Pharmacology Practice Test 2

A patient receives a Mantoux tuberculin skin test as part of screening for a new job. The test is administered on a Friday, and the patient returns to the clinic the following Wednesday. The primary care nurse practitioner (NP) notes a 3-mm area of induration. The patient has no risk factors for tuberculosis (TB). The NP should: a. repeat the test. b. record the test as negative. c. ask about previous TB exposure. d. record the test as positive.

a. repeat the test If the patient returns after more than 3 days and the results appear negative, the test should be repeated.

A primary care NP sees a patient who has fever, flank pain, and dysuria. The patient has a history of recurrent urinary tract infections (UTIs) and completed a course of trimethoprim-sulfamethoxazole (TMP/SMX) the week before. A urine test is positive for leukocyte esterase. The NP sends the urine for culture and should treat this patient empirically with: a. ciprofloxacin. b. azithromycin. c. gemifloxacin. d. TMP/SMX.

a. ciprofloxacin. Fluoroquinolones are effective in treatment of UTIs that are resistant to other antibiotics. Because this patient recently completed a course of TMP/SMX, the NP can assume that the bacterium causing the infection is resistant to TMP/SMX. Gemifloxacin is not indicated for UTI, but ciprofloxacin is. Azithromycin is not a fluoroquinolone.

A primary care NP sees a patient who was recently hospitalized for infection and treated with gentamicin for 10 days. The patient tells the NP that the drug was discontinued early because "my blood level was too high." The NP should order: a. a serial audiometric test. b. a urinalysis and complete blood count. c. a serum blood urea nitrogen (BUN) and creatinine. d. serum calcium, magnesium, and sodium.

a. a serial audiometric test. Aminoglycosides are associated with ototoxicity and nephrotoxicity. Recovery of renal function occurs if the drug is stopped at the first sign of renal impairment. The NP should evaluate the possibility of ototoxicity with a serial audiometric test.

A patient who takes isoniazid and rifampin for latent TB comes to the clinic with a new-onset cough and night sweats. The primary care NP should evaluate these findings by ordering: a. a sputum culture. b. renal function tests. c. tuberculin skin test. d. LFTs.

a. a sputum culture Patients with latent TB who develop symptoms while being treated should have a sputum culture.

A female patient who is 8 weeks pregnant is seen by a primary care nurse practitioner (NP) after a routine prenatal screen was positive for human immunodeficiency virus (HIV). A CD4 cell count is 750 cells/mm. The NP should: a. begin therapy with zidovudine when she is in her second trimester. b. begin immediate therapy with zidovudine and lamivudine. c. delay treatment with antiretroviral medications until after her pregnancy. d. initiate therapy with zidovudine if her CD4 cell count decreases to 500 cells/mm.

a. begin therapy with zidovudine when she is in her second trimester. Patients who are HIV positive and who are pregnant should be treated with antiretroviral medications, but treatment should be avoided during the first trimester if possible. Zidovudine is recommended and has been shown to reduce the risk of transmission to the fetus from 25% to 8%.

A patient who has genital herpes has frequent outbreaks. The patient asks the primary care NP why it is necessary to take oral acyclovir all the time and not just for acute outbreaks. The NP should explain that oral acyclovir may: a. cause episodes to be shorter and less frequent. b. reduce the chance of transmitting the virus to others. c. prevent the virus from developing resistance. d. actually eradicate the virus and cure the disease.

a. cause episodes to be shorter and less frequent. Oral acyclovir has prevented or reduced the frequency of severity of recurrences in more than 95% of patients and so should be given to patients with recurrent episodes. It does not affect resistance. The antiviral medication does not eradicate the virus; it prevents replication. The disease is transmitted even without symptoms.

An adult patient has cellulitis. The patient is a single parent with health insurance who works and is attending classes at a local university. To treat this infection, the primary care nurse practitioner (NP) should prescribe: a. cefadroxil (Duricef). b. cefdinir (Omnicef). c. ceftriaxone (Rocephin). d. cephalexin (Keflex).

a. cefadroxil (Duricef) First-generation cephalosporins, such as cephalexin and cefadroxil, are used for skin and soft tissue infections. Cefadroxil is preferred in this case because it can be given twice daily instead of four times daily, and this patient will be more likely to comply with the drug regimen. Cefdinir and ceftriaxone are both third-generation cephalosporins.

A patient is taking amantadine to treat a viral infection. The patient calls the primary care NP to report having blurred vision. The NP should: a. counsel the patient to avoid driving until this subsides. b. question the patient about suicidal ideation. c. tell the patient to stop the medication immediately. d. tell the patient to come to the clinic for an electroencephalogram.

a. counsel the patient to avoid driving until this subsides. Blurred vision or impaired mental acuity may result from the use of amantadine. Patients with a history of psychiatric illness may develop suicidal ideation, but this is not associated with blurred vision. It is not necessary to stop the medication. Patients with a history of seizures may have seizures with this drug, but this is not associated with blurred vision.

A patient who has been taking ciprofloxacin for 14 days for treatment of a UTI is seen in the clinic for a follow-up urinalysis. The urinalysis reveals crystalluria. The primary care NP should: a. counsel the patient to increase fluid intake. b. decrease the dose of ciprofloxacin. c. change the antibiotic to norfloxacin. d. discontinue the ciprofloxacin.

a. counsel the patient to increase fluid intake. Fluoroquinolones can cause renal irritation and urine crystals. Patients should be advised to maintain proper hydration to avoid this. It is not necessary to discontinue the ciprofloxacin or to decrease the dose.

