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National Patient Safety Goals (NPSGs)

***Set annually by TJC

What abbreviations should not be used?

1) U 2) IU 3) QD 4) QOD 5) Trailing 0 (X.0mg) 6) Lack of leading zero (.X mg) 7) MS 8) MSO4 and MgSO4

What are examples of high alert drugs?

1) hypertonic saline 2) insulin 3) heparin 4) potassium chloride 5) opioids 6) anti-coags 7) anything in epidurals

A patient needs to choose a stimulant laxative. Which of the following is considered a stimulant? Answer A Dulcolax B Mineral oil C Miralax D Amitiza E Colyte

Chief Complaint: "I am going to the bathroom 10 times a day". History of Present Illness: MJ is a 32 year-old female who presents to the ER describing a 2-week history of increasing abdominal pain and frequency of bowel movements. It started with 4-5 bowel movements per day and escalated to 6-8 bowel movements per day. There is sometimes blood in the stool. MJ saw her primary care physician 1 week ago and was told it could be irritable bowel syndrome. MJ has only been drinking Gatorade and eating saltine crackers for fear that the diarrhea and pain will get worse. She has lost weight, but doesn't weigh herself regularly, so she doesn't know how much. MJ has not traveled out of the country and has eaten the same foods as her husband (and he is not ill). Allergies: sulfa (rash) Past Medical History: none Medications: Seasonique, Loperamide (started one week ago), Bentyl (started one week ago) Physical Exam/Vitals: Height: 5'2" Weight: 102 pounds BP: 115/65 mmHg HR: 106 BPM RR: 14 BPM Temp: 99.2°F Pain: 5/10 General appearance: thin, young female HEENT: dry mucous membranes CV: tachycardia, regular rhythm Lungs: clear Abdomen: diffusely tender to palpation Extremities: dry skin Labs: Na (mEq/L) = 142 (135 - 145) K (mEq/L) = 4.8 (3.5 - 5) Cl (mEq/L) = 100 (95 - 103) HCO3 (mEq/L) = 26 (24 - 30) BUN (mg/dL) = 28 (7 - 20) SCr (mg/dL) = 1.3 (0.6 - 1.3) Glucose (mg/dL) = 79 (100 - 125) Ca (mg/dL) = 9.2 (8.5 - 10.5) Mg (mEq/L) = 1.9 (1.3 - 2.1) PO4 (mg/dL) = 4.2 (2.3 - 4.7) WBC (cells/mm3) = 9.3 (4 - 11 x 103) Hgb (g/dL) = 12.9 (12 - 16) Hct (%) = 39.2 (36 - 46) Plt (cells/mm3) = 399 (150 - 450 x 103) AST (IU/L) = 15 (10 - 40) ALT (IU/L) = 12 (10 - 40) Albumin (g/dL) = 4.5 (3.5 - 5) ESR (mm/hr) = 12 (≤ 20 male, ≤ 30 female) Tests: CT of the abdomen: Discontinuous pattern of inflammation in the ascending/transverse colon and ileum. Rectum appears unaffected. Numerous strictures and bleeding are noted throughout the GI tract. Plan: Admit for consultation with GI service. Question The Gastroenterologist diagnoses MJ with mild Crohn's disease. After 72 hours of therapy in the hospital she is feeling better, having fewer loose stools, and less pain. Which of the following is the best medication to discharge MJ on? Answer A Entocort EC capsules PO B Uceris tablets PO C Uceris rectal foam D Azulfadine PO E Canasa suppositories

Which of the following could be contributing to CD's constipation? Answer A Verapamil B Lisinopril C Dyslipidemia D Metformin E Hypertension

Avoid "Do Not Use" Abbreviations

Abbreviations are unsafe and contribute to many med errors The minimum list of DNU abbrev. per TJC is shown in the table ISMP also publishes a list of error prone abbrev, symbols, and dosage designations

Use Soap and Water

After caring for a patient with diarrhea or known C. diff ~ alcohol based hand rubs have poor activity against spores Before caring for patients with food allergies

"Which associated disorder might a client with ulcerative colitis exhibit " 1. Gallstone 2. Hyronephrosis 3.Nephrolithiasis 4. Toxic megacolon

Answer 4, Toxic megacolon is extreme dilation of a segemnt of the diseased colon caused by paralysis of the colon

A patient with constipation presents with a new prescription for Amitiza 24 mcg BID #60. Which of the following is an appropriate generic substitution for Amitiza? Answer A Alvimopan B Lubiprostone C Linaclotide D Methylnaltrexone E Plecanatide

How many half-lives are required to reach steady state (assuming a one compartment model and no loading dose)? A Approximately 2 B Approximately 5 C Approximately 8 D Approximately 12 E Steady state is reached after 2 days of continuous drug administration with no missed doses.

What is meant by the term "distal" ulcerative colitis? Answer A Near the duodenum B Near the rectum C Near the ileum D Near the lower esophageal sphincter E Adjacent to the stomach

What is the brand name of azathioprine? Answer A Zyloprim B Imuran C Azulfidine D Asacol E Rowasa

Chief Complaint: "I am going to the bathroom 10 times a day". History of Present Illness: MJ is a 32 year-old female who presents to the ER describing a 2-week history of increasing abdominal pain and frequency of bowel movements. It started with 4-5 bowel movements per day and escalated to 6-8 bowel movements per day. There is sometimes blood in the stool. MJ saw her primary care physician 1 week ago and was told it could be irritable bowel syndrome. MJ has only been drinking Gatorade and eating saltine crackers for fear that the diarrhea and pain will get worse. She has lost weight, but doesn't weigh herself regularly, so she doesn't know how much. MJ has not traveled out of the country and has eaten the same foods as her husband (and he is not ill). Allergies: sulfa (rash) Past Medical History: none Medications: Seasonique, Loperamide (started one week ago), Bentyl (started one week ago) Physical Exam/Vitals: Height: 5'2" Weight: 102 pounds BP: 115/65 mmHg HR: 106 BPM RR: 14 BPM Temp: 99.2°F Pain: 5/10 General appearance: thin, young female HEENT: dry mucous membranes CV: tachycardia, regular rhythm Lungs: clear Abdomen: diffusely tender to palpation Extremities: dry skin Labs: Na (mEq/L) = 142 (135 - 145) K (mEq/L) = 4.8 (3.5 - 5) Cl (mEq/L) = 100 (95 - 103) HCO3 (mEq/L) = 26 (24 - 30) BUN (mg/dL) = 28 (7 - 20) SCr (mg/dL) = 1.3 (0.6 - 1.3) Glucose (mg/dL) = 79 (100 - 125) Ca (mg/dL) = 9.2 (8.5 - 10.5) Mg (mEq/L) = 1.9 (1.3 - 2.1) PO4 (mg/dL) = 4.2 (2.3 - 4.7) WBC (cells/mm3) = 9.3 (4 - 11 x 103) Hgb (g/dL) = 12.9 (12 - 16) Hct (%) = 39.2 (36 - 46) Plt (cells/mm3) = 399 (150 - 450 x 103) AST (IU/L) = 15 (10 - 40) ALT (IU/L) = 12 (10 - 40) Albumin (g/dL) = 4.5 (3.5 - 5) ESR (mm/hr) = 12 (≤ 20 male, ≤ 30 female) Tests: CT of the abdomen: Discontinuous pattern of inflammation in the ascending/transverse colon and ileum. Rectum appears unaffected. Numerous strictures and bleeding are noted throughout the GI tract. Plan: Admit for consultation with GI service. Question MJ is prescribed oral budesonide at discharge. Which of following counseling points is correct? Answer A The brand name is Uceris; it should be taken twice daily for four weeks. B Budesonide has no drug interactions so MJ can use over the counter medications without issue. C The capsule can be opened and sprinkled in a small amount of applesauce or pudding. D Budesonide is generally used for eight weeks at a time to treat active disease (for treatment of an acute flare). E Budesonide works better than prednisone in treating the disease symptoms.

Proctitis refers to inflammation of the following: Answer A Small intestine B Gall bladder C Liver D Rectum E Esophagus

Who do experts think is the problem of medication errors?

Design of medical system and NOT individual error

What is the most common type of medication error?

Giving wrong drug or wrong dose to a pt

Contact precautions recommended for patients infected with

MRSA VRE C.Diff

Use of the Metric System

Measurements should be recorded in the metric system only

Risky technology behavior

Overriding computer alerts without proper consideration not using available technology

What is error of commission?

Something done incorrectly

Background

The Joint Commission (TJC) and the Institute for Safe Medical Practices (ISMP) are the 2 organizations actively involved in improving medication safety

Reporting

The hospital's Pharmacy and Therapeutics (P&T) committee and Medication Safety Committee (or similar entity) should be informed of the error

Contact precautions are recommended for which patients? How should healthcare professionals enter the room?

Those with MRSA, VRE, and/or C. difficile infections

Paroxetine

Which of the following medications is not used as a mood stabilizer in treatment of bipolar disease?

Contact precaution

for patients with colonized MRSA and VRE Need gloves and gown

Droplet precaution

for pts with Pertusis, influenza, adenovirus, rhinovirus, meningitides, group A step Need mask

Should u report errors to patients only?

no patients and prescribers ASAP

Hydromorphone is ___ times more potent than morphine

six times

What is error of omission?

something was left out that is needed for safety

Benefits of patient controlled analgesia

treat pain quickly mimics the pain pattern more closely and provides good pain control

Risky work environment behabior

trying to do multiple things vs. focusing on a single task inadequate supervision and training

airborne precautions recommended for patients infected with

tuberculosis measles chickenpox

What is a sentinel event?

unexpected occurrence involving death or serious physical / psychological injury

Steps to reduce harm from anticoagulant therapy

use standardized dosing protocols programmable pumps for heparin education to patients starting dose ranges alternate dosing strategies Address food/drug interactions Baseline INR requirements

What are 2016 NPSGs?

• Labeling in the sterile field, perioperative setting, etc. • Reduce harm associated with anticoagulation • Communicate accurate information (med reconciliation) • Report critical results in a timely manner • CDC hang hygiene • Reduce healthcare associated infections • Use at least 2 patient identifiers

What is preferred to "use as directed"?

"Use per instructions on the dosing calendar" for warfarin

How can high alert medication be used more safely?

- Developing protocols or order sets (insulin and KCl) - Using premixed products whenever possible (KCl) - Limiting concentrations available in the institution - Stocking high alert products in the pharmacy (not in ADCs or on nursing units)

What are the safety injection practices for healthcare facilities?

- Never admin an oral solution/suspension IV (use oral syringes) and label syringes for oral use only - Never reinsert used needles into a multiple-dose vial or solution (single are preferred) - Never touch the tip or plunger of syringe - Discard a disposable needle or sharp into container without recapping asap

Where can used sharps be disposed?

- Public drop boxes and mail boxes - Hazardous waste pick-up days or collection sites - Police and fire departments - Pharmacies

Why should multiple-dose vials be avoided?

- Risk for cross contamination (infection) - Overdosing If use, only use for a single patient until they are done. Discard the rest.

