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Pharmacology for Nursing - KUHS BSc Nursing Syllabus

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UNIT 1: General Pharmacology (Principles of Therapeutics)

1.1 Introduction

• Drug: Any chemical substance that alters the biological function of an organism
• Pharmacology: Study of drugs and their interactions with living systems
• Therapeutics: The use of drugs to treat, prevent, or diagnose disease
• Pharmacognosy: Study of natural sources of drugs (plants, animals, minerals)

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1.2 Pharmacokinetics (What the Body Does to the Drug)

"The processes of absorption, distribution, metabolism, and excretion - collectively termed drug disposition - determine the concentration of drug delivered to target effector molecules."

• Harrison's Principles of Internal Medicine, 22nd Ed.

A - Absorption

D - Distribution

• Blood-Brain Barrier (BBB): Only lipid-soluble, uncharged drugs cross easily
• Plasma protein binding: Drugs bound to albumin are pharmacologically inactive; only free drug acts
• Volume of distribution (Vd): Apparent volume in which drug distributes; large Vd = drug goes into tissues
• Lipid solubility: Lipophilic drugs penetrate tissues more

M - Metabolism (Biotransformation)

• Phase I reactions: Oxidation, reduction, hydrolysis (cytochrome P450 enzymes)
• Phase II reactions: Conjugation (glucuronidation, sulfation) - makes drug more water-soluble
• Enzyme induction (e.g., rifampicin): Increases metabolism, reduces drug effect
• Enzyme inhibition (e.g., ketoconazole): Decreases metabolism, increases drug effect/toxicity

E - Excretion

• Half-life (t½): Time for plasma drug concentration to fall by 50%. Determines dosing interval.
• Steady state: Reached after ~4-5 half-lives of regular dosing
• Renal impairment reduces drug excretion - nurse must monitor for toxicity and expect dose adjustments

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1.3 Pharmacodynamics (What the Drug Does to the Body)

Drug-Receptor Theory

Dose-Response Relationship

• Therapeutic dose: Dose that produces desired effect
• Toxic dose: Dose that produces harmful effects
• Lethal dose (LD50): Dose lethal to 50% of a test population
• Effective dose (ED50): Dose effective in 50% of the population
• Therapeutic Index (TI) = LD50 / ED50 - Wider TI = safer drug
  • Narrow TI drugs require careful monitoring: digoxin, warfarin, lithium, phenytoin, aminoglycosides

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1.4 Routes of Drug Administration

• IV - fastest onset, used in emergencies
• IM - deep muscles (deltoid, gluteus, vastus lateralis)
• SC - fatty tissue under skin
• Intradermal (ID) - skin testing (e.g., Mantoux test)
• Intrathecal, epidural, intraosseous (specialised)

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1.5 Drug Nomenclature and Classification

1. Chemical name: Exact molecular structure (e.g., N-acetyl-p-aminophenol)
2. Generic/nonproprietary name: Approved common name (e.g., paracetamol/acetaminophen)
3. Brand/proprietary name: Manufacturer's trademarked name (e.g., Crocin, Dolo)

• By pharmacological action (e.g., analgesics, antihypertensives)
• By therapeutic use (e.g., antibiotics, antiemetics)
• By chemical structure (e.g., penicillins, benzodiazepines)
• By mechanism (e.g., ACE inhibitors, beta-blockers)

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1.6 Factors Affecting Drug Action

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1.7 Adverse Drug Reactions (ADRs)

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1.8 Drug Interactions

• Pharmacokinetic interactions: One drug alters the ADME of another (e.g., rifampicin increases metabolism of oral contraceptives)
• Pharmacodynamic interactions:
  • Synergism: Combined effect greater than individual (e.g., alcohol + sedatives)
  • Antagonism: One drug reduces effect of another (e.g., naloxone reverses opioids)
  • Additive: Combined effect equals sum of individual effects

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1.9 Indian Pharmacopoeia and Drug Laws

• Indian Pharmacopoeia (IP): Official compendium of drug standards in India
• Drugs and Cosmetics Act, 1940: Regulates import, manufacture, distribution, and sale of drugs
• Schedule H drugs: Prescription-only (e.g., antibiotics, psychotropics) - cannot be sold without a doctor's prescription
• Schedule X drugs: Habit-forming drugs requiring special prescription
• Narcotic Drugs and Psychotropic Substances (NDPS) Act, 1985: Controls narcotics and psychotropics

• Administer only prescribed drugs
• Verify drug name, dose, route, time, patient identity (5 Rights: right drug, right dose, right route, right time, right patient - extended to 9 rights in modern practice)
• Keep controlled substances locked; maintain records

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UNIT 2: Antiseptics and Disinfectants

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UNIT 3: Drugs Acting on the GI System

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UNIT 4: Analgesics and Anti-inflammatory Drugs

Non-opioid Analgesics (NSAIDs)

Opioid Analgesics (Narcotic)

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UNIT 5: Antimicrobials

Antibiotics

Antitubercular Drugs (ATDs)

