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RESPIRATORY PRACTICE QUESTIONS
Which of the following best describes asthma? A. intermittent airway inflammation with occasional bronchospasm B. a disease of bronchospasm that leads to airway inflammation C. chronic airway inflammation with superimposed bronchospasm D. relatively fixed airway constriction - ANSWER-C The patient you are evaluating is having a severe asthma flare. You have assessed that his condition is appropriate for office treatment. You expect to find the following on physical examination: A. tripod posture B. inspiratory crackles C. increased vocal fremitus D. hyperresonance on thoracic percussion - ANSWER-D 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 metered-dose inhaler, one puff twice a day, and the use of albuterol 1 to 2 times a week as needed for 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 necessitated the use of albuterol, two puffs every 3 hours, which produced partial relief. Your next most appropriate action is to obtain a: A. chest radiograph. B. measurement of oxygen saturation (SaO2). C. spirometry measurement. D. sputum smear for white blood cells (WBCs). - ANSWER-C You examine Jane, a 24-year-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 a history of moderate persistent asthma that is in good control and an acceptable PEF. She is using budesonide (Pulmicort) and albuterol as directed and continues to have difficulty with coughing and wheezing. At home, her peak expiratory flow (PEF) is 55% of personal best. In the office, her FEV1 is 65% of predicted. Her medication regimen should be adjusted to include: A. theophylline. B. salmeterol (Serevent). C. prednisone. D. montelukast (Singulair). - ANSWER-C For Jane in the above question, you also prescribe: A. amoxicillin. B. azithromycin. C. levofloxacin. D. no antimicrobial therapy. - ANSWER-D Peak expiratory flow meters:
A. should only be used in the presence of a medical professional. 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. - ANSWER-B Which of the following is most likely to appear on a chest radiograph of a person during an acute severe asthma attack? A. hyperinflation B. atelectasis C. consolidation D. Kerley B signs - ANSWER-A 36-year-old man with asthma also needs antihypertensive therapy. Which of the following products should you avoid prescribing? A. hydrochlorothiazide B. propranolol C. amlodipine D. enalapril - ANSWER-B 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 per 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 - ANSWER-C The cornerstone of moderate persistent asthma drug therapy is the use of: A. oral theophylline. B. mast cell stabilizers. C. short-acting beta2-agonists. D. inhaled corticosteroids. - ANSWER-D Sharon is a 29-year-old woman with moderate persistent asthma. She is not using prescribed inhaled corticosteroids, but is using albuterol PRN to relieve her cough and wheeze with reported satisfactory clinical effect. Currently she uses about two albuterol metered-dose inhalers per month and is requesting a prescription 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 (Serevent) should be added to relieve bronchospasm and reduce her albuterol use. D. her asthma has better control with albuterol than inhaled corticosteroids. - ANSWER-B In the treatment of asthma, leukotriene receptor antagonists should be used as: A. controllers to prevent bronchospasm. B. controllers to inhibit inflammatory responses. C. relievers to treat acute bronchospasm. D. relievers to treat bronchospasm and inflammation. - ANSWER-B According to the 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?
