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NURS615 Updated PHarm 4 test review notes, Exams of Nursing

Chamberlain College of NursingNursing

NURS615 Updated PHarm 4 test review notes NURS615 Updated PHarm 4 test review notes NURS615 Updated PHarm 4 test review notes

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2025/2026

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1. What is tiotropium used to treat? Tiotropium bromide (originally marketed as Spiriva) is a
long-acting, 24-hour, anticholinergic bronchodilator used in the management of chronic
obstructive pulmonary disease (COPD).Tiotropium is used for maintenance treatment of
chronic obstructive pulmonary disease (COPD) which includes chronic bronchitis and
emphysema.[4] It is not however used for acute exacerbations.
Adverse effects Adverse effects are mainly related to its antimuscarinic effects. Common adverse
drug reactions (≥1% of patients) associated with tiotropium therapy include: dry mouth and/or
throat irritation. Rarely (<0.1% of patients) treatment is associated with :urinary retention,
constipation, acute angle closure glaucoma, palpitations (notably supraventricular tachycardia and
atrial fibrillation) and/or allergy (rash, angioedema, anaphylaxis). Tiotropium and another
member of its class ipratropium were linked to increased risk of heart attacks, stroke and
cardiovascular death.[6] Tiotropium mist inhaler (Respimat) has been found to be associated with
an increase of all cause mortality in people with COPD.
Dosage: The standard dose of tiotropium is 18 mcg which is administered by a HandiHaler
inhalation device.[9]
Mechanism of action: Tiotropium is a muscarinic receptor antagonist, often referred to as an
antimuscarinic or anticholinergic agent. Although it does not display selectivity for specific
muscarinic receptors, when topically applied it acts mainly on M3 muscarinic receptors located on
smooth muscle cells and submucosal glands. This leads to a reduction in smooth muscle
contraction and mucus secretion and thus produces a bronchodilatory effect.
2. What are the adverse effects with Montelukast (Singular)? Montelukast (trade name
Singulair) is a leukotriene receptor antagonist (LTRA) used for the maintenance treatment of
asthma and to relieve symptoms of seasonal allergies. Montelukast comes as a tablet, a
chewable tablet, flash tablet and granules to take by mouth. Montelukast is usually taken once a
day with or without food. Montelukast is a CysLT1 antagonist; it blocks the action of leukotriene
D4 (and secondary ligands LTC4 and LTE4) on the cysteinyl leukotriene receptor CysLT1 in the
lungs and bronchial tubes by binding to it. This reduces the bronchoconstriction otherwise
caused by the leukotriene and results in less inflammation.
Because of its mechanism of action, it is not useful in the treatment of acute asthma attacks.
The Mont in Montelukast stands for Montreal, the place where Merck developed the drug.
Medical Uses: Montelukast is used for a number of conditions including asthma, exercise
induced bronchospasm, allergic rhinitis, primary dysmenorrhoea (i.e. dysmenorrhoea not associated
with known causes; see dysmenorrhea causes), and urticaria. It is mainly used as a complementary
therapy in adults in addition to inhaled corticosteroids, if they alone do not bring the desired effect. It
is also used to prevent allergic reactions and asthma flare-ups during the administration of
intravenous immunoglobulin.
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1. What is tiotropium used to treat? Tiotropium bromide (originally marketed as Spiriva ) is a long-acting, 24-hour, anticholinergic bronchodilator used in the management of chronic obstructive pulmonary disease (COPD).Tiotropium is used for maintenance treatment of chronic obstructive pulmonary disease (COPD) which includes chronic bronchitis and emphysema.[4]^ It is not however used for acute exacerbations. Adverse effects Adverse effects are mainly related to its antimuscarinic effects. Common adverse drug reactions (≥1% of patients) associated with tiotropium therapy include: dry mouth and/or throat irritation. Rarely (<0.1% of patients) treatment is associated with :urinary retention, constipation, acute angle closure glaucoma, palpitations (notably supraventricular tachycardia and atrial fibrillation) and/or allergy (rash, angioedema, anaphylaxis). Tiotropium and another member of its class ipratropium were linked to increased risk of heart attacks, stroke and cardiovascular death.[6]^ Tiotropium mist inhaler (Respimat) has been found to be associated with an increase of all cause mortality in people with COPD. Dosage: The standard dose of tiotropium is 18 mcg which is administered by a HandiHaler inhalation device.[9] Mechanism of action: Tiotropium is a muscarinic receptor antagonist, often referred to as an antimuscarinic or anticholinergic agent. Although it does not display selectivity for specific muscarinic receptors, when topically applied it acts mainly on M 3 muscarinic receptors located on smooth muscle cells and submucosal glands. This leads to a reduction in smooth muscle contraction and mucus secretion and thus produces a bronchodilatory effect. 2. What are the adverse effects with Montelukast (Singular)? Montelukast (trade name Singulair ) is a leukotriene receptor antagonist (LTRA) used for the maintenance treatment of asthma and to relieve symptoms of seasonal allergies. Montelukast comes as a tablet, a chewable tablet, flash tablet and granules to take by mouth. Montelukast is usually taken once a day with or without food. Montelukast is a CysLT 1 antagonist; it blocks the action of leukotriene D4 (and secondary ligands LTC4 and LTE4) on the cysteinyl leukotriene receptor CysLT 1 in the lungs and bronchial tubes by binding to it. This reduces the bronchoconstriction otherwise caused by the leukotriene and results in less inflammation. Because of its mechanism of action, it is not useful in the treatment of acute asthma attacks. The Mont in Montelukast stands for Montreal, the place where Merck developed the drug. Medical Uses: Montelukast is used for a number of conditions including asthma, exercise induced bronchospasm, allergic rhinitis, primary dysmenorrhoea (i.e. dysmenorrhoea not associated with known causes; see dysmenorrhea causes), and urticaria. It is mainly used as a complementary therapy in adults in addition to inhaled corticosteroids, if they alone do not bring the desired effect. It is also used to prevent allergic reactions and asthma flare-ups during the administration of intravenous immunoglobulin.