During a gynecologic examination of a sexually active adolescent girl, the primary care NP notes mucopurulent cervicitis. A culture is positive for Neisseria gonorrhoeae. The NP should: a. give intramuscular ceftriaxone and a single dose of 1 g of azithromycin. b. give a single dose of 2 g of oral azithromycin. c. administer benzathine penicillin G 2.4 million units intramuscularly. d. prescribe oral doxycycline 100 mg daily for 7 days.

a. give intramuscular ceftriaxone and a single dose of 1 g of azithromycin. Many patients who present with one sexually transmitted disease (STD) have other concomitant STDs. When gonorrhea or urethritis/cervicitis is diagnosed, the NP should treat for both N. gonorrhoeae and Chlamydia. A single-dose treatment ensures compliance. A single, 2-g dose of azithromycin is indicated to treat chancroid. Benzathine penicillin G is indicated to treat syphilis. A 7-day regimen of doxycycline is used to treat Chlamydia, but not gonorrhea.

A parent brings a 6-year-old child to the clinic for evaluation of a rash. The primary care NP notes three annular lesions with elevated borders and central clearing on the child's face and a similar lesion on the back of the neck that extends above the hairline. The NP should prescribe: a. griseofulvin. b. topical ketoconazole. c. oral ketoconazole. d. fluconazole.

a. griseofulvin. Griseofulvin is used for tinea infections of the skin, hair, and nails that are not responsive to topical therapy. Topical treatment of tinea capitis is usually ineffective because the fungus invades the hair shaft. Fluconazole is not indicated for tinea infections.

A patient who has had two recent urinary tract infections is in the clinic with dysuria and fever. The primary care NP reviews the patient's chart and notes that in both previous cases the causative organism and sensitivity were the same. The NP should: a. order a urine culture and treat empirically pending culture results. b. order a microscopic evaluation of the urine and an antibiotic. c. treat the patient empirically without a culture. d. order a urine culture and sensitivity and wait for results before treating.

a. order a urine culture and treat empirically pending culture results. Because this patient has had similar infections in the past, treating empirically is acceptable. The NP must still obtain a culture and sensitivity so that appropriate antibiotic therapy can be provided, even though it is likely that this is a recurrence of the same organism. A culture should always be obtained when possible. A microscopic evaluation is used to determine whether or not a culture should be performed and is not diagnostic.

A female patient presents with grayish, odorous vaginal discharge. The primary care NP performs a gynecologic examination and notes vulvar and vaginal erythema. Testing of the discharge reveals a pH of 5.2 and a fishy odor when mixed with a solution of 10% potassium hydroxide. The NP should: a. order metronidazole 500 mg twice daily for 7 days. b. order topical fluconazole. c. withhold treatment until culture results are available. d. prescribe a clotrimazole vaginal suppository for 7 days.

a. order metronidazole 500 mg twice daily for 7 days. This patient has classic symptoms of bacterial vaginosis. The treatment of choice is metronidazole. Fluconazole is used to treat fungal infections. Cultures are generally not helpful in the diagnosis of bacterial vaginosis. Clotrimazole is used to treat Candida infections.

A patient who was recently hospitalized and treated with gentamicin tells the primary care NP, "My kidney function test was abnormal and they stopped the medication." The patient is worried about long-term effects. The NP should: a. reassure the patient that complete recovery should occur. b. monitor renal function for several months. c. refer the patient to a nephrologist for follow-up evaluation. d. monitor serum electrolytes and serum creatinine and BUN.

a. reassure the patient that complete recovery should occur Recovery of renal function occurs if the drug is stopped at the first sign of renal impairment. It is necessary to monitor blood values during therapy to ensure effectiveness and prevent toxicity.

A patient has been taking ciprofloxacin for 3 days and calls the primary care nurse practitioner (NP) to report having headaches and dizziness. The NP should: a. reassure the patient that these are common side effects. b. decrease the dose of ciprofloxacin. c. change to levofloxacin. d. change to an antibiotic in another drug class.

a. reassure the patient that these are common side effects. Headaches and dizziness are common side effects of fluoroquinolones. It is not necessary to change to another fluoroquinolone, decrease the dose, or change to another antibiotic class.

A patient is taking sulfisoxazole. The patient calls the primary care NP to report abdominal pain, nausea, and insomnia. The NP should: a. reassure the patient that these are minor adverse effects of this drug. b. order a CBC with differential, platelets, and a stool culture. c. change to TMP/SMX. d. tell the patient to stop taking the drug immediately.

a. reassure the patient that these are minor adverse effects of this drug. These side effects are considered common minor side effects of sulfonamide medications. They occur with all drugs in this class, so changing to TMP/SMX is not indicated. The patient should continue taking the medication. It is not necessary to perform laboratory tests.

A patient is diagnosed with onychomycosis. The primary care NP notes that the patient takes quinidine. The NP should prescribe: a. terbinafine (Lamisil). b. griseofulvin (Gris-PEG). c. itraconazole (Sporanox). d. fluconazole (Diflucan).

a. terbinafine (Lamisil). Sporanox and terbinafine are both indicated to treat onychomycosis. Sporanox is not indicated in patients taking quinidine because of the risk of cardiac arrhythmias. Fluconazole and griseofulvin are not indicated to treat onychomycosis.