Which associated disorder might a client with Crohn's disease exhibit most often? 1. Ankylosing spondylitis 2. Colon cancer 3. Malabsorption 4. Lactase deficiency Answer 3; Malabsorption Because of the transmural nature of Crohn's disease lesions, malabsorption may occur with Crohn's disease. Although ankylosing spondylitis and colon cancer are more commonly associated with ulcerative colitis, they may be seen in clients with Crohn's disease, Lactase deficiency is caused by a congenital defect in which an enzyme isn't present. Nurse is caring for a patient with a diagnosis of ulcerative colitis. Which finding, if noted on assessment of the client, would the nurse report to the Dr? A. Hypotension B. Bloody diarrhea C. Rebound tenderness D. Hemoglobin of 12 mg/ dl C. Rebound tenderness because this could indicate peritonitis. A client with acute colcerative colitis requests a snack. Which of the following foods is the most appropriate to give the client? A. Carrots and ranch dip B. Whole grain cereal and milk C. A cup of popcorn and a cola D. Applesauce and a graham cracker D, appelsauce and graham cracker, The diet for a client with ulcerative coliits should be a low-fiber, low residue diet. The nurse should avoid foods such as whole grains, nuts and fresh fruit or vegetables. Typically lactose containing foods are also poorly tolerated. The client should also avoid caffeine, pepper, and alcohol. The client is diagnosed with an acute exacerbation of ulcerative colitis. Which intervention should the nurse implement? 1. Provide a low-residue diet. 2. Monitor intravenous ﬂuids. 3. Assess vital signs daily. 4. Administer antacids orally. 1. The client's bowel should be placed on rest and no foods or ﬂuids should be introduced into the bowel. 2. (CORRECT) The client requires fluids to help prevent dehydration from diarrheh and to replace fluid lost through normal body functioning. 3. The vital signs must be taken more often than daily in a client who is having an acute exacerbation of ulcerative colitis. 4. The client will receive anti-inflammatory and antidiarrheal medications, not antacids, which are used for gastroenteritis. The client is diagnosed with Crohn's disease, also known as regional enteritis. Which statement by the client would support this diagnosis? 1. "My pain goes away when I have a bowel movement." 2."I have bright red blood in my stool all the time." 3."I have episodes of diarrhea and constipation." 4."My abdomen is hard and rigid and I have a fever." Correct answer: #1 pain goes away w/ BM, The terminal ileum is the most common site for regional enteritis and causes right lower quadrant pain that is relieved by defecation. The nurse is reviewing the record of a client with Chron's disease. Which stool characteristic should the nurse expect to note documented in the client's record? 1. Diarrhea 2. Chronic constipation 3. Constipation alternating with diarrhea 4. Stool constantly oozing from teh rectum Diarrhea, Crohn's disease is characterized by nonbloody diarrhea of usually not more than four to five stools daily. Over time, the diarrhea episodes increase in frequency, duration, and severity. Options 2, 3, and 4 are not characteristics of Crohn's disease. "In planning care for the patient with crohns disease the nurse recognizes that a major difference between UC and Crohn's disease is that: 1. Frequently results in toxic megacolon 2. causes fewer nutritional deficiencies than does UC 3. Often recurs after surgery whereas UC is curable with a colectomy 4. is manifested by rectal bleeding and anemia more frequently than UC" Answer 3, "Medication is the primary treatment for Crohn's disease" A client is admitted with irritable bowel syndrome. The nurse would anticipate the client's history to reflect which of the following? 1. Pattern of alternating diarrhea and constipation. 2. Chronic diarrhea stools occurring 10-12 times per day. 3. Diarrhea and vomiting with severe abdominal distention. 4. Bloody stools with increased cramping after eating. Think about each answer choice. (1) correct-condition is often called spastic bowel disease; no inflammation is present (2) refers to inflammatory bowel disease such as ulcerative colitis or Crohn's disease (3) refers to inflammatory bowel disease such as ulcerative colitis or Crohn's disease (4) bloody stools do not occur 38. The nurse is caring for a hospitalized female client with a diagnosis of ulcerative colitis. Which finding, if noted on assessment of the client, would the nurse report to the physician? "a. Hypotension b. Bloody diarrhea c. Rebound tenderness d. A hemoglobin level of 12 mg/dL" Answer C. Rebound tenderness may indicate peritonitis. Bloody diarrhea is expected to occur in ulcerative colitis. Because of the blood loss, the client may be hypotensive and the hemoglobin level may be lower than normal. Signs of peritonitis must be reported to the physician. "The nurse is teaching the client about gastritis. Which of the following statements by the nurse would be more accurate in describing gastritis? 1. Erosion of the gastric mucosa 2. Inflammation of a diverticulum 3. Inflammation of the gastric mucosa 4. Reflux of stomach acid into the esophagus" "3. Gastritis is an inflammation of the gastric mucosa that may be accute (often resulting from exposure to local irritants) or chronic (associated w/ autoimmune infections or atrophic disorders of the somach). Erosion of the mucosa results in ulceration. Inflammation of the diverticulum is called diverticulitis; reflux of stomach acid is known as gastroesophageal reflux disease." "Which sign/symptom should the nurse expect to find in a client diagnosed with ulcerative colitis? 1. Twenty bloody stools a day. 2. Oral temperature of 102 ̊F. 3. Hard, rigid abdomen. 4. Urinary stress incontinence." Answer = 1. The colon is ulcerated and unable to absorb water, resulting in bloody diar- rhea. Ten (10) to 20 bloody diarrhea stools is the most common symptom of ulcerative colitis. 2. Inflammation usually causes an elevated temperature but is not expected in the client with ulcerative colitis. 3.A hard, rigid abdomen indicates peritonitis, which is a complication of ulcerative colitis but not an expected symptom. 4. Stress incontinence is not a symptom of colitis." The nurse is caring for a client diagnosed with ulcerative colitis. Which symptom(s) support this diagnosis? 1. Increased appetite and thirst 2. Elevated hemoglobin 3. Multiple bloody, liquid stools. 4. Exacerbations unrelated to stress Answer 3: Clients report as many as 10 to 20 liquid bloody stools in a day. The nurse is reviewing the record of a client with Crohn's disease. Which stool characteristic should the nurse expect to note documented in the client's record? 1. Diarrhea 2. Chronic constipation 3. Constipation alternating with diarrhea 4. Stool constantly oozing from the rectum Diarrhea, Rationale: Crohn's disease is characterized by nonbloody diarrhea of usually not more than four to five stools daily. Over time, the diarrhea episodes increase in frequency, duration and severity. Options 2, 3 and 4 are not characteristics of Crohn's diease. The nurse prepares for the admission of a client with a perforated duodenal ulcer. Which of the following should the nurse expect to observe as the primary initial symptom? 1. Fever 2. Pain 3. Dizziness 4. Vomiting 2, Pain: 1. Fever - later with peritonitis (S/S: pain, nausea, vomiting, rigid abdomen, low-grade fever, absent bowel sounds, shallow respirations). 2. Pain - CORRECT: sudden, sharp, begins mid-epigastric; boardlike abdomen. 3. Dizziness - later with shock (S/S: hypotension, tachycardia, tachypnea, decreases urinary output, decrased LOC). 4. Vomiting - seen with peritonitis The client diagnosed with Crohn's disease is crying and tells the nurse, "I can't take itanymore. I never know when I will get sick and end up here in the hospital." Whichstatement would be the nurse's best response? 1."I understand how frustrating this must be for you."2."You must keep thinking about the good things in your life." 3. "I can see you are very upset. I'll sit down and we can talk."4."Are you thinking about doing anything like committing suicide?" Answer 3, I can see you are very upset, I'll sit down and we can talk, "1.The nurse should never tell a client that they understand what they are going through.2.This is not addressing the client's feelings. 3. (Correct answer) The client is crying and is expressing feel-ings of powerlessness; therefore the nurseshould allow the client to talk. 4.The client is crying and states "I can't take itanymore," but this is not a suicidal commentor situation." The client is diagnosed with Crohn's disease, also known as regional enteritis. Which statement by the client supports this diagnosis? 1. "My pain goes away when I have a bowel movement." 2. "I have bright red blood in my stool all the time." 3. "I have episodes of diarrhea and constipation." 4. "My abdomen is hard and rigid and I have a fever." 1. "My pain goes away when I have a bowel movement, 1. (correct) The terminal ileum is the most common site for regional enteritis, which causes right lower quandrant pain that is relieved by defecation. 2. Stools are liquid or semiformed and do not contain blood. 3. Episodes of diarrhea and constipation may be a sign/symptom of colon cancer, not Crohn's disease. 4. A fever and hard rigid abdomen are signs/symptoms of peritonitis, a complication of Crohn's disease. Following bowel resection, a patient has a nasogastric tube to suction, but complains of nausea and abdominal distention. The nurse irrigates the tube prn as ordered, but the irrigating fluid does not return. Which of the following should be the priority action by the nurse? A. Notify the physician B. Auscultate for bowel sounds. C. Reposition the tube and check for placement. D. Remove the tube and replace it with a new one. C, reposition the tube and check for placementThe tube may be resting against the stomach wall. The first action by the nurse, since this was intestinal surgery (not gastric surgery), is to reposition the tube and check it again for placement. "Older patients with longstanding or severe Crohn's disease can exhibit which of the following? a Hyperalbuminemia b)Hypoalbuminemia c) Decreased sedimentation rate d)Nausea and vomiting Hypoalbuminemia, Rationale wasn't given for this question but Crohns affects the GI tract which will affect the ability to absorb protein so it is lost through the urine. The nurse is caring for a male client postoperatively following creation of a colostomy. Which nursing diagnosis should the nurse include in the plan of care? -1) a. sexual dysfunction b. body image, disturbed c. fear related to poor prognosis d. Nutrition: more than body requirements, imbalanced Answer B. Body image, disturbed relates to loss of bowel control, the presence of a stoma, the release of fecal material onto the abdomen, the passage of flatus, odor, and the need for an appliance (external pouch). No data in the question support options A and C. Nutrition: less than body requirements, imbalanced is the more likely nursing diagnosis. 18. The client is diagnosed with an acute exacerbation of IBD. Which priority intervention should the nurse implement first? "1. Weigh the client daily and document it in the client's chart. 2. Teach coping strategies such as dietary modifications. 3. Record the frequency, amount, and color of stools. 4. Monitor the client's oral fluid intake every shift." Answer 3, Record the frequency, amount, and color of stools"Rationale by answer option: 1. Weighing the client daily will help identify if the client is experiencing malnutrition, but it is not the priority intervention during an acute exacerbation. 2. Coping strategies help develop healthy ways to deal with this chronic disease that has remissions and exacerbations, but it is not the priority intervention. 3. The severity of the diarrhea helps determine the need for fluid replacement. The liquid stool should be measured as part of the total output. (CORRECT) 4. The client will be NPO when there is an acute exacerbation of IBD to allow the bowel to rest." During the assessment of a patient with acute abdominal pain, the nurse should: a. perform deep palpation before ausculation b. obtain BP and pulse rateto determine hypervolemic changes c. auscultate bowel sounds because hyperactive bowel sounds suggest paralytic ileus d. measure body temperature because and elevated temperature may indicate an inflammatory or infectious process. Answer D, If the temperature is elevated pain may be due to infection. A patient returns to his room following a lower GI series. When he is assessed by the nurse, he complains of weakness. Which of the following nursing diagnoses should receive priority in planning his care? 1. Alteration in sensation - gustatory 2. Constipation, colonic 3. High risk for fluid volume deficit 4. Nutrition, less than body requirements Answer 3, high risk for fluid vol. deficitprep for test: low-residue or clear liquid diet 2 days, NPO midnight, enemas, laxatives, post-test: laxatives to remove barium The client is diagnosed with an acute exacerbation of ulcerative colitis. Which intervention should the nurse implement? 1.Provide a low-residue diet.2.Monitor intravenous ﬂuids.3.Assess vital signs daily.4.Administer antacids orally. 2. The client requires fluid to prevent dehydration from diarrhea and to replace fluid lost through normal body functioning. A client with inflammatory bowel disease is receiving TPN (total parenteral nutrition) via an infusion pump. When administering TPN it is essential that the nurse: A. monitor the clients blood glucose level Q2H at the bedside with a glucometer B. change the TPN solution bag every 24 hours even if there is solution left in the bag C. instruct the client to breathe shallowly when changing the TPN tubing using sterile technique D. speed up the rate of the TPN infusion if the amount delivered has fallen behind the prescribed hourly rate B. TPN solutions are high in glucose and are administered at room temperature, factors that increase the risk of microbial growth in the solution. They should be changed daily or sooner if they appear cloudy. A client with Crohn's disease is admitted to the hospital with a history of chronic, bloody diarrhea, weight loss, and signs of general malnutrition. The client has anemia, a low serum albumin level, and signs of negative nitrogen balance. The nurse concludes that the client's health status is related to a major deficiency of: 1. Iron 2. Protein 3. Vitamin C 4. Linoleic acid CORRECT ANSWER 2: Protein deficiency causes a low serum albumin level, which permits fluid shifts from the intravascular to the interstitial compartment, resulting in edema. Decreased protein also causes anemia; protein intake must be increased. Although a deﬁciency of iron will result in anemia, it will not cause the other adaptations. Vitamin C and linoleic acid are unrelated to these adaptations. The nurse is teaching a female client how to perform a colostomy irrigation. To enhance the effectiveness of the irrigation and fecal returns, what measure would the nurse tell the client to do? "a. Increase fluid intake b. Place heat on the abdomen c. Perform the irrigation in the evening d. Reduce the amount of irrigation solution" Answer A. To enhance effectiveness of the irrigation and fecal returns, the client is instructed to increase fluid intake and to take other measures to prevent constipation. Options B, C and D will not enhance the effectiveness of this procedure. Which diagnostic test is used first to evaluate a client with upper GI bleeding? "a) Hemoglobin levels and hematocrit (HCT) b) Endoscopy c) Arteriography d) Upper GI series Correct Answer: (A) Hgb and Hct levels" Hemoglobin and HCT are typically performed first in clients with upper GI bleeding to evaluate the extent of blood loss. Endoscopy is then performed to directly visualize the upper GI tract and locate the source of bleeding. An upper GI series, or barium study, usually isn't the diagnostic method of choice, especially in a client with acute active bleeding who's vomiting and unstable. An upper GI series is also less accurate than endoscopy. Although an upper GI series might confirm the presence of a lesion, it wouldn't necessarily reveal whether the lesion is bleeding. Arteriography is an invasive study associated with life-threatening complications and wouldn't be used for an initial evaluation. The nurse is assigning clients for the evening shift. Which of the following clients are appropriate for the nurse to assign to a licensed practical nurse to provide client care? Select all that apply. "1. A client with Crohn's disease who is receiving total parenteral nutrition (TPN). 2. A client who underwent inguinal hernia repair surgery 3 hours ago. 3. A client with an intestinal obstruction who needs a Cantor tube inserted. 4. A client with diverticulitis who needs teaching about his take-home medications. 5. A client who is experiencing an exacerbation of his ulcerative colitis." "2,5 The nurse should consider client needs and scope of practice when assigning staff to provide care. The client who is recovering from inguinal hernia repair surgery and the client who is experiencing an exacerbation of his ulcerative colitis are appropriate clients to assign to a licensed practical nurse as the care they require fall within the scope of practice for a licensed practical nurse. It is not within the scope of practice for the licensed practical nurse to administer TPN, insert nasoenteric tubes, or provide client teaching related to medications." THe nurse is caring for a client with a diagnosis of Crohn's disease. When evaluating a clients response to healthcare intervention, which expected outcome is the most important for the client: A. does skincare B. takes oral fluids C. gains .5 lb per week D. experiences less abdominal cramping Answer C = gains .5lbs/wk, weight loss usually is severe with Crohn's disease, therefore, weight gain is a priority. this goal is specific, realistic, measureable and has a timeframe. A client with inflammatory bowel disease (IBD) requires an ileostomy. The nurse would instruct the client to do which of the following measures as an essential part of caring for the stoma? 1.Perform massage of the stoma three times a day. 2.Include high-fiber foods in the diet, especially nuts. 3.Limit fluid intake to prevent loose stools. 4.Cleanse the peristomal skin meticulously. 4; cleanse peristomal skin meticulously1.It is not an intervention used for ileostomies. 2.Clients should avoid the high-fiber and gas-producing foods. 3.These clients are not on fluid restriction. 4.Careful cleansing is necessary to prevent skin breakdown and skin irritation. Older patients with longstanding or severe Crohn's disease can exhibit which of the following? A. Hyperalbumineria B. Hypoalbumenria C. Decreased Sedimentation Rate (ESR) D. Nausea and Vomiting B, hypoalbumenriaThey may be seen with conditions in which the body does not properly absorb and digest protein, such as Crohn's disease or celiac disease, or in which large volumes of protein are lost from the intestines. A client who has a history of Crohn's disease is admitted to the hospital with fever, diarrhea, cramping, abdominal pain, and weight loss. The nurse should monitor the client for: ) 1. Hyperalbuminemia. 2. Thrombocytopenia. (3.) Hypokalemia. 4. Hypercalcemia. Hypokalemia is the most expected laboratory finding owing to the diarrhea. Hypoalbuminemia can also occur in Crohn's disease; however, the client's potassium level is of greater importance at this time because a low potassium level can cause cardiac arrest. Anemia is an expected development, but thrombocytopenia is not. Calcium levels are not affected. "The client is diagnosed with Crohn's disease, also known as regional enteritis. Whichstatement by the client would support this diagnosis? (1)."My pain goes away when I have a bowel movement."2."I have bright red blood in my stool all the time."3."I have episodes of diarrhea and constipation."4."My abdomen is hard and rigid and I have a fever." "(1).The terminal ileum is the most common site for regional enteritis and causes right lower quadrant pain that is relieved by defecation. 2.Stools are liquid or semi-formed and usually do not contain blood.3.Episodes of diarrhea and constipation may be asign/symptom of colon cancer, not Crohn'sdisease.4.A fever and hard rigid abdomen are signs/symptoms of peritonitis, a complication of Crohn's disease." "Which of the following would be the highest priority information to include in preoperative teaching for a 68-year old patient scheduled for a colectomy? "A. how to care for the wound (B). how to deep breath and cough C. the location and care of drains after surgery D. what medications will be used during surgery" Because anasthesia, an abdominal incision, and pain can impair the patient's respiratory status in the postoperative period, it is of high priority to teach the pt. to cough and deep breathe. Otherwise, the pt. could develop atelectasis and pneumonia, which would delay early recovery from surgery and hospital discharge. "The results of a patient's recent endoscopy indicate the presence of peptic ulcer disease (PUD). Which of the following teaching points should the nurse provide to the patient in light of his new diagnosis? "A. "You'll need to drink at least two to three glasses of milk daily." B. "It would likely be beneficial for you to eliminate drinking alcohol." C. "Many people find that a minced or pureed diet eases their symptoms of PUD." D. "Your medications should allow you to maintain your present diet while minimizing symptoms."" "Although there is no specific recommended dietary modification for PUD, most patients find it necessary to make some sort of dietary modifications to minimize symptoms. Milk may exacerbate PUD and alcohol is best avoided because it can delay healing." In planning care for a patient with ulcerative colitis, the nurse should anticipate which of the following diagnostic procedures? a. sigmoidodscopy b. colonoscopy, c. rectal mucosa biopsy, d. all of the above Diagnosis of ulcerative colitis is confirmed with the use of sigmoidoscopy, colonoscopy, and rectal mucosa biopsy. The nurse performs a detailed assessment of the abdomen of a patient with a possible bowel obstruction, knowing that a manifestion of an obstruction in the large intestine is (select all that apply) a ) a largely distended abdomen b) diarrhea that is loose or liquid c) persistent, colickcy abdominal pain d) profuse vomiting that relieves abdominal pain. A & C: distended abd + colicky abd painPersistent, colicky abdominal pain is seen with lower intestinal obstruction. Abdominal distention is markedly incerased in lower interestinal obstructions. Onset of a large intestine obstruction is gradual, vomiting is rare, and there is usually absolute constipation. The client with inflammatory bowel disease had surgery to create a continent kock's ileostomy yesterday. The client refuses to look at the stoma when the nurse is teaching stoma care. The best nursing intervention for the nurse to take is to: "A. notify the physician that the patient is depressed. B. continue patient teaching to meet care goals. C. encourage the client to verbalize feelings related to the stoma. D. offer the client a mirror so they can examine the stoma later when they wish to do so." C, encourage to talk about feelingsRationale: Clients who have a stoma often experience alterations in body image. The nurse should encourage the client to verbalize feelings related to disease process and stoma A client who has a history of chronic ulcertaive colitis is diagnosed with anemia. The nurse intreprets that which factor is most likely responxible for the anemia? a. Blood Loss b. Intestinal hookworm c. intestinal malaborption d. Decreased intake of dietary iron Blood loss, The client with chronic ulcerative colitis is most likely enemic as a result of chronic blood loss in small amounts tha occurs with exacerbations of the disease. These clients often have bloody stools and are at increasd risk for anemia. There is no information in the question to supprot options b. or d. In ulcerative colitis, the large intestine is involves, not the small intestine, where vitamin B12 and folic acid are absorbed (option c.) "Which goal for the client's care should take priority during the first days of hospitalization for an exacerbation of ulcerative colitis? source: "A:promoting self care and independence B:managing diarrhea C:maintaining adequate nutrition D:promoting rest and comfort" "B. managing diarrhea Diarrhea is the primary symptom in an exacerbation of ulcerative colitis, and decreasing the frequency of stools is the first goal of treatment. The other goals are ongoing and will be best achieved by haulting the exacerbation. The client may recieve antidiarrheal agents, antispasmodic agents, bulk hydrophilic agents, or anti-inflammatory drugs." The nurse is preparing for discharge of a client who recieved a colectomy 4 days earlier. Which of the following nursing care goals has the highest priority prior to discharge?"A: Lung are clear per auscultation B: incision is healed without redness or drainage C: bowel sounds present, client expels flatus D: vital signs within normal limits" The correct answer is C because a collectomy involved the GI tract, the return of normal GI function is most important; the nurse assures the client is expelling gas prior to discharge. A client who has had ulcerative colitis for the past 5 years is admitted to the hospital with an exacerbation of the disease. Which of the following factors was most likely of greatest significance in causing an exacerbation of ulcerative colitis? 1. A demanding and stressful job. 2. Changing to a modified vegetarian diet 3. Beginning a weight-training program 4. Walking 2 miles every day C, Stressful and emotional events have been clearly linked to exacerbations of ulcerative colitis, although their role in the etiology of the disease has been disproved. A modified vegetarian diet or an exercise program is an unlikely cause of the exacerbation When planning care for a client with ulcerative colitis who is experiencing an exacerbation of symptoms, which client care activities can the nurse appropriately delegate to an unlicensed assistant? Select all that apply. / 1. Assessing the client's bowel sounds. 2. Providing skin care following bowel movements.3. Evaluating the client's response to antidiarrheal medications. 4. Maintaining intake and output records. 5. Obtaining the client's weight. (2,4, & 5 are CORRECT)The nurse can delegate the following basic care activities to the unlicensed assistant: providing skin care following bowel movements, maintaining intake and output records, and obtaining the client's weight. Assessing the client's bowel sounds and evaluating the client's response to medication are registered nurse activities that cannot be delegated. Which of the following would be the highest priority information to include in preoperative teaching for a 68-year-old patient scheduled for a colectomy? "A: How to care for the wound B: How to deep breathe and cough C: The location and care of drains after surgery D: What medications will be used during surgery" B: How to deep breathe and coughBecause anesthesia, an abdominal incision, and pain can impair the patient's respiratory status in the postoperative period, it is of high priority to teach the patient to cough and deep breathe. Otherwise, the patient could develop atelectasis and pneumonia, which would delay early recovery from surgery and hospital discharge. "Treatment of Crohn's disease? "1. Diet 2. Vitamins 3. Medications 4. Surgery 5. All of thee above "A low residue diet is recommend low fiber diet vitamins and iron suplements are recommended Surgery is an option and helps to relieve symptoms (lecture)" The client diagnosed with IBD is prescribed TPN. Which nursing intervention should the nurse implement? (Med-Surg Success, 2nd Edition, Davies Q&A Success Series) 1, Check the patients glucose level 2. Administer and oral hypoglycemic 3. Access the peripheral IV site. 4. Monitor the client's oral food intake 1, Check patient's glucose level The nurse cares for a client receiving a balanced completed food by tube. The nurse knows the MOST common complication of a tube feeding is which of the following? "1: Edema 2: Diarrhea 3: Hypokalemia 4: Vomiting" 2, diarrhea A patient with a history of peptic ulcer disease has presented to the emergency department with complaints of severe abdominal pain and a rigid, boardlike abdomen, prompting the health care team to suspect a perforated ulcer. Which of the following actions should the nurse anticipate? a. Providing IV fluids and inserting a nasogastric tube; b. Administering oral bicarbonate and testing the patient's gastric pH level; c. Performing a fecal occult blood test and administering IV calcium gluconate; d. Starting parenteral nutrition and placing the patient in a high-Fowler's position; A, IV fluids + NG tubeA perforated peptic ulcer requires IV replacement of fluid losses and continued gastric aspiration by NG tube. Nothing is given by mouth and gastric pH testing is not a priority. Calcium gluconate is not a medication directly relevant to the patient's suspected diagnosis and parenteral nutrition is not a priority in the short term "A client is admitted with inflammatory bowel syndrome (Crohn's disease). Which treatment measures should the nurse expect to be part of the care plan? SELECT ALL THAT APPLY! "1) Laculose therapy 2) High fiber diet 3) High protein milkshakes 4) Corticosteroid therapy 5) Antidiarrheal medications 4) Corticosteroid therapy 5) Antidiarrheal medications

...

What are the methods to reduce medication errors?

1) avoid the "Do not use" abbreviations, symbols and dosage designations 2) Tall man letting 3) High alert drugs 4) Med Recs 5) Metric system 6) Not relying on packaging for identification

A client with ulcerative colitis is to take sulfasalazine (Azulfidine). Which of the following instructions should the nurse provide for the client about taking this medication at home? Select all that apply. 1. Drink enough fluids to maintain a urine output of at least 1,200- 1,500 mL per day. 2. Discontinue therapy if symptoms of acute intolerance develop and notify the health care provider. 3. Stop taking the medication if the urine turns orange-yellow. 4. Avoid activities that require alertness. 5. If dose is missed, skip and continue with the next dose.

1, 2, 4. Sulfasalazine may cause dizziness and the nurse should caution the client to avoid driving or other activities that require alertness until response to medication is known. If symptoms of acute intolerance (cramping, acute abdominal pain, bloody diarrhea, fever, headache, rash) occur, the client should discontinue therapy and notify the health care provider immediately. Fluid intake should be sufficient to maintain a urine output of at least 1,200- 1,500 mL daily to prevent crystalluria and stone formation. The nurse can also inform the client that this medication may cause orange-yellow discoloration of urine and skin, which is not significant and does not require the client to stop taking the medication. The nurse should instruct the client to take missed doses as soon as remembered unless it is almost time for the next dose.

A client with ulcerative colitis expresses serious concerns about her career as an attorney because of the effects of stress on ulcerative colitis. Which of the following nursing interventions will be most helpful to the client? 1. Review her current coping mechanisms and develop alternatives, if needed. 2. Suggest a less stressful career in which she would still use her education and experience. 3. Suggest that she ask her colleagues to help decrease her stress by giving her the easier cases. 4. Prepare family members for the fact that she will have to work part-time.

1. A client with ulcerative colitis need not curtail career goals. Self-care is the cornerstone of long-term management, and learning to cope with and modify stressors will enable the client to live with the disease. Giving up a desired career could discourage and even depress the client. Placing the responsibility for minimizing stressors at work in the hands of others leads to a feeling of loss of control and decreases the sense of responsibility needed for sound self-care. Working part-time rather than full-time is unnecessary.

client who has had ulcerative colitis for the past 5 years is admitted to the hospital with an exacerbation of the disease. Which of the following factors was most likely of greatest significance in causing an exacerbation of ulcerative colitis? 1. A demanding and stressful job. 2. Changing to a modified vegetarian diet. 3. Beginning a weight-training program. 4. Walking 2 miles every day.

1. Stressful and emotional events have been clearly linked to exacerbations of ulcerative colitis, although their role in the etiology of the disease has been disproved. A modified vegetarian diet or an exercise program is an unlikely cause of the exacerbation.

The client is diagnosed with Crohn's disease, also known as regional enteritis. Which statement by the client would support this diagnosis? 1. "My pain goes away when I have a bowel movement" 2. "I have bright red blood in my stool all the time" 3. "I have episodes of diarrhea and constipation" 4. "My abdomen is hard and rigid and I have a fever".

