Pharm -Study guides from book

Question 1

A patient diagnosed with chronic pain calls to request an oxycodone (Oxycontin) refill. Which action should the prescriber take initially?

a. Fax the renewal order to the pharmacy.
b. Arrange to schedule an appointment with the patient.
c. Verify the patient’s adherence to the prescribed drug regimen.
d. Determine the patient’s current medication dosage and pain level.

Answer 1

b. Arrange to schedule an appointment with the patient.

Schedule II medications are not eligible for refills, and prescriptions must be handwritten. It is important to verify the patient’s adherence to the drug regimen and determine the current dosage of medication and pain level; however, this can be accomplished by scheduling an appointment and evaluating the patient in person.

Question 2

A metered-dose albuterol inhaler is prescribed for asthma management. The patient reports feeling jittery sometimes when taking the medication, and does not feel that the medication is always effective. Which action will the provider take to best minimize patient risks and maximize medication effectiveness?

a. Ask the patient to demonstrate use of the inhaler and assess effectiveness.
b. Assess the patient’s exposure to first- and second-hand tobacco smoke.
c. Auscultate the patient’s lung sounds and obtain other relevant vital signs.
d. Decrease the dosage to reduce side effects.

Answer 2

c. Auscultate the patient’s lung sounds and obtain other relevant vital signs.

Assessing and evaluating lung sounds as well as other vital signs helps determine the patient’s physical response to the medication and allows comparison to the patient’s baseline vital signs. Asking the patient to demonstrate inhaler use helps to evaluate the patient’s ability to administer the medication properly and is part of an effective evaluation, but is not a priority intervention based on the patient’s current report. Assessing tobacco smoke exposure helps determine whether nondrug therapies, such as smoke avoidance, can be used as an adjunct to drug therapy, but does not relate to the patient’s current problem. Rewriting the prescription to decrease the dosage may address the degree of jitteriness experienced, but does not address the patient’s concern that the drug is not always effective.

Question 3

A patient is prescribed metronidazole for bacterial vaginosis. Which patient history finding would be most concerning to the provider?

a. The patient had a recent yeast infection.
b. There is a family history of cervical cancer.
c. The patient drinks two glasses of wine every night.
d. The patient is unemployed.

Answer 3

c. The patient drinks two glasses of wine every night.

Patients taking metronidazole should be educated not to drink alcohol to prevent a disulfiram-like reaction. It would be concerning that the patient drinks wine daily. History of a yeast infection may indicate increased risk for recurrence with administration of an antimicrobial. A family history of cervical cancer is not related to administration of metronidazole. Unemployment can indicate lack of insurance coverage, which may limit the patient’s ability to purchase medications; however, generic metronidazole is one of the less expensive medications.

Question 4

The provider prepares a patient with newly diagnosed type 1 diabetes for hospital discharge. Which action by the provider will best support the patient’s ability to effectively manage medication therapy?

a. Asking the patient to demonstrate how to measure and administer insulin
b. Discussing methods of storing insulin and discarding syringes
c. Giving information about how diet and exercise affect insulin requirements
d. Teaching the patient about the long-term consequences of poor diabetes control

Answer 4

a. Asking the patient to demonstrate how to measure and administer insulin

Because insulin must be given correctly to control symptoms and prevent an overdose, it is most important for the patient to know how to measure and administer it. Asking for a demonstration of technique is the best way to determine whether the patient has understood the teaching. The other teaching points are important as well, but they are not as critical.

Question 5

A patient reports that a medication prescribed for recurrent migraine headaches is not working. Which action is the prescriber’s priority when addressing the patient’s concern?

a. Ask the patient about the number and frequency of tablets taken.
b. Assess the patient’s headache pain on a scale from 1 to 10.
c. Prescribe a new medication for migraine management.
d. Suggest biofeedback as an adjunct to drug therapy.

Answer 5

a. Ask the patient about the number and frequency of tablets taken.

When evaluating the effectiveness of a drug, it is important to determine how often the patient is using the drug. Asking the patient to identify how many tablets are taken and how often helps the provider determine effective dosages and adherence to the medication regimen. The patient has already stated that the medication is not working; the actual level of pain may determine the degree to which it is not working, but it does not help the provider to determine why it is not working. The assessment process should gather as much information about compliance, symptoms, and drug effectiveness as possible before enacting a change in treatment. Biofeedback may be an effective adjunct to treatment, but it should not be recommended without complete information about drug effectiveness.

Question 6

The drug manual states that older adult patients are at increased risk for hepatotoxicity. Which action is most important when prescribing this medication to an 80-year-old patient?

a. Obtaining baseline liver function studies
b. Ensuring that the drug is taken in the correct dose at the correct time
c. Discontinuing the order; the drug is contraindicated for this patient
d. Giving the medication intravenously to avoid first pass metabolism

Answer 6

a. Obtaining baseline liver function studies

The drug manual indicates that this drug increases risk of hepatotoxicity for elderly patients. Getting information about liver function before giving the drug establishes baseline data that can be compared with posttreatment data to determine whether the drug is affecting the liver. Taking the correct dose at the correct interval may minimize risk, but without baseline information, the effects cannot be determined. Drugs are not routinely contraindicated for an increased risk of adverse effects.

Question 7

A patient with bipolar disorder is prescribed daily lithium. Which action is most important for the provider to take in order to determine if the therapeutic level is maintained?

a. Evaluate preadministration blood work.
b. Prescribe the lithium to be taken at regular intervals.
c. Order periodic laboratory testing.
d. Assess the patient for signs and symptoms of lithium toxicity.

Answer 7

c. Order periodic laboratory testing.

Therapeutic serum levels are determined through periodic laboratory testing. Preadministration blood work may be necessary to obtain baseline status prior to initiating treatment, but it will not determine therapeutic levels. Scheduling medication administration at regular intervals will help to ensure medication is absorbed and metabolized predictably, but it will not determine therapeutic blood levels. Assessing the patient for signs and symptoms of toxicity will help to determine if the therapeutic level has been exceeded, not maintained.

Question 8

Which factor best supports an increase for full prescriptive authority for both advanced practice registered nurses (APRNs) and physician assistants (PAs)?

a. More patients will have access to health care.
b. Enrollment in medical schools is predicted to decrease.
c. Enrollment in both APRN and PA programs has increased.
d. Physician practices have become so large, quality care is in jeopardy.

Answer 8

a. More patients will have access to health care.

Implementation of the Affordable Care Act has increased the number of individuals with health care coverage, and thus the number who have access to health care services. The increase in the number of patients creates the need for more providers with prescriptive authority. APRNs and physical assistants can fill this practice gap. Enrollment in medical school has increased in recent years and shows no indication of decline. While some medical practices have increased in patient volume, there is no reason to believe care has suffered. While enrollment for both APRN and PA education has increased, that is not the primary factor associated with the need for increased prescriptive authority for these providers.

Question 9

A pediatric patient prescribed ampicillin for streptococcal pharyngitis reports new onset of a pruritic, dull red, maculopapular rash on the chest and neck. Which action is most important for the provider to take to minimize this patient’s risk for injury?

a. Prescribe azithromycin to replace the ampicillin.
b. Discontinue the ampicillin.
c. Prescribe an antihistamine for the itching.
d. Flag all medical records with an “Allergic to Penicillin” notice.

Answer 9

b. Discontinue the ampicillin.

The priority action is to discontinue the medication to prevent a potential worsening of the patient’s symptoms. A different prescription may be indicated depending on the length of treatment. An antihistamine may be administered for pruritis. Rashes are a common side effect of ampicillin. Pruritic maculopapular rashes such as the one described occur in 5% to 10% of children taking ampicillin, especially in the presence of viral infections. They do not contraindicate future administration of penicillin antibiotics.

Question 10

Which prescriber action will have the greatest impact on the patient’s commitment to adherence to any type of medication therapy?

a. Prescribing the medication in oral form whenever possible
b. Scheduling once a day administration
c. Providing medication education that the patient can easily understand
d. Assuring that the medication prescription will be covered by the patient’s
insurance

Answer 10

c. Providing medication education that the patient can easily understand

No other provider action assures the patient’s commitment to adhere to a medication plan more than effective medication education provided in a concise, understandable form. It is not always possible or appropriate to prescribe an oral form. While medication costs can present a barrier to compliance, insurance coverage is but one factor affecting costs.

Question 11

Which patient statement suggests to the provider that the patient’s nonadherence with their medication plan is related to dissatisfaction with the therapy?
a. “This medication is too expensive; I can’t afford it any longer.”
b. “I’ve been taking this medication for well over a week and I lost only a half a
pound.”
c. “It’s too hard to remember to take the pill every other day; so, I’ve missedseveral
doses.”
d. “I have a very intense, fast paced job; it’s hard to make time to take the
medication like I should.”

Answer 11

b. “I’ve been taking this medication for well over a week and I lost only a half a
pound. ”

Dissatisfaction with drug therapy can take the form of a patient’s unrealistic expectation of desired results such as in the case of significant weight loss in a relatively short period of time. Medication costs, forgetfulness, and lack of planning are suggested by the other options.

Question 12

How can the prescriber’s regular collaboration with a pharmacist improve positive outcomes for patients? (Select all that apply.)

a. Pharmacists can suggest foods that will help with the medications’ absorption.
b. Pharmacists have additional information on drug interactions.
c. The pharmacist can suggest adequate medication dosing.
d. Pharmacists have firsthand knowledge of the facility formulary.
e. Pharmacy can alter prescriptions when necessary to prevent patient harm.

Answer 12

b. Pharmacists have additional information on drug interactions.
c. The pharmacist can suggest adequate medication dosing.
d. Pharmacists have firsthand knowledge of the facility formulary.

Providers should collaborate with pharmacists because they will likely have additional information on formulary, drug interactions, and suggestions for adequate medication dosing. Dietitians can make food recommendations to treat the patient’s condition. The pharmacist can contact the prescriber about questionable prescriptions, but cannot alter the prescription without notification of and approval by the provider.

Question 13

Which statements made by the prescriber demonstrate an understanding of effective medication education? (Select all that apply.)

a. “This medication needs to be stored in the refrigerator.”
b. “Take 3 tablets daily: 1 with breakfast, 1 with lunch, and one with dinner.”
c. “You need to take the medication as we discussed until all the tablets are gone.”
d. “Call the office immediately if you begin experiencing any itching, headache, or
difficulty breathing.”
e. “When you call about a medication refill, be sure to let the pharmacist know you
are talking about your heart pill.”

Answer 13

a. “This medication needs to be stored in the refrigerator.”
b. “Take 3 tablets daily: 1 with breakfast, 1 with lunch, and one with dinner.”
c. “You need to take the medication as we discussed until all the tablets are gone.”
d. “Call the office immediately if you begin experiencing any itching, headache, or
difficulty breathing.”

There are basic components that should be included when teaching about any new medication. They are (1) medication name, (2) purpose, (3) dosing regimen, (4) administration, (5) adverse effects, (6) any special storage needs, (7) associated laboratory testing, (8) food or drug interactions, and (9) duration of therapy. The statement suggesting referring to the medication as “your heart pill” is inappropriate since being familiar with the drug’s name is important in avoiding medication errors.

Question 14

The patient who has been prescribed lithium for a diagnosis of bipolar disorder asks why blood tests are required on a regular basis. Which provider responses demonstrate an understanding of why the patient requires a variety of laboratory tests? (Select all that apply.)

a. “We need to monitor how your thyroid is functioning.”
b. “We need to monitor kidney function while you are on this drug.”
c. This medication can cause you to lose sodium, so we need to measure sodium
levels.”
d. “Your liver can be damaged by lithium; regular testing helps us monitor for that.”
e. “Lithium can cause you to lose potassium; so, we regularly monitor your blood
potassium level.”

Answer 14

a. “We need to monitor how your thyroid is functioning.”
b. “We need to monitor kidney function while you are on this drug.”
c. This medication can cause you to lose sodium, so we need to measure sodium
levels. ”

Lithium therapy can affect thyroid and renal function as well as deplete sodium levels. Regular laboratory testing is needed to monitor sodium levels and thyroid and renal function and so allows for modification of the lithium dose as needed. Lithium is not associated with altered liver function or potassium depletion.

Question 15

When prescribing lovastatin, what will a provider advise to decrease the risk of developing muscle toxicity?

a. Avoid exercise for 2 hours after administration.
b. Substitute grapefruit juice with orange juice.
c. Monitor aspartate aminotransferase (AST) and alanine aminotransferase (ALT).
d. Take the medication with an NSAID or other anti-inflammatory drug.

Answer 15

b. Substitute grapefruit juice with orange juice.

Grapefruit juice can inhibit the metabolism of certain drugs including statins like lovastatin. The juice raises drug levels decreasing the intestinal metabolism of the drug resulting in increased drug levels which increases the risk for adverse effects such as muscle toxicity. Taking the drug with an anti-inflammatory drug and avoiding exercise after administration are not supported by science. Monitoring AST and ALT detects liver toxicity, not muscle toxicity.

Question 16

When prescribing drugs with a narrow therapeutic index, what intervention does the provider take to decrease risk to the patient?

a. Schedule drug administration intervals that exceed the drug’s half-life.
b. Order the medication to be administered by the intravenous route.
c. Monitor the patient’s plasma drug levels at regular intervals.
d. Teach the patient that optimal outcomes will require adherence to themedication
regimen.

Answer 16

c. Monitor the patient’s plasma drug levels at regular intervals.

A drug with a narrow therapeutic range or index is more difficult to administer safely, because the difference between the minimum effective concentration and the toxic concentration is small. Patients taking these medications must have their plasma drug levels monitored closely to ensure that they are getting an effective dose that is not toxic. Administering medications at longer intervals risks increased periods of subtherapeutic levels. Drugs that have a narrow therapeutic range may be given by any route; intravenous administration is not preferable and in most cases will not be feasible. Medication regimen adherence is necessary; however, due to individual variation, for drugs with a narrow therapeutic range, what is an effective dose for one patient may be a lethal dose for another. For this reason, monitoring drug levels remains the primary method for decreasing risk.

Question 17

A patient reports that a medication no longer effectively alleviates symptoms. What process informs the provider’s response to the patient’s concerns?

a. Endogenous antagonists compete with the drug for receptor sites.
b. Decreased selectivity for receptors results in a variety of effects.
c. Desensitization of receptor sites results from continual exposure to the drug.
d. Additional receptor sites are synthesized in response to the medication.

Answer 17

c. Desensitization of receptor sites results from continual exposure to the drug.

Continual exposure to an agonist would cause the cell to become less responsive or desensitized. The body does not produce antagonists as a response to a medication. Medication tolerance is not related to receptor selectivity. Medications do not cause more receptors to be produced.

Question 18

A patient reports that Brand X tablets work faster than Brand Y tablets of the same amount of the same drug. Which statement informs the prescriber’s response when explaining this phenomenon to the patient?

a. Advertising by pharmaceutical companies can enhance patient expectations of
one brand over another, leading to a placebo effect.
b. Because the drug preparations are chemically equivalent, the actions of the two
brands must be identical.
c. Inactive ingredients used in composition can result in differing rates of
dissolution, which can alter the drug’s onset of action.
d. The bioavailability of a drug is determined by the amount of the drug in each
dose.

Answer 18

c. Inactive ingredients used in composition can result in differing rates of
dissolution, which can alter the drug’s onset of action.

Even if two brands of a drug are chemically equivalent (i.e., they have identical amounts of the same chemical compound), they can have different effects in the body if they differ in bioavailability. Tablets made by different manufacturers contain different binders and fillers, which disintegrate and dissolve at different rates and affect the bioavailability of the drug.

Question 19

A patient receiving intravenous gentamicin has a toxic serum drug level. The prescriber confirms that the dosing is correct. Which possible cause of this situation will the provider explore?

a. Whether a loading dose was administered
b. If the drug was completely dissolved in the IV solution
c. Whether patient is taking a medication that binds to serum albumin
d. If the ordered dose frequency is longer than the gentamicin half-life

Answer 19

c. Whether patient is taking a medication that binds to serum albumin

Gentamicin binds to albumin, but only weakly, and in the presence of another drug that binds to albumin, it can rise to toxic levels in blood serum. A loading dose increases the initial amount of a drug and is used to bring drug levels to the desired plateau more quickly. A drug that is not completely dissolved carries a risk of causing embolism but this addresses a different concern. A drug given at a frequency longer than the drug half-life will likely be at subtherapeutic levels and not at toxic levels.

Question 20

A patient takes a drug that is metabolized by CYP3A4 isoenzymes. If a CYP3A4 inducing drug is prescribed, what drug adjustment may be necessary to maintain a therapeutic level of CYP3A4 substrate?

a. Increase dosage of the CYP3A4 inducer.
b. Decrease dosage of the CYP3A4 inducer.
c. Increase dosage of the CYP3A4 substrate.
d. Decrease dosage of the CYP3A4 substrate.

Answer 20

c. Increase dosage of the CYP3A4 substrate.

A drug that acts as an inducing agent for an enzyme system increases the metabolism of drugs metabolized by that enzyme system, thereby lowering the level of those drugs in the body and requiring higher doses to maintain drug effectiveness. Although decreasing the dosage of the drug that induces metabolism may seem reasonable at first glance, this may decrease the therapeutic level of the drug making it ineffective in treating the condition for which it was prescribed.

Question 21

The provider prescribes hydrocodone with acetaminophen for a patient’s postsurgical pain. What instruction will the prescriber include regarding alcohol intake?

a. “If you plan to drink alcohol, I will write an order for acetaminophen without
hydrocodone for your pain.”
b. “I’d suggest that you substitute ibuprofen for pain on days when you plan to drink
alcohol.”
c. “You should avoid drinking alcohol while you are taking the pain medication I’ve
ordered.”
d. “You should limit your alcohol intake to no more than two servings ofalcohol
daily while on the pain medication.”

Answer 21

c. “You should avoid drinking alcohol while you are taking the pain medicationI’ve
ordered. ”

Combining a hepatotoxic drug with other hepatotoxic agents increases the risk of hepatotoxicity. When even therapeutic doses of acetaminophen are taken with alcohol, the acetaminophen can cause liver damage. Patients should be cautioned not to drink alcohol; even two drinks with acetaminophen can produce this effect. Hydrocodone does not contribute to hepatotoxicity. Ibuprofen is not indicated for postoperative pain unless the pain is mild. Limiting alcohol intake to two servings per day still increases the risk of hepatotoxicity.

Question 22

Which order for furosemide is written appropriately by the prescriber?

a. Furosemide [Lasix] 20 mg PO QD
b. Furosemide [Lasix] 20 mg PO qd
c. Furosemide [Lasix] 20 mg daily
d. Furosemide [Lasix] 20 mg PO daily

Answer 22

d. Furosemide [Lasix] 20 mg PO daily

The correct answer is a complete order; it contains the medication, dose, route, and time. “QD” and “qd” are no longer accepted abbreviations; it should be written out as “daily” or “every day.” The order of “20 mg daily” does not specify the route to be used.

Question 23

A drug can cause symptoms that resemble those of Parkinson disease. What action should the prescriber take to minimize the potential patient risk?

a. Explain that these are teratogenic effects that must be reported immediately.
b. Thoroughly educate the patient about recognizing such symptoms and the need to
notify the office immediately.
c. Order an evaluation of the patient’s genetic predisposition to these effects.
d. Educate the patient about these symptoms and provide reassurance that the
condition is expected.

Answer 23

b. Thoroughly educate the patient about recognizing such symptoms and the need to
notify the office immediately.

Some drugs can cause iatrogenic conditions, which are conditions whose symptoms are the same as those of a known disease. The patient should be prepared for this possibility and be prepared to recognize and report the symptoms immediately. Such effects are not teratogenic, since teratogenic effects affect the fetus. Patients with a genetic predisposition to respond differently to drugs are
known to have idiosyncratic effects. Although reassurance may dispel some fear on the part of the patient, it does provide the patient with actions (e.g., notifying the provider) that can allow for symptom management.

Question 24

A patient who has been taking sertraline for depression was prescribed azithromycin to treat an infection by a provider at an after-hours clinic. What action will the primary care provider take to address the risk this combination of medication has posed for the patient?

a. Discontinue the azithromycin and write an order for an alternative antibiotic.
b. Discontinue the sertraline and write an order for a different antidepressant
medication.
c. Reduce the sertraline dosage while taking azithromycin.
d. Withhold the sertraline until the azithromycin therapy is completed.

Answer 24

a. Discontinue the azithromycin and write an order for an alternative antibiotic.

Both sertraline and azithromycin prolong the QT interval, and when taken together, they increase the risk of fatal dysrhythmias. Because the antibiotic is used for a short time and because the patient was already taking sertraline, it is correct to consider using a different antibiotic. Reducing the dose of sertraline does not alter the combined effects of two drugs that lengthen the QT interval. Sertraline should not be stopped abruptly, so withholding it during antibiotic therapy is not indicated. Additionally, it is important to reinforce the need to tell all providers that sertraline is being taken.

Question 25

A patient reports mild nausea within an hour after taking the first two doses of a newly approved medication. Nausea is not listed among the known side effects of this drug. What instructions will the provider give the patient? a. “Take the next dose with food and call the office if the nausea reoccurs or if other symptoms develop.” b. “Discontinue the medication and a substitute will be prescribed.” c. “Reporting the situation to the MEDWATCH program will get us a recommendation about continuing the drug.” d. “I’ll write a prescription for an antiemetic to counter this drug’s effects.”

Answer 25

a. “Take the next dose with food and call the office if the nausea reoccurs or if other symptoms develop.” Not all adverse drug reactions (ADRs) are detected during clinical trials, and prescribers should be alert to any effects that may result from drug administration. The time of nausea onset suggests that this is drug-related. Unless contraindicated, taking drugs with food will usually relieve or decrease nausea. Because there is a possibility that the nausea is not drug-related, it is important to ask the patient to report the recurrence or worsening of the symptom or the addition of new symptoms. It is not necessary to hold the drug, because nausea is not a serious side effect. The MEDWATCH program should be notified when there is a greater suspicion that the drug may have caused the nausea, e.g., if the nausea occurs with subsequent doses. Until there is greater suspicion that the drug caused this patient’s nausea and because the patient is not vomiting, giving an antiemetic is not indicated.

Question 26

A patient develops shortness of breath shortly after taking the initial dose of a newly prescribed medication. The patient’s heartrate is 86 beats/minute, the respiratory rate is 24 breaths/minute, and the blood pressure is 120/70 mm Hg. The prescriber will discontinue the drug based on the assumption the patient experienced what medication induced effect? a. An allergic reaction b. An idiosyncratic effect c. An iatrogenic response d. A side effect

Answer 26

d. A side effect A side effect is a secondary drug effect produced at therapeutic doses. This patient received the correct dose of the drug and developed shortness of breath, which, in this case, is a drug side effect. To experience an allergic reaction, a patient must have prior exposure to a drug and sensitization of the immune response. An idiosyncratic effect results from a genetic predisposition to an uncommon drug response. An iatrogenic response occurs when a drug causes symptoms of a disease.

Question 27

A provider recommends genetic testing of a patient before prescribing a medication. What response should the provider give when asked by the patient about the purpose of genetic testing? a. “Genetic testing better establishes the drug’s therapeutic index.” b. “Such testing will tell us how quickly your body is likely to metabolize, or process, the drug.” c. “The testing helps identify any factors that could affect psychosocial variation in the drug’s response.” d. “It guides the production of a drug that is tailored to your individual genetic makeup.”

Answer 27

b. “Such testing will tell us how quickly your body is likely to metabolize, or process, the drug.” Pharmacogenomics is the study of the ways genetic variations affect individual responses to drugs through alterations in genes that code for drug-metabolizing enzymes and drug receptors. For some drugs, the FDA requires genetic testing, and for others, this testing is recommended but not required. Genetic testing does not determine a drug’s therapeutic index; this is a measure of a drug’s safety based on statistics of the drug’s use in the general population (see Chapter 5). Any distinct physiologic differences in drug response among various racial populations are related to genetic differences and do not affect psychosocial differences in drug responses. Genetic testing is recommended to identify how a patient will respond to a drug and not to design a drug specific to an individual.

Question 28

A patient is prescribed digoxin. Which screening will the provider order to monitor for potential adverse effects from this drug? a. Albumin b. Blood urea nitrogen (BUN) and creatinine c. Hepatic enzymes d. Serum electrolytes

Answer 28

d. Serum electrolytes Patients with low serum potassium are at increased risk for fatal cardiac dysrhythmias when taking digoxin, and it is essential to know this level before this medication is administered. Knowing a patient’s albumin level would be important when giving drugs that are highly protein bound. The BUN and creatinine levels are indicators of renal function. Hepatic enzymes are important to know when drugs are metabolized by the liver.

Question 29

A provider considers prescribing tamoxifen for a woman with breast cancer. Upon reviewing results of genetic testing, the prescriber notes that the patient has variations in the CYP2Dy allele resulting in a deficiency of the CYP2D6 isoenzymes. What action will this deficiency warrant in the prescribing of tamoxifen, a CYP2D6 substrate? a. The tamoxifen will not be prescribed. b. The individual doses of tamoxifen will be increased. c. The tamoxifen will be ordered but in lower than normal dosage. d. The patient’s serum tamoxifen level will be routinely monitored.

Answer 29

a. The tamoxifen will not be prescribed. Women with a deficiency of CYP2D6 isoenzymes lack the ability to convert tamoxifen to its active form, endoxifen, and will not benefit from this drug. Another drug should be used to treat this patient’s breast cancer. Increasing the dose, reducing the dose, or monitoring serum drug levels will not make this drug more effective in these women.

Question 30

A patient has taken a narcotic analgesic for chronic pain for several months. At a follow-up appointment, the provider notes that the patient has been taking more than the prescribed dosage. The patient has normal vital signs, is awake and alert, and reports mild pain. What does the provider suspect is responsible for the patient’s response? a. This patient exhibits a negative placebo effect with a reduced response to the drug. b. This patient has developed tachyphylaxis because of repeated exposure to the drug. c. This patient has developed pharmacodynamic tolerance, which has increased the minimal effective concentration (MEC) needed for analgesic effect. d. This patient has increased hepatic enzyme production as a result of prolonged exposure to the drug.

Answer 30

c. This patient has developed pharmacodynamic tolerance, which has increased the minimal effective concentration (MEC) needed for analgesic effect. Pharmacodynamic tolerance results when a patient takes a drug over a long period of time. Adaptive processes occur in response to chronic receptor occupation. The result is that the body requires increased drug, or an increased MEC, to achieve the same effect. This patient is getting adequate pain relief, so there is no negative placebo effect. Tachyphylaxis is a form of tolerance that can be defined as a reduction in drug responsiveness brought on by repeated dosing over a short time. Induced synthesis of hepatic enzymes increases metabolism of a drug, but it does not increase the MEC.

Question 31

Which patient ethnic ancestry creates a risk factor that may result in minimal beneficial response to tamoxifen therapy? a. African b. French c. Native American d. Japanese

Answer 31

b. French Between 8% and 10% of women of European ancestry have a gene variant that prevents the effective metabolism of tamoxifen that negatively affects the medication’s therapeutic effect. None of the other options present with a similar risk factor.

Question 32

Before initiating cetuximab therapy, the provider will order epidermal growth factor receptor (EGFR) testing for the patient having which condition? a. Breast cancer b. Colorectal cancer c. Bone cancer d. Brain cancer

Answer 32

b. Colorectal cancer Cetuximab is used mainly for metastatic colorectal cancer. The medication works only against tumors that express EGRF; all other tumors are unresponsive. This makes testing in advance of treatment required. Cetuximab is not appropriate for any of the other conditions listed.

Question 33

When considering the benefit of pharmacogenomics, what information should the prescriber include when prescribing a new medication? a. Stress the need to contact the primary health care prescriber immediately if side effects occur. b. Provide definitions and possible examples of related idiosyncratic responses to this medication. c. Explain any necessary precautions to take regarding medication administration. d. Give a detailed explanation regarding the method for discontinuing the medication, should it become necessary.

Answer 33

b. Provide definitions and possible examples of related idiosyncratic responses to this medication. A patient’s unique genetic makeup can lead to drug responses that are qualitatively and quantitatively different from those of the population at large. Adverse effects and therapeutic effects may be increased or reduced. Idiosyncratic responses to drugs may also occur. Educating the patient on the concept and examples of idiosyncratic responses should be included in the medication education provided. The other options are appropriate but not directly related to pharmacogenomics.

Question 34

A provider has prescribed a female patient a medication that induces P-glycoprotein (PGP). The provider will be particularly concerned about which aspects of the patient’s medical history? (Select all that apply.) a. Intestinal problems b. Kidney function c. Liver function d. Pregnancy e. Seasonal allergies

Answer 34

a. Intestinal problems b. Kidney function c. Liver function Drugs that induce PGP can increase drug export from cells of the intestinal epithelium into the intestinal lumen, thus decreasing absorption of the drug. PGP inducers also increase drug elimination and decrease brain and fetal drug exposure. Seasonal allergies are not generally a concern.

Question 35

When prescribing medications to infants, it is important for the provider to consider which fact? (Select all that apply.) a. Breast-feeding infants are more likely to develop toxicity when the mother is taking lipid-soluble drugs. b. Immaturity of renal function in infancy causes infants to excrete drugs less efficiently. c. Infants have immature livers, which slows drug metabolism. d. Infants are more sensitive to medications that act on the central nervous system (CNS). e. Oral medications are contraindicated in infants.

Answer 35

a. Breast-feeding infants are more likely to develop toxicity when the mother is taking lipid-soluble drugs. b. Immaturity of renal function in infancy causes infants to excrete drugs less efficiently. c. Infants have immature livers, which slows drug metabolism. d. Infants are more sensitive to medications that act on the central nervous system (CNS). Immature renal function causes infants to excrete drugs more slowly, and infants are at risk for toxicity until renal function is well developed. Infants’ livers are not completely developed, and they are less able to metabolize drugs efficiently. Because the blood-brain barrier is not well developed in infants, caution must be used when administering CNS drugs. Lipid-soluble drugs may be excreted in breast milk if the mother is taking them. Oral medications may be given safely to infants as long as they are awake and can swallow the drug.

Question 36

What will the provider consider when prescribing two drugs that compete for plasma albumin receptor sites? (Select all that apply.) a. Binding of one or both agents will be reduced. b. Plasma levels of free drug will rise. c. Plasma levels of free drug will fall. d. The increase in free drug will cause sustained intensification of effects. e. The increase in bound drug will cause sustained intensification of effects.

Answer 36

a. Binding of one or both agents will be reduced. b. Plasma levels of free drug will rise. c. Plasma levels of free drug will fall. When two drugs bind to the same site on plasma albumin, coadministration of those drugs produces competition for binding. As a result, binding of one or both agents is reduced, causing plasma levels of free drug to rise. The increase in free drug can intensify the effect, but it usually undergoes rapid elimination; therefore, the increase in plasma levels of free drug is rarely sustained. Drug that is bound to protein in the circulation is inactive; therefore, it cannot cause an effect.

Question 37

Which actions occur in most of the fatal medication errors? (Select all that apply.) a. Confusing drugs with similar packaging b. Giving a drug intravenously instead of intramuscularly c. Administering a drug that sounds like the prescribed drug d. Using an infusion device that malfunctions e. Writing a prescription illegibly

Answer 37

b. Giving a drug intravenously instead of intramuscularly c. Administering a drug that sounds like the prescribed drug e. Writing a prescription illegibly Ninety percent of fatal medication errors fall into three categories: human factors, communication mistakes, and name confusion. Giving a drug IV (intravenously) instead of IM (intramuscularly) is an example of a human factor; writing a prescription so that it is illegible is an example of a communication mistake; and giving a drug with a name that sounds like the name of another drug is an example of name confusion. Confusion of drugs with similar packaging and using a faulty device also can cause fatal drug errors, but these factors do not fall into the categories that account for most of fatal errors.

Question 38

A patient is found to have a genetic deficiency in the biomarker CYP2C19. The provider recognizes that prescribing clopidogrel will increase the patient’s risk for developing what serious conditions? (Select all that apply.) a. Myocardial infarction b. Stroke c. Peptic ulcer d. Dementia e. Stomach cancer

Answer 38

a. Myocardial infarction b. Stroke Clopidogrel, a drug that prevents platelet aggregation, is negatively affected by a variant in the genetic code of CYP2C19 resulting in a weak antiplatelet response, which increases their risk for stroke and myocardial infarction. The risk for the other options is not increased with this variant situation.

Question 39

A provider speaking to a class or a group of pregnant patients correctly teaches that the highest risk of teratogen-induced gross malformations exists during which time period? a. Immediately before conception b. During the first trimester c. During the second trimester d. During the third trimester

Answer 39

b. During the first trimester Gross malformations are caused by exposure to teratogens during the embryonic period, which is considered the first trimester. This is the time when the basic shape of internal organs and other structures is established. No risk exists immediately before conception. Teratogen exposure during the second and third trimesters usually disrupts function rather than gross anatomy.

Question 40

A pregnant patient asks her provider about the safe use of medications during the third trimester. What will the provider tell her about drugs taken at this stage? a. “They may need to be given in higher doses if they undergo renal clearance.” b. “They require lower doses if they are metabolized by the liver.” c. “They are less likely to cross the placenta and affect the fetus.” d. “Drugs are more likely to cause anatomical defects if they are taken during the second trimester.

Answer 40

a. “They may need to be given in higher doses if they undergo renal clearance.” In the third trimester, drugs excreted by the kidneys may have to be increased, because renal blood flow is doubled, the glomerular filtration rate is increased, and drug clearance is accelerated. Hepatic metabolism increases; therefore, drugs metabolized by the liver may need to be increased. Drugs are not less likely to cross the placenta. Anatomic defects are more likely to occur in the embryonic period, which is in weeks 3 through 8 in the first trimester.

Question 41

A woman who breastfeeds her infant must take a prescription medication for 2 weeks. The medication is safe, but the patient wants to make sure her baby receives as little of the drug as possible. What instructions will the prescriber give the patient to best address her concerns? a. “Give the baby formula as long as you are taking the medication.” b. “Take the medication immediately after breastfeeding your baby.” c. “Pump your breast milk and feed the baby by bottle.” d. “Take the medication 1 hour before breastfeeding.”

Answer 41

b. “Take the medication immediately after breastfeeding your baby.” Taking the medication immediately after breastfeeding minimizes the drug concentration in the breast milk at the next feeding. Disrupting breastfeeding is not indicated. Pumping the breast milk will not diminish the drugs or drug concentration in the breast milk. Taking the medication 1 hour before breastfeeding will increase concentrations of the drug in the breast milk.

Question 42

Which type of medication prescribed to a pregnant patient is more likely to have effects on her fetus? a. Drugs that are highly polar b. Ionized drugs c. Lipid-soluble drugs d. Protein-bound drugs

Answer 42

c. Lipid-soluble drugs Lipid-soluble drugs cross the placenta more readily. Drugs that are highly polar, ionized, or protein bound cross the placenta with difficulty.

Question 43

A pregnant woman asks why more is not known about the teratogenic effects of maternal medication ingestion during pregnancy. Which response will the provider offer to address the patient’s concern? a. “Clinical trials to determine teratogenic effects would put the fetus at risk.” b. “It is safer to recommend that pregnant women avoid medications while pregnant.” c. “Most women are reluctant to admit taking medications while they are pregnant.” d. “The relatively new MEPREP study will allow testing of medications during pregnancy in the future.”

Answer 43

a. “Clinical trials to determine teratogenic effects would put the fetus at risk.” One of the greatest challenges in identifying drug effects on a developing fetus has been the lack of clinical trials, which, by their nature, would put the developing fetus at risk of harm. Many pregnant women need prescription medications and not taking those would put the fetus at risk by compromising the health of the mother. The MEPREP study is a retrospective study to learn about possible outcomes related to known maternal drug exposure.

Question 44

An infant developed a pruritic rash following exposure to an allergen. The infant’s parents ask the provider about using a topical antihistamine. What information should the provider use to address the parents’ question? a. Antihistamines given by this route are not absorbed as well in children. b. Applying an antihistamine to the skin can cause toxicity in this age group. c. The child will also need oral medication to achieve effective results. d. Topical medications have fewer side effects than those given by other routes.

Answer 44

b. Applying an antihistamine to the skin can cause toxicity in this age group. Drug absorption through the skin is more rapid in infants, because their skin is thinner and has greater blood flow; therefore, infants are at increased risk of toxicity from topical drugs. Because of increased drug absorption through the skin, infants should not be given additional drugs via other routes. If a drug is more likely to be absorbed rapidly, it will have more side effects.

Question 45

The parents of a child with asthma ask the provider why their child cannot use oral corticosteroids more often, because they are so effective. The provider will base the discussion with the parents on what fact concerning oral corticosteroids? a. Chronic glucocorticoid use can inhibit physical growth. b. Frequent use of this drug may lead to a decreased response. c. A hypersensitivity reaction to this drug may occur. d. Systemic steroids are more toxic in children.

Answer 45

a. Chronic glucocorticoid use can inhibit physical growth. A specific age-related reaction to a drug is growth suppression caused by glucocorticoids. Children with asthma may need these from time to time for acute exacerbations, but chronic use is not recommended. None of the other three effects occurs in either adults or children.

Question 46

An infant is prescribed a medication that has a narrow therapeutic range and is excreted by the kidneys. The provider will monitor closely for which effect? a. Decreased drug effectiveness b. Tachyphylaxis c. Evidence of drug toxicity d. Unusual CNS effects

Answer 46

c. Evidence of drug toxicity Renal drug excretion is lower in infants, so drugs that are eliminated primarily by renal excretion should be given in reduced doses or at longer intervals. Drugs with a narrow therapeutic range should be monitored closely for toxicity. This drug likely will have intensified effects and be present for a longer time. Nothing in the question indicates that unusual CNS effects will occur; these would depend on the drug prescribed.

Question 47

A medication prescribed for a neonate is eliminated primarily by hepatic metabolism. What action will the prescriber take to minimize risk to the infant? a. Prescribe a dose that is relatively lower than an adult dose when adjusted for body surface area. b. Prescribe a dose that is relatively higher than an adult dose when adjusted for body surface area. c. Increase the frequency of medication dosing. d. Discontinue the drug after one or two doses.

Answer 47

a. Prescribe a dose that is relatively lower than an adult dose when adjusted for body surface area. The drug-metabolizing capacity of newborns is low. As a result, neonates are especially sensitive to drugs that are eliminated primarily by hepatic metabolism. When these drugs are used, dosages must be reduced. Because of the decreased ability of hepatic metabolism in the newborn, a lower dose is required, not a higher dose, and the frequency will not be increased. The medication dosage should be adjusted, not discontinued, for the newborn.

Question 48

A pediatric provider is teaching nursing students to calculate medication doses for children using a formula based on body surface area. Which statement by a nursing student indicates understanding of the teaching? a. “This formula helps approximate the first dose; other doses should be based on clinical observations.” b. “This formula accounts for pharmacokinetic factors that are different in children.” c. “Using this formula will prevent side effects of medications in children.” d. “This formula can determine medication dosing for a child of any age.”

Answer 48

a. “This formula helps approximate the first dose; other doses should be based on clinical observations.” This formula helps determine an approximate first dose for a child that is extrapolated from an adult dose; subsequent doses should be adjusted based on clinical outcome and serum plasma levels. The formula accounts only for differences in weight and not for differences in pharmacokinetic factors. The formula helps determine an effective dose but cannot account for unusual side effects that may occur in children. It may not be effective for all ages because of rapid changes in pharmacokinetics.

Question 49

A child attending daycare is prescribed 750 mg of an antibiotic for 10 days. The drug may be dosed in several ways and is available in two concentrations. Which dosing regimen will the provider consider to best assure drug adherence? a. 375 mg of a 250 mg/5 mL solution PO twice daily b. 250 mg of a 250 mg/5 mL solution PO three times daily c. 250 mg of a 500 mg/5 mL solution PO three times daily d. 375 mg of a 500 mg/5 mL solution PO twice daily

Answer 49

d. 375 mg of a 500 mg/5 mL solution PO twice daily To promote adherence to a drug regimen in children, it is important to consider the size and timing of the dose. In this case the preparation containing 500 mg/5 mL means that a smaller volume can be given, which is more palatable to a child. Twice daily dosing is more convenient for parents, especially when a child is in daycare or school; it also helps prevent the problem of the medication being left either at home or at school.

Question 50

A 5-year-old has gray teeth. When taking a medication history, the provider will ask about previous use of which group of medications? a. Glucocorticoids b. Salicylates c. Sulfonamides d. Tetracyclines

Answer 50

d. Tetracyclines Tetracyclines cause discoloration in developing teeth in children. Glucocorticoids are associated with growth suppression. Salicylates are associated with Reye syndrome. Sulfonamides are associated with kernicterus in newborns.

