Questions Flashcards
(75 cards)
1
Q
Based on labs, the FNP diagnoses her 45 year old patient with DMII, pt has a sulfa allergy, which would be avoided. Glipizide metformin miglitol rosigl
A
Glipizide- considered a sulonulyrea
2
Q
Which of the following classes of drugs is implicated with masking the s/s of hypoglycemia in DM? CCB Diuretics Beta-blockers ARBs
A
Beta-Blockers - block the sympathetic surge and masks the symptoms of hypoglycemia
3
Q
What is the 1st line treatment (drug) for GERD? A. Lifestyle B. Antacids C. H2 Blockers D. PPIs
A
H2 Blockers
PPIs are not meant to be long term therapy
4
Q
Which of the following is not an acceptable screening test for Type II DM?
A. 2 hour plasma glucose during an OGTT
B. fasting blood glucose level
C. HgA1C
D. Urine glucose
A
Urine Glucose
5
Q
Which of the following would be the best choice of insulin for a long-acting effect that can be given at night? A. insulin glargine B. insulin lispro C. NPH D. 70/30
A
insulin glargine (lantus)
6
Q
All of the following patients should be screened for DM except
a. an obese man of hispanic descent
b. an overweight middle aged black women whose mother has type 2 DM
c. a women who delivered an infant weighing 9.5 lbs
d. a 30 year old white man with HTN
A
30 year old white man with HTN
7
Q
your patient has chronic kidney disease and needs to be treated for HTN. which class would be first line option? ARB ACE BB CCB thiazide diuretic
A
ACE or ARB
8
Q
A patient with Type 2 DM is taking Metformin (Glucophage) and Glipizide (Glucotrol). He presents complaining of hypoglycemia episodes. He also takes Losartan (Cozaar) and Atorvastatin (Lipitor ). His glucoses have been dropping as low as 50mg/dL. Which medication is likely causing the hypoglycemia?
a. atorvastatin
b. glipizide
c. losartan
d. metformin
A
glipizide
9
Q
Lauren is 41 years old and is now unexpectedly pregnant. Her family has very strong history of heart attack, diabetes type 2 and hyperlipidemia.Her lipid profile reveals that she is now hyperlipidemic as well. Which of the following would be the safest choice?
a. atorvastatin
b. vitamin B3
c. fenofibrate
d. cholestyramine
A
D. cholestyramine ( the only one safe in pregnancy)
10
Q
Many patients self-medicate with antacids. Which patients should be counseled to not take calcium carbonate antacids without discussing it with their provider or a pharmacist first?
- Patients with kidney stones
- Pregnant patients
- Patients with heartburn
- Postmenopausal women
A
- Patients with kidney stones
11
Q
Patients taking antacids should be educated regarding these drugs, including letting them know that:
- They may cause constipation or diarrhea
- Many are high in sodium
- They should separate antacids from other medications by 1 hour
- All of the above
A
- All of the above
12
Q
Kelly has diarrhea and is wondering if she can take loperamide (Imodium) for the diarrhea. Loperamide:
- Can be given to patients of all ages, including infants and children, for viral gastroenteritis
- Slows gastric motility and reduces fluid and electrolyte loss from diarrhea
- Is the treatment of choice for the diarrhea associated with E. coli 0157
- May be used in pregnancy and by lactating women
A
- Slows gastric motility and reduces fluid and electrolyte loss from diarrhea
13
Q
Bismuth subsalicylate (Pepto Bismol) is a common OTC remedy for gastrointestinal complaints. Bismuth subsalicylate:
- May lead to toxicity if taken with aspirin
- Is contraindicated in children with flu-like illness
- Has antimicrobial effects against bacterial and viral enteropathogens
- All of the above
A
- All of the above
14
Q
Hannah will be traveling to Mexico with her church group over spring break to build houses. She is concerned she may develop traveler’s diarrhea. Advice includes following normal food and water precautions as well as taking:
- Loperamide four times a day throughout the trip
- Bismuth subsalicylate with each meal and at bedtime
- A prescription for diphenoxylate with atropine to use if she gets diarrhea
- None of the above
A
- Bismuth subsalicylate with each meal and at bedtime
15
Q
Josie is a 5-year-old patient who presents to the clinic with a 48-hour history of nausea, vomiting, and some diarrhea. She is unable to keep fluids down and her weight is 4 pounds less than her last recorded weight. Besides IV fluids, her exam warrants the use of an antinausea medication. Which of the following would be the appropriate drug to order for Josie?