• RIPE = Rifampicin + Isoniazid + Pyrazinamide + Ethambutol
  • Rifampicin: turns urine/body fluids orange-red (warn patient); enzyme inducer
  • Isoniazid: peripheral neuropathy - give pyridoxine (Vit B6) to prevent
  • Pyrazinamide: hepatotoxicity, hyperuricaemia
  • Ethambutol: optic neuritis - monitor visual acuity

Antimalarials

Antiviral Drugs

Antifungal Agents

Anthelmintics

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UNIT 6: Drugs Acting on the Cardiovascular System

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UNIT 7: Drugs Acting on the Respiratory System

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UNIT 8: Drugs Acting on the Nervous System

CNS Depressants

Antiepileptic Drugs (AEDs)

Antipsychotics (Neuroleptics)

Antidepressants

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UNIT 9: Drugs Acting on the Endocrine System

Insulin and Oral Hypoglycaemics

Thyroid Drugs

Corticosteroids

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UNIT 10: Drugs Acting on the Reproductive System

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UNIT 11: Rational Use of Drugs and Nurse's Role

1. Right drug
2. Right dose
3. Right route
4. Right time
5. Right patient
6. Right documentation
7. Right reason
8. Right response
9. Right to refuse

• Know the drug before giving it (action, dose, side effects)
• Verify prescription clearly; clarify doubts before administration
• Never administer an unlabelled drug
• Monitor therapeutic effects and ADRs after administration
• Educate patients about their medications
• Maintain medication records accurately
• Report medication errors immediately
• Handle controlled drugs per hospital and legal protocols
• Store drugs correctly (e.g., insulin refrigerated, light-sensitive drugs in dark containers)

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UNIT 12: Key Drug Antidotes (Important for Examinations)

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Quick Revision: High-Yield Points for KUHS Exams

1. Narrow Therapeutic Index drugs (require monitoring): Digoxin, Warfarin, Phenytoin, Lithium, Theophylline, Aminoglycosides
2. Nephrotoxic antibiotics: Aminoglycosides (gentamicin), Vancomycin, Amphotericin B
3. Ototoxic drugs: Aminoglycosides, Furosemide, Aspirin (high dose)
4. Teratogenic drugs (Class X/D): Thalidomide, Warfarin, Phenytoin, Valproate, ACEi, Methotrexate, Tetracyclines
5. Enzyme inducers: Rifampicin, Phenytoin, Carbamazepine, Phenobarbitone, Alcohol (chronic)
6. Enzyme inhibitors: Ketoconazole, Erythromycin, Ciprofloxacin, Cimetidine
7. Drugs requiring empty stomach: Levothyroxine, Proton pump inhibitors, Sucralfate
8. Drug-induced colour change in urine: Rifampicin (orange-red), Iron supplements (black stools), Nitrofurantoin (yellow-brown)
9. Antidotes (see Unit 12 above) - commonly asked in exams
10. Five Rights should be recited as 9 Rights in clinical context

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Respiratory Drugs - Pharmacology for Nursing (KUHS)

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Overview of Respiratory Conditions Requiring Drug Therapy

"Asthma is a chronic disease characterized by hyperresponsive airways that affects over 341 million patients worldwide. COPD is currently the fourth leading cause of death in the world and is predicted to become the third leading cause by 2030."

• Lippincott Illustrated Reviews: Pharmacology

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SECTION 1: BRONCHODILATORS

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1A. Beta-2 Adrenergic Agonists

Short-Acting Beta-2 Agonists (SABAs) - "Relievers"

Long-Acting Beta-2 Agonists (LABAs) - "Controllers"

CRITICAL: LABAs must NEVER be used alone in asthma without an inhaled corticosteroid (ICS). They are always combined with ICS in asthma. Monotherapy with LABAs increases risk of fatal asthma attacks.

• Tremor (skeletal muscle beta-2 stimulation) - most common
• Tachycardia, palpitations
• Hypokalaemia (with high doses - drives K+ into cells)
• Headache
• Throat irritation (inhaled forms)

• Teach correct inhaler technique - most patients use inhalers incorrectly
• SABAs = rescue only; if using more than 2x/week, review with doctor
• Monitor heart rate after nebulisation
• Warn patient about tremor - it reduces with time
• Shake MDI before use; use a spacer in children and when poor coordination exists

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1B. Anticholinergic Bronchodilators (Muscarinic Antagonists)

Short-Acting Muscarinic Antagonists (SAMAs)

Long-Acting Muscarinic Antagonists (LAMAs)

• Dry mouth (most common - often causes patients to stop using it)
• Urinary retention (caution in BPH - benign prostatic hyperplasia)
• Constipation
• Blurred vision (if drug accidentally gets into eyes - warn patient)
• Tachycardia
• Paradoxical bronchospasm (rare)

• Warn patient not to spray into eyes (especially with MDI forms)
• Caution in glaucoma and BPH
• Dry mouth: encourage sips of water, good oral hygiene
• Tiotropium: use HandiHaler device correctly - do not swallow capsule
• Unlike beta-2 agonists, slower onset - not for acute attacks (except ipratropium which has moderate speed)

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1C. Xanthine Derivatives (Methylxanthines)