A primary care NP is preparing to prescribe a macrolide antibiotic for a patient who has a history of a prolonged QT interval on electrocardiogram. Which macrolide antibiotic should the NP prescribe? a. Clarithromycin b. Azithromycin c. Telithromycin d. Erythromycin

b. Azithromycin Azithromycin does not cause a prolonged QT interval , unlike the other macrolides, so it would be safe for this patient. Visual disturbances have been found to occur with the use of telithromycin. Erythromycin has a wider range of adverse effects and can cause cardiac effects in patients who have a prolonged QT interval. The Ilosone, E-Mycin, and Erythrocin are all erythromycins.

An 80-year-old patient who has COPD takes TMP/SMX for acute exacerbations, which occur three or four times each year. To monitor this patient for adverse drug reactions, the primary care NP should order: a. blood urea nitrogen and creatinine. b. a complete blood count (CBC) with differential. c. serum bilirubin levels. d. liver function tests.

b. a complete blood count (CBC) with differential. The most frequently reported severe adverse reactions in elderly patients include bone marrow depression and decreased platelets. A CBC with differential is indicated to monitor for this. Evaluation of liver and renal function should be performed before beginning treatment because adverse effects are more common in patients with decreased renal and liver function.

A 70-year-old patient will begin taking cefdinir (Omnicef) for an acute exacerbation of COPD. Before initiating therapy, the primary care NP should order: a. an electrocardiogram (ECG). b. a creatinine clearance test. c. coagulation studies. d. liver function tests (LFTs).

b. a creatinine clearance test. Geriatric patients may need adjusted doses based on creatinine clearance testing, so obtaining a creatinine clearance test before initiating therapy is indicated. LFTs, coagulation studies, and an ECG are not indicated.

A patient who has HIV has been receiving a two-drug combination therapy for 6 months. At an annual physical examination, the primary care NP notes that the patient has a viral load of 60 copies/mL and a CD4 cell count of 350 cells/mm. The NP should contact the patient's infectious disease specialist to discuss: a. discontinuing the medications for a short period. b. changing both of the medications. c. increasing the dose of both medications. d. changing one of the medications.

b. changing both of the medications. This patient has a high viral load and a low cell count. When changing medications, both medications should be changed.

A patient is taking an aminoglycoside and a cephalosporin. The primary care NP should consider _____ the dose of _____. a. increasing; aminoglycoside b. decreasing; aminoglycoside c. decreasing; cephalosporin d. increasing; cephalosporin

b. decreasing; aminoglycoside Cephalosporins can heighten aminoglycoside toxicity, so a decrease in the dose of the aminoglycoside should be considered.

A patient has had severe diarrhea for 2 weeks. Laboratory testing reveals Clostridium difficile. The primary care NP should prescribe: a. clarithromycin. b. fidaxomicin. c. erythromycin. d. azithromycin.

b. fidaxomicin. Fidaxomicin is indicated only for treatment of C. difficile-associated diarrhea. The other macrolides are not used for this purpose.

A patient has a Mantoux tuberculin skin test with a 12-mm area of induration. The patient has a cough, and a chest radiograph is positive. The primary care NP should refer this patient to an infectious disease specialist and should plan to monitor a regimen of: a. isoniazid and rifapentine. b. isoniazid, rifampin, pyrazinamide, and ethambutol. c. isoniazid, rifapentine, and ethambutol. d. isoniazid for 6 months.

b. isoniazid, rifampin, pyrazinamide, and ethambutol. Newly diagnosed patients with active disease should be started on a four-drug regimen.

A patient was diagnosed with tinea corporis and given topical ketoconazole. The patient tells the primary care nurse practitioner (NP) that the infection is not getting better. The NP should: a. prescribe oral ketoconazole. b. obtain a culture of the infection site. c. recommend 3 more weeks of treatment with the topical medication. d. prescribe griseofulvin.

b. obtain a culture of the infection site. If infection is unresponsive to empirical therapy, cultures must be obtained to confirm the diagnosis and rule out resistant organisms. This should be done before changing treatment.

A patient is taking isoniazid, pyrazinamide, rifampin, and streptomycin to treat TB. The primary care NP should routinely perform: a. color vision, serum glucose, and LFTs. b. ophthalmologic, hearing, and serum glucose tests. c. bone marrow density and ophthalmologic tests. d. serum glucose and liver function tests (LFTs).

b. ophthalmologic, hearing, and serum glucose tests. For patients taking isoniazid, obtain periodic ophthalmologic examinations; for patients taking pyrazinamide, perform blood glucose tests.

A patient with otitis media is treated for 10 days with amoxicillin. At the follow-up visit, the primary care NP notes bilateral erythematous, bulging tympanic membranes. The NP should prescribe: a. amoxicillin for 10 more days. b. oral amoxicillin-clavulanate (Augmentin) for 10 days. c. oral dicloxacillin (Dynapen) for 10 days. d. intramuscular injection of penicillin G (Bicillin).

b. oral amoxicillin-clavulanate (Augmentin) for 10 days. Antibiotic resistance to penicillins occurs through three mechanisms, the most important being bacteria producing b-lactamase, which breaks down the b-lactam ring and renders the penicillin inactive. Clavulanic acid, used in combination with penicillins, prevents this inactivation. The NP should prescribe amoxicillin-clavulanate. Giving 10 more days of amoxicillin would not be effective. Dicloxacillin is used when resistance is caused by penicillinase-resistant staphylococcal infection. Penicillin G is not used to treat otitis media.

