PREVIOUS QUIZZES/EXAMS

Which of the following is recommended for malaria prevention for malaria risk area in Honduras?

* chloroquine* Atovaquone/proguanil, chloroquine, doxycycline, mefloquine, or primaquine are the recommended antimalarial drugs for this area.

If Heidi (from question 9) is prescribed ibuprofen 10mg/kg every 6 hours, how many milligrams of ibuprofen will she receive in 24 hours? Round your final answer to 2 decimal places.

254.55mg

Jason is a child with an ear infection. He has been prescribed Amoxicillin 85mg/kg/day in 2 divided doses. If Jason weighs 30kg and the amoxicillin suspension is 400mg/5mL, how many teaspoonfuls will Jason get for each dose? Round your final answer to 2 decimal places.

3.19 tsp

Steve is to receive 4g of magnesium in 500mL of 5% dextrose injection infused IV over 4 hours. The IV set is designed to deliver 30 drops/mL. Calculate the flow rate in drops per minute. Round up to the nearest drop.

63 drops/min

Which of the following routine vaccinations are recommended for person with COPD?

influenza, pneumococcal, Tdap

Amy is receiving IV hydration therapy with 1000mL of D5/0.9% NaCl. Her infusion is running at a rate of 125mL/hr. If you hang a bag at 2:00pm, what time will her infusion be complete? Your answer must specify am or pm OR be in military time.

10pm

How long it will take to see results from her new SSRI.

* 1 month * Antidepressants have a delayed onset of symptom relief and patients should see improvement in symptoms within 4-6 weeks.

Which of the following side effects will NOT need to be monitored for during David's time in the ED because he only got a single dose of an opioid?

* Constipation* While all opioids cause constipation, David does not need to be monitored for this during his stay in the ED. This would be something you would monitor with repeated doses either in the outpatient or inpatient settings. Respiratory depression, nausea/vomiting, and itching can all happen with a single dose of an opioid.

In adult patients with hypothyroidism, which of the following is the primary laboratory test that should be routinely monitored while on levothyroxine (Synthroid®) therapy?

* TSH * TSH is the primary laboratory test that should be routinely monitored for patients with hypothyroidism and taking levothyroxine. A high TSH is indicative of an underactive thyroid or hypothyroidism. This information can be found in the package insert for levothyroxine (Synthroid®) or mayoclinic.com.

Lisa also reports increased chest tightness and coughing. She had previously quit smoking over a year ago, but upon further questioning, you discover she recently started smoking again. She is currently smoking 3 or 4 cigarettes a day, but would like help quitting again. You provide Lisa with some behavior modification techniques. To cope with cravings, Lisa is going to use the nicotine lozenge. Which of the following would you include in your patient education to Lisa on how to use nicotine lozenges?

* avoid food or drink before using lozenges* The effectiveness of the lozenge is reduced by food and drinks. Lisa should not eat or drink 15 minutes before or while using the lozenge. The lozenge should be allowed to dissolve slowly. The lozenge should be occasionally rotated around the mouth. To reduce risk of GI side effects, the lozenge should not be chewed or swallowed. Patients who use more than one lozenge at a time, continuously use one lozenge after another, or chew or swallow the lozenge are more likely to experience heartburn or indigestion. Smoking Cessation presentation. Objective 4.

Lisa is still having difficulty falling and staying asleep. Which of the following would you recommend to Lisa to improve her sleep hygiene?

* leave the bedroom if unable to fall asleep* Lisa should avoid daytime napping as this can make it more difficult to sleep at night. If she must take a nap, she should keep it to less than one hour. The bedroom should be reserved for sleeping, not reading or watching television. If Lisa cannot fall asleep, she should leave the bedroom and engage in a relaxing activity until she feels sleepy. It is also important to establish a regular sleep routine by going to bed and waking up at nearly the same time every day. Sleeping in on the weekends disturbs the sleep routine and actually makes insomnia worse. Module 3 Learning Activity. Objective 4 and 6.

Kathy tells you that her symptoms have gotten worse since she changed to a different type of birth control pill. Given her symptoms, which of the following is Kathy likely experiencing?

* progestin excess * Kathy is likely experiencing progestin excess. Excess progestins can cause or exacerbate her symptoms of depressed mood, fatigue, weight gain and headache between pill packs.

Lisa's primary care provider decides to start an inhaled corticosteroid for her asthma. Which of the following do you educate Lisa on regarding use of her new medication?

* rinse mouth after use* Inhaled corticosteroids may cause fungal infections in the mouth commonly called thrush. Rinsing the mouth after use can prevent this infection. Inhaled corticosteroids are daily long-term control medications and should not be used as needed for symptoms. Asthma & COPD presentation. Objective 1 and 4.

The opioid medication is supplied as 400 mcg/8 mL and the ordered dose is 50 mcg IM. What is the volume of the administered dose?

*1 mL* 400 mcg/8 mL = 50 mcg/ X mL. X = 1 mL

Lisa returns to clinic with her younger sister. Her sister has a fever and is complaining of ear pain. She is diagnosed with otitis media. Her sister weighs 44 lbs. The primary care provider prescribes a penicillin to treat the infection. The recommended dose is 80 mg/kg/day given in two divided doses. The suspension is available as 400 mg of medication in each 5 mL of solution. How many milliliters of the medication should Lisa's sister receive in each dose?