• At therapeutic levels: Nausea, vomiting, headache, restlessness, insomnia
• Toxic levels: Tachycardia, arrhythmias
• Severely toxic: Seizures, cardiac arrest

• Liver disease, heart failure, elderly age
• Drug interactions: Cimetidine, ciprofloxacin, erythromycin (enzyme inhibitors increase levels)
• Fever reduces clearance

• Rifampicin, phenytoin, carbamazepine, smoking (enzyme inducers)

• Monitor theophylline blood levels regularly
• Signs of toxicity: nausea/vomiting, agitation, fast/irregular heartbeat, seizures - report immediately
• Give sustained-release form with food but avoid high-fat meals
• Encourage patient not to smoke (smoking reduces levels)
• Do not crush or chew sustained-release tablets
• IV aminophylline must be given slowly (rapid IV = cardiac arrhythmia/death)

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SECTION 2: ANTI-INFLAMMATORY DRUGS FOR RESPIRATORY USE

2A. Inhaled Corticosteroids (ICS) - "Preventers"

• Oral candidiasis (thrush in mouth/throat) - most important
• Hoarseness (dysphonia) - due to steroid effect on vocal cords
• Cough and throat irritation

• Growth suppression in children
• Adrenal suppression
• Osteoporosis (long-term high dose)
• Skin bruising

• Always rinse mouth with water and spit after using ICS - prevents oral candidiasis
• Use a spacer - improves lung delivery, reduces oral deposition
• Educate patient: "This inhaler prevents attacks - it does not stop an attack in progress"
• Never stop ICS suddenly
• For nasal steroid sprays: aim toward the nasal passage walls (not the septum) to avoid nosebleeds

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2B. Systemic Corticosteroids

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2C. Leukotriene Receptor Antagonists (LTRAs)

• Montelukast: Boxed warning - neuropsychiatric effects - agitation, depression, sleep disturbances, suicidal ideation
• Zafirlukast/Zileuton: elevated liver enzymes - monitor LFTs
• Headache, dyspepsia

• Ask patients/parents about mood changes, sleep disturbances, depression (especially in children on montelukast)
• Give montelukast at bedtime
• Take zafirlukast on empty stomach

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2D. Mast Cell Stabilisers

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SECTION 3: DRUGS FOR ALLERGIC RHINITIS

3A. Antihistamines (H1 Receptor Antagonists)

First-Generation (Sedating) Antihistamines

• Sedation/drowsiness (most prominent - "use before bed")
• Anticholinergic effects: dry mouth, urinary retention, blurred vision, constipation
• Paradoxical CNS stimulation in children
• Performance impairment (do not drive!)

Second-Generation (Non-Sedating) Antihistamines - Preferred

• Educate patient: 1st-gen = do not drive, do not drink alcohol
• 2nd-gen preferred for daytime use
• Administer 1st-gen at night if sedation is a concern
• Warn about anticholinergic effects of 1st-gen (dry mouth, urinary retention)

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3B. Nasal Decongestants (Alpha-Adrenergic Agonists)

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SECTION 4: DRUGS ACTING ON COUGH

4A. Antitussives (Cough Suppressants)

• Do not give codeine to children under 12 (risk of fatal respiratory depression - especially in CYP2D6 rapid metabolisers)
• Dextromethorphan: caution in patients on SSRIs/MAOIs (serotonin syndrome)
• Increase fluids - helps loosen secretions

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4B. Expectorants

• Encourage plenty of fluids (6-8 glasses/day) - potentiates expectorant effect
• Effective in productive cough; avoid combining with antitussives (works against each other)

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4C. Mucolytics

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SECTION 5: COMBINATION INHALERS

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SECTION 6: INHALER DEVICES AND TECHNIQUE

• MDI (Metered Dose Inhaler): Pressurised; must coordinate breathing with actuation; use spacer for children and elderly
• DPI (Dry Powder Inhaler): Breath-activated; no coordination needed; cannot use with spacer
• Nebuliser: Converts liquid drug to fine aerosol mist; for severe attacks, children, ICU

• Reduces oropharyngeal deposition (less oral candidiasis with ICS)
• Improves lung delivery
• Eliminates need for breath-actuation coordination

1. Shake well before use
2. Exhale fully
3. Place mouthpiece in mouth, seal lips
4. Begin slow deep inhalation, then press canister
5. Continue inhaling slowly and deeply
6. Hold breath for 10 seconds
7. Exhale slowly through nose

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SECTION 7: DRUGS FOR SPECIFIC SITUATIONS

Acute Severe Asthma (Status Asthmaticus) - Emergency

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Oxygen Therapy Note (COPD)

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QUICK SUMMARY TABLE

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HIGH-YIELD EXAM POINTS (KUHS)

1. SABA = rescue inhaler (salbutamol); ICS = preventer inhaler (budesonide/beclomethasone)
2. LABAs must never be used alone in asthma - always combine with ICS
3. Rinse mouth after ICS - prevents oral candidiasis
4. Theophylline has narrow therapeutic index (10-20 mcg/mL) - monitor levels
5. Ipratropium - caution in glaucoma and BPH; don't spray into eyes
6. Montelukast boxed warning - neuropsychiatric effects (depression, suicidal ideation)
7. Topical nasal decongestants - max 3-5 days (rebound congestion if used longer)
8. 1st-gen antihistamines = sedating + anticholinergic; 2nd-gen = non-sedating (preferred)
9. In COPD: target SpO2 88-92% (not 94-98%) - controlled oxygen therapy
10. Status asthmaticus: Salbutamol nebuliser + Ipratropium + IV hydrocortisone + O2

