a troublesome nocturnal cough at least 2 nights/week
B. need for albuterol to relieve shortness of breath at least twice a week
C. morning sputum production
D. two or more exacerbations/year requiring oral corticosteroids

The cornerstone of moderate persistent asthma drug therapy is the use of:

A. oral theophylline
B. mast cell stabilizers

Sharon is 29 year old woman with moderate persistent asthma. She is not using prescribed ICS, but is using albuterol PRN to relive her cough and wheeze with reported satisfactory clinical effect. Currently she uses about two albuterol inhalers per month and is requesting a refill. You consider that:

A. her asthma is well controlled and albuterol use can continue
B. excessive albuterol use is a risk factor for asthma death
C. her asthma is not well controlled and salmeterol should be added to relieve bronchospasm and reduce her albuterol use
D. her asthma has better control with albuterol than ICS

In the treatment of asthma, leukotriene receptor antagonists should be used as:

A. controllers to prevent bronchospasm
B. controllers to inhibit inflammatory response
C. relievers to treat acute bronchospasm
D. relievers to treat bronchospasm and inflammation

According to national asthma education and prevention program expert panel report 3 (NAEPP EPR 3) guidelines, which of the following is not a risk for asthma death?

A. hospitalization or an emergency department visit for asthma in the past month
B. current use of systemic corticosteroids or recent withdrawal from systemic corticosteroids
C. difficulty perceiving airflow obstruction or its severity
D. rural residence

An 18 year old high school senior presents, asking for a letter stating that he should not participate in gym class because he has asthma. The most appropriate action is to:

A. write a note because gym class participation could trigger asthma symptoms
B. excuse him from outdoor activities only to avoid pollen exposure
C. assess his level of asthma control and make changes in his treatment plan if needed so he can participate
D. write a note excusing him from gym until his follow up exam in 2 months

You see a 34 year old man with moderate persistent asthma who has an asthma flare and a regimen of oral prednisone is being considered. Which of the following is true?

A. a taper is needed for prednisone therapy lasting longer than 4 days
B. a taper is not needed if the prednisone regimen is for 7 days or less
C. a taper is not needed regardless of duration of prednisone therapy
D. a taper is needed if the patient is taking concomitant ICS

After ICS is initiated, improvement in control is usually seen:

A. on the first day of use
B. within 2-8 days
C. in about 3-4 weeks
D. in about 1-2 months

Compared with albuterol, levalbuterol (xopenex) has:

A. a different mechanism of action
B. the ability potentially to provide greater bronchodilation with a lower dose
C. an antiinflammatory effect similar to that of an ICS
D. contraindicated in elderly patients

Which of the following is consistent with NAEPP comment on the use of ICS for a child with asthma?

A. The potential but small risk of delayed growth with ICS is well balanced by their effectiveness
B. ICS should be used only if leukotriene receptor antagonist fails to control asthma
C. Permanent growth stunting is consistently noted in children using ICS
D. a leukotriene receptor antagonist are equal in therapeutic effect to the use of a LABA

A potential adverse effect from ICS use is:

A. oral candidiasis
B. tachycardia
C. GI upset
D. insomnia

Clinical findings characteristic of poorly controlled asthma include all of the following except:

A. a recurrent spasmodic cough that is worse at night
B. recurrent SOB and chest tightness with exercise
C. a congested cough that is worse during the day
D. wheezing with and without associated respiratory infections

Which of the following best describes the mechanism of action of SABA

A. reducer of inflammation
B. inhibition of secretions
C. modification of leukotrienes
D. smooth muscle relaxation

Regarding the use of LABA, which of the following is true?

A. LABAs enhance the anti inflammatory action of corticosteroids
B. use of LABAs is associated with a small increase in risk of asthma death
C. LABA use reduces the risk of asthma exacerbations
D. LABAs can be used as monotherapy t relieve bronchospasms in asthma

   B. Use of LABA is associated with a small increase in risk of asthma death

Which of the following is the therapeutic objective of using inhaled ipratropium bromide?

A. as an anti inflammatory
B. an increase in vagal tone in the airway
C. inhibition of muscarinic cholinergic receptors
D. an increase in salivary and mucus secretions

Which of the following is true regarding the use of systemic corticosteroids in the treatment of asthma?