*10 mL* Convert the weight from lbs to kg by dividing 44 lbs by 2.2. The child's weight is 20 kg. The dose given is mg/kg/day. 80 mg/kg X 20 kg gives us a daily dose of 1600 mg. To determine how many mL's are needed for each dose, divide the total daily dose by two; giving an individual dose of 800 mg. It will take 10 mL (or two teaspoonsful) of the 400 mg/5 mL suspension to get 800 mg per dose. Calculations handout and Module 1 Learning Activity. Objective 8.

Bobby has been ordered cefazolin IV for a skin infection. The ordered dose is 50mg/kg/day divided in 3 equal doses and Bobby weighs 40 pounds. How many milligrams of cefazolin will Bobby get for his first dose? Round your final answer to 2 decimal places.

*303.03mg*

If Brian does experience acute hypoglycemia, which of the following is appropriate for initial treatment?

*4 oz regular soft drink (15 g carb) * The best treatment for hypoglycemia is 15 grams of carbohydrate. This can be found in 3-4 glucose tablets, 5-6 pieces of hard candy, ½ cup or 4 oz of fruit juice or regular soft drink, among others. Six glucose tablets and 12 oz of fruit juice would be too much sugar, potentially overcorrecting and causing hyperglycemia. Max should be educated to drink a regular soft drink, not diet. A diet soft drink does not contain sugar and would not treat an episode of hypoglycemia.

Brian is a 22 year old male who presents to the Emergency Department with diabetic ketoacidosis. He is diagnosed with Type 1 Diabetes and started on an insulin IV infusion at a rate of 0.1 units/kg/hr. Brian weighs 150lbs. What is the flow rate of insulin in units per hour?

*6.81 units/hr* Brian is 150lbs X 1kg/2.2lbs = 68.18kg X 0.1units/kg/hr = 6.81 units/hr of insulin

For healthy, adult patients diagnosed with community acquired pneumonia, Avelox® should be prescribed for

*7 to 14 days* Complicated intra-abdominal infections can be treated in 5 to 14 days. Uncomplicated skin and skin structure infections can be treated in 7 to 21 days, and 3 to 7 days is not an appropriate duration of treatment with Avelox® for any FDA approved condition.

After examining the patient and obtaining labs, the provider decides to admit Brittany to the hospital overnight for IV antibiotics and observation. Vancomycin 15mg/kg administered every 12 hours is ordered. Brittany weighs 110 pounds. Which of the following vancomycin doses is appropriate?

*750 mg* The appropriate dose is 750 mg vancomycin. Brittany's weight in kilograms is 50 kg and multiplied by 15mg/kg = 750 mg.

Four months later Kathy returns to clinic and reports that her oral contraceptive pills have been changed and that the change seems to have helped somewhat. Her mood has improved most days, and she is less fatigued and is sleeping better. However, she reports some sexual dysfunction since starting her SSRI. Which of the following strategies could help alleviate her sexual dysfunction?

*Add on a dopamine reuptake inhibitor* All SSRIs carry the risk of sexual dysfunction, though some are worse than others. However, dopamine reuptake inhibitors (bupropion) do not cause sexual dysfunction and can be added on to SSRI therapy to alleviate these symptoms. Adding a TCA or stopping her multivitamin would not help her sexual dysfunction. Buspirone is indicated for anxiety and not depression.

Which of the following is TRUE regarding the evidence for willow bark for the treatment of osteoarthritis?

*Additional studies comparing willow bark to conventional medications are needed* Willow bark is a traditional analgesic therapy for osteoarthritis. Clinical research on willow bark extract for osteoarthritis is conflicting. The benefits of willow bark extract on patients that suffer from osteoarthritis have been studied in several trials. All treatment groups were compared to placebo to establish effectiveness. All studies showed a significant difference between willow bark extract and placebo in the treatment of chronic pain. One or two large, high quality studies are needed to confirm willow bark's efficacy for osteoarthritis pain. Studies comparing willow bark to conventional medicinal agents for safety and effectiveness are also needed.

You are educating Betty on her new VKA medication and she mentions that she likes to have 2-3 glasses of wine after dinner and before bed. What do you tell her about alcohol and her VKA?

*Alcohol should be avoided while taking a VKA* Alcohol increases the metabolism of VKAs and will increase the INR. This increases the patient's risk of bleeding. Ideally patients should avoid alcohol all together while taking a VKA.

The results of her pap test come back and she has bacterial vaginosis. Her primary care provider starts her on oral metronidazole to treat this infection. You educate Lisa on metronidazole's common adverse effects and caution her to avoid alcohol while taking it. Why do you caution her to avoid alcohol while on metronidazole?

*Alcohol will cause intense vomiting and flushing. * Lisa should be educated to avoid alcohol while taking metronidazole and for 72 hours after therapy. A disulfrim-like reaction will occur if alcohol is ingested while taking metronidazole. This reaction is characterized by intense vomiting, severe flushing, headache, and nausea. Overview of Antibiotics, Part II presentation. Objective 5.

Prevention of travelers' diarrhea (TD)?

*Bismuth subsalicylate is the primary agent studied in the prevention of TD.* Unfortunately, there are no vaccinations that protect against most pathogens that cause TD.

Since Denise is also a post-menopausal woman at risk for osteoporosis, you ask her about her dietary calcium and vitamin D intake. Which of the following statements are TRUE about calcium/vitamin D?