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MCQ Practice: Respiratory Drugs

KUHS BSc Nursing Pharmacology

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SECTION A: Bronchodilators (Q1-Q15)

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• A) Salmeterol inhaler
• B) Salbutamol (Albuterol) nebulisation
• C) Theophylline IV
• D) Montelukast oral

✅ Answer: B - Salbutamol nebulisation Salbutamol is a short-acting beta-2 agonist (SABA) - it is the first-line rescue drug for acute asthma. Salmeterol (LABA) is NOT for acute attacks. Theophylline IV is a second-line add-on. Montelukast does not relieve acute bronchospasm.

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• A) Shake the inhaler well before use
• B) Exhale fully before pressing the canister
• C) Use this inhaler every morning to prevent asthma attacks
• D) Hold your breath for 10 seconds after inhaling

✅ Answer: C - Use every morning to prevent asthma attacks Salbutamol (SABA) is a rescue inhaler used only when symptoms occur - NOT a preventer. Using it every morning suggests uncontrolled asthma requiring review. Inhalers used to prevent attacks are ICS (beclomethasone, budesonide) or LABAs combined with ICS.

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• A) Stop the drug immediately - this is a serious reaction
• B) Report it as a severe adverse drug reaction
• C) Reassure the patient that tremor is an expected, dose-related side effect that usually decreases over time
• D) Switch to ipratropium immediately

✅ Answer: C - Reassure - tremor is expected Skeletal muscle tremor is the most common adverse effect of beta-2 agonists due to stimulation of beta-2 receptors in skeletal muscle. It is dose-related and usually decreases with continued therapy. It is not a reason to stop the drug.

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• A) Salbutamol
• B) Terbutaline
• C) Levosalbutamol
• D) Salmeterol

✅ Answer: D - Salmeterol Salmeterol acts for 12 hours and is used for maintenance therapy, not acute attacks. Salbutamol, Terbutaline, and Levosalbutamol are all short-acting (SABA).

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• A) Administer as prescribed without question
• B) Clarify with the doctor - salmeterol should not be used as monotherapy in asthma
• C) Teach the patient to use it as a rescue inhaler
• D) Add an oral steroid without consulting the doctor

✅ Answer: B - Clarify with the doctor LABAs must NEVER be used alone in asthma without an inhaled corticosteroid (ICS). Monotherapy with LABAs increases the risk of fatal asthma attacks. This is a critical nursing safety responsibility.

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• A) Stimulating beta-2 receptors on bronchial smooth muscle
• B) Blocking muscarinic (M3) receptors to prevent bronchoconstriction
• C) Inhibiting phosphodiesterase to increase cAMP
• D) Stabilising mast cell membranes

✅ Answer: B - Blocking muscarinic (M3) receptors Ipratropium is an anticholinergic (muscarinic antagonist). It blocks M3 receptors in bronchial smooth muscle, preventing acetylcholine-induced bronchoconstriction.

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• A) Every 4-6 hours as needed
• B) Twice daily (morning and night)
• C) Once daily
• D) Only during acute exacerbations

✅ Answer: C - Once daily Tiotropium is a long-acting muscarinic antagonist (LAMA) with a 24-hour duration of action. It is the cornerstone of COPD maintenance therapy, given once daily.

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• A) Eye irritation and possible blurred vision / acute angle-closure glaucoma
• B) Eye redness due to allergy
• C) No effect - the drug is only inhaled
• D) Improved vision due to mydriasis

✅ Answer: A - Blurred vision / acute angle-closure glaucoma Ipratropium has anticholinergic properties. If it gets into the eyes, it can cause mydriasis (pupil dilation), blurred vision, and precipitate acute angle-closure glaucoma. This is a known complication - nurses must warn patients to avoid spraying toward the eyes.

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• A) Hypokalaemia
• B) Urinary retention
• C) Oral candidiasis
• D) Rebound congestion

✅ Answer: B - Urinary retention Anticholinergic drugs (tiotropium, ipratropium) block muscarinic receptors in the urinary bladder. In patients with BPH who already have outflow obstruction, anticholinergics can precipitate acute urinary retention. Monitor for inability to void.

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• A) 1-5 mcg/mL
• B) 5-10 mcg/mL
• C) 10-20 mcg/mL
• D) 20-30 mcg/mL

✅ Answer: C - 10-20 mcg/mL Theophylline has a narrow therapeutic index. The therapeutic range is 10-20 mcg/mL. Below this: no effect. Above 20 mcg/mL: toxicity (nausea, arrhythmias, seizures).