1. (CORRECT) The terminal ileum is the most common site for regional enteritis and causes right lower quadrant pain that is relieved by defecation 2. Stools are liquid or semi-formed and usually do not contain blood 3. Episodes of diarrhea and constipation may be a sign/symptom of colon cancer, not Crohn'sdisease 4. A fever and hard rigid abdomen are signs/symptoms of peritonitis, a complication of Crohn's disease

What are the five situations where soap and water is preferred over hand sanitizer?

1. Before eating 2. After using the restroom 3. Anytime there is visible soil 4. After caring for a patient with diarrhea or known C. diff or spore-forming organisms as alcohol based-hand rubs have poor activity against spores 5. Before caring for patients with food allergies

What are the top three High-Alert Drugs listed in the RxPrep book?

1. Insulin and oral hypoglycemics 2. Anticoagulants 3. Concentrated electrolytes (injectable KCL, phosphate, magnesium, hypertonic saline)

What are the top three High-Alert Drugs listed in the RxPrep book?

1. Insulin and oral hypoglycemics (hypoglycemia) 2. Anticoagulants (bleeding or clot risk) 3. Concentrated electrolytes (injectable KCL, phosphate, magnesium, hypertonic saline) Opioid (respiratory depression) Sedatives

List the five safe practices for "crash carts"

1. Meds should be unit-dose and age specific 2. Weight base dosing chart should be in cart 3. Prefilled syringes and drips if possible 4. Replace as soon as possible after use 5. Monitor expiration dates closely

What are the five methods to improve automated dispensing cabinet safety?

1. Require that pharmacists must review orders before medications can be removed 2. LASA medications should be stored in different locations within the ADC 3. Certain medications should not be put into the ADCs, including insulin, warfarin, and high-dose narcotics 4. Nurses should not put medications back into the medication compartments 5. Place the machine in a quiet, not busy environment

What are the five methods to improve automated dispensing cabinet safety?

1. Require that pharmacists must review orders before medications can be removed 2. LASA medications should be stored in different locations within the ADC (Barcode scanning improves ADC safety) 3. Look-alike and sound-alike medicaiton should be stored in different locations within the ADC 4. Certain medications should not be put into the ADCs, including insulin, warfarin, and high-dose narcotics 5. Nurses should not put medications back into the medication compartments 6. Place the machine in a quiet, not busy, and with great lighting

What are the five Do Not Use Abbreviations listed in the RxPrep book?

1. U, u for unit 2. IU for international unit 3. QD for daily and QOD for every other day 4. Trailing and leading zeros (0.1 or 1.0) 5. MS and MSO4 for morphine sulfate and magnesium sulfate

What are the five Do Not Use Abbreviations listed in the RxPrep book?

1. U, u for unit - write it out 2. IU for international unit - write it out 3. QD for daily and QOD for every other day (write daily or every other day) 4. Trailing and lacking leading zeros (0.1 or 1.0) 5. MS and MSO4 for morphine sulfate and magnesium sulfate- write it out

What are the six NPSGs listed in the RxPrep book?

1. Use at least two patient identifiers when providing care 2. Report critical results of tests and diagnostic procedures on a timely basis 3. Label all medications, their containers, and other solutions 4. Reduce the likelihood of harm associated with anticoagulant therapy 5. Maintain and communicate accurate patient medication information 6. Comply with the CDC hand hygiene guidelines

Doxycycline has a clearance of 4.5 L/hr and a volume of distribution of 65 L. Calculate the half-life (in hours) of doxycycline. (Answer must be numeric; no units or commas; round final answer to the nearest WHOLE number.)

Question Doxycycline has a clearance of 4.5 L/hr and a volume of distribution of 65 L. Calculate the half-life (in hours) of doxycycline. (Answer must be numeric; no units or commas; round final answer to the nearest WHOLE number.) Answer

10 Refer to pages 162-163 of the 2018 RxPrep Course Book.

10 First find Ke (Ke = Cl/Vd) Second use T 1/2 = 0.693/Ke

Following a 400 mg dose of voriconazole IV the area under the curve is measured at 38 mcg x hr/mL. Calculate the apparent clearance of voriconazole in L/hr. (Answer must be numeric; no units or commas; round final answer to the nearest WHOLE number.)

10.5 ~ 11 Dose x F = AUC x CL (note: don't need to convert 38mcg to mg because the x hr/mL need to be converted to L anyway)

Question Following a 400 mg dose of voriconazole IV the area under the curve is measured at 38 mcg x hr/mL. Calculate the apparent clearance of voriconazole in L/hr. (Answer must be numeric; no units or commas; round final answer to the nearest WHOLE number.) Answer

11 Refer to pages 159-160 of the 2018 RxPrep Course Book.

Following a 400 mg dose of cefpodoxime, the terminal elimination rate constant was determined to be 0.38 hr-1. Calculate the half-life (in hours) of cefpodoxime. (Answer must be numeric; no units or commas; round final answer to the nearest WHOLE number.)

2 (used the formula T 1/2 = 0.693/Ke)

Question Following a 400 mg dose of cefpodoxime, the terminal elimination rate constant was determined to be 0.38 hr-1. Calculate the half-life (in hours) of cefpodoxime. (Answer must be numeric; no units or commas; round final answer to the nearest WHOLE number.) Answer

2 Incorrect Refer to page 162 of the 2018 RxPrep Course Book.

2 Hours

When planning care for a client with ulcerative colitis who is experiencing an exacerbation of symptoms, which client care activities can the nurse appropriately delegate to an unlicensed assistant? Select all that apply. 1. Assessing the client's bowel sounds. 2. Providing skin care following bowel movements. 3. Evaluating the client's response to antidiarrheal medications. 4. Maintaining intake and output records. 5. Obtaining the client's weight.

2, 4, 5. The nurse can delegate the following basic care activities to the unlicensed assistant: providing skin care following bowel movements, maintaining intake and output records, and obtaining the client's weight. Assessing the client's bowel sounds and evaluating the client's response to medication are registered nurse activities that cannot be delegated.

The nurse is developing a plan of care for a client with Crohn's disease who is receiving total parenteral nutrition (TPN). Which of the following interventions should the nurse include? Select all that apply. 1. Monitoring vital signs once a shift. 2. Weighing the client daily. 3. Changing the central venous line dressing daily. 4. Monitoring the I.V. infusion rate hourly. 5. Taping all I.V. tubing connections securely.

2, 4, 5. When caring for a client who is receiving TPN, the nurse should plan to weigh the client daily, monitor the I.V. fluid infusion rate hourly (even when using an I.V. fluid pump), and securely tape all I.V. tubing connections to prevent disconnections. Vital signs should be monitored at least every 4 hours to facilitate early detection of complications. It is recommended that the I.V. dressing be changed once or twice per week or when it becomes soiled, loose, or wet.

The nurse is assigning clients for the evening shift. Which of the following clients are appropriate for the nurse to assign to a licensed practical nurse to provide client care? Select all that apply. 1. A client with Crohn's disease who is receiving total parenteral nutrition (TPN). 2. A client who underwent inguinal hernia repair surgery 3 hours ago. 3. A client with an intestinal obstruction who needs a Cantor tube inserted. 4. A client with diverticulitis who needs teaching about his take-home medications. 5. A client who is experiencing an exacerbation of his ulcerative colitis.

2, 5. The nurse should consider client needs and scope of practice when assigning staff to provide care. The client who is recovering from inguinal hernia repair surgery and the client who is experiencing an exacerbation of his ulcerative colitis are appropriate clients to assign to a licensed practical nurse as the care they require fall within the scope of practice for a licensed practical nurse. It is not within the scope of practice for the licensed practical nurse to administer TPN, insert nasoenteric tubes, or provide client teaching related to medications.

Which of the following should be a priority focus of care for a client experiencing an exacerbation of Crohn's disease? 1. Encouraging regular ambulation. 2. Promoting bowel rest. 3. Maintaining current weight. 4. Decreasing episodes of rectal bleeding.

2. A priority goal of care during an acute exacerbation of Crohn's disease is to promote bowel rest. This is accomplished through decreasing activity, encouraging rest, and initially placing client on nothing-by-mouth status while maintaining nutritional needs parenterally. Regular ambulation is important, but the priority is bowel rest. The client will probably lose some weight during the acute phase of the illness. Diarrhea is nonbloody in Crohn's disease, and episodes of rectal bleeding are not expected.

The client with ulcerative colitis is following orders for bed rest with bathroom privileges. When evaluating the effectiveness of this level of activity, the nurse should determine if the client has: 1. Conserved energy. 2. Reduced intestinal peristalsis. 3. Obtained needed rest. 4. Minimized stress.

2. Although modified bed rest does help conserve energy and promotes comfort, its primary purpose in this case is to help reduce the hypermotility of the colon. Remaining on bed rest does not by itself reduce stress, and if the client is having stress, the nurse can plan with the client to use strategies that will help the client manage the stress.

Which of the following diets would be most appropriate for the client with ulcerative colitis? 1. High-calorie, low-protein. 2. High-protein, low-residue. 3. Low-fat, high-fiber. 4. Low-sodium, high-carbohydrate.

2. Clients with ulcerative colitis should follow a well-balanced high-protein, high-calorie, low-residue diet, avoiding such high-residue foods as whole-wheat grains, nuts, and raw fruits and vegetables. Clients with ulcerative colitis need more protein for tissue healing and should avoid excess roughage. There is no need for clients with ulcerative colitis to follow low-sodium diets.

Which goal for the client's care should take priority during the first days of hospitalization for an exacerbation of ulcerative colitis? 1. Promoting self-care and independence. 2. Managing diarrhea. 3. Maintaining adequate nutrition. 4. Promoting rest and comfort.

2. Diarrhea is the primary symptom in an exacerbation of ulcerative colitis, and decreasing the frequency of stools is the first goal of treatment. The other goals are ongoing and will be best achieved by halting the exacerbation. The client may receive antidiarrheal agents, antispasmodic agents, bulk hydrophilic agents, or anti-inflammatory drugs.

A client with Crohn's disease has concentrated urine, decreased urinary output, dry skin with decreased turgor, hypotension, and weak, thready pulses. The nurse should do which of the following first? 1. Encourage the client to drink at least 1,000 mL per day. 2. Provide parenteral rehydration therapy ordered by the physician. 3. Turn and reposition every 2 hours. 4. Monitor vital signs every shift.

2. Initially, the extracellular fluid (ECF) volume with isotonic I.V. fluids until adequate circulating blood volume and renal perfusion are achieved. Vital signs should be monitored as parenteral and oral rehydration are achieved. Oral fluid intake should be greater than 1,000 mL/ day. Turning and repositioning the client at regular intervals aids in the prevention of skin breakdown, but it is first necessary to rehydrate this client.

A client newly diagnosed with ulcerative colitis who has been placed on steroids asks the nurse why steroids are prescribed. The nurse shuld tell the client? 1. "Ulcerative colitis can be cured by the use of steroids." 2. "Steroids are used in severe flare-ups because they can decrease the incidence of bleeding." 3. "Long-term use of steroids will prolong periods of remission." 4.. "The side effects of steroids outweigh their benefits to clients with ulcerative colitis."

2. Steroids are effective in management of the acute symptoms of ulcerative colitis. Steroids do not cure ulcerative colitis, which is a chronic disease. Long-term use is not effective in prolonging the remission and is not advocated. Clients should be assessed carefully for side effects related to steroid therapy, but the benefits of short-term steroid therapy usually outweigh the potential adverse effects.

An oral drug is administered as a 225 mg dose. The resulting AUC is 52 mg x hr/mL. Bioavailability of the oral formulation is 50%. Calculate the clearance of this drug in mL/hr. (Answer must be numeric; no units or commas; round final answer to two decimal places.)

2.16 *explanation*:Bioavailability can be presented as a percentage or a decimal. Cl = 225/52 x 0.5 = 2.1634, rounded to 2.16 mL/hr.

Question An oral drug is administered as a 225 mg dose. The resulting AUC is 52 mg x hr/mL. Bioavailability of the oral formulation is 50%. Calculate the clearance of this drug in mL/hr. (Answer must be numeric; no units or commas; round final answer to two decimal places.) Answer

2.16 Bioavailability can be presented as a percentage or a decimal. Cl = 225/52 x 0.5 = 2.1634, rounded to 2.16 mL/hr.

2.16 Dose x Bioavailability (F) = AUC x CL

A patient is receiving vancomycin 1,250 mg IV Q12H. The following drug levels are available and orders to hold vancomycin are received after the first level comes back. 1/8: 41.45 mcg/mL at 1800 1/8: 35.6 mcg/mL at 2230 1/9: 22.55 mcg/mL at 1200 1/9: 17.8 mcg/mL at 1900 1/9: 16.36 mcg/mL at 2130 What is the patient's vancomycin half-life in hours? (Answer must be numeric; no units or commas; round the final answer to the nearest TENTH.)

20.5

Question A patient is receiving vancomycin 1,250 mg IV Q12H. The following drug levels are available and orders to hold vancomycin are received after the first level comes back. 1/8: 41.45 mcg/mL at 1800 1/8: 35.6 mcg/mL at 2230 1/9: 22.55 mcg/mL at 1200 1/9: 17.8 mcg/mL at 1900 1/9: 16.36 mcg/mL at 2130 What is the patient's vancomycin half-life in hours? (Answer must be numeric; no units or commas; round the final answer to the nearest TENTH.) Answer

20.5 Half-life is the time required for the drug concentration to decrease by 50%. No math is required.

20.5 hours You first have to look where the concentration drops by half. So 35.6 at 22:30 on 1/8 to 17.8 at 1900 on 1/9. Count the hours in between 2230 to 1900 is 20.5 hours

Jonathan Williams is a 39 year old male admitted to the hospital for treatment of dehydration and Crohn's disease. Medications D51/2NS at 100 ml/hr x 2 liters Methylprednisolone 40 mg IV Q12H Norvasc 10 mg PO daily Tysabri 300 mg/115 mL over 1 hour x 1 dose today Ambien 10 mg QHS D51/2NS at 60 ml/hr Question The nurse is preparing to administer the dose of Tysabri. The nurse has IV tubing that delivers 15 drops/mL. At what rate should the Tysabri be infused in drops/min? (Answer must be numeric; no units or commas; round final answer to the nearest WHOLE number.)

The physician prescribes sulfasalazine (Azulfidine) for the client with ulcerative colitis to continue taking at home. Which instruction should the nurse give the client about taking this medication? 1. Avoid taking it with food. 2. Take the total dose at bedtime. 3. Take it with a full glass (240 mL) of water. 4. Stop taking it if urine turns orange-yellow.

3. Adequate fluid intake of at least 8 glasses a day prevents crystalluria and stone formation during sulfasalazine therapy. Sulfasalazine can cause gastrointestinal distress and is best taken after meals and in equally divided doses. Sulfasalazine gives alkaline urine an orange-yellow color, but it is not necessary to stop the drug when this occurs.

A client's ulcerative colitis signs and symptoms have been present for longer than 1 week. The nurse should assess the client for signs and symptoms of which of the following complications? 1. Heart failure. 2. Deep vein thrombosis. 3. Hypokalemia. 4. Hypocalcemia.

3. Excessive diarrhea causes significant depletion of the body's stores of sodium and potassium as well as fluid. The client should be closely monitored for hypokalemia and hyponatremia. Ulcerative colitis does not place the client at risk for heart failure, deep vein thrombosis, or hypocalcemia.

A client who has ulcerative colitis has persistent diarrhea. He is thin and has lost 12 lb since the exacerbation of his ulcerative colitis. Which of the following will be most effective in helping the client meet his nutritional needs? 1. Continuous enteral feedings. 2. Following a high-calorie, high-protein diet. 3. Total parenteral nutrition (TPN). 4. Eating six small meals a day.

3. Food will be withheld from the client with severe symptoms of ulcerative colitis to rest the bowel. To maintain the client's nutritional status, the client will be started on TPN. Enteral feedings or dividing the diet into six small meals does not allow the bowel to rest. A high-calorie, high-protein diet will worsen the client's symptoms.

A client who has a history of Crohn's disease is admitted to the hospital with fever, diarrhea, cramping, abdominal pain, and weight loss. The nurse should monitor the client for: 1. Hyperalbuminemia. 2. Thrombocytopenia. 3. Hypokalemia. 4. Hypercalcemia.

3. Hypokalemia is the most expected laboratory finding owing to the diarrhea. Hypoalbuminemia can also occur in Crohn's disease; however, the client's potassium level is of greater importance at this time because a low potassium level can cause cardiac arrest. Anemia is an expected development, but thrombocytopenia is not. Calcium levels are not affected.

A 2 mcg/kg dose of fentanyl is ordered for a patient in the ICU. The patient weighs 110 pounds. Following the intravenous dose of fentanyl, plasma levels of fentanyl were measured. The extrapolated concentration at time zero was determined to be 0.286 mcg/L. Calculate the volume of distribution (in liters) for fentanyl. (Answer must be numeric; no units or commas; round final answer to the nearest WHOLE number.)

350

350 First calculate the dose for the patient (110lbs =50kg) ==> 2mcg x 50kg = 100mcg Then use Vd formula: ==> Amt of drug in body / Conc of drug ==> 100mcg / .286 = 349.6 ~ 350

Question A 2 mcg/kg dose of fentanyl is ordered for a patient in the ICU. The patient weighs 110 pounds. Following the intravenous dose of fentanyl, plasma levels of fentanyl were measured. The extrapolated concentration at time zero was determined to be 0.286 mcg/L. Calculate the volume of distribution (in liters) for fentanyl. (Answer must be numeric; no units or commas; round final answer to the nearest WHOLE number.) Answer

350 Refer to page 158 of the 2018 RxPrep Course Book.

A client who has ulcerative colitis says to the nurse, "I can't take this anymore! I'm constantly in pain, and I can't leave my room because I need to stay by the toilet. I don't know how to deal with this." Based on these comments, an appropriate nursing diagnosis for this client would be: 1. Impaired physical mobility related to fatigue. 2. Disturbed thought processes related to pain. 3. Social isolation related to chronic fatigue. 4. Ineffective coping related to chronic abdominal pain.

4. It is not uncommon for clients with ulcerative colitis to become apprehensive and upset about the frequency of stools and the presence of abdominal cramping. During these acute exacerbations, clients need emotional support and encouragement to verbalize their feelings about their chronic health concerns and assistance in developing effective coping methods. The client has not expressed feelings of fatigue or isolation or demonstrated disturbed thought processes.

An intravenous drug is administered as a 225 mg dose. The resulting AUC is 52 mg x hr/mL. Bioavailability of the oral formulation is 50%. Calculate the clearance of this drug in mL/hr. (Answer must be numeric; no units or commas; round final answer to the nearest HUNDREDTH.)

4.33 *explanation*:Bioavailability is 100% (F = 1) following intravenous administration. Bioavailability of the oral formulation is not needed for this calculation. Cl = 225 / 52 = 4.33 mL/hr.

4.33 Bioavailability = 100% because IV Dose x Bioavailability = AUC x CL

Question An intravenous drug is administered as a 225 mg dose. The resulting AUC is 52 mg x hr/mL. Bioavailability of the oral formulation is 50%. Calculate the clearance of this drug in mL/hr. (Answer must be numeric; no units or commas; round final answer to the nearest HUNDREDTH.) Answer

4.33 Bioavailability is 100% (F = 1) following intravenous administration. Bioavailability of the oral formulation is not needed for this calculation. Cl = 225 / 52 = 4.33 mL/hr.

A dose of 750 mg of acetaminophen is administered to a patient. A blood sample is drawn two hours after the dose is administered. The concentration of acetaminophen is measured as 8 mcg/mL. Acetaminophen has a volume of distribution of 51 L. How many milligrams of drug remain in the body 2 hours after the dose is administered? (Answer must be numeric; no units or commas.)