A. frequent short bursts are preferred over daily inhaled corticosteroids
B. the oral corticosteroids should be started at day 3-4 of the asthma flare for optimal effect
C. the oral route is preferred over parenteral therapy
D. the adult dose to treat asthma flare should not exceed the equivalent of prednisone 40mg daily

Compared with SABA, LABAs:

A. are recommended as a first line therapy in mild intermittent asthma
B. have a significantly different pharmacodynamic profile
C. have a rapid onset of action across the drug class
D. should be added to therapy only when ICS use does not provide adequate asthma control

Which of the following statements is false regarding the use of omalizumab (Xolair)?

A. its use is recommended for patients with mild persistent asthma to prevent asthma flare ups
B. the medication selectively binds to IgE to reduce exacerbations
C. labeled indication is for patients with poorly controlled asthma with frequent exacerbations
D. Special evaluation is required prior to its use and ongoing monitoring is needed during use

Subcutaneous immunotherapy is recommended for use in patients:

A. with well controlled asthma and infrequent exacerbations
B. with allergic based asthma
C. with moderate persistent asthma
D. with poorly controlled asthma who fail therapy with omalizumab

A 6 year old boy has a 1 year history of moderate persistent asthma that is normally well controlled with budesonide via dry powder inhaler (DPI) twice a day and the use of albuterol once or twice a week as needed for wheezing. Three days ago, he developed a sore throat, clear nasal discharge, and a dry cough. In the past 24 hours, he has had intermittent wheezing, necessitating the use of albuterol two puffs with use of an age appropriate spacer every 3 hours with partial relief.
Your next most appropriate action is to obtain:
A. a chest radiograph
B. an oxygen saturation
C. a peak expiratory flow (PEF) measurement
D. sputum smear for WBC
You see a 4 year old girl who has a 2 day history of signs and symptoms of an acute asthma flare resulting from viral upper respiratory tract infection. She is using inhaled budesonide and albuterol as directed and continues to have difficulty with increased occurrence of coughing and wheezing. Her respiratory rate is within 50% of upper limits of normal for her age.
Her medication regimen should be adjusted to include:
A. oral theophylline
B. inhaled salmeterol
C. oral prednisolone
D. oral montelukast (singulair)

Which of the following is inconsistent with the diagnosis of asthma?

A. a troublesome nocturnal cough
B. cough or wheeze after exercise
C. morning sputum production
D. colds “go to the chest” or take more than 10 days to clear

Celeste is a 9 year old girl with moderate persistent asthma. She is not taking a prescribed inhaled corticosteroid but is using albuterol PRN to relieve her cough and wheeze.
According to her mother, she currently uses about 6 albuterol doses a day, in particular for cough and wheeze after active play.
You consider that:
A. albuterol use can continue at this level
B. excessive albuterol use is a risk for asthma death
C. she should also use salmeterol to reduce her albuterol yse
D. active play should be limited to avoid triggering cough and wheeze

In the treatment of asthma, a leukotriene modifier LTM should be used as:

A. long acting bronchodilator
B. an inflammatory inhibitor
C. a rescue drug
D. intervention in acute inflammation

After inhaled corticosteroid or leukotriene modifier therapy is initiated, clinical effects are seen:

A. routinely
B. with evidence of concomitant bacterial infection
C. when asthma flares are frequent
D. with sputum production

Poorly controlled asthma in children can lead to:

A. attenuated lung development
B. chronic tracheitis
C. sleep apnea
D. alveolar destruction

Which of the following is most consistent with asthma in a 4 year old child?

A. inspiratory stridor
B. expiratory wheezing
C. chronic cough with purulent sputum
D. loud barking cough predominantly during the day

Signs of respiratory distress during an asthma flare in a 2 year old child include all of the following except:

A. drowsiness
B. confusion
C. RR > 30
D. softer, shorter cry

A. nighttime awakening about once a week
B. asthma symptoms occurring about 2 times per week
C. asthma having little to no interference with normal activities.
D. SABA use 2 days or less per week

When discussing immunizations with a 67 year old woman with COPD, you advise that she:

A. receive live attenuated influenza virus vaccine
B. avoid immunization against flu because of the risk associated with the vaccine
C. receive inactivated flu virus vaccine
D. take an anti viral for the duration of the flu season

Seasonal flu vaccination is generally recommended for all persons over the age of 6 months

A 66 year old woman is an acceptable candidate for the high dose inactivated flu vaccine shot

Cigarette smokers should not receive the pneumococcal vaccine until age 65 or older

A 52 year old immunocompetent patient with COPD who receives the pneumococcal vaccine should get re vaccinated in 5 years

When used in treating COPD, ipratropium bromide (Atrovent) is prescribed to achieve which of the following therapeutic effects?