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• A) Theophylline toxicity - ciprofloxacin raises theophylline levels
• B) Reduced theophylline effect - ciprofloxacin lowers theophylline levels
• C) Ciprofloxacin toxicity only
• D) No interaction between these drugs

✅ Answer: A - Theophylline toxicity Ciprofloxacin is a CYP1A2 enzyme inhibitor. It reduces the metabolism of theophylline, raising its plasma levels. Monitor for signs of toxicity: nausea, vomiting, restlessness, tachycardia, seizures. Dose reduction of theophylline may be needed.

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• A) Give as a rapid IV bolus for fast effect
• B) Administer slowly via IV infusion - rapid injection can cause cardiac arrhythmia and death
• C) Mix with normal saline only, never 5% dextrose
• D) Give undiluted for best absorption

✅ Answer: B - Administer slowly via IV infusion Rapid IV aminophylline can cause severe hypotension, cardiac arrhythmias, and cardiac arrest. It must always be given as a slow IV infusion, typically over 20-30 minutes with continuous cardiac monitoring.

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• A) Salbutamol PRN
• B) Inhaled beclomethasone alone
• C) Long-acting muscarinic antagonist (e.g., tiotropium)
• D) Systemic prednisolone daily

✅ Answer: C - Long-acting muscarinic antagonist (tiotropium) According to GOLD guidelines, long-acting bronchodilators (LAMAs or LABAs) are the foundation of COPD maintenance therapy. Tiotropium (LAMA) is the gold standard. Salbutamol is only for rescue. ICS alone is not recommended in COPD. Oral steroids are not for long-term COPD.

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• A) Stimulates beta-2 adrenergic receptors
• B) Blocks muscarinic receptors
• C) Inhibits phosphodiesterase, preventing cAMP breakdown → smooth muscle relaxation
• D) Stabilises mast cells

✅ Answer: C - Inhibits phosphodiesterase Theophylline (xanthine derivative) inhibits the enzyme phosphodiesterase, which normally breaks down cAMP. When cAMP accumulates, smooth muscle relaxes → bronchodilation. It also blocks adenosine receptors.

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• A) Seizures
• B) Cardiac arrest
• C) Nausea, vomiting, and restlessness
• D) Respiratory depression

✅ Answer: C - Nausea, vomiting, restlessness Early theophylline toxicity presents with GI symptoms (nausea, vomiting, abdominal pain) and CNS stimulation (restlessness, headache, insomnia). Later toxicity causes arrhythmias; severe toxicity causes seizures and cardiac arrest.

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SECTION B: Inhaled Corticosteroids & Anti-inflammatory Drugs (Q16-Q25)

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• A) Oral herpes simplex
• B) Oral candidiasis (thrush) due to inhaled corticosteroid use
• C) Angioedema due to drug allergy
• D) Stevens-Johnson syndrome

✅ Answer: B - Oral candidiasis Inhaled corticosteroids (ICS) deposit in the oropharynx and suppress local immunity, predisposing to fungal overgrowth (Candida albicans). This is the most important local adverse effect of ICS. Prevention: rinse mouth with water and spit after every dose.

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• A) Use it only when you feel breathless
• B) Rinse your mouth with water and spit after each use
• C) It will give immediate relief during an asthma attack
• D) Double the dose if you miss a day

✅ Answer: B - Rinse mouth with water and spit Rinsing prevents oral candidiasis, the most common adverse effect of ICS. Never use ICS as a rescue inhaler (choice A is wrong). ICS takes 1-2 weeks for full effect (choice C wrong). Double dosing is never recommended (choice D wrong).

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• A) "Yes, budesonide is ineffective - you need a different drug"
• B) "Budesonide is a preventer inhaler that reduces airway inflammation over time. It does not relieve acute breathlessness. Use your salbutamol inhaler for immediate relief"
• C) "Increase the dose of budesonide until it works"
• D) "Stop budesonide and use salbutamol twice daily instead"

✅ Answer: B - Budesonide is a preventer, not a reliever ICS reduce chronic airway inflammation and prevent attacks. Full effect takes 1-2 weeks. For acute relief, a SABA (salbutamol) is used. This is a very commonly confused concept among patients and nurses.

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• A) Combivent (Salbutamol + Ipratropium)
• B) Seretide / Advair (Salmeterol + Fluticasone)
• C) Spiriva (Tiotropium alone)
• D) Ventolin (Salbutamol alone)

✅ Answer: B - Seretide/Advair (Salmeterol + Fluticasone) Seretide combines a LABA (salmeterol) with an ICS (fluticasone) - a controller combination for asthma and COPD. Combivent is SABA + SAMA (both bronchodilators). Spiriva and Ventolin are single drugs.

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• A) Stimulating beta-2 receptors
• B) Blocking leukotriene receptors (CysLT1) to reduce bronchoconstriction and inflammation
• C) Inhibiting histamine release
• D) Blocking muscarinic receptors

✅ Answer: B - Blocking leukotriene receptors Montelukast is a leukotriene receptor antagonist (LTRA). Leukotrienes are inflammatory mediators that cause bronchoconstriction and mucus secretion. Blocking their receptors reduces these effects. Used for asthma prevention and allergic rhinitis.