Question 51

A provider is concerned about renal function in an 84-year-old patient who is taking several medications. What laboratory result will the provider order? a. Creatinine clearance b. Sodium levels c. Potassium levels d. Serum creatinine

Answer 51

a. Creatinine clearance The proper index of renal function in older adults is creatinine clearance, which indicates renal function in older patients whose organs are undergoing age-related deterioration. Sodium and potassium levels are not indicative of renal function. Serum creatinine levels do not accurately reflect kidney function in older adults because lean muscle mass, which is the source of creatinine in serum, declines and may be low even with reduced kidney function.

Question 52

An older adult patient with a history of forgetfulness will need to take multiple drugs after discharge from the hospital. What provider action will most successfully promote medication adherence in a forgetful patient? a. Ask the patient to share the medication teaching with a neighbor or friend soon after discharge. b. Give the patient detailed written information about each drug. c. Schedule medications to be taken at the same times as much as possible. d. Make sure the patient understands the actions and side effects of each drug.

Answer 52

c. Schedule medications to be taken at the same times as much as possible. Unintentional nonadherence often is the result of confusion and forgetfulness. Grouping medications to reduce the number of medication times per day can simplify the regimen and help the patient remember medication times. Enlisting a neighbor, relative, or friend is a good idea, but this person should be included in the original teaching sessions. Asking the patient to share what is learned may not be a reasonable expectation of a patient who is forgetful. Detailed written information may just be more confusing; verbal and written information should be clear and concise. Making sure the patient understands the actions and side effects of medications helps when intentional nonadherence is an issue, but in this case it may just add to the patient’s confusion.

Question 53

A provider is reviewing an older adult patient’s chart during a routine visit. Which patient information is of most concern regarding the renewing of medication prescriptions for highly protein-bound drugs? a. Chronic constipation b. Increased body fat c. Low serum albumin d. Low serum creatinine

Answer 53

c. Low serum albumin Low serum albumin reduces protein binding of drugs and can cause levels of free drug to rise, increasing the risk of toxicity. The other options are not associated solely with protein-bound drugs. Additionally, altered gastrointestinal (GI) absorption is not a major factor of concern in the older adult, although delayed GI transit can delay drug responses. Increased body fat can alter drug distribution, causing reduced responses in lipid-soluble drugs; however, it is not the finding of greatest concern. Low serum creatinine may be an indicator of decreased lean muscle mass in older patients and does not necessarily reflect kidney function or drug excretion.

Question 54

Four older adult patients are taking multiple medications. For which patient is the provider most concerned about the risk for adverse drug effects? a. An obese patient b. A patient with decreased serum creatinine c. A patient who experiences chronic diarrhea d. An underweight patient with a chronically low appetite

Answer 54

d. An underweight patient with a chronically low appetite The patient who is thin and has a poor appetite has an increased risk of malnutrition, with significant lowering of serum albumin. This can result in increased free drug levels of protein-bound drugs and can lead to drug toxicity. Obesity, which involves increased adipose tissue, would cause lipid-soluble drugs to deposit in adipose tissue, with a resulting reduction of drug effects. Creatinine levels do not adequately reflect kidney function in older adults and may be normal even though renal function is greatly reduced. Chronic diarrhea would accelerate the passage of medications through the GI tract and reduce absorption resulting in a decrease in both beneficial and adverse effects.

Question 55

An older adult patient is entering into the immediate postoperative period after a total hip replacement. The patient’s son concerned about related pain asks meperidine be prescribed since, “I had it for severe pain when I injured when I was younger.” What action will the provider take to reduce the patient’s risk for injury while addressing the patient’s pain? a. Prescribe meperidine and request the initiation of the fall risk protocol. b. Provide a PRN order for diphenhydramine for the expected side effect of itching. c. Prescribe morphine and discuss the rationale with the patient’s son. d. Offer to prescribe diazepam to reduce the patient’s anxiety and thus reduce the need for narcotics.

Answer 55

c. Prescribe morphine and discuss the rationale with the patient’s son. In older adults, meperidine is not effective at usual doses and causes more confusion, delirium, and neurotoxicity than in younger patients. Morphine is recommended for severe pain among the older population. A fall risk protocol is appropriate, but the drug ordered is not. Diphenhydramine is not recommended for older adult patients, because it causes blurred vision. Both diphenhydramine and diazepam have central nervous system (CNS) sedative effects, which will compound the CNS effects of the narcotic. Diazepam also produces prolonged sedation in older adults.

Question 56

An older adult patient is admitted to the hospital for treatment of an exacerbation of a chronic illness. Admission laboratory work reveals an extremely low serum drug level of the drug used to treat this condition. The patient’s renal and hepatic function tests are normal. What might the provider suspect as a likely cause of this finding? a. Nonadherence to the medical regimen b. Chronic constipation c. Increased tolerance to the drug’s effects d. Concurrent administration of two highly protein-bound drugs

Answer 56

a. Nonadherence to the medical regimen Nonadherence is the most common cause of a subtherapeutic drug level. For example, older adult patients who have financial concerns about paying for medications often take less of the drug or take it less often to make the drug last longer. Chronic constipation would be more likely to cause a slight elevation of drug level due to the prolonged time for drug absorption. A patient with increased tolerance to a drug’s effects would require more of the drug to get effects. Concurrent administration of two highly protein-bound drugs would result in increased serum levels of one or both drugs.

Question 57

A provider obtains a drug history from an older adult who is a new patient. Of the multiple medications taken, which two, taken together, create a reason for concern? a. Acetaminophen and oxycodone b. Amitriptyline and diphenhydramine c. Fexofenadine and an over-the-counter (OTC) laxative d. Zolpidem and sertraline

Answer 57

b. Amitriptyline and diphenhydramine Both amitriptyline and diphenhydramine are on the BEERS list, amitriptyline for anticholinergic effects and diphenhydramine because it causes blurred vision. Additionally, they both have CNS effects that can compound each other when the drugs are given together. Acetaminophen and oxycodone are both acceptable and may be given together. Fexofenadine is a second-generation antihistamine with fewer side effects, and it is not contraindicated for use with a laxative. Zolpidem is a sedative that has less risk of physical dependence and less risk of confusion, falls, and cognitive impairment; sertraline is a safer antidepressant, because it has a shorter half-life than others.

Question 58

A frail older adult patient is admitted to the hospital after several days of vomiting, diarrhea, poor intake of foods and fluids, and anuria for 8 hours. What laboratory studies will the provider order to help guide medication administration? (Select all that apply.) a. Creatinine clearance b. Gastric pH c. Plasma drug levels d. Serum albumin e. Serum creatinine

Answer 58

a. Creatinine clearance c. Plasma drug levels d. Serum albumin Creatinine clearance is the best way to evaluate renal function in the older adult. Plasma drug levels are important for determining if the patient has toxic or subtherapeutic drug levels. Serum albumin may be decreased, especially in patients who are thin, are chronically undernourished, or have been vomiting, and the decreased level may result in higher levels of drugs that normally bind to proteins. Gastric pH is not as important; most GI changes result in lowered absorption and less free drug. Serum creatinine levels are related to the amount of lean muscle mass, which may be low in older adult patients, and not reflective of renal function.

Question 59

A patient is wheezing and short of breath with a heart rate of 88 beats/minute, a respiratory rate of 24 breaths/minute, and a blood pressure of 124/78 mm Hg. The primary health care prescriber orders a nonselective β agonist medication. Besides evaluating the patient for a reduction in respiratory distress, which side effect is of primary concern? a. Hypotension b. Tachycardia c. Tachypnea d. Urinary retention

Answer 59

b. Tachycardia β agonists are used for asthma because of their β2 effects on bronchial smooth muscle, causing dilation. Nonselective β agonists also have β1 effects. β1 effects cause tachycardia and hypertension. β receptors do not exert effects on the bladder.

Question 60

A pregnant patient is in premature labor. Which class of drug will her provider prescribe in an attempt to stop the contractions? a. α1 agonist b. Anticholinergic c. β2 agonist d. β2 antagonist

Answer 60

c. β2 agonist β2 agonists cause relaxation of uterine muscle, slowing or stopping the contractions that precipitate labor. An α1 agonist would have effects on the heart and arterioles. Anticholinergic drugs generally are given for their effects on the urinary and GI tracts and do not affect uterine muscle. A β2 antagonist would cause increased constriction of uterine muscle.

Question 61

Which assessment finding would be of greatest concern for a provider who is attempting to determine the appropriateness of prescribing the patient a nonselective β agonist? a. Pulse oximetry reading of 88% b. Blood pressure of 100/60 mm Hg c. Respiratory rate of 28 breaths/minute d. Heart rate of 110 beats/minute

Answer 61

d. Heart rate of 110 beats/minute Nonselective β agonists activate both β1 and β2 receptors. A nonselective β agonist dilates respiratory smooth muscle, but as a side effect, it can stimulate the heart. A heart rate of 110 beats/minute is a concern, because this medication may further increase the already elevated heart rate. A pulse oximetry reading of 88% is a concern, but the medication causes bronchodilation and improves oxygenation; this should increase the pulse oximetry reading. A blood pressure of 100/60 mm Hg is on the low side, but this medication may actually cause an increase in blood pressure as a side effect; this should not concern the nurse before administration of the medication. A respiratory rate of 28 breaths/minute is elevated; however, this medication should improve oxygenation by bronchodilation, and the patient’s respiratory rate should decrease once oxygenation has improved. Therefore, this should not concern the nurse.

Question 62

For what purpose will a provider prescribe pilocarpine? a. To reduce excessive secretions in a postoperative patient b. To lower intraocular pressure in a patient with glaucoma c. To inhibit muscular activity in a patient with an overactive bladder d. To prevent a hypertensive crisis in a patient with chronic hypertension

Answer 62

b. To lower intraocular pressure in a patient with glaucoma Pilocarpine is a muscarinic agonist used mainly for topical therapy of glaucoma to reduce intraocular pressure. Pilocarpine is not indicated for the treatment of excessive secretions and mucus; in fact, pilocarpine is used to treat dry mouth. Pilocarpine does not inhibit muscular activity in the bladder. Pilocarpine is not used to prevent hypertensive crisis.

Question 63

A provider reviews the patient’s chart before prescribing bethanechol for postoperative urinary retention. Which preexisting condition would be a contraindication to using this drug? a. Asthma b. Gastroesophageal reflux c. Hypertension d. Hypothyroidism

Answer 63

a. Asthma Bethanechol is contraindicated in patients with active or latent asthma because activation of muscarinic receptors in the lungs causes bronchoconstriction. It increases the tone and motility of the gastrointestinal (GI) tract and is not contraindicated in patients with reflux. It causes vasodilation and would actually lower blood pressure in a hypertensive patient. It causes dysrhythmias in hyperthyroid patients, not hypothyroid patients.

Question 64

An older adult patient who lives alone and admits to being “somewhat forgetful” has an overactive bladder (OAB) and occasional constipation. The patient has tried behavioral therapy to treat the OAB without success. Which treatment will the provider likely prescribe for this patient? a. Oxybutynin short-acting syrup b. Oxybutynin [Ditropan XL] extended-release tablets c. Oxybutynin [Oxytrol] transdermal patch d. Percutaneous tibial nerve stimulation (PTNS)

Answer 64

c. Oxybutynin [Oxytrol] transdermal patch The transdermal patch is applied weekly and may be the best option for a patient who is more likely to forget to take a daily medication. The transdermal preparation has fewer side effects than the systemic dose, so it is less likely to increase this patient’s constipation. The syrup has a high incidence of dry mouth and other anticholinergic side effects. The extended-release tablets must be given daily, and this patient may not remember to take them. PTNS is used after behavioral and drug therapies have failed.

Question 65

Bethanechol is being investigated for inclusion in treatment for which diagnosis? a. Gastric ulcers b. Gastroesophageal reflux c. Hypotension d. Intestinal obstruction

Answer 65

b. Gastroesophageal reflux Bethanechol is being investigated for the treatment of gastroesophageal reflux disease (GERD) because of its effects on esophageal motility and the lower esophageal sphincter. Bethanechol stimulates acid secretion and could intensify ulcer formation. Bethanechol can cause hypotension. Because bethanechol increases the motility and tone of intestinal smooth muscle, the presence of an obstruction could lead to bowel rupture.

Question 66

The prescriber has ordered neostigmine for a patient with myasthenia gravis. What physiological process would be assessed to best assure patient safety and the long-term effectiveness of the medication therapy? a. The patient’s ability to raise the eyelids b. The level of fatigue the patient generally experiences c. Current skeletal muscle strength the patient possesses d. The patient’s current swallowing ability

Answer 66

d. The patient’s current swallowing ability Many patients hospitalized for myasthenia gravis do not have the muscle strength to swallow well and need a parenteral form of the medication; therefore, assessing the patient’s ability to swallow is an important initial safety measure. Evaluating the patient’s ability to raise the eyelids, level of fatigue, and skeletal muscle strength are important assessments before drug administration and during drug treatment, because they indicate the effectiveness of the drug and help determine subsequent doses.

Question 67

A patient experiences delirium and hallucinations after beginning atropine treatment for bradycardia. Which medication will the provider prescribe to address these signs of possible atropine toxicity? a. Donepezil b. Edrophonium c. Neostigmine d. Physostigmine

Answer 67

d. Physostigmine Physostigmine is the drug of choice for treating poisoning from atropine and other drugs that cause muscarinic blockade. Donepezil is used to treat Alzheimer disease. Edrophonium is used to distinguish between a myasthenic crisis and a cholinesterase inhibitor overdose. Neostigmine does not cross the blood-brain barrier and would not effectively treat this patient’s CNS symptoms.

Question 68

The provider is assessing an older adult male patient prior to beginning a prescribed anticholinergic drug. Which question concerning preexisting conditions demonstrates the provider’s understanding of possible contraindications to this therapy? a. “Would you say that diarrhea is a problem you deal with regularly?” b. “Do you have any vision problems that require a prescribed medication?” c. “Have you ever been treated for prostate cancer?” d. “Do you have problems with urinary incontinence?”

Answer 68

b. “Do you have any vision problems that require a prescribed medication?” Anticholinergic drugs have been designated as potentially inappropriate for use in geriatric patients. They can cause confusion, blurred vision, tachycardia, urinary retention, and constipation. Many of these complicate preexisting conditions (e.g., urinary retention secondary to benign prostatic hyperplasia) and increase the risk for other conditions (e.g., narrow-angle glaucoma risk secondary to pupil dilation and heat-related illness secondary to hyperthermia and impaired sweating mechanisms).

Question 69

A client with a history of motion sickness asks the provider about medication to manage this condition during a planned cruise. What medication will the provider likely prescribe? a. Ipratropium b. Scopolamine c. Dicyclomine d. Atropine

Answer 69

b. Scopolamine Scopolamine is an anticholinergic drug with actions much like those of atropine, but with an exception. Scopolamine suppresses emesis and motion sickness, whereas atropine does not. Ipratropium is an anticholinergic drug used to treat asthma, COPD, and rhinitis caused by allergies or the common cold. Dicyclomine is indicated for irritable bowel syndrome (spastic colon, mucous colitis). It is also used for functional bowel disorders such as diarrhea and hypermotility. Neither dicyclomine nor ipratropium have antiemetic properties.

Question 70

A client is about to begin anticholinergic medication therapy. What instructions will the provider give to best minimize common side effects? a. Wear dark glasses both indoors and outdoors. b. Void just prior to taking the medication. c. Minimize fiber intake to avoid diarrhea. d. Hydrate well before engaging in outdoor exercise.

Answer 70

b. Void just prior to taking the medication. Advise patients that urinary retention can be minimized by voiding just before taking anticholinergic medication. Dark glasses are of value with outdoors if experiencing photophobia, but are unnecessary indoors. Constipation rather than diarrhea is associated with anticholinergic medication and so fiber consumption is important. Avoidance of outside exercise especially in warm/hot environments is related to impaired sweat production and hyperthermia rather than hydration issues.

Question 71

Dopamine is administered to a patient who has hypotension. Other than an increase in blood pressure, which indicator would the provider use to evaluate a successful response? a. Decrease in pulse b. Increase in urine output c. Weight gain d. Improved gastric motility

Answer 71

b. Increase in urine output Dopamine will cause an increase in urine output, because cardiac output is increased as a result of the increase in blood pressure. The effectiveness of dopamine would not be measured by a decrease in pulse, because dopamine’s primary effect is to increase blood pressure. Dopamine’s effectiveness would not be evaluated by a weight gain. Dopamine’s effectiveness would not be evaluated by improved gastric motility.

Question 72

A patient with asthma uses albuterol for wheezing. The provider notes current vital signs of HR, 96 beats/minute; RR, 18 breaths/minute; and BP, 116/78 mm Hg. The patient has clear breath sounds and fine hand tremors. What action will the provider take initially to treat this patient effectively? a. Ask how often the patient uses the inhaler. b. Check the patient’s blood glucose level. c. Prescribe isoproterenol to reduce side effects. d. Substitute isoproterenol to minimize the tremors.

Answer 72

a. Ask how often the patient uses the inhaler. Tachycardia is a response to activation of β1 receptors. It can occur when large doses of albuterol are used and selectivity decreases. The nurse should question the patient about the number of inhalations used. Isoproterenol can cause hyperglycemia in diabetic patients. Isoproterenol has more side effects than albuterol. Tremors are an expected side effect and are not an indication for stopping the drug.

Question 73

The provider is discussing home management with a patient who will begin taking an α-adrenergic antagonist for hypertension. Which statement by the patient indicates understanding of the teaching? a. “I need to stop the medication if my heart rate increases.” b. “I should not drive while taking this medication.” c. “I should take the first dose at bedtime.” d. “I will stop taking the medication if I feel dizzy.”

Answer 73

c. “I should take the first dose at bedtime.” Orthostatic hypotension is a common side effect of this class of drugs and is most severe with the first dose. Administering the first dose at bedtime eliminates the risk associated with this first-dose effect. Tachycardia is an expected side effect; if severe, it can be treated with other medications. Patients should not drive during the first 12 to 24 hours after taking these agents, because fainting and dizziness may occur, but they may drive after that. Dizziness is not an indication for stopping the drug; patients who experience dizziness are instructed to sit or lie down until symptoms pass.

Question 74

A patient prescribed phentolamine to treat pheochromocytoma now has a blood pressure of 76/52 mm Hg and a heart rate of 90 beats/minute. Which action will the provider take to provide effective care? a. Prescribe epinephrine. b. Ask to be notified if the heart rate increases. c. Prescribe a β blocker. d. Prescribe norepinephrine.

Answer 74

d. Prescribe norepinephrine. Phentolamine overdose can produce profound hypotension. When this occurs, blood pressure can be elevated with norepinephrine. Epinephrine should not be used because, in the presence of α1 blockade, the ability of epinephrine to promote vasodilation by activation of β2 receptors may outweigh its ability to cause vasoconstriction, causing further lowering of blood pressure. Norepinephrine does not activate β2 receptors. β blockers may be used to treat severe reflex tachycardia. This patient has significant hypotension, so it is not correct to continue to monitor rather than providing treatment.

Question 75

A patient who takes a β blocker reports experiencing shortness of breath and has respirations of 28 breaths/minute, a blood pressure of 78/50 mm Hg, a pulse of 68 beats/minute, and crackles are auscultated in all lung fields. The provider begins treatment for what condition based on the assessment data? a. Bronchoconstriction b. Left-sided heart failure c. Rebound cardiac excitation d. Sinus bradycardia

Answer 75

b. Left-sided heart failure β blockers can exacerbate symptoms in patients with acute decompensated heart failure or in those with preexisting myocardial dysfunction and borderline compensation, since the maintenance of cardiac output in such patients depends in part upon sympathetic drive. The signs and symptoms describe left-sided heart failure, in which the blood normally handled by the left ventricle and forced out through the aorta into the body backs up into the lungs, producing respiratory signs and symptoms. The patient’s signs and symptoms are not indicative of bronchoconstriction, which would cause wheezing and diminished breath sounds. Rebound cardiac excitation occurs when the β blocker is withdrawn, not during administration of the drug. The patient’s heart rate is not lowered to the point of sinus bradycardia.

Question 76

A male patient with benign prostatic hyperplasia (BPH) has stopped taking his α-adrenergic antagonist medication because of ejaculatory difficulties. Which medication will the provider to prescribe to best address the BPH and the patient’s concerns? a. Alfuzosin b. Prazosin c. Silodosin d. Tamsulosin

Answer 76

a. Alfuzosin Alfuzosin is used for BPH and does not interfere with ejaculation. All of the other drugs have ejaculatory related side effects. Prazosin may be useful for BPH, but it is not approved for this use.

Question 77

A patient will begin taking propranolol for hypertension. Which statement made by the prescriber is important when teaching this patient about the medication? a. “Notify the clinic if you start waking at night with shortness of breath or have difficulty lying flat.” b. “It is safe to take this medication with your calcium channel blocker.” c. “Stop taking the drug if you become short of breath.” d. “Take your pulse and do not take the medication if your heart rate is fast.”

Answer 77

a. “Notify the clinic if you start waking at night with shortness of breath or have difficulty lying flat.” Patients taking propranolol can develop heart failure because of the suppression in myocardial contractility. Symptoms typically begin with left heart failure, so patients should be taught to report onset of paroxysmal nocturnal dyspnea, orthopnea, and night coughs. Use of these agents with calcium channel blockers is contraindicated, because the effects are identical and excessive cardiosuppression can occur. Abrupt cessation of the drug can cause rebound cardiac excitability; therefore, shortness of breath should be reported rather than stopping the drug. Propranolol reduces the heart rate and should not be given if the pulse is less than 60 beats/minute.

Question 78

A provider prescribed methyldopa for a patient with hypertension. The patient is educated about drug actions, adverse effects, and the ongoing blood tests necessary with this drug. What additional statement should the provider include during the teaching? a. “If you have a positive Coombs test result, you will need to discontinue the medication, because this means you have hemolytic anemia.” b. “Methyldopa can be used for its analgesic effects and for its hypertensive effects.” c. “Xerostomia and orthostatic hypotension are serious side effects and indications for withdrawing the medication.” d. “You will need to contact the office immediately and stop taking the medication if your eyes look yellow.”

Answer 78

d. “You will need to contact the office immediately and stop taking the medication if your eyes look yellow.” Hepatotoxicity is a serious adverse effect of methyldopa and is an indication for withdrawal of the drug to prevent fatal hepatic necrosis. Jaundice is a sign of liver toxicity. Patients should undergo periodic liver function tests while taking the drug. Liver function usually improves when the drug is withdrawn. A positive Coombs test result is not an indication for withdrawal of the drug in itself. About 5% of patients with a positive Coombs test result develop hemolytic anemia; withdrawal of the drug is indicated for those patients. Methyldopa does not have analgesic effects. Xerostomia and orthostatic hypotension are known side effects of methyldopa but usually are not serious. Additionally, drug education should be provided using terms the patient can easily understand; most patients will not know the meaning of xerostomia or a positive Coombs test.

Question 79

A patient reports that the clonidine recently prescribed for hypertension is causing drowsiness. Which response by the provider to this concern is appropriate? a. “Drowsiness is a common side effect initially, but it will lessen with time.” b. “You may also experience hypotension when you stand along with the drowsiness. ” c. “You may be at risk for addiction if you have central nervous systemside effects. ” d. “You should discontinue the medication and I’ll prescribe analternative medication. ”

Answer 79

a. “Drowsiness is a common side effect initially, but it will lessen with time.” CNS depression, evidenced in this patient by drowsiness, is common in about 35% of the population. These responses become less intense with continued drug use. Orthostatic hypotension is less likely with clonidine, because its antihypertensive effects are not posture dependent. The experience of drowsiness does not indicate abuse potential. The patient should not discontinue the medication abruptly because of the potential for rebound hypertension; there is no need to change prescriptions.

Question 80

A prescriber orders clonidine ER (Kapvay ER) tablets for a 12-year-old child to treat which condition? a. ADHD b. Hypertension c. Severe pain d. Tourette syndrome

Answer 80

a. ADHD Kapvay ER is used to treat ADHD. This form of clonidine is not used for hypertension, severe pain, or treatment of Tourette syndrome.

Question 81

A patient is prescribed both a diuretic and a dobutamine in the immediate postoperative period. What adverse drug reactions will the prescriber consider as possible in this patient? (Select all that apply.) a. Angina b. Dysrhythmias c. Hypotension d. Oliguria e. Tachycardia

Answer 81

b. Dysrhythmias d. Oliguria e. Tachycardia Hypertension, dysrhythmias, and tachycardia are the most common adverse effects of dopamine; general anesthetics can increase the likelihood of dysrhythmias. Dopamine elevates blood pressure by increasing cardiac output. Diuretics complement the beneficial effects of dopamine on the kidney, so urine output would be increased, not decreased.

Question 82

A prescriber has ordered methyldopa for a female patient diagnosed with hypertension. The nurse understands that which laboratory tests are important before beginning therapy with this drug? (Select all that apply.) a. Coombs test b. Hemoglobin and hematocrit (H&H) c. Liver function tests d. Pregnancy test e. Urinalysis

Answer 82

a. Coombs test b. Hemoglobin and hematocrit (H&H) c. Liver function tests A positive Coombs test result occurs in 10% to 20% of patients who take methyldopa chronically. A few of these patients (5%) develop hemolytic anemia. Blood should be drawn for a Coombs test and an H&H before treatment is started and at intervals during treatment. Because methyldopa is associated with liver disorders, liver function tests should be performed before therapy is started and periodically during treatment. Methyldopa is one of the hypertensives recommended during pregnancy, so pregnancy testing is not needed. A urinalysis is not indicated.

Question 83

Clonidine is approved for the treatment of which conditions? (Select all that apply.) a. ADHD b. Hypertension c. Opioid withdrawal d. Severe pain e. Smoking cessation

Answer 83

a. ADHD b. Hypertension d. Severe pain Clonidine has three approved uses: treatment of ADHD, hypertension, and severe pain. It has investigational (off-label) uses for management of opioid withdrawal and for smoking cessation.

Question 84

A patient diagnosed with Parkinson disease (PD) begins treatment with levodopa/carbidopa. After several months of therapy, the patient reports no change in symptoms. The provider will implement what action? a. Prescribing the patient a dopamine agonist b. Discussing the effects of the “on-off” phenomenon with the patient c. Increasing the daily dose of levodopa/carbidopa d. Ordering tests to reevaluate the patient’s diagnosis

Answer 84

d. Ordering tests to reevaluate the patient’s diagnosis Patients beginning therapy with levodopa/carbidopa should expect therapeutic effects to occur after several months of treatment. Levodopa/carbidopa is so effective that a diagnosis of PD should be questioned if the patient fails to respond in this time frame. Adding a dopamine agonist is not indicated. The “on-off” phenomenon occurs when therapeutic effects are present. Increasing the dose of levodopa/carbidopa is not indicated.

Question 85

A patient who takes levodopa/carbidopa for Parkinson disease reports periods of lost drug effect lasting from minutes to several hours with no relationship to the timing of drug administration. What course of action will the provider take? a. Prescribe a COMT inhibitor, such as entacapone. b. Add the DA-releasing agent amantadine to the regimen. c. Prescribe a direct-acting dopamine agonist. d. Shorten the dosing interval of levodopa/carbidopa.

Answer 85

a. Prescribe a COMT inhibitor, such as entacapone. This patient is describing abrupt loss of effect, or the “off” phenomenon, which is treated with entacapone or another COMT inhibitor. Amantadine is used to treat dyskinesias. A direct-acting dopamine agonist is useful for gradual loss of effect, which occurs at the end of the dosing interval as the dose is wearing off. Shortening the dosing interval does not help with abrupt loss of effect.

Question 86

When selecting a dopamine agonist for a patient with Parkinson disease, the provider identifies which side effect associated with pramipexole as being less likely to occur than with other dopamine agonists? a. Sleep attacks b. Dizziness c. Hallucinations d. Dyskinesias

Answer 86

a. Sleep attacks A few patients taking pramipexole have experienced sleep attacks, or an overwhelming and irresistible sleepiness that comes on without warning. Dizziness, hallucinations, and dyskinesias are listed as side effects of all dopamine agonists

Question 87

A patient has been newly diagnosed with Parkinson disease. Before beginning therapy with pramipexole, the provider will ask the patient which assessment question in order to minimize risk for injury? a. “Do you have any history of alcohol abuse or compulsive behaviors?” b. “Have you have any previous history of hypertension?” c. “Do you have any difficulty falling asleep or staying asleep?” d. “Do you have family history associated with psychoses?”

Answer 87

a. “Do you have any history of alcohol abuse or compulsive behaviors?” Pramipexole has been associated with impulse control disorders, and this risk increases in patients with a history of alcohol abuse or compulsive behaviors. Pramipexole increases the risk of hypotension and sleep attacks, so a history of hypertension or insomnia would not be cautionary. Unlike with levodopa, the risk of psychoses is not increased.

Question 88

A hospitalized patient newly diagnosed with Parkinson disease is prescribed apomorphine but develops medication-related nausea and vomiting. What drug will the provider prescribe to manage these side effects effectively? a. Levodopa b. Ondansetron c. Prochlorperazine d. Trimethobenzamide

Answer 88

d. Trimethobenzamide Trimethobenzamide can be used as an antiemetic in patients treated with apomorphine. Serotonin receptor agonists (e.g., ondansetron) and dopamine receptor antagonists (e.g., prochlorperazine) cannot be used, because they increase the risk of serious postural hypotension. Levodopa only increases nausea and vomiting.

Question 89

The provider prescribes bromocriptine for a patient who takes levodopa/carbidopa. Afterward, the patient becomes agitated and has frequent nightmares. What action will the provider take to manage the patient’s symptoms? a. Add an antipsychotic medication to the patient’s medication regimen. b. Discontinue the bromocriptine and prescribe cabergoline. c. Reduce the dose of bromocriptine. d. Reduce the dose of levodopa/carbidopa.

Answer 89

c. Reduce the dose of bromocriptine. Bromocriptine is used to treat levodopa-induced dyskinesias and has dose-dependent psychological side effects. Reducing the dose of this drug can minimize these side effects. Adding an antipsychotic medication is not indicated. Cabergoline is not approved for this use. Reducing the dose of levodopa/carbidopa is not indicated.

Question 90

An infant is prescribed a central nervous system (CNS) drug. The parents are concerned that the child exhibits unusual drowsiness and sedation. The provider explains these effects based on an understanding of which difference in the physiology of infants and adults? a. Blood-brain barrier b. First-pass effect c. Gastrointestinal absorption d. Renal filtration

Answer 90

a. Blood-brain barrier The blood-brain barrier is not fully developed at birth, making infants much more sensitive to CNS drugs than older children and adults. CNS symptoms may include sedation and drowsiness. The first-pass effect and GI absorption affect metabolism and absorption of drugs, and renal filtration affects elimination of drugs, all of which may alter drug levels.

Question 91

A patient reports stopping baclofen the day before being admitted to the hospital. The provider instructs the hospital staff to monitor the patient for which withdrawal effects? a. Dizziness b. Fatigue c. Hallucinations d. Dyspnea

Answer 91

c. Hallucinations Abrupt discontinuation of baclofen is associated with visual hallucinations, paranoid ideation, and seizures. Adverse effects (not withdrawal effects) of baclofen include weakness, dizziness, fatigue, and drowsiness. Respiratory depression is a result of overdose of baclofen.

Question 92

When a patient with a lower back injury begins experiencing muscle spasms, the provider orders cyclobenzaprine 10 mg three times a day. What information will the provider include when teaching this patient about this drug? a. “This drug carries some risk of developing hallucinations and psychotic symptoms. ” b. “This medication may cause your urine to turn brown, black, or dark green.” c. “You may experience blurred vision, dry mouth, or constipation.” d. “You will need to have liver function tests performed while taking this medication. ”

Answer 92

c. “You may experience blurred vision, dry mouth, or constipation.” Cyclobenzaprine has significant anticholinergic effects and patients should be warned about dry mouth, blurred vision, and constipation. Tizanidine, not cyclobenzaprine, can cause hallucinations and psychotic symptoms. Methocarbamol, not cyclobenzaprine, may turn urine brown, black, or green, which is a harmless side effect. Tizanidine and metaxalone, not cyclobenzaprine, can cause liver toxicity and require monitoring.

Question 93

A provider is considering prescribing tizanidine for patient who is experiencing localized muscle spasms after an injury. What information in the patient’s health history will be concerning enough to the provider to warrant selecting a different drug? a. Chronic use of aspirin b. A history of hepatitis c. A history of malignant hyperthermia d. Occasional use of alcohol

Answer 93

b. A history of hepatitis Hepatotoxicity is a serious potential problem in a patient receiving tizanidine. Baseline liver enzymes should be obtained before dosing and periodically thereafter. Analgesic anti-inflammatory drugs commonly are used in conjunction with centrally acting muscle relaxants, so using aspirin is not a concern. This drug does not contribute to malignant hyperthermia. Patients should be advised to avoid alcohol when taking this drug, but a history of occasional alcohol use is not a contraindication.

Question 94

A provider has prescribed dantrolene for the following patients. Which patient will the provider monitor most closely for risk of injury? a. A 20-year-old woman with a spinal cord injury b. A 45-year-old man with a history of malignant hyperthermia c. A 55-year-old woman with multiple sclerosis d. An 8-year-old child with cerebral palsy

Answer 94

c. A 55-year-old woman with multiple sclerosis Dose-related liver damage is the most serious adverse effect of dantrolene and is most common in women older than 35 years. Dantrolene is used to treat spasticity associated with multiple sclerosis, cerebral palsy, and spinal cord injury, so all of these patients would be candidates for this agent. Dantrolene also is used to treat malignant hyperthermia.

Question 95

A patient with cerebral palsy has severe muscle spasticity and muscle weakness which makes it difficult to take anything by mouth. The provider will prescribe and educate the patient on which medication for home therapy? a. Baclofen b. Dantrolene c. Diazepam d. Metaxalone

Answer 95

a. Baclofen Baclofen is used to treat muscle spasticity associated with multiple sclerosis, spinal cord injury, and cerebral palsy. It does not reduce muscle strength, so it will not exacerbate this patient’s muscle weakness. It can be given intrathecally, via an implantable pump, and therefore is a good choice for patients who cannot take medications by mouth. Dantrolene causes muscle weakness and must be given by mouth or intravenously, so it would not be a good option for this patient. Diazepam is not the first-line drug of choice. Metaxalone is used to treat localized muscle spasms caused by injury and is not used for cerebral palsy.

Question 96

A patient with cerebral palsy who has been receiving baclofen for 3 months is admitted to the hospital for evaluation of new-onset seizures. What assessment question will the provider ask to help identify the most likely cause of these seizures? a. “Have you taken any extra doses of baclofen?” b. “Are you aware of the most common adverse effect of baclofen?” c. “Did you know that seizures are an idiopathic response to baclofen?” d. "Have you missed any doses of baclofen?”

Answer 96

d. "Have you missed any doses of baclofen?” Baclofen does not appear to cause physical dependence, but abrupt discontinuation has been associated with adverse reactions. Abrupt withdrawal of oral baclofen can cause visual hallucinations, paranoid ideation, and seizures and should be considered when a patient develops these symptoms. Seizures are not a symptom of baclofen toxicity.

Question 97

A provider provides teaching for a patient with a newly diagnosed partial complex seizure disorder who will begin therapy with an antiepileptic drug (AED). Which statement by the patient indicates to the provider an understanding of the teaching? a. “I may need to try several drugs before finding one is effective.” b. “I will know that the drug is effective if I am seizure-free for two months.” c. “Serious side effects may occur, and if they do, I should stop taking the medication.” d. “When the drug level is maintained at therapeutic levels, I can expect to be seizure free.”

Answer 97

a. “I may need to try several drugs before finding one is effective.” Even with an accurate diagnosis of seizures, many patients have to try more than one AED to find a drug that is effective and well tolerated. Unless patients are being treated for absence seizures, which occur frequently, monitoring of the clinical outcome is not sufficient for determining effectiveness, because patients with convulsive seizures often have long seizure-free periods. Serious side effects may occur, but withdrawing a drug precipitously can induce seizures. Not all patients have seizure control with therapeutic drug levels, because not all medications work for all patients.

Question 98

A patient who has been taking an antiepileptic drug for several weeks reports little change in seizure frequency, what action will the provider take to provide effective care? a. Ask the patient to complete a seizure frequency chart for the past few weeks. b. Write an order for serum drug levels. c. Reinforce to the patient the need to take the medications as prescribed. d. Increase the dose of the antiepileptic drug.

Answer 98

b. Write an order for serum drug levels. If medication therapy is not effective, it is important to measure serum drug levels of the medication to determine whether therapeutic levels have been reached. Patients should be asked at the beginning of therapy to keep a seizure frequency chart to help deepen their involvement in therapy; asking for historical information is not helpful. Until it is determined that the patient is not complying, the nurse should not reinforce the need to take the medication. Until the drug level is known, increasing the dose is not indicated.

Question 99

A provider counsels a patient who is prescribed phenytoin for epilepsy. Which statement by the patient indicates understanding of the teaching? a. “I should brush and floss my teeth regularly.” b. “Once therapeutic blood levels are reached, they are easy to maintain.” c. “I can consume alcohol in moderation while taking this drug.” d. “Rashes are a common side effect but are not serious.”

Answer 99

a. “I should brush and floss my teeth regularly.” Gingival hyperplasia occurs in about 20% of patients who take phenytoin. It can be minimized with good oral hygiene, so patients should be encouraged to brush and floss regularly. Because small fluctuations in phenytoin levels can affect response, maintaining therapeutic levels is not easy. Patients should be cautioned against consuming alcohol while taking phenytoin. Rashes can be serious and should be reported immediately.

Question 100

A patient who takes phenytoin for seizures asks the provider for a prescription for oral contraceptives. What recommendation will the provider make to help assure the effectiveness of the contraception method? a. She may need to increase her dose of phenytoin while taking oral contraceptives. b. She should consider a different form of birth control while taking phenytoin. c. She should adhere strictly to oral contraceptive schedules because phenytoin causes birth defects. d. She should not take oral contraceptives, because they reduce the effectiveness of phenytoin.

Answer 100

b. She should consider a different form of birth control while taking phenytoin. Because phenytoin can reduce the effects of oral contraceptive pills (OCPs) and because avoiding pregnancy is desirable when taking phenytoin, patients should be advised to increase the dose of oral contraceptives or use an alternative method of birth control. Increasing the patient’s dose of phenytoin is not necessary; OCPs do not affect phenytoin levels. Phenytoin is linked to birth defects; OCPs have decreased effectiveness in patients treated with phenytoin, and the patient should be advised to increase the OCP dose or to use an alternative form of birth control. OCPs do not alter the effects of phenytoin.

Question 101

A patient with a seizure disorder is admitted to the hospital after an increase in seizure frequency. The prescriber considers adding carbamazepine 100 mg twice daily to the patient’s medication regimen, but notes that the patient is already taking lamotrigine 375 mg twice daily. What changes will the prescriber make to the patient’s medication regimen? a. Reduce the carbamazepine dose to 50 mg twice daily. b. Reduce the lamotrigine dose to 225 mg twice daily. c. Increase the carbamazepine dose to 200 mg twice daily. d. Increase the lamotrigine dose to 500 mg twice daily.

Answer 101

d. Increase the lamotrigine dose to 500 mg twice daily. Carbamazepine induces hepatic drug-metabolizing enzymes and can increase the rate at which lamotrigine is metabolized; therefore, the lamotrigine dosage will need to be increased. Reducing the dose of either drug is not indicated. Increasing the dose of carbamazepine may be necessary but only after serum drug levels have been checked.

Question 102

The patient who is on memantine therapy has a slight elevation in the creatinine clearance. What action will the provider take in response to this laboratory result? a. Add sodium bicarbonate to the patient’s drug regimen. b. Order a serum creatinine level to validate the creatinine clearance. c. Discontinue the memantine. d. Reduce the dose of memantine.

Answer 102

d. Reduce the dose of memantine. Patients with severe renal impairment may require discontinuation, but with a slight elevation, a dosage reduction is indicated. Adding sodium bicarbonate would alkalinize the urine and increase memantine levels, causing toxicity. It is not necessary to discontinue or decrease the dose of the memantine with mild or moderate renal impairment. A serum creatinine level is less sensitive than creatinine clearance for monitoring renal function in older adults and it cannot be used to validate creatinine clearance findings.

Question 103

The spouse of a patient with Alzheimer disease asks the provider for more information about the rivastigmine transdermal patch that is being used. After the discussion with the provider, which statement by the spouse indicates a need for further explanation? a. “Doses are lower but more steady with the transdermal patch.” b. “Reduced side effects occur with the transdermal patch.” c. “We only need to change the patch every 2 weeks.” d. “We should remove the old patch before applying the new one.”