A. increase mucociliary clearance
B. reduce alveolar voulume
C. bronchodilation
D. mucolytic action

What is the desired therapeutic action of ICS when used to treat COPD?

A. reversal of fixed airway obstruction
B. improvement of central respiratory drive
C. reduction of airway inflammation
D. mucolytic activity

Which is most consistent with the diagnosis of COPD?

A. FEV1/FVC ratio equal to or less than 0.70 after properly timed SABA use
B. dyspnea on exhalation
C. elevated diaphragms noted on xray
D. polycythemia noted on CBC

The most effective nonpharmacologic method to prevent exacerbations in patients with COPD is:

A. weight loss for those with BMI > 25
B. avoid exposure to children or day care centers
C. brisk walking for at least 5 minutes 3-5 times a day as tolerated
D. avoid exposure to pulmonary irritants, such as cigarette smoke

When managing patients with COPD who continue to smoke cigarettes, a discussion on the importance of smoking cessation should occur:

A. at the initial diagnosis visit
B. with each COPD flare up
C. once ICS therapy is initiated
D. at every office visit

According to the GOLD COPD guidelines, which of the following medications is indicated for use in all COPD stages?

A. minimize the risk of repeated exacerbations
B. improve cough function
C. reverse alveolar hypertrophy
D. help mobilize secretions

Which of the following systemic corticosteroid doses is most potent?

A. methylprednisolone 8mg
B. triamcinolone 10mg
C. prednisone 15 mg
C. hydrocortisone 18 mg

Which of the following pathogens is often implicated in a COPD exacerbation caused by respiratory tract infection?

A. a 5 day course of levofloxacin
B. a 7 day course of amoxicillin
C. a 10 day course of doxycyline
D. antimicrobial therapy usually not indicated

Which is the most appropriate statement about therapy for a severe COPD exacerbation in a 52 year old man?

A. a 5 da course of azithromycin should be prescribed
B. a 10 day course of amoxicillin/clvulanate is advisable
C. a 7 day course of bactrim
D. the role of antimicrobial therapy is debated, even for severe exacerbation

You see a 67 year old man with very severe (GOLD 4) COPD who asks “when should I use my home oxygen?” you respond:

A. as needed for SOB
B. primarily during sleep hours
C preferably during waking hours
D. for at least 15 hours a day

With a COPD exacerbation, a chest xray should be obtained:

A. routinely in all patients
B. when attempting to rule out concomitant pneumonia
C. if sputum volume is increased
D. when work of breathing is increased

Which of the following best describes the role of theophylline in COPD treatment?

A. routinely indicated in moderate to very severe COPD
B. use limited by narrow therapeutic profile and drug-drug interaction potential
C. a potent bronchodilator
D. available only in parenteral form

All of the following are consistent with the GOLD COPD recommendation for pulmonary rehab except:

A. it is reserved for very severe COPD
B. its goals include improvement in overall well being
C. it is an underused therapeutic option
D. its components are aimed at reducing the deconditioning common in COPD

An asthma exacerbation is characterized by all of the following symptoms except:

A. mild intermittent asthma
B. mild persistent asthma
C. moderate persistent asthma
D. severe asthma

A. a barrel shaped chest
B. pursed lip breathing
C. a chest x ray result with infiltrates and flattening of the costovertebral angle
D. dyspnea when at rest

A 67-year-old woman with a 30-pack-year history of smoking presents for a routine annual physical examination. She complains of being easily short of breath and is frequently fatigued. Physical examination reveals diminished breath sounds, hyperresonance, and hypertrophied respiratory accessory muscles. Her complete blood count (CBC) results reveal that her hematocrit level is elevated. Her pulmonary function test (PFT) results show increased total lung capacity. What is the most likely diagnosis for this patient?