- Prochlorperazine (Compazine)
- Meclizine (Antivert)
- Promethazine (Phenergan)
- Ondansetron (Zofran)
A
per the book Phenergan
16
Q
Jim presents with complaints of “heartburn” that is minimally relieved with Tums (calcium carbonate) and is diagnosed with gastroesophageal reflux disease (GERD). An appropriate first-step therapy would be:
- Omeprazole (Prilosec) twice a day
- Ranitidine (Zantac) twice a day
- Famotidine (Pepcid) once a day
- Metoclopramide (Reglan) four times a day
A
- Ranitidine (Zantac) twice a day
17
Q
_Patients who are on chronic long-term proton pump inhibitor therapy require monitoring for:
- Iron deficiency anemia, vitamin B12 and calcium deficiency
- Folate and magnesium deficiency
- Elevated uric acid levels leading to gout
- Hypokalemia and hypocalcemia
A
- Iron deficiency anemia, vitamin B12 and calcium deficiency
18
Q
Sadie is a 72-year-old patient who takes omeprazole for her chronic GERD. Chronic long-term omeprazole use places her at increased risk for:
- Megaloblastic anemia
- Osteoporosis
- Hypertension
- Both A and B
A
- Both A and B Megaloblastic anemia (blood dyscrasias)
19
Q
Patrick is a 10-year-old patient who presents with uncomfortable constipation. Along with diet changes, a laxative is ordered to provide more rapid relief of constipation. An appropriate choice of medication for a 10-year-old child would be:
- PEG 3350 (Miralax)
- Bisacodyl (Dulcolax) suppository
- Docusate (Colace) suppository
- Polyethylene glycol electrolyte solution
A
- Bisacodyl (Dulcolax) suppository
20
Q
Methylnaltrexone is used to treat constipation in:
- Patients with functional constipation
- Patients with irritable bowel syndrome-associated constipation
- Children with encopresis
- Opioid-associated constipation
A
- Opioid-associated constipation
21
Q
An elderly person has been prescribed lactulose for treatment of chronic constipation. Monitoring with long-term treatment would include:
- Electrolytes, including potassium and chloride
- Bone mineral density for osteoporosis
- Magnesium level
- Liver function
A
- Electrolytes, including potassium and chloride
22
Q
Patients with cystic fibrosis are often prescribed enzyme replacement for pancreatic secretions. Each replacement drug has lipase, protease, and amylase components, but the drug is prescribed in units of:
- Lipase
- Protease
- Amylase
- Pancreatin
A
- Lipase
23
Q
Brands of pancreatic enzyme replacement drugs are:
- Bioequivalent
- About the same in cost per unit of lipase across brands
- Able to be interchanged between generic and brand-name products to reduce cost
- None of the above
A
- About the same in cost per unit of lipase across brands
24
Q
When given subcutaneously, how long until neutral protamine Hagedorn insulin begins to take effect (onset of action) after administration?
- 15 to 30 minutes
- 60 to 90 minutes
- 3 to 4 hours
- 6 to 8 hours
A
- 60 to 90 minutes
25
Hypoglycemia can result from the action of either insulin or an oral hypoglycemic. Signs and symptoms of hypoglycemia include:
1. "Fruity" breath odor and rapid respiration
2. Diarrhea, abdominal pain, weight loss, and hypertension
3. Dizziness, confusion, diaphoresis, and tachycardia
4. Easy bruising, palpitations, cardiac dysrhythmias, and coma
3. Dizziness, confusion, diaphoresis, and tachycardia
26
Nonselective beta blockers and alcohol create serious drug interactions with insulin because they:
1. Increase blood glucose levels
2. Produce unexplained diaphoresis
3. Interfere with the ability of the body to metabolize glucose
4. Mask the signs and symptoms of altered glucose levels
4. Mask the signs and symptoms of altered glucose levels
27
Lispro is an insulin analogue produced by recombinant DNA technology. Which of the following statements about this form of insulin is NOT true?