Answer 103

c. “We only need to change the patch every 2 weeks.” The rivastigmine transdermal patch needs to be changed daily. Sites used should not be reused for 14 days. Transdermal dosing provides lower, steady levels of the drug. Intensity of side effects is lower with the transdermal patch. The old patch must be removed prior to applying the new patch to prevent toxicity.

Question 104

An older adult patient displays confusion, memory loss, and disorientation in familiar surroundings. Although the patient has been taking donepezil 10 mg once daily for 6 months, the symptoms have begun to worsen, and the patient’s spouse asks if the medication dose can be increased. What response will the prescriber provide to best address the spouse’s concerns? a. “The dose can be increased, because the patient has been taking the drug for longer than 3 months.” b. “The dose can be increased to twice daily dosing instead of once daily dosing.” c. “The increase in symptoms is the result of hepatotoxicity from the medication’s side effects.” d. “The patient must take the drug for longer than 1 year before the dose can be increased.”

Answer 104

a. “The dose can be increased, because the patient has been taking the drug for longer than 3 months.” Donepezil is given for mild, moderate, and severe Alzheimer disease (AD), and dosing may be increased, although it must be titrated up slowly. For patients with moderate to severe AD who have taken 10 mg once daily for at least 3 months, the dose can be increased to 23 mg once daily. Donepezil is not given twice daily. Donepezil does not cause hepatotoxicity; hepatotoxicity occurs with tacrine, the first acetylcholinesterase (AChE) inhibitor, which now is rarely used. Dosing is increased after 3 months, not 1 year.

Question 105

An older adult patient with Alzheimer disease is prescribed a cholinesterase inhibitor drug. When providing medication education to the care giver, the prescriber will prioritize which possible side effects? (Select all that apply.) a. Confusion b. Memory impairment c. Constipation d. Slowed heart rate e. Lightheadedness

Answer 105

d. Slowed heart rate e. Lightheadedness Cardiovascular effects of cholinesterase inhibitor drugs are uncommon but cause the most concern. Bradycardia and fainting can occur when cholinergic receptors in the heart are activated. Confusion and memory impairment are signs of the disease and are not side effects of the drug. Diarrhea, not constipation, is an expected adverse effect.

Question 106

A patient who has infrequent migraine headaches wants to prevent them from occurring. What intervention will the provider take? a. Prescribe prochlorperazine. b. Prescribe amitriptyline. c. Ask the patient to keep a headache diary to help determine possible triggers. d. Schedule the abortive medication to be taken regularly instead of PRN.

Answer 106

c. Ask the patient to keep a headache diary to help determine possible triggers. Keeping a headache diary to try to identify triggers to migraines can be helpful when a patient is trying to prevent them and is the first step in managing headaches. Prochlorperazine is an antiemetic and does not prevent or abort migraine headaches. Prophylactic medications such as amitriptyline are used when headaches are more frequent. To prevent medication-overuse headache, abortive medications should not be used more than 1 to 2 days at a time.

Question 107

A patient who has recurrent migraine headaches is prescribed sumatriptan. Which condition in this patient’s history is of concern to the prescriber? a. Asthma b. Coronary artery disease c. Diabetes d. Renal disease

Answer 107

b. Coronary artery disease Serotonin receptor agonists can cause vasoconstriction and coronary vasospasm and should not be given to patients with coronary artery disease, current symptoms of angina, or uncontrolled hypertension. There is no contraindication for asthma, diabetes, or renal disease.

Question 108

A provider considers prescribing sumatriptan for a patient experiencing a migraine headache. Before prescribing this drug, what is the most important information to obtain? a. Is there a family history of migraines? b. Has acetaminophen been taken in the past 3 hours? c. Has the patient taken ergotamine in the past 24 hours? d. Is the patient allergic to sulfa compounds?

Answer 108

c. Has the patient taken ergotamine in the past 24 hours? Triptans and ergot alkaloids cause vasoconstriction and, if combined, excessive and prolonged vasospasm could result. Sumatriptan should not be used within 24 hours of an ergot derivative. A family history is important, but it is not vital assessment data as it relates to this scenario. Acetaminophen has no drug-to-drug interaction with sumatriptan. Sulfa is not a component of sumatriptan and, therefore, is not relevant.

Question 109

A patient reports numbness in the extremities. The assessment history notes that the patient’s hands and feet are cool and pale and that the patient has a history of migraine headaches. The provider focuses on further assessing for what likely cause of the symptoms? a. Ergotamine withdrawal b. Ergotism c. Severe migraine symptoms d. Sumatriptan side effects

Answer 109

b. Ergotism Ergotism is a serious toxicity caused by acute or chronic overdose of ergotamine. The toxicity results in ischemia, causing the extremities to become cold, pale, and numb. Symptoms associated with ergotamine withdrawal include headache, nausea, vomiting, and restlessness. These are not symptoms of a severe migraine or side effects of sumatriptan.

Question 110

A young female adult who has recently begun taking sumatriptan reports a sensation of chest pressure, without pain, and arm heaviness. What action will the provider take? a. Focus on identifying any history of hypertension or coronary artery disease. b. Determine whether the patient might be pregnant. c. Reassure the patient that this is a transient, reversible side effect of the medication. d. Discontinue the sumatriptan.

Answer 110

c. Reassure the patient that this is a transient, reversible side effect of the medication. Some patients taking sumatriptan experience unpleasant chest symptoms, usually described as “heavy arms” or “chest pressure.” These symptoms are transient and are not related to heart disease. Patients experiencing angina-like pain when taking sumatriptan, as a result of coronary vasospasm, should be asked about hypertension or coronary artery disease (CAD); they should not take sumatriptan if they have a history of either of these. The symptoms this patient describes are not characteristics of pregnancy. There is no need to stop taking the medication.

Question 111

A patient with a history of asthma experiences three or four migraine headaches each month, uses sumatriptan as an abortive medication but has developed medication-overuse headaches. When asked what can be done to prevent migraines, the provider suggests prescribing which medication? a. Botulinum toxin b. Meperidine c. Timolol d. Topiramate

Answer 111

d. Topiramate Topiramate can be used for migraine prophylaxis, and its benefits appear equal to those of the first-line β blockers. Botulinum toxin can be used for migraine prophylaxis in patients who have 15 or more headaches a month. Meperidine may be used as abortive therapy, not prophylaxis. Timolol is a β blocker; this patient has asthma, and because β blockers cause bronchoconstriction, these agents are not recommended.

Question 112

A patient who has migraine headaches has been using sumatriptan with good initial results but now reports frequent migraine recurrence 24 hours later. Which medication will the provider order for this patient? a. Aspirin b. Ergotamine c. Naratriptan d. Zolmitriptan

Answer 112

c. Naratriptan Naratriptan has effects that persist longer than other triptans, and the 24-hour recurrence rate may be reduced when taking this formulation. Aspirin has a shorter half-life than the triptans.

Question 113

A patient has been taking oxycodone to manage severe, chronic pain for the last 6 months but now reports that it is no longer effective. The provider will discuss prescribing which medication for the patient? a. Fentanyl transdermal patch b. Hydrocodone PO c. Meperidine PO d. Pentazocine PO

Answer 113

a. Fentanyl transdermal patch Transdermal fentanyl is indicated only for persistent, severe pain in patients already opioid tolerant. Hydrocodone, a combination product, has actions similar to codeine and is not used for severe, chronic pain. Meperidine is not recommended for continued use because of the risk of harm caused by the accumulation of a toxic metabolite. Pentazocine is an agonist–antagonist opioid and is less effective for pain; moreover, when given to a patient who is already opioid tolerant, it can precipitate an acute withdrawal syndrome.

Question 114

A patient has been taking methadone for 5 months to overcome an opioid addiction. The provider will monitor the patient for which electrocardiographic change? a. Prolonged QT interval b. Prolonged P-R interval c. Bundle branch block d. Elevated ST segment

Answer 114

a. Prolonged QT interval Methadone prolongs the QT interval. It does not prolong the P-R interval, cause a bundle branch block, or produce an elevated ST segment.

Question 115

A patient receives an epidural anesthetic during labor and delivery. What effect in the newborn in the immediate postpartumperiod must the provider be prepared to address? a. Bradycardia b. Hypoglycemia c. Jitteriness d. Tachypnea

Answer 115

a. Bradycardia Local anesthetics can cross the placenta, causing bradycardia and central nervous system (CNS) depression in the infant. They do not affect blood glucose. Jitteriness is a sign of CNS excitation, not depression. Increased respirations are not an adverse effect in the newborn.

Question 116

A provider has prescribed the topical anesthetic lidocaine for a patient who has a second-degree burn on one arm. Which statement by the patient indicates understanding of the teaching regarding this treatment? a. “I will apply a thin layer of the medication to only the burned area.” b. “I will cover the burn with a dressing after applying the medication.” c. “Applying an occlusive dressing is needed to increase absorption to relieve pain.” d. “I need to limit use of the medication to areas where the blisters have ruptured.”

Answer 116

a. “I will apply a thin layer of the medication to only the burned area.” Topical anesthetics can be absorbed in sufficient amounts to cause serious and even life-threatening systemic toxicity, so they should be applied in the smallest amount needed to as small an area as possible. Covering the site increases the skin’s temperature, which increases absorption, so this should be avoided. Applying the medication to broken skin increases systemic absorption and should be avoided.

Question 117

Within a few minutes of administration of a local anesthetic, the patient has a pulse of 54 beats/minute, respirations of 18 breaths/minute, and a blood pressure of 90/42 mm Hg. The provider should monitor the patient for further signs of what condition? a. Heart block b. Anaphylaxis c. Central nervous system excitation d. Respiratory depression

Answer 117

a. Heart block When absorbed in a sufficient amount, local anesthetics can affect the heart and blood vessels. These drugs suppress excitability in the myocardium and conduction system and can cause hypotension, bradycardia, heart block, and potentially cardiac arrest. Anaphylaxis would be manifested by hypotension, bronchoconstriction, and edema of the glottis. Central nervous system excitation would be manifested by hyperactivity, restlessness, and anxiety and may be followed by convulsions. No evidence indicates respiratory depression; this patient’s respirations are within normal limits.

Question 118

The provider used lidocaine with epinephrine as a local anesthetic when suturing a laceration on a patient’s hand. Following the procedure, which patient symptom causes the most concern? a. Difficulty moving the fingers of the affected hand b. Inability to feel pressure at the suture site c. Nervousness and tachycardia d. Sensation of pain returning to the wound

Answer 118

c. Nervousness and tachycardia Absorption of the vasoconstrictor can cause systemic effects, including nervousness and tachycardia. Local anesthetics are nonselective modifiers of neuronal function and also can block motor neurons, so it is expected that patients may have difficulty with movement. The sensation of pressure also is affected and is an expected effect. As the local anesthetic wears off, the sensation of the pain will return.

Question 119

Which medications would a provider prescribe to treat menstrually associated migraine? (Select all that apply.) a. Amitriptyline b. Estrogen c. Ergotamine d. Frovatriptan e. Naproxen

Answer 119

b. Estrogen d. Frovatriptan e. Naproxen Menstrual migraines may be treated with estrogen, some perimenstrual triptans, such as frovatriptan, and Naproxyn. Neither amitriptyline nor ergotamine are used for that purpose

Question 120

The provider has prescribed a vasoconstrictor to be given in combination with a local anesthetic. What is the expected goal for this action? (Select all that apply.) a. Enhanced absorption of the anesthetic b. A reduction of the risk of anesthetic toxicity c. The prevention of bradycardia d. A shortened duration of action e. A prolonging of the anesthesic effect

Answer 120

b. A reduction of the risk of anesthetic toxicity e. A prolonging of the anesthesic effect Vasoconstrictors, when combined with local anesthetics, reduce the risk of toxicity and prolong the anesthetic effects. Vasoconstrictors, when combined with local anesthetics, slow down the absorption process. They do not prevent bradycardia or shorten the duration of action.

Question 121

A patient is brought to the emergency department with shortness of breath, a respiratory rate of 30 breaths/minute, intercostal retractions, and frothy, pink sputum. After the patient’s provider renders a diagnosis of heart failure, which diuretic will be prescribed to address these assessment findings? a. Furosemide b. Hydrochlorothiazide c. Mannitol d. Spironolactone

Answer 121

a. Furosemide Furosemide, a potent diuretic, is used when rapid or massive mobilization of fluids is needed. This patient shows signs and symptoms of severe heart failure and needs immediate reduction of fluid overload. Hydrochlorothiazide and spironolactone are not indicated for pulmonary edema, because they are less efficacious, and diuresis is less rapid. Mannitol is indicated for patients with increased intracranial pressure and must be discontinued immediately if signs of pulmonary congestion or heart failure occur.

Question 122

The provider orders furosemide for a patient who takes digoxin and is admitted to the hospital for treatment of heart failure. The morning assessment identifies an irregular heart rate of 86 beats/minute, a respiratory rate of 22 breaths/minute, and a blood pressure of 130/82 mm Hg. Crackles are heard in both lungs. Which laboratory result will be of greatest concern to the provider? a. Blood glucose level of 120 mg/dL b. Oxygen saturation of 90% c. Potassium level of 3.4 mEq/L d. Sodium level of 140 mEq/L

Answer 122

c. Potassium level of 3.4 mEq/L This patient has an irregular, rapid heartbeat that might be caused by a dysrhythmia. This patient’s serum potassium level is low, which can trigger fatal dysrhythmias, especially in patients taking digoxin. Furosemide contributes to loss of potassium through its effects on the distal nephron. Potassium-sparing diuretics often are used in conjunction with furosemide to prevent this complication. This patient’s serum glucose and sodium levels are normal and of no concern at this point, although they can be affected by furosemide. The oxygen saturation is somewhat low and needs to be monitored, although it will likely improve with diuresis.

Question 123

Verapamil is prescribed for the client who takes digoxin. The provider will monitor closely for which adverse reaction? a. AV blockade b. Gingival hyperplasia c. Migraine headaches d. Reflex tachycardia

Answer 123

a. AV blockade Verapamil and digoxin both suppress impulse conduction through the AV node; when the two drugs are used concurrently, the risk of AV blockade is increased. Gingival hyperplasia can occur in rare cases with verapamil, but it is not an acute symptom. Verapamil can be used to prevent migraine, although its use for this purpose is under investigation. Verapamil and digoxin both suppress the heart rate, so tachycardia is not anticipated. The calcium channel blocker nifedipine, not verapamil, causes reflex tachycardia.

Question 124

Which medication will the provider prescribe for a patient admitted with severe hypertensive crisis? a. Captopril PO b. Hydralazine PO c. Minoxidil PO d. Sodium nitroprusside IV

Answer 124

d. Sodium nitroprusside IV Sodium nitroprusside, the drug of choice for hypertensive emergencies, is given intravenously. ACE inhibitors, such as captopril, are not used. Hydralazine may be used but should be given IV instead of PO. Minoxidil is effective, but its severe side effects make it a second-line drug.

Question 125

A patient had a blood pressures of 150/95 mm Hg and 148/90 mm Hg on two separate office visits. This is consistent with a blood pressure of 145/92 mm Hg taken in an ambulatory setting. The patient’s diagnostic tests are all normal. What will the patient’s provider order to best manage the patient’s hypertension? a. A β blocker b. A loop diuretic and spironolactone c. A thiazide diuretic d. An α1 blocker

Answer 125

c. A thiazide diuretic This patient has primary, or essential, hypertension as evidenced by systolic pressure greater than 140 and diastolic pressure greater than 90, along with normal tests ruling out another primary cause. Thiazide diuretics are first-line drugs for hypertension. β blockers are effective but are most often used to counter reflex tachycardia associated with reduced blood pressure caused by therapeutic agents. Loop diuretics cause greater diuresis than is usually needed and so are not first-line drugs. α1 blockers are not drugs of first choice.

Question 126

A patient with diabetes develops hypertension. Which type of medication will the provider prescribe to treat hypertension in this patient? a. Angiotensin-converting enzyme (ACE) inhibitors b. β blockers c. Direct-acting vasodilators d. Thiazide diuretics

Answer 126

a. Angiotensin-converting enzyme (ACE) inhibitors ACE inhibitors slow the progression of kidney injury in diabetic patients with renal damage. β blockers can mask signs of hypoglycemia and must be used with caution in diabetics. Direct-acting vasodilators are third-line drugs for chronic hypertension. Thiazide diuretics promote hyperglycemia.

Question 127

A patient reports a family history of hypertension and cardiovascular disease but has no other risk factors. Current blood pressure is 126/82 mm Hg and the patient has a normal weight and body mass index for height and age. What will be the provider’s focus when providing patient education? a. Angiotensin-converting enzyme (ACE) inhibitors and calcium channel blocker medications b. The DASH diet, sodium restriction, and exercise c. Increased calcium and potassium supplements d. Thiazide diuretics and lifestyle changes

Answer 127

b. The DASH diet, sodium restriction, and exercise This patient has elevated hypertension without other risk factors. Lifestyle changes are indicated at this point. If blood pressure rises to hypertensive levels, other measures, including drug therapy, will be initiated. Calcium and potassium supplements are not indicated.

Question 128

A patient taking an angiotensin-converting enzyme (ACE) inhibitor to treat hypertension tells the provider that she wants to become pregnant. What response will the provider give to the patient? a. “Controlling your blood pressure will decrease your risk of preeclampsia.” b. “We need to consider changing you to an angiotensin receptor blocker during pregnancy. ” c. “It will be safe to continue taking the ACE inhibitor during your pregnancy.” d. “Let’s discuss using methyldopa instead of the ACE inhibitor while you are pregnant. ”

Answer 128

d. “Let’s discuss using methyldopa instead of the ACE inhibitor while you are pregnant. ” Methyldopa has limited effects on uteroplacental and fetal hemodynamics and does not adversely affect the fetus or neonate. Controlling blood pressure does not lower the risk of preeclampsia. ACE inhibitors and ARBs are specifically contraindicated during pregnancy.

Question 129

A patient with a recent onset of nephrosclerosis has been taking an angiotensin-converting enzyme (ACE) inhibitor and a thiazide diuretic. The patient’s initial blood pressure was 148/100 mm Hg. After 1 month of drug therapy, the patient’s blood pressure is 130/90 mm Hg. What action will the provider take to address the patient’s blood pressure? a. Add a calcium channel blocker to this patient’s drug regimen. b. Lower doses of the antihypertensive medications. c. Order a high-potassium diet. d. Add spironolactone to the drug regimen.

Answer 129

a. Add a calcium channel blocker to this patient’s drug regimen. In patients with renal disease, the goal of antihypertensive therapy is to lower the blood pressure to 130/80 mm Hg or less. Adding a third medication is often indicated. Lowering the dose of the medications is not indicated because the patient’s blood pressure is not in the target range. Adding potassium to the diet and using a potassium-sparing diuretic are contraindicated.

Question 130

A patient with chronic hypertension is admitted to the hospital. During the admission assessment, the nurse notes a heart rate of 96 beats/minute, a blood pressure of 150/90 mm Hg bibasilar crackles, 2+ pitting edema of the ankles, and distention of the jugular veins. What will the provider order in response to this assessment data? a. Angiotensin-converting enzyme (ACE) inhibitor b. Digoxin c. Furosemide d. Spironolactone

Answer 130

c. Furosemide This patient shows signs of fluid volume overload and needs a diuretic. Furosemide is a loop diuretic, which can produce profound diuresis very quickly even when the glomerular filtration rate (GFR) is low. An ACE inhibitor will not reduce fluid volume overload. Digoxin has a positive inotropic effect on the heart, which may improve renal perfusion, but this is not its primary effect. Spironolactone is a potassium-sparing diuretic with weak diuresis effects; it is used in conjunction with other diuretics to improve electrolyte balance.

Question 131

A patient with heart failure who takes an angiotensin-converting enzyme (ACE) inhibitor, a thiazide diuretic, and a β blocker for several months comes to the clinic for evaluation. As part of the ongoing assessment of this patient, the provider will focus on which evaluation? a. Complete blood count b. Ejection fraction c. Maximal exercise capacity d. Serum electrolyte levels

Answer 131

d. Serum electrolyte levels Patients taking thiazide diuretics can develop hypokalemia, which can increase the risk for dysrhythmias; therefore, the serum electrolyte levels should be monitored closely. A complete blood count is not recommended. This patient is taking the drugs recommended for patients with Stage C heart failure; although the patient’s quality of life and ability to participate in activities should be monitored, routine measurement of the ejection fraction and maximal exercise capacity is not warranted at this time.

Question 132

A patient diagnosed with heart failure (HF) and taking an angiotensin-converting enzyme (ACE) inhibitor, has developed fibrotic changes in the heart and vessels. Which type of medication will the provider order to counter this development? a. Aldosterone antagonist b. Angiotensin II receptor blocker (ARB) c. β blocker d. Direct renin inhibitor (DRI)

Answer 132

a. Aldosterone antagonist Aldosterone antagonists are added to therapy for patients with worsening symptoms of HF. Aldosterone promotes myocardial remodeling and myocardial fibrosis, so aldosterone antagonists can help with this symptom. ARBs are given for patients who do not tolerate ACE inhibitors. β blockers do not prevent fibrotic changes. DRIs are not widely used.

Question 133

A patient taking a thiazide diuretic for hypertension and quinidine to treat a dysrhythmia, is now prescribed digoxin 0.125 mg to improve cardiac output. Which action will the provider take to best assure the patient’s safety? a. Add spironolactone. b. Reduce the dose of digoxin. c. Discontinue the quinidine. d. Give potassium supplements.

Answer 133

c. Discontinue the quinidine. Quinidine can cause plasma levels of digoxin to rise; concurrent use of quinidine and digoxin is contraindicated. There is no indication for adding spironolactone in this scenario. The dose of digoxin ordered is a low dose. Potassium supplements are contraindicated with digoxin.

Question 134

Which effect will the provider expect when prescribing a cardiac glycoside? a. Decreased cardiac output b. Decreased force of contraction c. Decreased heart rate d. Positive inotropic effects

Answer 134

c. Decreased heart rate Digoxin slows the heart rate and increases the force of contraction. It does not decrease cardiac output or result in positive inotropic effects.

Question 135

A prescriber considers ordering propranolol for a patient with recurrent ventricular tachycardia. What information in the patient’s medical history will be of greatest concerned to the prescriber? a. Asthma b. Exercise-induced tachyarrhythmias c. Hypertension d. Paroxysmal atrial tachycardia associated with emotion

Answer 135

a. Asthma Propranolol is to be used cautiously in patients with asthma because it is a nonselective β-adrenergic antagonist and can cause bronchoconstriction and exacerbate asthma. It is used to treat tachyarrhythmias and paroxysmal atrial tachycardia evoked by emotion, so it is not contraindicated for patients with these conditions. It lowers blood pressure, so it would be helpful in patients with hypertension.

Question 136

Azithromycin is prescribed for a patient who develops an infection. The patient’s only other medication is simvastatin. Which patient symptom will create the greatest concern for the provider? a. Nausea b. Tiredness c. Muscle pain d. Headache

Answer 136

c. Muscle pain Statins can injure muscle tissue, causing muscle aches and pain known as myopathy/rhabdomyolysis. Azithromycin also can cause myopathy and therefore should be used with caution in patients concurrently taking simvastatin. Nausea, tiredness, and headache would not cause the provider as much concern as the likelihood of myopathy.

Question 137

A patient with new-onset exertional angina has taken three nitroglycerin sublingual tablets at 5-minute intervals, but the pain has intensified. The patient has a heart rate of 76 beats/minute and a blood pressure of 120/82 mm Hg. The electrocardiogram is normal. The patient’s lips and nail beds are pink, and there is no respiratory distress. The provider will prescribe what intervention? a. An angiotensin-converting enzyme (ACE) inhibitor b. Intravenous nitroglycerin and a β blocker c. Ranolazine and quinidine STAT d. Supplemental oxygen and intravenous morphine

Answer 137

b. Intravenous nitroglycerin and a β blocker This patient has unstable angina, and the next step, when pain is unrelieved by sublingual nitroglycerin, is to give intravenous nitroglycerin and a β blocker. ACE inhibitors should be given to patients with persistent hypertension if they have left ventricular dysfunction or heart failure (HF). Ranolazine is a first-line angina drug, but it should not be given with quinidine because of the risk of increasing the QT interval. Supplemental oxygen is indicated if cyanosis or respiratory distress is present. IV morphine may be given if the pain is unrelieved by nitroglycerin.

Question 138

A patient who uses transdermal nitroglycerin for angina reports occasional periods of tachycardia. What intervention will the prescriber order? a. Order digoxin to slow the heart rate. b. Discontinue the nitroglycerin. c. Recommend periods of rest when the heart rate increases. d. Prescribe verapamil as an adjunct to nitroglycerin therapy.

Answer 138

d. Prescribe verapamil as an adjunct to nitroglycerin therapy. Nitroglycerin lowers blood pressure by reducing venous return and dilating the arterioles. The lowered blood pressure activates the baroreceptor reflex, causing reflex tachycardia, which can increase cardiac demand and negate the therapeutic effects of nitroglycerin. Treatment with a β blocker or verapamil suppresses the heart to slow the rate. Digoxin is not recommended. Discontinuation of the nitroglycerin is not indicated. Resting does not slow the heart when the baroreceptor reflex is the cause of the tachycardia.

Question 139

A patient presents to the emergency department after accidentally taking too much prescribed warfarin. The patient’s heart rate is 78 beats/minute and the blood pressure is 120/80 mm Hg. A dipstick urinalysis is normal. The patient does not have any obvious hematoma or petechiae and does not report any pain. What will the provider order initially to address the patient’s current condition? a. Vitamin K b. Protamine sulfate c. An activated partial thromboplastin time (aPTT) d. A prothrombin time (PT) and an international normalized ratio (INR)

Answer 139

d. A prothrombin time (PT) and an international normalized ratio (INR) This patient does not exhibit any signs of bleeding from a warfarin overdose. The vital signs are stable, there are no hematomas or petechiae, and the patient does not have pain. A PT and INR should be drawn to evaluate the anticoagulant effects. Vitamin K may be given if laboratory values indicate overdose. Protamine sulfate is given for heparin overdose. PTT evaluation is used to monitor heparin therapy.

Question 140

A patient who has taken warfarin for a year has now been prescribed carbamazepine. What additional action will the provider take to assure the patient’s safety? a. Decrease the usual dose of carbamazepine. b. Increase the dose of warfarin. c. Order more frequent activated partial thromboplastin time (aPTT) monitoring. d. Order extra dietary vitamin K.

Answer 140

b. Increase the dose of warfarin. Carbamazepine is a powerful inducer of hepatic drug-metabolizing enzymes and can accelerate warfarin degradation. The warfarin dose should be increased if the patient begins taking carbamazepine. Decreasing the dose of carbamazepine is not indicated. It is not necessary to perform more frequent aPTT monitoring or to add extra vitamin K.

Question 141

A patient has been receiving iron replacement therapy for 2 days after hip replacement surgery. The provider is alerted to the following assessment data: Patient’s stools appear black. Patient is pale and reports feeling tired. Patient’s heart rate is 98 beats/minute, respirations are 20 breaths/minute, and the blood pressure is 100/50 mm Hg. What order will the provider take initially to best assure appropriate care for this patient? a. Packed red blood cells b. Hemoglobin and hematocrit (H&H) c. A stool guaiac d. Hypertonic fluid bolus

Answer 141

b. Hemoglobin and hematocrit (H&H) This patient is showing signs of iron deficiency anemia, as manifested by tachycardia and pallor. Because this patient’s blood pressure is low, the anemia probably has occurred secondary to blood loss, a common occurrence with hip replacement surgery. The first response should be to obtain an H&H to compare baseline and posttreatment levels. This should be done before an intervention is ordered. A stool guaiac is not indicated because black stools are an expected effect of oral iron administration. If the patient has blood loss that is causing hypotension, an isotonic fluid bolus and packed red blood cells (PRBCs) are indicated to treat this.

Question 142

A patient is admitted to the hospital with a diagnosis of vitamin B12 deficiency, hypoxia and anemia. In addition to oxygen therapy, what will the provider order to address these problems? a. IM cyanocobalamin and folic acid b. IM cyanocobalamin and antibiotics c. PO cyanocobalamin and folic acid d. PO cyanocobalamin and blood transfusions

Answer 142

a. IM cyanocobalamin and folic acid The patient has anemia with associated hypoxia secondary to vitamin B12 deficiency; therefore, cyanocobalamin should be given parenterally along with folic acid. Antibiotics are indicated only when signs of infection are present. Oral cyanocobalamin is not recommended.

Question 143

Which conditions will the provider consider as a therapeutic use for verapamil? (Select all that apply.) a. Angina of effort b. Cardiac dysrhythmias c. Essential hypertension d. Sick sinus syndrome e. Suppression of preterm labor

Answer 143

a. Angina of effort b. Cardiac dysrhythmias c. Essential hypertension Verapamil is used to treat both vasospastic angina and angina of effort. It slows the ventricular rate in patients with atrial flutter, atrial fibrillation, and paroxysmal supraventricular tachycardia. It is a first-line drug for the treatment of essential hypertension. It is contraindicated in patients with sick sinus syndrome. Nifedipine has investigational uses in suppressing preterm labor.

Question 144

Amiodarone is prescribed for a patient. Which baseline tests will the prescriber order before this medication is started? (Select all that apply.) a. Chest radiograph b. Complete blood count with differential c. Ophthalmologic examination d. Pulmonary function tests e. Thyroid function tests

Answer 144

a. Chest radiograph c. Ophthalmologic examination d. Pulmonary function tests e. Thyroid function tests Amiodarone has many potential toxic side effects, including pulmonary toxicity, ophthalmic effects, and thyroid toxicity, so these systems should be evaluated at baseline and periodically while the patient is taking the drug. A complete blood count is not indicated.

Question 145

A patient receiving heparin postoperatively to prevent deep vein thrombosis has a blood pressure of 90/50 mm Hg and a heart rate of 110 beats/minute. The patient’s most recent aPTT is greater than 90 seconds. The patient reports lumbar pain. The provider will order what interventions initially? (Select all that apply.) a. A repeat aPTT to be drawn immediately b. Analgesic medication c. Changing heparin to aspirin d. Protamine sulfate e. Discontinue heparin

Answer 145

d. Protamine sulfate e. Discontinue heparin Heparin overdose may cause hemorrhage, which can be characterized by low blood pressure, tachycardia, and lumbar pain. Protamine sulfate should be given, and the heparin should be discontinued. An aPTT may be drawn later to monitor the effectiveness of protamine sulfate. Analgesics are not indicated because the lumbar pain is likely caused by adrenal hemorrhage. Not only will aspirin increase the risk of hemorrhage, but antiplatelet drugs are used to prevent excessive arterial clotting while anticoagulants are used to prevent excessive venous clotting; therefore, they are not used interchangeably.

Question 146

A provider caring for a patient infected with the human immunodeficiency virus (HIV) will be most concerned about which lab result? a. High level of eosinophils b. Low neutrophil count c. Decreased red blood cell (RBC) count d. Very low helper T lymphocyte count

Answer 146

d. Very low helper T lymphocyte count The provider understands that this patient may be vulnerable to opportunistic infections, especially if there were an indication of the HIV conversion to acquired immunodeficiency syndrome (AIDS). A very low helper T lymphocyte count would most concern the nurse, because the helper T cells are essential to the immune system, and people with AIDS have a low or deficient count. A high level of eosinophils likely indicates an allergy. A decreased RBC count is unrelated to HIV infection and is only a concern ifit is low. A high neutrophil count, not a low count, indicates infection. Low counts often reflect an increased percentage of another WBC in the differential.

Question 147

A provider is caring for a patient who has undergone organ transplantation. Because the major histocompatibility complex (MHC) molecules of the donor are different from those of the patient, the provider will prescribe a drug from which drug class? a. Antibiotics b. Antihistamines c. Immune globulins d. Immunosuppressants

Answer 147

d. Immunosuppressants The MHC molecules from one individual are recognized as foreign by the immune system of another individual; therefore, when an attempt is made to transplant organs between individuals who are not identical twins, immune rejection of the transplant is likely. Immunosuppressants are given to counter this response. Antibiotics are used to destroy bacteria. Antihistamines block hypersensitivity reactions. Immune globulins are given to confer passive immunity when specific acquired immunity has not yet developed a response.

Question 148

A provider prescribing vaccines to a child with an immune deficiency disorder will avoid ordering which vaccination? a. Diphtheria and tetanus toxoids and acellular pertussis (DTaP) vaccine b. Haemophilus influenzae type b (Hib) vaccine c. Polio injection d. Varicella virus vaccine

Answer 148

d. Varicella virus vaccine Live vaccines, such as the varicella vaccine, should be avoided by individuals who are immunocompromised. The DTaP vaccine, Hib vaccine, and polio injection may be administered to immunocompromised individuals, because these are not live vaccines.

Question 149

A 2-month-old infant is scheduled to receive the first dose of DTaP. What information will the provider include in instructions given to the parents? a. “Usually reactions are mild; a low-grade fever is most common.” b. “Most children do not experience any reaction.” c. “Seizures are common and may require anticonvulsant medication.” d. “The most common reaction is a rash that develops into itchy blisters.”

Answer 149

a. “Usually reactions are mild; a low-grade fever is most common.” Mild reactions to the first dose of the DTaP vaccine are common and most often are manifested by a low-grade fever, fretfulness, drowsiness, and local reactions of swelling and redness. At least 50% of children experience reactions. Seizures are not common. Itchy vesicles do not appear with the DTaP vaccine.

Question 150

A 1-year-old child receives the MMR vaccine. The next day, the child’s parent calls to report that the child has a temperature of 102.8°F. What action will the provider take? a. File an adverse event report with the Vaccine Adverse Event Reporting System (VAERS). b. Order a lab test to rule out thrombocytopenia. c. Reassure the parent that fever can occur with the MMR vaccine. d. Advise the parent to take the child to the emergency department.

Answer 150

c. Reassure the parent that fever can occur with the MMR vaccine. The MMR vaccine can have several adverse effects, including fever up to 103°F. This is not considered a serious effect and does not warrant filing an adverse event report with VAERS. Thrombocytopenia is a rare but serious side effect of the MMR vaccine that would take longer than 24 hours to develop and is not associated with fever. There is no need to have the parent take the child to the emergency department.

Question 151

A 2-month-old infant presents with a low-grade fever, runny nose, and severe bursts of coughing resulting in transient cyanosis. When taking a history, the provider will specifically inquire about the vaccination history for which condition? a. Pertussis b. Hepatitis B c. Measles, mumps, and rubella (MMR) d. Influenza

Answer 151

a. Pertussis This infant may have pertussis, for which the primary symptoms are low-grade fever, persistent cough, and runny nose. Infants who have not received the first set of immunizations, including the DTaP vaccine, are especially vulnerable to this disease. The hepatitis B vaccine does not protect against these symptoms. The influenza and MMR vaccines are not given to children this young.

Question 152

A 3-year-old child who has asthma is in the clinic for a well-child checkup. The nurse notes that the child is up to date for the DTaP, hepatitis A, hepatitis B, and the MMR vaccines but has only had one each of the Hib, the rotavirus, and the PCV13 vaccines. Which vaccine will the provider prescribe for this child? a. Hib b. PCV13 c. PCV13 and Hib d. Rotavirus

Answer 152

b. PCV13 The PCV13 should be given to all children under the age of 2 years and to all healthy children between ages 2 and 5 years, especially those who have conditions that put them at high risk of serious pneumococcal disease. The Hib vaccine is only given up to age 15 months. The rotavirus vaccine is not given after 32 weeks of age.

Question 153

A 5-year-old child with seasonal allergies has been taking 2.5 mL of cetirizine syrup once daily. The parents tell the provider that the child does not like the syrup, and they do not think that the drug is effective. The provider will discuss which change in medication therapy? a. Cetirizine 5-mg chewable tablet once daily b. Loratadine 10-mg chewable tablet once daily c. Fexofenadine syrup 5 mL twice daily d. Desloratadine 5-mg rapid-disintegrating tablet once daily

Answer 153

a. Cetirizine 5-mg chewable tablet once daily The child is receiving a low dose of cetirizine and can receive up to 5 mg/day in either a single dose or two divided doses. Cetirizine is available in a chewable tablet, which this child may tolerate better, so the parents should explore this option with their provider. The loratadine 10-mg chewable tablet is approved for children 6 years and older. Fexofenadine would be safe for this child, but it is unlikely that the syrup would be any better than the cetirizine syrup. Desloratadine is not approved for children under the age of 12 years.

Question 154

A patient who has seasonal allergies works as a truck driver and needs the least sedating antihistamine to control symptoms. Which medication will the provider recommend? a. Cetirizine b. Fexofenadine c. Levocetirizine d. Loratadine

Answer 154

b. Fexofenadine Fexofenadine is the least sedating of the second-generation antihistamines and so is the least likely to have synergistic effects with alcohol. Cetirizine, levocetirizine, and loratadine all have sedative side effects to some extent and thus would be less safe.

Question 155

A provider orders hydroxyzine for a patient with acute urticaria. What information will the provider include when teaching the patient about this drug? a. The drug will reduce redness and itching but not edema. b. This antihistamine is not likely to cause sedation. c. Alcohol should be avoided while taking the drug. d. Shortness of breath may occur while taking the drug.

Answer 155

c. Alcohol should be avoided while taking the drug. Hydroxyzine is a first-generation antihistamine and has sedative effects, so patients should be cautioned not to consume alcohol while taking the drug. In capillary beds, antihistamines reduce edema, itching, and redness. This antihistamine causes sedation. It is not associated with respiratory depression or shortness of breath at therapeutic doses.

Question 156

Parents report that their 5-year-old child has frequent motion sickness. Which antihistamine will the provider recommend? a. Desloratadine b. Dimenhydrinate c. Hydroxyzine d. Promethazine

Answer 156

b. Dimenhydrinate Some antihistamines, including dimenhydrinate and promethazine, are labeled for use in motion sickness. Promethazine, however, is contraindicated in children under age 2 years and should be used with caution in children older than 2 years because of the risks for severe respiratory depression. Desloratadine and hydroxyzine are not approved for motion sickness.

Question 157

A patient who takes aspirin daily is scheduled for surgery in 1 week. What action will the provider suggest to minimize the patient’s risk for injury? a. Continue to use aspirin as scheduled. b. Reduce the aspirin dosage by half until after surgery. c. Stop taking aspirin immediately. d. Stop taking aspirin 3 days before surgery.

Answer 157

c. Stop taking aspirin immediately. Aspirin should be withdrawn at least 1 week before surgery. Aspirin cannot be continued as scheduled, because the risk for bleeding is too great. An interval of 3 days is not long enough for the bleeding effects of aspirin to be reversed. Cutting the dose in half would not reduce the effects of bleeding associated with aspirin use.

Question 158

A patient who takes aspirin for rheumatoid arthritis develops a headache and tinnitus. The patient’s lab result includes a plasma salicylate level of 300 μg/mL, and a urine pH of 6.0. What action will the provider take? a. Increase the aspirin dose to better treat the patient’s headache. b. Order lab work to identify possible renal toxicity. c. Prepare to provide respiratory support, related to a possible overdose. d. Withhold the aspirin until the patient’s symptoms have subsided.

Answer 158

d. Withhold the aspirin until the patient’s symptoms have subsided. This patient shows signs of salicylism, which occurs when ASA levels climb above the therapeutic level. Salicylism is characterized by tinnitus, sweating, headache, and dizziness. Tinnitus is an indication that the maximum acceptable dose has been achieved. Toxicity occurs at a salicylate level of 400 mcg/mL or higher. ASA should be withheld until the symptoms subside and then should be resumed at a lower dose. Increasing the dose would only increase the risk of toxicity. Signs of renal impairment include oliguria and weight gain, which are not present in this patient. This patient has salicylism, not salicylate toxicity, so respiratory support measures are not indicated.

Question 159

An adolescent is brought to the emergency department after consuming a bottle of extended-release acetaminophen tablets between 8 and 10 hours ago. Which intervention will the provider order? a. Acetylcysteine administration b. Activated charcoal administration c. Hemodialysis d. Gastric lavage

Answer 159

a. Acetylcysteine administration Acetylcysteine is the specific antidote for acetaminophen overdose. It is 100% effective when given within 8 to 10 hours after ingestion and may still have some benefit after this interval. Activated charcoal and gastric lavage are effective only if given before the medication is absorbed. Hemodialysis is not indicated.