408

408 Refer to page 158 of the 2018 RxPrep Course Book.

408 VD = Amount of drug in body / Concentration of drug So VD is given as 51L so 51 = Amount of drug in body / 8mcg/mL

A study was conducted to assess the pharmacokinetics of drug X in volunteers of average weight 110 pounds. Following an intravenous dose of 1.2 mg/kg, administered as a bolus injection, the AUC was determined to be 4.5 mg x hr/mL and the volume of distribution was 62 L. Following a 4 mg/kg oral dose, administered as a capsule, the AUC was 7.36 mg x hr/mL and the volume of distribution was 59 L. Calculate the absolute bioavailability of drug X. (Answer must be numeric; no units or commas; round final answer to the nearest WHOLE number.)

49 100 x (AUCextravascular/AUCintravascular) x (Dose extravascular / Dose intravascular)

Question A study was conducted to assess the pharmacokinetics of drug X in volunteers of average weight 110 pounds. Following an intravenous dose of 1.2 mg/kg, administered as a bolus injection, the AUC was determined to be 4.5 mg x hr/mL and the volume of distribution was 62 L. Following a 4 mg/kg oral dose, administered as a capsule, the AUC was 7.36 mg x hr/mL and the volume of distribution was 59 L. Calculate the absolute bioavailability of drug X. (Answer must be numeric; no units or commas; round final answer to the nearest WHOLE number.) Answer

49 Refer to page 157 of the 2018 RxPrep Course Book.

Data was obtained after oral and intravenous administration of drug X in volunteers of average weight 50 kg. Following an intravenous dose of 1.2 mg/kg, administered as a bolus injection, the AUC was 4.50 mg x hr/mL. Following a 4.0 mg/kg oral dose, administered as a solution, the AUC was 8.2 mg x hr/mL. Calculate the absolute bioavailability of drug X. (Answer must be numeric; no units or commas; round final answer to the nearest WHOLE number.)

55 100 x (AUCextravascular/AUCintravascular) x (Dose extravascular / Dose intravascular)

Question Data was obtained after oral and intravenous administration of drug X in volunteers of average weight 50 kg. Following an intravenous dose of 1.2 mg/kg, administered as a bolus injection, the AUC was 4.50 mg x hr/mL. Following a 4.0 mg/kg oral dose, administered as a solution, the AUC was 8.2 mg x hr/mL. Calculate the absolute bioavailability of drug X. (Answer must be numeric; no units or commas; round final answer to the nearest WHOLE number.) Answer

55 Refer to pages 156-157 of the 2018 RxPrep Course Book.

A newly approved drug has a volume of distribution of 82 L and a clearance of 9.26 L/hr. Calculate the half-life (in hours) of this drug. (Answer must be numeric; no units or commas; include a leading zero when answer is less than 1; round final answer to the nearest TENTH.)

6.1

6.1 First find ke = Cl /VD T 1/2 life = 0.693/ke

Question A newly approved drug has a volume of distribution of 82 L and a clearance of 9.26 L/hr. Calculate the half-life (in hours) of this drug. (Answer must be numeric; no units or commas; include a leading zero when answer is less than 1; round final answer to the nearest TENTH.) Answer

6.1 Refer to pages 162-163 of the 2018 RxPrep Course Book.

AUC values of drug X following IV administration of 50 mg and oral administration of 100 mg were found to be 70 mg x hr/mL and 90 mg x hr/mL respectively. Calculate the absolute bioavailability of drug X. (Answer must be numeric; no units or commas; round final answer to the nearest WHOLE number.)

64 100 x (AUCextravascular/AUCintravascular) x (Dose extravascular / Dose intravascular)

Question AUC values of drug X following IV administration of 50 mg and oral administration of 100 mg were found to be 70 mg x hr/mL and 90 mg x hr/mL respectively. Calculate the absolute bioavailability of drug X. (Answer must be numeric; no units or commas; round final answer to the nearest WHOLE number.) Answer

64 Refer to pages 156-157 of the 2018 RxPrep Course Book.

A pharmacist will counsel a patient on the possible side effects of bismuth subsalicylate. The most likely side effects from the use of this antidiarrheal agent are: Answer A Blackened tongue and stool B Insomnia C Loss of appetite D Erectile dysfunction E Alopecia

A physician has ordered infliximab. The pharmacist calls the prescriber to ask if she wishes to pre-medicate with acetaminophen, antihistamine and steroids. Which of the following statements is correct? Answer A This regimen may be used for infusion related reactions from infliximab therapy. B This regimen is missing ondansetron for prophylaxis against nausea and vomiting. C Only acetaminophen and an antihistamine should be used; steroids should be avoided due to side effect profile. D Infliximab can be given as a subcutaneous injection to avoid infusion-related reactions. E Infliximab does not cause infusion-related reactions so pre-medication is not necessary.

Choose the pharmacokinetic term used to describe oral formulations breaking up in the gut in order for absorption to take place. A Dissolution B Absorption C Distribution D Metabolism E Excretion

The Noyes-Whitney equation includes this important factor in determining the rate at which a compound will dissolve in the gut. A The compound's surface area. B The compound's chemical ingredients. C The flavoring agent used in the preparation. D The coloring used in the preparation. E None of the above.

When a drug is administered intravenously, which of the following steps does not occur? A Absorption B Distribution C Metabolism D Excretion E All of the steps (absorption, distribution, metabolism and excretion) occur when a drug is administered intravenously

Which of the following is an agonist of guanylate cyclase C, approved for chronic idiopathic constipation or for irritable bowel-syndrome with constipation? Answer A Linzess B Entereg C Relistor D Amitiza E Viberzi

Question The Noyes-Whitney equation includes this important factor in determining the rate at which a compound will dissolve in the gut. Answer A The compound's surface area. B The compound's chemical ingredients. C The flavoring agent used in the preparation. D The coloring used in the preparation. E None of the above.

A Incorrect Increasing the surface area will speed dissolution. Processes such as micronization can increase surface area dramatically and are used to increase absorption in some drugs which would otherwise be poorly absorbed, including some hormones and some of the fenofibrate formulations.

A patient is given a prescription for Lomotil to treat diarrhea. Which of the following is a correct statement? Answer A This medication is a C-V. B This medication is available OTC; a prescription is not needed. C This medication is the drug of choice for diarrhea caused by enterotoxin-producing bacteria. D The maximum daily dose is 16 mg. E This medication contains loperamide and atropine.

A Lomotil is diphenoxylate and atropine. It is a C-V drug and the maximum dose is 20 mg daily. It is contraindicated when diarrhea is caused by enterotoxin-producing bacteria.

A patient reports that he became light headed and started wheezing, with trouble getting "enough air in" when he was prescribed ampicillin. He has a strep throat infection and the decision is made to start antibiotic therapy today. Which antibiotic therapy would represent a potentially unsafe choice in this patient? Answer A Moxatag B Avelox C Doxycycline D Zithromax E Minocin

A Penicillin is a beta-lactam antibiotic and there are many related compounds in this family, including amoxicillin (Moxatag). It is best to avoid related compounds unless the infection warrants use and the patient can be monitored.

A patient is participating in a pharmacokinetic trial. She received 1 gram of an investigational drug at 1800. Serum drug concentrations are drawn hourly for 24 hours. At the conclusion of the trial, the investigator determines that 15% of the drug remaining was removed per hour for all time points measured. Which of the following is true of this scenario? Answer A This drug demonstrated zero-order kinetics over the range of concentrations studied. B The half life of this drug is 1 hour. C The volume of distribution of this drug is 67 liters. D This drug should be administered once daily to maintain serum levels in the therapeutic range. E This drug demonstrated first-order kinetics over the range of concentrations studied.

A A constant percentage of drug is removed per unit of time for drugs with first-order kinetics.

A drug that exhibits first-order kinetics will display which of the following properties? A A linear relationship between dose and serum level B A nonlinear relationship between dose and serum level C A Michaelis-Menten relationship D As the concentration increases the AUC decreases in a corresponding manner E Short half-life and increased bioavailability

A In first-order kinetics, the rate of elimination is directly proportional to the amount of drug remaining in the body.

Which of the following is an appropriate recommendation for EK? Answer A Senna B Psyllium C Docusate D Alvimopan E Methylnaltrexone

A Stimulant laxatives are the treatment of choice for opioid-induced constipation. Newer agents should be reserved for patient's who do not gain relief with stimulant laxatives.

In bipolar I, mania and psychosis can require hospitalization.

A patient has been diagnosed with bipolar I disorder. Which of the following statement concerning bipolar disorder is correct?

What is a code blue?

A patient requiring emergency medical care, typically for cardiac or respiratory arrest

What is a failure mode and effects analysis (FMEA)?

A proactive method used to reduce the frequency and consequences of error; evaluates the potential for failures

What is a root cause analysis (RCA)?

A retrospective investigation of an event that has already occurred, which includes reviewing the sequence of events that led to the error

A patient has overdosed on phenytoin and is experiencing symptoms of phenytoin toxicity. The prescriber asks how much drug the patient has consumed because he wishes to calculate how long it will take the patient to clear the drug. The pharmacist offers the following correct advice. (Select ALL that apply.) A Phenytoin exhibits Michaelis-Menten elimination. B Once the metabolizing enzymes are saturated, phenytoin elimination follows zero-order elimination. The elimination will not correlate in a linear fashion with the amount of drug consumed. C With significant overdose the patient will display extreme irritability, anxiety and difficulty sleeping and concentrating. D With significant overdose the patient will exhibit CNS depressant effects. E Phenytoin initially follows first-order elimination.

A, B, D, E

Choose the correct statement/s that describe the elimination half-life (t½). (Select ALL that apply.) A The half-life is the time required for the plasma concentration of the drug to decrease by 50%. B If a drug is eliminated via zero order kinetics, the half life is always the same. C The elimination half-life refers to the time it takes for half of the dose to be absorbed through the gut lining. D After approximately 5 half-lives, the elimination is considered to be nearly complete. E The half-life can be calculated if the elimination rate constant (ke) is known.

A, D, E

"The nurse is teaching about irritable bowel syndrome. Which of the following would be most important? "A. Reinforcing the need for a balanced diet B. Encouraging the client to drink 16 ounces of fluid with each meal C. Telling the client to eat a diet low in fiber D. Instructing the client to limit his intake of fruits and vegetables"

A, reinforce the need for balanced dietThe nurse should reinforce the need for a diet balanced in all nutrients and fiber. Foods that often cause diarrhea and bloating associated with irritable bowel syndrome include fried foods, caffeinated beverages, alcohol, and spicy foods. Therefore, answers B, C, and D are incorrect.

Which of the following is a brand name for mesalamine? (Select ALL that apply.) Answer A Lialda B Pentasa C Rowasa D Asacol HD E Canasa

A,B,C,D,E

Which statements are true regarding Asacol HD? (Select ALL that apply.) Answer A The active ingredient is an aminosalicylate. B It is a delayed-release product. C It should be avoided in a patient who has difficulty breathing with aspirin. D It can be crushed and administered via a nasogastric tube. E The patient may see the Asacol HD tablet in the stool.

A,B,C,E

Which of the following can trigger symptoms in patients with inflammatory bowel disease? (Select ALL that apply.) Answer A NSAIDs B Meats C Infection D Lactose-free dairy products E Beans, cabbage, broccoli

A,C,E

A patient with ulcerative colitis is being initated on sulfasalazine therapy. Which of the following situations would represent a contraindication to the use of sulfasalazine? (Select ALL that apply.) Answer A A salicylate allergy B High triglycerides C A history of gout D A history of severe sunburns E A sulfa allergy

A,E

The term Inflammatory Bowel Disease (IBD) refers primarily to which of the following condition(s)? (Select ALL that apply.) Answer A Crohn's disease B Irritable bowel syndrome C Inflammation of the gut lining caused by H. pylori disease D Stomatitis E Ulcerative colitis

A,E

Put the following parts of the GI tract in the order that orally ingested food would pass through them. Left-click the mouse to highlight, drag, and order the answer options; ALL options must be used. Answer A Small intestine B Esophagus C Stomach D Rectum E Large intestine

A-Esophagus B-Stomach C-Small intestine D-Large intestine E-Rectum

A drug that exhibits first-order kinetics will display which of the following properties? A: A linear relationship between dose and serum level B: A nonlinear relationship between dose and serum level C: A Michaelis-Menten relationship D: As the concentration increases the AUC decreases in a corresponding manner E: Short half-life and increased bioavailability

A: A linear relationship between dose and serum level *explanation*:In first-order kinetics, the rate of elimination is directly proportional to the amount of drug remaining in the body

A drug that exhibits Michaelis-Menten kinetics will display which of the following properties? (Select ALL that apply.) A: A linear relationship between dose and serum level until the metabolizing enzymes are saturated B: Improved distribution C: A nonlinear relationship between dose and serum level D: Saturable kinetics E: Poor bioavailability

A: A linear relationship between dose and serum level until the metabolizing enzymes are saturated C: A nonlinear relationship between dose and serum level D: Saturable kinetics *Explanation*: Michaelis-Menten (or saturable) kinetics begins as first-order, but when the metabolism becomes saturated, the concentration increases rapidly. Drugs with this type of kinetics begin as first-order kinetics, but can change to zero order once a certain dose is reached and metabolizing enzymes are saturated. At this point, toxicity can result.

When a drug is administered intravenously, which of the following steps does not occur? A: Absorption B: Distribution C: Metabolism D: Excretion E: All of the steps (absorption, distribution, metabolism and excretion) occur when a drug is administered intravenously

A: Absorption *Explanation*:When a drug is given IV, there is no absorption. The drug directly enters the systemic circulation.

Choose the pharmacokinetic term used to describe oral formulations breaking up in the gut in order for absorption to take place. A: Dissolution B: Absorption C: Distribution D: Metabolism E: Excretion

A: Dissolution

A patient has overdosed on phenytoin and is experiencing symptoms of phenytoin toxicity. The prescriber asks how much drug the patient has consumed because he wishes to calculate how long it will take the patient to clear the drug. The pharmacist offers the following correct advice. (Select ALL that apply.) A: Phenytoin exhibits Michaelis-Menten elimination. B: Once the metabolizing enzymes are saturated, phenytoin elimination follows zero-order elimination. The elimination will not correlate in a linear fashion with the amount of drug consumed. C: With significant overdose the patient will display extreme irritability, anxiety and difficulty sleeping and concentrating. D: With significant overdose the patient will exhibit CNS depressant effects. E: Phenytoin initially follows first-order elimination.

A: Phenytoin exhibits Michaelis-Menten elimination. B: Once the metabolizing enzymes are saturated, phenytoin elimination follows zero-order elimination. The elimination will not correlate in a linear fashion with the amount of drug consumed. D: With significant overdose the patient will exhibit CNS depressant effects. E: Phenytoin initially follows first-order elimination. *explanation*:When a drug such as phenytoin is overdosed, the elimination changes from first to zero-order. This is because the enzymes that metabolize phenytoin are full of the drug (or saturated) and cannot metabolize the extra drug. The additional phenytoin will not be subjected to first-pass (it will pass through the saturated liver) and increase the serum concentration dramatically. This is called Michaelis-Menten, or saturable, kinetics. Overdose of phenytoin produces CNS-depressant effects.

The Noyes-Whitney equation includes this important factor in determining the rate at which a compound will dissolve in the gut. A: The compound's surface area. B: The compound's chemical ingredients. C: The flavoring agent used in the preparation. D: The coloring used in the preparation. E: None of the above.

A: The compound's surface area. *explanation*:Increasing the surface area will speed dissolution. Processes such as micronization can increase surface area dramatically and are used to increase absorption in some drugs which would otherwise be poorly absorbed, including some hormones and some of the fenofibrate formulations.

Choose the correct statement/s that describe the elimination half-life (t½). (Select ALL that apply.) A: The half-life is the time required for the plasma concentration of the drug to decrease by 50%. B: If a drug is eliminated via zero order kinetics, the half life is always the same. C: The elimination half-life refers to the time it takes for half of the dose to be absorbed through the gut lining. D: After approximately 5 half-lives, the elimination is considered to be nearly complete. E: The half-life can be calculated if the elimination rate constant (ke) is known.

A: The half-life is the time required for the plasma concentration of the drug to decrease by 50%. C: The elimination half-life refers to the time it takes for half of the dose to be absorbed through the gut lining. D: After approximately 5 half-lives, the elimination is considered to be nearly complete. E: The half-life can be calculated if the elimination rate constant (ke) is known.

Which of the following statements concerning MiraLax are correct? (Select ALL that apply.) Answer A It is an OTC formulation of polyethylene glycol. B It works by drawing fluid into the gut. C It causes abdominal cramping and should not be used unless a patient has failed stimulant laxatives. D It is best to recommend a similar product called GoLytely if an OTC agent is required. E It activates sodium chloride channels in the gut.

AB OSMOTIC AGENT DRAWS FLUID TO GUT

Which of the following lifestyle measures could help reduce CD's problem with chronic constipation? (Select ALL that apply.) Answer A Increase his physical activity. B Consume more fiber, including fruits and vegetables. C Limit caffeine and consume more water. D Eat larger meals. E Substitute soda for coffee.

ABC

History of Present Illness: EK is a 48 year old female who is asking for a recommendation for constipation. Allergies: NKDA Past Medical History: Migraines Urinary incontinence Chronic back pain Medications: Ferrous sulfate 325 mg PO BID MS Contin 60 mg PO BID Darifenacin 15 mg PO daily Inderal LA 160 mg once daily Ibuprofen 400 mg PO Q4-6H PRN Question Which of EK's medications are most likely contributing to the constipation? (Select ALL that apply.) Answer A Morphine B Ferrous sulfate C Darifenacin D Propranolol E AcetaminOPHEN

ABC Opioids, iron, and darifenacin (an anticholinergic drug) are all medications that can cause constipation.

If a patient has a true allergy to penicillin, they may have an allergic reaction to which of the following drugs? (Select ALL that apply.) Answer A Zosyn B Augmentin C Keflex D Primaxin E Zithromax

ABCD All except azithromycin are beta-lactam antibiotics. If the pharmacist sees an allergy to penicillin (or another beta lactam) on the exam, he/she should not choose drugs in the same class. In reality, the cross-reactivity between penicillins and other beta lactams is much lower than previously thought. But the exams are primarily safety-focused and you should not pick an agent that can cross-react. See the course book for rare exceptions to this. Primaxin (cilastin/imipenem)

CD developed hives and got a swollen face from using sulfamethoxazole. CD should avoid the use of which of these drugs? (Select ALL that apply.) Answer A Sulfasalazine B Furosemide C Zonisamide D Celecoxib E Morphine sulfate

ABCD Commonly called a "sulfa" allergy, reactions are most likely due to the sulfonamide component in Bactrim (sulfamethoxazole). If there was a reaction to this drug the patient should avoid using sulfasalazine. Regarding the other formulations: the likelihood of a reaction with zonisamide or celecoxib is lower, but they are contraindicated with a sulfa allergy; furosemide and the the loop diuretics carry a warning for use in patients with sulfa allergy. The safest choice for all of these is to avoid them altogether, especially on the exam. Sulfate is not the same as sulfonamide; morphine sulfate can be used in this patient.

CK lives in southern California. She is fair-skinned and burns easily. CK recently had a urinary tract infection and received a prescription for sulfamethoxazole/trimethoprim (Bactrim). CK was not told that she would burn even more easily when using this medication. Which of the following medications also cause photosensitivity? (Select ALL that apply.) Answer A Tetracyclines B Tacrolimus C Thiazide diuretics D Quinolone antibiotics E Metronidazole

ABCD Many drugs can cause photosensitivity, which requires limiting sun exposure and using sunscreens that block both UVA (causes aging, skin cancer) and UVB (causes sunburn). Sunscreens that cover both UVA and UVB are labeled broad-spectrum.

