Pharm Exam #1 Practice Test

Phase I drug studies involve A. the use of laboratory animals to test chemicals B. patients with the disease the drug is designed to treat C. mass marketing surveys of drug effects in large numbers of people D. healthy human volunteers who are often paid for their participation

D. healthy human volunteers who are often paid for their participation

Drug-Drug interactions are important considerations in clinical practice. When evaluating a patient for potential drug-drug interactions, what would the nurse expect to address? Select all that apply. A. Bizarre drug effects on the body B. The need to adjust drug dose or timing of administration C. The need for more drugs to balance the effects of the drugs being given D. A new therapeutic effect not encountered with either drug alone E. Increased adverse effects F. The use of herbal or alternative therapies

B, E, F B. The need to adjust drug dose or timing of administration E. Increased adverse effects F. The use of herbal or alternative therapies

A healthcare provider prescribes oral antacids and intravenous ranitidine for a client with burns and crushing injuries caused by an accident. The client asks how these medications work. Which explanation would the nurse provide? A. "These medications work together to decrease bowel irritability." B. "They limit acidity in the gastrointestinal tract." C. "They are very effective in clients with multiple trauma." D. "These medications decrease nausea and vomiting."

B. "They limit acidity in the gastrointestinal tract."

An orphan drug is a drug that A. has failed to go through the approval process B. is available in a foreign country but not in this country C. has been tested but is not considered to be financially viable D. is available without a prescription

C. has been tested but is not considered to be financially viable

Chemotherapeutic agents are drugs that A. are used only to treat cancers B. replace normal body chemical that are missing because of disease C. interfere with foreign cell functioning causing cell death, such as invading microorganisms or neoplasms D. stimulate the normal functioning of a cell

C. interfere with foreign cell functioning causing cell death, such as invading microorganisms or neoplasms

A patient has been taking fluoxetine (Prozac) for several years, but when picking up the prescription this month found that the tablets looked different and became concerned. The nurse, checking with the pharmacist, found that fluoxetine had just become available in the generic form and the prescription had been filled with the generic product. The nurse should tell the patient A. that the new tablet may have similar effects or may not so the patient should carefully monitor response B. that generic drugs are available without a prescription and they are just as safe as the brand name medication C. that the law requires the prescriptions be filled with the generic form if available to cut down the cost of medications D. that the pharmacist filled the prescription with the wrong drug and it should be returned to the pharmacy for a refund

C. that the law requires the prescriptions be filled with the generic form if available to cut down the cost of medications

A health care provider prescribes sodium biphosphate for a client before colonoscopy. How would the medication accomplish its therapeutic effects? A. Irritates the intestinal mucosa B. Provides water-absorbing bulk C. Softens stool by exerting a detergent effect D. Increases osmotic pressure in the intestines

D. Increases osmotic pressure in the intestines

A client is experiencing a reaction to the penicillin injection that the nurse administered approximately 1/2 hour ago. the nurse is concerned that it might be an anaphylactic reaction. What signs and symptoms would validate her suspicion? Select all that apply. A. Rapid heart rate B. Diaphoresis C. Constricted pupils D. Hypotension E. Rash F. Client report of a panicky feeling

A, B, E, F A. Rapid heart rate B. Diaphoresis E. Rash F. Client report of a panicky feeling

A patient is taking a drug that is known to be toxic to the liver. the patient is being discharged to home. What teaching points related to liver toxicity and the drug should the nurse teach the patient to report to the physician? Select all that apply. A. Fever; changes in the color of urine B. Changes in the color of the stool; malaise C. Rapid, deep respirations; increased sweating D. Dizziness; drowsiness; dry mouth E. Rash; black or hairy tongue; white spots in the mouth or throat F. Yellowing of he skin or the whites of the eyes

A, B, F A. Fever; changes in the color of urine B. Changes in the color of the stool; malaise F. Yellowing of he skin or the whites of the eyes

A patient asks what generic drugs are and if he should be using them to treat his infection. Which of the following statements should be included in the nurse's explanation? A. A generic drug is a drug that is sold by the name of the ingredient, not the brand name B. Generic drugs are always the best drugs to use because they are never any different from the familiar brand names C. Generic drugs are not available until the patent expires on a specific drug D. Generic drugs are usually cheaper than the well-known brand names, and some insurance companies require that you receive the generic drug if one is available F. Your physician may want you to have the brand name of a drug, not the generic form, and a DAW will be on your prescription form G. Generic drugs are less likely to cause adverse effects than brand name drugs