D. wheezing with and without associated respiratory infections. - ANSWER-C Which of the following best describes the mechanism of action of short-acting beta2-agonists? A. reducer of inflammation B. inhibition of secretions C. modification of leukotrienes D. smooth muscle relaxation - ANSWER-D Regarding the use of long-acting beta2-agonists (LABAs), which of the following is not true? A. LABAs enhance the antiinflammatory 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 to relieve bronchospasms in asthma. - ANSWER-B Which of the following is the therapeutic objective of using inhaled ipratropium bromide? A. as an antiinflammatory. B. an increase in vagal tone in the airway C. inhibition of muscarinic cholinergic receptors D. an increase in salivary and mucous secretions - ANSWER-C 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 corticosteroid 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 an asthma flare should not exceed the equivalent of prednisone - ANSWER- C Compared with short-acting beta2-agonists, long-acting beta2-agonists: 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 - ANSWER-D 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 flares. 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. - ANSWER-A 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 who are intolerant of ICS. D. with poorly-controlled asthma who fail therapy with omalizumab. - ANSWER-B True or False? Most prescribers are well versed in the relative potency of ICS and prescribe an appropriate dose for the patient's clinical presentation. - ANSWER-FALSE
True or False? Approximately 80% of an ICS dose is systemically absorbed. - ANSWER-FALSE True or False? LTRA and ICS are interchangeable clinically because both groups of medications have equivalent anti- inflammatory effect. - ANSWER-FALSE True or False? Little systemic absorption of mast cell stabilizers occurs with inhaled or intranasal use. - ANSWER- TRUE True or False? Due to safety concerns, mast cell stabilizers are no longer available. - ANSWER-FALSE When discussing immunizations with a 67-year-old woman with chronic obstructive pulmonary disease (COPD), you advise that she: A. receive live attenuated influenza virus vaccine. B. avoid immunization against influenza because of the risk associated with the vaccine. C. receive inactivated influenza virus vaccine. D. take an antiviral for the duration of the influenza season. - ANSWER-C True or False? Seasonal influenza vaccination is generally recommended for all persons over 6 months of age. - ANSWER-TRUE True or False? A 66 yo woman is an acceptable candidate for the high dose inactivated influenza vaccine. - ANSWER- TRUE True or False? Cigarette smokers should not receive the pneumococcal vaccine until 65 yo. - ANSWER-FALSE True or False? A 52 yo immunocompetent patient with COPD who receives the pneumococcal vaccine should get revaccinated in 5 years. - ANSWER-FALSE 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 volume C. bronchodilation D. mucolytic action - ANSWER-C What is the desired therapeutic action of inhaled corticosteroids 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 - ANSWER-C 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
Which is the most appropriate statement about therapy for a severe COPD exacerbation in a 52-year- old man? A. A 5-day course azithromycin should be prescribed. B. A 10-day course of amoxicillin/clavulanate is advisable, C. A 7-day course of trimethoprim-sulfamethoxazole is recommended. D. The role of antimicrobial therapy is debated, even for severe disease. - ANSWER-D You see a 67-year-old man with stage IV (very severe) COPD who asks, "When should I use my home oxygen?" You respond: A. as needed when short of breath. B. primarily during sleep hours. C. preferably during waking hours. D. for at least 15 hours a day. - ANSWER-D With a COPD exacerbation, a chest x-ray should be obtained: A. routinely in all patients B. when attempting to rule out a concomitant pneumonia. C. if sputum volume is increased. D. when work of breathing is increased. - ANSWER-B Which of the following best describes the role of theophylline in COPD treatment? A. 