*Calcium can be found in low-fat dairy products.* Total dietary intake of calcium should be 1200mg daily for a woman over 50 years old. Low-fat dairy, dark leafy greens, soybeans and fortified foods can be good dietary sources of calcium. Most people do not get enough vitamin D from sun exposure alone and need supplementation, especially here in MN. Increased calcium supplementation, not vitamin D, can increase the risk of heart disease.

Later in your education you ask about Betty's diet. She says she is mostly a "meat and potatoes" kind of eater, but she occasionally likes to have a spinach salad with bacon dressing when she goes out to eat. What do you tell Betty about her diet and her VKA?

*Eating spinach is not a problem as long as her intake is consistent* Foods that are high in vitamin K, including spinach, will lower the INR. This increases her risk for clotting, including stroke, MI or pulmonary embolism. If she does like having a spinach salad, she should be consistent, either by eating the same amount per week or not at all.

Lisa mentions that she was given a generic version of one of her medications. She feels that is the explanation for her worsening medical condition. How would you respond to Lisa?

*Generic medications are held to the same quality standards as brand medications and must demonstrate equivalency* Generic medications are held to the same quality standards as brand medications and must demonstrate bio-equivalency (which means the drug is dissolved, absorbed, and cleared the same way as the brand name drug). Generic medications have the same active ingredient and the same amount of active ingredient. Regulation of Medications presentation. Objective 4 and 6.

Lisa returns to clinic complaining of a severe sore throat and pain while swallowing. She is diagnosed with strep throat. Her primary care provider wants to start her on a cephalosporin. What do you think about this antibiotic choice?

*Given the severity of her allergic reaction to penicillins, Lisa should not take a cephalosporin* Given Lisa's previous reaction of anaphylaxis to penicillins, she should not be given a cephalosporin. There is cross reactivity between penicillins and cephalosporins. If patients experience difficulty breathing, like bronchospasm or swelling of the lips, tongue or throat, or experiences an anaphylactic reaction as a result of taking penicillins, cephalosporins should be avoided due to the severity of the patients' allergic reaction to penicillins. Overview of Antibiotics, Part I presentation and Drug Effects and Adverse Drug Reactions handout. Objective 4 and 5.

Sally is taking the vitamin K antagonist, warfarin. What can you tell her about taking warfarin concurrently with glucosamine sulfate and willow bark?

*Glucosamine and willow bark may increase the risk of bleeding when taken with warfarin.* Glucosamine and willow bark may increase the risk of bleeding when taken with drugs that increase the risk of bleeding. This would include the vitamin K antagonist, wafarin (Coumadin®). In case reports, glucosamine has been shown to elevate INR and potentiate the anticoagulant effects of warfarin. Taking willow bark and warfarin together theoretically may increase the risk of bleeding due to decreased platelet aggregation.

She is worried glucosamine may affect her blood glucose levels. What do you advise her regarding glucosamine and diabetes?

*Glucosamine has no adverse effects on blood glucose levels* Early studies and some case reports have indicated glucosamine sulfate may raise blood glucose because of concerns that it increases insulin resistance or decreases insulin production. However, clinical studies have shown that there are no adverse effects on either blood glucose levels or hemoglobin A1c.

You are also instructing Brian how to test his blood glucose at home using a new monitor. Which of the following instructions is TRUE?

*He can use another site (like his forearm or thigh) to test his blood glucose depending on his meter* While most patients use their fingertips, some meters do allow testing in other sites, such as your forearm or thigh. Brian should code his glucometer to match each new vial of test strips. Brian should use the side of his fingertips, which is less sensitive than the flat side of his fingertips. Lancets are considered hazardous waste and should be discarded into a safe container and not the regular trash.

Before Adam leaves the clinic, you go over his asthma action plan. He reports using his peak flow meter once a week. What do you tell him about using his peak flow meter?

*He should exhale as fast and hard as possible to determine his peak flow* To determine a peak flow, Adam should exhale as fast and hard as possible into the meter and record the best of the 3 readings in his asthma log. Peak flow can be done any time of day, as long as the time of day is consistent between measurements. Coughing into the meter is not a valid reading.

The provider tells David that he can also take OTC acetaminophen in addition to his NSAID if he is still having pain. Which of the following education points do you tell him about acetaminophen?

*He should not drink alcohol while on this medication* Acetaminophen is metabolized through the liver and has a narrow therapeutic index. Because alcohol can impair liver function, David should not drink while taking acetaminophen. You cannot assume that because it is OTC it is safe, even small amounts over the recommended daily limit can cause toxicity. Acetaminophen can be taken with or without food. It also does not cause kidney problems; those can be associated with NSAIDs.

He shakes the inhaler, removes the cap and puts the mouthpiece in his mouth. He then puffs the inhaler twice and takes a deep breath. After holding his breath for 10 seconds, he exhales. What would you tell Adam about his inhaler technique?

*He should only puff the inhaler once per administration* Adam should only puff the inhaler once per administration. If he needs to use a second puff he should wait one minute before taking the next puff. Rinsing his mouth out would only apply to inhaled corticosteroids.

David is being discharged with his NSAID prescription. Which of the following education points do you tell him about this medication?

*He should stay hydrated while on this medication* NSAIDs can cause impaired renal function, especially in patients who are volume depleted, so David should be instructed to stay hydrated while on this medication. NSAIDs do not affect the liver, so jaundice is not an issue. He should be instructed NOT to take this medication on an empty stomach as it can cause GI bleeding and ulcers. NSAIDs do not cause constipation, so a stool softener is not needed

Which of the following is NOT appropriate when administering a LMWH injection?