A, C, D, F A. A generic drug is a drug that is sold by the name of the ingredient, not the brand name C. Generic drugs are not available until the patent expires on a specific drug D. Generic drugs are usually cheaper than the well-known brand names, and some insurance companies require that you receive the generic drug if one is available F. Your physician may want you to have the brand name of a drug, not the generic form, and a DAW will be on your prescription form

A client is receiving patient-controlled analgesia (PCA) after surgery. Which benefit would this type of therapy provide? Select all that apply. A. Client is able to self-administer pain-relieving medications as necessary B. Amount of medication received is determined entirely by the client C. Decreases client dependency D. relieves the nurse of monitoring the client E. Increases client sense of autonomy

A, C, E A. Client is able to self-administer pain-relieving medications as necessary C. Decreases client dependency E. Increases client sense of autonomy

After teaching a patient about digoxin (Lanoxin) - a drug used to increase the effectiveness of the heart's contractions - which statement indicates hat the teaching as effective? A. "I need to take my pulse very morning before I take my pill." B. "If I forget my pills, I usually make up the missed dose once I remember." C. "this pill might help my hay fever when if becomes a problem." D. "I don't remember the name if it, but it is the white one."

A. "I need to take my pulse very morning before I take my pill."

The storing, prescribing, and distributing of controlled substances - drugs that are more apt to be addictive - are monitored by A. the FDA B. the Department of Commerce C. the FBI D. the DEA

D. the DEA

A health care provider prescribes psyllium 3.5g twice a day for constipation. Which statement is important for the nurse to teach this client? A. "Urine may be discolored." B. "Each dose should be taken with a full glass of water." C. "Use only when necessary because it can cause dependence." D. "Daily use may inhibit the absorption of some fat-soluble vitamins."

B. "Each dose should be taken with a full glass of water."

A health care provider prescribes biscodyl for a client with constipation. the nurse explains to the client that this medication acts by which mechanism? A. Producing bulk B. Softening feces C. Lubricating feces D. Stimulating peristalsis

D. Stimulating peristalsis

Which medication is safest to take for pain in the week before a surgical procedure? A. Naproxen B. Aspirin C. Ketorolac D. Acetaminophen

D. Acetaminophen

When teaching a patient about OTC drugs, which points should the nurse include? Select all that apply. A. these drugs are very safe and can be used freely to relieve your complaints B. these compounds are called drugs, but they aren't really drugs C. many of these drugs were once prescription drugs but are now thought to be safe for use without a prescription when used as directed D. reading the label of these drugs is very important; the name of the active ingredient is prominent; you should always check the ingredient name E. it is important to read the label and to see what the recommended dose is; some of these drugs can cause serious problems if too much of the drug is taken F. it is important to report the use of any OTC drug to your health care provider because many of then can interact with drugs that might be prescribed for you

C, D, E, F C. many of these drugs were once prescription drugs but are now thought to be safe for use without a prescription when used as directed D. reading the label of these drugs is very important; the name of the active ingredient is prominent; you should always check the ingredient name E. it is important to read the label and to see what the recommended dose is; some of these drugs can cause serious problems if too much of the drug is taken F. it is important to report the use of any OTC drug to your health care provider because many of then can interact with drugs that might be prescribed for you

A woman has had repeated bouts of bronchitis throughout the fall and has been taking antibiotics. She calls the clinic with complaints of vaginal pain and itching. When she is seen, it is discovered that she has developed a yeast infection. You understand that a. her bronchitis has moved to the vaginal area. b. she has developed a superinfection, because the antibiotics kill bacteria that normally provide protection. c. she probably has developed a sexually transmitted disease related to her lifestyle. d. she will need to take even more antibiotics to treat this new infection.

b. she has developed a superinfection, because the antibiotics kill bacteria that normally provide protection.