Montelukast is administered as montelukast sodium, with 5.2 mg of montelukast sodium being equivalent to 5 mg of montelukast.

5. What medication would you prescribe for bronchospasm for a

patient taking propranalol?

  • Ipratropium
  • Sold under the name Atrovent
  • opens up the medium and large airways in the lungs.
  • It is used to treat the symptoms of chronic obstructive pulmonary disease and asthma.
  • It is used by inhaler or nebulizer. Onset of action is typically within 15 to 30 minutes and lasts for three to five hours.
  • Common side effects include dry mouth, cough, and inflammation of the airways. Potentially serious side effects include urinary retention, worsening spasms of the airways, and a severe allergic reaction.
  • ]It appears to be safe in pregnancy and breastfeeding.[1][2]Ipratropium is a muscarinic antagonist, a type of anticholinergic, which works by causing smooth muscles to relax.

• Contraindicated in patients’ w/ soy or Peanut allergy

6. What is the mechanism of action of Albuterol? This is a relatively selective β 2 - adrenergic bronchodilator used for relief of bronchospasm in patients with reversible obstructive airway disease. Called also salbutamol. The pharmacologic effects of beta-adrenergic agonist drugs, including Albuterol, are at least in part attributable to stimulation through beta-adrenergic receptors of intracellular adenyl cyclase, the enzyme that catalyzes the conversion of adenosine triphosphate (ATP) to cyclic-3',5'- adenosine monophosphate (cyclic AMP). Increased cyclic AMP levels are associated with relaxation of bronchial smooth muscle and inhibition of release of mediators of immediate hypersensitivity from cells, especially from mast cells. They act on the smooth muscles within the bronchial tree. Patient Teaching: Store albuterol in a cool, dry place out of light. Take the medicine as directed. If you take albuterol as a rescue medicine, keep it with you at all times. If you need to take more medicine to help with breathing than has been prescribed, contact your health care provider. A different medicine may be needed. Tell your doctor or health care provider if you have any of these conditions. There may be reasons to not use albuterol medicines: Heart disease or high blood pressure Allergy to albuterol, levalbuterol, sulfites, preservatives or dyes. Your health care provider may talk with you about other medicines for breathing. History of seizures Diabetes. Albuterol can raise blood glucose levels. Side Effects Some of the common side effects of albuterol are: Feel nervous or shaky Cough or sore throat Headache Runny or stuffy nose Dry mouth or throat Sleeping problems

7. What is the mechanism of action of inhaled corticosteroids? Pg.

Most potent and effective anti-inflammatory medication currently available. Lead to reduction in severity of asthma symptoms. Increase peak flow readings. Decrease airway hyperresponsiveness. Safe and tolerated at recommended dosages and can be used for both children and adults. Commonly prescribed inhaled corticosteroid used is beclomethasone dipropionate (QVAR), triamcinolone acetonide (Azmacort), budesomide (Pulmicort), flunisolide (AeroBid), mometasone furoate (Asmanex Twsthaler), fluticasone (Flovent), and ciclesonide (Alvesco).