Which of the following are true regarding alvimopan? (Select ALL that apply.) Answer A The brand name is Entereg B It is safe to use in patients who use chronic opioid therapy C It is a REMS drug D It has a boxed warning for myocardial infarction when used long-term E It should be limited to a maximum of 15 doses

ACDE

A community pharmacist is reviewing a new prescription for azithromycin for a young man. The pharmacist asks about his allergies and he says the only allergy he has is to erythromycin. Which of the following questions should the pharmacist ask the patient? (Select ALL that apply.) Answer A What happened when you took erythromycin? Was it a mild rash, a severe rash with blisters, trouble breathing, upset stomach or nausea? B Did you take erythromycin for more than 72 hours to confirm that is was a "true" allergy? C Have you ever used azithromycin (Zithromax) or clarithromycin (Biaxin)? If so, what happened when you took these? D Are any of your family members allergic to azithromycin? E When did your reaction to erythromycin occur? About how old were you?

ACE Erythromycin commonly causes cramping and stomach upset. This is commonly reported as an allergy, and it should be listed it as an intolerance and the reaction (since it bothered the patient and, if possible, the drug should be avoided), but this is not an allergy and should not prevent drugs in the same class from being used.

Hand Hygiene

Alcohol based hand rubs are more effective in the HC setting than plain soap or antimicrobial soap and water Antimicrobial hand soaps that contain chorhexidine (Hibiclens) may be preferable to reduce infections in HC facilities

What is more effective in healthcare settings: soap and water or hand sanitizer?

Alcohol based hand sanitizer

What is a sentinel event?

An unexpected occurrence involving death or serious physical or psychological injury

The nurse is reviewing the record of a female client with Crohn's disease. Which stool characteristics should the nurse expect to note documented in the client's record 1. Diarrhea 2. Chronic constipation 3. Constipation alternating with diarrhea 4. Stools constantly oozing form the rectum

Answer 1: Diarrhea, Crohn's disease is characterized by non-bloody diarrhea and around 4-5 stools per day. Over time, episodes of diarrhea increase in frequency, duration, and severity.

In planning care for the patient with Crohn's disease, the nurse recognizes that a major difference between ulcerative colitis and Crohn's disease is that Crohn's disease: A. frequently results in toxic megacolon, B. causes fewer nutritional deficiencies than does ulcerative colitis, C. often recurs after surgery, whereas ulcerative colitis is curable with a colectomy, D. is manifested by rectal bleeding and anemia more frequently than is ulcerative colitis.

Answer C - often recurs after surgery, whereas ulcerative colitis is curable with a colectomy Rationale: Because there is a high recurrence rate after surgical treatment of Crohn's disease, medications are the preferred treatment.

What is a medication error?

Any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer

A physician has written a prescription for Entocort EC. Choose the appropriate therapeutic interchange. Answer A Prednisone B Budesonide C Azathioprine D Mesalamine enema E Sulfasalazine

Golytely, NuLytely, Trilyte, and MoviPrep can be used prior to colonoscopy or endoscopy procedures to clean out the gut. These laxatives have the following mechanism of action: Answer A Stimulants B Osmotics C Opioid receptor blockers D Stool softeners E Activates chloride channels in the gut

History of Present Illness: AF is a 38 year old female with worsening symptoms of her inflammatory bowel disease. She presents to her gastroenterologist on 11/3 to discuss treatment options for her disease, which is assessed as moderate-severe. Allergies: Aspirin (hives) Past Medical History: Crohn's disease (15 years), chronic urinary tract infections Medications: Entocort EC 9 mg once daily Yaz take 1 tablet daily Norvasc 10 mg take 1 daily Diflucan 150 mg take 1 tablet daily Prozac 20 mg take 1 capsule daily Xyzal 5 mg PO QHS Height: 5'4" Weight: 115 lbs Question Which of the following monoclonal antibodies are approved for treatment of AF's disease? A Remicade, Rituxan, Cimzia B Humira, Remicade, Tysabri C Rituxan, Entyvio, Simponi D Humira, Enbrel, Cimzia E Remicade, Simponi, Enbrel

History of Present Illness: CD is a 54 year old male who comes to the pharmacy to get his medications refilled. He comes to the counter with a tub of Metamucil powder. After asking CD some questions and reviewing his profile, you learn that his diet consists of largely refined foods, with little fruit or vegetable intake. He drinks 3-4 cups of coffee daily and rarely consumes other liquids. He has no regular physical activity. Allergies: Bactrim, erythromycin, ciprofloxacin, gentamicin eye drops Past Medical History: Pre-diabetes Dyslipidemia Hypertension Chronic constipation Medications: Lisinopril 10 mg PO daily Lipitor 10 mg PO daily Verelan PM 300 mg QHS Metformin 500 mg PO BID Question Choose the correct statement concerning Metamucil: Answer A Based on his allergies, this is not a safe option. B It is generally considered first-line treatment for constipation. C It is an emollient laxative that will soften the stool. D It is a stimulant laxative. E The onset of action is generally about 6-12 hours.

KL has ulcerative colitis that is extensive. He has been started on sulfasalazine therapy. Choose the correct counseling statement for sulfasalazine. Answer A The brand name is Asacol HD. B Common side effects are headache, nausea and upset stomach. C Sulfasalazine is contraindicated in a penicillin allergy. D Take this medication before meals on an empty stomach. E Sulfasalazine is also used to treat osteoarthritis.

MM has a pretty good diet, but she is a vegetarian and suffers from iron-deficiency anemia. The physician recommended that MM use OTC iron twice daily long-term to help correct the problem and prevent anemia in the future. MM eats primarily whole grains and lots of fruits and vegetables. She is using the iron but finds it has caused constipation with hard, compact stools. She is asking the pharmacist for a laxative recommendation. She is not pregnant and is finished having children. Choose the best recommendation: Answer A The preferred laxative is a bulk-forming agent such as psyllium. B Counsel her to begin Colace 100 mg twice daily. C Due to the compact stool problem, she can use a glycerin suppository. D She should begin therapy with MiraLax. E Any of the above recommendations would provide benefit.

Reduction, hydrolysis and oxidation are what type of metabolic reactions? A First pass B Phase I C Michaelis-Menten D Phase II E Zero-order

Which formula is used to describe the rate of drug dissolution (or the rate at which the drug dissolves)? A Michaelis-Menten B Noyes-Whitney C Henderson-Hasselbach D Remington's Coefficient E Stimmel's

Which of the following are true statements regarding mesalamine enemas? Answer A Empty the bowels immediately after use. B Patients should ideally retain drug in the rectum overnight (8 hours). C Topical mesalamine is preferred for proximal disease. D The medication is generally prescribed for 1 week at a time because it is poorly tolerated. E Each bottle can be used multiple times until it is empty.

Which of the following is *not* an important counseling point for a patient starting Cortifoam? Answer A After use, take apart and clean the parts with warm water for next use. B Throw away the applicator and dispense the foam directly from the foam container into the anus. C Wait 5-10 seconds for the foam to expand and fill the applicator barrel. D Hold the applicator firmly, insert the tip into the anus, and push the plunger to expel the foam. E Shake the foam container well for 5-10 seconds before using.

A 19 month old male is diagnosed with his 3rd case of acute otitis media in the past 14 months. He has received amoxicillin twice before. The second time he developed a red rash on his torso and arms. Which of the following would be recommended for use in this patient for the current illness? Answer A Augmentin suspension B Cefuroxime suspension C MInocycline suspension D Doxycycline suspension E Levofloxacin suspension

B Augmentin contains amoxicillin, so it would not be appropriate with the history of rash. Tetracyclines and levofloxacin have appropriate spectrum of activity, but are not appropriate for the patient's age. A second or third generation cephalosporin is recommended if the penicillin allergy was mild (not life-threatening). This is a rare exception, as generally on the exam, when an allergy to one beta-lactam is present all beta-lactams should be avoided.

MV is a 52 year-old Hispanic female with hypertension, anemia, dyslipidemia, chronic heart failure and renal insufficiency due to IgA nephropathy. Her creatinine clearance is estimated at 18 mL/minute. She has been seen by a gastroenterologist for abdominal pain. He instructed MV to take OsmoPrep to clear out her gut prior to a colonoscopy. Choose the correct statement. Answer A This is a preferred laxative in patients with renal insufficiency. B She cannot safely use this laxative due to her history of heart failure. C The generic name for OsmoPrep is magnesium hydroxide. D She cannot safely use this laxative because of her age. E A better choice would be Milk of Magnesia.

B This laxative has a boxed warning for nephropathy so should not be used in patients with renal disease. It should also be avoided in patients with cardiac disease due to electolyte and fluid abnormalities that can occur. Milk of Magnesia (magnesium hydroxide) should also be avoided in patients with renal impairment.

A mother asks the pharmacist what to use to help her four year-old daughter have a bowel movement. The mother states the child "forgets to go" when she is playing, and now it seems too late. The child is squirming and crying. The mother is anxious to help relieve the problem urgently. Choose the best recommendation: Answer A Docusate syrup B Glycerin suppository C Psyllium, in the form of carboxymethylcellulose D Bisacodyl E Loperamide

B For a child with constipation, a glycerin suppository (pediatric size) will work right away. If not, a second dose should be sufficient.

A chemist wishes to increase the rate of gut dissolution of a new tablet formulation. Which of the following would be the most useful option to consider for most medications? A Decreasing the surface area of the tablet. B Increasing the surface area of the tablet. C Adding an emulsifying agent. D Instructing the patient to take thirty minutes after the morning dose of a proton pump inhibitor. E Instructing the patient to take thirty minutes after the morning dose of an antacid.

B In order to increase tablet dissolution the chemist could increase the tablet's surface area and/or decrease the size.

A patient has been using phenytoin 100 mg three times daily for 6 months. A steady state phenytoin level was taken and found to be 9.8 mcg/mL. The patient recently had a seizure, so the prescriber increased the dose to 100 mg with breakfast and lunch, and 200 mg with dinner. The prescriber calculated that if 300 mg/day provided a level of 9.8 mcg/mL, then 400 mg/day would increase the level to approximately 13 mcg/mL. After the dosage change, the patient started to slur her words, felt fatigued and returned to the medical office. The level was retaken and found to be 18.7 mcg/mL. At both visits, her serum albumin level was 4.2 g/dL. What is the most likely reason for the phenytoin level? A Phenytoin exhibits increased metabolism with higher doses. B Phenytoin exhibits Michaelis-Menten kinetics. C Phenytoin has reduced protein binding at higher doses. D Patient non-compliance. E The patient did not take with food.

B The prescriber did not consider that this drug exhibits Michaelis-Menten kinetics. It is important for pharmacists to be prepared to answer questions about Michaelis-Menten kinetics and patient scenarios like this one.

A patient with severe Crohn's disease will receive infliximab therapy. Which of the following statements is correct? (Select ALL that apply.) Answer A The brand name is Entyvio. B Infusion-related reactions from infliximab are common (hypotension, fever, chills, pruritus). C Patients should be screened for TB before starting this agent. D Infliximab is administered by subcutaneous injection; no oral formulation is available. E This is the agent of choice in patients with concomitant heart failure.

B,C

Chief Complaint: "I am going to the bathroom 10 times a day". History of Present Illness: MJ is a 32 year-old female who presents to the ER describing a 2-week history of increasing abdominal pain and frequency of bowel movements. It started with 4-5 bowel movements per day and escalated to 6-8 bowel movements per day. There is sometimes blood in the stool. MJ saw her primary care physician 1 week ago and was told it could be irritable bowel syndrome. MJ has only been drinking Gatorade and eating saltine crackers for fear that the diarrhea and pain will get worse. She has lost weight, but doesn't weigh herself regularly, so she doesn't know how much. MJ has not traveled out of the country and has eaten the same foods as her husband (and he is not ill). Allergies: sulfa (rash) Past Medical History: none Medications: Seasonique, Loperamide (started one week ago), Bentyl (started one week ago) Physical Exam/Vitals: Height: 5'2" Weight: 102 pounds BP: 115/65 mmHg HR: 106 BPM RR: 14 BPM Temp: 99.2°F Pain: 5/10 General appearance: thin, young female HEENT: dry mucous membranes CV: tachycardia, regular rhythm Lungs: clear Abdomen: diffusely tender to palpation Extremities: dry skin Labs: Na (mEq/L) = 142 (135 - 145) K (mEq/L) = 4.8 (3.5 - 5) Cl (mEq/L) = 100 (95 - 103) HCO3 (mEq/L) = 26 (24 - 30) BUN (mg/dL) = 28 (7 - 20) SCr (mg/dL) = 1.3 (0.6 - 1.3) Glucose (mg/dL) = 79 (100 - 125) Ca (mg/dL) = 9.2 (8.5 - 10.5) Mg (mEq/L) = 1.9 (1.3 - 2.1) PO4 (mg/dL) = 4.2 (2.3 - 4.7) WBC (cells/mm3) = 9.3 (4 - 11 x 103) Hgb (g/dL) = 12.9 (12 - 16) Hct (%) = 39.2 (36 - 46) Plt (cells/mm3) = 399 (150 - 450 x 103) AST (IU/L) = 15 (10 - 40) ALT (IU/L) = 12 (10 - 40) Albumin (g/dL) = 4.5 (3.5 - 5) ESR (mm/hr) = 12 (≤ 20 male, ≤ 30 female) Tests: CT of the abdomen: Discontinuous pattern of inflammation in the ascending/transverse colon and ileum. Rectum appears unaffected. Numerous strictures and bleeding are noted throughout the GI tract. Plan: Admit for consultation with GI service. Question Which of the following could be the cause of dry mouth in MJ? (Select ALL that apply.) Answer A Loperamide B Diarrhea C Bentyl D Seasonique E Chronic dry mouth syndrome

B,C

Droplet precautions recommended for patients infected with

B. pertussis Imfluenza RSV N. Meningitidis Group A. Strep - for first 24 hours of abx therapy

How many half-lives are required to reach steady state (assuming a one compartment model and no loading dose)? A: Approximately 2 B: Approximately 5 C: Approximately 8 D: Approximately 12 E: Steady state is reached after 2 days of continuous drug administration with no missed doses.

B: Approximately 5

A chemist wishes to increase the rate of gut dissolution of a new tablet formulation. Which of the following would be the most useful option to consider for most medications? A: Decreasing the surface area of the tablet. B: Increasing the surface area of the tablet. C: Adding an emulsifying agent. D: Instructing the patient to take thirty minutes after the morning dose of a proton pump inhibitor. E: Instructing the patient to take thirty minutes after the morning dose of an antacid.

B: Increasing the surface area of the tablet. *explanation*:In order to increase tablet dissolution the chemist could increase the tablet's surface area and/or decrease the size.

Which formula is used to describe the rate of drug dissolution (or the rate at which the drug dissolves)? A: Michaelis-Menten B: Noyes-Whitney C: Henderson-Hasselbach D: Remington's Coefficient E: Stimmel's

B: Noyes-Whitney

Reduction, hydrolysis and oxidation are what type of metabolic reactions? A: First pass B: Phase I C: Michaelis-Menten D: Phase II E: Zero-order

B: Phase I

A patient has been using phenytoin 100 mg three times daily for 6 months. A steady state phenytoin level was taken and found to be 9.8 mcg/mL. The patient recently had a seizure, so the prescriber increased the dose to 100 mg with breakfast and lunch, and 200 mg with dinner. The prescriber calculated that if 300 mg/day provided a level of 9.8 mcg/mL, then 400 mg/day would increase the level to approximately 13 mcg/mL. After the dosage change, the patient started to slur her words, felt fatigued and returned to the medical office. The level was retaken and found to be 18.7 mcg/mL. At both visits, her serum albumin level was 4.2 g/dL. What is the most likely reason for the phenytoin level? A: Phenytoin exhibits increased metabolism with higher doses. B: Phenytoin exhibits Michaelis-Menten kinetics. C: Phenytoin has reduced protein binding at higher doses. D: Patient non-compliance. E: The patient did not take with food.

B: Phenytoin exhibits Michaelis-Menten kinetics. *explanation*:The prescriber did not consider that this drug exhibits Michaelis-Menten kinetics. It is important for pharmacists to be prepared to answer questions about Michaelis-Menten kinetics and patient scenarios like this one

JB is a 7 year old who has a severe allergy to peanuts that he and his mother carries an EpiPen. Which of the following medications are in a soy base and must be avoided in patients with a peanut allergy? (Select ALL that apply.) Answer A Albuterol inhaler B Cleviprex C Diprivan D Precedex E Morphine

BC Clevidipine, propofol and progesterone in Prometrium must be avoided in patients with a peanut allergy.

A mother presents to the pharmacy asking for a recommendation for her three year-old child who has a fever and diarrhea. She is concerned that the child did not sleep well last night due to the fever. The diarrhea appears to be resolving and the mother has taken care not to let the child become dehydrated. Choose the correct recommendation(s) for the fever: (Select ALL that apply.) Answer A Baby aspirin B Acetaminophen oral suspension C Ibuprofen oral suspension D Loperamide E Bismuth subsalicylate

BC If fever/cold symptoms are present, aspirin can (rarely) cause Reye's Syndrome in children and should be avoided except under a physician's care (it may rarely be used in a child with a heart condition, where benefit may outweigh risk).

If a patient has a true allergy to eggs, they cannot receive which of the following agents? (Select ALL that apply.) Answer A Advair B Cleviprex C Diprivan D Pneumovax E Flublok

BC Patients with an egg allergy should not receive clevidipine and propofol. Flublok is a recombinant influenza vaccine that contains no eggs

A female patient presents to the pharmacy counter with a large container of Metamucil. Choose the correct counseling statement(s): (Select ALL that apply.) Answer A There are no drug interactions to be concerned about. B This agent is a bulk-forming laxative. C You should stop this product if you become pregnant. D Drink adequate fluids. E It may cause gas and stomach bloating.

BDE

What is the most important medication error reduction tool available?

Barcoding

What is the most important medication error reduction tool available? Why?

Barcoding Follows the drug through the medication use process to make sure it is being properly stocked, through compounding, and administered to the pt

Barcoding

Barcoding may be the most important med error reduction tool available right now The barcode follows the drug through the med use process to make sure it is being properly stocked ~ such as in the right space in the pharmacy or in the right pocket in the dispensing cabinet The barcode is used at the bedside to ID that the correct drug is going to the right patient

Boxed warnings are one of the FDA's strictest warnings regarding medication safety aspects. Which of the following is false regarding boxed warnings?

Boxed warnings are used only to indicate when a drug can cause increased risk of death in all patients.

A female patient was using Ex-Lax for constipation, but complained of cramping. The physician has recommended polyethylene glycol (PEG). Choose the correct statement. Answer A A brand name for polyethylene glycol is Osmoprep. B Ex-Lax is the brand name for bisacodyl. C GoLytely and MoviPrep contain PEG. D PEG is characterized as a stimulant laxative. E PEG is characterized as an emollient laxative.

A mother is asking for help with her seven-month old child. He has diarrhea that started in the morning. Which of the following is a correct counseling statement that the pharmacist could provide? Answer A Self-treatment is recommended for up to 7 days; if diarrhea is unresolved, contact a healthcare provider. B Diarrhea is very normal in small children and is usually not a major health concern. C Fluid replacement is best provided by products such as Pedialyte or Infalyte. D Start loperamide 4mg once, then 2 mg with each loose stool. E Start bisacodyl suppositories 5 mg daily.

A new antibiotic for community-acquired pneumonia (CAP) was recently FDA approved. The drug was presented at the Pharmacy and Therapeutics Committee meeting. The drug monograph included the following information: Community-acquired pneumonia dosing (IV): 675 mg IV Q8H Community-acquired pneumonia dosing (PO): 675 mg PO TID Protein binding: 18% Metabolism: partially hepatic Half-life (elimination): 1.6 - 2.1 hours What hospital policy/protocol should this drug be added to? A The CAP Policy B The Antibiogram Protocol C The Therapeutic Interchange Protocol D The Pharmacokinetic Policy E The High Risk Medication Protocol

A patient has a prescription for mesalamine rectal suppositories for distal ulcerative colitis symptoms. Which of the following statements is correct? Answer A The suppositories should be used four times daily and retained in the rectum fro 1-3 hours each time. B The suppository should be rolled between the hands into a point prior to insertion. C The suppository should be used each night and kept in the rectum for 1-3 hours, or preferably overnight. D Mesalamine is indicated for patients who have failed to achieve symptom control with infliximab. E Mesalamine rectal suppositories should only be used if patients have failed rectal steroids.