Question 160

An older male patient takes furosemide and low-dose aspirin. Urine output is low despite the diuretic. Today’s blood pressure is 140/80 mm Hg and the serum creatinine and blood urea nitrogen (BUN) levels are elevated. The patient has also gained 10-pounds over the past 3 months. What action will the provider discuss with the patient? a. Adding an antihypertensive medication b. Recheck the serum creatinine and BUN c. Ordering a potassium-sparing diuretic d. Withdrawing the aspirin

Answer 160

d. Withdrawing the aspirin This patient shows signs of renal impairment, as evidenced by weight gain despite the use of diuretics, decreased urine output, hypertension, and elevated serum creatinine and BUN. Aspirin can cause acute, reversible renal impairment and should be withdrawn. Hypertensive medications do not treat the underlying cause. Rechecking the serum creatinine and BUN are not indicated because elevated values are typical for the situation presented. Addition of a potassium-sparing diuretic is not indicated.

Question 161

A pregnant patient in her third trimester asks the nurse whether she can take aspirin for headaches. Which response by the nurse is correct? a. “Yes, but it is safe during only the second and third trimesters of pregnancy.” b. “Aspirin may cause premature closure of the ductus arteriosus in your baby so should be avoided.” c. “Aspirin may induce premature labor and should be avoided in the third trimester.” d. “No, you should use a first-generation nonsteroidal anti-inflammatory medication.”

Answer 161

b. “Aspirin may cause premature closure of the ductus arteriosus in your baby so should be avoided.” Aspirin poses risks to the pregnant patient and her fetus, including premature closure of the ductus arteriosus. ASA is not safe, especially in the third trimester, because it can cause anemia and can contribute to postpartum hemorrhage. ASA does not induce labor but can prolong labor by inhibiting prostaglandin synthesis. NSAIDs have similar effects and also should be avoided.

Question 162

A provider is about to prescribe prednisone to a patient for tendonitis. What item in the patient’s medical history would cause the provider to reconsider that action? a. Allergic rhinitis b. Gouty arthritis c. Seborrheic dermatitis d. Systemic fungal infection

Answer 162

d. Systemic fungal infection Glucocorticoids are contraindicated in patients with a history of systemic fungal infections. Glucocorticoids are used to treat, allergic rhinitis, gout, and seborrheic dermatitis.

Question 163

A 60-year-old female patient is about to begin long-term therapy with a glucocorticoid. Which intervention will the provider prescribe to help minimize the patient’s risk of developing osteoporosis? a. Baseline vitamin D level b. Calcium and vitamin D supplements c. Estrogen therapy d. Skeletal x-rays before treatment

Answer 163

b. Calcium and vitamin D supplements Calcium and vitamin D supplements can help minimize the patient’s risk of developing osteoporosis. A baseline vitamin D level is not recommended. Estrogen therapy can help in postmenopausal women, but its risks outweigh its benefits at this patient’s age. Patients should undergo evaluation of the bone mineral density of the lower spine, not skeletal x-rays.

Question 164

A patient taking high doses of a glucocorticoid develops weakness in the muscles of the upper arms and in the legs. What action will the provider take? a. Reducing the dose of the glucocorticoid medication b. Encourage the patient to restrict sodium intake. c. Reassure the patient that this is an expected side effect. d. Discontinue the medication immediately.

Answer 164

a. Reducing the dose of the glucocorticoid medication High-dose glucocorticoid therapy can cause myopathy, manifesting as weakness. If muscle weakness occurs, the dose should be reduced. Reducing the sodium intake is recommended to minimize sodium and water retention, not to decrease muscle weakness. Muscle weakness is not an expected side effect, because it indicates myopathy. It is incorrect to tell the patient to stop taking the drug, because a glucocorticoid must be withdrawn slowly to allow time for recovery of adrenal function.

Question 165

A patient taking a glucocorticoid for arthritis reports feeling bloated and peripheral edema is noted. Which action by the provider is relevant to the care of this patient? a. Asking the patient about sodium intake b. Obtaining a blood glucose level c. Suggesting the patient limit potassium intake d. Discontinuing the drug

Answer 165

a. Asking the patient about sodium intake Because of their mineralocorticoid activity, glucocorticoids can cause sodium and water retention and potassium loss. Asking about the sodium intake can help the nurse evaluate this patient. Although glucocorticoids can affect glucose tolerance, this patient does not have signs of hyperglycemia. Patients with sodium and water retention should be encouraged to increase their potassium intake. Telling a patient to stop taking the drug is incorrect, because this side effect can be managed and this action does not take into consideration the benefits versus the risks.

Question 166

A patient who has been taking a glucocorticoid for several months arrives in the clinic. The patient’s cheeks appear full and there is a prominent hump of fat present on the upper back. The provider will order which test? a. Liver function tests b. Serum electrolytes c. Tuberculin skin test d. Vitamin D levels

Answer 166

b. Serum electrolytes This patient shows signs of iatrogenic Cushing syndrome, which may include serum electrolyte disturbances; therefore, the electrolyte levels should be monitored. Liver function tests, tuberculin skin testing, and vitamin D levels are not indicated.

Question 167

A provider is teaching a patient who has taken glucocorticoids for over a year about glucocorticoid withdrawal. Which statement by the patient indicates a need for further teaching? a. “I should reduce the dose by half each day until I stop taking the drug.” b. “I will need to have cortisol levels monitored during the withdrawal process.” c. “The withdrawal schedule may take several months.” d. “If I have surgery, I may need to take the drug for a while, even after I have stopped. ”

Answer 167

a. “I should reduce the dose by half each day until I stop taking the drug.” Glucocorticoid therapy can suppress adrenal function, so withdrawal should be done slowly to allow recovery of adrenal function. Reducing the dose of a glucocorticoid by half each day is not recommended. Patients should have their cortisol levels monitored to determine when therapy can be stopped. The withdrawal schedule may take several months. Patients who have stopped the drug may still experience adrenal insufficiency in times of physiologic stress, such as surgery.

Question 168

A patient who takes a glucocorticoid reports having tarry stools but denies gastric pain. After ruling out anemia and determining that the patient is not in danger, which action will the provider take? a. Prescribing an antiulcer medication. b. Counseling the patient to use over-the-counter antacids. c. Reassuring the patient not to worry unless there is gastric pain. d. Discontinuing the glucocorticoid immediately.

Answer 168

a. Prescribing an antiulcer medication. Glucocorticoid therapy can increase the risk of gastric ulcer and possibly GI bleeding. Treatment with antiulcer medications is indicated, but not with OTC antacids. Gastric pain is usually decreased because of the glucocorticoids, so absence of gastric pain is not reassuring. The glucocorticoid should be withdrawn slowly, not immediately.

Question 169

A patient will begin taking fexofenadine for hay fever. What information will the provider include in patient teaching? a. Fexofenadine should be taken with food to prevent gastrointestinal symptoms. b. The medication may be taken once or twice daily. c. Tolerance to sedation will occur in a few weeks. d. With renal impairment, this drug should be taken every other day.

Answer 169

b. The medication may be taken once or twice daily. Fexofenadine may be given 60 mg twice daily or 180 mg once daily. Fexofenadine does not need to be given with food. Sedation is not a common side effect of fexofenadine. There is no caution to reduce the dosage or increase the dosing interval in patients with renal impairment who take fexofenadine.

Question 170

An 11-year-old boy received all childhood immunizations before attending kindergarten. Which vaccines will the provider recommended for this child at his current age? (Select all that apply.) a. Hepatitis B b. PCV-23 c. Tdap d. MCV4 e. HPV

Answer 170

c. Tdap d. MCV4 e. HPV At age 11, both males and females should receive a booster of diphtheria, tetanus, and pertussis (Tdap); the Menactra vaccine against meningitis (MCV4); and the human papillomavirus (HPV) vaccine. The PCV-23 vaccine is indicated only in high-risk patients. The MMR is not given at this age. The hepatitis B vaccine is not given at this age.

Question 171

An older adult patient with a history of chronic obstructive pulmonary disease (COPD) develops bronchitis. The patient has a temperature of 39.5°C. What action will the provider initially take to assure effective care for this patient? a. Order a sputum culture and prescribe an antibiotic based on the results. b. Order an empiric antibiotic while waiting for sputum culture results. c. Treat symptomatically, because antibiotics are usually ineffective against bronchitis. d. Treat the patient with more than one antibiotic without obtaining cultures.

Answer 171

b. Order an empiric antibiotic while waiting for sputum culture results. Patients with severe infections should be treated while culture results are pending. If a patient has a severe infection or is at risk of serious sequelae if treatment is not begun immediately, it is not correct to wait for culture results before beginning treatment. Until a bacterial infection is ruled out, treating symptomatically is not indicated. Treating without obtaining cultures is not recommended.

Question 172

A patient has a localized skin infection, which is most likely caused by a gram-positive cocci. Until the culture and sensitivity results are available, the provider will order a -spectrum agent. a. broad; systemic b. broad; topical c. narrow; systemic d. narrow; topical

Answer 172

d. narrow; topical When infections are treated before the causative agent has been identified, and after cultures have been obtained, antibiotics may be used based on the knowledge of which microbes are most likely to cause infection at that particular site. Because this is a localized infection, a topical agent is recommended. Unless the infection is very serious, a narrow-spectrum antibiotic is best.

Question 173

A patient is given a new prescription for potassium penicillin G given intravenously (IV) every 8 hours and gentamicin given IV every 12 hours. Which is the best schedule for administering these drugs? a. Give the penicillin at 0800, 1600, and 2400; give the gentamicin [Garamycin] at 1800 and 0600. b. Give the penicillin at 0800, 1600, and 2400; give the gentamicin [Garamycin] at 1200 and 2400. c. Give the penicillin at 0600, 1400, and 2200; give the gentamicin [Garamycin] at 0600 and 1800. d. Give the penicillin every 8 hours; give the gentamicin [Garamycin] simultaneously with two of the penicillin doses.

Answer 173

a. Give the penicillin at 0800, 1600, and 2400; give the gentamicin [Garamycin] at 1800 and 0600. Gentamicin should never be administered concurrently with penicillin, because they will interact, and the penicillin may inactivate the aminoglycoside. All the other options show concurrent administration.

Question 174

A child with an ear infection is not responding to treatment with amoxicillin. What alternative medication will the provider order? a. Amoxicillin–clavulanic acid b. Ampicillin c. Nafcillin d. Penicillin G

Answer 174

a. Amoxicillin–clavulanic acid β-lactamase inhibitors are drugs that inhibit bacterial β-lactamases. These drugs are always given in combination with a penicillinase-sensitive penicillin. Augmentin contains amoxicillin and clavulanic acid and is often used when patients fail to respond to amoxicillin alone. Ampicillin is similar to amoxicillin, but amoxicillin is preferred and, if drug resistance occurs, ampicillin is equally ineffective. Pharmaceutical chemists have developed a group of penicillins that are resistant to inactivation by β-lactamases (e.g., nafcillin), but these drugs are indicated only for penicillinase-producing strains of staphylococci. Penicillin G would be as ineffective as amoxicillin if β-lactamase is present.

Question 175

A patient is receiving intravenous potassium penicillin G, 2 million units to be administered over 1 hour. At 1900, the nurse notes that the dose hung at 1830 has infused completely. What action will the provider take when notified of this medication error? a. Order an immediate assessment of the skin at the infusion site for signs of tissue necrosis. b. Order that the patient be closely observed for confusion and other neurotoxic effects. c. Order a serum electrolyte test and cardiac monitoring STAT. d. Request immediate notification of any bizarre behaviors demonstrated by the patient.

Answer 175

c. Order a serum electrolyte test and cardiac monitoring STAT. Although penicillin G is the least toxic of all antibiotics, certain adverse effects may be caused by compounds coadministered with penicillin. When large doses of potassium penicillin G are administered rapidly, hyperkalemia can occur, which can cause fatal dysrhythmias. When penicillin G is administered IM, tissue necrosis occurs with inadvertent intraarterial injection. Confusion, seizures, and hallucinations can occur if blood levels of the drug are too high. Bizarre behaviors result with large IV doses of procaine penicillin G.

Question 176

A patient is about to receive penicillin G for an infection that is highly sensitive to this drug. While obtaining the patient’s medication history, the nurse learns that the patient experienced a rash when given amoxicillin as a child 20 years earlier. What action will the provider take when made aware of the patient’s past reaction to amoxicillin? a. Order a cephalosporin. b. Reassure the patient that allergic responses diminish over time. c. Request an order for a skin test to assess the current risk. d. Order a desensitization schedule to be used to administer the drug safely.

Answer 176

c. Request an order for a skin test to assess the current risk. Allergy to penicillin can decrease over time; therefore, in patients with a previous allergic reaction who need to take penicillin, skin tests can be performed to assess the current risk. Until this risk is known, changing to a cephalosporin is not necessary. Reassuring the patient that allergic responses will diminish is not correct, because this is not always the case; the occurrence of a reaction must be confirmed with skin tests. Desensitizing schedules are used when patients are known to be allergic and the drug is required anyway.

Question 177

A patient with an infection caused by Pseudomonas aeruginosa is being treated with piperacillin. The nurse providing care reviews the patient’s laboratory reports and notes that the patient’s blood urea nitrogen and serum creatinine levels are elevated. What action will the provider take when notified of the elevated lab results? a. Prescribes an aminoglycoside b. Discontinues the piperacillin and orders penicillin G c. Reduces the dosage of piperacillin d. Discontinues the piperacillin and prescribes nafcillin

Answer 177

c. Reduces the dosage of piperacillin Patients with renal impairment should receive lower doses of piperacillin than patients with normal renal function. Aminoglycosides are nephrotoxic. Penicillin G and nafcillin are not effective against Pseudomonas infections.

Question 178

A patient diagnosed with cystic fibrosis has a Pseudomonas aeruginosa infection and the provider has ordered aztreonam. What instruction will the provider give the patient regarding the administration of this drug? a. Take one pill twice daily. b. Take a daily dose for 28 days. c. Inhale the powdered drug as ordered three times each day. d. Use the nebulizer to administer the drug three times daily.

Answer 178

d. Use the nebulizer to administer the drug three times daily. Cayston is a form of aztreonam formulated for inhalation administration for patients with cystic fibrosis who have P. aeruginosa lung infections. The reconstituted powder is given using a nebulizer system three times daily for 28 days followed by 28 days off. This form of the drug is not given IM. The dose is three times daily. The drug is reconstituted and administered via a nebulizer.

Question 179

A patient has a skin infection and the culture reveals methicillin-resistant Staphylococcus aureus (MRSA). What medication treatment should the provider prescribe for this patient? a. Cefaclor b. Cefazolin c. Cefotaxime d. Ceftaroline

Answer 179

d. Ceftaroline Ceftaroline is a fifth-generation cephalosporin with a spectrum similar to third-generation cephalosporins but also with activity against MRSA. Cefaclor is a second-generation cephalosporin. Cefazolin is a first-generation cephalosporin. Cefotaxime is a third-generation cephalosporin.

Question 180

A patient receiving a cephalosporin develops a secondary intestinal infection caused by Clostridium difficile. What action will the provider take to provide effective care for this patient? a. Adding an additional antibiotic to the patient’s regimen b. Discontinuing the cephalosporin and beginning metronidazole c. Discontinuing all antibiotics and providing fluid replacement d. Increasing the dose of the cephalosporin and providing isolation measures

Answer 180

b. Discontinuing the cephalosporin and beginning metronidazole Patients who develop C. difficile infection (CDI) as a result of taking cephalosporins or other antibiotics need to stop taking the antibiotic in question and begin taking either metronidazole or vancomycin. Adding one of these antibiotics without withdrawing the cephalosporin is not indicated. CDI must be treated with an appropriate antibiotic, so stopping all antibiotics is incorrect. Increasing the cephalosporin dose would only aggravate the CDI.

Question 181

A patient is to undergo orthopedic surgery, and the prescriber will order a cephalosporin to be given preoperatively as prophylaxis against infection. Which generation of cephalosporin will the provider order? a. First b. Second c. Third d. Fourth

Answer 181

a. First First-generation cephalosporins are widely used for prophylaxis against infection in surgical patients, because they are effective, less expensive, and have a narrower antimicrobial spectrum than second-, third-, and fourth-generation cephalosporins.

Question 182

A patient will be discharged home to complete treatment with intravenous cefotetan. The prescriber will include which instruction when teaching the patient about this drug treatment? a. Abstain from alcohol consumption during therapy. b. Avoid dairy products while taking this drug. c. Take an antihistamine if a rash occurs. d. Use nonsteroidal anti-inflammatory drugs (NSAIDs), not acetaminophen, for pain.

Answer 182

a. Abstain from alcohol consumption during therapy. Two cephalosporins, including cefotetan, can induce a state of alcohol intolerance and cause a disulfiram-like reaction when alcohol is consumed; therefore, patients should be advised to avoid alcohol. It is not necessary to avoid dairy products. Patients who experience a rash should report this to their provider. Cefotetan can also promote bleeding, so drugs that inhibit platelet aggregation should be avoided.

Question 183

A patient reporting burning on urination and increased frequency has a history of frequent urinary tract infections (UTIs). The patient is going out of town in 2 days and the provider wants to treat the infection quickly. What medication will the provider order? a. Aztreonam b. Fosfomycin c. Trimethoprim/sulfamethoxazole d. Vancomycin

Answer 183

b. Fosfomycin Fosfomycin has been approved for single-dose therapy of UTIs in women. Vancomycin and aztreonam are not indicated for UTIs. Bactrim is indicated for UTIs, but administration of a single dose is not therapeutic.

Question 184

Which cephalosporin may the prescriber order to treat meningitis? a. Cefaclor b. Cefazolin c. Cefoxitin d. Cefotaxime

Answer 184

d. Cefotaxime Cefotaxime has increased ability to reach the cerebrospinal fluid (CSF) and to treat meningitis. Cefaclor, cefazolin, and cefoxitin do not reach effective concentrations in the CSF.

Question 185

A patient who has been taking linezolid for 6 months develops vision problems and is worried about blindness. What response will the provider give to address the patient’s concern? a. Reassure the patient that this is a harmless side effect of this drug. b. Tell the patient that blindness rarely occurs with this drug. c. Tell the patient that this symptom is reversible when the drug is discontinued. d. Suggest the patient take tyramine supplements to minimize this effect.

Answer 185

c. Tell the patient that this symptom is reversible when the drug is discontinued. Linezolid is associated with neuropathy, including optic neuropathy. This is a reversible effect that will stop when the drug is withdrawn. Reassuring the patient that this is a harmless side effect is not correct. It is not an indication that blindness will occur. Tyramine supplements are not indicated.

Question 186

A patient develops Clostridium difficile–associated diarrhea (CDAD). Which antibiotic will the prescriber order to treat this infection? a. Chloramphenicol b. Clindamycin c. Linezolid d. Vancomycin

Answer 186

d. Vancomycin Vancomycin and metronidazole are the drugs of choice for treating CDAD.

Question 187

Which side effect of clindamycin causes the provider the most concern and may warrant discontinuation of the drug? a. Diarrhea b. Headache c. Nausea d. Vomiting

Answer 187

a. Diarrhea Clostridium difficile–associated diarrhea (CDAD) is a serious, sometimes fatal suprainfection associated with clindamycin. Patients with diarrhea should notify their prescriber immediately and discontinue the drug until this condition has been ruled out. Headache, nausea, and vomiting do not warrant discontinuation of the drug and are not associated with severe side effects.

Question 188

A patient received 500 mg of azithromycin at 0800 as a first dose. What order will the provider write for the amount and time ofthe second dose of azithromycin? a. 250 mg at 2000 the same day b. 500 mg at 2000 the same day c. 250 mg at 0800 the next day d. 500 mg at 0800 the next day

Answer 188

c. 250 mg at 0800 the next day Azithromycin generally is given as 500 mg on the first day and then 250 mg/day for the next 4 days, so the second dose would be 24 hours after the first dose.

Question 189

A 6-week-old infant who has not yet received immunizations develops a severe cough. While awaiting nasopharyngeal culture results, the provider will prescribe which antibiotic? a. Clindamycin b. Doxycycline c. Erythromycin ethylsuccinate d. Penicillin G

Answer 189

c. Erythromycin ethylsuccinate Erythromycin is the drug of first choice for infections caused by Bordetella pertussis, the causative agent of whooping cough. Infants who have not received their first set of immunizations are at increased risk of pertussis. Clindamycin, doxycycline, and penicillin are not recommended.

Question 190

A patient who is taking doxycycline for a serious infection reports anal itching. What action will the provider take? a. Prescribing an antihistamine to the patient’s existing drug regimen b. Ordering liver function tests to test for hepatotoxicity c. Prescribing an antifungal drug to treat a superinfection d. Testing the patient for a C. difficile secondary infection

Answer 190

c. Prescribing an antifungal drug to treat a superinfection A superinfection occurs secondary to suppression of drug-sensitive organisms. Overgrowth with fungi, especially Candida albicans, is common and may occur in the mouth, pharynx, vagina, or bowel. Anal itching is a sign of such an infection, not a sign of hepatotoxicity. Antihistamines will not treat the cause. C. difficile infection is characterized by profuse, watery diarrhea.

Question 191

A patient is to begin taking doxycycline to treat a rickettsial infection. Which statement by the patient indicates a need for further teaching by the provider about this drug? a. “I should consult my provider before using laxatives or antacids while taking this drug. ” b. “I should not take a calcium supplement or consume dairy products with this drug. ” c. “I should take this drug with food to ensure more complete absorption.” d. “If I get diarrhea, I should stop taking the drug and let my provider know immediately. ”

Answer 191

c. “I should take this drug with food to ensure more complete absorption.” Absorption of tetracyclines is reduced in the presence of food. The tetracyclines form insoluble chelates with calcium, iron, magnesium, aluminum, and zinc, so patients should not take tetracyclines with dairy products, calcium supplements, or drugs containing these minerals. Patients who experience diarrhea should stop taking the drug and notify the provider so they can be tested for C. difficile infection.

Question 192

A patient recently began receiving clindamycin to treat an infection. After 8 days of treatment, the patient reports having 10 to 15 watery stools per day. What action will the provider take to address the patient’s diarrhea? a. Increase the clindamycin dose to aggressively treat this infection. b. Assure the patient this is known side effect of clindamycin, and suggest consuming extra fluids. c. Discontinue the clindamycin immediately. d. Prescribe Lomotil or a bulk laxative to minimize the diarrheal symptoms.

Answer 192

c. Discontinue the clindamycin immediately. Clostridium difficile–associated diarrhea (CDAD) is the most severe toxicity of clindamycin; if severe diarrhea occurs the patient should be told to stop taking clindamycin immediately and to contact the provider so that treatment with vancomycin or metronidazole can be initiated. Increasing the dose of clindamycin will not treat this infection. Consuming extra fluids while still taking the clindamycin is not correct, because CDAD can be fatal if not treated. Taking Lomotil or bulk laxatives only slows the transit of the stools and does not treat the cause.

Question 193

The provider is reviewing the culture results of a patient receiving an aminoglycoside. The report reveals an anaerobic organism as the cause of infection. What action will the provider take? a. Discuss an increased risk of aminoglycoside toxicity with the patient. b. Continue the aminoglycoside as ordered. c. Prescribe a different class of antibiotic. d. Add a penicillin to the patient’s drug regimen.

Answer 193

c. Prescribe a different class of antibiotic. Aminoglycosides are not effective against anaerobic microbes, so another class of antibiotics is indicated. There is no associated increase in aminoglycoside toxicity with anaerobic infection. The aminoglycoside will not be effective, so continuing to administer this drug is not indicated. Adding another antibiotic is not useful, because the aminoglycoside is not necessary.

Question 194

A patient is diagnosed with a lung infection caused by P. aeruginosa. The culture and sensitivity report shows sensitivity to all aminoglycosides. The provider knows that the rate of resistance to gentamicin is common in this hospital. What provider will order which medication? a. Amikacin b. Gentamicin c. Paromomycin d. Tobramycin

Answer 194

a. Amikacin When resistance to gentamicin and tobramycin is common, amikacin is the drug of choice for initial treatment of aminoglycoside-sensitive infections. Gentamicin would not be indicated, because resistance is more likely to develop. Paromomycin is used only for local effects within the intestine and is given orally. Tobramycin is not indicated, because organisms can more readily develop resistance.

Question 195

A provider has ordered intravenous gentamicin at a dose that is half the usual dose for an adult patient. What factor noted in the patient’s medical history would be a likely reason for this action? a. Antibiotic resistance b. Interpatient variation c. Liver disease d. Renal disease

Answer 195

d. Renal disease The aminoglycosides are eliminated primarily by the kidneys, so in patients with renal disease, doses should be reduced or the dosing interval should be increased to prevent toxicity. Patients with antibiotic resistance would be given amikacin. Interpatient variation may occur but cannot be known without knowing current drug levels. Aminoglycosides are not metabolized by the liver, so liver disease would not affect drug levels.

Question 196

A patient who has been receiving intravenous gentamicin for several days reports having had a headache for 2 days. What action will the provider take? a. Discontinue the gentamicin. b. Order a gentamicin trough before the next dose is given. c. Prescribe an analgesic to control headache discomfort. d. Order renal function tests to evaluate for potential nephrotoxicity.

Answer 196

a. Discontinue the gentamicin. A persistent headache may be a sign of developing ototoxicity, and since ototoxicity is largely irreversible, gentamicin should be withdrawn at the first sign of developing ototoxicity. A gentamicin trough should be obtained before the next dose is given when high gentamicin levels are suspected. Analgesics are not indicated until a serious cause of the headache has been ruled out. A headache is an early sign of ototoxicity, not nephrotoxicity.

Question 197

A patient shows signs and symptoms of conjunctivitis. Which aminoglycoside will the provider order? a. Amikacin b. Kanamycin c. Neomycin d. Paromomycin

Answer 197

c. Neomycin Neomycin is used for topical treatment of infections of the eye, ear, and skin. Amikacin, kanamycin, and paromomycin are not topical treatments and are not indicated for eye infections.

Question 198

A patient is receiving tobramycin three times daily. The provider has ordered a trough level with the 8:00 AM dose and will expect the level to be drawn at what time? a. 4:00 AM b. 7:00 AM c. 7:45 AM d. 8:45 AM

Answer 198

c. 7:45 AM When a patient is receiving divided doses of an aminoglycoside, the trough level should be drawn just before the next dose; therefore, 7:45 AM would be the appropriate time. It would not be appropriate to draw a trough at the other times listed.

Question 199

A patient will be discharged from the hospital with a prescription for TMP/SMZ. When providing teaching for this patient,the provider will discuss the importance of what action while taking this medication? a. Drinking 8 to 10 glasses of water every day b. Eating foods that are high in potassium c. Taking the medication with food d. Taking a folic acid supplement

Answer 199

a. Drinking 8 to 10 glasses of water every day TMP/SMZ can injure the kidneys, because it causes deposition of sulfonamide crystals in the kidneys. Patients should be advised to drink 8 to 10 glasses of water a day to maintain a urine flow of 1200 mL in adults. Trimethoprim can cause hyperkalemia, so consuming extra potassium is unnecessary. The medication should be taken on an empty stomach. It is not necessary to consume extra folic acid, because mammalian cells use dietary folate and do not have to synthesize it; it is the process of folic acid synthesis that is altered by sulfonamides.

Question 200

A patient with a urinary tract infection is given a prescription for TMP/SMZ. When reviewing the drug with the patient, the provider learns that the patient has type 1 diabetes mellitus and consumes alcohol heavily. What action will the provider take? a. Prescribe a different antibiotic for this patient. b. Order daily blood glucose determinations while giving TMP/SMZ. c. Suggest that the patient take a potassium supplement while taking TMP/SMZ. d. Suggest that the patient avoid excessive fluid intake while taking TMP/SMZ.

Answer 200

a. Prescribe a different antibiotic for this patient. Alcoholics are likely to be folate deficient and have an increased risk of megaloblastic anemia when taking TMP/SMZ, so withholding this drug in this population is recommended. TMP/SMZ shares hypersensitivity reactions with oral sulfonylurea-type hypoglycemics that are used with type 2 diabetes mellitus, so it is not necessary to assess the blood glucose level more often. TMP/SMZ can cause hyperkalemia, so potassium supplements are contraindicated. Patients taking TMP/SMZ should consume more fluids to maintain renal blood flow and prevent renal damage.

Question 201

A drug history from a patient about to receive sulfadiazine identifies that the patient takes warfarin, glipizide, and a thiazide diuretic. Based on this information, what action will the provider take? a. Change the antibiotic to TMP/SMZ. b. Increase the dose of the glipizide. c. Order daily lab testing of the patient’s electrolytes. d. Order daily coagulation levels to be drawn.

Answer 201

d. Order daily coagulation levels to be drawn. Sulfonamides interact with several drugs and through metabolism-related interactions can intensify the effects of warfarin. Patients taking both should be monitored closely for bleeding tendencies. Changing to the combination product will not help, because sulfonamides are still present. Sulfonamides intensify glipizide levels, so this drug may actually need to be reduced. Trimethoprim, not sulfonamides, raises potassium levels.

Question 202

A patient who takes an ACE inhibitor and an angiotensin receptor blocker (ARB) medication will begin taking TMP/SMZ to treat a urinary tract infection. Which serum electrolyte will the provider monitor closely? a. Calcium b. Chloride c. Potassium d. Sodium

Answer 202

c. Potassium Trimethoprim suppresses renal excretion of potassium, increasing the risk of hyperkalemia. Patients at greatest risk are those taking high doses of trimethoprim and those taking other drugs that elevate potassium, including ACE inhibitors and ARB medications. Trimethoprim does not affect other serum electrolytes.

Question 203

A patient presents to the emergency department with chills, severe flank pain, dysuria, and urinary frequency. The patient has a temperature of 102.9°F, a pulse of 92 beats/minute, respirations of 24 breaths/minute, and a blood pressure of 119/58 mm Hg.The provider suspects that the patient is showing signs and symptoms of what pathology? a. Acute cystitis b. Urinary tract infection c. Pyelonephritis d. Prostatitis

Answer 203

c. Pyelonephritis The provider should suspect pyelonephritis. Pyelonephritis is characterized by fever, chills, severe flank pain, dysuria, urinary urgency and frequency, and pyuria and bacteriuria. Clinical manifestations of acute cystitis include dysuria, urinary urgency and frequency, suprapubic discomfort, pyuria, and bacteriuria. Urinary tract infections (UTIs) are very general and are classified by their location. These symptoms are specific to pyelonephritis. Prostatitis is manifested by high fever, chills, malaise, myalgia, localized pain, and various UTI symptoms, but not by severe flank pain.

Question 204

An older male patient comes to the clinic with reports of chills, malaise, myalgia, localized pain, dysuria, nocturia, and urinary retention. The provider will suspect what cause for the patient’s symptomology? a. Acute cystitis b. Urinary tract infection c. Pyelonephritis d. Prostatitis

Answer 204

d. Prostatitis The provider should suspect prostatitis, which is manifested by high fever, chills, malaise, myalgia, and localized pain, and may also be manifested by dysuria, nocturia, and urinary urgency, frequency, and retention. Clinical manifestations of acute cystitis include dysuria, urinary urgency and frequency, suprapubic discomfort, pyuria, and bacteriuria. Urinary tract infections are very general and are classified by their location. Pyelonephritis is characterized by fever, chills, severe flank pain, dysuria, and urinary frequency and urgency, as well as by pyuria and bacteriuria.

Question 205

A 20-year-old female patient presents with suprapubic discomfort, pyuria, dysuria, and bacteriuria greater than 100,000/mL of urine. Which are the most likely diagnosis and treatment? a. Uncomplicated lower urinary tract infection treatable with short-course therapy b. Complicated lower urinary tract infection treatable with single-dose therapy c. Uncomplicated upper urinary tract infection requiring 14 days of oral antibiotics d. Complicated upper urinary tract infection requiring parenteral antibiotics

Answer 205

a. Uncomplicated lower urinary tract infection treatable with short-course therapy These are symptoms of uncomplicated cystitis, which is a lower urinary tract infection that can be treated with a short course of antibiotics. Short-course therapy is more effective than single-dose therapy and is preferred. A complicated lower urinary tract infection would be associated with some predisposing factor, such as renal calculi, an obstruction to the flow of urine, or an indwelling catheter. Upper urinary tract infections often include severe flank pain, fever, and chills.

Question 206

A young, nonpregnant female patient with a history of a previous urinary tract infection is experiencing dysuria, urinary urgency and frequency, and suprapubic pain of 3 days’ duration. She is afebrile. A urine culture is positive for more than 100,000/mL of urine. The provider orders which treatment to assure the most effective treatment for this patient? a. A 14-day course of amoxicillin with clavulanic acid b. A 7-day course of ciprofloxacin c. A single dose of fosfomycin d. A 3-day course of trimethoprim/sulfamethoxazole

Answer 206

d. A 3-day course of trimethoprim/sulfamethoxazole Short-course therapy is recommended for uncomplicated, community-acquired lower urinary tract infections. The short course is more effective than a single dose, and compared with longer course therapies, it is less costly, has fewer side effects, and is more likely to foster compliance. Amoxicillin with clavulanic acid is a second-line drug used for pyelonephritis. Fosfomycin is a second-line drug and can be useful in patients with drug allergies.

Question 207

A patient with a history of renal calculi has fever, flank pain, and bacteriuria. What action will the provider take? a. Prescribe antibiotic therapy after urine culture and sensitivity results are available. b. Order an prophylactic antibiotic for 6 weeks after the acute infection has cleared. c. Initiate immediate treatment with a prescription for a broad-spectrum antibiotic. d. Refer the patient for intravenous antibiotics and hospitalization.

Answer 207

a. Prescribe antibiotic therapy after urine culture and sensitivity results are available. Patients with renal calculi are more likely to have complicated urinary tract infections that have less predictable microbiologic etiologies. Because the symptoms are mild, it is important first to obtain a culture and sensitivity to assist with antibiotic selection. If symptoms worsen, a broad-spectrum antibiotic may be started until sensitivity information is available. Intravenous antibiotics are indicated for severe pyelonephritis. Long-term prophylaxis is not indicated unless this patient develops frequent reinfection.

Question 208

A patient has a positive urine culture 1 week after completion of a 3-day course of antibiotics. What action will the prescriber take? a. Prescribe a 2-week course of antibiotics. b. Order tests to evaluate for a structural abnormality of the urinary tract. c. Prescribe long-term prophylaxis with low-dose antibiotics. d. Treat the patient with intravenous antibiotics.

Answer 208

a. Prescribe a 2-week course of antibiotics. Patients who develop a subsequent urinary tract infection after treatment are treated in a stepwise fashion, beginning with a longer course of antibiotics. The next steps would be to begin a 4- to 6-week course of therapy, followed by a 6-month course of therapy if that is unsuccessful. If urinary tract infections are thought to be caused by other complicating factors, an evaluation for structural abnormalities may be warranted. Unless the infections are severe or are complicated, intravenous antibiotics are not indicated.

Question 209

A pregnant female patient diagnosed with bacteriuria, suprapubic pain, urinary urgency and frequency, and a low-grade fever is allergic to sulfa, ciprofloxacin, and amoxicillin. The provider will prescribe which alternative medication to treat this patient? a. Cephalexin b. Fosfomycin c. Methenamine d. Nitrofurantoin

Answer 209

c. Methenamine Methenamine is an excellent second-line drug for this patient and is indicated because of the patient’s multiple drug sensitivities. It is safe in pregnancy, and there is no drug resistance. Nitrofurantoin has potential harmful effects on the fetus and should not be used during pregnancy. Single-dose regimens are not recommended in pregnant women. Cephalexin can have cross-reactivity with amoxicillin.

Question 210

Which patient diagnosed with a urinary tract infection will be hospitalization and prescribed intravenous antibiotics? a. A 5-year-old child with a fever of 100.5°F, dysuria, and bacteriuria b. A pregnant woman with bacteriuria, suprapubic pain, and fever c. A young man with dysuria, flank pain, and a previous urinary tract infection d. An older adult man with a low-grade fever, flank pain, and an indwelling catheter

Answer 210

d. An older adult man with a low-grade fever, flank pain, and an indwelling catheter The patient with an indwelling catheter and signs of pyelonephritis shows signs of a complicated UTI, which is best treated with intravenous antibiotics. Three other patients show signs of uncomplicated urinary tract infections that are not severe and can be treated with oral antibiotics.

Question 211

Before prescribing methenamine, it is important for the provider to review the patient’s history for evidence of which problem? a. Elevated blood urea nitrogen and creatinine b. History of reactions to antibiotic agents c. Possibility of pregnancy d. Previous resistance to antiseptic agents

Answer 211

a. Elevated blood urea nitrogen and creatinine Methenamine should not be given to patients with renal impairment, because crystalluria can occur. There is no cross-reactivity between methenamine and antibiotic agents. Methenamine is safe for use during pregnancy. There is no organism drug resistance to methenamine.

Question 212

A patient who is taking nitrofurantoin reports experiencing several side effects. Which side effect would cause the provider the most concern and would require discontinuation of the medication? a. Anorexia, nausea, and vomiting b. Brown-colored urine c. Drowsiness d. Tingling of the fingers

Answer 212

d. Tingling of the fingers Tingling of the fingers can indicate peripheral neuropathy, which can be an irreversible side effect of nitrofurantoin. The other side effects are not serious and can be reversed.

Question 213

A patient is beginning treatment for active tuberculosis (TB) in a region with little drug-resistant TB. Which treatment regimen will the provider prescribe initially? a. Isoniazid and pyrazinamide b. Isoniazid, pyrazinamide, and ethambutol c. Rifampin, pyrazinamide, and ethambutol d. Isoniazid, rifampin, pyrazinamide, and ethambutol

Answer 213

d. Isoniazid, rifampin, pyrazinamide, and ethambutol The induction phase of treatment for patients in a region without drug resistance is the same as for patients who are human immunodeficiency virus (HIV) negative or HIV positive and includes isoniazid, rifampin, pyrazinamide, and ethambutol. It is not correct to begin with two drugs. The three-drug regimen is used for inductions in areas with resistance to either isoniazid or rifampin.

Question 214

A patient with HIV who takes protease inhibitors develops tuberculosis and will begin treatment. Which drug regimen will the provider prescribe for this patient? a. Isoniazid, pyrazinamide, ethambutol + rifabutin b. Isoniazid, pyrazinamide, ethambutol c. Isoniazid, rifampin, pyrazinamide, ethambutol d. Isoniazid + rifabutin

Answer 214

a. Isoniazid, pyrazinamide, ethambutol + rifabutin Patients with HIV who take protease inhibitors are susceptible to drug interactions with rifampin, which accelerates the metabolism of protease inhibitors. Rifabutin can be substituted for rifampin in patients with HIV, because the degree of acceleration of this metabolism is less. A three-drug regimen would increase drug resistance, as would a two-drug regimen.

Question 215

A patient comes to a clinic for tuberculosis medications 2 weeks after beginning treatment with a four-drug induction phase. The patient’s sputum culture remains positive, and no drug resistance is noted. At this point, the provider will take what action? a. Change the regimen to a two-drug continuation phase. b. Continue the four-drug regimen and recheck the sputum in 2 weeks. c. Obtain a chest radiograph and consider adding another drug to the regimen. d. Question the patient about adherence to the drug regimen.

Answer 215

b. Continue the four-drug regimen and recheck the sputum in 2 weeks. In patients with positive pretreatment sputum test results, sputum should be evaluated every 2 to 4 weeks until cultures are negative and then monthly thereafter. In the absence of drug resistance, treatment with the same regimen should continue. Sputum cultures should become negative in over 90% of patients in 3 or more months. The induction phase should last 2 months, so this patient should remain on a four-drug regimen. It is not necessary to order a chest radiograph or to add another drug at this stage of treatment. The patient is stable and has not developed symptoms that cause concern, so the patient does not need to be questioned about adherence.

Question 216

Which patient will the provider determine should begin treatment for tuberculosis? a. A patient with HIV and a tuberculin skin test result of a 4-mm region of induration b. A recent immigrant from a country with a high prevalence of TB with a 10-mm region of induration c. A patient with no known risk factors who has a job-related tuberculin skin test result of a 12-mm area of induration d. An intravenous drug abuser with a tuberculin skin test result of a 5-mm region of induration

Answer 216

b. A recent immigrant from a country with a high prevalence of TB with a 10-mm region of induration The immigrant is considered to be at moderate risk, meaning that a 10-mm area of induration on a tuberculin skin test (TST) is considered a positive result. After being evaluated for active TB, this patient should be treated for latent TB. A patient with HIV is considered high risk, but this patient has a negative TST result of less than 5 mm. For a low-risk patient receiving a screening TST for a job, the area of induration must be 15 mm or greater to be considered a positive result. An IV drug abuser is in the moderate-risk category; an area of induration of 10 mm or greater is needed to be considered a positive TST result.