  • Intranasal corticosteroids applied topically in the nasal tissue exert anti- inflammatory effects without glucocorticoid effects.

8. When is it appropriate to use a short acting beta agonist?

  • Acute asthma attacks
  • Rescue therapy
  • Asthma exacerbation
  • Opens the airways-exchange of o2/Co
  • Relieve asthma symptoms once started
  • Do not control or prevent inflammation of airways
  • Relax the tightened bands around the airways (bronchospasm)
  • Works quickly
  • Should be needed occasionally no more than twice a week Possible Side effects: fast heartbeat, nervousness, shakiness, usually pass quickly when the medicine is inhaled. Examples: Albuerol, Proventil, Ventolin, Xopenex, ProAir Caution: It's a good idea to carry your rescue medication with you wherever you go.

9. What is the mechanism of action of inhaled muscarinic

receptor antagonists? Pg. 378 book Also question 1

  • Blocks the action of acetylcholine
  • Blocking the cholinergic monophosphate (cGMP), which leads to decreased contractility of the smooth muscles of the lungs, probably because of the action of cGMP on intracellular calcium.
  • Ipratropiums action is confined to the mouth and airways; Tiotropium exhibit its effects on the by inhibit the m3 muscarinic receptors in the lungs, causing smooth muscle bronchodilation.

10. What are the adverse effects associated with inhaled

corticosteroids?

  • Cough upon inhalation
  • Oral candidiasis (rinse after use)
  • Burning smell of plastic, unpleasant taste
  • Dysphonia (hoarseness)
  • Cataracts
  • Dry mouth

11. What special population should not be prescribed

pseudoephedrine?

Dose in adults is 60mg q 4 - 6 hours, dose in children age 6 - 12 years is 30mg every 4 - 6 hours.

  • Children under age of 4
  • Treat children with colds supportive, hydrate, rest
  • Hard to get this drug d/t increased use in METH
  • Do not prescribe to those with recent stroke, HTN, CAD
  • They increase HR, hyperpyrexia (extreme increase in body temperature)

12. What drug should be prescribed for a patient with nasal

congestion with hypertension?

  • Topical nasal sprays can be used – decongestant for common cold relief of nasal symptoms or allergic rhinitis.
  • 3 - 5 days only
  • If used longer you may have rebound congestions
  • They may help alleviate nasal congestion and ear pressure

16. Which medications are considered antitussives?

  • Codeine, dextromethorphan, benzochloraphate
  • Tessalon pearls (do not chew or break) swallow whole!! If chewed or broken can cause an anaphylactic reaction
  • Expectorants such as guaifenesin are not antitussives
  • Why is the cough occurring? Treat the cause.
  • IF it is a cold, remember it is likely viral will not require an antibiotic. If the patient has a bronchitis it is likely viral, but can go for more than 10 days and turn into a secondary bacterial infection requiring ATBs.

17. How are upper respiratory infections treated?

  • Supportive care
  • Fluids
  • Rest
  • Phenylephrine can help with symptomatic relief in adults without HTN or Heart disease
  • Guaifenesin

18. What patient education should be provided to the patient

taking antacids?

  • Antacids consist of a metallic cations and basic ion (calcium carbonate, magnesium hydroxide) they neutralize acidity in the stomach by raising the pH. The basic property of these medications causes them to interact with most medications by either binding to the drug molecule or altering the pH and thus the absorption of drugs that need the optimal acidic environment is changed.
  • Tetracyclines, quinolones, antibiotics such as cipro, and ofloxin are changed by antacids should be taken at least 2 hours after the medication.
  • The mechanism of action of the antacids – neutralize the gastric acid, increase pH of stomach, and duodenal bulb, and inhibit the proteolytic activity of pepsin and increase lower esophageal sphincter tone. ➢ Aluminum-and magnesium-based antacids – not absorbable with routine use. ➢ Alumimum concentrates in the CNS ➢ Calcium-based antacids required vitamin D for absorption from the GI tract. ➢ If taken 1 hour after a meal, acidity is reduced for 2 - 3 hours. ➢ The action occurs in the GI tract so there is minimal metabolism. ➢ Magnesium-based antacids bind with phosphate ions in the intestine to from insoluble aluminum phosphate, which is excreted in the feces. ➢ Calcium-based antacids are excreted mainly in the feces, with 20% eliminated in the urine. ➢ All antacids are contraindicated in presence of severe ABD pain and fever ➢ Calcium based antacids are contraindicated in the presence of hypercalcemia and renal calculi ➢ Renal impairment – magnesium based antacids are contraindicated and used with caution in patients with any degree of renal insufficiency (hypermagnesemia). ➢ The use of aluminum based antacids in dialysis patients will worsen dialysis osteomylacia. (binds to albumin and transferrin, which do not cross the dialysis membrane)