A patient presents to the pharmacy to pick up a refill on his Androgel. This medication requires a MedGuide. Which of the following is not true? Answer A MedGuides are FDA approved patient handouts. B MedGuides are written in non-technical language. C The MedGuide is not considered part of the drug labeling. D The MedGuide must be dispensed with every new prescription. E The MedGuide must be dispensed with every prescription refill.

CK is pregnant with her first child. She eats a primarily refined diet, but did not suffer from constipation until the second trimester of her pregnancy. Choose the preferred agent

Chief Complaint: "I am going to the bathroom 10 times a day". History of Present Illness: MJ is a 32 year-old female who presents to the ER describing a 2-week history of increasing abdominal pain and frequency of bowel movements. It started with 4-5 bowel movements per day and escalated to 6-8 bowel movements per day. There is sometimes blood in the stool. MJ saw her primary care physician 1 week ago and was told it could be irritable bowel syndrome. MJ has only been drinking Gatorade and eating saltine crackers for fear that the diarrhea and pain will get worse. She has lost weight, but doesn't weigh herself regularly, so she doesn't know how much. MJ has not traveled out of the country and has eaten the same foods as her husband (and he is not ill). Allergies: sulfa (rash) Past Medical History: none Medications: Seasonique, Loperamide (started one week ago), Bentyl (started one week ago) Physical Exam/Vitals: Height: 5'2" Weight: 102 pounds BP: 115/65 mmHg HR: 106 BPM RR: 14 BPM Temp: 99.2°F Pain: 5/10 General appearance: thin, young female HEENT: dry mucous membranes CV: tachycardia, regular rhythm Lungs: clear Abdomen: diffusely tender to palpation Extremities: dry skin Labs: Na (mEq/L) = 142 (135 - 145) K (mEq/L) = 4.8 (3.5 - 5) Cl (mEq/L) = 100 (95 - 103) HCO3 (mEq/L) = 26 (24 - 30) BUN (mg/dL) = 28 (7 - 20) SCr (mg/dL) = 1.3 (0.6 - 1.3) Glucose (mg/dL) = 79 (100 - 125) Ca (mg/dL) = 9.2 (8.5 - 10.5) Mg (mEq/L) = 1.9 (1.3 - 2.1) PO4 (mg/dL) = 4.2 (2.3 - 4.7) WBC (cells/mm3) = 9.3 (4 - 11 x 103) Hgb (g/dL) = 12.9 (12 - 16) Hct (%) = 39.2 (36 - 46) Plt (cells/mm3) = 399 (150 - 450 x 103) AST (IU/L) = 15 (10 - 40) ALT (IU/L) = 12 (10 - 40) Albumin (g/dL) = 4.5 (3.5 - 5) ESR (mm/hr) = 12 (≤ 20 male, ≤ 30 female) Tests: CT of the abdomen: Discontinuous pattern of inflammation in the ascending/transverse colon and ileum. Rectum appears unaffected. Numerous strictures and bleeding are noted throughout the GI tract. Plan: Admit for consultation with GI service. Question Based on the information above, what is MJ's most likely diagnosis? Answer A Irritable bowel syndrome B Ulcerative colitis C Crohn's disease D Infectious diarrhea E C. difficile associated diarrhea

Choose the correct statement concerning loperamide therapy: Answer A It is safe for pharmacists to recommend to infants less than two years old. B It is safe to self-treat with loperamide for up to 7 days if the patient does not exceed the recommended (daily) doses. C The correct dose is 4 mg PO after the first loose stool; then 2 mg after each subsequent stool; not to exceed 16 mg/day. D The correct dose is 4 mg PO daily after each loose stool; not to exceed 32 mg/day. E Loperamide comes in a tablet, suspension, and suppository.

Choose the pharmacokinetic term used to describe the dispersion, or passage of the drug throughout the body. A Dissolution B Absorption C Distribution D Metabolism E Excretion

EK uses bisacodyl for a few days then returns to the pharmacy to say that she is now having bowel movements but the stool is hard to push out. Choose a reasonable recommendation, to be taken daily, to help EK: Answer A Add psyllium B Add Fleet Enema C Add docusate D Add Miralax E Add alvimopan

Jonathan Williams is a 39 year old male admitted to the hospital for treatment of dehydration and Crohn's disease. Medications D51/2NS at 100 ml/hr x 2 liters Methylprednisolone 40 mg IV Q12H Norvasc 10 mg PO daily Tysabri 300 mg/115 mL over 1 hour x 1 dose today Ambien 10 mg QHS D51/2NS at 60 ml/hr Question Which of the following is a correct statement regarding Tysabri? Answer A The generic name of Tysabri is adalimumab. B It is administered IV once daily. C It has a boxed warning for PML. D It is a first-line option for Crohn's. E It is approved for both UC and Crohn's.

Large changes in drug distribution can be caused by small changes in which of the following? A Release of parathyroid hormone B Release of growth hormone C Protein binding D Protein consumption E Protein absorption

Methylnaltrexone is indicated for opioid-induced constipation. This drug is a: Answer A Centrally-acting mu-opioid receptor agonist B Peripherally-acting mu-opioid receptor agonist C Peripherally-acting mu-opioid receptor antagonist D An activator of gut chloride channels (increases peristalsis) E A stimulant laxative that increases colonic neuron activity (increases peristalsis)

Which of the following defines pharmacokinetics? A What the kidney does to the drug. B What the drug does to the body. C What the body does to the drug. D What the liver does to the drug E What the drug does to the microorganism.

Which of the following describes the mechanism of action of infliximab? Answer A Monoclonal antibody that binds to integrin B Monoclonal antibody against interleukin-1 C Monoclonal antibody that binds to TNF D Monoclonal antibody that depletes CD20 B cells E Monoclonal antibody that inhibits T cell activation

Which of the following is a first-line treatment option for a patient newly diagnosed with distal mild ulcerative colitis? Answer A Sulfasalazine oral B Azathioprine oral C Mesalamine suppository D Infliximab injection E Methotrexate oral

Which of the following is true of vedolizumab? Answer A Vedolizumab is approved only for Crohn's disease. B Vedolizumab has a boxed warning for PML. C The brand name of vedolizumab is Entyvio. D Vedolizumab must be used in conjunction with another immunosuppressant. E Vedolizumab is an integrin receptor agonist.

TL is a 27 year old female who is pregnant and has been diagnosed with syphilis. She has an allergy listed to penicillin (hives). The doctor has ordered a penicillin desensitization procedure followed by Bicillin L-A. Which of the following is false regarding penicillin desensitization? Answer A Very small doses of penicillin will be administered, slowly escalating up to therapeutic doses. B The procedure should take place in a setting where emergency care can be provided if anaphylaxis develops. C The penicillin allergy should be removed from the profile after desensitization and the patient can safely receive penicillins in the future. D Desensitization is not recommended if the patient previously had an idiosyncratic reaction such as Stevens-Johnson syndrome or toxic epidermal necrolysis (TEN). E Desensitization allows the use of the first-line treatment option.

C Desensitization is a temporary "fix" that induces tolerance to a drug that would otherwise cause the patient to have an allergic reaction. It does not "cure" a penicillin allergy and if the patient were to need penicillin again in the future, desensitization would need to be repeated. For this reason, the allergy should not be removed from the profile.

A patient has been using Pepto-Bismol several times daily. His other medications include aspirin, lisinopril, metformin and glipizide. The patient complains of a ringing, "hollow" sound in his ears that is quite bothersome. What is the likely cause of the patient's complaint? Answer A Hypoglycemia B Hyperkalemia C Salicylate toxicity D Metformin use E Hypermagnesemia

C Salicylates such as aspirin and bismuth subsalicylate can cause ringing in the ears - this may be a sign of toxicity.

Before a drug can be absorbed through the GI tract, which of the following must have taken place to the compound. A The drug must be conjugated to a free base. B If the drug is an acid it must be encapsulated in a micelle. C The drug must be dissoved in the gut solution. D The drug must be conjugated to a free acid. E The drug must be metabolized to a hydrophilic form.

C Before an orally administered drug is absorbed it must be dissolved.

What is the primary pathway of drug degradation in the gut? A Oxidation B Phase II conjugation reactions C Hydrolysis D Proteolysis E P-glycoprotein efflux drug transportation

C Hydrolysis (lysis with water) occurs when the compound is cleaved into two parts by the addition of a water molecule. One part of the compound takes the proton (H+) and the other takes the hydroxyl group (OH-).

A drug that exhibits Michaelis-Menten kinetics will display which of the following properties? (Select ALL that apply.) A A proportionate increase in serum concentration for a given increase in dose at all serum concentrations B Improved distribution C A nonlinear relationship between dose and serum level at very high concentrations D Saturable kinetics E Poor bioavailability

C, D Michaelis-Menten (or saturable) kinetics mimic a first-order process at low concentrations, but when the metabolism becomes saturated, the concentration increases rapidly (in a nonlinear fashion). At this point, toxicity can result if dose adjustments are not made carefully.

Choose the pharmacokinetic term used to describe how the drug moves from the site of administration and into the circulation. A: Excretion B: Dissolution C: Absorption D: Distribution E: Metabolism

C: Absorption *Explanation*: Absorption is determined by the drug's bioavailability, which is represented by "F" in pharmacokinetic calculations.

Choose the pharmacokinetic term used to describe the dispersion, or passage of the drug throughout the body. A: Dissolution B: Absorption C: Distribution D: Metabolism E: Excretion

C: Distribution *Explanation*:Lipophilic compounds are uncharged and can pass more easily through lipid membranes. Polar, charged compounds cannot pass easily through cell walls and more of the drug will stay in the blood compartment (e.g., aminoglycosides, which have a charged amino group).

What is the primary pathway of drug degradation in the gut? A: Oxidation B: Phase II conjugation reactions C: Hydrolysis D: Proteolysis E: P-glycoprotein efflux drug transportation

C: Hydrolysis *explanation*:Hydrolysis (lysis with water) occurs when the compound is cleaved into two parts by the addition of a water molecule. One part of the compound takes the proton (H+) and the other takes the hydroxyl group (OH-).

Large changes in drug distribution can be caused by small changes in which of the following? A: Release of parathyroid hormone B: Release of growth hormone C: Protein binding D: Protein consumption E: Protein absorption

C: Protein binding *explanation*:For highly protein bound drugs, changes in albumin (normal range 3.5-5 g/dL) will cause changes in the amount of bound drug.

A new antibiotic for community-acquired pneumonia (CAP) was recently FDA approved. The drug was presented at the Pharmacy and Therapeutics Committee meeting. The drug monograph included the following information: Community-acquired pneumonia dosing (IV): 675 mg IV Q8H Community-acquired pneumonia dosing (PO): 675 mg PO TID Protein binding: 18% Metabolism: partially hepatic Half-life (elimination): 1.6 - 2.1 hours What hospital policy/protocol should this drug be added to? A: The CAP Policy B: The Antibiogram Protocol C: The Therapeutic Interchange Protocol D: The Pharmacokinetic Policy E: The High Risk Medication Protocol

C: The Therapeutic Interchange Protocol *Explanation*: Drugs like this are easily converted to the oral formulation in the same dose. Most hospitals have a "Therapeutic Interchange" Protocol or "IV to PO" Protocol (approved by the Medical Staff) that allows medications to be converted if certain criteria are met (e.g., the patient is able to take oral medications).

Before a drug can be absorbed through the GI tract, which of the following must have taken place to the compound. A: The drug must be conjugated to a free base. B: If the drug is an acid it must be encapsulated in a micelle. C: The drug must be dissoved in the gut solution. D: The drug must be conjugated to a free acid. E: The drug must be metabolized to a hydrophilic form.

C: The drug must be dissoved in the gut solution.

Which of the following defines pharmacokinetics? A: What the kidney does to the drug. B: What the drug does to the body. C: What the body does to the drug. D: What the liver does to the drug E: What the drug does to the microorganism.

C: What the body does to the drug.

Computerized Prescriber Order Entry and Clinical Decision Support

CPOE: Allows direct entry of med orders by prescribers A much greater benefit is seen with the combo of CPOE and CDS tools Clinical GL and patient labs can notify a prescriber if the drug is inappropriate, or if labs indicate that the drug could be unsafe

Cefuroxime suspension

Which kind of line has the highest risk for blood stream infections?

Central lines

Caution should be utilized when used with other serotonergic drugs, such as tramadol. Lithium is not metabolized; it is excreted renally.

Choose the correct statement/s concerning lithium and drug interactions: (Select ALL that apply.)

If a patient has a true allergy to eggs, they cannot receive which of the following agents? (Select ALL that apply.)

Cleviprex, Diprivan

Automated Dispensing Cabinets

Common names are Pyxis, Omnicell, ScriptPro, and AccDose Methods to improve ADC safety: TJC requires that the pharmacist review the order before the med can be removed from the ADC for a patient, except in special circumstances (an override) Barcode scanning improves ADC safety Certain medications should not be put into ADCs: insulin, warfarin, high dose narcotics (dilaudid 10 mg/ml, morphine 20 mg/ml)

What is CPOE and what are the advantages of CPOE?

Computerized physician/provider order entry Clinical decision support (CDS) and patient labs can be built into CPOE and can notify prescriber for inappropriate drugs or lab indications.

Common Precautions to Prevent Transmission of Nosocomial Infections

Contact precautions are recommended for patients colonized or infected with MRSA/VRE/C.diff Airborne precautions are recommended for patients with active pulmonary TB, measles, or varicella (chickenpox)

A 55 year-old male has diarrhea and asks the pharmacist if Pepto-Bismol is safe for him to take. His medications include metoprolol, digoxin, amiodarone and warfarin. Pepto-Bismol is not recommended for use in this patient due to the following concern: Answer A Increased risk of arrhythmia B Increased risk of bradycardia C Increased risk of digoxin toxicity D Increased risk of bleeding E Increased risk of heart block

Chief Complaint: "I am going to the bathroom 10 times a day". History of Present Illness: MJ is a 32 year-old female who presents to the ER describing a 2-week history of increasing abdominal pain and frequency of bowel movements. It started with 4-5 bowel movements per day and escalated to 6-8 bowel movements per day. There is sometimes blood in the stool. MJ saw her primary care physician 1 week ago and was told it could be irritable bowel syndrome. MJ has only been drinking Gatorade and eating saltine crackers for fear that the diarrhea and pain will get worse. She has lost weight, but doesn't weigh herself regularly, so she doesn't know how much. MJ has not traveled out of the country and has eaten the same foods as her husband (and he is not ill). Allergies: sulfa (rash) Past Medical History: none Medications: Seasonique, Loperamide (started one week ago), Bentyl (started one week ago) Physical Exam/Vitals: Height: 5'2" Weight: 102 pounds BP: 115/65 mmHg HR: 106 BPM RR: 14 BPM Temp: 99.2°F Pain: 5/10 General appearance: thin, young female HEENT: dry mucous membranes CV: tachycardia, regular rhythm Lungs: clear Abdomen: diffusely tender to palpation Extremities: dry skin Labs: Na (mEq/L) = 142 (135 - 145) K (mEq/L) = 4.8 (3.5 - 5) Cl (mEq/L) = 100 (95 - 103) HCO3 (mEq/L) = 26 (24 - 30) BUN (mg/dL) = 28 (7 - 20) SCr (mg/dL) = 1.3 (0.6 - 1.3) Glucose (mg/dL) = 79 (100 - 125) Ca (mg/dL) = 9.2 (8.5 - 10.5) Mg (mEq/L) = 1.9 (1.3 - 2.1) PO4 (mg/dL) = 4.2 (2.3 - 4.7) WBC (cells/mm3) = 9.3 (4 - 11 x 103) Hgb (g/dL) = 12.9 (12 - 16) Hct (%) = 39.2 (36 - 46) Plt (cells/mm3) = 399 (150 - 450 x 103) AST (IU/L) = 15 (10 - 40) ALT (IU/L) = 12 (10 - 40) Albumin (g/dL) = 4.5 (3.5 - 5) ESR (mm/hr) = 12 (≤ 20 male, ≤ 30 female) Tests: CT of the abdomen: Discontinuous pattern of inflammation in the ascending/transverse colon and ileum. Rectum appears unaffected. Numerous strictures and bleeding are noted throughout the GI tract. Plan: Admit for consultation with GI service. Question MJ needs to be treated for new-onset, acute IBD. Which of the following is an appropriate recommendation? Answer A Vedolizumab IV B Certolizumab SC C Loperamide PO D Prednisone PO E Methotrexate PO

Choose the pharmacokinetic term used to describe the process by which the body breaks down drugs into compounds that can be more readily eliminated. A Dissolution B Absorption C Distribution D Metabolism E Excretion

History of Present Illness: AF is a 38 year old female with worsening symptoms of her inflammatory bowel disease. She presents to her gastroenterologist on 11/3 to discuss treatment options for her disease, which is assessed as moderate-severe. Allergies: Aspirin (hives) Past Medical History: Crohn's disease (15 years), chronic urinary tract infections Medications: Entocort EC 9 mg once daily Yaz take 1 tablet daily Norvasc 10 mg take 1 daily Diflucan 150 mg take 1 tablet daily Prozac 20 mg take 1 capsule daily Xyzal 5 mg PO QHS Height: 5'4" Weight: 115 lbs Question The pharmacist in the clinic reviews AF's medication list. Which, if any, of the medications shown would require the dose of Entocort EC to be reduced? Answer A Prozac B Norvasc C Yaz D Diflucan E None of the medications listed interact with Entocort EC

Sulfasalazine can reduce absorption of which of the following? Answer A Metoclopramide B Phenytoin C Spironolactone D Folic acid E Methotrexate

Which of the following are true statements regarding aminosalicylates? Answer A Giazo is only approved for females. B The toxicities of each agent in the class are similar. C Sulfasalazine is the preferred aminosalicylate in ulcerative colitis. D Oral products should be not be administered with PPIs, H2RAs, or antacids. E Oral products are delayed-release and can be given once daily.

Which of the following defines pharmacodynamics? A What the kidney does to the drug. B What the liver does to the drug. C What the body does to the drug. D What the drug does to the body. E What the drug does to the microorganism.

Which of the following is a brand name for calcium polycarbophil, a bulk-forming laxative? Answer A Metamucil B Citrucel C Ex-Lax D Fibercon E Constulose

Which of the following associations is not correct? Answer A Type A reaction - predictable, dose-related (e.g., orthostasis with an alpha-blocker) B Type B reaction - unpredictable (e.g., itching with opioids) C Type I reaction - occurs within 15-30 min, immune-mediated (e.g., anaphylaxis) D Type II - pseudoallergic reaction (e.g., red man syndrome with rapid vancomycin infusion) E Type IV reaction - delayed hypersensitivity occuring 48 hours to weeks after exposure

D An example of a Type II reaction is hemolytic anemia. Pseudoallergic reactions would fall into type B reactions (unpredictable, but may be more likely under certain circumstances-in this case rapid infusion), but do not fall into types I-IV, which apply to immune-mediated allergic responses.

A patient developed hives after using Bactrim. Choose a medication that is not contraindicated with this type of allergy: Answer A Celecoxib B Sulfapyridine C Zonisamide D Dapsone E Sulfasalazine

D Sulfa allergies are most common with sulfamethoxazole, and the related compounds sulfapyridine, sulfadiazine, and sulfisoxasole. Celecoxib and zonisamide are contraindicated with this allergy, although a cross-reaction is less likely.

Choose the pharmacokinetic term used to describe the process by which the body breaks down drugs into compounds that can be more readily eliminated. A: Dissolution B: Absorption C: Distribution D: Metabolism E: Excretion

D: Metabolism *explanation*:The liver (along with drug-metabolizing enzymes in the gut wall) can extract, or pull out, a portion of the drug by changing the drug's structure. This results in less drug being available for therapeutic benefit (or more drug if a pro-drug is hepatically metabolized to the active form).