Pregnant women should be advised of the potential risk to the fetus any time they take a drug during pregnancy. What fetal problems can be related to drug exposure in utero? Select all that apply. A. Fetal death B. Nervous system disruption C. Skeletal and limb abnormalities D. Cardiac defects E. Low-set ears F. Deafness

A, B, C, D, E, F A. Fetal death B. Nervous system disruption C. Skeletal and limb abnormalities D. Cardiac defects E. Low-set ears F. Deafness

The nursing care of a patient receiving drug therapy should include measures to decrease the anticipated adverse effects of the drug. Which of the following measures would a nurse consider? Select all that apply. A. A positive approach B. Environmental temperature control C. Safety measures D. Skin care E. Refrigeration of the drug F. Involvement of the family

A, B, C, D, F A. A positive approach B. Environmental temperature control C. Safety measures D. Skin care F. Involvement of the family

Which action is the nurse's responsibility when administering prescribed opioid analgesics? Select all that apply. A. Count the client's respirations B. Document the intensity of the client's pain C. Withhold the medication if the client reports pruritus D. Verify the number of doses in the locked cabinet before administering the prescribed dose E. Discard the medication in the client's toilet before leaving the room if the medication is refused.

A, B, D A. Count the client's respirations B. Document the intensity of the client's pain D. Verify the number of doses in the locked cabinet before administering the prescribed dose

A client is experiencing a serum sickness reaction to a recent rubella vaccination. Which of the following interventions would be appropriate when caring for this client? Select all that apply. A. Administration of epinephrine B. Cool environment C. Positioning to provide comfort D. Ice to joints as needed E. Administration of antiinflammatory agents F. Administration of topical corticosteroids

B, C, D, E B. Cool environment C. Positioning to provide comfort D. Ice to joints as needed E. Administration of antiinflammatory agents

Which action would the nurse perform when administering fluticasone proprionate to a client with asthma? Select all that apply. A. Assessing heart rate and rhythm B. Monitoring liver function blood tests C. Rinsing the oral cavity with after after use D. Obtaining blood glucose levels before meals E. Giving stool softeners to prevent constipation

C. Rinsing the oral cavity with after after use

The evaluation step of the nursing process A. is often used as a last resort B. is important primarily in the acute setting C. is a continuous process D. includes making nursing diagnoses

C. is a continuous process

Which effect explains the purpose for gradual dosage reduction of glucocorticoids such as dexamethasone? A. Builds glycogen stores in the muscle B. Produces antibodies by the immune system C. Allows the increased intracranial pressure to return to normal D. Promotes return of cortisone production by the adrenal glands

D. Promotes return of cortisone production by the adrenal glands

Patients receiving antineoplastic drugs that disrupt cell function often have adverse effects involving cells that turn over rapidly in the body. These cells include A. ovarian cells B. liver cells C. cardiac cells D. bone marrow cells

D. bone marrow cells

Which complication is an adverse effect of cortisone therapy? A. Hypoglycemia B. Severe anorexia C. Anaphylactic shock D. Behavioral changes

D. Behavioral changes

An adolescent with leukemia is to be given a chemotherapeutic agent. Which time is the BEST for the nurse to administer the prescribed antiemetic? A. As nausea occurs B. An hour before meals C. Just before each meal is eaten D. Before each dose of chemotherapy

D. Before each dose of chemotherapy

Which intervention would the nurse include in the plan of care for a client receiving antibiotics and antifungal medication for treatment of a vaginal infection? A. Avoid spicy foods B. Drink more fruit juices C. Take a multivitamin every day D. Eat yogurt with active cultures daily

D. Eat yogurt with active cultures daily

After cataract surgery, a client reports feeling nauseated. How can the nurse prevent vomiting? A. Administer the prescribed antiemetic medication B. Provide some dry crackers for the client to eat C. Explain that this is expected after surgery D. Teach how to breathe deeply until the nausea subsides

A. Administer the prescribed antiemetic medication

Which mechanism of action explains why naloxone is administered for heroin overdose? A. Competition with opioids for occupancy of opioid receptors B. Blunts severity of withdrawal symptoms as heroin wears off C. Accelerated metabolism of heroin and stimulation of respiratory centers D. Stimulation of cortical sites that control consciousness and cardiovascular function

A. Competition with opioids for occupancy of opioid receptors

A client receiving morphine is being monitored by the nurse for adverse effects of the medication. Which clinical findings warrant immediate follow up by the nurse? Select all that apply. A. Polyuria B. Unconsciousness C. Bradycardia D. Dilated pupils E. Bradypnea