1. Optimal time of preprandial injection is 15 minutes.
2. Duration of action is increased when the dose is increased.
3. It is compatible with neutral protamine Hagedorn insulin.
4. It has no pronounced peak.
2. Duration of action is increased when the dose is increased.
28
The decision may be made to switch from twice daily neutral protamine Hagedorn (NPH) insulin to insulin glargine to improve glycemia control throughout the day. If this is done:
1. The initial dose of glargine is reduced by 20% to avoid hypoglycemia.
2. The initial dose of glargine is 2 to 10 units per day.
3. Patients who have been on high doses of NPH will need tests for insulin antibodies.
4. Obese patients may require more than 100 units per day.
1. The initial dose of glargine is reduced by 20% to avoid hypoglycemia.
29
When blood glucose levels are difficult to control in type 2 diabetes some form of insulin may be added to the treatment regimen to control blood glucose and limit complication risks. Which of the following statements is accurate based on research?
1. Premixed insulin analogues are better at lowering HbA1C and have less risk for hypoglycemia.
2. Premixed insulin analogues and the newer premixed insulins are associated with more weight gain than the oral antidiabetic agents.
3. Newer premixed insulins are better at lowering HbA1C and postprandial glucose levels than long-acting insulins.
4. Patients who are not controlled on oral agents and have postprandial hyperglycemia can have neutral protamine Hagedorn insulin added at bedtime.
3. Newer premixed insulins are better at lowering HbA1C and postprandial glucose levels than long-acting insulins.
30
Metformin is a primary choice of drug to treat hyperglycemia in type 2 diabetes because it:
1. Substitutes for insulin usually secreted by the pancreas
2. Decreases glycogenolysis by the liver
3. Increases the release of insulin from beta cells
4. Decreases peripheral glucose utilization
2. Decreases glycogenolysis by the liver
31
Prior to prescribing metformin, the provider should:
1. Draw a serum creatinine to assess renal function
2. Try the patient on insulin
3. Tell the patient to increase iodine intake
4. Have the patient stop taking any sulfonylurea to avoid dangerous drug interactions
1. Draw a serum creatinine to assess renal function
32
The action of "gliptins" is different from other antidiabetic agents because they:
1. Have a low risk for hypoglycemia
2. Are not associated with weight gain
3. Close ATP-dependent potassium channels in the beta cell
4. Act on the incretin system to indirectly increase insulin production
4. Act on the incretin system to indirectly increase insulin production
33
Sitagliptin has been approved for:
1. Monotherapy in once-daily doses
2. Combination therapy with metformin
3. Both 1 and 2
4. Neither 1 nor 2
3. Both 1 and 2
34
GLP-1 agonists:
1. Directly bind to a receptor in the pancreatic beta cell
2. Have been approved for monotherapy
3. Speed gastric emptying to decrease appetite
4. Can be given orally once daily
1. Directly bind to a receptor in the pancreatic beta cell
35
Avoid concurrent administration of exenatide with which of the following drugs?
1. Digoxin
2. Warfarin
3. Lovastatin
4. All of the above
4. All of the above
36
Administration of exenatide is by subcutaneous injection:
1. 30 minutes prior to the morning meal
2. 60 minutes prior to the morning and evening meal
3. 15 minutes after the evening meal
4. 60 minutes before each meal daily
2. 60 minutes prior to the morning and evening meal
37
Type 2 diabetes is a complex disorder involving:
1. Absence of insulin production by the beta cells
2. A suboptimal response of insulin-sensitive tissues in the liver
3. Increased levels of glucagon-like peptide in the postprandial period
4. Too much fat uptake in the intestine
2.A suboptimal response of insulin-sensitive tissues in the liver
38
Diagnostic criteria for diabetes include:
1. Fasting blood glucose greater than 140 mg/dl on two occasions
2. Postprandial blood glucose greater than 140 mg/dl
3. Fasting blood glucose 100 to 125 mg/dl on two occasions
4. Symptoms of diabetes plus a casual blood glucose greater than 200 mg/dl
4.Symptoms of diabetes plus a casual blood glucose greater than 200 mg/dl
39
Routine screening of asymptomatic adults for diabetes is appropriate for:
1. Individuals who are older than 45 and have a BMI of less than 25 kg/m2
2. Native Americans, African Americans, and Hispanics
3. Persons with HDL cholesterol greater than 100 mg/dl
4. Persons with prediabetes confirmed on at least two occasions
2.Native Americans, African Americans, and Hispanics
40
Screening for children who meet the following criteria should begin at age 10 and occur every 3 years thereafter:
1. BMI above the 85th percentile for age and sex
2. Family history of diabetes in first- or second-degree relative
3. Hypertension based on criteria for children
4. Any of the above
4.Any of the above
41
Insulin is used to treat both types of diabetes. It acts by:
1. Increasing beta cell response to low blood-glucose levels
2. Stimulating hepatic glucose production
3. Increasing peripheral glucose uptake by skeletal muscle and fat
4. Improving the circulation of free fatty acids
3.Increasing peripheral glucose uptake by skeletal muscle and fat
42
Adam has type 1 diabetes and plays tennis for his university. He exhibits a knowledge deficit about his insulin and his diagnosis. He should be taught that:
1. He should increase his carbohydrate intake during times of exercise.
2. Each brand of insulin is equal in bioavailability, so buy the least expensive.
3. Alcohol produces hypoglycemia and can help control his diabetes when taken in small amounts.
4. If he does not want to learn to give himself injections, he may substitute an oral hypoglycemic to control his diabetes.
1.He should increase his carbohydrate intake during times of exercise.
43
Insulin preparations are divided into categories based on onset, duration, and intensity of action following subcutaneous injection. Which of the following insulin preparations has the shortest onset and duration of action?
1. Lispro
2. Glulisine
3. Glargine
4. Detemir
2.Glulisine
44
The drug of choice for type 2 diabetics is metformin. Metformin:
1. Decreases glycogenolysis by the liver
2. Increases the release of insulin from beta cells
3. Increases intestinal uptake of glucose
4. Prevents weight gain associated with hyperglycemia
1.Decreases glycogenolysis by the liver
45
Before prescribing metformin, the provider should:
1. Draw a serum creatinine level to assess renal function.
2. Try the patient on insulin.
3. Prescribe a thyroid preparation if the patient needs to lose weight.
4. All of the above
1.Draw a serum creatinine level to assess renal function.
46
Sulfonylureas may be added to a treatment regimen for type 2 diabetics when lifestyle modifications and metformin are insufficient to achieve target glucose levels. Sulfonylureas have been moved to Step 2 therapy because they:
1. Increase endogenous insulin secretion
2. Have a significant risk for hypoglycemia
3. Address the insulin resistance found in type 2 diabetics
4. Improve insulin binding to receptors
2.Have a significant risk for hypoglycemia
47
Dipeptidyl peptidase-4 inhibitors (gliptins) act on the incretin system to improve glycemic control. Advantages of these drugs include:
1. Better reduction in glucose levels than other classes
2. Less weight gain than sulfonylureas
3. Low risk for hypoglycemia
4. Can be given twice daily
3.Low risk for hypoglycemia
48
Control targets for patients with diabetes include:
1. HbA1C between 7 and 8
2. Fasting blood glucose levels between 100 and 120 mg/dl
3. Blood pressure less than 140/90 mm Hg
4. LDL lipids less than 130 mg/dl
3.Blood pressure less than 140/90 mm Hg
49
Establishing glycemic targets is the first step in treatment of both types of diabetes. For type 1 diabetes:
1. Tight control/intensive therapy can be given to adults who are willing to test their blood glucose at least twice daily.
2. Tight control is acceptable for older adults if they are without complications.
3. Plasma glucose levels are the same for children as adults.
4. Conventional therapy has a fasting plasma glucose target between 120 and 150 mg/dl.
4.Conventional therapy has a fasting plasma glucose target between 120 and 150 mg/dl.
50
Treatment with insulin for type 1 diabetics:
1. Starts with a total daily dose of 0.2 to 0.4 units per kg of body weight
2. Divides the total doses into three injections based on meal size
3. Uses a total daily dose of insulin glargine given once daily with no other insulin required
4. Is based on the level of blood glucose
1.Starts with a total daily dose of 0.2 to 0.4 units per kg of body weight
51
When the total daily insulin dose is split and given twice daily, which of the following rules may be followed?
1. Give two-thirds of the total dose in the morning and one-third in the evening.
2. Give 0.3 units per kg of premixed 70/30 insulin with one-third in the morning and two-thirds in the evening.
3. Give 50% of an insulin glargine dose in the morning and 50% in the evening.
4. Give long-acting insulin in the morning and short-acting insulin at bedtime.
1.Give two-thirds of the total dose in the morning and one-third in the evening.
