NURS 621 Assignment 7.1 Version 2: Advanced Asthma
Management – 2026 GINA-Based Clinical Reasoning, Biologic
Selection, Adherence Strategies, and Population Health for the
Advanced Practice Nurse
Section 1: Diagnostic Reasoning (Questions 1–15)
1. A 34-year-old with episodic cough, chest tightness, and normal spirometry. What is the most
appropriate next diagnostic step?
✅ A) Bronchoprovocation challenge with methacholine – Detects airway hyperresponsiveness when
spirometry is normal
B) High-resolution CT chest – Not indicated without suspicion of other pathology
C) Serum IgE level – Non-diagnostic; elevated in atopy but not specific
D) Empiric oral steroids – Inappropriate without diagnosis
2. Which peak expiratory flow (PEF) variability confirms asthma diagnosis?
✅ A) Diurnal variation >10% over 14 days – GINA 2026 diagnostic criterion
B) Single low reading – Insufficient
C) Variation <5% – Normal
D) Any variation after exercise – Non-specific
3. A patient on daily ICS has normal spirometry and low FeNO (15 ppb). To assess for underlying
reversibility, you should?
✅ A) Withhold ICS for 2–4 weeks then repeat spirometry – Reveals masked reversibility
B) Increase ICS dose – Will not unmask diagnosis
C) Order methacholine challenge while on ICS – May be falsely negative
D) Diagnose as not asthma – Premature
4. Which patient history element most increases pretest probability of asthma?
✅ A) Symptoms worse at night or early morning – Circadian variation hallmark
B) Chronic productive cough year-round – Suggests bronchitis or COPD
C) Hemoptysis – Alarming sign, not asthma
D) Pleuritic chest pain – Suggests pericarditis or pulmonary embolism
5. Fractional exhaled nitric oxide (FeNO) level that indicates type 2 inflammation in a child not on
ICS?
✅ A) ≥35 ppb – Age-adjusted threshold per ATS/ERS
B) ≥50 ppb – Adult threshold
C) 10–20 ppb – Normal range
D) <25 ppb – Low type 2
,6. Which test confirms exercise-induced bronchoconstriction (EIB) in a competitive athlete?
✅ A) FEV1 fall ≥10% from baseline after standardized exercise challenge – Diagnostic
B) Normal resting spirometry – Does not rule out EIB
C) Positive methacholine challenge – Supports but not specific to exercise
D) History of wheezing after running – Symptom history alone insufficient
7. Methacholine challenge is considered positive at which PC20 threshold?
✅ A) ≤8 mg/mL – Defines airway hyperresponsiveness
B) ≤16 mg/mL – Borderline
C) >16 mg/mL – Normal; essentially excludes asthma
D) Any fall in FEV1 – Not specific without dose-response
8. Which differential diagnosis should be considered in an adult with new-onset wheezing and
normal FeNO? (Select 2)
✅ A) Vocal cord dysfunction – Inspiratory stridor, normal FeNO
✅ B) Heart failure – Cardiac wheeze, may have normal FeNO
C) Eosinophilic asthma – Typically elevated FeNO
D) Allergic bronchopulmonary aspergillosis – Elevated IgE, eosinophils
9. A patient has a flow-volume loop showing a flattened inspiratory limb. This suggests?
✅ A) Vocal cord dysfunction – Classic finding
B) Asthma – Expiratory flow limitation
C) Upper airway tumor – Rare, fixed obstruction
D) COPD – Not inspiratory
10. Impulse oscillometry (IOS) is particularly useful in which population?
✅ A) Young children unable to perform forced maneuvers – Requires tidal breathing only
B) Adults with classic asthma – Spirometry remains first-line
C) Acute exacerbation – Not validated
D) Screening for COPD – Not primary use
11. Blood eosinophil level that supports eosinophilic asthma phenotype?
✅ A) ≥150 cells/μL – Threshold for biologic consideration (GINA 2026)
B) ≥300 cells/μL – *Higher likelihood of anti-IL5 response*
C) ≥500 cells/μL – Very high, but not required
D) <100 cells/μL – Non-eosinophilic
12. A patient with suspected asthma has a normal methacholine challenge (PC20 >16 mg/mL). What
is the most appropriate next step?
✅ A) Diagnose asthma as unlikely – High negative predictive value
B) Treat empirically for asthma – Not indicated
C) Repeat challenge in 1 week – Unlikely to change
D) Order bronchoscopy – Overtesting
13. Which finding on chest CT suggests allergic bronchopulmonary aspergillosis (ABPA)?
✅ A) Central bronchiectasis – Hallmark radiologic finding
B) Peripheral nodules – Not specific
, C) Ground glass opacities – Non-specific
D) Normal CT – Does not exclude ABPA
14. In a patient with aspirin-exacerbated respiratory disease (AERD, Samter's triad), which test
confirms the diagnosis?