*Injection site should be rubbed after injection* LMWH should be injected subcutaneously in the anterolateral and posterolateral abdominal wall while the patient is lying down. Injection sites should be rotated between the left and right side to prevent irritation and the formation of nodules. After injection, patients should not rub the injection site.

Kate's levothyroxine (Synthroid®) dose is increased. Which of the following do you advise her after the dosing change?

*It may take 4 to 6 weeks to see therapeutic effects* Peak therapeutic effects of levothyroxine are seen in 4-6 weeks due to its long half-life. After a dose adjustment, TSH is generally rechecked no sooner than 6 weeks and potentially out to 8-12 weeks. Hypothyroidism is a chronic condition that usually requires life-long therapy. Doses of levothyroxine should be taken on empty stomach for best absorption. This information can be found in the package insert.

Which of the following statements about hemoglobin A1c is TRUE?

*It measures average blood glucose* Hemoglobin A1c is a measure of average blood glucose over the previous 90 days. This average includes both fasting and post-prandial blood glucose concentrations. A1c is not a measure of the amount of insulin produced.

The nurse attaches the IV bag of vancomycin to a pump and sets the infusion to run over 30 minutes. Within 5 minutes of starting the infusion, Brittany complains of feeling hot, and the nurse notices a bright red rash spreading over Brittany's neck, back and face. Brittany does not report any trouble breathing. What should the nurse do?

*Keep the same IV bag and infuse over 90 minutes* Brittany is experiencing "Red-Man Syndrome" which is not an allergic reaction, but it is infusion related. The nurse should slow the infusion to treat this reaction. Diluting the solution, but not changing the infusion rate will not help as the drug infusion rate is the same.

Adam's mother has heard that using inhaled steroids can cause Adam's growth to be stunted. She looked online and saw that there is an inhaler with only a long-acting beta agonist. She is wondering if Adam could switch to that medication instead. What do you tell her?

*Long-acting beta agonists alone are contraindicated in asthma due to risk of death* Long-acting beta agonists should not be used alone in asthma treatment due to risk of asthma related death. Inhaled corticosteroids do cause some growth retardation in children and may cause a decrease in final adult height. Anticholinergic bronchodilators are not used in asthma, only in COPD.

Lisa wants to find patient information about the penicillin prescribed for her sister. Which of the following resources would be most appropriate to recommend for a patient to use?

*Mayo Clinic (www.mayoclinic.org) * Mayo Clinic website has information for patients about conditions, treatments, and other health topics. This would be an easy resource for Phyllis to both access and comprehend. Google ScholarTM is a search engine used for journal articles, and a journal article would likely not provide the information Phyllis is looking for. Additionally, journal articles (primary literature- like clinical trial data or second literature - like a review article) are written for healthcare professionals and may be difficult for a patient to understand.

Would you recommend Kate take selenium for her hypothyroidism?

*No, it has unclear evidence for efficacy* Selenium has unclear or conflicting scientific evidence (Natural Medicines "Insufficient Reliable Evidence to Rate"). Further research is needed before selenium supplementation can be recommended for thyroid conditions. Thyroid function is thought to depend on selenium, and thyroid problems may be common with selenium deficiency. Selenium deficiency is implicated in the development of autoimmune thyroiditis, primarily in genetically predisposed people. On the other hand, in patients with iodine deficiency, hypothyroidism has been reported as a result of selenium supplementation. There is no evidence selenium interacts with ACE inhibitors. This information can be found in Natural Medicines.

You are educating Alexis on using nystatin and preventing oral thrush in the future.

*Nystatin should be swished around her mouth, gargled, and then swallowed* Alexis should rinse her mouth after using the corticosteroid inhaler, not before.

The next morning Brittany is feeling better and the redness around her wound has subsided. She is going home on an oral antibiotic. Since vancomycin worked so well, she wants to know if she can take that orally at home. What do you say?

*Oral vancomycin is not absorbed into the bloodstream, so it will not work* Vancomycin is available orally; however, it is not absorbed systemically and is only used for intestinal infections caused by C. difficile. Brittany did not have an allergic reaction to vancomycin and since oral vancomycin is not absorbed, it does not cause hearing loss.

The provider prescribes penicillin 500mg orally every six hours. Which of the following educational points should you discuss with Brittany?

*Penicillin should be taken every 6 hours around the clock* Because penicillin is a time-dependent antibiotic, it is important to take the doses spaced evenly throughout the day to ensure a consistent level above the MIC. Penicillin actually causes diarrhea, not constipation and does not interact with calcium containing products. It also does not cause sun sensitivity.

Erin is in the ER with a broken ankle. She has morphine 4mg IV ordered every 2 hours as needed for pain. Morphine is available from the pharmacy in a syringe containing 10mg morphine in 1 mL. How many milliliters of morphine will Erin get in one dose?

0.4 mL

Two days later, Maggie calls the clinic to report painful swelling in the back of her heel and pain upon standing. How will you advise her?

*Rest and avoid exercise; contact her prescriber immediately to rule out tendon rupture* Moxifloxacin is associated with a rare, but serious potential adverse reaction of tendon rupture. Patients using moxifloxacin should seek medical attention immediately if they experience a painful swelling or inflammation in the back of the heel or experience inability to bear weight (use the joint).

Which of the following statements is TRUE about rhabdomyolysis?

