Seven respiratory meds you’ll actually see on the NCLEX—organized by what they do and exactly what the nurse does. We walk through Albuterol, Ipratropium, Salmeterol, Budesonide, Prednisone, Montelukast, Acetylcysteine (AIS-BPMA), priority assessments, true black-box warnings, sequence rules (bronchodilator → steroid), peak-flow action plans, peds/pregnancy watchouts, delegation lines, and three rapid “what do you do first?” scenarios to sharpen clinical judgment—not just memorization.
Memory map: AIS-BPMA
A — Albuterol (SABA, rescue): Give for acute wheeze/bronchospasm. Hold if HR ≥ 120. Assess lungs, O₂ sat, and heart rate. Can increase blood glucose; caution with digoxin.
I — Ipratropium (anticholinergic): COPD maintenance med. Watch for dry mouth, constipation, urinary retention. Avoid with glaucoma or enlarged prostate.
S — Salmeterol (LABA): Controller only, not rescue. Must always be paired with an inhaled corticosteroid.
B — Budesonide (ICS): Long-term inflammation control. Rinse mouth after each use to prevent thrush. If switching from systemic steroids, taper slowly.
P — Prednisone (systemic steroid): Used short-term for severe flares. Monitor glucose, GI bleeding, infection risk, mood, fluid retention. Never stop abruptly.
M — Montelukast (leukotriene modifier): Prevents asthma symptoms. Black box: mood changes, depression, suicidal thoughts—report immediately.
A — Acetylcysteine (mucolytic/antidote): Breaks up thick mucus; also antidote for acetaminophen toxicity. Give bronchodilator first before nebulizing. Smells like rotten eggs—warn patients.
Administration sequence:
Bronchodilator first → then ICS. Wait 1–2 minutes between meds.
Peak flow zones:
Green (80–100%): Continue usual meds.
Yellow (50–80%): Add rescue inhaler; call provider if persistent.
Red (<50%): Emergency—use rescue inhaler, start oral steroid if ordered, seek care.
Clinical context:
COPD = respiratory acidosis: Clear airway (ipratropium + acetylcysteine).
Asthma attack = respiratory alkalosis: Use albuterol first; monitor HR closely.
Pediatrics:
Use spacer/mask with inhalers.
Monitor growth with long-term ICS use.
Montelukast granules → mix with soft food only.
Prednisone dosing is weight-based.
Pregnancy:
Continue controller meds—budesonide preferred.
Uncontrolled asthma is riskier than medication exposure.
Delegation:
RN: Assessment, judgment, teaching, setting hold parameters.
UAP (if trained): May give neb after RN assessment; RN still responsible.
Quickfire NCLEX Scenarios:
Ipratropium → urinary retention → assess bladder.
Acetylcysteine → new wheeze → stop treatment, give rescue inhaler.
Prednisone taper → glucose 250 → recheck, assess infection, confirm taper.