B, C, E B. Unconsciousness C. Bradycardia E. Bradypnea

When trying to determine why the desired therapeutic effect is not being seen with an oral drug, the nurse should consider A. the blood flow to muscle beds B. food altering the makeup of gastric juices C. the weight of the patient D. the temperature of the peripheral environment

B. food altering the makeup of gastric juices

A client is being started on a laxative regimen. Before administering the medication, the nurse should perform which of the following processes? Select all that apply A. Assessing for allergies B. Evaluating the medication effectiveness C. Evaluating the route of administration D. Diagnosing the patient with ischemic colitis E. Asking the patient for name and birth date record when the medication was dispensed from the pharmacy

A, C, E A. Assessing for allergies C. Evaluating the route of administration E. Asking the patient for name and birth date record when the medication was dispensed from the pharmac

Which medication would the nurse anticipate the health care provider will prescribe to relieve the pain experienced by a client with rheumatoid arthritis? A. Aspirin B. Hydromorphone C. Meperidine D. Alprazolam

A. Aspirin

Which medication is indicated for management of clinical manifestations associated with an opioid overdose? A. Naloxone B. Methadone C. Epinephrine D. Amphetamine

A. Naloxone

The half-life of a drug A. is determined by a balance of all pharmacokinetic processes B. is a constant factor for all drugs taken by a patient C. is only influenced by the fat distribution of the patient D. can be calculated with the use of a body surface nomogram

A. is determined by a balance of all pharmacokinetic processes

Which therapeutic outcomes are expected after administering ibuprofen? Select all that apply. A. Diuresis B. Pain relief C. Temperature reduction D. Bronchodilation E. Anticoagulation F. Reduced inflammation

B, C, F B. Pain relief C. Temperature reduction F. Reduced inflammation

A patient reports that she has a drug allergy. In exploring the allergic reaction with the patient, which of the following might indicate an allergic response? A. Increased urination B. Dry mouth C. Rash D. Drowsiness

C. Rash

J.B. has Parkinson's disease that has been controlled for several years with levodopa. After he begins a health food regimen with lots of vitamin B6, his tremors return, and he develops a rapid heart rate, hypertension, and anxiety. The nurse investigating the problem discovers that vitamin B6 can speed the conversion of levodopa to dopamine in the periphery, leading to these problems. The nurse would consider this problem... a. a drug-laboratory test interaction. b. a drug-drug interaction. c. an accumulation effect. d. a sensitivity reaction.

b. a drug-drug interaction.

Which medication would the nurse expect to administer to actively reverse the overdose sedative effects of benzodiazepines? A. Lithium B. Flumazenil C. Methadone D. Chlorpromazine

B. Flumazenil

A client with burns develops a wound infection. the nurse plans to teach the client that local wound infections are PRIMARILY treated with which antibiotic formulation? A. Oral B. Topical C. Intravenous D. Intramuscular

B. Topical

Receptor sites A. are a normal part of enzyme substrates B. are protein areas on cell membranes that react with specific chemicals C. can usually be stimulated by many different chemicals D. are responsible for all drug effects in the body

B. are protein areas on cell membranes that react with specific chemicals

A client with irritable bowel syndrome has instructions to take psyllium for constipation. Which statement is important for the nurse to include int he teaching plan? A. "Urine may be discolored." B. "Stop takingt he laxative once a bowel movement occurs." C. "Each dose should be taken with a full glass of water or juice." D. "Daily use may inhibit the absorption of some fat-soluble vitamins."

C. "Each dose should be taken with a full glass of water or juice."

The nurse provides teaching about ampicillin. Which client statement indicates that additional teaching is needed? A. "I should take this on an empty stomach with a full glass of water." B. "This medicine will work best if I space the time out evenly." C. "I can stop this medication after I am symptom-free for 48 hours." D. "If I get worse, I will notify my primary health care provider."

C. "I can stop this medication after I am symptom-free for 48 hours."

A client reports frequently taking calcium carbonate. The nurse advises the client that this can have which effect? A. Diarrhea B. Water retention C. Rebound hyperacidity D. Bone demineralization

C. Rebound hyperacidity

An example of a drug allergy is A. dry mouth occurring with use of an antihistamine B. increased urination occurring with use of a thiazide diuretic C. breathing difficulty after an injection of penicillin D. urinary retention associated with atropine use

C. breathing difficulty after an injection of penicillin

A patient taking glyburide (an anti-diabetic drug) has his morning dose and then does not have a chance to eat for several hours. An adverse effect that might be expected from this would be A. a teratogenic effect B. a skin rash C. an anticholinergic effect D. hypoglycemia

D. hypoglycemia

A patient is preparing to administer a drug to a client for the first time. What questions should the nurse consider before actually administering the drug? Select all that apply. A. Is this the right patient? B. Is this the right drug? C. Is there a generic drug available? D. Is this the right route for this patient? E. is this the right dose, as ordered? F. Did I record this properly?