A school-age child comes to the clinic with a 5-day history of cough and low-grade fever. The primary care NP auscultates crackles and diminished breath sounds bilaterally. The NP should: a. recommend symptomatic treatment. b. obtain a sputum culture. c. order azithromycin. d. prescribe doxycycline.

c. order azithromycin. Community-acquired pneumonia in school-age children is commonly caused by Mycoplasma. Azithromycin is a first-line drug of choice to treat this type of pneumonia.

A woman has a urinary tract infection (UTI) and has been taking TMP-SMX for 3 days along with increased fluids. She reports continued dysuria and urinary frequency and has a consistent, low-grade fever. The primary care NP should: a. prescribe amoxicillin-clavulanate twice daily for 7 days. b. prescribe ciprofloxacin twice daily for 3 days. c. order doxycycline twice daily for 7 to 14 days. d. order TMP-SMX DS twice daily for 7 days.

b. prescribe ciprofloxacin twice daily for 3 days. Initial treatment of uncomplicated UTI is a 3-day course of TMP-SMX. Ciprofloxacin is used if the patient is still symptomatic. Doxycycline is a second-line treatment. Amoxicillin-clavulanate is used to treat pyelonephritis.

A new patient comes to see the primary care NP with fever, mild dehydration, and dysuria with flank pain. The patient tells the NP that a previous provider always prescribed trimethoprim-sulfamethoxazole and wonders why a urine culture is necessary because this antibiotic has worked in the past. The NP should tell this patient that a culture is necessary to help determine: a. the correct dose of the antibiotic. b. whether antibiotic resistance is occurring. c. whether multiple organisms are causing infection. d. the length of antibiotic therapy needed to treat the infection.

b. whether antibiotic resistance is occurring. Antibiotic resistance can occur when bacteria are repeatedly exposed to antibiotic agents. Even though a particular antibiotic is effective for a certain type of infection, resistance can occur, and another antibiotic may be necessary. A culture and sensitivity test is essential for choosing the right antibiotic. The culture and sensitivity test does not help determine the dose or the length of therapy.

A patient is seen in the clinic with a 1-week history of frequent watery stools. The primary care NP learns that a family member had gastroenteritis a week prior. The patient was treated for a UTI with a sulfonamide antibiotic 2 months prior. The NP should suspect: a. viral gastroenteritis. b. serum sickness reaction. c. Clostridium difficile-associated disease (CDAD). d. recurrence of the UTI.

c. Clostridium difficile-associated disease (CDAD). Cases of CDAD have been reported 2 months after a course of antibiotics, and CDAD should be suspected in all patients who present with diarrhea after antibiotic use. Viral gastroenteritis is possible, but the possibility of CDAD must be investigated. Serum sickness reaction is not usually associated with diarrhea and generally occurs within weeks of drug administration.

A 60-year-old patient comes to the clinic reporting a sudden onset of a painful rash that began the day before. The primary care NP notes a vesicular rash along a dermatome on one side of the patient's back. The patient has a low-grade fever. The NP will prescribe: a. varicella vaccine. b. metronidazole (Flagyl). c. acyclovir (Zovirax). d. amantadine (Symmetrel).

c. acyclovir (Zovirax). Acyclovir is effective against herpes viruses including the varicella-zoster virus that causes shingles. Varicella vaccine is given to prevent shingles in older patients. Metronidazole is an antiprotozoal. Amantadine is given to treat influenza.

A patient who is taking isoniazid and rifampin for latent TB is seen by the primary care NP for a routine follow-up visit. The patient reports having nausea, vomiting, and a decreased appetite. The NP should: a. suggest taking the medications with food. b. reassure the patient that these side effects are common. c. ask about alcohol intake. d. order liver and renal function tests and serum glucose.

c. ask about alcohol intake. Concomitant use of alcohol with isoniazid increases the risk of hepatitis. This patient shows signs of hepatitis, so the NP should ask about alcohol consumption. Isoniazid should be taken on an empty stomach.

A child with a febrile illness is taking a cephalosporin. While in the clinic for a follow-up visit, the child has a tonic-clonic seizure. The primary care NP should: a. suspect the development of a secondary central nervous system infection. b. reassure the parent that seizures can occur while taking cephalosporins. c. ask the child's parent how much of the cephalosporin the child has taken. d. administer acetaminophen because this is likely a febrile seizure.

c. ask the child's parent how much of the cephalosporin the child has taken. Seizures can occur with an overdose of cephalosporins, so the NP should determine whether this has occurred. It is not correct to assume that the seizure is fever-related or that it is a normal side effect of the cephalosporin.

A patient is taking tetracycline for a rickettsial infection and reports having heartburn. The primary care NP should: a. recommend drinking milk when taking the medication. b. tell the patient to use antacids when heartburn occurs. c. ask the patient how the medication is taken. d. tell the patient to take the medication with food.

c. ask the patient how the medication is taken Patients should sit up for at least 30 minutes after taking tetracycline to avoid the risk of esophageal ulceration. Tetracycline should not be taken with food, antacids, or milk.