A. bronchogenic carcinoma
C. chronic bronchitis

A 10-year-old boy who was recently accepted onto his school’s soccer team has a history of exercise-induced asthma. He wants to know when he should use his albuterol inhaler. The nurse practitioner would advise the patient to:

A. premedicate 10 to 15 minutes before starting exercise
B. wait until he starts to exercise before using the inhaler
C. Pre medicate 30 min before exercise
D. wait until he finishes exercise before using inhlaer

A patient with chronic obstructive pulmonary disease (COPD) is referred for pulmonary function testing. All of the following results are characteristic of pulmonary function tests in patients with COPD except:

A. increase in the TLC (total lung capacity)
B. dyspnea
C. increase in the RV (residual volume)
D. reduction of the FEV1 (forced expiratory volume in 1 second)

An asthmatic 20-year-old woman who was seen for a viral upper respiratory infection 2 weeks ago presents to the nurse practitioner’s office complaining of a recent onset of shortness of breath, inspiratory and expiratory wheezing, and chest tightness. She has been using her albuterol inhaler four to six times a day with poor relief. She is unable to speak in full sentences. When the nurse practitioner quickly evaluates the patient, she notices that the patient is pale, diaphoretic, fatigued, and using her sternocleidomastoid accessory muscles for respiration. Her respiratory rate is 32 breaths/min and pulse is 130 beats/min. Which of the following interventions is not indicated?

A. administer o2 via NC
B. give the patient a neb SABA
C. quickly assess the patient with pulse ox and check breath sounds
D. initiate CPR

A. age
B. gender
C. height
D. weight

A 62-year-old man with chronic obstructive pulmonary disease (COPD) complains to the nurse practitioner that his prescription for ipratropium bromide (Atrovent) is not working. He reports that he still feels short of breath even after using it four times a day for 3 months. Which of the following actions is the next step for the nurse practitioner?

A. Increase the patient’s dose of ipratropium bromide (Atrovent) to three inhalations QID

B. Continue the ipratropium bromide and start the patient on oxygen by nasal cannula

C. Continue ipratropium bromide (Atrovent) and add two inhalations of an albuterol (Ventolin) inhaler QID

D. Start the patient on oxygen by nasal cannula at bedtime and PRN during the daytime

A 30-year-old woman with mild persistent asthma and allergic rhinitis is seen in an urgent care clinic for complaints of shortness of breath and wheezing. She reports using her albuterol inhaler two to three times per day for 4 days the previous week. She reports waking up for 3 nights due to wheezing the past week. She had previously been prescribed low-dose flunisolide (AeroBid), two inhalations twice per day. Vital signs reveal a temperature of 99.0°F, pulse of 88 beats/min, and respiratory rate of 14 breaths/min. Which of the following action is the next step?

A. administer neb albuterol treatment
B. prescribe medrol dose pack
C. use spiromtery to assess severity of symptoms
D. add LABA inhaler

You examine a 38 year old woman who has presented for an initial exam and pap test. She has no complaint. Her BP is 154/98 bilaterally and her body mass is 31. The rest of her physical exam is unremarkable.
Your next best action is to:
A. initiate antihypertensive therapy
B. arrange for at least two additional BP measurements during the next two weeks
C. order blood urea nitrogen, creatinine, and potassium measurements and urinalysis
D. advise her to reduce her sodium intake
You see a 68 year old woman as a patient who is transferring care into your practice. She has a 10 year history of hypertension, diabetes, and hyperlipidemia. Current medications include hydrochlorothiazide, glipizide, metformin, simvastatin, and daily low dose aspirin. Today’s BP reading 158/92 and the rest of her history and exam are unremarkable. Documentation from her former healthcare provider indicates that her BP has been in the range for the past 12 months. Your next best action is to:
A. prescribe ACEI
B. have her return for a BP check in 1 week
C. advise that her current therapy is adequate
D. add therapy with an aldosterone antagonist

In the person with HTN, the NP recommends all of the following to potentially reduce BP in a patient with a BMI of 30 except:

A. 10kg weight loss
B. dietary sodium restriction to 2.4kg per day
C. regular aerobic physical activity, such as 30-40 minutes of brisk walking most days of the week
D. consuming at least 1-2 servings of alcohol

You see a 38 year old african american male with HTN who is currently being treated with thiazide type diuretic. His current BP reading is 156/94 and he has no history of diabetes or chronic kidney disease. Following current best evidence, you consider adding which of the following medications?