Question 217

A patient taking isoniazid for 4 months for latent tuberculosis reports bilateral tingling and numbness of the hands and feet, as well as feeling clumsy. What action will the provider take? a. Discontinue the isoniazid. b. Lower the isoniazid dose and order rifampin. c. Order pyridoxine 100 mg per day. d. Order another tuberculin skin test to monitor disease status.

Answer 217

c. Order pyridoxine 100 mg per day. Patients sometimes develop peripheral neuropathy, characterized by paresthesias, clumsiness, and muscle aches. If these occur, they may be reversed by administering pyridoxine (vitamin B6). It is not necessary to discontinue the isoniazid. Lowering the isoniazid dose and adding rifampin is not indicated. Rechecking the TST is not indicated.

Question 218

A patient is about to begin treatment with isoniazid. When the provider learns that the patient also takes phenytoin for seizures what action will be taken? a. Increasing the phenytoin dose b. Reducing the isoniazid dose c. Monitoring isoniazid levels d. Monitoring phenytoin levels

Answer 218

d. Monitoring phenytoin levels Isoniazid is a strong inhibitor of three cytochrome P450 enzymes, and inhibition of these enzymes can raise the levels of other drugs, including phenytoin. Patients taking phenytoin should have the levels of this drug monitored, and the dose should be reduced if appropriate. Reducing the dose of isoniazid is not indicated. It is not necessary to monitor isoniazid levels.

Question 219

A patient who is being treated for HIV infection has a 5-mm area of induration after a routine TB skin test. The patient’s chest radiograph is normal, and there are no other physical findings. The provider will prescribe which medications to begin treatment? a. Isoniazid and rifabutin b. Isoniazid and rifampin c. Isoniazid and rifapentine d. Isoniazid and pyrazinamide

Answer 219

a. Isoniazid and rifabutin Rifabutin is used off-label as an alternative to rifampin to treat TB in patients with HIV, because it has less impact on the metabolism of protease inhibitors. The effects of rifapentine on protease inhibitors are similar to those of rifampin. Pyrazinamide is not indicated.

Question 220

A patient comes to the clinic and receives valacyclovir for a herpes-zoster virus. When will the provider instruct the patient to take the medication? a. Without regard to meals b. Without any dairy products c. Each morning d. On an empty stomach

Answer 220

a. Without regard to meals The patient may take the medication without regard to meals. The patient does not need to avoid dairy products, take the pill only in the morning, or take it on an empty stomach.

Question 221

A patient is about to begin therapy with ethambutol. Before initiating treatment with this drug, the provider orders which test(s) to determine an accurate baseline? a. Color vision and visual acuity b. Complete blood cell (CBC) count c. Hearing testing and a tympanogram d. Hepatic function tests

Answer 221

a. Color vision and visual acuity Optic neuritis is a dose-related adverse effect of ethambutol. Patients receiving this drug should have color vision and visual acuity testing before therapy starts and periodically thereafter. A CBC, hearing evaluations, and hepatic function testing are not recommended

Question 222

A patient who is being treated with medication for both HIV and tuberculosis but a four-drug regimen taken for 3 months has shown no improvement in symptoms. Which drug will the provider add to this patient’s regimen? a. Bedaquiline b. Capreomycin c. Ethionamide d. Pyridoxine

Answer 222

a. Bedaquiline Bedaquiline is a newer, highly effective anti-TB drug that does not accelerate the metabolism of HIV drugs and is sued for multidrug-resistant TB. Capreomycin is a second-line drug used for drug-resistant TB, but is not as effective as bedaquiline. Ethionamide is a second-line drug that is less well tolerated of all anti-TB agents and is used only when there is no alternative. Pyridoxine is given to prevent peripheral neuritis in patients taking isoniazid.

Question 223

A nurse is preparing to administer oral ofloxacin to a patient. While taking the patient’s medication history, the nurse learns that the patient takes warfarin and theophylline. Upon learning this information, what action will the provider take? a. Reduce the dose of ofloxacin. b. Increase the dose of ofloxacin. c. Increase the dose of theophylline. d. Order daily coagulation levels.

Answer 223

d. Order daily coagulation levels. Ofloxacin increases plasma levels of warfarin, so coagulation tests should be monitored. The ofloxacin dose should not be reduced or increased. Ofloxacin does not affect theophylline levels.

Question 224

A patient who is receiving intravenous ciprofloxacin for pneumonia develops diarrhea. A stool culture is positive for Clostridium difficile. What action will the provider take? a. Prescribe metronidazole. b. Increase the dose of ciprofloxacin. c. Restrict dairy products. d. Switch to gemifloxacin.

Answer 224

a. Prescribe metronidazole. C. difficile is resistant to fluoroquinolones; metronidazole is the drug of choice to treat this infection. Metronidazole is lethal only to anaerobic organisms, so the ciprofloxacin should be continued to treat the pneumonia. Increasing the dose of ciprofloxacin is not indicated, because C. difficile is resistant to ciprofloxacin. Gemifloxacin is approved for use in respiratory infections. Dairy consumption will have little effect on the diarrhea.

Question 225

A provider would prescribe which antibiotic to a patient diagnosed with methicillin-resistant Staphylococcus aureus (MRSA)? a. Daptomycin b. Levofloxacin c. Norfloxacin d. Ciprofloxacin

Answer 225

a. Daptomycin Daptomycin is active against MRSA. Levofloxacin and norfloxacin are not approved to treat MRSA. Ciprofloxacin is a poor choice for staphylococcal infections, including MRSA.

Question 226

Which condition is generally treated with oral antifungal agents? a. Tinea capitis b. Tinea corporis c. Tinea cruris d. Tinea pedis

Answer 226

a. Tinea capitis Tinea capitis must be treated with oral agents for 6 to 8 weeks. Tinea corporis, tinea cruris, and tinea pedis may be treated topically

Question 227

A patient will begin taking an immunosuppressant medication. The provider learns that a patient about to begin immunosuppressant medication has a history of frequent candidal infections. The provider will order which drug as prophylaxis? a. Fluconazole b. Ketoconazole c. Posaconazole d. Voriconazole

Answer 227

c. Posaconazole Posaconazole is used as prophylaxis for invasive Aspergillus and Candida infections in immunocompromised patients. Fluconazole, ketoconazole, and voriconazole are not used prophylactically.

Question 228

The nurse is preparing to administer amphotericin B intravenously. The provider will pretreat the patient with which medications? a. Acetaminophen and diphenhydramine b. Aspirin and diphenhydramine c. Ibuprofen and diphenhydramine d. Morphine sulfate and acetaminophen

Answer 228

a. Acetaminophen and diphenhydramine Optimum pretreatment before the administration of amphotericin B comprises acetaminophen and diphenhydramine [Motrin] is not suggested as pretreatment. Aspirin is an option, but it may increase kidney damage. Morphine is not indicated in the pretreatment regimen.

Question 229

A provider has ordered oral voriconazole for a patient who has a systemic fungal infection. The nurse obtains a medication history and learns that the patient takes phenobarbital for seizures. When the nurse contacts the provider what action will the provider take? a. Confirm the intravenous voriconazole order. b. Reduce the dose of phenobarbital. c. Reduce the dose of voriconazole. d. Prescribe a different antifungal agent.

Answer 229

d. Prescribe a different antifungal agent. Voriconazole can interact with many drugs. It should not be combined with drugs that are powerful P450 inhibitors, including phenobarbital, because these can reduce the levels of voriconazole. Administering the voriconazole IV will not increase the serum level. It is not correct to reduce the dose of either drug.

Question 230

A patient has an invasive aspergillosis infection. Which antifungal agent will the prescriber consider the drug of choice for this infection? a. Amphotericin B b. Fluconazole c. Posaconazole d. Voriconazole

Answer 230

d. Voriconazole Voriconazole has replaced amphotericin B as the drug of choice for treating invasive aspergillosis. Fluconazole, which is fungistatic, is not used to treat aspergillosis. Posaconazole is used for prophylaxis of aspergillosis in immunocompromised patients.

Question 231

A patient diagnosed with histoplasmosis is being treated with itraconazole. The provider will teach this patient to report which symptoms? a. Gynecomastia and decreased libido b. Headache and rash c. Nausea, vomiting, and anorexia d. Visual disturbances

Answer 231

c. Nausea, vomiting, and anorexia Itraconazole is associated with rare cases of liver failure, some of which were fatal. Patients should be instructed to report signs of liver toxicity, including nausea, vomiting, and anorexia. Ketoconazole is associated with gynecomastia and libido changes. Headache and rash are associated with fluconazole. Visual disturbances may occur with voriconazole.

Question 232

A patient with a history of congestive heart failure and renal impairment is diagnosed with esophageal candidiasis. Which antifungal agent will the provider prescribe this patient? a. Amphotericin B b. Fluconazole c. Itraconazole d. Voriconazole

Answer 232

b. Fluconazole Fluconazole is a drug of choice for treating systemic candidal infections. Amphotericin is nephrotoxic and should not be used in patients with existing renal disease. Itraconazole is a possible alternative agent for treating candidiasis but has serious cardiac side effects. Voriconazole is a drug of first choice for treating aspergillosis but not for candidiasis.

Question 233

A patient is taking oral ketoconazole for a systemic fungal infection. The medication administration record notes that the patient is also taking omeprazole for reflux disease. What instructions will the provider give the patient to maximize medication effectiveness? a. Take the omeprazole 1 hour before the ketoconazole. b. Take the omeprazole at least 2 hours after the ketoconazole. c. Restrict intake of dairy products. d. Wear sun glasses when outdoors to manage photosensitivity.

Answer 233

b. Take the omeprazole at least 2 hours after the ketoconazole. The nurse should administer the omeprazole at least 2 hours after the ketoconazole to prevent a drug-to-drug interaction. Drugs that reduce gastric acidity should be administered no sooner than 2 hours after ingestion of ketoconazole, because they reduce absorption of the drug. There is no need to restrict dairy products or wear sun glasses because neither ketoconazole nor omeprazole have a potential to require such measures.

Question 234

A patient with HIV contracts herpes simplex virus (HSV), and the prescriber orders acyclovir 400 mg PO twice daily for 10days. After 7 days of therapy, the patient reports having an increased number of lesions. What action will the provider take? a. Extend this patient’s drug therapy to twice daily for 12 months. b. Order intravenous foscarnet every 8 hours for 2 to 3 weeks. c. Increase the acyclovir dose to 800 mg PO five times daily. d. Order intravenous valacyclovir [Valtrex] 1 g PO twice daily for 10 days.

Answer 234

b. Order intravenous foscarnet every 8 hours for 2 to 3 weeks. Foscarnet is active against all known herpesviruses and is used in immunocompromised patients with acyclovir-resistant HSV or VZV. This patient is demonstrating resistance to acyclovir, so extending acyclovir therapy or increasing the acyclovir dose will not be effective. Valacyclovir is not approved for use in immunocompromised patients because of the risk for thrombotic thrombocytopenic purpura/hemolytic uremic syndrome.

Question 235

A patient diagnosed with HIV and mucocutaneous HSV is being treated with foscarnet after failing treatment with acyclovir. After 2 weeks, the patient’s dose is increased to 90 mg/kg over 2 hours from 40 mg/kg over 1 hour. The patient reports numbness in the extremities and perioral tingling. What action will the provider take? a. Order a serum calcium level. b. Treat for a potential foscarnet overdose. c. Order a creatinine clearance level. d. Order IV saline to be given before the next dose.

Answer 235

a. Order a serum calcium level. Foscarnet frequently causes hypocalcemia and other electrolyte and mineral imbalances. Paresthesias, numbness in the extremities, and perioral tingling can indicate hypocalcemia, so a calcium level should be drawn. These are not signs of foscarnet overdose. Nephrotoxicity may occur, but these are not signs of renal complications, so a creatinine clearance is not indicated. If nephrotoxicity occurs, prehydration with IV saline is indicated to reduce the risk of renal injury.

Question 236

A female patient who has hepatitis C is being treated with pegylated interferon α and ribavirin. It will be important for the provider to discuss what topic with the patient? a. If she gets pregnant, she should use the inhaled form of ribavirin. b. If she is taking oral contraceptives, she should also take a protease inhibitor. c. She should use a hormonal contraceptive to avoid pregnancy. d. She will need a monthly pregnancy test during her treatment.

Answer 236

d. She will need a monthly pregnancy test during her treatment. Ribavirin causes severe fetal injury and is contraindicated during pregnancy. Women taking ribavirin must rule out pregnancy before starting the drug, monthly during treatment, and monthly for 6 months after stopping treatment. Inhaled ribavirin is also embryo lethal and teratogenic. Adding a protease inhibitor will reduce the efficacy of oral contraceptives. Women using ribavirin should use two reliable forms of birth control.

Question 237

A patient diagnosed with hepatitis B begins treatment with adefovir and asks how long the drug therapy will last. What timeframe will the prescriber give the patient? a. A lifetime b. An indefinite, prolonged period of time c. 48 weeks d. Until nephrotoxicity occurs

Answer 237

b. An indefinite, prolonged period of time Current guidelines recommend treatment only for patients at highest risk; it is unknown whether treatment should continue lifelong. Treatment is usually prolonged, without a specific period of time. Nephrotoxicity is common but is not the deciding factor when determining length of effective treatment.

Question 238

A patient who is taking nelfinavir reports moderate to severe diarrhea. What action will the provider recommend? a. An over-the-counter antidiarrheal drug b. Immediate discontinuation of the nelfinavir c. Reducing the dose of nelfinavir by half d. Taking the nelfinavir with food to avoid side effects

Answer 238

a. An over-the-counter antidiarrheal drug A dose-limiting effect of nelfinavir is moderate to severe diarrhea, which can be managed with OTC antidiarrheal medications. Unless the symptoms become severe, withdrawing the nelfinavir is not indicated. Reducing the dose by half or taking it with food is not indicated.

Question 239

The nurse is caring for a patient who is taking a protease inhibitor (PI). Upon review of the laboratory test results, the nurse notes that the patient has newly elevated plasma triglycerides and cholesterol. Upon being notified of the test results, what action will the provider take? a. Prescribe lovastatin. b. Prescribe simvastatin. c. Discuss diet modification and exercise. d. Prescribe pancrease.

Answer 239

c. Discuss diet modification and exercise. All PIs can elevate plasma levels of cholesterol and triglycerides. Potential interventions for hyperlipidemia include modified diet, exercise, and lipid-lowering agents. Lovastatin and simvastatin should be avoided, because they can accumulate to dangerous levels. Pancreas is not indicated to lower triglycerides and cholesterol.

Question 240

A patient starting therapy with efavirenz asks about the timing of the medication with regard to meals. What patient education about the administration of this medication should the prescriber provide? a. The drug must be taken within 30 minutes after a meal. b. The drug is best taken with a high-fat meal. c. The drug can be taken anytime without regard to meals. d. The drug should be taken once daily on an empty stomach.

Answer 240

d. The drug should be taken once daily on an empty stomach. The nurse should advise the patient that the medication should be taken once daily on an empty stomach. Thirty minutes after a meal is too soon to take the medication. The medication is taken on an empty stomach, because high-fat meals increase plasma levels by 39% with capsules and by 79% with tablets. The medication must not be taken with high-fat meals.

Question 241

A patient who is taking didanosine reports nausea, vomiting, and abdominal pain. What will the provider recommend to this patient? a. “Take the drug with food to minimize these side effects.” b. “Stop taking the drug immediately and resume taking it once your symptoms subside. ” c. “Take the medication in the evening to avoid experiencing these kinds of symptoms. ” d. “You will need laboratory tests to determine if these are serious effects of the drug. ”

Answer 241

d. “You will need laboratory tests to determine if these are serious effects of the drug. ” As with all NRTIs, pancreatitis may occur and may manifest as nausea, vomiting, and abdominal pain. The patient will need evaluation of serum amylase, triglycerides, and calcium. Taking the drug with food or at a different time of day is not indicated. It is not correct to discontinue the drug and to resume it when symptoms subside, since pancreatitis may be fatal.

Question 242

A patient is HIV positive and has a previous history of drug and alcohol abuse. The patient is being treated with combination therapies, including didanosine. Which laboratory findings would most concern the provider? a. Increased serum amylase and triglycerides and decreased serum calcium b. Decreased serum amylase and serum triglycerides and increased serum calcium c. Decreased hemoglobin and hematocrit d. Increased serum amylase, decreased triglycerides, and increased platelets

Answer 242

a. Increased serum amylase and triglycerides and decreased serum calcium The nurse should be concerned about increased serum amylase triglycerides and a decrease in serum calcium, which are symptoms of pancreatitis, the major adverse effect of didanosine. The other laboratory test results and assessment findings are not consistent with pancreatitis and are not a concern.

Question 243

A patient is HIV positive and the provider is about to prescribe zidovudine. Before the medication therapy is initialed the provider will review which of the patient’s latest laboratory values? a. Ketones in the urine and blood b. Serum immunoglobulin levels c. Serum lactate dehydrogenase d. Complete blood count (CBC)

Answer 243

d. Complete blood count (CBC) The patient’s CBC should be reviewed to determine whether the patient has anemia and neutropenia. Ketones are not an adverse effect of zidovudine. Nothing indicates a need to monitor the immunoglobulin levels or serum lactate dehydrogenase.

Question 244

A patient complains of painful urination. A physical examination reveals vesicles on her labia, vagina, and the foreskin of her clitoris. Which medication will the provider prescribe? a. Acyclovir b. Azithromycin c. Metronidazole d. Tinidazole

Answer 244

a. Acyclovir Genital herpes can be treated with acyclovir, famciclovir, or valacyclovir, which are antiviral medications. Azithromycin, metronidazole, and tinidazole are antibiotics and do not have antiviral effects.

Question 245

A mother brings her 3-year-old child to the clinic with complaints of lesions appearing several days ago on the mouth and nose of the child and it is getting worse. Some of the vesicular is tender, edematous, red with yellow crusts and an erythematous base. What will you prescribe? - Gently wash the lesions with antibacterial soap and remove the yellow crusts - Diphenhydramine (Benadryl) to decrease itching and spreading - Mupirocin ointment (Bactoban) four times a day for 10 days. - Amoxicillin-clavulanate (Augmentin)

Answer 245

-Amoxicillin-clavulanate (Augmentin)****** Mupirocin is definitely wrong.

Question 246

An elderly patient with hypertension and hyperlipidemia who has been prescribed a statin medication comes for a follow-up visit after 4 months of therapy. The patient's laboratory reports show elevated blood cholesterol levels, and the urine examination reveals rhabdomyolysis. What could be the reasons for this condition? (select all that apply) a. The patient is taking grapefruit juice along with statins b. The patient is taking cyclosporine along with statins c. The patient is taking amiodarone along with statins d. The patient is eating fiber-rich food along with statins e. The patient is not responding to treatment

Answer 246

Sara picked A, B, C, D. Got 1.6/2 correct I think Amber picked A, B, and C and got it right???

Question 247

A 60-year-old male patient suffered an MI 3 months ago and has been treated for hypercholesterolemia for the last 10 years. His current LDL-C level is 172 mg/dL. Which of the following drugs is the most appropriate treatment for this patient? a. Rosuvastatin b. Ezetimibe c. Alirocumab d. Fenofibrate e. Pravastatin

Answer 247

C? | b is definitely WRONG

Question 248

When reviewing the medical records of a patient who is scheduled for surgery, you ascertain that the patient is at risk for which of the following related to a prescription for metformin (glumetza, riomet, Glucophage, fortamet)? a. Hemorrhage b. lactic acidosis c. hyperglycemia d. hypoglycemia

Answer 248

We think it is: b. lactic acidosis d is WRONG

Question 249

A teratogenic drug, such as methotrexate, is most likely to cause learning deficits during which phase of fetal development? a. conception through week 2 b. first trimester c. weeks 3-8 d. second and third trimesters

Answer 249

d. second and third trimesters

Question 250

The developmental variation in enzymes has what impact on pediatric prescribing? a. none, since there are no problems with developmental variation in enzymes because it is stable throughout childhood. b. Children should always be prescribed higher than adult doses per weight due to high enzyme activity c. Children should always be prescribed lower than adult doses per weight due to high enzyme activity d. Prescribing dosages will vary based on the developmental activity of each enzyme, at times requiring lower than adult doses and other times higher than adult doses based on the age of the child.

Answer 250

d. Prescribing dosages will vary based on the developmental activity of each enzyme, at times requiring lower than adult doses and other times higher than adult doses based on the age of the child. B is definitely wrong

Question 251

The FDA recommends that individuals taking the COX-2 inhibitor celecoxib should take a drug holiday to decrease the risk associated with this drug. The increased risk associated with the chronic use of COX-2 inhibitors may be attributed to: a. Respiratory depression b. A hypersensitivity reaction c. Renal insufficiency d. Gastrointestinal bleeding e. Increased platelet aggregation

Answer 251

D is definitely wrong. We are thinking maybe C??

Question 252

Naloxone reverses which effects when given to a client experiencing an opioid overdose? a. Sedation b. Respiratory depression c. Abdominal cramping d. Pain relief e. Euphoria

Answer 252

Sara put A, B, D, and E. She got 1.6/2 points

Question 253

Which of the following diseases or disorders are most likely treated with ACE-inhibitors? - Hyperthyroidism - Pulmonary hypertension - Cushing's Syndrome - Angina - Chronic kidney disease (with or without diabetes)

Answer 253

-Chronic kidney disease (with or without diabetes)?? Angina was definitely wrong

Question 254

Agonists act on the cell by: a. Neutralizing the cell action b. Blocking the cell action c. Activating the cell action d. Reducing the cell action

Answer 254

c. Activating the cell action **Questions from Pharm Midterm

Question 255

Lower doses of sublingual nitroglycerin can be used effectively because: a. It bypasses the liver b. The potency is 100 times higher c. It does not need to be absorbed into the bloodstream d. It is not catabolized down by gastric acids

Answer 255

a. It bypasses the liver **Question from Pharm Midterm

Question 256

The nurse is caring for a patient who is receiving a drug with a low therapeutic index. Which is the most important nursing intervention for this patient? a. Instruct the patient not to drive after taking the medication b. Instruct the patient not to take the drug after a high-fat meal c. Monitor the patient's plasma drug level periodically d. Monitor the patient's serum albumin levels periodically

Answer 256

c. Monitor the patient's plasma drug level periodically **Question from Pharm Midterm

Question 257

When prescribing lovastatin, what will a provider advise to decrease the risk of developing muscle toxicity? a. Monitor aspartate aminotransferase AST) and alanine aminotransferase (ALT) b. Substitute grapefruit juice with orange juice c. Avoid exercise for 2 hours after administration d. Take the medication with an NSAID or other anti-inflammatory drug

Answer 257

b. Substitute grapefruit juice with orange juice **Question from Pharm Midterm

Question 258

Which enzyme system is responsible for metabolizing drugs in the liver? a. Pancreatic lipase b. Gastric lipase c. Ptyalin d. CYP450 enzymes

Answer 258

d. CYP450 enzymes **Question from Pharm Midterm

Question 259

A patient reports that a medication no longer effectively alleviates symptoms. What process informs the provider's response to the patient's concerns? a. Desensitization of receptor sites results from continual exposure to the drug b. Endogenous antagonists compete with the drug for receptor sites c. Decreased selectivity for receptors results in a variety of effects d. Additional receptor sites are synthesized in response to the medication

Answer 259

a. Desensitization of receptor sites results from continual exposure to the drug **Question from Pharm Midterm

Question 260

Drugs that stimulate the synthesis of CYP isoenzymes are referred to as a/an: a. Inducing agent b. Rapid metabolizer c. Reduction agent d. Normal metabolizer

Answer 260

a. Inducing agent **Question from Pharm Midterm

Question 261

Anemia of chronic renal failure is caused by the lack of: a. Parathyroid hormone b. Erythropoietin c. Adrenaline d. Thyroid hormone

Answer 261

b. Erythropoietin **Question from Pharm Midterm

Question 262

Anemia due to chronic renal failure is treated with: a. Hydroxyurea b. Ferrous sulfate c. Vitamin B12 d. Epoetin alfa (Epogen)

Answer 262

d. Epoetin alfa (Epogen) **Question from Pharm Midterm

Question 263

A 60-year-old woman had a myocardial infarction. Which of the following should be used to prevent life-threatening arrhythmias that can occur post-myocardial infarction in this patient? a. Flecainide b. Procainamide c. Digoxin d. Metoprolol

Answer 263

d. Metoprolol **Question from Pharm Midterm

Question 264

A patient has a recent onset of atrial tachycardia is started on a calcium-channel blocker that slows conduction at the sinoatrial and atrioventricular nodes. Which of the following therapy will be prescribed? a. Felodipine b. Nifedipine c. Amlodipine d. Diltiazem

Answer 264

d. Diltiazem **Question from Pharm Midterm

Question 265

Which drug blocks alpha-1, beta-1, and beta-2 adrenoceptors? - Metoprolol - Propranolol - Dobutamine - Carvedilol

Answer 265

-Carvedilol **Question from Pharm Midterm

Question 266

A patient has been diagnosed with uncomplicated primary HTN. Which of the drug or combination of drug would be prescribed? a. Direct-acting vasodilator b. Two types of beta-blockers, a cardioselective and a nonselective one c. An ACE inhibitor and an ARB d. Thiazide diuretic

Answer 266

d. Thiazide diuretic **Question from Pharm Midterm

Question 267

A female patient who is being treated for chronic hepatitis B develops nephrotoxicity while on treatment. Which is the most likely medication she is taking for HBV treatment? a. Lamivudine b. Adefovir c. Telbivudine d. Entecavir

Answer 267

b. Adefovir **Question from Pharm Midterm

Question 268

Which antibiotic is recommended for the treatment of Chlamydia? a. High dose cephalosporin b. High dose fluoroquinolone c. High dose macrolide d. High dose penicillin

Answer 268

c. High dose macrolide **Question from Pharm Midterm

Question 269

A 24-year old patient is diagnosed with genital herpes simplex virus infection. Which of the following agents is indicated for use in this diagnosis? a. Zanamivir b. Valacyclovir c. Cidofovir d. Lamivudine

Answer 269

b. Valacyclovir **Question from Pharm Midterm

Question 270

A patient with bipolar is prescribed daily lithium. Which action is most important for the provider to take in order to determine if the therapeutic level is maintained? a. Evaluate pre-administration blood work b. Asses the patient for signs and symptoms of lithium toxicity c. Prescribe the lithium to be taken at regular intervals d. Order periodic laboratory testing

Answer 270

d. Order periodic laboratory testing **Question from Pharm Midterm

Question 271

What does aldosterone directly increase the reabsorption of? a. Sodium b. Water c. Magnesium d. Calcium

Answer 271

a. Sodium **Question from Pharm Midterm

Question 272

A patient who has congestive heart failure requires a diuretic. The patient also has a history of chronic kidney disease with a glomerular filtration rate (GFR) of less than 30 ml/min. Which drug would you prescribe this patient? a. Metolazone b. Furosemide c. Methyclothiazide d. Hydrochlorothiazide

Answer 272

b. Furosemide **Question from Pharm Midterm

Question 273

A 3-year-old child is treated for TB. Which of the following medications would be of great concern? a. Pyrazinamide b. Rifampin c. Isoniazid d. Ethambutol

Answer 273

d. Ethambutol **Question from Pharm Midterm

Question 274

Ivermectin works by: a. Paralyzing the helminths b. Killing the larvae c. Stop replication d. Keeps the eggs from hatching

Answer 274

a. Paralyzing the helminths | **Question from Pharm Midterm Helminths are parasitic worms

Question 275

You are managing a stable middle-aged adult with emphysema. In addition to reinforcing smoking cessation and medication schedules, which annual intervention will you recommend? a. Pneumococcal polysaccharide vaccine (PPSV23) b. Quadrivalent inactivated influenza vaccine (QIV) c. Pneumococcal conjugate vaccine (PCV13) d. Live attenuated influenza vaccine (LAIV)

Answer 275

b. Quadrivalent inactivated influenza vaccine (QIV) **Question from Pharm Midterm

Question 276

A patient with a history of congestive heart failure and renal impairment is diagnosed with esophageal candidiasis. Which antifungal agent will the provider prescribe this patient? a. Fluconazole b. Amphotericin B. c. Itraconazole d. Voriconazole

Answer 276

a. Fluconazole **Question from Pharm Midterm

Question 277

The selection of antibiotics for the treatment of infections is based on which understanding of selective toxicity? a. The ability to act against a specific microbe b. The ability to suppress bacterial resistance c. The ability to avoid injuring host cells d. The ability to transfer DNA coding

Answer 277

c. The ability to avoid injuring host cells **Question from Pharm Midterm

Question 278

Before prescribing Ampicillin to an 80-year-old patient what should be assessed? a. Renal function b. Hepatic function c. Cross sensitivity d. Total body fluid

Answer 278

a. Renal function **Question from Pharm Midterm

Question 279

A patient has a glucose-6-phosphate dehydrogenase deficiency (G6PD) and requires an antibiotic. Which class of antibiotics should be avoided in this patient? a. Penicillins b. Sulfonamides c. Macrolides d. Cephalosporins

Answer 279

b. Sulfonamides **Question from Pharm Midterm

Question 280

Every antibiotic drug class has resistant organisms that influence prescribing decisions. a. True b. False

Answer 280

a. True **Question from Pharm Midterm

Question 281

Which of the following patients would not be a candidate for treatment with tetracycline? a. A 23-year-old female who is considering becoming pregnant b. A 70-year-old female with a history of cardiac dysrhythmias c. A 59-year-old male with a history of kidney stones d. A 7-year-old female with no history of chronic illnesses

Answer 281

d. A 7-year-old female with no history of chronic illnesses **Question from Pharm Midterm

Question 282

The lowest concentration of an antimicrobial that will inhibit visible growth of a microorganism after overnight incubation under standard conditions is: a. Minimum inhibitory concentration (MIC) b. Recommended antibiotic dose c. Antibiotic underdosing d. Minimum bactericidal concentration (MBC)

Answer 282

a. Minimum inhibitory concentration (MIC) **Question from Pharm Midterm

Question 283

A mother brings her 3-year-old child to the clinic with complaints of lesions appearing

Question 284

On assessment of a patient with hyperlipidemia, you learn that the patient has recently undergone liver transplantation. Which antihyperlipidemic drug should be EXCLUDED from the patient's prescription? a. Ezetimibe b. Atorvastatin c. Gemfibrozil d. Cholestyramine

Answer 284

b. Atorvastatin **Question from Pharm Midterm

Question 285

Which resource would the NP use to determine if adverse effects had been identified after a drug was on the market? a. The phase II trials of the drug b. Ethnopharmacologic studies c. The black box warning d. The phase I trials of the drug

Answer 285

c. The black box warning **Question from Pharm Midterm

Question 286

A parent of a 5-year-old child with allergic rhinitis is seeking an approved treatment to make the child feel better. Which of the following is recommended? a. Cetirizine b. Meclizine c. Promethazine d. Diphenhydramine

Answer 286

a. Cetirizine **Question from Pharm Midterm

Question 287

You are treating an adolescent female for facial acne with isotretinoin (Accutane). What teaching or counseling related to the use of this medication will you provide? a. Emphasize the importance of effective contraception if the patient is sexually active b. Exposure to sunlight without burning can be helpful in hastening the healing process c. Avoid eating a fatty diet d. Dieting is not required

Answer 287

a. Emphasize the importance of effective contraception if the patient is sexually active **Question from Pharm Midterm

Question 288

Severe contact dermatitis caused by poison ivy or poison oak exposure often requires treatment with: a. Oral corticosteroids for 2 to 3 weeks b. Isolation of the patient to prevent spread of the dermatitis c. Thickly applied topical intermediate-dose corticosteroids d. Topical antipruritics

Answer 288

a. Oral corticosteroids for 2 to 3 weeks **Question from Pharm Midterm

Question 289

Isotretinoin (Accutane) is a drug employed in the treatment of severe recalcitrant cystic acne. Which one of the following is NOT an adverse effect associated with its use? a. Hypertriglyceridemia b. Fetal abnormalities c. Hyponatremia d. Conjunctivitis

Answer 289

c. Hyponatremia **Question from Pharm Midterm

Question 290

Which of the following is the antibiotic of choice in treating acute otitis media? a. Amoxicillin b. Cefaclor c. Azithromycin d. Trimethoprim/Sulfamethoxazole

Answer 290

a. Amoxicillin **Question from Pharm Midterm

Question 291

A patient is diagnosed with otitis externa caused by Aspergillus organisms. All of the following therapy is appropriate EXPECT? a. Ciprofloxacin plus hydrocortisone otic solution b. Topical 1% clotrimazole c. 2% acetic acid solution ear drops d. Oral fluconazole

Answer 291

a. Ciprofloxacin plus hydrocortisone otic solution **Question from Pharm Midterm

Question 292

Which antithrombic drug is most likely to cause thrombocytopenia? a. Argatroban b. Rivaroxaban c. Heparin d. Bivalirudin

Answer 292

c. Heparin **Question from Pharm Midterm

Question 293

Which of the following will you find in a patient taking warfarin and levothyroxine? a. Weight loss of 5 kg b. Cardiac dysrhythmias c. Excessive bruising d. Shortness of breath

Answer 293

c. Excessive bruising **Question from Pharm Midterm

Question 294

Tolerance may be caused by desensitization, internalization or downregulation of receptors, requiring higher drug doses to maintain the same response. Tolerance also often results from enhanced drug elimination that alters the concentrations of drugs available to interact with the receptor. a. True b. False

Answer 294

a. True **Question from Pharm Midterm

Question 295

Which of the following four patients you would NOT prescribe this drug to? a. Clonidine to a patient with severe pain b. Reserpine to a patient with a history of depression c. Methyldopa to a patient with a diagnosis of hypertension d. Guanfacine to a patient with ADHD

Answer 295

b. Reserpine to a patient with a history of depression **Question from Pharm Midterm

Question 296

The nurse practitioner is teaching the NP student about acetaminophen. Which of the following would be included when teaching the student? a. The antidote to acetaminophen overdose is acetylcysteine b. All of the answers are correct c. Patients need to watch over-the-counter medications for acetaminophen in the product to prevent an overdose d. Patients with normal kidney and liver function should not take more than 4000 mg per day

Answer 296

b. All of the answers are correct **Question from Pharm Midterm

Question 297

Beta Lactamase inhibitors are often indicated in which of the following? a. Often combined with penicillin antibiotics b. May decrease absorption of medication c. First dose effect d. Delayed absorption of oral drugs

Answer 297

a. Often combined with penicillin antibiotics

Question 298

Which of the following best classifies aminoglycosides, macrolides, and clindamycin? a. Cell wall inhibitors b. Folic acid synthesis inhibitors c. Mycolic acid synthesis inhibitors d. Protein synthesis inhibitors

Answer 298

d. Protein synthesis inhibitors **Question from Pharm Midterm

Question 299

Which of the following groups of antibiotics has a beta-lactam ring in the molecular structure? a. Macrolides b. Sulfonamides c. Cephalosporins d. Tetracyclines e. Fluoroquinolones

Answer 299

c. Cephalosporins **Question from Pharm Midterm

Question 300

Which of the following groups of antibiotics is notable for side effects such as nephrotoxicity and ototoxicity? a. Cephalosporins b. Aminoglycosides c. Tetracyclines d. Beta-lactams

Answer 300

b. Aminoglycosides **Question from Pharm Midterm

Question 301

Which of the following drug TREATMENT STRATEGIES is associated with peptic ulcer disease? a. Corticosteroids b. Antibiotics (amoxicillin and clarithromycin) c. Opioids d. Hormonal therapy

Answer 301

b. Antibiotics (amoxicillin and clarithromycin) **Question from Pharm Midterm

Question 302

Which antibiotic class disrupts folate metabolism in bacteria and is often combined with trimethoprim? a. Aminoglycosides b. Cephalosporins c. Macrolides d. Sulfonamides

Answer 302

d. Sulfonamides **Question from Pharm Midterm

Question 303

Which of the following drug classes should be avoided in peptic ulcer disease? a. Avoid diuretics b. Avoid proton pump inhibitors c. Avoid NSAIDs d. Avoid antibiotics

Answer 303

c. Avoid NSAIDs **Question from Pharm Midterm

Question 304

Which of the following best classifies penicillins, cephalosporins, and carbapenems? a. Mycolic acid synthesis inhibitors b. Cell wall inhibitors c. RNA synthesis inhibitors d. Protein synthesis inhibitors

Answer 304

b. Cell wall inhibitors **Question from Pharm Midterm

Question 305

Which of the following terms best describes the mechanism of action of metoprolol? a. Alpha-1 antagonist effects b. Beta-1 selective c. Nonselective Beta with Alpha blocking d. Nonselective Alpha-blockers

Answer 305

b. Beta-1 selective **Question from Pharm Midterm

Question 306

Which of the following medications are classified as macrolides? a. Erythromycin b. Azithromycin c. Clarithrymycin d. All are macrolides

Answer 306

d. All are macrolides **Question from Pharm Midterm

Question 307

The laboratory analysis conducted on a patient with acute-onset fever and malaise reveals an elevated neutrophil count. This finding suggests that the problem is most likely a: a. Sinus infection b. Viral infection c. Bacterial infection d. Parasitic infection

Answer 307

c. Bacterial infection **Question from Pharm Midterm

Question 308

What is the mechanism of action of Sulfonamides? a. Inhibits the synthesis of folic acid b. Inhibits the DNA gyrase c. Bind to the 50S subunit causing inhibition of protein synthesis d. Bind to the 30S subunit causing production of abnormal proteins

Answer 308

a. Inhibits the synthesis of folic acid **Question from Pharm Midterm

Question 309

Which medication is associated with risk for superinfection? a. Ciprofloxacin b. Gentamicin c. Rifampin d. Vancomycin

Answer 309

a. Ciprofloxacin **Question from Pharm Midterm

Question 310

When prescribing a tetracycline or quinolone antibiotic it is critical to instruct the patient: a. Not to take their regularly prescribed medication while on these antibiotics b. Not to take antacids while on these medications, as the antacid decreases absorption c. Regarding the need for lots of acidic foods and juices, such as orange juice, to enhance absorption d. That there are no drug interactions with these antibiotics

Answer 310

b. Not to take antacids while on these medications, as the antacid decreases absorption **Question from Pharm Midterm

Question 311

Which of the following statements is (are) true of Metronidazole (Flagyl)? a. all of the answers are correct b. It is used as an antiprotozoal to treat Trichomoniasis c. It is used to treat Clostridium difficile d. It has a disulfiram-like activity

Answer 311

a. all of the answers are correct **Question from Pharm Midterm

Question 312

Which outcome should the NP establish for a patient with trichomoniasis who is receiving metronidazole? a. Improvement in pain in the back of the testicles b. Decrease in yellow-green, odorous vaginal discharge c. Absence of painful urination and watery discharge d. Resolution of genital and perianal warts

Answer 312

b. Decrease in yellow-green, odorous vaginal discharge **Question from Pharm Midterm

Question 313

A patient found to have "strawberry spots" on the vagina and cervix. What is the treatment option? a. Metronidazole b. Lindane 1% cream c. Acyclovir d. Tetracycline

Answer 313

a. Metronidazole **Question from Pharm Midterm

Question 314

Treatment for fungal infections of the toenails (onychomycosis) include: a. Miconazole cream b. Ketoconazole cream c. Mupirocin cream d. Oral griseofulvin

Answer 314

d. Oral griseofulvin **Question from Pharm Midterm

Question 315

Which of the following is true regarding the CDC guidelines for the treatment of influenza? a. all the answers are true b. Oral osteltamivir is the preferred treatment in pregnant women. Pregnant women are recommended to receive the same antiviral dosing as nonpregnant women c. The CDC does not recommend baloxavir for treatment of influenza in pregnant women or breastfeeding mothers d. Antiviral treatment is recommended as soon as possible for any patient with suspected or confirmed influenza who is hospitalized; has severe, complicated, or progressive illness; or is at higher risk for influenza complications. e. Treatment should be initiated within 24 hours of illness onset

Answer 315

Pretty sure it is C. Book says "At this time there is not enough data to adequately determine safety during pregnancy, breastfeeding, children <12, or adults >65) d is definitely WRONG

Question 316

Which pneumococcal vaccine is routinely recommended for infants in the United States? a. 23-valent pneumococcal polysaccharide vaccine (PPSV23) b. 13-valent pneumococcal conjugate vaccine (PCV13) c. 10-valent pneumococcal conjugate vaccine (PHiD-CV) d. 7-valent pneumococcal conjugate vaccine (PCV7)

Answer 316

b. 13-valent pneumococcal conjugate vaccine (PCV13) **Question from Pharm Midterm

Question 317

A pediatric patient presents with one golden-crusted lesion at the site of an insect bite consistent with impetigo. His parents have limited finances and request the least-expensive treatment. Which medication would be the best choice for treatment? a. Mupirocin (Bactroban) b. Retapamulin (Altabax) c. Oral cephalexin (Keflex) d. Bacitracin and polymixin B (generic double antibiotic ointment)