A primary care NP is planning to order a macrolide antibiotic for a patient who is experiencing an exacerbation of chronic obstructive pulmonary disease. The patient is taking a cytochrome (CYP) 3A medication. The NP should order: a. clarithromycin. b. erythromycin base. c. azithromycin. d. erythromycin estolate.

c. azithromycin.

A patient comes to the clinic with a history of fever of 102° F for several days, poor appetite, and cough. A sputum culture is pending, but Gram stain indicates a bacterial infection. The primary care nurse practitioner (NP) should: a. use a broad-spectrum antibiotic for initial treatment. b. offer symptomatic treatment only unless the patient's condition worsens. c. begin empirical antibiotic therapy. d. prescribe an antibiotic when culture and sensitivity results are known.

c. begin empirical antibiotic therapy. Patients with signs and symptoms of a bacterial infection may be treated empirically, especially if Gram stain is positive. The antibiotic may need to be changed when culture and sensitivity results become available. It is best to use an antibiotic that is specific to the suspected organism and not a broad-spectrum antibiotic.

A patient who has HIV is being treated with Emtriva. The patient develops hepatitis B. The primary care NP should contact the patient's infectious disease specialist to discuss: a. adding zidovudine. b. ordering Combivir and tenofovir. c. changing to Truvada. d. changing to tenofovir.

c. changing to Truvada. Truvada contains the antiretroviral therapies in Emtriva plus tenofovir. Tenofovir is effective against hepatitis B and is used in combination with emtricitabine as a preferred first-line choice.

A patient comes to the clinic before a trip to an area where malaria is endemic. The primary care NP will prescribe: a. amantadine (Symmetrel). b. metronidazole (Flagyl). c. chloroquine (Plaquenil). d. tinidazole (Tindamax).

c. chloroquine (Plaquenil). Chloroquine is used as malaria prophylaxis.

A patient who has HIV frequently expresses concerns about the costs of treatment. The primary care NP should: a. suggest taking half doses of the medications on a regular basis. b. recommend an occasional "drug holiday" when cell and viral counts are good. c. discuss the risks associated with underdosing of antiretroviral therapies. d. suggest the patient limit therapy to a one- or two-drug regimen.

c. discuss the risks associated with underdosing of antiretroviral therapies. Antiretroviral therapy should include three fully active agents. Patients should be cautioned that underdosing may be worse than not taking drugs at all because resistant strains will be developed. Taking half doses, having drug holidays, or limiting therapy to one to two drugs are not recommended.

A woman is in the 36th week of pregnancy. The nurse practitioner (NP) providing prenatal care learns that the woman has a history of two previous urinary tract infections during this pregnancy. A dipstick urinalysis in the office today is negative for leukocyte esterase and nitrites. The NP should: a. prescribe a low-dose sulfonamide antibiotic for urinary tract infection prophylaxis. b. order a voiding cystourethrogram to rule out structural anomalies that may cause urinary tract infection. c. encourage the patient to increase daily water intake and to wear only cotton underwear. d. order nitrofurantoin daily to minimize the patient's risk of urinary tract infection late in her pregnancy.

c. encourage the patient to increase daily water intake and to wear only cotton underwear. For women at risk for recurrent urinary tract infection while pregnant, prevention and treatment begin with nonpharmacologic therapy: forcing fluids and wearing cotton underpants. Sulfonamide antibiotics and nitrofurantoin are used for documented urinary tract infection during pregnancy, but not after the 36th week of gestation. A voiding cystourethrogram is not indicated and would expose the fetus to radiation.

A patient has confirmed Rocky Mountain spotted fever, and the infectious disease specialist is treating the patient with doxycycline 100 mg orally for 7 days. The patient comes to the clinic for follow-up care with the primary care NP at the end of therapy and reports continued fever, headache, and myalgia. The NP will consult with the infectious disease specialist and order: a. 7 more days of doxycycline. b. erythromycin 250 mg four times daily for 7 days. c. hospital admission for intravenous chloramphenicol. d. amoxicillin 500 mg three times daily for 10 to 14 days.

c. hospital admission for intravenous chloramphenicol. With treatment, the patient's condition should start to improve in 2 to 3 days. Continued elevation of the temperature may indicate lack of efficacy or drug fever. Chloramphenicol is used to treat Rocky Mountain spotted fever. It is not correct to continue therapy with doxycycline because treatment failure is likely. Erythromycin is used to treat Lyme disease. Amoxicillin is not indicated.

A 5-year-old child who has no previous history of otitis media is seen in clinic with a temperature of 100° F. The primary care NP visualizes bilateral erythematous, nonbulging, intact tympanic membranes. The child is taking fluids well and is playing with toys in the examination room. The NP should: a. prescribe amoxicillin-clavulanate twice daily for 10 days. b. prescribe amoxicillin twice daily for 10 days. c. initiate antibiotic therapy if the child's condition worsens. d. prescribe azithromycin once daily for 5 days.

c. initiate antibiotic therapy if the child's condition worsens. Signs and symptoms of otitis media that indicate a need for antibiotic treatment include otalgia, fever, otorrhea, or a bulging yellow or red tympanic membrane. This child has a low-grade fever, no history of otitis media, a nonbulging tympanic membrane, and no otorrhea, so watchful waiting is appropriate. When an antibiotic is started, amoxicillin is the drug of choice.