*Rhabdomyolysis is the rapid breakdown of muscle* While rhabdomyolysis is life-threatening, it is very rare. Patients may experience bilateral muscle pain; however pain alone is not indicative of rhabdomyolysis. Rhabdomyolysis is the rapid breakdown of muscle, which releases damaged cells into the bloodstream. These damaged cells are directly toxic to kidney cells, which leads to potentially fatal renal failure.

Since Betty has atrial fibrillation, she is at a higher risk of stroke and is in need of chronic anticoagulation therapy. She is started on both a vitamin K antagonist (VKA) and a low-molecular weight heparin (LMWH). Why are both medications started at the same time?

*The VKA needs time to reach a therapeutic concentration, so the LMWH is used as a bridge* Vitamin K antagonists take at least 3 days to reach a therapeutic INR. During this time patients are susceptible to thrombosis. Low-molecular weight heparins are used as "bridging" therapy as they provide therapeutic anticoagulation right after the first administration. Once the patient's INR is therapeutic, the low-molecular weight heparin can be discontinued.

Brittany returns to the ER 3 days later with complaint of a new onset fever, as well as increased swelling, redness, and pain around the wound. Which of the following statements is accurate?

*The bacteria are likely resistant to penicillin and she should change antibiotics* Since Brittany's infection is getting worse and she now has a fever, the bacteria is likely resistant to the penicillin. Patients should notice an improvement in symptoms within 24-36 hours of starting the antibiotic. Fever is not a side effect of penicillin and there is no indication that Brittany is having an allergic reaction as she does not have itching or hives.

Which of the following is another important general education point about HMG-CoA reductase inhibitors (statins)?

*They are contraindicated in pregnancy* HMG-CoA reductase inhibitors (statins) can be taken with or without food and are best dosed in the evening. Some are potent inhibitors of CYP P450 enzymes, so they may have numerous drug interactions. HMG-CoA reductase inhibitors (statins) are pregnancy category X and are contraindicated in pregnancy.

Adam asks if there is any way to prevent an attack when he is playing basketball. What do you tell him?

*Use your short-acting beta agonist 5-30 minutes before you play basketball* Exercise induced bronchospasm can be pre-treated with a short-acting beta agonist 5-30 minutes prior to activity. Extra doses of long-acting beta agonists, inhaled corticosteroids and leukotriene receptor antagonists should not be used. All patients with asthma should be encouraged to participate in regular physical activity and should not be excluded because of their condition.

Can she take antacids while she is also taking Avelox®? Why or why not?

*Yes, but Maggie should take Avelox® at least 4 hours before antacids* Antacids may decrease the GI absorption of moxifloxacin, resulting in lower than desired levels. Doses of moxifloxacin should be taken at least 4 hours before or 8 hours after doses of antacids. Moxifloxacin can be taken without regard to food.

During the conversation, Sally reveals she has a shellfish allergy. She breaks out in an itchy rash and develops hives, but not does experience difficulty breathing. Can she use glucosamine for her osteoarthritis even though she has a shellfish allergy?

*Yes, the allergy is to the meat, not the shell; it should be safe for patients with a shellfish allergy* Glucosamine is derived from the exoskeletons of shrimp, lobster, and crabs. Allergic reactions in people with shellfish allergies are caused by IgE antibodies to antigens in the meat of shellfish, not to antigens in the shell. There are no documented reports of allergic reaction to glucosamine in patients with a shellfish allergy. There is also some evidence that patients with a shellfish allergy can safely take glucosamine products. It is important to ask Sally what her reaction to shellfish is; if she experiences an anaphylactic reaction, it may be too risky to have her use a product which could theoretically have some contamination with shellfish meat. If her reaction is mild (such as rash) it is more reasonable for her to risk a potential reaction.

Due to Adam's increase symptoms around playing basketball, the provider diagnoses him with exercise induced bronchospasm and prescribes a leukotriene receptor antagonist. Which of the following points should you communicate to Adam and his mom?

*You want to watch for possible changes in mood* Leukotriene receptor antagonists can rarely cause neuropsychiatric events. However, these events can be severe and include suicidal thinking or behavior. Leukotriene receptor antagonists should be taken at bedtime and can be taken without regard to food or other medications.

Opioids decrease the motility of the gut. Which pharmacokinetic step in the pathway through the body is impacted by this ability to decrease gut motility?

*absorption* Opioids can profoundly affect the function of the gut by decreasing motility. This is an example of how medications can affect the process of absorption. Drug Effects and Adverse Drug Reactions handout. Objective 3.

At the next visit, Nancy reports that Jim's behavior has worsened. He is experiencing auditory hallucinations. He has become increasingly agitated and hostile. Nancy is concerned with his aggressive behavior towards her. These symptoms are a significant decline in Jim's function. Initially, non-pharmacologic approaches were tried without success. Which of the following agents would be the most appropriate to treat Jim's current symptoms?

*antipsychotic* Jim is experiencing severe symptoms, a significant decline in function, and exhibiting behaviors that have the potential to harm themselves or others. Non-pharmacologic approaches have failed. Based on his symptoms of hallucinations, agitation, hostility, and aggression, the most appropriate drug therapy would be an antipsychotic. Antidepressants would target mood (depressive and anxiety symptoms). Anxiolytics treat anxiety symptoms and may help with agitation. Anticholinergic agents should be avoided in patients with AD.

Which of the following is an appropriate way to approach communicating with AD patinets?