Answer 317

Pretty sure I picked A and got it WRONG **Question from Pharm Midterm

Question 318

The patient asks if there is any other option besides antibiotics to treat acute otitis media. How will you respond? a. "Pain management is only necessary when antibiotics are prescribed" b. "Pain management is reserved for use when the tympanic membrane is burst" c. "Pain management is also part of the treatment plan for otitis media" d. "Antibiotics are the only way to cure otitis media"

Answer 318

c. "Pain management is also part of the treatment plan for otitis media" **Question from Pharm Midterm

Question 319

Which statement is true regarding iron replacement therapy? a. Carbonyl iron may cause anaphylactic reactions b. Parenteral iron should be reserved for patients who are unable to absorb oral iron or who are unable to tolerate oral iron, or who have persistent anemia despite oral iron replacement therapy c. Carbonyl iron is the mainstay treatment for iron deficiency anemia d. Ferrous sulfate may cause less intestinal discomfort than other treatments

Answer 319

b. Parenteral iron should be reserved for patients who are unable to absorb oral iron or who are unable to tolerate oral iron, or who have persistent anemia despite oral iron replacement therapy **Question from Pharm Midterm

Question 320

A female patient has an iron deficiency anemia and GI bleed has been ruled out. You will: a. Schedule the patient to return in 6 months for additional stool guaiac testing b. Refer the patient to a hematologist c. Prescribe ferrous sulfate 325 mg PO three times a day and schedule the patient to return in 1 month for a repeat CBC, serum iron, and TIBC d. Prescribe iron dextran 50 mg IM weekly for 4 weeks and schedule the weekly office visits for injections

Answer 320

c. Prescribe ferrous sulfate 325 mg PO three times a day and schedule the patient to return in 1 month for a repeat CBC, serum iron, and TIBC **Question from Pharm Midterm

Question 321

A patient reports chest pain that occurs most often during sleep. What treatment does the healthcare professional discuss with the patient? a. Oral calcium channel blockers b. Treatment of obstructive sleep apnea c. Short-acting nitroglycerin tablets d. A low-dose aspirin regimen

Answer 321

a. Oral calcium channel blockers **Question from Pharm Midterm

Question 322

34-year-old woman is noted to be diagnosed with stage I hypertension and after an evaluation is noted to have no complications. Which of the following antihypertensive agents are generally considered first-line agents for this individual? a. Vasodilators such as hydralazine b. Angiotensin-receptor blockers c. Alpha-blocking agents d. Thiazide diuretics e. Nitrates

Answer 322

d. Thiazide diuretics **Question from Pharm Midterm

Question 323

A drug that is used for ischemic heart disease has an adverse effect of gingival hyperplasia: a. Nitroglycerin b. Metoprolol c. Ranolazine d. Clopidogrel e. Verapamil

Answer 323

e. Verapamil **Question from Pharm Midterm

Question 324

A patient with HTN and left ventricular hypertrophy takes Losartan 50 mg daily. What is the benefit of this therapy for a patient with hypertension? a. This medication has no side effects b. This medication is less expensive than others c. This medication decreases blood pressure more effectively than others d. This medication decreases the risk of stroke

Answer 324

d. This medication decreases the risk of stroke **Question from Pharm Midterm

Question 325

Which patient diagnosis would a prescription for nifedipine be LEAST appropriate? a. Vasospastic angina b. Angina pectoris c. Atrial fibrillation d. Essential hypertension

Answer 325

c. Atrial fibrillation **Question from Pharm Midterm

Question 326

To improve positive outcomes when prescribing for the elderly the NP should: a. Assess cognitive function in the elder b. None of the answers are correct c. Encourage the patient to cut drugs in half with a knife to lower costs d. All the answers are correct e. Encourage the patient to take a weekly "drug holiday" to keep drug costs down

Answer 326

a. Assess cognitive function in the elder **Question from Pharm Midterm

Question 327

A medication review of an elderly person's medication involves: a. Asking the patient to bring a list of current prescription medications to the visit b. Asking what other providers are writing prescriptions for them c. Having the patient bring all of their prescription, over-the-counter, and herbal medications to the visit d. All the answers are correct

Answer 327

d. All the answers are correct **Question from Pharm Midterm

Question 328

Warfarin's primary mechanism of action is inhibition of the synthesis of vitamin K dependent clotting factors. These factors include which of the following? a. Factors II, VII, VIII, and X and protein C b. Factors II, VII, VIII, and XII and proteins C and S c. Factors II, VII, IX, and X and proteins C and S d. Factors VII, IX, X, and XII and protein S

Answer 328

c. Factors II, VII, IX, and X and proteins C and S **Question from Pharm Midterm

Question 329

What would you prescribe for warfarin overdose? a. Aspirin b. Phytonadione c. Calcium d. Potassium

Answer 329

b. Phytonadione **Question from Pharm Midterm

Question 330

A patient who has been taking warfarin is admitted with coffee-ground emesis. How will you manage this patient? a. Administer protamine sulfate b. Administer vitamin E c. Administer vitamin K d. Administer calcium gluconate

Answer 330

c. Administer vitamin K **Question from Pharm Midterm

Question 331

Which drug inhibits the intestinal absorption of cholesterol? a. Fenofibrate b. Colestipol c. Ezetimibe d. Colesevelam

Answer 331

c. Ezetimibe **Question from Pharm Midterm

Question 332

Before prescribing simvastatin, which baseline date are collected to help prevent adverse effects of drug therapy? (select all that apply) a. Gastric distress b. Potassium c. Liver enzymes d. Uric acid e. Muscle pain f. Renal function

Answer 332

a. Gastric distress c. Liver enzymes e. Muscle pain f. Renal function **Question from Pharm Midterm

Question 333

Laboratory reports indicate that a patient's serum cholesterol concentration is 250 mg/dL and triglyceride levels are 450 mg/dL. The health care provider prescribes gemfibrozil to lower cholesterol levels. What is the desired effect of the drug on the patient's lipoprotein levels? a. There would be an increase in very-low-density lipoprotein (VLDL) levels b. There would be a decrease in low-density lipoprotein (LDL) levels c. There would be an increase in low-density lipoprotein (LDL) levels d. There would be a decrease in high-density lipoprotein (HDL) levels

Answer 333

b. There would be a decrease in low-density lipoprotein (LDL) levels **Question from Pharm Midterm

Question 334

You are treating a patient with a history of hypercholesterolemia and an MI. The patient is a 45-year old female and she is on the maximum dose of rosuvastatin which she is tolerating well. Her LDL-C is 167 mg/dL. What would be the best drug to add to her rosuvastatin therapy? a. Fenofibrate b. Nicotinic acid c. Colesevelam d. Mipomersen e. Ezetimibe

Answer 334

e. Ezetimibe **Question from Pharm Midterm

Question 335

Narcan is considered an: a. Inhibitor b. Antagonist c. Agonist d. Inducer e. Partial agonist

Answer 335

b. Antagonist **Question from Pharm Midterm

Question 336

Which of the following statements best explains the observation that morphine is more likely to cause nausea and vomiting in ambulatory patients? a. Morphine sensitizes medulla cough center neurons b. Opioids cause sedation, which makes walking more difficult c. Opioids increase vestibular sensitivity d. Morphine inhibits the chemoreceptor trigger zone neurons

Answer 336

c. Opioids increase vestibular sensitivity **Question from Pharm Midterm

Question 337

A 30-year-old man has been abusing cocaine and is agitated, tachycardic, hypertensive, and hyperthermic. Which statement is correct regarding treatment in this situation? a. Phenobarbitol should be the first choice as an anticonvulsant b. Atropine should be administered to reverse the CNS depression that can occur with cocaine toxicity c. Benzodiazepines should be administered to calm the patient and decrease heart rate, blood pressure, and body temperature d. This patient should undergo gastric lavage; that is, he should have his stomach pumped immediately

Answer 337

c. Benzodiazepines should be administered to calm the patient and decrease heart rate, blood pressure, and body temperature **Question from Pharm Midterm

Question 338

Which agent is MOST likely to cause serious respiratory depression as a potential adverse reaction? a. Pentazocine b. Hydrocodone c. Morphine d. Nalmefene

Answer 338

c. Morphine **Question from Pharm Midterm

Question 339

What education will you provide a patient who is starting treatment with Febuxostat (Uloric)? a. Febuxostat may cause severe diarrhea b. The patient should consume a high-calcium diet c. The patient will need frequent CBC monitoring d. Gout may worsen with therapy

Answer 339

d. Gout may worsen with therapy **Question from Pharm Midterm

Question 340

Your patient is diagnosed with Psoriasis. You can prescribe all EXCEPT: a. Tars b. Glucocorticoids c. Methotrexate d. Vitamin E analogs

Answer 340

d. Vitamin E analogs **Question from Pharm Midterm

Question 341

Appropriate initial treatment for psoriasis would be: a. Anthralin (Drithocreme) b. Wet soaks with Burrow's or Domeboro solution c. An immunomodulator (Protopic or Elidel) d. Intermittent therapy with intermediate potency topical corticosteroids

Answer 341

d. Intermittent therapy with intermediate potency topical corticosteroids **Question from Pharm Midterm

Question 342

A patient who has end-stage renal disease will begin antibiotic therapy. What should the NP do when ordering a drug for this patient? a. Initiate therapy with a lower dose than recommended b. Prescribe an antibiotic with a narrow therapeutic index c. Increase the dose from the recommended dose d. Administer the antibiotic with diuretic medications

Answer 342

a. Initiate therapy with a lower dose than recommended **Question from Pharm Midterm

Question 343

During which gestational period is drug transfer to the fetus more likely to happen? a. Third trimester b. Second trimester c. Perinatal period d. First trimester

Answer 343

a. Third trimester **Question from Pharm Midterm

Question 344

Which concept guides the NP care of infants receiving a variety of medications? a. Drugs given subcutaneously (subQ) remain in the body longer in infants than in adults b. The blood-brain barrier protects the infant's brain from toxic drugs c. Drugs given intravenously (IV) leave the body more quickly in infants than in adults d. Gastric emptying time is shorter in infants than in children and adults

Answer 344

a. Drugs given subcutaneously (subQ) remain in the body longer in infants than in adults **Question from Pharm Midterm

Question 345

A 78-year-old patient after taking a beta-adrenergic receptor antagonist for several years for HTN, the drug has lost efficacy. This is due to: a. Gastric acid secretion decreases the absorption of the drug b. Increased body fat increases the volume of distribution of the drug c. Increased serum albumin leads to more drug sequestered in the circulation d. The sensitivity of these receptors to drug decreases with age e. Enhanced glomerular filtration clears the drug faster

Answer 345

I picked B, think I got it wrong. Probably D?? **Question from Pharm Midterm

Question 346

Match the correct adverse drug reactions unique to the pediatric populations: a. Aspirin -Reye syndrome b. Sulfonamides -staining of developing teeth c. Glucocorticoids -weight loss d. Chloramphenicol -Red man syndrome e. Fluoroquinolones -muscle hypertrophy f. Tetracyclines -kernicterus

Answer 346

a. Aspirin -Reye syndrome **Question from Pharm Midterm

Question 347

Which antibiotic class disrupts folate metabolism in bacteria and is often combined with trimethoprim? a. Sulfonamides b. Fluoroquinolones c. Aminoglycosides d. Cephalosporins e. Macrolides

Answer 347

a. Sulfonamides **Question from Pharm Midterm

Question 348

Fluoroquinolone antibiotics are most likely indicated in which of the following conditions? a. GERD b. Genital infections c. Follicular conjunctivitis d. Asthma

Answer 348

b. Genital infections **Question from Pharm Midterm

Question 349

Which of the following medications is a fluoroquinolone antibiotic? a. Penicillin b. Azithromycin c. Amikacin d. Ciprofloxacin

Answer 349

d. Ciprofloxacin **Question from Pharm Midterm

Question 350

Which of the following best classifies aminoglycosides, macrolides, and clindamycin? a. Protein synthesis inhibitors b. Folic acid synthesis inhibitors c. Mycolic acid synthesis inhibitors d. Cell wall inhibitors

Answer 350

a. Protein synthesis inhibitors **Question from Pharm Midterm

Question 351

Beta lactamase inhibitors are often indicated in which of the following? a. First dose effect b. Often combined with penicillin antibiotics c. Delayed absorption of oral drugs d. May decrease absorption of medications

Answer 351

b. Often combined with penicillin antibiotics **Question from Pharm Midterm

Question 352

Which of the following correctly describes the intramuscular route of parenteral drug administration? a. Used to administer drug-suspensions that are slowly absorbed b. Bypasses the process of drug absorption to achieve an immediate effect c. Cannot be used for drugs that undergo a high degree of first-pass metabolism d. Drug absorption is erratic and unpredictable

Answer 352

a. Used to administer drug-suspensions that are slowly absorbed **Question from Pharm Midterm

Question 353

Which of the following statements is most accurate regarding generic drugs and patient adherence? a. Adherence is lower for patients prescribed generic medications due to negative media coverage surrounding the safety and effectiveness of generic drugs b. Compared with branded drugs, the lower out-of-pocket costs of generic medications lead to increased patient adherence c. Adherence is lower for patient taking generic medications than branded medications due to a higher rate of adverse events associated with generic drugs d. Patient adherence is the same regardless of drug branding status

Answer 353

b. Compared with branded drugs, the lower out-of-pocket costs of generic medications lead to increased patient adherence **Question from Pharm Midterm

Question 354

Patients who have a poor metabolism phenotype will have: a. Slowed metabolism of a prodrug into an active drug, leading to accumulation of prodrug b. Increased elimination of an active drug c. A need for increased dosages of medications d. Accumulation of inactive metabolites of drugs

Answer 354

a. Slowed metabolism of a prodrug into an active drug, leading to accumulation of prodrug **Question from Pharm Midterm

Question 355

A drug with a high therapeutic index is: a. Extremely potent b. A lethal dose c. Has low efficacy d. Is relatively safe

Answer 355

d. Is relatively safe **Question from Pharm Midterm

Question 356

You are caring for a patient with bipolar disorder who is taking lithium. Which abnormal laboratory value is MOST essential for you to re-evaluate this patient's dosage of lithium? a. Blood urea nitrogen level of 20 mg/dL b. Sodium level of 128 mEq/L c. Potassium level of 5.0 mEq/L d. Prothromin time of 8 seconds

Answer 356

b. Sodium level of 128 mEq/L **Question from Pharm Midterm

Question 357

The patient is receiving anticoagulant therapy. The INR value for the patient today is 1.5, in response to this, what will you do? a. The level is outside the expected target therapeutic level of anticoagulation; it is too high b. The level is within the expected target therapeutic level of anticoagulation c. The level is outside the expected target therapeutic level of anticoagulation; it is too low d. The level cannot be interpreted without knowing the prothrombin time and the international normalized ratio (INR)

Answer 357

c. The level is outside the expected target therapeutic level of anticoagulation; it is too low **Question from Pharm Midterm

Question 358

A patient has been prescribed sildenafil (Viagra) for erectile dysfunction. Which instruction should the nurse include in the teaching plan? a. Take the medication on an empty stomach b. Drink plenty of fluids to prevent priapism c. Avoid taking nitroglycerin with this drug d. Constipation is a common adverse effect

Answer 358

c. Avoid taking nitroglycerin with this drug

Question 359

A patient is taking finasteride (Proscar) for benign prostatic hyperplasia (BPH). The nurse should explain that this medication has what effect? a. Decreases the size of the prostate gland b. Relaxes smooth muscle of the prostate gland c. Reduces the risk of prostate cancer d. Improves sexual performance during intercourse

Answer 359

a. Decreases the size of the prostate gland

Question 360

A patient is taking tamsulosin (Flomax) for benign prostatic hyperplasia (BPH). The nurse should explain that this medication has what effect? a. Decreases the size of the prostate gland b. Relaxes smooth muscle of the prostate gland c. Reduces the risk of prostate cancer d. Improves sexual performance during intercourse

Answer 360

b. Relaxes smooth muscle of the prostate gland

Question 361

The nurse should instruct a patient prescribed sildenafil (Viagra) to avoid taking this medication with what? a. Grapefruit juice b. Milk c. Crackers d. Eggs

Answer 361

a. Grapefruit juice

Question 362

The major difference between varicose veins and arteriosclerosis is the: a. limbs affected. b. gender affected. c. vessels affected. d. degree of pain.

Answer 362

c. vessels affected. Varicose veins and arteriosclerosis are very different disease processes. While differences can be found in the gender affected, the major difference between the two diseases is the vessel affected. Arteriosclerosis affects the arteries; varicose veins affect the veins. While there is a predilection for the lower extremities in varicose veins, peripheral artery disease (PAD) is most common in the lower extremities too. Varicose veins are especially common in women 2:1; PAD is more common in men 2:1 after age 70 years. Pain is a subjective measure.

Question 363

A patient has had poorly controlled hypertension for more than 10 years. Indicate the most likely position of his point of maximal impulse (PMI): a. 5th intercostal space (ICS) midclavicular line (MCL). b. 8th ICS MCL. c. 5th ICS, left of MCL. d. 6th, right of MCL.

Answer 363

c. 5th ICS, left of MCL. The PMI or apical impulse is produced when the left ventricle moves anteriorly and touches the chest wall during contraction. This is normally found at the 5th intercostal space, midclavicular line. Certain conditions and diseases like heart failure or cardiomyopathy may account for this; or left ventricular hypertrophy from prolonged hypertension can displace the apical impulse. The displacement usually occurs left and laterally from its usual location. Thus, 5th ICS, left of midclavicular line. Conditions like pregnancy may displace the apical impulse upward and to the left.

Question 364

A 43-year-old Hispanic male has an audible diastolic murmur best heard in the mitral listening point. There is no audible click. His status has been monitored for the past 2 years. This murmur is probably: a. mitral valve prolapse. b. acute mitral regurgitation. c. chronic mitral regurgitation. d. mitral stenosis.

Answer 364

d. mitral stenosis. Mitral valve prolapse (MVP) is an unlikely etiology since MVP is a systolic murmur. Additionally, the question states there is no audible click, and a mid to late systolic click is characteristic of MVP. Acute mitral regurgitation (MR) usually develops after rupture of the chordae tendineae, ruptured papillary muscle after myocardial infarction, or secondary to bacterial endocarditis. Symptoms of failure appear with abrupt clinical deterioration in the patient. A 2-year course for this patient as described would not be appropriate if this were an acute development. Dilation of the left atrium and ventricle is typical in chronic MR since both chambers are affected from regurgitant blood flow across the diseased valve, but MR is a systolic murmur, not diastolic. This is mitral stenosis (MS) because MS produces the only diastolic murmur listed in the question.

Question 365

A patient who has diabetes presents with pain in his lower legs when he walks and pain resolution with rest. When specifically asked about the pain in his lower leg, he likely will report pain: a. in and around the ankle joint. b. in the calf muscle. c. radiating down his leg from the thigh. d. pain in his lower leg that waxes and wanes.

Answer 365

b. in the calf muscle. This patient's symptoms are typical of arteriosclerosis. The term used to describe this patient's symptom is intermittent claudication. When there is compromised arterial blood flow in the lower legs, a common complaint is reproducible pain in a specific group of muscles. The pain occurs because there is an incongruence between blood supply and demand. This produces pain that causes a patient to stop exercising in order to obtain pain relief.

Question 366

A patient with hypertension describes a previous allergic reaction to a sulfa antibiotic as "sloughing of skin" and hospitalization. Which medication is contraindicated in this patient? a. Ramipril b. Metoprolol c. Hydrochlorothiazide d. Verapamil

Answer 366

c. Hydrochlorothiazide This patient's allergy to "sulfa" sounds like Stevens-Johnson Syndrome, a potentially life-threatening allergic reaction. Hydrochlorothiazide has a sulfonamide ring in its chemical structure, generally referred to as "sulfa." This sulfonamide ring can initiate an allergic reaction in patients with sulfa allergy. Since the patient's allergic reaction to sulfa was so serious, other sulfonamide medications should be completely avoided until consultation with an allergist. The other medications can be used without concern in the presence of a patient with a sulfa allergy because there is no sulfonamide component

Question 367

A 75-year-old patient who has aortic stenosis wants to know what symptoms indicate worsening of his stenosis. The nurse practitioner replies: a. palpitations and weakness. b. ventricular arrhythmias. c. shortness of breath and syncope. d. fatigue and exercise intolerance.

Answer 367

c. shortness of breath and syncope. The three most common symptoms associated with aortic stenosis are angina, syncope, and heart failure evidenced by dyspnea. Syncope is usually exertional. Angina may be due to aortic stenosis, but underlying coronary artery disease accounts for half of anginal symptoms in these patients. There is usually a prolonged asymptomatic phase, but the presence of symptoms usually indicates a need for valve replacement. Without replacement, there is a rapid decline in the patient's status and death will ensue ensue.

Question 368

A 74-year-old patient has peripheral artery disease (PAD). Which item listed below is an important nonmodifiable risk factor for PAD? a. Cigarette smoking b. Hyperlipidemia c. Diabetes d. Alcohol consumption

Answer 368

c. Diabetes Modifiable risk factors for PAD include hyperlipidemia, cigarette smoking, and hypertension. Diabetes is typically a nonmodifiable risk factor. Cigarette smoking is often considered the most important risk factor for PAD. Stopping cigarette smoking reduces the progression of PAD and is associated with lower rates of amputation, and improves rest ischemia and pain in patients who experience this. Alcohol consumption actually reduces the risk of PAD but can increase the risk of many other diseases.

Question 369

Benazepril should be discontinued immediately if: a. dry cough develops. b. pregnancy occurs. c. potassium levels decrease. d. gout develops.

Answer 369

b. pregnancy occurs. Benazepril is an ACE inhibitor and this class of drugs is contraindicated during pregnancy because of teratogenic effects on the renal system of the developing fetus. D1y cough is an aggravating side effect that occurs in some patients who take ACE inhibitors, but discontinuation is elective. ACE inhibitor use is associated with increased potassium levels, not decreased levels. Gout is not exacerbated by ACE inhibitor use.

Question 370

Which choice below characterizes a patient who has aortic regurgitation? a. Long asymptomatic period followed by exercise intolerance, then dyspnea at rest b. An acute onset of shortness of breath in the fifth or sixth decade c. Dyspnea on exertion for a long period of time before sudden cardiac death d. A long asymptomatic period with sudden death, usually during exercise

Answer 370

a. Long asymptomatic period followed by exercise intolerance, then dyspnea at rest The natural course of aortic regurgitation (AR) is that the patient has a long asymptomatic period with slowing of activities but remains essentially asymptomatic. Shortness of breath develops with activity and finally, shortness of breath at rest. The left ventricle eventually fails unless the aortic valve is replaced.

Question 371

Classic symptoms of deep vein thrombosis (DVT) include: a. swelling, pain, redness. b. calf complaints, pain with walking, history of exercise. c. swelling, pain, and discoloration in lower extremity. d. warmth, edema, and relief of pain with walking.

Answer 371

c. swelling, pain, and discoloration in lower extremity. Swelling, pain, and discoloration from impaired blood flow are the classic symptoms. Choice A could describe infection, like cellulitis, and is not classic for DVT. Redness is an inconsistent sign of DVT as is a positive Roman's sign. A history of exercise actually decreases the risk of DVT. Pain secondary to DVT is not relieved by walking. The lower extremities are the most likely location of DVT, but symptoms don't always correlate with location of the thrombosis. Patients must be asked about history, family history of DVT, and precipitating conditions.

Question 372

A characteristic of an ACE inhibitor-induced cough is that it: a. is mildly productive. b. is worse at nighttime. c. usually begins within 2 weeks of starting therapy. d. is more common in men.

Answer 372

c. usually begins within 2 weeks of starting therapy. The cough associated with use of an ACE inhibitor is typically dry and nonproductive. It is more common in women than men and is thought to be due to the buildup of bradykinin. Bradykinin is partly degraded by ACE (angiotensin converting enzyme). Degradation of bradykinin and conversion of angiotensin I to angiotensin II by ACE occurs in the lung. When degradation is impaired, bradykinin can accumulate and cough can ensue.

Question 373

The valve most commonly involved in chronic rheumatic heart disease is the: a. aortic. b. mitral. c. pulmonic. d. tricuspid.

Answer 373

b. mitral. The mitral valve has a propensity for disorders secondary to rheumatic heart disease. Rarely is the pulmonic valve involved, but the aortic and tricuspid valves follow in descending order of involvement. Following an episode of rheumatic fever, which occurs infrequently in the US today but is common in developing countries, the valves can become stenotic or regurgitant. This is a major cause of valvular disease in the US, and it is seen primarily in immigrants

Question 374

Which medication could potentially exacerbate heart failure (HF)? a. Naproxen b. Furosemide c. Atorvastatin d. Aspirin

Answer 374

a. Naproxen Naproxen is an NSAID. NSAIDs cause sodium retention and thus, water retention. A single dose of naproxen is unlikely to produce HF symptoms, but repeated subsequent doses are very likely to produce water retention sufficient to cause edema and possible shortness of breath in susceptible people. The other medications listed are unlikely to have any direct effect on cardiac output in a patient who has HF.

Question 375

A patient taking an ACE inhibitor should avoid: a. strenuous exercise. b. potassium supplements. c. protein-rich meals. d. grapefruit juice.

Answer 375

b. potassium supplements. An ACE inhibitor potentially can produce hyperkalemia because its mechanism of action is to spare potassium in the renin angiotensin aldosterone system. If potassium is taken in the form of potassium supplements, the effect will be additive and the risk of hyperkalemia can be great.

Question 376

A 28-year-old has a Grade 3 murmur. Which characteristic indicates a need for referral? a. A fixed split b. An increase in splitting with inspiration c. A split S2 with inspiration d. Changes in intensity with position change

Answer 376

a. A fixed split A split is created because of closure of valves. For example, an S2 is created by closure of the aortic and pulmonic valves. Normally these split with inspiration and almost never with expiration. Splits should never be fixed. This indicates pathology such as an atrial septal defect, pulmonic stenosis, or possibly mitral regurgitation. In any event, this patient needs initial evaluation with an echocardiogram because fixed splits are always considered abnormal. He will almost certainly be referred to cardiology.

Question 377

Which group of medications would be detrimental if used to treat a patient who has heart failure (HF)? a. Ramipril, aspirin, metoprolol b. Digoxin, furosemide, aspirin c. Fosinopril, HCTZ, verapamil d. Furosemide, enalapril, aspirin

Answer 377

c. Fosinopril, HCTZ, verapamil ``` The medications often used in managing patients who have HF include ACE inhibitors, beta blockers, diuretics, aspirin, or digoxin. Verapamil is a calcium channel blocker and is contraindicated in patients who have HF because this class depresses myocardial contractility ```

Question 378

Mr. Smith is a 72-year-old patient who takes warfarin for chronic atrial fibrillation. His INR today is 4.0. The nurse practitioner should: a. Stop the warfarin for the next 4 days and repeat the INR on day 5. b. Admit to the hospital immediately. c. Administer vitamin K and repeat INR in 2 hours. d. Stop the warfarin today and repeat the INR tomorrow.

Answer 378

d. Stop the warfarin today and repeat the INR tomorrow. An INR range of 2.0-3.0 is therapeutic for most people who take warfarin for chronic atrial fibrillation. An INR of 4.0 is elevated, and this patient could suffer a devastating bleed anywhere in the body. A patient with an INR < 5 without bleeding may have warfarin stopped temporarily. The maintenance dose should be decreased when it is safe to resume warfarin, i.e. when the INR is closer to the patient's therapeutic range. If the patient were at high risk for bleeding, was bleeding, or if the INR was greater than 4.0, vitamin K could be administered. A good history should be completed to find out the reason for the increase in JNR. A high-risk client with an elevated INR would be admitted to the hospital and closely monitored, but a client with no comorbidities (no bleeding history or thrombocytopenia) and considered low risk, may be monitored as an outpatient. Five days is too long to stop warfarin without an INR check.

Question 379

According to the National Heart, Lung and Blood Institute, which characteristic listed below is a coronary heart disease (CHD) risk equivalent; that is, which risk factor places the patient at a CHD risk similar to a history of CHD? a. Hypertension b. Cigarette smoking c. Male age > 45 years d. Diabetes mellitus

Answer 379

d. Diabetes mellitus In determining whether a patient should be treated for hyperlipidemia, a patient's risk factors must be determined. After assessing fasting lipids, specifically LDLs, CHD equivalents must be identified. These are diabetes, symptomatic carotid artery disease, peripheral artery disease, abdominal aortic aneurysm, and multiple risk factors that confer a 10-year risk of CHD > 20%. Major CHD risk factors are elevated LDL cholesterol, cigarette smoking, hypertension, low HDL cholesterol, family history of premature CHD [in male first-degree relatives (FDR)< 55 years; female FDR, 65 years], and age (men> 45 years, women> 55 years). Patients with 2 or more risk factors should have a 10-year risk assessment performed and be treated accordingly.

Question 380

A patient is diagnosed with mild heart failure (HF). What drug listed below would be a good choice for reducing morbidity and mortality long term? a. Verapamil b. Digoxin c. Furosemide d. Metoprolol

Answer 380

d. Metoprolol Metoprolol is a beta blocker. Beta blockers are known to reduce morbidity and mortality associated with HF. Verapamil is a calcium channel blocker. This class of medications is contraindicated because they decrease contractility of the heart. Furosemide and digoxin will improve symptoms but not long-term outcomes. Their main benefit is in treating symptomatic patients.

Question 381

A patient taking atorvastatin for newly diagnosed dyslipidemia complains of fatigue, weakness, and muscle aches in his lower back, arms, and legs for the past three days. It has not improved with rest. How should this be evaluated? a. Stop the atorvastatin immediately. b. Check liver enzymes first. c. Order a CPK level. d. Ask about nighttime muscle cramps.

Answer 381

a. Stop the atorvastatin immediately. This patient has complaints highly suggestive of rhabdomyolysis. The atorvastatin should be stopped immediately and a CPK should be ordered. Liver enzymes would not assess for the etiology of myalgias. They assess tolerance of statins in the liver. Nighttime muscle cramps are not usually associated with statin use. Myalgias are common but are typically not associated with an elevated CPK. Rhabdomyolysis is a rare side effect of statins.

Question 382

A patient with poorly controlled hypertension and history of myocardial infarction 6 years ago presents today with mild shortness of breath. He takes quinapril, ASA, metoprolol, and a statin daily. What symptom is NOT indicative of heart failure? a. Fatigue b. Headache c. Orthopnea d. Cough

Answer 382

b. Headache Fatigue is a common symptom in cardiac patients, and it can represent a worsening of many cardiac diseases, such as coronary artery disease, heart failure, or valvular dysfunction. Orthopnea and cough, especially nocturnal, are classic symptoms of worsening heart failure. Headache is a nonspecific symptom and is not typical of heart failure

Question 383

A 65-year-old male patient has the following lipid levels. What class of medications is preferred to normalize his lipid levels and reduce his risk of a cardiac event? Total Cholesterol 260 mg/dL LDL Cholesterol 190 mg/dL HDL Cholesterol 37 mg/dL Triglycerides 140 mg/dL a. Niacin b. Fibric acids c. HMG CoA reductase inhibitors d. Bile acid sequestrants

Answer 383

c. HMG CoA reductase inhibitors The only medication class that reduces elevated lipid levels and has proven efficacy in reducing risk of cardiac events, even for primary prevention, are the HMG CoA reductase inhibitors, also known as the statins. Statin therapy has been shown to reduce overall mortality resulting from cardiovascular deaths. The statin should significantly reduce his total cholesterol and LDL values.

Question 384

A patient has shortness of breath. If heart failure is the etiology, which test demonstrates the highest sensitivity in diagnosing this? a. Echocardiogram b. B type natriuretic peptide (BNP) c. EKG d. Chest X-ray

Answer 384

b. B type natriuretic peptide (BNP) BNP is a hormone involved in regulation of blood pressure and fluid volume. When the BNP level is 80 pg/mL or greater, the sensitivity and specificity is 98% and 92%, favoring a diagnosis of heart failure. Alternatively, BNP levels less than 80 pg/mL strongly suggest that heart failure is not present (some US institutions use 100 pg/mL). Other conditions may cause elevated BNP levels: thoracic and abdominal surgery, renal failure, and subarachnoid hemorrhage. Consequently, careful assessment of the patient is prudent. Echocardiograms mechanically evaluate the heart and establish an ejection fraction. If< 35-40%, then HF can usually be diagnosed. Ejection fractions do not always correlate with patient symptoms. EKG evaluates the electrical activity of the heart. Chest X-ray can indicate heart failure, but a BNP is a more sensitive measure.

Question 385

The nurse practitioner is caring for an independent 74-year-old female who had acute coronary syndrome (ACS) about 6 weeks ago. What medications should be part of her regimen unless there is a contraindication? · a. ASA and beta blocker b. ACE and beta blocker c. ACE, ASA, and beta blocker d. ACE, ASA, beta blocker and statin

Answer 385

d. ACE, ASA, beta blocker and statin After a myocardial event, an aspirin, ACE inhibitor, beta blocker, and statin should be dosed daily. The aspirin will provide anticoagulation; the ACE inhibitor, statin and beta blocker are associated with reduced morbidity and mortality if given soon after ACS.

Question 386

Which patient could be expected to have the highest systolic blood pressure? a. A 21-year-old male b. A 50-year-old perimenopausal female c. A 35-year-old with Type 2 diabetes d. A 75-year-old male

Answer 386

d. A 75-year-old male Nearly 25% of the US population has hypertension. The greatest incidence is in older adults because of changes in the intima of vessels as aging and calcium deposition occur. Males of any age are more likely to be hypertensive than females of the same age. African American adults have the highest incidence in the general population. Among adolescents, African Americans and Hispanics have the highest rates. Hypertension occurs in 5-10% of pregnancies

Question 387

Which test below is most cost-effective to screen for abdominal aortic aneurysm? a. CT of the abdomen b. MRI of the abdomen c. Abdominal ultrasound d. Two-hand palpation test

Answer 387

c. Abdominal ultrasound While an abdominal aortic aneurysm (AAA) might be detected by multiple modalities, including a plain film of the abdomen, it is most cost effectively and efficiently identified using ultrasound. The sensitivity and specificity for AAA identification with ultrasound is nearly 100%. Both CT and MRI are very accurate in identifying AAA, but they are both more expensive than ultrasound.

Question 388

A 77-year-old patient has had an increase in blood pressure since the last exam. His blood pressure has increased from 144/90 mmHg to readings in the upper 160's/upper 90's. If medication is to be started on this patient, what would be a good first choice? a. ACE inhibitor b. Beta blocker c. Calcium channel blocker d. Thiazide diuretic

Answer 388

c. Calcium channel blocker This patient is 77 years old and should have a goal blood pressure of< 150/90 mmHg according to JNC8. A thiazide diuretic is not a good first choice in this patient because it will not be potent enough to decrease blood pressure by about 20 points to get him to goal. A long-acting calcium channel blocker is appropriate for patients who have isolated systolic hypertension and will be more likely to get this patient to goal pressure than HCTZ. Beta blockers are no longer recommended first line for uncomplicated hypertension. ACE inhibitors are very effective in patients who are high renin producers. Older patients tend to produce lower amounts of renin

Question 389

Besides hypertension, which risk factor most contributes to development of an abdominal aortic aneurysm? a. Valvular dysfunction b. Elevated LDL values c. Cigarette smoking d. Alcohol consumption

Answer 389

c. Cigarette smoking Smoking clearly increases the risk for abdominal aortic aneurysm (AAA). The prevalence in women is far lower than in men, and the benefits associated with screening women for AAA do not justify the costs. However, the United States Preventive Services Task Force and American Heart Association recommend one-time screening for males aged 65 to 75 who have ever smoked. Other learned authorities recommend screening between ages 65 and 75 if they have a first-degree relative who required repair of an AAA

Question 390

A 40-year-old African American patient has blood pressure readings of 175/100 mmHg and 170/102 mmHg. What is a reasonable plan of care for this patient today? a. Start 12.5 mg hydrochlorothiazide daily (usual dose 12.5-50 mg daily). b. Start 10 mg lisinopril daily (usual dose is 10-40 mg daily). c. Initiate 5 mg amlodipine daily (usual dose is 5-10 mg daily). d. Initiate 5 mg amlodipine and 10 mg lisinopril daily.

Answer 390

c. Initiate 5 mg amlodipine daily (usual dose is 5-10 mg daily). This patient's blood pressure goal is< 140/90 rmmHg according to JNC8. Since he is African American, two drug classes should be considered initially, a thiazide diuretic or a calcium channel blocker. Since a thiazide diuretic is a mild antihypertensive agent and the average systolic decrease is 2-8 points, amlodipine is a better choice because it will provide a greater decrease in blood pressure and a better chance at reaching his goal blood pressure.

Question 391

The usual clinical course of mitral valve prolapse: a. is benign. b. results in sudden cardiac death. c. results in chronic heart failure. d. is associated with multiple episodes of emboli.

Answer 391

a. is benign. The usual course of mitral valve prolapse (MVP) is benign, and most patients who have MVP are asymptomatic. A murmur may be present and is best auscultated with the diaphragm of the stethoscope over the cardiac apex. In a minority of patients, symptoms of heart failure or sudden death may occur. When heart failure results, it is usually a result of mitral regurgitation. Embolization may occur, but this is not common or usual in the majority of patients.

Question 392

A 50-year-old patient with hypertension has taken hydrochlorothiazide 25 mg daily for the past 4 weeks. Her blood pressure has decreased from 155/95 mmHg to 145/90 mmHg. How should the nurse practitioner proceed? a. Wait 4 weeks before making a dosage change. b. Increase the hydrochlorothiazide to 50 mg daily. c. Add a drug from another class to the daily 25 mg hydrochlorothiazide. d. Stop the hydrochlorothiazide and start a drug from a different class.

Answer 392

c. Add a drug from another class to the daily 25 mg hydrochlorothiazide. The recommended target blood pressure, according to JNC 8, for this 50-year-old patient is < 140/90 mmHg. The current plan has not allowed this patient to meet this goal, so it is not acceptable to continue the current dose. Increasing the hydrochlorothiazide to 50 mg daily will not result in a decrease in blood pressure, only an increase in potassium loss. Adding a drug from a different medication class is a good choice because the combined effects of antihypertensive medications nearly always produce a decrease in blood pressure and both drugs can be maintained in low doses to minimize side effects.

Question 393

A patient who has mitral valve prolapse (MVP) reports chest pain and frequent arrhythmias. In the absence of other underlying cardiac anomalies, the drug of choice to treat her symptoms is: a. lisinopril. b. metoprolol. c. amlodipine. d. chlorthalidone.

Answer 393

b. metoprolol. Beta blockers like metoprolol are indicated to alleviate atrial or ventricular arrhythmias associated with mitral valve prolapse. However, long-term effectiveness of beta blockers is uncertain. Most patients with MVP who do not have symptoms of arrhythmias or ectopy at rest usually do not require further evaluation. However, they should be monitored at least annually for a change in their condition.

Question 394

Which hypertensive patient is most likely to have adverse blood pressure effects from excessive sodium consumption? a. 21-year-old Asian American male b. 35-year-old menstruating female c. 55-year-old postmenopausal female d. 70-year-old African American male

Answer 394

d. 70-year-old African American male Two groups of patients typically experience adverse blood pressure effects from consumption of sodium greater than 2,000 mg daily. Those patients considered to be most sodium sensitive are elderly patients and African American patients. Thus, choice d is the best choice listed

Question 395

Where would the murmur associated with mitral regurgitation best be auscultated? a. Aortic listening point b. Mitral listening point c. Pulmonic listening point d. Tricuspid listening point

Answer 395

B The mitral listening point is where the murmur associated with mitral regurgitation (MR) can be heard loudest. Murmurs tend to be loudest at the point where they originate. In this case, that is the mitral listening point. As the left ventricle enlarges secondary to MR, the apical impulse becomes displaced left and laterally and becomes diffuse.

Question 396

A patient with a positive history of a tick bite about 2 weeks ago and erythema migrans has a positive ELISA for Borrelia burgdorferi. The Western blot is positive. How should he be managed? a. He should receive doxycycline for Lyme disease. b. He should receive penicillin for Rocky Mountain spotted fever (RMSF). c. He does not have Lyme disease or RMSF. d. He needs additional testing to confirm Lyme disease.

Answer 396

a. He should receive doxycycline for Lyme disease. The first serologic test for Lyme disease is the ELISA. If this is positive, it should be confirmed. In this case, it was confirmed by a Western blot and it is positive. This patient can be diagnosed with Lyme disease. The appropriate treatment for erythema migrans is doxycycline, amoxicillin, or cefuroxime for 21 days. All three medications were found to be of equal efficacy.