✅ A) Oral aspirin challenge in controlled setting – Gold standard
B) Skin testing to aspirin – Not reliable
C) Serum IgE – Elevated but non-specific
D) Blood eosinophils – Often elevated but not diagnostic
15. A smoker with dyspnea and wheezing. Which test best distinguishes asthma from COPD?
✅ A) DLCO (diffusing capacity) – Normal in asthma, low in COPD
✅ B) FeNO – High in eosinophilic asthma
C) Spirometry alone – Overlap common
D) Chest X-ray – Not diagnostic
Section 2: Stepwise Pharmacotherapy (Questions 16–35)
16. According to GINA 2026, what is the preferred as-needed therapy for mild intermittent asthma
(Step 1)?
✅ A) Low-dose ICS-formoterol taken as needed – *Anti-inflammatory rescue reduces exacerbations
by ~65% vs SABA alone*
B) Albuterol as needed – No longer recommended as monotherapy
C) Daily low-dose ICS – Acceptable alternative but over-treatment for intermittent
D) Oral montelukast daily – Second-line, slower onset
17. A patient using as-needed ICS-formoterol reports symptoms on 4 days per week. What is the
appropriate step-up?
✅ A) Daily low-dose ICS plus as-needed ICS-formoterol (Step 2) – *Symptoms >2 days/week indicate
need for regular controller*
B) Increase as-needed ICS-formoterol to high dose – Not a step
C) Add oral montelukast – Not first-line step-up
D) Switch to SABA alone – Unsafe, backward
18. Which regimen represents GINA Step 3 preferred therapy for adults?
✅ A) Low-dose ICS-LABA maintenance + as-needed ICS-formoterol – Single inhaler or two inhalers
B) Medium-dose ICS alone – Alternative but less effective
C) LABA alone – Contraindicated
D) LAMA alone – Insufficient as monotherapy
19. A patient is on Step 4 therapy (medium-dose ICS-LABA + LAMA) but remains uncontrolled.
What should be assessed before escalating to Step 5? (Select 2)
✅ A) Inhaler technique – Most common cause of poor control
✅ B) Adherence to current regimen – Up to 70% of “difficult asthma” is poor adherence
Management – 2026 GINA-Based Clinical Reasoning, Biologic
Selection, Adherence Strategies, and Population Health for the
Advanced Practice Nurse
Section 1: Diagnostic Reasoning (Questions 1–15)
1. A 34-year-old with episodic cough, chest tightness, and normal spirometry. What is the most
appropriate next diagnostic step?
✅ A) Bronchoprovocation challenge with methacholine – Detects airway hyperresponsiveness when
spirometry is normal
B) High-resolution CT chest – Not indicated without suspicion of other pathology
C) Serum IgE level – Non-diagnostic; elevated in atopy but not specific
D) Empiric oral steroids – Inappropriate without diagnosis
2. Which peak expiratory flow (PEF) variability confirms asthma diagnosis?
✅ A) Diurnal variation >10% over 14 days – GINA 2026 diagnostic criterion
B) Single low reading – Insufficient
C) Variation <5% – Normal
D) Any variation after exercise – Non-specific
3. A patient on daily ICS has normal spirometry and low FeNO (15 ppb). To assess for underlying
reversibility, you should?
✅ A) Withhold ICS for 2–4 weeks then repeat spirometry – Reveals masked reversibility
B) Increase ICS dose – Will not unmask diagnosis
C) Order methacholine challenge while on ICS – May be falsely negative
D) Diagnose as not asthma – Premature
4. Which patient history element most increases pretest probability of asthma?
✅ A) Symptoms worse at night or early morning – Circadian variation hallmark
B) Chronic productive cough year-round – Suggests bronchitis or COPD
C) Hemoptysis – Alarming sign, not asthma
D) Pleuritic chest pain – Suggests pericarditis or pulmonary embolism
5. Fractional exhaled nitric oxide (FeNO) level that indicates type 2 inflammation in a child not on
ICS?
✅ A) ≥35 ppb – Age-adjusted threshold per ATS/ERS
B) ≥50 ppb – Adult threshold
C) 10–20 ppb – Normal range
D) <25 ppb – Low type 2
,6. Which test confirms exercise-induced bronchoconstriction (EIB) in a competitive athlete?