A patient who has been taking medications to treat TB tells the primary care NP that the infectious disease specialist has added ethambutol to the drug regimen. The patient asks the NP for information about this drug. The NP should explain that this drug: a. requires more frequent monitoring of LFTs. b. should be taken 1 hour before or 2 hours after a meal. c. means the patient will need regular vision examinations and evaluation of color vision. d. should not be taken by patients who have renal impairment.

c. means the patient will need regular vision examinations and evaluation of color vision. Ethambutol can cause changes in vision, including red-green color blindness. It should be taken with food. It may be taken by patients with renal impairment with adjustment of doses.

A patient was seen in a local emergency department and was treated empirically for pharyngitis with ampicillin and comes to the clinic 2 days later with an urticarial rash. The patient has no previous history of atopy and does not have respiratory symptoms. The primary care NP should suspect: a. penicillin allergy. b. serum sickness. c. mononucleosis. d. scarlatina.

c. mononucleosis. A nonallergic urticarial rash occasionally occurs with ampicillin and is common in patients with mononucleosis. This patient has pharyngitis, which was not diagnosed by throat culture. The NP should suspect mononucleosis and a nonallergic rash. Serum sickness and penicillin allergy are possible but less likely. A scarlatiniform rash is not urticarial.

A primary care nurse practitioner (NP) sees a child who has several honey-colored crusted lesions around the nose and mouth. The NP notes that no other lesions are present. The NP should prescribe: a. dicloxacillin. b. trimethoprim-sulfamethoxazole (TMP-SMX). c. mupirocin topical. d. clarithromycin.

c. mupirocin topical. Although systemic antibiotics are often required to treat impetigo, mupirocin can be used for topical treatment of mild impetigo. Because this is a localized infection, mupirocin can be ordered empirically. Dicloxacillin and clarithromycin are used when systemic empirical treatment is indicated. TMP-SMX is used to treat cellulitis.

A patient with group A b-hemolytic streptococcal pharyngitis is treated with penicillin V. At a follow-up visit 2 weeks later, the patient presents with edema of the hands and feet, blood pressure of 140/85 mm Hg, and cola-colored urine. A urine dipstick shows proteinuria. The primary care NP should: a. order oral amoxicillin-clavulanate for 14 days. b. prescribe 10 more days of penicillin V. c. obtain an ASO titer and creatinine clearance. d. perform a repeat throat culture.

c. obtain an ASO titer and creatinine clearance. A minimum of 10 days of treatment is recommended for any infection caused by group A b-hemolytic streptococcus to prevent the occurrence of rheumatic fever or acute glomerulonephritis. This patient shows signs of acute glomerulonephritis, so the NP should obtain an ASO titer and creatinine clearance to help confirm the diagnosis. It is not necessary to repeat the throat culture. Treatment involves controlling blood pressure and maintaining renal function, not giving antibiotics.

A woman has a Chlamydia infection. Before initiating treatment with a tetracycline antibiotic, the primary care nurse practitioner (NP) should: a. obtain baseline liver function and renal function tests. b. tell her she must stop using oral contraceptive pills. c. perform a pregnancy test. d. check her bilirubin and serum amylase levels.

c. perform a pregnancy test Tetracycline antibiotics can permanently stain teeth in children and in pregnant women. Before using a tetracycline in a woman who may be pregnant, the NP should perform a pregnancy test. Other laboratory tests are not indicated for short-term use. Women taking oral contraceptive pills should continue to take them.

A young woman will begin taking minocycline. The primary care NP should tell this patient to: a. expect headaches while taking this medication. b. always take the medication on an empty stomach. c. use a backup form of contraception if currently taking oral contraceptive pills. d. avoid taking antacids while taking this drug.

c. use a backup form of contraception if currently taking oral contraceptive pills Tetracyclines may decrease the effects of oral contraceptive pills, so patients should use a backup form of contraception. Headaches are uncommon. Minocycline may be taken with food and is not affected by antacids.

A primary care NP provides teaching to a patient who will begin taking cefadroxil (Duricef). Which statement by the patient indicates a need for further teaching? a. "I should take this medication with food." b. "I will take this medication twice daily." c. "I should report any rash that occurs." d. "Gastrointestinal (GI) symptoms are common but not worrisome."

d. "Gastrointestinal (GI) symptoms are common but not worrisome." The FDA advises that CDAD be considered in all patients who present with diarrhea after antibiotic use. Patients should be taught to report all GI symptoms.

A primary care NP provides teaching for a patient who is about to begin taking levofloxacin tablets to treat an infection. Which statement by the patient indicates a need for further teaching? a. "I should take the tablet 2 hours before taking vitamins or an antacid." b. "I should use caution while driving when taking this medication." c. "I should use sunscreen while taking this medication." d. "I should take this medication on an empty stomach."

d. "I should take this medication on an empty stomach." Levofloxacin tablets may be taken without regard to food, although levofloxacin solution must be taken on an empty stomach. Patients should be cautioned to use sunscreen and to avoid situations where drowsiness may impair function. Levofloxacin should not be taken with antacids or vitamins.