Question 397

A patient has seborrheic dermatitis. Which vehicle would be most appropriate to use in the hairline area to treat this? a. Ointment b. Cream c. Powder d. Foam

Answer 397

d. Foam Seborrheic dermatitis affects the hairy areas of the body. In hairy areas of the body, foams are specifically used because they spread easily and are transparent. Lotions can be used in hairy areas because they provide a cooling, drying effect and are transparent. Lotions are the weakest of all vehicles. Creams and powders could be used, but patients prefer other vehicles and so adherence is less with these.

Question 398

A microscopic examination of the sample taken from a skin lesion indicates hyphae. What type of infection might this indicate? a. Bacterial b. Viral c. Parasitic d. Fungal

Answer 398

d. Fungal Under microscopic exam, hyphae are long, thin and branching and indicate dermatophytid infections. Hyphae are typical in tinea pedis, tinea cruris, and tinea corporis

Question 399

A patient has been diagnosed with MRSA. She is allergic to sulfa. Which medication could be used to treat her? a. Augmentin b. Trimethoprim-sulfamethoxazole (TMP/SMX) c. Ceftriaxone d. Doxycycline

Answer 399

d. Doxycycline MRSA is methicillin-resistant Staph aureus. This is very common in the community and is typically treated with sulfa medications like TMP/SMX (Bactrim DS and Septra DS). If the patient is allergic to sulfa, this should not be used. A narrow-spectrum antibiotic that can be used is doxycycline or minocycline. It is given twice daily and is generally well tolerated. MRSA is resistant to the antibiotics in the other choices and so they should NOT be used to treat it

Question 400

A 15-year-old male has worked this summer as a lifeguard at a local swimming pool. He complains of itching in the groin area. He is diagnosed with tinea cruris. The nurse practitioner is likely to identify: a. swelling of the scrotum. b. macular lesions on the penis. c. well marginated half-moon macules on the inner thigh. d. maceration of the scrotal folds with erythema of the penis.

Answer 400

c. well marginated half-moon macules on the inner thigh. Tinea cruris, "jock itch" is common during warm months and in humid areas. It is a fungal infection that affects the scrotum and inner thighs, but never affects the penis and is never evidenced by scrotal swelling. He is probably at increased risk because he is working as a lifeguard and may wear damp or wet swim trunks during work. He should be treated with a topical antifungal cream, advised to dry off after swimming, and to put on dry swim trunks.

Question 401

A patient exhibits petechiae on both lower legs but has no other complaints. How should the NP proceed? a. Refer to hematology b. Order a CBC c. Order blood cultures d. Stop aspirin and reassess in 1 week

Answer 401

b. Order a CBC The presence of petechiae on the lower legs (or anywhere on the body) should prompt the NP to consider a problem that is related to a low platelet count. A CBC should be checked to assess the platelet count and for any evidence of anemia from blood loss. If the platelet count is found to be low, referral to hematology should be done. Blood cultures are of no value in this patient, who is otherwise asymptomatic.

Question 402

A patient has been diagnosed with scabies. What is the medication of choice to treat this? a. Permethrin b. Coal tar c. Ketoconazole d. Mupirocin

Answer 402

a. Permethrin Scabies is eradicated by using permethrin and good hygiene. All household and personal contacts must be treated simultaneously, and meticulous care must be exercised to prevent transmission by cross contamination. All clothing, stuffed animals, linens, mattresses, and cloth furniture must be treated to prevent further transmission.

Question 403

A patient has been in the sun for the past few weeks and has developed darkened skin and numerous 3-6 mm light-colored, flat lesions on his trunk. What is the likely etiology? a. Tinea corporis b. Tinea unguium c. Tinea versicolor d. Human papillomavirus

Answer 403

c. Tinea versicolor Tinea versicolor is typically visualized during the spring and summer months when a patient has become darkened after sun exposure. The areas that are infected do not tan and so become very noticeable. The chest and back are common areas to observe tinea versicolor. There can be 100 or more in some infections. This can be treated with topical selenium sulfide or an oral antifungal agent.

Question 404

Which vehicle is least appropriate in a patient who has atopic dermatitis? a. Lotions b. Creams c. Thick creams d. Ointments

Answer 404

a. Lotions Patients who have atopic dermatitis need continuous skin hydration. Lotions can worsen xerosis (dry skin) due to evaporation of water on the skin. In contrast to creams and ointments, lotions have a high-water content and a low oil content. Creams have a lower water content. Ointments have no water and are excellent agents to use on dry skin as well as to prevent dry skin.

Question 405

A patient presents with small vesicles on the lateral edges of his fingers and intense itching. On close inspection, there are small vesicles on the palmar surface of the hand. What is this called? a. Seborrheic dermatitis b. Dyshidrotic dermatitis c. Herpes zoster d. Varicella zoster

Answer 405

b. Dyshidrotic dermatitis This dermatitis is intensely pruritic and involves the palms and soles and lateral aspects of the fingers. Over a couple of weeks, the vesicles desquamate. Recurrences are common. Seborrheic dermatitis affects only hairy areas of the body. The vesicles might raise suspicion of a viral infection, but this is not present in this case.

Question 406

A low-potency topical hydrocortisone cream would be most appropriate in a patient who has been diagnosed with: a. psoriasis. b. impetigo. c. cellulitis. d. atopic dermatitis.

Answer 406

d. atopic dermatitis. Low-potency steroid creams are almost never potent enough to treat psoriasis. Psoriasis requires higher-potency steroid preparation or systemic agents. Impetigo is a superficial bacterial infection, and a steroid cream would be contraindicated. Cellulitis is an infection of the subcutaneous layer of the skin and requires an oral or systemic antibiotic. Atopic dermatitis is a chronic inflammatory disorder of the skin that involves a genetic defect in the proteins supporting the epidermal layer. A patient with atopic dermatitis would be the most appropriate (of those listed above) to use a low-potency topical steroid cream

Question 407

The most common form of skin cancer is: a. squamous cell carcinoma. b. basal cell carcinoma. c. malignant melanoma. d. cutaneous carcinoma.

Answer 407

b. basal cell carcinoma. Skin cancers are divided into two major groups: nonmelanoma and melanoma skin cancer. Basal cell carcinoma is considered nonmelanoma skin cancer and is the most common form of skin cancer in the US. It is most common in 40- to 60-year-olds, but can occur at any age if the skin is regularly exposed to sunlight or ultraviolet radiation. Basal cell carcinoma grows slowly, and if not treated it can spread to surrounding areas of tissue or bone.

Question 408

Which of the following areas of the body has the greatest percutaneous absorption? a. Sole of the foot b. Scalp c. Forehead d. Genitalia

Answer 408

d. Genitalia Genitalia have the highest percutaneous absorption across the entire body. This is important because low-potency creams will act with greater potency in this area. Low-potency creams/lotions should be used initially for treating skin conditions involving the genitalia. The sole of the foot has the lowest percutaneous absorption, followed by the scalp, forehead, and genitalia. Therefore, the sole of the foot will require more potent vehicles to enhance absorption.

Question 409

The most common place for basal cell carcinoma to be found is the: a. scalp. b. face. c. ear. d. anterior shin

Answer 409

b. face. The most common presentation of basal cell carcinoma (BCC) is on the face. This is probably because BCC occurs secondary to sun damage. The most common sun exposure occurs on the face. In fact, 70% of BCC occurs on the face; 15% occurs on the trunk.

Question 410

A 74-year-old woman is diagnosed with shingles. The NP is deciding how to best manage her care. What should be prescribed? a. An oral antiviral agent b. An oral antiviral agent plus an oral steroid c. An oral antiviral agent plus a topical steroid d. A topical steroid only

Answer 410

a. An oral antiviral agent An oral antiviral agent such as acyclovir, famciclovir or valacyclovir should be prescribed, especially if it can be initiated within 72 hours after the onset of symptoms. The addition of oral corticosteroids to oral antiviral therapy demonstrates only modest benefit Adverse events to therapy are more commonly reported in patients receiving oral corticosteroids. There is no evidence that corticosteroid therapy decreases the incidence or duration of postherpetic neuralgia or improved quality of life. Corticosteroids should be limited to use in patients with acute neuritis who have not derived benefit from opioid analgesics

Question 411

The American Cancer Society uses an ABCDE mnemonic to help patients develop awareness of suspicious skin lesions. What does the "B" represent? a. Bleeding b. Black c. Border d. Benign

Answer 411

c. Border The mnemonic is helpful when looking at skin lesions, but it is primarily used for patient education. The "A" represents asymmetry (asymmetrical lesions are worrisome), "B" is border (irregular borders), "C" is color (colored lesions have more melanin and may be associated with malignant melanoma), "D" is diameter (larger than a pencil eraser [6 mm] is concerning), and "E" represents enlarging or elevated (lesions that are actively enlarging are growing; elevated lesions are concerning).

Question 412

What finding is most characteristic of shingles? a. Pain, burning, and itching b. Single dermatome affected c. Presence of grouped vesicles d. Presence of rash and crusting

Answer 412

b. Single dermatome affected Shingles is herpes zoster. It characteristically affects a single dermatome. Grouped vesicles on an erythematous base may occur in some patients with shingles, but this is not unique to shingles. In fact, it is typical in many viral infections. Crusting may be seen with shingles, chicken pox, or impetigo. Pain, burning, and itching are symptoms that some patients have with shingles, but not all patients report itching with shingles.

Question 413

An example of a premalignant lesion that develops on sun-damaged skin is: a. actinic keratosis. b. basal cell carcinoma. c. squamous cell carcinoma. d. molluscum contagiosum.

Answer 413

a. actinic keratosis. Actinic keratoses (AK) are a result of solar damage to the skin. They are most common on the face, bald scalp, and forearms. Patients who present with AK usually have multiple of them. A characteristic that helps identification of AK is an area of erythema that surrounds the lesion. AK is sometimes easier felt than seen.

Question 414

A 76-year-old obese patient has fatigue, thirst, and frequent urination. She was asked to measure AM fasting glucose values for 1 week. The values range from 142-175 mg/dL. This patient: a. can be diagnosed with Type 2 diabetes. b. has impaired fasting glucose. c. should have an Hgb AlC performed for diagnosis. d. has prediabetes.

Answer 414

a. can be diagnosed with Type 2 diabetes. Fasting glucose values that equal or exceed 126 mg/dL on different days constitute a diagnosis of Type 2 diabetes. Therefore, an Al C is not needed for diagnosis but may be ordered to establish a baseline for this patient. Impaired fasting glucose can be diagnosed when two fasting glucose values are between 100 mg/dL and 125 mg/dL on different days.

Question 415

The most appropriate time to begin screening for renal nephropathy in a patient with Type 2 diabetes is: a. at diagnosis. b. 1 year after diagnosis. c. 2-3 years after diagnosis. d. 5 years after diagnosis.

Answer 415

a. at diagnosis. Nephropathy develops in about 20-40% of patients with diabetes. Patients with Type 2 diabetes should be screened for renal nephropathy at the time of diagnosis. Screening for albuminuria is most easily accomplished by performing a random urine collection. Albuminuria may be considered if 2 of 3 specimens of urinary albumin-to-creatinine ratio (UACR) collected within 3-6 months are abnormal. Normal UACR is less than 30 mg/gm Cr

Question 416

In order to determine how much T4 replacement a patient needs to reestablish a euthyroid state, the nurse practitioner considers: a. the TSH value. b. the patient's T4. c. the patient's body weight. d. the patient's gender

Answer 416

c. the patient's body weight. Replacement is based on body weight and is usually calculated in kilograms. The patient's weight is calculated in kilograms and multiplied by 1.6 to determine the replacement needed in one day. This is the amount that should be prescribed provided the patient is otherwise healthy, is less than 50 years old, and has no evidence of underlying cardiac disease.

Question 417

A patient has been diagnosed today with Type 2 diabetes. A criterion for diagnosis is: a. an abnormal random blood glucose. b. proteinuria. c. a fasting glucose > or equal to 126 and confirmed on a previous day. d. an abnormal postprandial glucose.

Answer 417

c. a fasting glucose > or equal to 126 and confirmed on a previous day. Type 2 diabetes is diagnosed after a random fasting glucose greater than or equal to 126 mg/dL and confirmed on a subsequent day. Other diagnostic criteria include a random blood glucose > 200 mg/dL with polyuria, polydipsia, or polyphagia; or an Al C greater than or equal to 6.5% (and confirmed on a subsequent day). A glucose tolerance test may also be used for diagnosis, but this is usually reserved for pregnant women.

Question 418

The most appropriate screen for diabetic nephropathy is: a. creatinine clearance and eGFR. b. urinary albumin to creatinine ratio and eGFR. c. Micro alburninuria. d. serum creatinine.

Answer 418

b. urinary albumin to creatinine ratio and eGFR. 2017 American Diabetes Association (ADA) recommends urinary albumin-to-creatinine ratio and an estimated GFR (eGFR) at least once a year in all patients who have Type 2 diabetes. It is an appropriate screen for undiagnosed diabetic nephropathy. Previously, microalbuminuria was the standard of care.

Question 419

A 38-year-old male patient presents for his annual exam. He reports nervousness and weight loss, but denies any change in his dietary intake or exercise level. Based on these findings and the following lab values, what is his most likely diagnosis? TSH: 0.01 mlU/L Normal values: 0.4-3.8 mlU/L Free T4: 6 ne/dL Normal values: 0.8-2.8 ne/dL Free T3: 205 n2/dL Normal values: 70-205 ne/dL a. Hypothyroidism b. Hyperthyroidism c. Subclinical hyperthyroidism d. Subclinical hypothyroidism

Answer 419

b. Hyperthyroidism Hyperthyroidism is commonly diagnosed in men ages mid 20-40 years of age. A decreased TSH level and elevated levels of T4 and/or T3 are characteristic of hyperthyroidism. Nervousness, weight loss incongruent with daily dietary intake and exercise level, palpitations, and tremor are common findings in younger patients diagnosed with hyperthyroidism. More severe cardiovascular symptoms such as atrial fibrillation, are the most common findings in older adults (>60 years of age) who have hyperthyroidism. While the TSH level is also decreased in subclinical hyperthyroidism, the T4 and/or T3 levels remain normal. A low TSH is not consistent with a diagnosis of hypothyroidism.

Question 420

A patient has two fasting glucose values (121 mg/dL and 136 mg/dL) that were measured on 2 separate days in the same week. This patient: a. has normal blood glucose values. b. has impaired fasting glucose. c. has Type 2 diabetes mellitus. d. should have an Hgb AlC performed.

Answer 420

d. should have an Hgb AlC performed. This patient has elevated glucose readings. One reading indicates impaired fasting glucose (100-125 mg/dL) and the other reading indicates possible Type 2 diabetes (> or equal to 126 mg/dL). Further testing should be done to confirm a diagnosis. Hemoglobin AlC is a good choice to help confirm the diagnosis. AlC > or equal to 6.5% would confirm a diagnosis of Type 2 diabetes. AlC 5.7-6.4 percent helps confirm impaired fasting glucose.

Question 421

A diabetic patient with albuminuria has been placed on an ACE inhibitor. How soon can the antiproteinuric effect of the ACE inhibitor be realized in this patient? a. 6-8 weeks b. 3 months c. 6 months d. 3-5 years

Answer 421

a. 6-8 weeks The effect can be realized as early as 6-8 weeks after starting an ACE inhibitor or ARB. Monitor the patient's serum creatinine and potassium levels with dose changes because both can increase to unacceptable levels when drugs affecting the renin-angiotensin-aldosterone system are used.

Question 422

Hyperthyroidism may affect the blood pressure: a. by producing an increase in systolic and diastolic readings. b. by producing a decrease in diastolic blood pressure. c. when the heart rate is increased. d. with unpredictable results

Answer 422

a. by producing an increase in systolic and diastolic readings. A common effect of hyperthyroidism on blood pressure is an increase in both systolic and diastolic readings over the patient's usual readings. In fact, hyperthyroidism is a common endocrine cause of secondary hypertension. Other endocrine causes of secondary hypertension are pheochromocytoma, Cushing's syndrome, and neuroblastoma. It is common to measure a resting heart rate of greater than 100 bpm in patients who have untreated hyperthyroidism.

Question 423

Mr. Smith, an overweight 48-year-old male with undiagnosed Type 2 diabetes mellitus, presents to your clinic. Which symptom is least likely associated with Type 2 diabetes mellitus? a. Fatigue b. Constipation c. Athlete's foot d. Impetigo

Answer 423

b. Constipation Fatigue is a common early symptom of diabetes. Athlete's foot could represent peripheral fungal infections related to sustained elevations in glucose. Impetigo, though not common in adults, could represent a superficial bacterial infection related to elevated glucose levels. Constipation could be due to many factors, but not specifically diabetes. Conversely, the three factors most closely associated with diabetes are fatigue and infections

Question 424

``` A 55-year-old female patient with diabetes has the following fasting lipid values and HgbAlC. What is the relationship between Hgb AlC and this patient's lipid values? LDL Cholesterol: 120 mg/dL HDL Cholesterol: 45 mg/dL Total Cholesterol: 200 mg/dL Triglycerides: 309 mg/dL Hgb A1c: 9.2% ``` a. There is no specific relationship. b. Elevated LDLs will increase as Hgb AlC increases. c. As Hgb AlC decreases, triglycerides decrease. d. Hgb AIC will decrease as HDL values increase.

Answer 424

c. As Hgb AlC decreases, triglycerides decrease. Two factors known to contribute to elevated triglyceride levels are elevated glucose values and excessive alcohol consumption. Diabetic patients with elevated triglyceride levels and elevated Hgb Al C levels can usually expect to have improved triglyceride levels as Hgb Al C levels begin to normalize.

Question 425

When the serum free T4 concentration falls: a. the TSH falls. b. the TSH rises. c. there is no relationship between T4 and TSH. d. T3 falls.

Answer 425

b. the TSH rises. As a patient's T4 concentration falls (although still within normal range), the anterior lobe of the pituitary gland responds by secreting TSH. TSH stimulates the thyroid gland to increase T4 secretion. In this manner, T4 concentrations remain within a normal range and help maintain a euthyroid state in the patient.

Question 426

What is the earliest detectable glycemic abnormality in a patient with Type 2 diabetes? a. Postprandial glucose elevation b. Nighttime hyperglycemia c. Fasting glucose elevation d. Abnormal Hgb AlC

Answer 426

a. Postprandial glucose elevation The earliest glycemic abnormality is postprandial glucose elevation. Early in the pathogenesis of diabetes, glucose levels increase to abnormal levels after eating. Over the next few hours, if the patient does not eat, the glucose levels will fall to a normal range again, via many different physiologic mechanisms. This may occur for months or years before glucose levels become consistently elevated and are not able to return to normal despite long periods of fasting. Once glucose levels are elevated and remain elevated, patients usually experience symptoms such as fatigue, thirst, frequent urination, and hunger.

Question 427

Mr. Jones, a patient with Type 2 diabetes, brings his obese 15-year-old son in to see the nurse practitioner. You examine the 15-year-old son and identify acanthosis nigricans. This probably indicates: a. undiagnosed diabetes. b. insulin resistance. c. familial skin changes. d. poor hygiene.

Answer 427

b. insulin resistance. Acanthosis nigricans (AN) has been associated with insulin resistance. While the majority of cases are benign and associated with obesity, AN is also associated with certain GI tumors (unlikely in a 15 y/o). However, in a 15-year-old this is particularly important since AN in children and adolescents is often a predictor of development of type 2 diabetes. It is also associated with type 2 diabetes in adults. AN is prevalent on the flexor surfaces of the axillae and neck. The lesions are slightly elevated and have a velvety appearance.

Question 428

A female patient has the following characteristics. Which one represents a risk factor for Type 2 diabetes? a. LDL < than 160 mg/dL b. History of gestational diabetes c. BMI of 22 d. Family history of Type 1 diabetes

Answer 428

b. History of gestational diabetes History of gestational diabetes is associated with an 83% chance of developing Type 2 diabetes (within 17 years of delivery). A family history of Type 2 diabetes, HDL less than 35 mg/dL, as well as a BMI of greater than or equal to 25, significantly increase the risk of developing diabetes. Sedentary lifestyle promotes weight gain and thus increases a person's risk for Type 2 diabetes.

Question 429

``` A 45-year-old patient who has hypothyroidism takes levothyroxine. Based on the following lab results, how should the nurse practitioner proceed? TSH :32.7 mlU/L (0.4-3.8 mlU/L) Free T4: 0.09 ng/dL (0.8-2.8 ng/dL) Total Cholesterol: 260 mg/dL LDL Cholesterol: 190 mg/dL HDL Cholesterol: 37 mg/dL Triglycerides: 140 mg/dL ``` a. Begin statin therapy. b. Adjust levothyroxine dose. c. Encourage diet modifications. d. Encourage lifestyle modifications.

Answer 429

b. Adjust levothyroxine dose. Dyslipidemia is a common finding when TSH values exceed 10 mIU/L. In patients who have hypothyroidism, there is decreased catabolism of LDL, primarily due to a reduction of cell surface receptors for LDL. This causes an accumulation of LDL cholesterol. The NP should first treat the TSH to 10 mlU/L or less. Lipids should be treated if they remain elevated after TSH < 10 mIU/L.

Question 430

A 40-year-old patient with newly diagnosed Type 2 diabetes asks what his target blood pressure should be. The most correct response in mm Hg is: a. about 130/90. b. in the low 140s over the 90s. c. less than 140/90. d. the systolic should be in the 120s-130s

Answer 430

c. less than 140/90. The 2017 American Diabetes Association's target blood pressure for "most patients with diabetes and hypertension" is less than 140/90 mmHg. Less than 140/90 means that the systolic blood pressure should be in the 130s at the highest and the diastolic blood pressure should be in the 80s at the highest. Lower blood pressure targets such as 130/80 mmHg may be appropriate for patients at high risk for cardiovascular disease if they can be easily achieved (Level C).

Question 431

A patient presents with the following lab values. What is the diagnosis? TSH = 14 mlU/L (0.4-3.8 mlU/L) Free T4 = 0.1 ng/dL (0.8-2.8 ng/dL) a. Hypothyroidism b. Hyperthyroidism c. Subclinical hypothyroidism d. Subclinical hyperthyroidism

Answer 431

a. Hypothyroidism Primary hypothyroidism can be diagnosed in the presence of an elevated thyroid-stimulating hormone (TSH) and a low serum-free thyroxine (T4). TSH is also elevated in subclinical hypothyroidism, but free T4 remains normal. The TSH is decreased in patients who have hyperthyroidism. The CBC and ESR results are within normal limits.

Question 432

Which medication used to treat diabetes is associated with diarrhea and flatulence? a. Pioglitazone b. Insulin c. Metformin d. Glimepiride

Answer 432

c. Metformin Metformin is associated with these symptoms---especially in the first 2 weeks of use. These symptoms can also be seen with increases in the dose of metformin. The other medications listed do not produce lower gastrointestinal symptoms. If the medication can be continued for a couple of weeks, generally, GI symptoms will resolve. Metformin is known to decrease morbidity and mortality associated with diabetes.

Question 433

A 45-year-old female patient has fatigue for the past 3 months and a 10-pound weight gain. She previously had regular menses occurring about every 30 days, but in the last 3 months her menses has varied between 30 and 45 days. Her TSH value is 13 mlU/L (Normal values: 0.4-3.8 mlU/L). It was repeated 1 week later and found to be 15 mlU/L. What explains this finding? a. Subclinical hypothyroidism b. Hypothyroidism c. Transient hypothyroidism d. Perimenopause

Answer 433

b. Hypothyroidism This patient has hypothyroidism because her TSH exceeds 5 mU/L. Common symptoms associated with hypothyroidism include fatigue, weight gain, dry skin, cold intolerance, constipation, menstrual irregularities, and hair and nails that break easily. The diagnosis should be easily realized since the TSH is elevated on two occasions

Question 434

A patient who is taking long-acting insulin basal insulin has elevated blood sugars. Which blood sugars are important to review in order to increase the dose of insulin? a. AM fasting b. 2-hour postprandial c. Preprandial d. Bedtime

Answer 434

a. AM fasting Long-acting insulin mimics the amount of insulin the pancreas produces at a steady rate throughout the day and night. Adjustments in doses of long-acting insulin are typically based on the AM fasting glucose values. The other blood sugars reflect blood sugars in relation to meals.

Question 435

A patient has a TSH value of 13.1 today. The nurse practitioner has decided to initiate replacement with levothyroxine 88 mcg daily. When should the NP recheck the patient's TSH level? a. 2 weeks b. 4 weeks c. 6 weeks d. 8 weeks

Answer 435

c. 6 weeks Oral thyroid hormone replacement therapy is intended to restore a euthyroid state, thereby reversing manifestations of hypothyroidism. Although symptoms can begin to improve within 2-3 weeks of initiation of replacement therapy, steady TSH concentrations are not achieved for at least 6 weeks. The TSH should be measured after the patient has been taking levothyroxine for 6 weeks. TSH can then be monitored annually unless the patient is symptomatic.

Question 436

A patient presents with consistently elevated blood glucose before his evening meal. What choice below represents an insulin change that would improve his evening glucose? Current AM regimen: 22u NPH, 12u short-acting insulin Current PM regimen: 10u NPH, 5u short-acting insulin a. 24u NPH insulin in AM b. 14u short-acting insulin in AM c. 12u NPH insulin in PM d. 10u NPH insulin in PM

Answer 436

a. 24u NPH insulin in AM This patient's blood sugar is consistently elevated before the evening meal. This indicates that he needs more AM NPH (intermediate-acting) insulin on board. A prudent increase in insulin dose involves 2 or 3-unit increases at a time. He is taking 22 units of NPH in the AM. His dose should be increased to 24 or 25 units in the AM, followed by blood sugar checks for 3 days after the insulin change (blood sugar checks before dinner). If he is not at goal, the AM NPH insulin can be increased by an additional 2-3 units until blood sugars are at goal, or the patient becomes symptomatic with low blood glucose values.

Question 437

A 30-year-old female patient who complains of fatigue undergoes a screening TSH. Her TSH is 8 mlU/L (Normal values: 0.4-3.8 mlU/L). What should be done next? a. Begin thyroid supplementation. b. Repeat the TSH and add T4. c. Begin supplementation and repeat the TSH in 4-6 weeks. d. Measure the T4 and consider repeating the test in a month.

Answer 437

b. Repeat the TSH and add T4. TSH values rise and fall continuously. Consequently, TSH levels are repeated and an average is usually calculated. A diagnosis of hypothyroidism can be made after a second abnormal TSH unless the initial value is very elevated and the patient is symptomatic. When an elevated TSH is discovered, it should be repeated and a serum-free T4 can be measured. Depending on these results, a diagnosis of thyroid disease can be made.

Question 438

A 65-year-old diabetic has been on oral antihyperglycemic agents and is still having poor glycemic control. His AM fasting glucoses range from 140-160 mg/dL. You decide to add insulin. He weighs 127 kilograms. What should the NP order as an initial starting dose? a. 10 units long-acting insulin at bedtime b. 30 units long-acting before breakfast c. 5 units intermediate insulin at bedtime d. 20 units short-acting insulin at breakfast

Answer 438

a. 10 units long-acting insulin at bedtime ``` According to the American Diabetes Association (ADA) consensus algorithm for initiation and adjustment of insulin therapy (ADA, 2017), an intermediate or long-acting insulin should be started at bedtime or morning as a once-daily dosage. A prudent starting dose is 10 units insulin or 0.1-0.2 units per kilogram (approximately 13-25 units of insulin for this patient) ```

Question 439

The nurse practitioner performs a fundoscopic exam on a patient who has recently been diagnosed with hypertension. What is the significance of AV nicking? a. This is indicative of retinal detachment. b. This is indicative of longstanding hypertension. c. The patient should be screened for diabetes. d. This is a variant of normal.

Answer 439

b. This is indicative of longstanding hypertension. AV (arteriovenous) nicking can be observed as arteries cross veins when the arteries have narrowed secondary to hypertension. Generally, AV nicking takes time to develop and would be expected in patients with longstanding hypertension; especially when it is poorly controlled. Normally, veins are larger than arteries in the eyes. The vessels in the eyes are particularly susceptible to increased blood pressure. In severe hypertension, the retina can become detached.

Question 440

Mr. O has been diagnosed with hearing loss secondary to exposure to an ototoxic medication. Which one may be associated with ototoxicity? a. Digoxin b. Aspirin c. Ramipril d. Metoprolol

Answer 440

b. Aspirin Many medications are ototoxic in patients who are otherwise healthy. Some patients are at increased risk (for ototoxicity) when they consume ototoxic medications if they have impaired renal function. Renal impairment makes excretion of the ototoxic drug more difficult, and ototoxicity becomes more likely. Hearing loss secondary to use of the following medications should always be assessed: aspirin, aminoglycosides, vancomycin, erythromycin, loop diuretics (like furosemide), the antimalarial medications, sildenafil (tadalafil, vardenafil) and cisplatin. ACE inhibitors, digoxin, and beta blockers are not associated with ototoxicity.

Question 441

A 70-year-old male has a yellowish, triangular nodule near the iris. This is probably: a. a stye. b. a chalazion. c. a pinguecula. d. subconjunctival hemorrhage.

Answer 441

b. a chalazion. Pinguecula are common as patients age. They usually appear on the nasal side first and then on the temporal side. This is a completely benign finding. A stye is also called a hordeolum. It is a tender, painful infection of a gland at the eyelid margin. These are self-limiting. A chalazion is a nontender enlargement of a meibomian gland. A subconjunctival hemorrhage is a blood-red colored area on the sclera that does not affect vision. It occurs and resolves spontaneously.

Question 442

A 93-year-old demented adult has been recently treated for an upper respiratory infection (URI) but drainage from the right nostril persists. What should the NP suspect? a. Allergic rhinitis b. Presence of a foreign body c. Unresolved URI d. Dental caries

Answer 442

b. Presence of a foreign body Two clinical clues should make the examiner suspect a foreign body. First, the patient has continued drainage despite treatment. Second, the drainage is unilateral. Unilateral drainage from a nostril should prompt the examiner to visualize the turbinates. In this case, a foreign body could probably be visualized.

Question 443

A 70-year-old patient has begun to have hearing loss. She relates that her elderly parents had difficulty hearing. Which complaint below is typical of presbycusis? a. Inability to hear consonants b. Asymmetrical loss of hearing c. Inability to hear low-pitched sounds d. Pulsatile noise in the ear

Answer 443

a. Inability to hear consonants Presbycusis is age-related hearing loss. The significance of this patient's parental hearing loss is important for history. Presbycusis is influenced by genetics as well as noise exposure, medications, and infections. Loss of ability to hear speech in crowded rooms or noisy areas, inability to understand consonants, and loss of high-pitched sounds is typical. Hearing loss is symmetrical. Asymmetrical hearing loss is a red flag, regardless of the age at which it occurs. Tinnitus is common and is an annoying sensation associated with presbycusis. A pulsatile noise in the ear raises suspicion of a tumor or arteriovenous malformation.

Question 444

A patient presents with findings of pain, warmth, redness, and swelling below the inner canthus toward nose. Tearing is present and when pressure is applied to the lacrimal sac, a purulent discharge from the puncta is noted. This is suggestive of: a. blepharitis. b. dacryocystitis. c. a hordeolum. d. a chalazion.

Answer 444

b. dacryocystitis. Dacryocystitis is infection and blockage of the lacrimal sac and duct. Symptoms include pain, warmth, redness, and swelling below the inner canthus toward nose. Tearing is present and when pressure is applied to the lacrimal sac, a purulent discharge from the puncta is noted. Red, scaly, greasy flakes and thickened, crusted lid margins are consistent with blepharitis. Symptoms include burning, itching, tearing, foreign body sensation, and some pain. Hordeolum is a localized staphylococcal infection of the hair follicles at the lid margin. A beady nodule protruding on the lid, chalazion is an infection or retention cyst of a meibomian gland and if infected, it points inside and not on lid margin

Question 445

A 58-year-old farmer presents with a wedge-shaped, pinkish, clear growth on the nasal side of his eye. He states that it has been present for a while, but only recently began to feel as if a foreign body was in his eye. This is probably a: a. stye. b. pinguecula. c. xanthelasma. d. pterygium.

Answer 445

d. pterygium. Pterygia can occur in children, but it is more prevalent in older adults and is associated with chronic sun exposure. It is a benign growth of fibrovascular conjunctival tissue that usually appears on the nasal side first and extends laterally toward the iris. Although it is often initially asymptomatic, it can cause irritation and even visual impairment as it extends onto the cornea toward the pupil. A stye or hordeolum is a painful, self-limiting infection of a gland at the eyelid margin. Xanthelasma are typically associated with hyperlipidemia and appear as soft, yellow plaques on the medial aspect of the eyelids. A pinguecula is a benign, yellow, triangular nodule that does not affect vision.

Question 446

A patient presents with severe toothache. She reports sensitivity to heat and cold. There is visible pus around the painful area. What is this termed? a. Pulpitis b. Caries c. Gingivitis d. Periodontitis

Answer 446

a. Pulpitis The predominant symptom of patients who exhibit pulpitis is pain especially elicited by thermal changes, cold and hot. The pain can become severe and patients are ill appearing. Pus may be seen around the gum area or may be restricted to the pulp cavity. Caries and gingivitis do not produce pus. Periodontitis is characterized by gingival inflammation and pain. Pus is not present in this disease. A periodontal abscess produces pain and pus, but the pus is usually only expressed after probing.

Question 447

Acute otitis media can be diagnosed by identifying which otic characteristic(s)? a. Decreased mobility of the tympanic membrane (TM) b. Cloudy, bulging TM with impaired mobility c. Opacity and erythema of the tympanic membrane d. Marked redness of the tympanic membrane

Answer 447

b. Cloudy, bulging TM with impaired mobility The best predictor of acute otitis media (AOM) is a cloudy, bulging tympanic membrane (TM) with impaired mobility. Decreased mobility of the TM can be a result of fluid behind the TM. This is known as a middle ear effusion (MEE). MEE is characterized by the presence of middle ear fluid (bubbles or an air fluid interface) or finding of TM abnormalities (opacity, impaired mobility, or color change). Redness of the TM alone does not constitute infection. The other finding that constitutes a diagnosis of AOM is the finding of acute, purulent otorrhea that is not due to otitis externa. This describes a ruptured TM from otitis media.

Question 448

A nurse practitioner performs a fundoscopic exam. He identifies small areas of dull, yellowish-white coloration in the retina. What might these be? a. Cotton wool spots b. Microaneurysms c. Hemorrhages d. Exudates

Answer 448

a. Cotton wool spots These are cotton wool spots. They are due to swelling of the surface layer of the retina. Swelling occurs because of impaired blood flow to the retina. The most common causes of cotton wool spots are diabetes and high blood pressure. A microaneurysm is the earliest manifestation of a diabetic retinopathy. These appear as small, round, dark red dots on the retinal surface. Exudates are an accumulation of lipid and protein. These are typically bright, reflective white or cream-colored lesions seen on the retina.

Question 449

A 39-year-old has a sudden onset of a painful right red eye. He reports sensitivity to light and the sensation of a foreign body, though his history for a foreign body is negative. He does not wear contact lenses. How should the NP manage this? a. Refer to ophthalmology. b. Treat for viral conjunctivitis. c. Treat for bacterial conjunctivitis. d. Observe for 24 hours if visual acuity is normal.

Answer 449

a. Refer to ophthalmology. While no clear diagnosis can be made from this scenario, there are several red flags. Collectively, the red flags necessitate referral to ophthalmology. First, the eye is red and painful. This patient is photophobic and has the sensation of a foreign body. There is no mention of eye discharge, but eye discharge with this scenario would cause the examiner to consider bacterial conjunctivitis or keratitis. The symptoms of photophobia and foreign body sensation are symptoms of an active corneal process. Glaucoma should also be considered in the differential. He should be referred to ophthalmology.

Question 450

A 70-year-old patient in good health has a large, white plaque on the oral mucosa of the inner cheek. There is no pain associated with this. What is a likely diagnosis? a. Cheilitis b. Aphthous ulcer c. Sjogren's syndrome d. Leukoplakia

Answer 450

d. Leukoplakia The etiology of this white plaque is unclear from the given information, but it cannot be cheilitis. This affects the lips. It cannot be an aphthous ulcer, because this is painful. Sjogren's syndrome does involve the mucous membranes but manifests itself as dry mouth, not a plaque or lesion. The differential diagnosis for a white oral plaque should include oral leukoplakia, a premalignant lesion. This is often related to human papillomavirus. Risk factors include smokeless tobacco. Others in the differential include oral hairy leukoplakia (seen almost exclusively in patients with HIV), squamous cell carcinoma, and malignant melanoma. It may also be a completely benign growth, but this can only be established after biopsy.

Question 451

A 17-year-old has a complaint of ear pain. If he has otitis externa, which complaint is most likely? a. Tragal pain b. Difficulty hearing the TV c. Fever d. Concurrent upper respiratory infection

Answer 451

a. Tragal pain A patient with otitis externa has swimmer's ear, an infection of the external canal. The classic complaint is tragal pain or even pinnae pain. When significant edema exists in the external canal, hearing may be impaired, but the most common complaint is tragal pain. Systemic complaints do not accompany swimmer's ear unless a second diagnosis is present simultaneously. Fever and upper respiratory infection are not likely

Question 452

Papilledema is noted in a patient with a headache. What is the importance of papilledema in this patient? a. It is not related to this patient's headache. b. It is an incidental finding in patients with migraines. c. It could be an important finding in this patient. d. This is a common finding in patients with headaches.

Answer 452

c. It could be an important finding in this patient. Papilledema represents swelling of the optic nerve head and disc secondary to increased intracranial pressure (ICP). It is not a common finding in patients with headaches, only those with headache secondary to ICP. The pressure disrupts fluid flow within the nerve and swelling results. The cardinal symptom of ICP is a headache; papilledema is a secondary finding.

Question 453

A patient presents to a nurse practitioner clinic with paroxysmal sneezing, clear rhinorrhea, nasal congestion, and facial pain. Which symptom below is NOT associated with allergic rhinitis? a. Sneezing b. Rhinorrhea c. Nasal congestion d. Facial pain

Answer 453

d. Facial pain Facial pain is not associated with allergic rhinitis. In conjunction with nasal congestion, it is most likely a sinus infection. Patients with allergic rhinitis and nasal congestion are more likely to develop acute and chronic bacterial sinusitis because untreated allergic rhinitis results in impaired mucus flow. This increases the risk of infection. Symptoms of bacterial sinusitis include nasal congestion, purulent postnasal drip or rhinorrhea, facial pain and maxillary tooth pain. Bacterial sinusitis may be suspected if symptoms have been present for more than 10 days, however, no symptom can differentiate bacterial from viral sinusitis.

Question 454

Group A Strep pharyngitis: a. is characterized by a single symptom. b. can be accompanied by abdominal pain. c. usually does not have exudative symptoms. d. is commonly accompanied by an inflamed uvula.

Answer 454

b. can be accompanied by abdominal pain. Group A Streptococcus is usually characterized by multiple symptoms with an abrupt onset. Sore throat is usually accompanied by fever and headache. GI symptoms are common too; nausea, vomiting and abdominal pain are usual. Even without treatment, symptoms usually resolve in 3-5 days.

Question 455

A 12-year-old complains of itching in his right ear and pain when the pinna is pulled or the tragus is pushed. Examination revealed slight redness in the ear canal with a clear odorless fluid. This could be suggestive of: a. right otitis media. b. otitis externa. c. mastoiditis. d. a ruptured tympanic membrane.

Answer 455

b. otitis externa. Otitis externa, swimmer's ear, is an infection or inflammation of the external ear or the ear canal. Symptoms include itching in the ear with an increase in pain when the pinna is pulled or the tragus is pushed. Slight redness appears in the ear canal, along with a clear odorless fluid. Otitis media is a middle ear infection and usually the tympanic membrane is bulging with fluid or pus behind it. Mastoiditis is an infection of the mastoid process (temporal bone adjacent to the middle ear) and generally results from inadequately treated otitis media. A ruptured tympanic membrane occurs more often in children. The infection causes pus or fluid to build up behind the eardrum and as the pressure increases, the eardrum may rupture. Ear pain decreases when the membrane ruptures and the discharge can be pus, bloody, or clear.

Question 456

The patient presents with complaints of morning eyelash crusting and itchy red eyes. It began on the left and now has become bilateral. Based on the most likely diagnosis, what should the nurse practitioner tell the caregivers about this condition? a. It produces blurred vision in affected eye. b. This usually begins as a viral infection. c. Anterior cervical lymphadenopathy is common. d. Pain is normal in the affected eye.