Which of the following defines pharmacodynamics? A: What the kidney does to the drug. B: What the liver does to the drug. C: What the body does to the drug. D: What the drug does to the body. E: What the drug does to the microorganism.

D: What the drug does to the body.

Chief Complaint: "I am going to the bathroom 10 times a day". History of Present Illness: MJ is a 32 year-old female who presents to the ER describing a 2-week history of increasing abdominal pain and frequency of bowel movements. It started with 4-5 bowel movements per day and escalated to 6-8 bowel movements per day. There is sometimes blood in the stool. MJ saw her primary care physician 1 week ago and was told it could be irritable bowel syndrome. MJ has only been drinking Gatorade and eating saltine crackers for fear that the diarrhea and pain will get worse. She has lost weight, but doesn't weigh herself regularly, so she doesn't know how much. MJ has not traveled out of the country and has eaten the same foods as her husband (and he is not ill). Allergies: sulfa (rash) Past Medical History: none Medications: Seasonique, Loperamide (started one week ago), Bentyl (started one week ago) Physical Exam/Vitals: Height: 5'2" Weight: 102 pounds BP: 115/65 mmHg HR: 106 BPM RR: 14 BPM Temp: 99.2°F Pain: 5/10 General appearance: thin, young female HEENT: dry mucous membranes CV: tachycardia, regular rhythm Lungs: clear Abdomen: diffusely tender to palpation Extremities: dry skin Labs: Na (mEq/L) = 142 (135 - 145) K (mEq/L) = 4.8 (3.5 - 5) Cl (mEq/L) = 100 (95 - 103) HCO3 (mEq/L) = 26 (24 - 30) BUN (mg/dL) = 28 (7 - 20) SCr (mg/dL) = 1.3 (0.6 - 1.3) Glucose (mg/dL) = 79 (100 - 125) Ca (mg/dL) = 9.2 (8.5 - 10.5) Mg (mEq/L) = 1.9 (1.3 - 2.1) PO4 (mg/dL) = 4.2 (2.3 - 4.7) WBC (cells/mm3) = 9.3 (4 - 11 x 103) Hgb (g/dL) = 12.9 (12 - 16) Hct (%) = 39.2 (36 - 46) Plt (cells/mm3) = 399 (150 - 450 x 103) AST (IU/L) = 15 (10 - 40) ALT (IU/L) = 12 (10 - 40) Albumin (g/dL) = 4.5 (3.5 - 5) ESR (mm/hr) = 12 (≤ 20 male, ≤ 30 female) Tests: CT of the abdomen: Discontinuous pattern of inflammation in the ascending/transverse colon and ileum. Rectum appears unaffected. Numerous strictures and bleeding are noted throughout the GI tract. Plan: Admit for consultation with GI service. Question The GI service prescribes methylprednisolone IV 60 mg Q12H for 2 days, then wants to transition to oral prednisone to complete a 7 day course. Which of the following short-term adverse effects could MJ experience? Answer A Cataracts and poor wound healing B Osteoporosis and immunosuppression C Fat deposits in the face and adrenal suppression D Cushing syndrome and growth retardation E Insomnia and mood changes

Choose the pharmacokinetic term used to describe the process by which the body rids itself of drugs or metabolites either through the kidneys or back into the gut. A Dissolution B Absorption C Distribution D Metabolism E Excretion

Which of the following drugs can cause the skin or urine to become orange-yellowish in color? Answer A Methotrexate B Mesalamine C Ciprofloxacin D Infliximab E Sulfasalazine

Which of the following medications is considered a first-line option for a patient newly diagnosed with mild Crohn's disease of the ileum and right colon? Answer A 6-mercaptopurine B Metronidazole C Ciprofloxacin D Infliximab E Oral budesonide

Which steroids are available as rectal foam products for IBD? Answer A Prednisone and budesonide B Budesonide and dexamethasone C Hydrocortisone and prednisone D Hydrocortisone and methylprednisolone E Budesonide and hydrocortisone

A new antibiotic for community-acquired pneumonia (CAP) was recently FDA approved. The drug was presented at the hospital's Pharmacy and Therapeutics Committee meeting. The drug monograph included the following information: Community-acquired pneumonia dosing (IV): 675 mg IV Q8H Community-acquired pneumonia dosing (PO): 675 mg PO TID Protein binding: 18% Metabolism: partially hepatic Half-life (elimination): 1.6 - 2.1 hours What is the bioavailability of this new drug? A 0% B 1% C 25% D 50% E 100%

E (The IV dose and the PO dose is the same- so it is assumed bioavailability is 100%)??

Epinephrine injection now comes in a "talking" injection device that can help guide patients how to administer the injection. What is the name of this device? Answer A Evzio B Copaxone C Lemtrada D Arixtra E Auvi-Q

E Auvi-Q is a newer device that is easy to use; however, the EpiPen is also simple to use.

If EK does not obtain relief using a stimulant laxative with a stool softener, which of the following can be considered? Answer A Eluxadoline B Dicyclomine C Alvimopan D Linaclotide E Lubiprostone

E Lubiprostone is indicated for opioid-induced constipation but due to cost, it is typically reserved for patients who are still constipated after a trial of laxative therapy.

RH is a 71 year old female who has a life-threatening allergy to aspirin. She takes ticlopidine 250 mg BID after a stroke 3 years prior. She is at her routine clinic visit and as the nurse applies the blood pressure cuff, she notices that the patient has small red and purple pinpoint spots on her skin and some larger bruises on her hand and upper arm, where she states she had bumped them on a doorway when she lost her balance a few days ago. Upon questioning, she reports no recent fever or other systemic symptoms. Which of the following is consistent with this presentation? Answer A A photosensitivity reaction B Drug Reaction with Eosinophilia and Systemic Symptoms C Stevens-Johnson Syndrome D Toxic epidermal necrolysis E Thrombotic thrombocytopenic purpura

E Pinpoint bruises (petechiae) and larger bruises (purpura) are signs that she may have developed thrombotic thrombocytopenic purpura (TTP), for which ticlopidine carries a boxed warning. This ADR has also been reported with clopidogrel (although with lower freuqency).

A medical resident asks the pharmacy student to explain to the medical students why most drugs are weak acids or weak bases. Which of the following points are correct and could be included in the explanation? A If the drug dissolves in the gut fluid it will not get absorbed. B If the compound is charged it cannot interact with the cell receptors. C Weak acids are highly charged compounds in physiological pH. D Weak bases are highly charged compounds in physiological pH. E Charged compounds dissolve more easily in water than uncharged compounds.

E In order for absorption to occur the drug has to dissolve in the watery-contents of the stomach. If the drug is a weak acid it will have a negative charge and if it is a weak base more of the drug will be charged because more of the drug will have either lost or gained a proton. Charged compounds dissolve easily in water. A dissolved drug can get absorbed into the blood.

E: 100%

A medical resident asks the pharmacy student to explain to the medical students why most drugs are weak acids or weak bases. Which of the following points are correct and could be included in the explanation? A: If the drug dissolves in the gut fluid it will not get absorbed. B: If the compound is charged it cannot interact with the cell receptors. C: Weak acids are highly charged compounds in physiological pH. D: Weak bases are highly charged compounds in physiological pH. E: Charged compounds dissolve more easily in water than uncharged compounds.

E: Charged compounds dissolve more easily in water than uncharged compounds. *explanation*:In order for absorption to occur the drug has to dissolve in the watery-contents of the stomach. If the drug is a weak acid it will have a negative charge and if it is a weak base more of the drug will be charged because more of the drug will have either lost or gained a proton. Charged compounds dissolve easily in water. A dissolved drug can get absorbed into the blood.

Choose the pharmacokinetic term used to describe the process by which the body rids itself of drugs or metabolites either through the kidneys or back into the gut. A: Dissolution B: Absorption C: Distribution D: Metabolism E: Excretion

E: Excretion

A patient is participating in a pharmacokinetic trial. She received 1 gram of an investigational drug at 1800. Serum drug concentrations are drawn hourly for 24 hours. At the conclusion of the trial, the investigator determines that 15% of the drug remaining was removed per hour for all time points measured. Which of the following is true of this scenario? A: This drug demonstrated zero-order kinetics over the range of concentrations studied. B: The half life of this drug is 1 hour. C: The volume of distribution of this drug is 67 liters. D: This drug should be administered once daily to maintain serum levels in the therapeutic range. E: This drug demonstrated first-order kinetics over the range of concentrations studied.

E: This drug demonstrated first-order kinetics over the range of concentrations studied. *Explanation*:A constant percentage of drug is removed per unit of time for drugs with first-order kinetics.

Auvi-Q

Epinephrine injection now comes in a "talking" injection device that can help guide patients how to administer the injection. What is the name of this device?

Medication Therapy Management (MTM)

Errors may be discovered during a comprehensive medication review (CMR), through the process of MTM A personal med record (PMR) is prepared, and a med related action plan (MAP) is developed, preferably by a pharmacist led team The next steps involve interventions, referrals, documentation and plans for follow up Patients targeted for MTM include those with multiple chronic conditions who are taking multiple drugs and are likely to incur annual costs for covered drugs that exceed a predetermined level Reviews ID missed therapy such as a lack of an ACEI/ARB in patients with DM and albuminuria, missing BB therapy SP-MI, missing bisphosphonate therapy with high dose chronic steroids

High Alert Drugs

Ex. Insulin, oral hypoglycemics, anticoagulants, injectable KCl, PO4, Mg, hypertonic saline, antiarrhythmics, anesthetics, chemotherapeutics, opioids, inotropes, epidural/intrathecal meds HAD can be used more safely by developing protocols or order sets for use, using premixed product whenever possible, limiting conc, stocking high alert products only in the pharmacy

System Based Causes

Experts in med safety concur that the most common cause of med errors is not individual error but problems with the design of the medical system itself

True or False You can take Toradol IV for as long as you need to manage pain for IBD?

FALSE Can only give for 72hrs b/c it causes renal failure then give Tylenol

What is FMEA?

Failure Mode and Effect Analysis is a prospective analysis to reduce the frequency and consequences of errors

JL's mother is leaving him with his aunt for the weekend. She will instruct the aunt in the proper use of the EpiPen. Put the following steps in order representing proper use of the EpiPen. Left-click the mouse to highlight, drag, and order the answer options; ALL options must be used.

Grasp the epinephrine shot injector in one fist with the tip pointing down. Do not touch the tip. Remove the safety release by pulling straight up. Hold the orange tip close to the middle of the outer thigh. Swing away from leg, then push the auto-injector against the thigh until it "clicks". The injector should be at a 90-degree angle to the thigh and the injection can be given through clothing. Keep the injector in place against the outer thigh while slowly counting to 3. Remove the injector and rub the area where the medicine entered the skin for 10 seconds.

What is more effective in healthcare settings: soap and water or hand sanitizer?

Hand sanitizer

What drug does morphine get mixed up with in the hospital settings?

Hydromorphone (more potent)

Where can you report medication errors and close calls?

ISMP National Medication Errors Reporting Program (MERP) online website www.ismp.org

What is the first line Tx of IBD exacerbation?

IV steriods corticosteriods/methylprednisolone Antibiotics

Education

If a patient questions any part of the medication dispensing process, the pharmacist must be receptive not defensive It may be necessary to provide pictograms or other means of instruction to patients who do not speak English or are unable to read English Attempts must be made to communicate to the patient in their language, using on site staff or dial in translation services

What is ISMP

Institute for safe medication practices

Which of the following best describes the utility of the Naranjo Scale?

It is used to help determine causality of an adverse drug reaction.

When should medication reconciliation be done?

It should be done at each stage of health care delivery: - Admission - Status - Patient transfer within or between facilities/provider teams - Discharge

Tall Man Lettering

LASA meds are a common cause of med errors Drugs that are easily mixed up should be labeled with tall man letters (ex. celeXA, celeBREX)

Severe CNS sedation Arrhythmias Seizure Coma, death could occur

LT has been using lithium for most of her adult life. She cannot afford air conditioning and has been living in an apartment where the temperature has been over 90 degrees for the past five days. She succumbed to the heat and has been brought into the hospital with dehydration, acute renal failure and lithium toxicity. The lithium level is taken and found to be 3.2 mEq/L. The following adverse effects may be present when the lithium concentration is at this level: (Select ALL that apply.)

Medication Reconciliation (Med Rec)

Med Rec: A process of comparing a patient's med orders to all of the meds that the pt has been taking This rec is done to avoid med errors such as: omissions, duplications, dosing errors, or DIs

Catheter Related Bloodstream Infections

Minimize through aseptic technique during catheter insertion, including proper hand washing and utilization of standard protocols/catheter insertion checklist Other strategies include the use of skin antiseptics (2% chlorhexidine), abx impregnated central venous catheters

What is the name of the goals set by TJC that decrease injuries to patients?

National patient safety goals (NPSG)

What are NPSGs?

National patient safety goals set by TJC annually

Are friends and family allowed to administer PCA?

Risky communication behaviors

Not addressing questions/concerns rushed communication

Patient-controlled analgesia (PCA)

Opioids may be administered with PCA devices ~ PCAs allow the patient to treat pain quickly Friends and family should not administer PCA doses ~ TJC requirement

If post-marketing safety surveillance is required, in which stage does it occur?

Phase IV

Automated dispensing cabinets include

Pyxis omnicell scriptpro accudose

Which of the following is true of Risk Evaluation and Mitigation Strategies (REMS)?

REMS are developed by manufacturers and approved by the FDA to ensure the benefits of a drug outweigh the risks.

What are drug use evaluation (DUE)?

Retrospective analyses of pt drug usage, or of physician prescribing habits. Helpful in guiding therapy to guidelines, or in saving money, or BOTH

five rights of medication administration

Right patient right medication right dosage right time right route

Evaluation and Quality Improvement

Root Cause Analysis (RCA): A retrospective investigation of an event that has already occurred ~ includes reviewing the sequence of events that led to the error RCA is often considered to be a repetitive process, and is frequently viewed as an important continuous quality improvement (CQI tool) An analysis can also be done prospectively to ID pathways that could lead to errors and ID ways to reduce error risk Failure mode and effects analysis (FMEA) is a proactive method used to reduce the frequency and consequence of errors

What is an error of commission?

Something that was done incorrectly Ex. Prescribing buproprion to a patient with a history of seizures

What is an error of commission?

Something that was done incorrectly; prescribing buproprion to a patient with a history of seizures

Errors of commission

Something was done incorrectly

Errors of omission

Something was left out that is needed for safety

What is an error of omission?

Something was left out that is needed for safety; Ex. Failing to warn a patient about a side effect

What is an error of omission?

Something was left out that is needed for safety; failing to warn a patient about a side effect

Safe Practices for Emergency Medications/Crash Carts

Staff must be properly trained to handle emergencies and use crash cart meds The meds should be unit dose and age specific, including pediatric specific doses

What is Failure Modes and Effects Analysis (FMEA)?

Step-by-step approach for identifying all possible ways in which something might fail

CD developed hives and got a swollen face from using sulfamethoxazole. CD should avoid the use of which of these drugs? (Select ALL that apply.)

Sulfasalazine, Furosemide, Zonisamide, Celecoxib

Type I hypersensitivity reaction

TB is a 64 year-old male dialysis patient who requires IV iron supplementation. At the outpatient infusion clinic he receives a test dose of iron dextran. Within 20 minutes, his blood pressure reading is 82/42, he is unable to talk and has wheezing breath sounds. What type of reaction is TB having?

Tetracyclines, Tacrolimus, Thiazide diuretics, Quinolone antibiotics

Organizations that Specialize in Error Prevention

The ISMP Medication Errors Reporting Program (MERP) is a confidential national voluntary reporting program that provides expert analysis of the system causes of med errors and disseminates recommendations for prevention Errors and close calls can be reported on ismp.org

A patient presents to the pharmacy to pick up a refill on his Androgel. This medication requires a MedGuide. Which of the following is not true?

The MedGuide is not considered part of the drug labeling.

Medication Errors

The definition of a med error developed by the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP: Any preventable event that may cause or lead to inappropriate medication use or patient harm while the med is in the control of the HC professional, patient, or consumer Do not confuse med errors with ADRs ~ ADRs are generally not avoidable, although they may be more likely to occur if the drug is given to a patient at high risk for certain complications Sentinel Event: An unexpected occurrence involving death or serious physical or psychological injury, or risk thereof

What act authorized creation of patient safety orgs? PSO

The patient safety and quality improvement act of 2005

Airborne precautions are recommended for which patients?

Those with active pulmonary tuberculosis, measles, or varicella virus (chickenpox)

Which of the following associations is not correct?

Type II - pseudoallergic reaction (e.g., red man syndrome with rapid vancomycin infusion)

Common types of hospital acquired infections

UTI Blood stream infections from IV lines Decubitus ulcers Hepatitis C.Diff Pneumonia/bronchitis

What are common hospital acquired infections?

UTI, Blood stream infections from IV lines, Surgical site infections, Decubitus ulcers, Hepatitis, Cdif, Pneumonia/ bronchitis

What is a very common infection from indwelling catheters?

UTIs remove catheters as soon as possible

Common Nosocomial Infections

UTIs from indwelling catheters, remove catheter ASAP Bloodstream infections from IV lines (central lines have highest risk) and catheters C. diff Pneumonia (mostly due to vent use)

Sentinel event definition

Unexpected event involving death or serious injury

Indications and Proper Instructions on Prescriptions

Using the term "as directed" is not acceptable on prescriptions bc the pt often has no idea what this means and the pharmacist cannot verify a proper dosing regimen

What might increase the risk of PNA in a hospital?

Ventilator use

MedWatch

What is the name of the FDA's adverse event reporting system program?

When a drug is administered intravenously, which of the following steps does not occur? Answer A Absorption B Distribution C Metabolism D Excretion E All of the steps (absorption, distribution, metabolism and excretion) occur when a drug is administered intravenously

When a drug is given IV, there is no absorption. The drug directly enters the systemic circulation. a

A patient who experiences respiratory depression after receiving Norco 10/325 instead of Norco 5/325 should be reported to MedWatch as an ADR.

Which of the following statements is false regarding adverse drug reactions (ADRs)?

If a patient has a true allergy to penicillin, they may have an allergic reaction to which of the following drugs? (Select ALL that apply.)

Zosyn, Augmentin, Keflex, Primaxin

Question A drug that exhibits first order kinetics will display which of the following properties? Answer A A linear relationship between dose and serum level B A nonlinear relationship between dose and serum level C A Michaelis-Menten relationship D As the concentration increases the AUC decreases in a corresponding manner E Short half-life and increased bioavailability

a In first order kinetics, the rate of elimination is directly proportional to the amount of drug remaining in the body. First order kinetics is also called "linear" kinetics.

Question Choose the pharmacokinetic term used to describe oral formulations breaking up in the gut in order for absorption to take place. Answer A Dissolution B Absorption C Distribution D Metabolism E Excretion

a Incorrect The active ingredient must be released from the dosage form as it dissolves in the GI tract. This is dissolution.

A patient reports that he became light headed and started wheezing, with trouble getting "enough air in" when he was prescribed ampicillin. He has a strep throat infection and the decision is made to start antibiotic therapy today. Which antibiotic therapy would represent a potentially unsafe choice in this patient? a) Moxatag b) Avelox c) Tygacil d) Zithromax e) Minocin

a) Moxatag Penicillin is a beta-lactam antibiotic and there are many related compounds in this family, including amoxicillin (Moxatag). It is best to avoid related compounds unless the infection warrants use and the patient can be monitored.