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• A) Reassure the parent that this is a normal side effect and continue the drug
• B) Report this as a potential neuropsychiatric adverse effect of montelukast (boxed warning) and refer to the doctor immediately
• C) Increase the montelukast dose
• D) Stop the drug without consulting the doctor

✅ Answer: B - Report to doctor - this is a boxed warning Montelukast carries a boxed warning (the most serious FDA warning) for neuropsychiatric effects including agitation, depression, sleep disturbances, hallucinations, and suicidal ideation - particularly in children. The drug should be reviewed by the prescriber.

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• A) A patient needing immediate relief from an acute asthma attack
• B) An asthma patient who also takes aspirin/NSAIDs and develops respiratory symptoms after taking them
• C) A patient with COPD needing primary bronchodilation
• D) An ICU patient in status asthmaticus

✅ Answer: B - Aspirin-exacerbated respiratory disease (AERD) LTRAs are specifically indicated for aspirin-sensitive asthma (AERD), exercise-induced bronchospasm, and as add-on therapy to ICS in persistent asthma. They do NOT relieve acute attacks (choice A wrong) and are not primary therapy for COPD.

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• A) Immediate relief during an acute asthma attack
• B) Prevention of exercise-induced bronchospasm when taken before exercise
• C) Treatment of COPD exacerbations
• D) Replacement of corticosteroids in severe asthma

✅ Answer: B - Prevention of exercise-induced bronchospasm Cromolyn stabilises mast cells and prevents degranulation. When taken 15-20 minutes before exercise, it can prevent exercise-induced bronchospasm. It has NO role in acute attacks (it is not a bronchodilator) and is not used in COPD.

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• A) Rapid hair growth
• B) Growth suppression
• C) Hyperactivity
• D) Tooth discolouration

✅ Answer: B - Growth suppression High-dose ICS can cause systemic effects including suppression of the hypothalamic-pituitary-adrenal (HPA) axis, which may slow linear growth in children. This is why ICS should be used at the lowest effective dose in paediatric patients.

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• A) Stop abruptly after the 7th dose
• B) A short 7-day course can be stopped abruptly without tapering
• C) Always taper gradually over 3 months
• D) Continue indefinitely until reviewed

✅ Answer: B - Short courses can be stopped abruptly Short courses of oral corticosteroids (up to 7-14 days) do not cause significant adrenal suppression and can be stopped without tapering. Tapering is required only for long-term users (>3-4 weeks) to allow the adrenal glands to recover normal cortisol production.

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SECTION C: Drugs for Allergic Rhinitis (Q26-Q35)

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• A) Severe hypertension
• B) Drowsiness impairing patient care and safety
• C) Bronchospasm in asthmatic patients on the ward
• D) Drug-induced hypertension

✅ Answer: B - Drowsiness impairing performance Chlorphenamine is a first-generation antihistamine with significant sedating properties due to H1 blockade in the CNS. Healthcare professionals should NOT take sedating antihistamines before clinical work - it impairs reaction time, concentration, and patient safety. Second-generation (cetirizine, loratadine) are preferred.

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• A) Chlorphenamine (Piriton)
• B) Diphenhydramine (Benadryl)
• C) Promethazine (Phenergan)
• D) Cetirizine (Zyrtec)

✅ Answer: D - Cetirizine Cetirizine is a second-generation antihistamine with minimal CNS penetration - it does not cause significant sedation and does not impair driving. First-generation antihistamines (choices A, B, C) all cause sedation and are contraindicated for people who drive or operate machinery.

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• A) Fexofenadine
• B) Loratadine
• C) Promethazine (Phenergan)
• D) Cetirizine

✅ Answer: C - Promethazine Promethazine is a first-generation antihistamine that also blocks dopamine receptors in the chemoreceptor trigger zone (CTZ) and vestibular apparatus - giving it antiemetic and anti-motion sickness properties. It is used for nausea, vomiting, pre-operative sedation, and motion sickness.

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• A) Blocking H1 receptors in nasal mucosa
• B) Stimulating alpha-adrenergic receptors → vasoconstriction → reduced mucosal oedema
• C) Inhibiting leukotriene synthesis
• D) Stabilising mast cells

✅ Answer: B - Alpha-adrenergic stimulation → vasoconstriction Xylometazoline and oxymetazoline are alpha-adrenergic agonists. They constrict dilated blood vessels in the nasal mucosa, reducing mucosal engorgement and oedema, thereby relieving nasal blockage.

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• A) Drug allergy to oxymetazoline
• B) Bacterial rhinitis developing
• C) Rebound congestion (Rhinitis Medicamentosa) due to prolonged use of nasal decongestant
• D) Increased sinusitis due to the drug

✅ Answer: C - Rebound congestion (Rhinitis Medicamentosa) Topical nasal decongestants should not be used for more than 3-5 days. Prolonged use causes rebound vasodilatation when the drug wears off - nasal congestion becomes worse than the original complaint. Patients become dependent on the spray. Treatment involves gradual withdrawal.