*ask them to point or gesture* It is important to be clear, patient, and attentive when caring for patient's with AD; however, volume is not always the solution to the problem involved with communication. Shouting into a patient's ear may make them feel poorly about their condition, which he or she is not able to control. Keeping words simple and sentences short may also help to effectively improve communication. Allow the patient to speak, without interrupting.

Sally is wondering about willow bark as she heard that it could help her pain. Which of these agents is most similar in BOTH structure and analgesic activity to willow bark?

*aspirin* The active constituent of willow bark is thought to be salicin, a salicylate. Willow bark is structurally related to acetylsalicylic acid (aspirin). Willow bark's analgesic activity showed the same effect as aspirin. In studies, willow bark influenced cyclooxygenase activity release. Willow bark inhibits platelet aggregation, but to a lesser degree than aspirin.

Lisa returns to clinic to follow up on a recent accident. She fell while rollerblading and broke her arm. She is still having significant pain. Her primary care provider prescribes an opioid. Which of the following of Lisa's medical problems is a precaution to use with opioid therapy?

*asthma* Opioid therapy should be used cautiously in patients with respiratory diseases, such as asthma. Opioid therapy can cause respiratory depression if used inappropriately. Pain Management presentation. Objective 5.

Two hours after receiving the medication you recommended, Tim is still experiencing tachycardia. His shortness of breath and edema have improved dramatically. Which one of the following medications would be appropriate treatment for Tim's tachycardia?

*beta blocker* A beta blocker would be appropriate as it slows the heart rate by competitively blocking adrenergic stimulation of beta 1 receptors. ACE inhibitors and angiotensin II receptor blockers work on the renin-angiotensin-aldosterone system and do not affect heart rate. Alpha blockers competitively inhibit alpha adrenergic receptors causing veins and arterioles to dilate. This dilation can actually increase heart rate.

You are also educating Brian on signs and symptoms of hypoglycemia and how to prevent it from happening. Which of the following steps can appropriately be used to prevent acute hypoglycemia?

*checking blood glucose before administering rapid-acting insulin* Blood glucose should be checked before administering rapid-acting insulin and if the reading is lower than expected the dose should be skipped or reduced. Checking blood glucose before long-acting insulin would not have very much effect on acute hypoglycemia as it is not effective immediately. Taking less insulin than prescribed or increasing sugar intake may prevent hypoglycemia, but they would worsen his overall diabetes and are not appropriate

Lisa develops anaphylaxis after taking a dose of the cephalosporin in the clinic. Which of the following describes the most appropriate immediate response to Lisa's reaction?

*contact emergency staff at clinic and administer epinephrine* Anaphylactic reactions are severe and potentially life-threatening reactions. The appropriate immediate action would be to contact the emergency staff and administer epinephrine. After treating Lisa, the prescriber and his pharmacist should be notified to ensure documentation of the allergic reaction. Drug Effects & Adverse Drug Reactions handout. Objective 5 and 6.

Which of the following is a symptom of hypothyroidism?

*depression* Symptoms of hypothyroidism include fatigue, increased sensitivity to cold, constipation, dry skin, elevated cholesterol, weight gain, depression, and brittle hair. Diarrhea, sweating, and weight loss are symptoms of hyperthyroidism. This information could potentially be found on mayoclinic.com or the American Thyroid Association website.

The provider decides to start Denise on a biguanide as initial therapy. Which of the following adverse effects would you want to educate Denise about?

*diarrhea* GI effects are the most common adverse effects seen with biguanides and include nausea, vomiting and diarrhea. Over time patients develop a tolerance to these effects. Because biguanides do not stimulate insulin release, they do not cause hypoglycemia. Biguanides should be used cautiously in patients with renal dysfunction as they are at higher risk of lactic acidosis, however biguanides do not cause renal dysfunction. Overall, biguanides are weight neutral and may cause weight loss in some patients.

Common adverse effect reported with the NMDA antagonist, memantine (Namenda®)

*dizziness* include dizziness, headache, constipation, and confusion.

Combination oral contraceptive pills are classified as pregnancy category X. What does this mean?

*evidence of human fetal risk; risk of use clearly outweighs any possible benefit* Pregnancy category X means that there is evidence of human fetal risk (abnormalities or adverse reaction). The risk of use clearly outweighs any possible benefit. Pregnancy category D: evidence of human fetal risk; benefits may outweigh the risks in certain patients. Pregnancy category C: harm in animal studies & no studies in women OR no studies in animals or women; benefit must outweigh the risk. Pregnancy category B: no harm in animal studies & no studies in pregnant women OR harm in animals but no harm in women studies. Pregnancy category A: studied in pregnant women, no harm to fetus. Regulation of Medications presentation. Objective 4 and 5.

Lisa returns to clinic a few weeks later for her routine yearly pap test. She also wants to discuss her current method of contraception. She does not like the residue the Ortho-Evra® patch adhesive leaves on her skin. She stopped the patch last month. She would like to try a combination oral contraceptive pill. When do you instruct Lisa to start taking her new contraceptive?

*first day of menses * To ensure maximum effectiveness, combination oral contraceptive pills may be started by several different methods: on the first day of bleeding, on the first Sunday after menses begins, or on the fifth day after menses begins. Lisa should use additional contraceptive methods for at least seven days after starting the pill, preferably for the entire first cycle. Contraception handout. Objective 4 and 6.