➢ High NA content – use with caution in HTN, CHF, renal

failure

➢ Aluminum and Calcium based antacids cause constipation ➢ Magnesium based antacids cause diarrhea

• BLACK BOX WARINING: TORSADES DE POINTE, CARIAC ARREST AND DEATH W/

HIGHER THAN USUAL DOSES. CONTRAINDICATED IN PATIENTS <

20. What are adverse effects of Bismuth?

  • Reye syndrome
  • Black stool
  • Black tongue
  • Constipation
  • Tinnitus
  • Contraindications: Pregnancy at 20 weeks gestation; coagulation disorders, GI bleeding, caution in renal impairment, hepatic impairment, gout, GSPD deficienc
  • Do not give with warfarin or coumadin

21. What special population should not be administered bismuth

subsalicylate?

  • Children recovering from flu/flu like symptoms, influenza, chickenpox
  • Association between ASA containing medications and viral infections and the onset of Reyes syndrome
  • Toxic to cats
  • Mega colon

22. When should bismuth subsalicylate be administered?

  • Prophylactically for travelers’ diarrhea; binds the exotoxins made by e-coli
  • Take with each meal and at bedtime
  • It is also used as a multi drug regimen for H pylori eradication to reduce the risk of duodenal ulcer reoccurrence

23. What lab values should be monitored with long-term

administration of proton pump

inhibitors (PPIs)?

  • Patients on PPIs may have low levels of Vit B12 > Mg, Megablatic Anemia, Iron def. anemia
  • CBC, H-Pylori test, Iron levels, Ca levels,
  • Decreased calcium levels, increased osteoporosis, increased risk of fractures

24. Why is osteoporosis a risk when taking omeprazole?

  • Long term use of PPIs has been associated with increased risk of OA and decreased bone mineral density. Increased risk of fractures.
  • PPI induced bone fractures – dietary calcium absorption is dependent upon an acidic environment in the GI tract – due to the decrease in acidity from the use of PPIs potential loss of Ca occurs. The reduction in Ca absorption leads to decreased osteoclastic activity and decreased bone mineral density, increasing the risk of fractures.
  • Osteoblast = build
  • Osteoclast = breakdown

25. What is the most rapid acting laxative and why?

  • Stimulant laxatives
  • Rectal admin. Of Bisacodyl most rapid

26. How does metoclopramide improve GERD?

  • Acts on Dopamine receptors and at higher doses also on serotonin receptors
  • The action on the Dopamine recptors (D2/5HT3) produces antiemetic effects
  • Stimulates upper GI tract motility

32. What are the disadvantages of using stimulant laxatives for

prolonged periods of time?

  • Laxatives like Bisacodyl work by simulating enteric nerves to cause colonic contractions
  • It also increases fluid and salt excretion
  • Stimulant laxatives mainly promote the evacuation of the large intestine
  • Long-term use of stimulant laxatives can lead to dependence

33. What is the mechanism of action of the phenothiazine

antiemetic?

  • are a type of medicine that may be used to relieve nausea and vomiting. They work by inhibiting dopamine, muscarinic and histamine (H1) receptors generally in the vomiting center and chemoreceptor trigger zone.
  • Anticholinergic properties, resulting in antiemetic and sedative effects.

34. What is the mechanism of action of docusate sodium?

  • Laxative used to treat constipation – used in children who have hard stools.
  • Constipation d/t opioid use
  • It can be used with stimulant laxatives
  • Taken by mouth or rectally, works in 1 - 3 days
  • Side effects are uncommon, abd. pain and cramps may be present, diarrhea; long- term use may cause poor bowel function
  • Colace is an acceptable drug in pregnancy and while breast feeding
  • Colace is a laxative of the stool softener type and works by allowing more water to be absorbed by the feces; it typically comes in the form of sodium, calcium or potassium salt

35. What is the mechanism of action of a Proton Pump Inhibitor

(PPI)?