Answer 456

b. This usually begins as a viral infection. This image is consistent with conjunctivitis. Conjunctivitis or "pink eye" usually begins as a viral infection. As the conjunctiva becomes irritated, the eye is rubbed and fingers introduce bacteria. A secondary bacterial infection develops. Conjunctivitis produces a red (or pink) eye, but should never produce blurred vision. A patient with a red eye and blurred vision should be referred to ophthalmology. The preauricular nodes may be palpable when a patient has conjunctivitis; the anterior cervical nodes will not be. Pain is not common in conjunctivitis, but usually occurs with acute closed angle glaucoma.

Question 457

The single most effective maintenance therapy for allergic rhinitis is: a. an antihistamine. b. a decongestant. c. a topical nasal steroid. d. a topical antihistamine.

Answer 457

c. a topical nasal steroid. Many studies have shown that topical nasal steroids like budesonide, fluticasone, and mometasone provide relief of nasal stuffiness, nasal discharge, sneezing, and postnasal drip that is superior to antihistamines. Decongestants treat symptoms associated with nasal stuffiness. Currently, topical nasal steroids are the treatment of choice for relief of symptoms associated with allergic rhinitis (AR). Antihistamines and decongestants can be added to the regimen of a patient with AR. Nasal decongestant sprays are not recommended as monotherapy in the management of chronic allergic rhinitis. Use greater than 3-7 days may lead to downregulation of the alpha-adrenergic receptor, resulting in rebound nasal congestion.

Question 458

A patient diagnosed with Strep throat received a prescription for azithromycin. She has not improved in 48 hours. What course of action is acceptable? a. The patient should wait another 24 hours for improvement. b. The antibiotic should be changed to a first-generation cephalosporin. c. A different macrolide antibiotic should be prescribed. d. A penicillin or cephalosporin with beta lactamase coverage should be considered.

Answer 458

d. A penicillin or cephalosporin with beta lactamase coverage should be considered. The patient should demonstrate improvement after 48 hours if an antibiotic with the appropriate antimicrobial spectra was prescribed. A macrolide would be a poor choice because there are high rates of Strep resistance to macrolide antibiotics. In light of this, strong consideration should be given to an antibiotic with different antimicrobial spectra. Since Strep was diagnosed and azithromycin was ineffective, the prescriber should consider that the causative agent has macrolide resistance and could be beta lactamase producing. An antibiotic with beta lactamase coverage should be considered. A penicillin or cephalosporin with beta lactamase provides this coverage.

Question 459

A 14-year-old was diagnosed and treated for left acute otitis media 4 weeks ago. She presents today for a follow-up visit. There is an effusion in the left ear. She denies complaints. How should this be managed? a. This should be monitored. b. She should be given another antibiotic. c. She should be evaluated with pneumatic otoscopy. d. She needs a tympanogram.

Answer 459

a. This should be monitored. About 40% of children have effusion 4 weeks after acute otitis media. This should be monitored and not treated with another antibiotic. Effusion is a stage in the resolution of otitis media. Pneumatic otoscopy will identify the presence of fluid or pus behind the TM, but it will not help in diagnosis or treatment once an effusion has been established. A tympanogram will establish that hearing is diminished, a fact that should be assumed since fluid is present in the middle ear.

Question 460

A 61-year-old male presents with a 12-hour history of an extremely painful left red eye. The patient complains of blurred vision, haloes around lights, and vomiting. It began yesterday evening. On examination, the eye is red, tender and inflamed. The cornea is hazy and pupil reacts poorly to light. The most likely diagnosis in this patient is: a. acute angle glaucoma. b. increased intracranial pressure. c. macular degeneration. d. detached retina.

Answer 460

a. acute angle glaucoma. The clinical presentation of a patient with acute angle glaucoma is as this patient has presented, age greater than 60 years, eye pain, and blurred vision. Nausea and vomiting are common. Pain is usually present when the intraocular pressure rises rapidly. This produces conjunctiva! redness. Symptoms are more common in the evening when light levels diminish and mydriasis occurs. In chronic angle closure, pressures rise slowly and pain is usually absent. Both can produce blindness.

Question 461

What symptom tetrad is most commonly associated with infectious mononucleosis? a. Fatigue, fever, lymphadenopathy, pharyngitis b. Fatigue, cough, fever, pharyngitis c. Body aches, fatigue, fever, splenomegaly d. Headache, fatigue, lymphadenopathy, tonsillar exudates

Answer 461

a. Fatigue, fever, lymphadenopathy, pharyngitis The tetrad includes fatigue, fever, pharyngitis, and lymphadenopathy (posterior cervical lymph nodes are most common). Approximately 50% of patients with mono have splenomegaly. Body aches are probably the effect of fever, but they do not characterize the disease. The etiologic agent of mononucleosisis the Epstein Barr virus. It is often spread by intimate contact between susceptible contacts. It is spread via saliva and has been called "the kissing disease."

Question 462

A 32-year-old patient is a newly diagnosed diabetic. She has developed a sinus infection. Her symptoms have persisted for 10 days. Six weeks ago, she was treated with amoxicillin for an upper respiratory infection. It cleared without incident. What should be recommended today? a. Prescribe amoxicillin again. b. Prescribe amoxicillin-clavulanate today. c. Do not prescribe an antibiotic; a decongestant only is indicated. d. Prescribe a decongestant and antihistamine

Answer 462

b. Prescribe amoxicillin-clavulanate today. Amoxicillin is not indicated when a beta lactamase-producing organism is suspected. It should be suspected because she took an antibiotic 6 weeks ago. Amoxicillin-clavulanate is a good choice because it covers beta lactamase producers. A bacterial cause can be assumed since she's had symptoms for 10 days. A viral infection likely would have run its course by now. This patient is diabetic and may be having blood sugar elevations that facilitate growth of the causative organism of the sinus infection. A decongestant could be added depending on her blood pressure and personal history of using decongestants.

Question 463

A 45-year-old patient describes a spinning sensation that has occurred intermittently for the past 24 hours. It is precipitated by position changes like rolling over in bed. During these episodes, he complains of intense nausea. Which choice best describes benign paroxysmal positional vertigo? a. Duration of symptoms < 3 days b. Sensation of spinning c. Symptoms precipitated by a position change d. Nausea and nystagmus

Answer 463

c. Symptoms precipitated by a position change Vertigo is a symptom, not a disease. It may have either a peripheral or central (brainstem or cerebellum) etiology. The most common form of peripheral vertigo is benign paroxysmal positional vertigo (BPPV). It is usually due to calcium debris in the ear's semicircular canals. Symptoms can be reproduced by a position change and are usually assessed using the Dix-Hallpike maneuver. It is characterized by the sensation of moving, having objects around the patient move, or a tilting/swaying sensation. Spinning sensation is a typical description of a patient with BPPV. During acute attacks of vertigo, regardless of the etiology, nausea, vomiting and nystagmus are common. Attacks can be transient and last for days to weeks.

Question 464

A 70-year-old female states that she sees objects better by looking at them with her peripheral vision. She is examined and found to have a loss of central vision, normal peripheral vision, and a normal lens. This best characterizes: a. glaucoma. b. cataracts. c. macular degeneration. d. detached retina.

Answer 464

c. macular degeneration. Macular degeneration presents most commonly with a loss of central vision. The macula is the central part of the retina. As it degenerates, central vision is lost. Questions should be asked about the rate of loss of vision. Reports of rapid vision loss require urgent ophthalmologic evaluation. Known risk factors are age greater than 50 years (greatest prevalence older than age 65), smoking, family history, and history of stroke, MI, or angina

Question 465

A patient has been diagnosed with acute rhinosinusitis. Symptoms began 3 days ago. Based on the most likely etiology, how should this patient be managed? a. Amoxicillin with clavulanate b. Decongestant and analgesic c. Azithromycin and decongestant d. Levofloxacin

Answer 465

b. Decongestant and analgesic The vast majority of patients who have acute rhinosinusitis have a viral infection. When bacteria are the causative agents, Streptococcus and Staphylococcus are common pathogens. Since the most likely pathogen is a virus, symptomatic treatment should occur unless a red flag such as fever, facial pain, purulent drainage, etc. is present. Typically, conservative measures should be used for 10 days prior to antibiotic use. In clinical practice, patients typically request antibiotics earlier than 10 days.

Question 466

What medication should always be avoided in patients with mononucleosis? a. Clindamycin b. Ibuprofen c. Amoxicillin d. Topical lidocaine

Answer 466

c. Amoxicillin A generalized rash may be seen in patients with mononucleosis (mono) who are given amoxicillin or ampicillin at the time of the acute phase of the illness. The rash does not represent an allergic reaction, but instead probably represents a reaction between the Epstein Barr virus and the penicillin molecule. The rash is usually described as maculopapular and may be pruritic. The rash has also been described with other beta-lactam antibiotics, azithromycin, cephalexin and levofloxacin

Question 467

A 43-year-old female patient reports a possible exposure to hepatitis C about 4 months ago. She has the following laboratory values. Which statement is true about this patient? HBsA2 Negative anti-HBc Negative anti-HBs Positive Anti-HCV Nonreactive HCVRNA Not detectable a. The patient has hepatitis B and hepatitis C. b. The patient does not have hepatitis C, but has immunity to hepatitis B. c. The patient does not have hepatitis B, but could have hepatitis C. d. More tests are needed to determine this patient's hepatitis B status.

Answer 467

b. The patient does not have hepatitis C, but has immunity to hepatitis B. This patient does not have hepatitis C (HCV) infection. An HCV antibody test (anti-HCV) is recommended as the initial screen for infection. However, development of detectable antibodies (anti-HCV) usually occurs between 2-6 months following exposure. Although it is negative, she was exposed less than 6 months ago and thus a confirmatory test (HCV RNA) is necessary. Since the HCV RNA is negative, she does not have hepatitis C. Typically, subsequent evaluation to detect the presence of HCV RNA is not necessary following a nonreactive anti-HCV result. Because exposure occurred less than 6 months ago, she may lack detectible levels of anti-HCV antibodies, which warrants testing for HCV RNA. HCV RNA levels become detectible before reactive antibodies. HCV RNA was not detected in this patient. This confirms that this patient has a true negative screen for infection with HCV. A positive hepatitis B surface antibody (anti-HBs) in the presence of a negative core antibody (anti-HBc) indicates immunity to hepatitis B from immunization

Question 468

An 83-year-old patient is diagnosed with diverticulitis. The most common complaint is: a. rectal bleeding. b. bloating and crampiness. c. left lower quadrant pain. d. frequent belching and flatulence.

Answer 468

c. left lower quadrant pain. Diverticular disease is more common in older adults. About 70% of patients diagnosed with diverticulitis have left lower quadrant pain. Rectal bleeding may have varied etiologies, such as rectal carcinoma or hemorrhoids. Bloating and cramping are often found in patients with diverticular disease (diverticulosis) but not specifically diverticulitis. Belching and flatulence are not specifically associated with diverticulosis

Question 469

A patient with a suspected inguinal hernia should be examined: a. in the prone position. b. standing. c. side-lying. d. with patient squatting.

Answer 469

b. standing. The patient should be examined while he is standing. He should be asked to bear down, cough, or strain during the exam. Though hernias are far more common in males, they can be found in females too. In males, the patient should be asked to stand. The examiner should put his 2nd or 3rd finger through the scrotum and into the external ring. When the patient is asked to cough, a "silky" feel will butt up against the examiner's finger, and the hernia can be easily felt.

Question 470

``` A 35-year-old patient has the following laboratory values. How should they be interpreted? HBsAg = Negative anti-HBc = Negative anti-HBs = Negative ``` a. The patient had hepatitis B. b. The patient has hepatitis B. c. The patient should consider hepatitis B immunization. d. The patient has had hepatitis B immunization.

Answer 470

c. The patient should consider hepatitis B immunization. This patient has a negative hepatitis B surface antigen (HBsAg). Therefore, he does not have hepatitis B. The patient has a negative hepatitis B core antibody (anti-HBc). Therefore, he has never had hepatitis B. The patient has a negative hepatitis B surface antibody (anti-HBs). Therefore, he is not considered immune, and immunization should be considered. There is a remote possibility that this patient has been immunized but did not produce hepatitis B surface antibodies. If this were the case, he should consider immunization once again

Question 471

An older patient presents with left lower quadrant pain. If diverticulitis is suspected, how should the NP proceed? a. Order a chest and abdominal X-ray b. CT scan of abdomen c. Barium enema d. Ultrasound of the abdomen

Answer 471

b. CT scan of abdomen CT scan of the abdomen is the diagnostic test of choice for this patient with suspected diverticulitis. The CT scan is able to demonstrate inflammatory changes in the colonic wall, colonic diverticula, thickening of the bowel wall, fistula formation, peritonitis, and other complications associated with diverticulitis. A chest and abdominal X-rays are commonly ordered and can help exclude other causes of abdominal pain, but they do not help diagnose diverticulitis. Barium enema would be contraindicated if there were a potential for perforation. Ultrasound is much less widely used than CT.

Question 472

A 56-year-old male patient has been diagnosed with an inguinal hernia. What symptom would make the nurse practitioner suspect an incarcerated hernia? a. Dilated scrotal veins b. Change in skin color c. Constipation d. Pain

Answer 472

d. Pain A hernia is a weakened area in the muscle where loop of bowel protrudes through the abdominal wall. Normally, hernias are not frankly painful, though they may be tender. A painful hernia should be suspected as one that has become incarcerated or strangulated. Incarceration means that the hernia cannot be reduced; it is trapped. A strangulated hernia means that it is incarcerated and ischemia is present. A strangulated hernia is a surgical emergency. Emergency surgery should be performed within 4-6 hours to prevent loss of bowel. Dilated scrotal veins should cause the examiner to consider varicocele.

Question 473

``` A patient has the following laboratory values. What does this mean? HBsA2 = Positive anti-HBc = Positive IgM anti-HBc = Positive anti-HBs = Negative ``` a. He has acute hepatitis B. b. He has immunity to hepatitis B. c. He has no immunity to hepatitis B. d. More data are needed.

Answer 473

a. He has acute hepatitis B A positive hepatitis B surface antigen and positive IgM means that this patient has acute hepatitis B. The first serologic marker to be positive is the surface antigen. It can become positive as soon as 3-4 weeks after exposure to hepatitis B. A positive IgM indicates acute infection.

Question 474

Which description is more typical of a patient with acute cholecystitis? a. The patient rolls from side to side on the exam table. b. The patient is ill-appearing and febrile. c. An elderly patient is more likely to exhibit Murphy's sign. d. Most are asymptomatic until a stone blocks the bile duct.

Answer 474

b. The patient is ill-appearing and febrile. Which description is more typical of a patient with acute cholecystitis? a. The patient rolls from side to side on the exam table. b. The patient is ill-appearing and febrile. c. An elderly patient is more likely to exhibit Murphy's sign. d. Most are asymptomatic until a stone blocks the bile duct.

Question 475

What choice below is most commonly associated with pancreatitis? a. Gallstones and alcohol abuse b. Hypertriglyceridemia and cholecystitis c. Appendicitis and renal stones d. Viral infection and cholecystitis

Answer 475

a. Gallstones and alcohol abuse In adults, the most common causes of acute pancreatitis are gallstones and alcohol abuse. Pancreatitis in women is more often due to gallstones; in men, due to alcohol abuse. Hypertriglyceridemia can precipitate pancreatitis, but a serum amylase measurement may be normal. This can be a difficult diagnosis to make. The other conditions listed are not associated with pancreatitis. However, viral infections of the pancreas can produce pancreatitis.

Question 476

Most patients who have acute hepatitis B infection: a. are females. b. are acutely ill. c. have varied clinical presentations. d. develop subsequent cirrhosis.

Answer 476

c. have varied clinical presentations. Most patients with hepatitis B (70%) have subclinical hepatitis. Development of cirrhosis is rare following hepatitis B infection unless other systemic factors are present, such as ethanol abuse, HN infection, hepatitis C infection, etc. There is no predilection for this disease by gender. When patients are symptomatic, they typically develop nausea, jaundice, and flu-like symptoms with fever, body aches, and fatigue.

Question 477

Which of the following would be usual in a patient with biliary colic? a. Presence of gallstones on imaging studies b. Presence of gallstones and unpredictable abdominal pain c. Positive Murphy's sign only d. Pain in upper abdomen in response to eating fatty foods

Answer 477

d. Pain in upper abdomen in response to eating fatty foods Biliary colic refers to discomfort produced by contraction of the gallbladder. This occurs in response to eating. Typically, pain occurs in the upper right quadrant or chest, peaks an hour after eating, and then remains constant and finally subsides over the next several hours. Biliary colic usually lasts at least 30 min, but less than 6 hours. An episode of acute cholecystitis usually lasts greater than 6 hours. A positive Murphy's sign is elicited when the gallbladder wall is inflamed. It can be elicited by palpating the gallbladder just beneath the liver as the patient takes a deep breath.

Question 478

A 70-year-old patient states that he had some bright red blood on the toilet tissue this morning after a bowel movement. He denies pain. What is the LEAST likely cause in this patient? a. Hemorrhoids b. Diverticulitis c. Colon cancer d. Anal fissure

Answer 478

d. Anal fissure Nearly 1 in 3 patients in this age group with acute lower gastrointestinal bleeding have bleeding secondary to diverticulitis. Nearly 1 in 5 have colorectal cancer or polyps, though, polyps usually do not bleed. Patients who have anal fissures often complain of a tearing pain during bowel movements. Regardless of the etiology, this patient needs referral for a colonoscopy to identify the cause of bleeding. He is at high risk for colon cancer because of his age. The appropriate recommendation is referral to gastroenterology for colonoscopy.

Question 479

A patient has the following laboratory value. What is the clinical interpretation? anti-HAV IgG I = Positive a. He has hepatitis A. b. He has immunity to hepatitis c. He has no immunity to hepatitis A. d. More data are needed to interpret this.

Answer 479

b. He has immunity to hepatitis This patient is immune to hepatitis because he has a positive immunoglobulin G (IgG). This signifies immunity secondary to: (1) past infection, or (2) immunization. A negative IgG signifies absence of immunity to hepatitis A and susceptibility if exposed.

Question 480

A 26-year-old female complains of pain at McBurney's point. She feels nauseated and has a low-grade fever (100.1 °F). The most appropriate initial action by the NP is to: a. order a CBC and pregnancy test. b. order an abdominal ultrasound. c. order a KUB. d. order an abdominal CT.

Answer 480

a. order a CBC and pregnancy test. Patients with appendicitis usually have pain at McBurney's point, the painful area in the right lower quadrant of the abdomen. However, because this patient is of childbearing age, pregnancy is part of the differential and must be ruled out initially. Once pregnancy status is determined, patient disposition can be determined. If pregnancy is ruled out, then workup for appendicitis can proceed. CT scan of abdomen has very high sensitivity and specificity for appendicitis (95 and 94%, respectively) and so it is the gold standard for diagnosis of appendicitis.

Question 481

An 85-year-old adult has chronic constipation. She has a history of hypertension, osteoporosis, osteoarthritis and overactive bladder. What is the most likely cause of her constipation? Her medication list includes: amlodipine 5 mg; oxybutynin 2.5 mg; naproxen 375 mg; Prevacid 30 mg; calcium and vitamin D supplement a. Inadequate fluid intake b. Age-related changes c. Medication-related d. Inadequate fiber intake

Answer 481

c. Medication-related While all of these choices can contribute to constipation in an 85-year-old, she is on multiple medications that can increase her risk of constipation. Amlodipine, a calcium channel blocker, slows down motility in the gut. Oxybutynin has anticholinergic properties, which dry up mucus in the gut. Naproxen, an NSAID, increases the likelihood of constipation by inhibiting prostaglandins in the gut. Proton pump inhibitors and calcium supplements are commonly associated with constipation.

Question 482

Most patients who have acute hepatitis A infection: a. develop fulminant disease. b. become acutely ill. c. have a self-limited illness. d. develop subsequent cirrhosis.

Answer 482

c. have a self-limited illness. Clinical presentation of patients infected with hepatitis A virus (HAV) is variable. However, most adult patients have a self-limited, uncomplicated course. There may be mild, flu-like symptoms or there may be a more acute and severe clinical manifestation. Rarely does HAV result in hepatic failure unless other complicating illnesses, like HIV or hepatitis B or C, are present. In children, most are asymptomatic.

Question 483

A 24-year-old female presents with pain and tenderness in the right lower abdominal quadrant. Her pelvic exam and urinalysis are within normal limits. Her WBC is elevated and her urine pregnancy test is negative. What is part of the differential diagnosis? a. Pelvic inflammatory disease b. Appendicitis c. Ectopic pregnancy d. UTI

Answer 483

b. Appendicitis A CBC with a mild elevation in white cell count indicates that infection is likely. This finding is present in most patients who have acute appendicitis. Right lower quadrant abdominal pain, anorexia, and nausea/vomiting are considered classic symptoms of acute appendicitis. Pelvic inflammatory disease is characterized by cervical motion and adnexal tenderness on bimanual examination. Purulent endocervical discharge may be present. This is unlikely in the presence of a normal pelvic exam. Acute pelvic pain and a positive pregnancy test in women of childbearing age may suggest ectopic pregnancy. The patient's pregnancy test is negative. Symptoms of a urinary tract infection (UTI) can mimic appendicitis, but this can be ruled out with the patient's normal urinalysis report.

Question 484

A 24-year-old male has recently returned from a weekend camping trip with friends. He has ulcerative colitis and history of migraine headaches. He reports a 2-day history of headache, nausea, and vomiting with weakness. Which of the following is not part of the differential diagnosis? a. Migraine headache b. Exacerbation of ulcerative colitis c. Acute gastroenteritis d. Norovirus

Answer 484

b. Exacerbation of ulcerative colitis The patient presents with headache, nausea and vomiting. His symptoms could be due to migraine headache or acute gastroenteritis. Norovirus is a common cause of gastroenteritis. An exacerbation of ulcerative colitis would produce lower GI symptoms (diarrhea, flatulence, or bleeding), not nausea, vomiting, and headache.

Question 485

A 48-year-old patient has the following laboratory values. How should they be interpreted? anti-HCV = Reactive HCVRNA = Detectable a. The patient has hepatitis C. b. The patient does not have hepatitis C. c. The patient should consider immunization. d. The results are indeterminate.

Answer 485

a. The patient has hepatitis C. This patient has hepatitis C. He has a reactive HCV antibody (anti-HCV). This is a positive screen for hepatitis C. The HCV RNA level is detectable, which confirms infection. When both the anti-HCV and HCV RNA are positive, the patient can be diagnosed with hepatitis C. At this time, there is no immunization for hepatitis C.

Question 486

What medication may be used to treat GERD if a patient has tried over-the-counter ranitidine without benefit? a. Calcium carbonate b. Prescription-strength ranitidine c. Cimetidine d. Pantoprazole

Answer 486

d. Pantoprazole If a patient has been diagnosed with GERD and he is symptomatic on an H2 blocker like ranitidine, a proton pump inhibitor (PPI) should be considered. An example of a proton pump inhibitor is pantoprazole. Relief of symptoms after using a PPI does not indicate a benign condition. This patient could have esophageal erosions, Barrett's esophagitis, or esophageal cancer. He should be screened for risk factors for these conditions and then a decision to refer this patient to gastroenterology can be made.

Question 487

Which patient has the least worrisome symptoms associated with his diarrhea? One with: a. bloody diarrhea. b. temperature > 101.3° F. c. duration of illness > 48 hours. d. moderate amounts of watery diarrhea.

Answer 487

d. moderate amounts of watery diarrhea. Diarrhea is extremely common. Evaluation of diarrhea should take place when specific criteria suggest severe illness. In addition to those listed, some conditions which indicate further work-up are: profuse watery diarrhea with signs of hypovolemia, passage of > 6 unformed stools per 24 hours or a duration of illness > 48 hours, recent antibiotic use or recent hospitalization, and diarrhea in a patient > 70 years old.

Question 488

Dipeptidyl peptidase-4 inhibitors (gliptins) act on the incretin system to improve glycemic control. Advantages of these drugs include: a. can be given twice daily b. low risk for hypoglycemia c. better reduction in glucose levels than other classes d. less weight gain than sulfonylureas

Answer 488

I think this is D?? A is definitely wrong, usual dosage is once daily for all gliptins. ***Question came from Pharm final that was emailed to Amber***

Question 489

Which statement is most accurate regarding incretin-based therapy and weight loss? a. GLP-1 receptor agonists have natriuretic and osmotic diuretics b. GLP-1 receptor agonists may be more appropriate than DPP-4 inhibitors when weight loss or greater reductions in A1c are treatment goals c. Combination therapy with GLP-1 receptor agonists and SGLT2 inhibitors compounds weight loss benefits d. GLP-1 receptor agonists are more effective in inducing weight loss than SGLT2 inhibitors.

Answer 489

***Question came from Pharm final that was emailed to Amber*** The student thought B was right... Pretty sure A is WRONG Pretty sure D is WRONG

Question 490

Which of the following statements is true regarding acceptable administration of metformin? a. In the presence of NYHA class II heart failure b. The morning a patient will undergo CT scan with IV contrast dye c. In a patient with pyelonephritis who remains normotensive d. In patients who tend to skip meals e. In patients on the day of elective surgery

Answer 490

d. In patients who tend to skip meals (p. 408 of our book) ***Question came from Pharm final that was emailed to Amber*** Heart failure & surgery can predispose to lactic acidosis. CT with contrast, pyelonephritis can impair renal excretion, leading metformin accumulation and toxicity (metabolic acidosis)

Question 491

Which of the following medications acts by inhibiting the synthesis of thyroid hormone and is used because it causes fewer effects on the liver? a. methimazole (Tapazole) b. liothyronine (Cytomel) c. progesterone (Progestins) d. amlodipine

Answer 491

a. methimazole (Tapazole) ***Question came from Pharm final that was emailed to Amber***

Question 492

What medication may be used to manage persistent mild asthma? a. Eculizumab b. Montelukast (leukotriene receptor antagonist) c. high-dose inhaled corticosteroid d. Selegiline

Answer 492

The student who sent the question said A, I think the right answer is B (page 577 of the book, step 2 says low dose intranasal glucocorticoids are preferred, alternate options are cromolyn or LTRA or theophyline ***Question came from Pharm final that was emailed to Amber***

Question 493

Patients who are taking lithium for bipolar disorder should be taught to: a. Eat a diet with consistent levels of salt (sodium) b. Drink at least 2 quarts of water in a hot environment c. Take lithium with food d. Monitor blood glucose levels

Answer 493

a. Eat a diet with consistent levels of salt (sodium) ***Question came from Pharm final that was emailed to Amber*** The student who sent it thought it was C, but I think it is A. Look at pg. 230 of the book

Question 494

A 25-year-old with a history of seizures was diagnosed with a thrombophilia and is now on long-term anticoagulation therapy, warfarin. Which of the following antiepileptic medications may interact with warfarin therapy? a. Iamotrigine b. Carbamazepine c. Levetiracetam d. Gabapentin

Answer 494

b. Carbamazepine Carbamazepine is a P450 enzyme inducer. This causes warfarin to be metabolized more quickly, decreasing the effects of warfarin. ***Question came from Pharm final that was emailed to Amber***

Question 495

Which is most accurate regarding the treatment of GERD? a. Prokinetic therapy can be initiated in patients with GERD when empirical PPI therapy begins, and long-term use is recommended. b. Sucralfate is routinely recommended as an adjunct to PPI therapy in patients with GERD who have only a partial response to PPI therapy c. Proton pump inhibitors are generally safe for use in patients with GERD who are pregnant d. Surgical therapy is recommended in patients who do not respond to PPI therapy because they are much more likely to respond to surgery

Answer 495

The student picked C. I don't know if that is right. The book says Some PPIs (esomeprazole) are safe for use in pregnancy (p. 596). I'm more inclined to think that B might be correct, but I'm not sure (p. 596) ***Question came from Pharm final that was emailed to Amber***

Question 496

During your assessment of a patient taking Gabapentin, which of the following side effects is most likely to be seen? a. Hypertension b. Hypotension c. SLE-like syndrome d. Hypohidrosis e. Sedation

Answer 496

e. Sedation | * **Question came from Pharm final that was emailed to Amber***

Question 497

A patient presents to the ED with dilated pupils, flushed face, heart rate of 125 beats/minute, temperature of 102 degrees F, and urinary retention. The patient's significant other reports the patient has been taking diphenhydramine for hay fever but is unaware of any other medications taken. What do you suspect? a. Paradoxical effect b. Reaction from unknown drug c. Acute toxicity d. Side effect

Answer 497

The student selected A. The book states "a paradoxical effect is the opposite of the intended drug response. A common example is the excitement that may occur when some children take first-generation antihistamines or when older adults are given benzodiazepines for sedation but experience paradoxical excitation" ***Question came from Pharm final that was emailed to Amber***

Question 498

Which of the following is most likely indicated as a treatment for Thyroid Storm? a. Passive rewarming b. Propranolol c. Benzodiazepines d. Prazosin (Minipress)

Answer 498

b. Propranolol ***Question came from Pharm final that was emailed to Amber***

Question 499

Levodopa/carbidopa is useful in treating Parkinson's disease because of which property? a. Cross blood-brain barrier b. Increases serotonin in the brain c. Inhibit serotonin and norepinephrine reuptake d. Increases dopamine and norepinephrine

Answer 499

?? I hate this question. A is almost right. Levodopa crosses the blood brain barrier. It is given instead of dopamine because dopamine can't cross the BBB. But carbidopa doesn't cross the BBB. B is just wrong. C is just wrong. D was selected by the student who sent it and it was wrong. My guess is A... ***Question came from Pharm final that was emailed to Amber***

Question 500

Which of the following is a common adverse event associated with non-stimulants? a. Motor tics b. Bradycardia c. Drowsiness d. Reduced appetite

Answer 500

d. Reduced appetite ***Question came from Pharm final that was emailed to Amber***

Question 501

In which patient is it appropriate to prescribe Chlorpromazine? (Select all that apply). a. A 48-year-old woman with schizoaffective disorder b. A 78-year-old man with intractable hiccups c. A 76-year-old woman with severe dementia d. An 85-year-old man with Alzheimer's disease

Answer 501

The book really only says that they are contraindicated in children below 2 years of age. Adverse effects do include extrapyramidal side effects, anticholinergic effects, hypotension, and sedation (p. 608). This makes me think that B, C, and D are wrong. ***Question came from Pharm final that was emailed to Amber***

Question 502

If thyroid-stimulating hormone (TSH) levels are above the reference range, which of the following is recommended as the next step in assessment for hypothyroidism? a. Measurement of free thyroxine concentration (T4) b. Assays for anti-thyroid peroxidase (anti-TIPO) and antithyroglobulin (anti-Tg) antibody levels c. Investigations to identify decreased creatinine kinase levels d. Thyrotropin-releasing hormone (TRH) stimulation testing

Answer 502

a. Measurement of free thyroxine concentration (T4) The student who said it had B selected...? I think A seems more likely ***Question came from Pharm final that was emailed to Amber***

Question 503

A patient presents to your clinic complaining of fatigue, lack of interest in activities, and poor libido. Blood tests reveal normal fasting blood glucose, HbA1C, and TSH. His testosterone level was 97 ng/dL. An appropriate treatment is: a. Levothyroxine b. Testosterone c. Metformin d. Sildenafil e. Insulin

Answer 503

b. Testosterone ***Question came from Pharm final that was emailed to Amber***

Question 504

If the measles, mumps, rubella, and varicella (MMRV) combined vaccine is ordered to be given as the first MMR and varicella dose to a child, the CDC recommends: a. Patients must also receive the MMRV as the second dose of MMR and varicella in order to build adequate immunity b. Patients be premedicated with acetaminophen 15 minutes before the vaccine is given c. Parents be informed of the increased risk of fever and febrile seizures over the MMR plus varicella two-shot regimen d. Patients should not be around pregnant women for the first 48 hours after the vaccine is given

Answer 504

The student selected A and got it WRONG ***Question came from Pharm final that was emailed to Amber***

Question 505

A patient has been prescribed a progestin medication as a part of menopausal hormone therapy. The NP prescribed this medication based on which desired therapeutic effect? a. To relieve vasomotor symptoms b. To suppress endometrial proliferation c. To reduce urogenital atrophy d. To prevent adverse cardiac events

Answer 505

The student selected A (Got it wrong). I think that B is the correct answer ***Question came from Pharm final that was emailed to Amber***

Question 506

A patient with a history of migraine headaches has recently started on daily topiramate to control her headaches. She says that she still experiences headaches at least two days a week, lasting up to 24 hours that keep her home from work. She experiences nausea, photophobia, and pnonophobia during the headaches. To control her headaches, she usually takes ibuprofen 200 mg 2 tablets every 4-6 hours without much relief. Which medication is most appropriate to treat this patient's migraine headache? a. Naproxen b. Butalbital/acetaminophen/caffeine c. Ergotamine tartrate d. Sumatriptan

Answer 506

?? The student selected C and got it WRONG..... ***Question came from Pharm final that was emailed to Amber***

Question 507

a male patient experiences migraine attacks four times per month and is requesting a medication to help prevent the occurrence of migraines. Which drug classes will be prescribed for this patient? SELECT ALL THAT APPLY a. Beta Blockers b. Estrogens c. Ergot alkaloids d. antiepileptic drugs e. monoamine oxidase inhibitors f. Triptans

Answer 507

***Question came from Pharm final that was emailed to Amber*** The student selected A, C and F... I haven't looked this one up yet. The student got 1.333 out of 2 points..

Question 508

To achieve therapeutic effectiveness, an NP teaches a patient with chronic asthma to use an inhaled glucocorticoid medication according to which schedule? a. Only in an emergency b. To abort an asthma attack c. On a consistent, daily basis d. 2 weeks on, 2 weeks off

Answer 508

The student said B, but I'm pretty sure C is the correct answer ***Question came from Pharm final that was emailed to Amber***

Question 509

Which of the following can be mixed with Lantus insulin? a. None of these insulins should be mixed with Lantus b. Regular insulin c. Humalog insulin d. Ultralente insulin

Answer 509

The student said C, but I kind of think A is right. I haven't looked it up yet ***Question came from Pharm final that was emailed to Amber***

Question 510

Glutamate is an excitatory amino acid in the CNS. Overstimulation of glutamate receptors may lead to cell death. Memantine, by antagonizing the NDMA type of glutamate receptors, may improve cognitive function in Alzheimer's disease. a. True b. False

Answer 510

a. True ***Question came from Pharm final that was emailed to Amber***

Question 511

Why is it beneficial to take norethindrone acetate and ethinyl estradiol and ferrous sulfate? a. This pill will prevent the occurrence of headaches during the menstrual cycle. b. This pill will increase the period of withdrawal bleeding c. This pill will prevent iron-deficiency anemia associated with menstruation d. This pill will provide high estrogen levels for ovarian suppression

Answer 511

The student selected D and got it wrong. I think the answer is C, but haven't looked it up yet. ***Question came from Pharm final that was emailed to Amber***

Question 512

Which of the following patients is not an appropriate candidate for oral contraceptive therapy? a. A 30-year-old smoker b. A 34-year-old with a history of obesity c. A 20-year-old on antianxiety drug d. A 24-year-old with irregular menstrual cycles

Answer 512

The student selected C and was WRONG. I wonder about A, but it's a hard contraindication for 35 and greater who smoke. the history of obesity thing is strange. Maybe because OCs cause weight gain?? ***Question came from Pharm final that was emailed to Amber***

Question 513

What is a unique advantage of a Progesterone T IUD? a. Must be replaced annually b. Lowest failure of IUDs c. Decreases menstrual blood loss and dysmenorrhea d. May be left in place for up to 10 years

Answer 513

Student selected B and was WRONG. I'm pretty sure the correct answer is C ***Question came from Pharm final that was emailed to Amber***

Question 514

Which of the following statements is true regarding Liothyronine (synthetic T3)? a. The side effects can include palpitations and insomnia b. It is the treatment of choice for hypothyroidism c. It has a half-life of about 1 hour d. It produces stable serum levels of both T4 and T3

Answer 514

The student selected D and was WRONG. I'm also confident that B is wrong. I think the answer is A, but I would want to look up the half life before answering for sure ***Question came from Pharm final that was emailed to Amber***

Question 515

What is/are the therapeutic uses of estrogens? Select all that apply a. Hormone replacement therapy b. Female hypogonadism c. Contraception d. Acne e. Osteoporosis f. Uterine bleeding g. Dysmennorrhea

Answer 515

Sara picked A, B, C, D. She got 1.143/2 points correct... **Pharm Final

Question 516

What conditions can Topiramate be used in? Select all that apply. a. PTSD b. Alcohol dependence c. Neuropathic pain d. Bipolar disorder e. Migraine f. Epilepsy

Answer 516

Sara picked B, C, D, E, F She got 1.667 out of 2 points **Pharm Final

Question 517

Which statements should the NP use to explain to a patient with migraines why metoclopramide is prescribed? Select all that apply. a. "This medication will improve gastric stasis and increase absorption of your antimigraine drugs" b. "This medication will directly decrease the production of calcitonin gene-related peptide and migraine pain" c. "This medication will help suppress the nausea and vomiting you experience with your migraine" d. "This medication will improve sensitivity to light and touch" e. "This medication will prevent medication overuse headache"

Answer 517

Sara picked C | She got 1.6 out of 2 correct. We think just one more option needs to be selected.

Question 518

An asthmatic patient who was prescribed antihistamine, which of the following is the most important teaching you will provide? a. Restrict your fluid intake b. Increase fiber and fluid in your diet to prevent constipation c. Increase your fluid intake in order to decrease viscosity of secretions d. Take the medication at bedtime.

Answer 518

Sara picked D and was WRONG... we think A is wrong also. **Pharm Final

Question 519

Which of these medications is most likely to interfere with thyroid function testing in patients taking levothyroxine? a. Prednisolone b. Fluoxetine c. Omeprazole d. Acetaminophen

Answer 519

Sara picked C and got it WRONG My best guess is A **Pharm Final

Question 520

Which one of the following statements concerning H1 antihistamines is correct? a. Because of the established long-term safety of first-generation H1 antihistamines, they are the first choice for allergic rhinitis b. The motor coordination involved in driving an automobile is not affected by the use of first-generation H1 antihistamine c. Second-generation H1 antihistamines are relatively free of adverse effects d. H1 antihistamines can be used in the treatment of acute anaphylaxis.

Answer 520

Sara picked D and got it WRONG ***Pharm Final

Question 521

Which of the following is a sign of very poorly controlled asthma? a. Nighttime awakening one to three times per week b. Fev1 or peak flow >60%-80% predicted/personal best c. Symptoms two or fewer days per week d. Two or more exacerbations per year requiring oral systemic corticosteroids

Answer 521

Amber picked A and got it wrong PHARM FINAL

Question 522

Drugs that suppress the CNS cough reflex are: Select all that apply a. Morphine b. Acetaminophen c. Aspirin d. Hydromorphone e. Codeine f. Dextromethorphan

Answer 522

Amber picked A, E, and F. She got 1.667 out of 2. I'm pretty sure D is also right.

Question 523

A 12-month-old child is being treated with amoxicillin for acute otitis media. His parents call the clinic and say he has developed diarrhea. The appropriate action would be to: a. Change the antibiotic to one that is less of a gastrointestinal irritant b. Recommend increased fluids and fiber in his diet c. Order stool cultures for suspected viral pathogens not treated by the amoxicillin d. Advise the parents that some diarrhea is normal with amoxicillin and recommend probiotics daily

Answer 523

Amber picked B and got it WRONG Pharm final

Question 524

In addition to vaccination for all children ages 12 through 23 months, hepatitis A vaccination (HepA) is recommended in which situations? Select all that apply. a. When an individual lives in an Alaskan Native village b. When a female has cervical cancer c. When an individual travels to Central America d. When a patient has a history of myocardial disease e. When a male has sex with men

Answer 524

Amber picked C and E. She got 1.6 out of 2, we think A is also correct

Question 525

A 22-year old college student reports tremor, sweating, dizziness, and being unable to concentrate at times that last for about 10-20 minutes. He is diagnosed with panic disorder without agoraphobia. Which of this medication is the first choice for this condition? a. Lithium b. Fluoxetine c. Klonopin d. Chlordiazepoxide

Answer 525

C was WRONG, we think D is probably correct PHARM FINAL

Question 526

A patient has been prescribed Citalopram (Celexa) to treat his depression. Education regarding how quickly selective serotonin reuptake inhibitor (SSRI) antidepressants work would be: a. Appetite and concentration improve in the first 1 to 2 weeks b. Sleep should improve almost immediately upon starting citalopram c. His dysphoric mood will improve in 1-2 weeks d. Full response to the SSRI may take 2-4 months after he reaches the full therapeutic dose

Answer 526

D is WRONG Pharm FINAL