She states she has been using her short-acting beta agonist inhaler every day, sometimes 2 or 3 times a day. Lisa demonstrates good inhaler technique. Which of the following would you monitor given Lisa's current medications?

*heart rate* Monitoring for short-acting beta agonists include signs and symptoms of tremor and agitation as well as monitoring the heart rate for tachycardia. Asthma & COPD presentation. Objective 4.

Which of the following travel vaccinations should Alexis receive prior to her trip to Honduras?

*hepatitis A, hepatitis B, rabies, typhoid* Yellow fever would be recommended if she was coming from a country with risk of yellow fever virus transmission or if she had been in transit more than 12 hours in an airport located in a country with risk of yellow fever virus transmission.

Can improve the safety of AD patinets home by:

*keeping medications in locked area* While patients with AD should be monitored regularly, it is not necessary for a caregiver to keep them in sight at all times. Additionally, if wandering is a problem, keys should be removed from all vehicles and the vehicles should be locked. Bright lighting in hallways will help decrease the risk of falls. All medications and other chemicals should be properly labeled and kept out of reach of a patient who is confused. Locks should be removed from bathrooms and bedrooms to prevent a patient with AD from getting locked inside.

Upon examination and EKG, he is found to have an acute exacerbation of his heart failure. His symptoms include shortness of breath, especially when lying down, 3+ pitting edema in his ankles and tachycardia. Which of the following medications should Tim be given intravenously for his acute symptoms?

*loop diuretic* A loop diuretic should be administered immediately. Excess fluid is likely the reason for his shortness of breath, tachycardia and edema. The only way to quickly remove this fluid from his circulation is with a loop diuretic. Thiazide diuretics and potassium-sparing diuretics are not as potent and are not used for acute fluid accumulation. Alpha-blockers are not appropriate for a patient with edema.

Now that she is starting a cardiac glycoside, which laboratory value should you monitor closely?

*magnesium* Cardiac glycosides are very narrow therapeutic index medications. Electrolyte abnormalities, especially low magnesium and potassium, can cause patients to become toxic, which can lead to cardiac arrest. Both potassium and magnesium, as well as renal function and drug levels should be monitored regularly while patients are on cardiac glycosides. Although cardiac glycosides increase intracellular calcium as part of their mechanism of action, calcium level monitoring is not needed. Serum calcium levels do not correlate with levels of intracellular calcium.

The inhaled corticosteroid is available as a metered dose inhaler. You suggest Lisa use a spacer with the inhaled corticosteroid. Why do you recommend using a spacer?

*makes performing proper inhaler technique easier* Spacers improve delivery of the medication by slowing down the aerosolized particles. They make performing proper inhaler technique easier for patients. Peak flow meters help to measure how well asthma is controlled. Asthma action plans help patients recognize worsening symptoms and provides a plan of how to deal with them.

Lisa's primary care provider decides to prescribe a selective serotonin receptor inhibitor to treat her chronic anxiety. Which of the following would you include in your patient education of her new medication?

*may take several weeks to see benefits* The full therapeutic effects of SSRIs can take four to six weeks. This is important for patients to know. SSRIs can be taken with or without food. They should be taken at the same time of day, but patients do not need to avoid taking at bedtime. SSRIs are not associated with a high potential for dependence. Depression & Anxiety presentation. Objective 4.

Which of the following strategies is an appropriate recommendation for Kathy to improve her sleep?

*meditate at night before bed* Napping during the day can disrupt the normal sleep/wake cycle and lead to poor sleep at night. Alcohol is not recommended before bed because, although it is a depressant, it will disrupt sleep later in the night. Kathy should not do other activities such as reading or watching TV in bed. While vigorous exercise should not be done immediately before bed, relaxation exercises like meditation and yoga can help initiate sleep.

Lisa returns to clinic to follow up on her anxiety. She reports increased fatigue and restlessness. She is having trouble concentrating and finishing tasks. She feels like she cannot remember things anymore. She is also having palpitations and episodes in which she becomes sweaty and shaky. These symptoms are occurring almost daily. Over the past 2 weeks, she has needed to use her benzodiazepine daily. Which of her symptoms could be attributed with the use of her benzodiazepine?

*memory loss* Common adverse effects of benzodiazepines include memory loss, sedation, and impaired coordination. Depression & Anxiety presentation. Objective 3.

Denise wants to know what some of the long-term effects of diabetes are. Which of the following is NOT a complication of diabetes?

*migraine headaches* Diabetes has many long-term microvascular and macrovascular complications including retinopathy, neuropathy, nephropathy, peripheral vascular disease and cardiovascular disease. However, diabetes is not known to be associated with migraine headaches.

What is the generic name of Avelox®?

*moxifloxacin* Class of antibiotic = Fluoroquinolone

Lisa calls the clinic a few days later. She is having nausea as a result of her opioid. She is prescribed a dopamine antagonist. Which of the following is a potential, serious adverse effect of dopamine antagonist?

*muscle rigidity* Muscle rigidity is a type of extra pyramidal side effect (EPS) associated with dopamine antagonists. It can also be a symptom of neuroleptic malignant syndrome (NMS), which is a potentially fatal side effect of dopamine blockade. Nausea and vomiting presentation

Common side effects of Avelox®?

*nausea and diarrhea * The most common adverse effects of Avelox® are nausea, diarrhea, headache, dizziness, and vomiting.