52
Studies have shown that control targets that reduce the HbA1C to less than 7% are associated with fewer long-term complications of diabetes. Patients who should have such a target include:
1. Those with long-standing diabetes
2. Older adults
3. Those with no significant cardiovascular disease
4. Young children who are early in their disease
3.Those with no significant cardiovascular disease
53
The drugs recommended by the American Academy of Pediatrics for use in children with diabetes (depending upon type of diabetes) are:
1. Metformin and insulin
2. Sulfonylureas and insulin glargine
3. Split-mixed dose insulin and GPL-1 agonists
4. Biguanides and insulin lispro
1.Metformin and insulin
54
Unlike most type 2 diabetics where obesity is a major issue, older adults with low body weight have higher risks for morbidity and mortality. The most reliable indicator of poor nutritional status in older adults is:
1. Weight loss in previously overweight persons
2. Involuntary loss of 10% of body weight in less than 6 months
3. Decline in lean body mass over a 12-month period
4. Increase in central versus peripheral body adiposity
2.Involuntary loss of 10% of body weight in less than 6 months
55
The drugs recommended for older adults with type 2 diabetes include:
1. Second-generation sulfonylureas
2. Metformin
3. Pioglitazone
4. Third-generation sulfonylureas
4.Third-generation sulfonylureas
56
Ethnic groups differ in their risk for and presentation of diabetes. Hispanics:
1. Have a high incidence of obesity, elevated triglycerides, and hypertension
2. Do best with drugs that foster weight loss, such as metformin
3. Both 1 and 2
4. Neither 1 nor 2
3.Both 1 and 2
57
The American Heart Association states that people with diabetes have a 2- to 4-fold increase in the risk of dying from cardiovascular disease. Treatments and targets that do not appear to decrease risk for micro- and macro-vascular complications include:
1. Glycemic targets between 7% and 7.5%
2. Use of insulin in type 2 diabetics
3. Control of hypertension and hyperlipidemia
4. Stopping smoking
1.Glycemic targets between 7% and 7.5%
58
All diabetic patients with known cardiovascular disease should be treated with:
1. Beta blockers to prevent MIs
2. Angiotensin-converting enzyme inhibitors and aspirin to reduce risk of cardiovascular events
3. Sulfonylureas to decrease cardiovascular mortality
4. Pioglitazone to decrease atherosclerotic plaque buildup
2.Angiotensin-converting enzyme inhibitors and aspirin to reduce risk of cardiovascular events
59
All diabetic patients with hyperlipidemia should be treated with:
1. HMG-CoA reductase inhibitors
2. Fibric acid derivatives
3. Nicotinic acid
4. Colestipol
1.HMG-CoA reductase inhibitors
60
Both angiotensin converting enzyme inhibitors and some angiotensin II receptor blockers have been approved in treating:
1. Hypertension in diabetic patients
2. Diabetic nephropathy
3. Both 1 and 2
4. Neither 1 nor 2
3.Both 1 and 2
61
The American Diabetic Association has recommended which of the following tests for ongoing management of diabetes?
1. Fasting blood glucose
2. HbA1C
3. Thyroid function tests
4. Electrocardiograms
2.HbA1C
62
Allison is an 18-year-old college student with type 1 diabetes. She is on NPH twice daily and Novolog before meals. She usually walks for 40 minutes each evening as part of her exercise regimen. She is beginning a 30-minute swimming class three times a week at 1 p.m. What is important for her to do with this change in routine?
1. Delay eating the midday meal until after the swimming class.
2. Increase the morning dose of NPH insulin on days of the swimming class.
3. Adjust the morning insulin injection so that the peak occurs while swimming.
4. Check glucose level before, during, and after swimming.
4
RATIONALE: BG must be checked more often in T1 especially when adding more exercise, which can lower the BG levels. The other answers would cause hypoglycemia either during or after exercise.
63
Allison is an 18-year-old college student with type 1 diabetes. Allison's pre-meal BG at 11:30 a.m. is 130. She eats an apple and has a sugar-free soft drink. At 1 p.m. before swimming her BG is 80. What should she do?
1. Proceed with the swimming class.
2. Recheck her BG immediately.
3. Eat a granola bar or other snack with CHO.
4. Take an additional dose of insulin.
3
RATIONALE: Although her BG is normal, it will more than likely drop during exercise so she should eat a CHO source before exercising. A and D would likely increase her likelihood of hypoglycemia. B would not be helpful in this situation.