A, B, D, E A. Is this the right patient? B. Is this the right drug? D. Is this the right route for this patient? E. is this the right dose, as ordered?

When considering the pharmacokinetics of a drug, what points would the nurse need to consider? Select all that apply. A. How the drug will be absorbed B. The way the drug affects the body C. Receptor site activation and suppression D. How the drug will be excreted E. How the drug will be metabolized F. the half-life of the drug

A, D, E, F A. How the drug will be absorbed D. How the drug will be excreted E. How the drug will be metabolized F. the half-life of the drug

A client on duloxetine therapy ingests ibuprofen for pain relief. Which adverse effect would the nurse anticipate with this combination of medications? A. Bleeding B. Hepatotoxicity C. Serotonin syndrome D. Cardiac dysrhythmias

A. Bleeding

A 12-year old child has just received a dose of epinephrine. Which assessment is the PRIORITY after this medication is administered? A. Heart rate B. Glucose level C. Neurological status D. Blood pressure

A. Heart rate

The nurse obtains a medical history from a patient before beginning drug therapy based on an understanding of which of the following? A. Medial conditions can alter a drug's pharmacokinetics and pharmacodynamics B. A medical history is a key component of any nursing protocol C. A baseline of information is necessary to evaluate a drug's effects D. The medical history if the first step in the nursing process

A. Medial conditions can alter a drug's pharmacokinetics and pharmacodynamics

The nurse is assessing an adolescent after the administration of epinephrine. Which side effect is MOST important for the nurse to identify? A. Tachycardia B. Hypoglycemia C. Constricted pupils D. Decreased blood pressure

A. Tachycardia

A client is prescribed albuterol to relieve severe asthma. Which adverse effects will the nurse instruct the client to anticipate? Select all that apply. A. Tremors B. Lethargy C. Palpitations D. Bronchoconstriction E. Decreased pulse rate

A. Tremors C. Palpitations

A patient receiving an antihistamine complains of dry mouth and nose. An appropriate comfort measure for this patient would be to A. suggest that the patient use a humidifier B. encourage voiding before taking the drug C. have the patient avoid sun exposure D. give the patient a back rub

A. suggest that the patient use a humidifier

The FDA pregnancy categories were used A. to indicate a drug's potential or actual teratogenic effects B. for research purposes only C. to list drugs that are more likely to have addicting properties D. to follow regulations set by the DEA

A. to indicate a drug's potential or actual teratogenic effects

The nurse provides discharge teaching about ampicillin that is prescribed for a client. The nurse evaluates that the teaching is effective when the teaching is effective when the client makes which statement? A. "I will miss eating grapefruit." B. "I must increase my fluid intake." C. "I can stop taking this medication any time." D. "I should take this medication just after eating."

B. "I must increase my fluid intake."

According to the FDA Pregnancy Risk Categories, the nurse identifies which category of drugs may cause slight risk to the fetus? A. Category A B. Category B C. Category C D. Category D

B. Category B

The nurse teaches an adolescent about the effects of azithromycin. The nurse determines the teaching has been understood when the adolescent identifies which problem as the MOST common side effect of this medication? A. Tinnitus B. Diarrhea C. Dizziness D. Headache

B. Diarrhea

A toddler with cystic fibrosis has been hospitalized with bacterial pneumonia. The nurse concludes which is the reason the health care provider selected a specific antibiotic? A. Tolerance of the child B. Sensitivity to the bacteria C. Selectivity of the bacteria D. Preference of the health care provider

B. Sensitivity of the bacteria

Clinical pharmacology is the study of A. the biological effects of chemicals B. drugs used to treat, prevent, or diagnose disease C. plant components that can be used as medicines D. binders and other vehicles for delivering medication