A patient has begun treatment for HIV. The primary care NP should monitor the patient's complete blood count (CBC) at least every _____ months. a. 6 to 9 b. 9 to 12 c. 1 to 3 d. 3 to 6

d. 3 to 6 The patient's CBC should be monitored at least every 3 to 6 months and more frequently if values are low and bone marrow toxicity is present.

A patient has a sore throat with fever. The primary care NP observes erythematous 4+ tonsils with white exudate. A rapid antigen strep test is negative, and a culture is pending. The NP orders amoxicillin as empiric treatment. The patient calls the next day to report a rash. The NP should suspect: a. scarlatiniform rash from the streptococcal infection. b. a serum sickness reaction to the penicillin. c. penicillin drug allergy. d. a viral cause for the patient's symptoms.

d. a viral cause for the patient's symptoms. Certain viral infections, such as mononucleosis, increase the frequency of rash in response to penicillin and is commonly attributed to penicillin allergy.

A patient who is taking metronidazole calls the primary care NP to report severe nausea and vomiting along with heart palpitations. The NP should: a. instruct the patient to go to an emergency department for intravenous fluids. b. counsel the patient to take the medication with food. c. reassure the patient that these symptoms will subside. d. ask the patient about any recent alcohol consumption.

d. ask the patient about any recent alcohol consumption. Metronidazole can cause a disulfiram-like reaction if taken with alcohol. Mild gastrointestinal upset may be prevented by taking the medication with food. The patient needs to be told not to drink alcohol with this drug to prevent this severe reaction. If the symptoms persist, it may be recommended that the patient go to the emergency department.

A patient who is taking a fluoroquinolone antibiotic for pyelonephritis develops Clostridium difficile-associated disease (CDAD). The primary care NP should treat for C. difficile and _____ fluoroquinolone. a. increase the dose of b. continue the c. decrease the dose of d. discontinue the

d. discontinue the Patients who develop CDAD while taking fluoroquinolones should stop taking the drug immediately

A primary care NP sees a 6-month-old patient who has a persistent staccato cough. The NP is aware that there is a pertussis outbreak in the community. The NP should obtain appropriate cultures and treat empirically with: a. telithromycin. b. azithromycin. c. clarithromycin. d. erythromycin.

d. erythromycin. Erythromycin is a first-choice drug for the treatment of pertussis.

A primary care NP sees a 5-year-old child for a tuberculin skin test. The child lives in a high-risk community, and a grandparent who babysits has active TB. The PPD shows a 6-mm area of induration. A chest radiograph is normal. The NP will refer this patient to an infectious disease specialist and should expect the patient to be on _____ for _____ months. a. ethambutol; 3 b. ethambutol and amikacin; 6 c. isoniazid; 6 d. isoniazid and rifapentine; 3

d. isoniazid and rifapentine; 3 This child has a positive PPD with no pulmonary signs, so a 3-month course of isoniazid and rifapentine is indicated. Ethambutol is not recommended in children younger than 13 years.

A primary care NP is preparing to prescribe a fluoroquinolone for a patient who has a history of alcohol abuse that has caused liver damage. The NP should choose: a. ciprofloxacin. b. gemifloxacin. c. norfloxacin. d. levofloxacin.

d. levofloxacin. Levofloxacin has less risk of hepatic adverse events than other fluoroquinolones.

A patient has urethritis. The primary care NP should prescribe: a. tetracycline. b. demeclocycline. c. doxycycline. d. minocycline.

d. minocycline. Minocycline is indicated to treat urethritis.

A patient who was hospitalized for an infection was treated with an aminoglycoside antibiotic. The patient asks the primary care nurse practitioner (NP) why outpatient treatment wasn't an option. The NP should tell the patient that aminoglycoside antibiotics: a. cause serious adverse effects. b. are more likely to be toxic. c. carry more risk for serious allergic reactions. d. must be given intramuscularly or intravenously.

d. must be given intramuscularly or intravenously Aminoglycoside antibiotics must be given intramuscularly or intravenously when treating infection. Their side effects may be serious, which is an indication for hospitalization.

A patient comes to the clinic to have a Mantoux tuberculin skin test read after 48 hours. The primary care NP notes a 6-mm area of induration. The patient is a young adult with no known contacts and has never traveled abroad. The NP should: a. repeat the test. b. refer to an infectious disease specialist. c. tell the patient the test is negative. d. order a chest radiograph.

d. order a chest radiograph. A chest x-ray should be obtained on all patients who have a positive purified protein derivative tuberculin test (PPD). The test was read in the appropriate time frame, so repeating the test is not necessary. This patient has a positive PPD. Referral to an infectious disease specialist should be made when the diagnosis is confirmed.

A patient has recently returned from travel in Central America and reports having seven to eight liquid stools each day with severe tenesmus. The primary care NP notes a temperature of 102° F. A stool specimen is Hemoccult positive with leukocytes present. The NP will: a. order tests for Clostridium difficile. b. prescribe tinidazole 2000 mg for 3 days. c. give 750 mg of ciprofloxacin one time only. d. order a stool culture and begin therapy with a fluoroquinolone.

d. order a stool culture and begin therapy with a fluoroquinolone. By history, this patient likely has traveler's diarrhea. The NP should obtain a culture and should start a fluoroquinolones antibiotic empirically. C. difficile is suspected in patients who have been taking antibiotics, which is not true in this case. Tinidazole is used for amebiasis or giardiasis. Ciprofloxacin may be given as a single dose for mild traveler's diarrhea.