Lisa is a 23 year-old woman with a history of asthma since early childhood. She also suffers from anxiety that often leads to insomnia. Which of the following vaccinations is Lisa a candidate for?

*pneumococcal and influenza * Given her asthma, Lisa is a candidate for pneumococcal and influenza vaccinations. Lisa may also be a candidate for the HPV vaccination as it is recommended for all females aged ≤26 years. Module 2 Learning Activity. Objective 1.

What is the mechanism of action for donezepil (Aricept®)?

*prevents the breakdown of acetylcholine* Donezepil prevents the breakdown of acetylcholine in the brain. This supports communication among nerve cells by keeping acetylcholine levels high. Acetylcholine is a chemical messenger important for learning and memory.

In addition to ensuring adequate dietary calcium and vitamin D intake, there are many other lifestyle changes that can help lower the risk of osteoporosis related fracture. Which of the following does NOT lower osteoporosis related fracture risk?

*red wine consumption* Lifelong weight bearing exercise, such as weight lifting, smoking cessation and fall prevention can all help lower the risk of osteoporosis related fractures. Red wine consumption does not lower risk for fracture and may actually increase fracture risk if consumption is in excess or leading to falls.

Once Brian has been stabilized and treated, he is being sent home with 2 vials of insulin to use, long-acting and rapid acting. You are first teaching him to self-inject his rapid acting insulin. Which of the following steps is NOT correct for injection using a needle and syringe?

*remove air from the vial using the syringe to balance the pressure* Brian should be educated to never shake clear insulin. This can cause air bubbles and may damage the insulin. He should visually inspect the vial. There should be no lumps, crystals, or discoloration. The units of air injected should be equal to the units of the insulin dose in order to balance the pressure in the vial. The tip of the stopper indicates the insulin dose. The syringe should be inspected for air bubbles and any bubbles should be removed.

What patient education would you provide to Kate on taking both calcium carbonate and levothyroxine (Synthroid®)?

*separate doses by at least 4 hours* Calcium carbonate can decrease or prevent the absorption of levothyroxine, potentially resulting in hypothyroidism. Doses of these medications should be separated by at least 4 hours. This information can be found in the package insert for levothyroxine (Synthroid®).

What medication (other than an SSRI) would be MOST appropriate for initial therapy to treat Kathy's depression? Kathy scores 13 points which indicates moderate depression. After more questioning, Kathy reports having depressed mood, fatigue, insomnia, weight gain and impaired concentration nearly every day for the past two weeks.

*serotonin norepinephrine reuptake inhibitor (SNRI)* A serotonin norepinephrine reuptake inhibitor (SNRI) would be the other choice for first line therapy for Kathy. TCAs are not commonly used for depression as they are not as effective at low doses and high doses tend to cause significant side effects. A dopamine reuptake inhibitor would not be the next choice as they are activating and can exacerbate insomnia, which Kathy has. Benzodiazepines are not indicated in depression, only anxiety.

After staying overnight, Tim is being discharged with an increased dose of his ACE inhibitor and a new prescription for a loop diuretic. He is to return to clinic in 2 weeks for follow up and labs. Which of the following lab values would be most appropriate to monitor the safety of both the ACE inhibitor and the loop diuretic?

*serum creatinine* Both loop diuretics and ACE inhibitors can affect renal function, so serum creatinine is the lab that should be checked. Another common lab would be potassium levels. Calcium and sodium can be affected by loop diuretics only and chloride is not relevant to either medication.

The x-ray comes back negative for fracture, and David is discharged with a prescription for a non-steroidal anti-inflammatory drug (NSAID) as well as with instructions for non-drug therapy of his injury, specifically R.I.C.E. Which of the following is NOT part of R.I.C.E. recommendations?

*stretch the joint constantly* R.I.C.E. recommendations are to rest, ice, compress and elevate the affected extremity or joint. Constant stretching is not recommended during the acute period as it can worsen the inflammation.

Which of the following is an indicator that Lisa's asthma is uncontrolled?

*using her short-acting beta agonist more than 2 times a week* Indicators of poor asthma control include reaction to environmental triggers, symptoms, increased use of short-acting beta agonist, poor inhaler technique, and non-adherence to daily medications. Use of short-acting beta agonists can further be assessed by using the "rule of twos." Lisa has been using her short-acting beta agonist more than 2 times a week. Adherence is not an issue for Lisa as she is not currently on any daily long-term controller medications for her asthma. As reported in the case, she demonstrates good inhaler technique. Having peak flow readings in the green zone indicates good control.

Anna is a 55 year old female receiving treatment for breast cancer. Her orders are for Herceptin 8mg/kg IV infused over 90 minutes. Anna weighs 50kg. What is the rate of the Herceptin infusion in milligrams per minute? Round your final answer to 2 decimal places.

4.44 mg/min

Heidi weighs 14 lb, what is her weight in kilograms? Round your final answer to 2 decimal places.

6.36 kg

Jenny has had a cough for the past few days and decides to take Delsym OTC. The regular adult dose is 10mL every 12 hours. If the concentration of Delsym in the bottle is 180mg/fl oz, how many milligrams will Jenny take in one dose?

60 mg

Bobby also has a fever and is ordered acetaminophen 15mg/kg to be given every 4 hours as needed for a temperature > 101.5F. The pharmacy sends a bottle of acetaminophen liquid that has 160mg in 5mL. How many milliliters of acetaminophen will Bobby get for each dose? Round your final answer to 2 decimal places.

8.52 mL