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 - ANSWER-B All of the following are consistent with the GOLD COPD recommendation for pulmonary rehabilitation except: A. reserved for very severe COPD. B. goals include improvement in overall well-being. C. an underused therapeutic option. D. components aimed at reducing the deconditioning common in COPD. - ANSWER-A You examine a 28-year-old woman who has emigrated from a country where tuberculosis (TB) is endemic. She has documentation of receiving Bacille Calmette-Guérin (BCG) vaccine as a child. With this information, you consider that: A. she will always have a positive tuberculin skin test (TST) result. B. biannual chest radiographs are needed to assess her health status accurately. C. a TST finding of 10 mm or more induration should be considered a positive result. D. isoniazid therapy should be given for 6 months before TST is undertaken. - ANSWER-C A 33-year-old woman works in a small office with a man recently diagnosed with active pulmonary TB. Which of the following would be the best plan of care for this woman? A. She should receive TB chemoprophylaxis if her TST result is 5 mm or more in induration. B. Because of her age, TB chemoprophylaxis is contraindicated even in the presence of a positive TST result. C. If the TST result is positive but the chest radiograph is normal, no further evaluation or treatment is needed. D. Further evaluation is needed only if the TST result is 15 mm or more in induration. - ANSWER-A
Compared with TST, potential advantages of the QuantiFERON-TB Gold test (QTF-G) include all of the following except: A. ability to have entire testing process complete with one clinical visit. B. results are available within 24 hours. C. interpretation of test is not subject to reader bias. D. provides a prediction as to who is at greatest risk for active disease development. - ANSWER-D Does this patient have a reactive TST? A 45 yo woman with T2DM and chest radiograph finding consistent with previous TB and a 7 mm induration. - ANSWER-YES Does this patient have a reactive TST? A 21 yo man with no identifiable TB risk factors and a 10 mm induration. - ANSWER-NO Does this patient have a reactive TST? A 31 yo man with HIV and a 6 mm induration. - ANSWER-YES Does this patient have a reactive TST? A 45 yo woman from a country in which TB is endemic who has a 11 mm induration. - ANSWER-YES Does this patient have a reactive TST? A 42 yo woman with RA who is taking etanercept who has a 7 mm induration. - ANSWER-YES Risk factors for development of infection reactivation in patients with latent TB infection include all of the following except: A. diabetes mellitus. B. immunocompromise. C. long-term oral corticosteroid therapy. D. male gender. - ANSWER-D Clinical presentation of progressive primary TB most commonly includes all of the following except: A. malaise. B. fever. C. dry cough. D. frank hemoptysis. - ANSWER-D According to the American Thoracic Society/Infectious Disease Society of American (ATS/IDSA) Consensus Guidelines on the Management of Community-Acquired Pneumonia in Adults, which of the following is the most appropriate antimicrobial for treatment of community-acquired pneumonia (CAP):A 42-year-old man with no comorbidity, no reported drug allergy, and no recent antimicrobial use? A. azithromycin B. cefpodoxime C. trimethoprim-sulfamethoxazole D. ciprofloxacin - ANSWER-A According to the American Thoracic Society/Infectious Disease Society of American (ATS/IDSA) Consensus Guidelines on the Management of Community-Acquired Pneumonia in Adults, which of the following is the most appropriate antimicrobial for treatment of community-acquired pneumonia (CAP): A 46-year-old well woman with a history of a bilateral tubal ligation who is macrolide intolerant? A. clarithromycin B. amoxicillin
B. altered mental status. C. dyspnea. D. pleuritic chest pain. - ANSWER-B A diagnosis of pneumonia is confirmed by: A. sputum culture. B. sputum Gram stain C. bronchoalveolar lavage. D. chest radiograph. - ANSWER-D Which of the following is a quality of respiratory fluoroquinolones? A. activity against drug-resistant S. pneumoniae (DRSP) B. poor activity against atypical pathogens C. predominantly hepatic route of elimination D. poor activity against beta-lactamase producing organisms. - ANSWER-A The mechanism of resistance of DRSP is through the cell's: A. beta-lactamase production. B. hypertrophy of cell membrane. C. alteration in protein-binding sites. D. failure of DNA gyrase reversal. - ANSWER-C The primary mechanism of antimicrobial resistance of H. influenzae is through the organism's: A. beta-lactamase production. B. hypertrophy of cell membrane. C. alteration in protein-binding sites. D. failure of DNA gyrase reversal. - ANSWER-A Which of the following characteristics applies to macrolides? A. consistent activity against DRSP B. contraindicated