B. angiotensin receptor blocker (ARB)
C. beta blocker
D. calcium channel blocker

Nondihydropyridine calcium channel blockers are contraindicated in patients with:

A. type 1 diabetes
B. history of venous thromboembolism
C. severe LVH
D. concomitant treatment with an ACEI

A 68 year old woman presents with hypertension and BP of 152-158/92-96 documented over 2 months on three difference occasions. ECG and creatinine are normal, and she has no proteinuria. Clinical findings include the following BMI 26.4, no s3, S4, murmur, and PMI at 5th Interocstal space.
Which of the following represents the best intervention?
A. initiate therapy with metoprolol
B. initiate therapy with hydrchlorothiazide
C. initiate therapy with methyldopa
D. continue to monitor BP, and start drug therapy if evidence of target organ damage
You see a 62 year old man without chronic kidney disease or diabetes who is currently being treated with low dose HCTZ and losartan. His blood pressure is currently 162/88.
All of the following are appropriate next courses of action except:
A. increasing the dose of losartan
B. adding beta blocker
C. adding CCB
D. increasing dose of HCTZ
Heart failure:
thiazide, bb, ACEI/ARB, aldoaterone antagonist, CCB
thiazide, BB, ACEI, ARB, CCBAngina pectoris:
thiazide, BB, ACEI, CCBaortic aneurysm:
thiazide, BB, ACEI, CCBrecurrent stroke prevention:
thiazide diuretic, BB, ARB, CCB

Which of the following are risk factors fir hypertension in children and teens, choose all that apply:

A. obesity
B. drinking whole milk
C. being exposed to secondhand smoke
D. 2 or more hours per day of screen time

Fruit juice intake is acceptable in children 6 months and older per which of the following recommendations, choose all that apply:

A. a juice is mixed in a small amounts to flavor water
B. only 100% juice is used
C. juice replaces no more than one serving of milk
D. the juice is consumed in the morning with breakfast
E. no more than 6 oz per day is recommend for children 6 months to 5 years

In evaluating a 9 year old child with a healthy BMI during a well visit, a comprehensive cardiovascular evaluation should be conducted by the following methods, choose all that apply:

A. obtain fasting lipid profile
B. screen for type 2 diabetes by measuring hgba1c
C. assess for family history of thyroid disease
D. assess diet and physical activity

Which of the following is not consistently performed as part of the work up for sepsis?

A. CBC with WBC differential
B. stool culture
C. blood culture
D. urine culture

Rates of sepsis in children have lowered in recent years mainly because of:

A. more stringent screening and diagnosis of the febrile illness
B. increased use of antipyretics
C. longer observation period in children with febrile illness
D. higher rates of select immunization

The mechanism of action in fever includes which of the following?

A. an increase in systematic vascular resistance
B. endogenous pyrogens increase prostaglandin synthesis
C. immature neutrophil forms in circulation
D. atypical or reactive lymphocytes

When assessing a febrile child, the NP considers that:

A. even minor temperature elevation is potentially harmful
B. nuchal rigidity is usually not found in early childhood meningitis
C. fever-related seizures usually occur at the peak of the temperature
D. most children with temps 101-104 F have a potentially serious bacterial infection

Which of the following is not seen during body temperature increase found in fever?

A. lower rate of viral replication
B. toxic effect on select bacteria
C. negative effect on S. pneumoniae growth
D. increased rate of atypical pneumonia pathogen replication

Concerning the use of the antipyretics in a febrile young child, which of the following statements is false?

A. a child with a serious bacterial infection usually does not have significant fever reduction with an antipyretic
B. the degree of temperature reduction in response to antipyretic therapy is not predictive f presence or absence of bacteremia
C. compared with iburpofen, acetaminphen has a shorter duration of antipyretic action
D. ibuprofen should not be used if a child is also taking macrolide antimicrobial

When counseling the family of an otherwise healthy 2 year old child who just had febrile seizure, you consider which of the following regarding whether the child is at risk for future febrile seizures, select all that apply:

A. the occurrence of one febrile seizure is predictive of having another
B. intermittent diazepam can be used prophylactically during febrile illness to reduce risk of recurrence
C. a milder temp elevation in a child with a history of a febrile seizure poses significant risk for future recurrent febrile and non febrile seizures
D. consistent use of antipyretics during a febrile illness will significantly reduce the risk of a future febrile seizure

Gina is a 2 year old and presents with a 3 day history of fever, crankiness, and congested cough. Her respiratory rate is more than 50% of the upper limit of normal for her age. tubular breath sounds are noted at the right lung base. Skin turgor is normal , and she is wearing a wet diaper. She is alert, is resisting the exam as age appropriate and engages in eye contact.
Temp is 101.
Gina’s diagnostic evaluation should include:
A. chest xray
B. urine culture and sensitivity
C. lumbar puncture
D. sputum culture

Potential adverse events with acetaminophen use in a child with fever and mild dehydration include:

A. seizure
B. hepatotoxicity
C. petechial rash
D. gastric ulcer