✅ A) FEV1 fall ≥10% from baseline after standardized exercise challenge – Diagnostic
B) Normal resting spirometry – Does not rule out EIB
C) Positive methacholine challenge – Supports but not specific to exercise
D) History of wheezing after running – Symptom history alone insufficient
7. Methacholine challenge is considered positive at which PC20 threshold?
✅ A) ≤8 mg/mL – Defines airway hyperresponsiveness
B) ≤16 mg/mL – Borderline
C) >16 mg/mL – Normal; essentially excludes asthma
D) Any fall in FEV1 – Not specific without dose-response
8. Which differential diagnosis should be considered in an adult with new-onset wheezing and
normal FeNO? (Select 2)
✅ A) Vocal cord dysfunction – Inspiratory stridor, normal FeNO
✅ B) Heart failure – Cardiac wheeze, may have normal FeNO
C) Eosinophilic asthma – Typically elevated FeNO
D) Allergic bronchopulmonary aspergillosis – Elevated IgE, eosinophils
9. A patient has a flow-volume loop showing a flattened inspiratory limb. This suggests?
✅ A) Vocal cord dysfunction – Classic finding
B) Asthma – Expiratory flow limitation
C) Upper airway tumor – Rare, fixed obstruction
D) COPD – Not inspiratory
10. Impulse oscillometry (IOS) is particularly useful in which population?
✅ A) Young children unable to perform forced maneuvers – Requires tidal breathing only
B) Adults with classic asthma – Spirometry remains first-line
C) Acute exacerbation – Not validated
D) Screening for COPD – Not primary use
11. Blood eosinophil level that supports eosinophilic asthma phenotype?
✅ A) ≥150 cells/μL – Threshold for biologic consideration (GINA 2026)
B) ≥300 cells/μL – *Higher likelihood of anti-IL5 response*
C) ≥500 cells/μL – Very high, but not required
D) <100 cells/μL – Non-eosinophilic
12. A patient with suspected asthma has a normal methacholine challenge (PC20 >16 mg/mL). What
is the most appropriate next step?
✅ A) Diagnose asthma as unlikely – High negative predictive value
B) Treat empirically for asthma – Not indicated
C) Repeat challenge in 1 week – Unlikely to change
D) Order bronchoscopy – Overtesting
13. Which finding on chest CT suggests allergic bronchopulmonary aspergillosis (ABPA)?
✅ A) Central bronchiectasis – Hallmark radiologic finding
B) Peripheral nodules – Not specific
, C) Ground glass opacities – Non-specific
D) Normal CT – Does not exclude ABPA
14. In a patient with aspirin-exacerbated respiratory disease (AERD, Samter's triad), which test
confirms the diagnosis?
✅ A) Oral aspirin challenge in controlled setting – Gold standard
B) Skin testing to aspirin – Not reliable
C) Serum IgE – Elevated but non-specific
D) Blood eosinophils – Often elevated but not diagnostic
15. A smoker with dyspnea and wheezing. Which test best distinguishes asthma from COPD?
✅ A) DLCO (diffusing capacity) – Normal in asthma, low in COPD
✅ B) FeNO – High in eosinophilic asthma
C) Spirometry alone – Overlap common
D) Chest X-ray – Not diagnostic
Section 2: Stepwise Pharmacotherapy (Questions 16–35)
16. According to GINA 2026, what is the preferred as-needed therapy for mild intermittent asthma
(Step 1)?
✅ A) Low-dose ICS-formoterol taken as needed – *Anti-inflammatory rescue reduces exacerbations
by ~65% vs SABA alone*
B) Albuterol as needed – No longer recommended as monotherapy
C) Daily low-dose ICS – Acceptable alternative but over-treatment for intermittent
D) Oral montelukast daily – Second-line, slower onset
17. A patient using as-needed ICS-formoterol reports symptoms on 4 days per week. What is the
appropriate step-up?
✅ A) Daily low-dose ICS plus as-needed ICS-formoterol (Step 2) – *Symptoms >2 days/week indicate
need for regular controller*
B) Increase as-needed ICS-formoterol to high dose – Not a step
C) Add oral montelukast – Not first-line step-up
D) Switch to SABA alone – Unsafe, backward
18. Which regimen represents GINA Step 3 preferred therapy for adults?
✅ A) Low-dose ICS-LABA maintenance + as-needed ICS-formoterol – Single inhaler or two inhalers
B) Medium-dose ICS alone – Alternative but less effective
C) LABA alone – Contraindicated
D) LAMA alone – Insufficient as monotherapy
19. A patient is on Step 4 therapy (medium-dose ICS-LABA + LAMA) but remains uncontrolled.
What should be assessed before escalating to Step 5? (Select 2)
✅ A) Inhaler technique – Most common cause of poor control
✅ B) Adherence to current regimen – Up to 70% of “difficult asthma” is poor adherence