in pregnancy C. effective against atypical pathogens D. unstable in the presence of beta-lactamase - ANSWER-C According to the ATS/IDSA guidelines, what is the usual length of antimicrobial therapy for the treatment of CAP for outpatients? A. less than 5 days B. 5 to 7 days C. 7 to 10 days D. 10 to 14 days - ANSWER-B Treat inpatient or outpatient? A 47 yo man with no confusion, BUN=17, RR=32, BP=110/52. - ANSWER-Outpatient Treat inpatient or outpatient? A 56 yo woman with no confusion. BUN=22. RR=27, BP 88/56. - ANSWER-Inpatient Treat inpatient or outpatient? A 72 yo man with confusion, BUN=18, RR=35, BP=102/66 - ANSWER-Inpatient Risk factors for pneumonia caused by P. aeruginosa include all of the following except:
A. mechanical ventilation. B. cystic fibrosis. C. community residence. D. chronic tracheostomy. - ANSWER-C Which of the following most accurately describes sputum analysis in the evaluation of the person with community-acquired pneumonia? sputum Gram stain and culture is A. Gram stain is routinely advised. B. Antimicrobial therapy should not be initiated until sputum specimen for culture has been obtained. C. Sputum analysis is not recommended in the majority of patients with community-acquired pneumonia. D. If required, chest physical therapy can be used to facilitate sputum production. - ANSWER-C Which of the following best describes the mechanism of transmission in an atypical pneumonia pathogen? A. microaspiration B. respiratory droplet C. surface contamination D. aerosolized contaminated water - ANSWER-B Risk factors for death resulting from pneumonia include: A. viral origin. B. history of allergic reaction to multiple antimicrobials. C. renal insufficiency. D. polycythemia. - ANSWER-C All of the following antimicrobial strategies help facilitate the development of resistant pathogens except: A. longer course of therapy. B. lower antimicrobial dosage. C. higher antimicrobial dosage. D. prescribing a broader spectrum agent. - ANSWER-C Findings of increased tactile fremitus and dullness to percussion at the right lung base in the person with CAP likely indicate an area of: A. atelectasis. B. pneumothorax. C. consolidation. D. cavitation. - ANSWER-C You are caring for a 52 yo man who is currently smoking 1.5 PPD, has a 40 pack-year history and has CAP. It is the third day of his antimicrobial therapy and he is without fever, less short of breath, and well hydrated. CXR shows a R lower lobe infiltrate. PE reveals peak inspiratory crackles with increased tactile fremitus in the R posterior thorax. Which of the following represents the most appropriate next step in this patient's care? A. His current plan of care should continue because he is improving clinically. B. A CXR should be taken today to confirm resolution of pneumonia. C. Given the persistence of abnormal thoracic findings, his antimicrobial therapy should be changed. D. A CT scan of the thorax is needed today to image better any potential thoracic abnormalities. - ANSWER-A
C. C. pneumonia D. B. pertussis - ANSWER-A A 34 yo woman presents with a 7 day history of cough with no fever or difficulty breathing. She is otherwise healthy. She is producing small amounts of yellow tinged sputum. As part of her treatment, you recommend. A. an antitussive B. an antihistamine C. a macrolide D. a beta-lactam antimicrobial - ANSWER-A Lung cancer ranks number ____ as a cause of cancer related death in men and women. A. 1 B. 2 C. 3 D. 4 - ANSWER-A Symptoms of lung cancer caused by a primary tumor include all of the following except: A. chest discomfort B. dyspnea C. hoarseness D. hemoptysis - ANSWER-C According to ACCP guidelines, annual screening for lung cancer should occur in 55 to 74 yo smokers with a smoking history of at least ___ pack-years. A. 15 B 30 C. 50 D. 70 - ANSWER-B Guidelines form the National Comprehensive Cancer Network recommend screening high risk smokers beginning at age: A. 40 B. 45 C. 50 D. 55 - ANSWER-C When compared with screening for breast cancer, screening for lung cancer results in: A. a lower number needed to screen to prevent one death B. approximately the same number needed to screen to prevent one death C. a higher number needed to screen to prevent one death D. a higher percentage of patients identified where can cancer can be prevented - ANSWER-A Current limitations of screening smokers with CT scan include all of the following except: A. a high false positive rate B. low sensitivity C. radiation exposure from multiple CT scans D. patient anxiety - ANSWER-B