64
Bart is a patient is a 67-year-old male with T2 DM. He is on glipizide and metformin. He presents to the clinic with confusion, sluggishness, and extreme thirst. His wife tells you Bart does not follow his meal plan or exercise regularly, and hasn't checked his BG for 1 week. A random glucose is drawn and it is 500. What is a likely diagnosis based on preliminary assessment?
1. Diabetic keto acidosis (DKA)
2. Hyperglycemic hyperosmolar syndrome (HHS)
3. Infection
4. Hypoglycemia
2
RATIONALE: HHS is the most likely diagnosis based on diagnosis, age, and signs and symptoms. DKA may occur in T2 diabetes, but initially HHS would be suspect.
65
Gastroesophageal reflux disease may be aggravated by the following medication that affects lower esophageal sphincter (LES) tone:
1. Calcium carbonate
2. Estrogen
3. Furosemide
4. Metoclopramide
2.Estrogen
66
Lifestyle changes are the first step in treatment of gastroesophageal reflux disease (GERD). Food or drink that may aggravate GERD include:
1. Eggs
2. Caffeine
3. Chocolate
4. Soda pop
2.Caffeine
67
Metoclopramide improves gastroesophageal reflux disease symptoms by:
1. Reducing acid secretion
2. Increasing gastric pH
3. Increasing lower esophageal tone
4. Decreasing lower esophageal tone
3.Increasing lower esophageal tone
68
If a patient with symptoms of gastroesophageal reflux disease states that he has been self-treating at home with OTC ranitidine daily, the appropriate treatment would be:
1. Prokinetic (metoclopramide) for 4 to 8 weeks
2. Proton pump inhibitor (omeprazole) for 12 weeks
3. Histamine2 receptor antagonist (ranitidine) for 4 to 8 weeks
4. Cytoprotective drug (misoprostol) for 2 weeks
.Proton pump inhibitor (omeprazole) for 12 weeks
69
If a patient with gastroesophageal reflux disease who is taking a proton pump inhibitor daily is not improving, the plan of care would be:
1. Prokinetic (metoclopramide) for 8 to 12 weeks
2. Proton pump inhibitor (omeprazole) twice a day for 4 to 8 weeks
3. Histamine2 receptor antagonist (ranitidine) for 4 to 8 weeks
4. Cytoprotective drug (misoprostol) for 4 to 8 weeks
2.Proton pump inhibitor (omeprazole) twice a day for 4 to 8 weeks
70
The next step in treatment when a patient has been on proton pump inhibitors twice daily for 12 weeks and not improving is:
1. Add a prokinetic (metoclopramide)
2. Referral for endoscopy
3. Switch to another proton pump inhibitor
4. Add a cytoprotective drug
2.Referral for endoscopy
71
Infants with reflux are initially treated with:
1. Histamine2 receptor antagonist (ranitidine)
2. Proton pump inhibitor (omeprazole)
3. Anti-reflux maneuvers (elevate head of bed)
4. Prokinetic (metoclopramide)
3.Anti-reflux maneuvers (elevate head of bed)
72
Long-term use of proton pump inhibitors may lead to:
1. Hip fractures in at-risk persons
2. Vitamin B6 deficiency
3. Liver cancer
4. All of the above
1.Hip fractures in at-risk persons
73
An acceptable first-line treatment for peptic ulcer disease with positive H. pylori test is:
1. Histamine2 receptor antagonists for 4 to 8 weeks
2. Proton pump inhibitor bid for 12 weeks until healing is complete
3. Proton pump inhibitor bid plus clarithromycin plus amoxicillin for 14 days
4. Proton pump inhibitor bid and levofloxacin for 14 days
3.Proton pump inhibitor bid plus clarithromycin plus amoxicillin for 14 days
74
Treatment failure in patients with peptic ulcer disease associated with H. pylori may be because of:
1. Antimicrobial resistance
2. An ineffective antacid
3. Overuse of proton pump inhibitors
4. All of the above
1.Antimicrobial resistance
75
After H. pylori treatment is completed, the next step in peptic ulcer disease therapy is:
1. Testing for H. pylori eradication with a serum ELISA test
2. Endoscopy by a specialist
3. A proton pump inhibitor for 8 to 12 weeks until healing is complete
4. All of the above
3.A proton pump inhibitor for 8 to 12 weeks until healing is complete