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• A) The drug is not effective - switch to a different drug
• B) Intranasal corticosteroids take 1-2 weeks to reach maximum effect - continue regular use
• C) Double the dose for faster effect
• D) Add oral steroids immediately

✅ Answer: B - Takes 1-2 weeks for full effect Intranasal corticosteroids are the most effective treatment for allergic rhinitis but have a delayed onset of 3 hours to 1-2 weeks for full effect. Patients need to be counselled about this to prevent early discontinuation.

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• A) Seasonal allergic rhinitis
• B) Benign prostatic hyperplasia (BPH)
• C) Hypertension
• D) Peptic ulcer disease

✅ Answer: B - Benign prostatic hyperplasia First-generation antihistamines have anticholinergic effects - they block muscarinic receptors in the urinary bladder sphincter. In BPH patients who already have urinary outflow obstruction, this can precipitate acute urinary retention. Also contraindicated in narrow-angle glaucoma.

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• A) Chlorphenamine
• B) Diphenhydramine
• C) Hydroxyzine
• D) Fexofenadine

✅ Answer: D - Fexofenadine Fexofenadine (Allegra) is a second-generation antihistamine with minimal CNS penetration. It is the least sedating of all antihistamines. Chlorphenamine, diphenhydramine, and hydroxyzine are all first-generation sedating antihistamines.

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• A) Take with a full glass of orange juice for better absorption
• B) Avoid taking with antacids or fruit juice - they reduce absorption
• C) Take with high-fat food
• D) Take on empty stomach only

✅ Answer: B - Avoid antacids and fruit juice Fexofenadine absorption is significantly reduced by antacids (aluminium/magnesium-containing) and fruit juices (grapefruit, orange, apple). Take with water, not fruit juice. Allow 2-hour gap between fexofenadine and antacid administration.

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• A) Antitussive + expectorant
• B) Antihistamine + nasal decongestant
• C) ICS inhaler + LABA
• D) Mucolytic + antibiotic

✅ Answer: B - Antihistamine + nasal decongestant Antihistamines address sneezing, itching, and rhinorrhoea (histamine-mediated symptoms). Decongestants address nasal congestion (vascular engorgement). Combination products are commonly available (e.g., cetirizine + pseudoephedrine) for patients with both symptoms.

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SECTION D: Cough Medicines and Special Situations (Q36-Q45)

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• A) Codeine linctus to suppress the cough
• B) Ambroxol (mucolytic) to thin the secretions
• C) Dextromethorphan to suppress cough reflex
• D) Antihistamine to dry up secretions

✅ Answer: B - Ambroxol (mucolytic) In productive cough with thick secretions, a mucolytic such as ambroxol or acetylcysteine (NAC) is appropriate to thin and loosen secretions for easier expectoration. Antitussives (codeine, dextromethorphan) are CONTRAINDICATED in productive cough - suppressing the cough will cause retention of secretions.

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• A) Morphine
• B) Pholcodine
• C) Dextromethorphan
• D) Tramadol

✅ Answer: C - Dextromethorphan Dextromethorphan acts on the cough centre in the medulla but lacks significant opioid activity (it is a non-opioid antitussive). It is widely available OTC and has much lower abuse potential than codeine. It can cause serotonin syndrome if combined with SSRIs/MAOIs.

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• A) Children cannot swallow the tablets
• B) It causes more sedation in children
• C) Some children are ultra-rapid CYP2D6 metabolisers who convert codeine to high levels of morphine, causing fatal respiratory depression
• D) It causes rebound cough in children

✅ Answer: C - Ultra-rapid CYP2D6 metabolisers can produce lethal morphine levels Codeine is a prodrug converted to morphine by CYP2D6 enzymes. Children who are ultra-rapid CYP2D6 metabolisers convert codeine to morphine dangerously quickly, leading to opioid overdose and fatal respiratory depression. This led to worldwide bans on codeine in children under 12.

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• A) Avoid water intake to prevent nausea
• B) Drink plenty of water (6-8 glasses/day) to maximise the expectorant effect
• C) Take the drug only at bedtime
• D) Avoid taking it with food

✅ Answer: B - Drink plenty of water Adequate hydration is essential with expectorants. Water thins respiratory secretions and works synergistically with guaifenesin to loosen mucus. Without adequate fluids, expectorants are less effective.

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• A) The patient has eaten a full meal
• B) A bronchodilator (salbutamol) is kept ready - NAC can cause bronchospasm
• C) Blood glucose monitoring is available
• D) The patient is lying flat

✅ Answer: B - Keep a bronchodilator ready Acetylcysteine (NAC) used as a mucolytic via nebulisation can cause bronchospasm, particularly in patients with reactive airway disease (asthma). A bronchodilator should always be available before administration, and some protocols pre-treat with salbutamol nebulisation.

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• A) Loratadine
• B) Montelukast
• C) IV Magnesium sulphate
• D) IV Theophylline (aminophylline)

✅ Answer: C - IV Magnesium sulphate IV magnesium sulphate is now recommended in severe/life-threatening asthma unresponsive to initial treatment. It causes bronchial smooth muscle relaxation through calcium antagonism. Aminophylline (answer D) is still used but carries more risk; most guidelines prefer magnesium first.