CD developed hives and got a swollen face from using sulfamethoxazole. CD should avoid the use of which of these drugs? (Select ALL that apply.) a) Sulfasalazine b) Sulfisoxazole c) Zonisamide d) Celecoxib e) Morphine sulfate

a), b), c) and d) A "sulfa" allergy is most likely due to the sulfamethoxazole component in Bactrim. If there was a reaction to this drug the patient should avoid using sulfasalazine and sulfisoxazole. They are unlikely, however, to react to zonisamide or celecoxib but they are contraindicated with a sulfa allergy and therefore should be avoided. Sulfate is not the same as sulfa; morphine sulfate can be used in this patient.

If a patient has a true allergy to penicillin, they may have a similar reaction to which of the following drugs? (Select ALL that apply.) a) Zosyn b) Augmentin c) Keflex d) Primaxin e) Zithromax

a), b), c) and d) All except azithromycin are beta-lactam antibiotics. If the pharmacist sees an allergy to penicillin (or other beta lactam) on the exam, he/she should not choose drugs in the same class. In reality, the cross-reactivity between penicillins and other beta lactams is much lower than previously thought. But the exams are primarily safety-focused and you should not pick an agent that can cross-react.

CK lives in southern California. She is fair-skinned and burns easily. Ms. Knarl recently had a urinary tract infection and received a prescription for sulfamethoxazole/trimethoprim (Bactrim). Ms. Knarl was not told that she would burn even more easily when using this medication. Which of the following medications also cause photosensitivity? (Select ALL that apply.) a) Tetracyclines b) Tacrolimus c) Thiazide diuretics d) Quinolone antibiotics e) Metronidazole

a), b), c) and d) Many drugs can cause photosensitivity, which requires limiting sun exposure and using sunscreens that block both UVA (causes aging, skin cancer) and UVB (causes sunburn). Sunscreens that cover both UVA and UVB are labeled broad-spectrum.

A community pharmacist is reviewing a new prescription for azithromycin for a young man. The pharmacist asks about his allergies and he says the only allergy he has is to erythromycin. Which of the following questions should the pharmacist ask the patient? (Select ALL that apply.) a) What happened when you took erythromycin? Was it a mild rash, a severe rash with blisters, trouble breathing, stomach cramps or nausea? b) Did you take erythromycin for more than 72 hours to confirm that it was a "true" allergy? c) Have you ever used azithromycin (Zithromax) or clarithromycin (Biaxin)? If so, what happened when you took these? d) Are any of your family members allergic to azithromycin? e) When did your reaction to erythromycin occur? About how old were you?

a), c) and e) Erythromycin commonly causes cramping and stomach upset. This is commonly reported as an allergy, and you should list the reaction (since it bothered the patient and, if possible, the drug should be avoided), but this is not an allergy and should not prevent drugs in the same class from being used.

Question A patient has overdosed on phenytoin and is experiencing symptoms of phenytoin toxicity. The prescriber asks how much drug the patient has consumed because he wishes to calculate how long it will take the patient to clear the drug. The pharmacist offers the following correct advice. (Select ALL that apply.) Answer A Phenytoin exhibits Michaelis-Menten elimination. B Once the metabolizing enzymes are saturated, phenytoin elimination follows zero-order elimination. The elimination will not correlate in a linear fashion with the amount of drug consumed. C With significant overdose the patient will display extreme irritability, anxiety and difficulty sleeping and concentrating. D With significant overdose the patient will exhibit CNS depressant effects. E Phenytoin initially follows first-order elimination.

abde When a drug such as phenytoin is overdosed, the elimination changes from first to zero-order. This is because the enzymes that metabolize phenytoin are full of the drug (or saturated) and cannot metabolize the extra drug. The additional phenytoin will not be subjected to first-pass (it will pass through the saturated liver) and increase the serum concentration dramatically. This is called Michaelis-Menten, or saturable, kinetics. Overdose of phenytoin produces CNS-depressant effects.

Question Choose the correct statement/s that describe the elimination half-life (t½). (Select ALL that apply.) Answer A The half-life is the time required for the plasma concentration of the drug to decrease by 50%. B If a drug is eliminated via zero order kinetics, the half life is always the same. C The elimination half-life refers to the time it takes for half of the dose to be absorbed through the gut lining. D After approximately 5 half-lives, the elimination is considered to be nearly complete. E The half-life can be calculated if the elimination rate constant (ke) is known.

ade \ Incorrect A good understanding of half-life is important for NAPLEX. Half-life is used to determine time to steady state or time for drug washout if no additional doses are given.

Medication error definition

any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer

Question Which formula is used to describe the rate of drug dissolution (or the rate at which the drug dissolves)? Answer A Michaelis-Menten B Noyes-Whitney C Henderson-Hasselbach D Remington's Coefficient E Stimmel's

b The rate of dissolution is described by the Noyes-Whitney equation.

Question Reduction, hydrolysis and oxidation are what type of metabolic reactions? Answer A First pass B Phase I C Michaelis-Menten D Phase II E Zero-order

b Phase I and phase II reactions are involved in drug metabolism.

Question A chemist wishes to increase the rate of gut dissolution of a new tablet formulation. Which of the following would be the most useful option to consider for most medications? Answer A Decreasing the surface area of the tablet. B Increasing the surface area of the tablet. C Adding an emulsifying agent. D Instructing the patient to take thirty minutes after the morning dose of a proton pump inhibitor. E Instructing the patient to take thirty minutes after the morning dose of an antacid.

b In order to increase tablet dissolution the chemist could increase the tablet's surface area and/or decrease the size.

How many half-lives are required to reach steady state (assuming a one compartment model and no loading dose)? Answer A Approximately 2 B Approximately 5 C Approximately 8 D Approximately 12 E Steady state is reached after 2 days of continuous drug administration with no missed doses.

b It takes 5 half-lives for a drug to reach steady state.

Question A patient has been using phenytoin 100 mg three times daily for 6 months. A steady state phenytoin level was taken and found to be 9.8 mcg/mL. The patient recently had a seizure, so the prescriber increased the dose to 100 mg with breakfast and lunch, and 200 mg with dinner. The prescriber calculated that if 300 mg/day provided a level of 9.8 mcg/mL, then 400 mg/day would increase the level to approximately 13 mcg/mL. After the dosage change, the patient started to slur her words, felt fatigued and returned to the medical office. The level was retaken and found to be 18.7 mcg/mL. At both visits, her serum albumin level was 4.2 g/dL. What is the most likely reason for the phenytoin level? Answer A Phenytoin exhibits increased metabolism with higher doses. B Phenytoin exhibits Michaelis-Menten kinetics. C Phenytoin has reduced protein binding at higher doses. D Patient non-compliance. E The patient did not take with food.

b The prescriber did not consider that this drug exhibits Michaelis-Menten kinetics. It is important for pharmacists to be prepared to answer questions about Michaelis-Menten kinetics and patient scenarios like this one.

JB has a severe allergy to peanuts that he and his mother carries an EpiPen. Which of the following medications are in a soy base and must be avoided in patients with a peanut allergy? (Select ALL that apply.) a) Albuterol inhaler b) Cleviprex c) Diprivan d) Precedex e) Morphine

b) and c) Clevidipine, propofol and progesterone in Prometrium must be avoided in patients with a peanut allergy.

*If a patient has a true allergy to eggs, they cannot receive which of the following agents? (Select ALL that apply.)* a) Advair b) Cleviprex c) Diprivan d) Pneumovax e) Flublok

b) and c) Patients with an egg allergy should not receive clevidipine and propofol. Flublok is a recombinant influenza vaccine that contains no eggs.

One of the most important medication error reduction tools is

barcoding

When to use water/soap over alcohol rubs for hand hygeine

before eating after using restroom After caring for patients with c.diff or spore forming organisms - alcohol has poor activity Before caring for patients with food allergies

Question Choose the pharmacokinetic term used to describe how the drug moves from the site of administration and into the circulation. Answer A Excretion B Dissolution C Absorption D Distribution E Metabolism

c Absorption is determined by the drug's bioavailability, which is represented by "F" in pharmacokinetic calculations.

Question Before a drug can be absorbed through the GI tract, which of the following must have taken place to the compound. Answer A The drug must be conjugated to a free base. B If the drug is an acid it must be encapsulated in a micelle. C The drug must be dissolved in the gut solution. D The drug must be conjugated to a free acid. E The drug must be metabolized to a hydrophilic form.

c Before an orally administered drug is absorbed it must be dissolved.

Question A new antibiotic for community-acquired pneumonia (CAP) was recently FDA approved. The drug was presented at the Pharmacy and Therapeutics Committee meeting. The drug monograph included the following information: Community-acquired pneumonia dosing (IV): 675 mg IV Q8H Community-acquired pneumonia dosing (PO): 675 mg PO TID Protein binding: 18% Metabolism: partially hepatic Half-life (elimination): 1.6 - 2.1 hours What hospital policy/protocol should this drug be added to? Answer A The CAP Policy B The Antibiogram Protocol C The Therapeutic Interchange Protocol D The Pharmacokinetic Policy E The High Risk Medication Protocol

c Drugs like this are easily converted to the oral formulation in the same dose. Most hospitals have a "Therapeutic Interchange" Protocol or "IV to PO" Protocol (approved by the Medical Staff) that allows medications to be converted if certain criteria are met (e.g., the patient is able to take oral medications).

Question Large changes in drug distribution can be caused by small changes in which of the following? Answer A Release of parathyroid hormone B Release of growth hormone C Protein binding D Protein consumption E Protein absorption

c For highly protein bound drugs, changes in albumin (normal range 3.5-5 g/dL) will cause changes in the amount of bound drug.

Question What is the primary pathway of drug degradation in the gut? Answer A Oxidation B Phase II conjugation reactions C Hydrolysis D Proteolysis E P-glycoprotein efflux drug transportation

c Hydrolysis (lysis with water) occurs when the compound is cleaved into two parts by the addition of a water molecule. One part of the compound takes the proton (H+) and the other takes the hydroxyl group (OH-).

Which of the following defines pharmacokinetics? Answer A What the kidney does to the drug. B What the drug does to the body. C What the body does to the drug. D What the liver does to the drug E What the drug does to the microorganism.

c The effect of the body on the drug is pharmacokinetics.

Question Choose the pharmacokinetic term used to describe the dispersion, or passage of the drug throughout the body. Answer A Dissolution B Absorption C Distribution D Metabolism E Excretion

c Lipophilic compounds are uncharged and can pass more easily through lipid membranes. Polar, charged compounds cannot pass easily through cell walls and more of the drug will stay in the blood compartment (e.g., aminoglycosides, which have a charged amino group).

Boxed warnings are one of the FDA's strictest warnings regarding medication safety aspects. Which of the following is false regarding boxed warnings? a) Boxed warnings are used to convey risk of serious injury or death associated with a medication b) Boxed warnings are always listed at the beginning of the package labeling and are set apart in a black box c) Boxed warnings are used only to indicate when a drug can cause increased risk of death in all patients d) Boxed warnings can be used to avoid prescribing or dispensing errors e) Boxed warnings can be used to convey risk of using a drug in certain patient populations

c) Boxed warnings are used only to indicate when a drug can cause increased risk of death in all patients Boxed warnings are used for a variety of reasons. They can alert healthcare providers to specific patient types or certain conditions that put patients at risk of serious injury or death (e.g., beta blockers have a boxed warning that therapy should not be stopped abruptly, but should be tapered to avoid acute tachycardia, hypertension and ischemia). Amphotericin B deoxycholate has a boxed warning regarding ordered doses > 1.5 mg/kg, to avoid patients being overdosed when the intended product was one of the lipid-based formulations (which are dosed much higher).

TH is a 57 year-old male who presents to the ED on January 12 by ambulance with decreased level of consciousness. He was found next to his bed by his daughter, who came to check on him after a call from the dialysis center that he had missed 2 sessions. She had spoken to him 2 days prior, when he told her he had been to the doctor and gotten a prescription for Tamiflu. Past Medical History: End stage renal disease (anuric), hemodialysis on MWF for 3.5 hours each session; hypertension and restless leg syndrome Medications: Ropinirole 0.5 mg PO daily Diovan 160 mg PO daily Calcium acetate 667 mg capsules PO TID with meals Calcitriol 0.5 mg PO daily Procrit 10,000 units 3x/week on hemodialysis Tamiflu 30 mg PO daily x 5 days (started 2 days prior to admission) Allergies: Captopril (cough), eggs (hives, stopped breathing) Vitals: Height: 5'8" Weight: 198 lbs BP: 98/57 mmHg HR: 111 BPM RR: 26 BPM Temp: 100.4ºF Pain: 1/10 Tests: ECG shows peaked T-waves, widened QRS interval. Chest X-ray: cardiac enlargement, thin bilateral pleural effusions Labs (1/12): GLU (65 - 99 mg/dL) 112 Na (135 - 145 mEq/L) 141 K (3.5 - 5 mEq/L) 6.7 Cl (95 - 103 mEq/L) 100 HCO3 (24 - 30 mEq/L) 20 BUN (7 - 20 mg/dL) 30 SCr (0.6 - 1.3 mg/dL) 12.1 Mg (1.3 - 2.1 mEq/L) 1.9 PO4 6.2 (2.3 - 4.7 mg/dL) 6.2 Ca (8.5 - 10.5 mg/dL) 10.5 AST (10 - 40 units/L) 48 ALT (10 - 40 units/L) 42 Plan: Due to decreased level of consciousness and inability to maintain an airway, the patient will be intubated and transferred to the Medical ICU. Question: Which of the following could be considered for sedation in this patient, while he requires mechanical ventilation? a) Vecuronium b) Diprivan c) Lorazepam d) Haloperidol e) Propofol

c) Lorazepam Vecuronium is a neuromuscular blocker which causes paralysis, not a analgesia or sedation and haloperidol is used for psychosis/delirium. According the the prescribing information, Diprivan and the generic propofol products are contraindicated in patients with a soy/egg hypersensitivity.

Question A drug that exhibits Michaelis-Menten kinetics will display which of the following properties? (Select ALL that apply.) Answer A A proportionate increase in serum concentration for a given increase in dose at all serum concentrations B Improved distribution C A nonlinear relationship between dose and serum level at very high concentrations D Saturable kinetics E Poor bioavailability

cd Incorrect Michaelis-Menten (also called "saturable" or "non-linear" or "mixed order") kinetics mimic a first-order process at low concentrations, but when the metabolism becomes saturated, the concentration increases rapidly (in a nonlinear fashion). At this point, toxicity can result if dose adjustments are not made carefully.

Medication reconciliation notes

compare patient's emdication order to what the patient has been taking to avoid med errors Perform at every transition of care in which new meds are ordered or rewritten

Methods to discovering errors

comprehensive medication review (CMR) Medication Therapy Management (MTM) Personal Medication Record (PMR) with Medication Related Action Plan (MAP)

Medication errors reporting program (MERP) function

confidential national voluntary reporting program analyzes systems for causes of medication errors and provides recommendations

types of transmission based precautions

contact droplet airborne

A client has been placed on long-term sulfasalazine (Azulfidine) therapy for treatment of his ulcerative colitis. The nurse should encourage the client to eat which of the following foods to help avoid the nutrient deficiencies that may develop as a result of this medication? 1. Citrus fruits. 2. Green, leafy vegetables. 3. Eggs. 4. Milk products.

correct answer - 2. rational - In long-term sulfasalazine therapy, the client may develop folic acid deficiency. Green, leafy vegetables are a good source of folic acid. Citrus fruits, eggs, and milk products are not

Choose the pharmacokinetic term used to describe how the drug moves from the site of administration and into the circulation. A Excretion B Dissolution C Absorption D Distribution E Metabolism

Which of the following defines pharmacodynamics? Answer A What the kidney does to the drug. B What the liver does to the drug. C What the body does to the drug. D What the drug does to the body. E What the drug does to the microorganism.

d The effect of the drug on the body is pharmacodynamics.

Question Choose the pharmacokinetic term used to describe the process by which the body breaks down drugs into compounds that can be more readily eliminated. Answer A Dissolution B Absorption C Distribution D Metabolism E Excretion

d The liver (along with drug-metabolizing enzymes in the gut wall) can extract, or pull out, a portion of the drug by changing the drug's structure. This results in less drug being available for therapeutic benefit (or more drug if a pro-drug is hepatically metabolized to the active form).

Computerized physician order entry benefits

direct entry of medication orders minimizing ambiguity Medication alerts Standard sets and protocols may be included

Question A patient is participating in a pharmacokinetic trial. She received 1 gram of an investigational drug at 1800. Serum drug concentrations are drawn hourly for 24 hours. At the conclusion of the trial, the investigator determines that 15% of the drug remaining was removed per hour for all time points measured. Which of the following is true of this scenario? Answer A This drug demonstrated zero-order kinetics over the range of concentrations studied. B The half life of this drug is 1 hour. C The volume of distribution of this drug is 67 liters. D This drug should be administered once daily to maintain serum levels in the therapeutic range. E This drug demonstrated first-order kinetics over the range of concentrations studied.

e A constant percentage of drug is removed per unit of time for drugs with first-order kinetics.

Question A medical resident asks the pharmacy student to explain to the medical students why most drugs are weak acids or weak bases. Which of the following points are correct and could be included in the explanation? Answer A If the drug dissolves in the gut fluid it will not get absorbed. B If the compound is charged it cannot interact with the cell receptors. C Weak acids are highly charged compounds in physiological pH. D Weak bases are highly charged compounds in physiological pH. E Charged compounds dissolve more easily in water than uncharged compounds.

e In order for absorption to occur the drug has to dissolve in the watery-contents of the stomach. If the drug is a weak acid it will have a negative charge and if it is a weak base more of the drug will be charged because more of the drug will have either lost or gained a proton. Charged compounds dissolve easily in water. A dissolved drug can get absorbed into the blood.

Question A new antibiotic for community-acquired pneumonia (CAP) was recently FDA approved. The drug was presented at the hospital's Pharmacy and Therapeutics Committee meeting. The drug monograph included the following information: Community-acquired pneumonia dosing (IV): 675 mg IV Q8H Community-acquired pneumonia dosing (PO): 675 mg PO TID Protein binding: 18% Metabolism: partially hepatic Half-life (elimination): 1.6 - 2.1 hours What is the bioavailability of this new drug? Answer A 0% B 1% C 25% D 50% E 100%

e Since the IV and oral dose are exactly the same, we know the drug is 100% bioavailable. No math is required.

Question Choose the pharmacokinetic term used to describe the process by which the body rids itself of drugs or metabolites either through the kidneys or back into the gut. Answer A Dissolution B Absorption C Distribution D Metabolism E Excretion

e The primary route of excretion for most drugs is the kidney (renal excretion).

Drug and patient related behaviors that compromise safety

failure to check/reconcile home meds Dispensing meds without complete knowledge not questioning unusual doses Not verifying allergies

Airborne precaution

for pts with rubella, varicella or tuberculosis should be in an airborne infection isolation room Need mask or N95 level or higher respirator

High risk medications

insulin anticoagulants concentrated electrolytes chemotherapeutics opioids

PCA safety steps

limit opioid stock use standard order sets Educate staff about hydromorphone and morphine mix-ups PCA protocols Comparing PCA label to patient MAR Barcoding Friends and family should not administer dose

What is MERP

medication errors reporting program

Safe injection practices

never administer an oral solution/suspension IV, use oral syringes and label for oral use only Never reinsert needles into a MDV SDV are preferred Never touch the tip or plunger of a syringe Throw the entire needle/syringe assembly into sharps container when finished without recapping

Organizations accredited by the joint commission must undergo an ______ at least every _____ years

on-site survey 3 years

If a medication error occurs in a hospital, it should be reported to the

pharmacy and therapeutics committee medication safety committee

Failure mode and effects analysis (FMEA) define

proactive method used to reduce future errors and to evaluate potentials for errors

Code blue definition

refers to patient requiring emergency medical care, typically for cardiac or respiratory arrest

RCA is considered as what?

repetitive process and is viewed as continuous quality improvement

What is a root cause analysis?

retrospective investigation of an event that already occurred. Info is used to prevent future errors

root cause analysis define

retrospective investigation of an event, reviewing sequence of events that led to error and incorporating design changes to prevent future errors

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