B. drugs used to treat, prevent, or diagnose disease

Healthy young women are sometimes not able to be involved in phase I studies of drugs because A. male bodies are more predictable and responsive to chemicals B. females are more apt to suffer problems with ova, which are formed only before birth C. males can tolerate the unknown adverse effects of many drugs better than females D. there are no standards to use to evaluate the female response

B. females are more apt to suffer problems with ova, which are formed only before birth

A patient with a severe infection is given gentimicin, the only antibiotic shown to be effective in culture and sensitivity tests. A few hours after the drug is started intravenously, the patient becomes very restless and develops edema. Blood tests reveal abnormal electrolytes and elevated blood urea nitrogen. This reaction was most likely caused by A. an anaphylactic reaction B. renal toxicity associated with gentimicin C. superinfection related o the antibiotic D. hypoglycemia

B. renal toxicity associated with gentimicin

Which client would benefit from MOST from the administration of prophylactic antibiotics? Select all that apply. A. Chickenpox infection B. Fever of unknown origin C. Preoperative hip replacement D. Congenital bicuspid aortic valve E. Current chemotherapy treatment

C, D, E C. Preoperative hip replacement D. Congenital bicuspid aortic valve E. Current chemotherapy treatment

When reviewing a drug to be given, the nurse notes that the drug is excreted in the urine. What points should be included in the nurse's assessment of the patient? Select all that apply. A. The patient's liver function tests B. The patient's bladder tone C. The patient's renal function tests D. The patient's fluid intake E. Other drugs being taken that could affect the kidney F. The patient's intake and output for the day

C, D, E C. The patient's renal function tests D. The patient's fluid intake E. Other drugs being taken that could affect the kidney

Which instruction would the nurse give to clients prescribed psychotropic medications who are experiencing anticholinergic-like side effects? A. "Restrict fluid intake." B. "Eat a diet high in carbohydrates." C. "Suck on sugar-free hard candies." D. "Avoid products that contain aspirin."

C. "Suck on sugar-free hard candies."

The nurse is preparing to discharge a client who presented tot he emergency department for an acute asthma attack. The nurse notes that upon discharge the health care provider has prescribed theophylline 300mg orally to be taken daily at 9:00am, The nurse will teach the client to take the medication on which schedule? A. One hour before or 2 hours after eating B. At bedtime C. At the specific time prescribed D. Daily until symptoms are gone

C. At the specific time prescribed

The nurse writes a nursing diagnosis for which reason? A. Direct medical care B. Help to increase patient compliance C. Identify actual or potential alteration in patient function D. Determine insurance reimbursement in most cases

C. Identify actual or potential alteration in patient function

A client takes morphine sulfate for severe metastatic bone pain. The nurse will assess the client for which adverse effect? A. Diarrhea B. Addiction C. Respiratory depression D. Diuresis

C. Respiratory depression

The generic name of a drug is A. the name assigned to the drug by the pharmaceutical company developing is B. the chemical name of the drug based on its chemical structure C. the original name assigned to the drug at the beginning of the evaluation process D. the name that is often used in advertising campaigns

C. the original name assigned to the drug at the beginning of the evaluation process

Knowing that a patient is taking a loop diuretic and is at risk for developing hypokalemia the nurse would assess the patient for A. hypertension, headache, and cold and clammy skin B. decreased urinary output and yellowing of the sclera C. weak pulse, low blood pressure, and muscle cramping D. diarrhea and flatulence

C. weak pulse, low blood pressure, and muscle cramping

When establishing the nursing interventions appropriate for a given patient A. the patient should not be actively involved B. the patient support systems should be included only at discharge C. teaching should be done when the patient states he or she is ready to learn D. an evaluation of all of the data accumulated should be incorporated to achieve an effective care plan

D. an evaluation of all of the data accumulated should be incorporated to achieve an effective care plan

Selective toxicity is A. the ability of a drug to seek out a specific bacterial species or microorganism B. the ability of a drug to cause only specific adverse effects C. the ability of a drug to cause fetal damage D. the ability of a drug to attack only those systems found in foreign or abnormal cells

D. the ability of a drug to attack only those systems found in foreign or abnormal cells

Much of the biotransformation that occurs when a drug is taken occurs as part of a. the protein-binding effect of the drug. b. the functioning of the renal system. c. the first-pass effect through the liver. d. the distribution of the drug to the reactive tissues.

c. the first-pass effect through the liver.