  • Proton pump inhibitors ( PPIs ) mechanism of action ....... The proton pump is the terminal stage in gastric acid secretion, being directly responsible for secreting H+ ions into the gastric lumen, making it an ideal target for inhibiting acid secretion.
  • What are proton pump inhibitors (PPIs) and how do they work? Proton pump inhibitors (PPIs) reduce the production of acid by blocking the enzyme in the wall of the stomach that produces acid.
  • Proton pump inhibitors (PPIs) block the gastric H, K-ATPase, inhibiting gastric acid secretion. This effect enables healing of peptic ulcers, gastroesophageal reflux disease (GERD), Barrett's esophagus, and Zollinger-Ellison syndrome, as well as the eradication of Helicobacter pylori as part of combination regimens.
  • Why PPI should be taken before food? Food ingestion stimulates gastric parietal cell ATPase molecules to secrete acid, allowing PPIs to inhibit acid secretion when they are taken before meals
  • Over-the-counter PPIs include: lansoprazole (Prevacid 24 HR) omeprazole (Prilosec) esomeprazole (Nexium) Lansoprazole and omeprazole are also available by prescription, as are the following PPIs : dexlansoprazole (Dexilant, Kapidex) pantoprazole sodium (Protonix) rabeprazole sodium (Aciphex)

36. What is the mechanism of action of Ondansetron?

  • Highly selective serotonin receptor antagonist, low affinity for dopamine receptors
  • It acts on the gastric parietal cells inhibiting gastric acid secretion by the G protein coupled receptors mediation
  • Inhibition of adenlate cyclase leading to decreased cyclic AMP and decreased proton pump activity
  • PPIs and H2Ras are more effective for the use in treatment of acute peptic ulcers, Misoprostol is only indicated for the use in people who are both taking NSAIDS and/ or are at high risk for NSAID induced ulcres
  • Elderly and those with ulcer complications
  • Sometimes prescribed with NSAIDS to reduce gastric irritation
  • Not to be used in pregnancy, increases uterine tone, causes abortion
  • Prostaglandin analogue, prostaglandin E

• Used off label to induce labor (category X-pregnancy)

  • Used in combination w/ prostaglandin antagonist to cause abortion for 1 st^ trimester

38. What are H2RA Blockers?

  • Class of drugs that block the action of histamine on the parietal cells in the stomach.
  • Decrease acid production
  • H2 antagonist
  • Treatment for dyspepsia, but surpassed by PPIs
  • Fomotidine 40mg
  • Zantac 150mg
  • Ranitidine is better absorbed by body then famotidine, but takes more time to exert action

39. How will you choose a diuretic in the treatment of

hypertension?

  • Check kidney function
  • Thiazide diuretics need to have GFR higher than mid 40 mL/min range
  • Bun/Creatinine

40. What is the mechanism of action of the different classes of

diuretics?

41. Loop diuretics — When administered at maximum dose, the loop diuretics, furosemide, bumetanide, torsemide, and ethacrynic acid, can lead to the excretion of up to 20 to 25 percent of filtered sodium [1,10]. They act in the medullary and cortical aspects of the thick ascending limb, including the macula densa cells in the early distal tubule. At each of these sites, sodium entry is primarily mediated by a Na-K-2Cl carrier in the luminal membrane that is activated when all four sites are occupied (figure 2) [1,5,11,12]. The loop diuretics appear to compete for the chloride site on this carrier, thereby diminishing net reabsorption [12,13]. Inhibition of an isoform of this cotransporter in the inner ear is thought to be responsible for the ototoxicity that is rarely seen with high dose intravenous loop diuretic therapy. (See "Treatment of refractory edema in adults", section on 'Risk of ototoxicity'.)

Loop diuretics also have important effects on renal calcium handling. The reabsorption of calcium in the loop of Henle is primarily passive, being driven by the electrochemical gradient created by NaCl transport and occurring through the paracellular pathway [14,15]. As a result, inhibiting the reabsorption of NaCl leads to a parallel reduction in that of calcium, thereby increasing calcium excretion. In the past, saline plus high doses of furosemide was a mainstay of the treatment of hypercalcemia. Volume expansion is still important, but other drugs, such as bisphosphonates, have largely replaced loop diuretics in this setting. (See "Treatment of hypercalcemia".)