A patient is taking cefadroxil (Duricef) and comes to the clinic complaining of loose stools for several days. The primary care NP notes normal vital signs; warm, pink skin with elastic turgor; and moist mucous membranes. The NP should: a. reassure the patient that loose stools are common with antibiotics. b. recommend consuming lactobacillus-containing foods to minimize diarrhea. c. discontinue the cefadroxil. d. order tests for Clostridium difficile-associated disease (CDAD).

d. order tests for Clostridium difficile-associated disease (CDAD). The U.S. Food and Drug Administration (FDA) advises that CDAD be considered in all patients who present with diarrhea after antibiotic use. This patient's symptoms are mild, so discontinuation of the drug is not warranted unless CDAD is present.

A patient comes to the clinic several days after an outpatient surgical procedure complaining of swelling and pain at the surgical site. The primary care NP notes a small area of erythema but no abscess or induration. The NP should: a. refer the patient to the surgeon for further evaluation. b. prescribe topical mupirocin four times daily. c. suggest that the patient apply warm soaks three times daily. d. prescribe TMP-SMX

d. prescribe TMP-SMX This patient has cellulitis, so empirical treatment with TMP-SMX is indicated. Topical mupirocin is used for superficial skin infections, not cellulitis. Warm soaks may be used as an adjunct to antimicrobial treatment. Unless the cellulitis becomes worse, it is not necessary to refer the patient to the surgeon.

A primary care NP sees a patient who reports a 2-week history of nasal congestion and runny nose. The NP performs a history and learns that the nasal discharge has changed from yellow to green in the past few days, accompanied by a fever of 102° F and unilateral facial pain. To treat this patient, the NP should: a. order azithromycin daily for 5 days. b. prescribe cefdinir twice daily for 10 days. c. recommend symptomatic treatment because this is probably a viral infection. d. prescribe amoxicillin-clavulanate twice daily for 10 days.

d. prescribe amoxicillin-clavulanate twice daily for 10 days. Evidence of a bacterial sinus infection includes prolonged symptoms without improvement for 10 to 14 days, fever greater than 102° F, and unilateral pain. A bacterial infection should be suspected if nasal discharge turns from yellow to green. Amoxicillin-clavulanate is a recommended first-line drug to treat sinusitis.

A primary care NP sees a patient who has dysuria, fever, and urinary frequency. The NP orders a urine dipstick, which is positive for nitrates and leukocyte esterase, and sends the urine to the laboratory for a culture. The patient is allergic to sulfa drugs. The NP should: a. order cefaclor (Ceclor). b. administer intramuscular ceftriaxone (Rocephin). c. wait for culture results before ordering an antibiotic. d. prescribe cefixime (Suprax).

d. prescribe cefixime (Suprax). Cephalosporins are useful for empirical treatment of many of the most common infections seen in primary care. Cefixime is a third-generation cephalosporin, which has greater activity against Escherichia coli and excellent penetration into body fluids, making it a good choice for empirical treatment of urinary tract infection.

A primary care NP provides primary care for a woman who has HIV. The woman asks the NP if she will ever be able to have children. The NP should tell her: a. there is no risk of disease transmission to a fetus if she complies with therapy. b. she will need to take medications throughout her pregnancy and lactation. c. none of the antiretroviral medications are safe to take during pregnancy. d. strict adherence to antiretroviral therapy decreases her risk of transmitting HIV to the fetus.

d. strict adherence to antiretroviral therapy decreases her risk of transmitting HIV to the fetus Antiretroviral therapy reduces, but does not eliminate, the risk of transmitting HIV to the fetus. Antiretroviral therapy medications may be taken during pregnancy. Women with HIV should not breastfeed because of the high risk of transmission.

A patient who is currently not sexually active has an outbreak of genital herpes. The patient asks the primary care NP how this could have occurred without active infection since being treated more than 2 years ago. The NP should tell the patient that: a. the original infection may have been partially treated. b. the infection must be due to a resistant herpes simplex virus (HSV) strain. c. the current infection may be from contact with a toilet seat. d. successful treatment won't prevent future outbreaks of active infection.

d. successful treatment won't prevent future outbreaks of active infection. Treatment of acute infection does not eliminate chronic infection, and outbreaks can occur at any time. Latency and outbreaks are not necessarily caused by resistant HSV strains. The current infection is not caused by contact with a toilet seat.

A female patient has vaginal candidiasis and has taken a single dose of fluconazole without resolution of the infection. The primary care NP obtains a culture and should order: a. another dose of fluconazole. b. griseofulvin for 4 weeks. c. oral ketoconazole. d. topical miconazole (Monistat).

d. topical miconazole (Monistat). Topical miconazole is still recommended as the drug of first choice and should be given when oral fluconazole has failed. Fluconazole has been approved for single-dose treatment of vulvovaginal candidiasis, although the Centers for Disease Control and Prevention continues to recommend topical therapy with an imidazole derivative because of fluconazole-resistant candidiasis. Ketoconazole and griseofulvin are not recommended first-line treatments for vulvovaginal candidiasis. Another dose of fluconazole would not be effective if resistance is present.