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• A) 95-100% (high flow oxygen to maximise oxygenation)
• B) 88-92% (controlled low-flow oxygen)
• C) Below 85% to maintain hypoxic drive
• D) SpO2 monitoring is not needed in COPD

✅ Answer: B - 88-92% (controlled low-flow oxygen) In COPD patients who are chronic CO2 retainers, high-flow oxygen removes the hypoxic drive (the only remaining stimulus to breathe) and can cause respiratory depression and CO2 narcosis. Target SpO2 is 88-92% using a Venturi mask (24% or 28% oxygen). The normal target (94-98%) applies to patients without COPD.

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• A) It converts the MDI to a dry powder device
• B) It reduces the need to coordinate breathing with actuation, increases lung delivery, and reduces oropharyngeal deposition
• C) It filters all particles above 5 microns for safety
• D) It is only useful in adults, not children

✅ Answer: B - Reduces coordination need, improves lung delivery, reduces oral deposition Spacers are especially valuable in children, elderly, and anyone with poor hand-breath coordination. They also reduce oral steroid deposition (reducing risk of candidiasis with ICS) and improve the fraction of drug reaching the lungs.

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• A) Shake the device well before use
• B) Use a spacer device with the DPI
• C) Inhale forcefully and deeply to activate the device
• D) Connect to a nebuliser machine for administration

✅ Answer: C - Inhale forcefully and deeply DPIs are breath-activated - the force of inhalation disaggregates the powder and carries it into the lungs. Unlike MDIs, DPIs: (a) do NOT need shaking; (b) cannot be used with a spacer; (c) do NOT require hand-breath coordination. The patient must inhale with sufficient force.

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• A) Ignore it as long as both patients have the same drug prescribed
• B) Advise the colleague that inhalers are single-patient devices to prevent cross-infection; each patient must have their own labelled inhaler
• C) Wipe the mouthpiece with alcohol and continue
• D) Report to the pharmacist for a new inhaler label

✅ Answer: B - Each patient must have their own inhaler Inhalers are single-patient devices. Sharing them risks cross-infection (respiratory pathogens including MRSA, Mycobacterium tuberculosis, influenza virus). This is a basic infection control principle in nursing practice.

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SECTION E: High-Order Application Questions (Q46-Q50)

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• A) Add montelukast orally
• B) Add salbutamol nebulisation + oral prednisolone + antibiotic (amoxicillin/doxycycline)
• C) Double the dose of tiotropium
• D) Start IV aminophylline immediately

✅ Answer: B - Salbutamol + prednisolone + antibiotic Acute COPD exacerbation with purulent (yellow/green) sputum suggests infective trigger. Management: (1) Short-acting bronchodilator (salbutamol ± ipratropium) for acute relief; (2) Short course oral prednisolone (5 days) to reduce inflammation; (3) Antibiotic for infective exacerbation; (4) Controlled oxygen to SpO2 88-92%.

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• A) Theophylline
• B) Oral prednisolone daily
• C) Low-dose inhaled corticosteroid (e.g., beclomethasone or budesonide)
• D) Salmeterol LABA

✅ Answer: C - Low-dose inhaled corticosteroid Step 2 in asthma management = add a low-dose ICS as the preferred controller medication. Symptoms 3x/week (>2x/week) indicate the need to step up. ICS is the cornerstone of asthma control at step 2 and above. Salmeterol (LABA) is added at step 3 and only in combination with ICS.

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• A) Use the budesonide first, then salbutamol if not better
• B) Use salbutamol (the blue/rescue inhaler) - it acts within minutes. Use budesonide every day to prevent attacks, not during attacks
• C) Use both inhalers at the same time for fastest effect
• D) Budesonide is faster - use it first

✅ Answer: B - Salbutamol for acute attack; budesonide daily for prevention This tests a fundamental nursing education point: SABA (salbutamol) = reliever/rescue = used when symptoms occur; ICS (budesonide) = preventer/controller = used every day whether or not symptomatic. Confusion between the two is the most common patient education error in asthma management.

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• A) High-dose fluticasone
• B) Budesonide - it has the most safety data in pregnancy
• C) Triamcinolone systemic injection
• D) Oral prednisolone is safer than inhaled steroids in pregnancy

✅ Answer: B - Budesonide Budesonide has the largest safety database in pregnancy and is the preferred ICS according to multiple obstetric guidelines (including Creasy & Resnik's Maternal-Fetal Medicine). The general principle is: uncontrolled asthma is more dangerous to the fetus than well-managed asthma on ICS.

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• A) Increased theophylline levels and risk of toxicity
• B) Decreased theophylline levels due to enzyme induction by tobacco smoke - the dose may need to be increased
• C) No change in theophylline levels - smoking does not affect drug metabolism
• D) Theophylline will cause more bronchospasm in smokers

✅ Answer: B - Decreased theophylline levels (enzyme induction by smoking) Tobacco smoke is a potent inducer of CYP1A2 enzymes in the liver, which significantly increases theophylline metabolism and reduces its plasma levels. Smokers may require up to 50% higher theophylline doses than non-smokers. When a patient stops smoking, theophylline levels rise and toxicity can occur - monitor closely during smoking cessation.

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Score Yourself

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Quick-Recall Summary for Last-Minute Revision

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