pharm Module 2

983. A patient asks a nurse what a sun protection factor (SPF) of 15 indicates. The nurse will tell the patient that an SPF of 15 indicates: a. a 93% block of UVB radiation. b. half the protection of a sunscreen with an SPF of 30. c. low protection. d. that it takes 15 minutes for the sun to burn.

ANS: A A sun protection factor of 15 indicates a 93% block of UVB. As the SPF increases, the increment in protection gets progressively smaller, so an SPF of 15 is not half that of an SPF of 30. Low protection is indicated by an SPF of 2 to 14. The SPF is calculated by the time required for the development of erythema in the protected region divided by the time required for the development of erythema in the unprotected region.

989. A patient with severe psoriasis will begin taking acitretin [Soriatane]. The nurse obtains a health history and learns that the patient takes a combination oral contraceptive. What will the nurse do? a. Counsel the patient to use another form of birth control along with the OCP. b. Tell the patient she may stop using contraception when the medication is withdrawn. c. Tell the patient that acitretin is safe to take during pregnancy. d. Tell the patient to report spotting to the provider so that another form of contraceptive may be ordered.

ANS: A Acitretin is contraindicated during pregnancy and can reduce the effectiveness of progestin-only oral contraceptives. Patients should be counseled to use two reliable forms of birth control when taking this drug. Patients must continue using birth control for at least 3 months after treatment has stopped. Acitretin is teratogenic. Patients may experience spotting with progestin-only contraceptives, which this woman is not taking.

991. An adolescent patient who is on the school swim team asks a nurse about ways to prevent swimmer's ear. The nurse will tell the patient to: a. allow the ears to drain well after every swim and shower. b. clean the ears with a cotton-tipped applicator after swimming. c. keep the ear canals free of cerumen. d. use antifungal ear drops before and after swimming.

ANS: A Acute otitis externa (OE) can be minimized by keeping the natural defenses of the external auditory canal (EAC) healthy. Swimmers should be taught to dry the EAC after showering and swimming. Cleaning the ears with cotton-tipped swabs can remove the cerumen and abrade the epithelium. Removing cerumen removes the natural barrier to infection. Antifungal ear drops are used to treat acute OE but not as a preventive measure.

559. A pregnant patient asks the nurse if she can take antihistamines for seasonal allergies during her pregnancy. What will the nurse tell the patient? a. Antihistamines should be avoided unless absolutely necessary. b. Second-generation antihistamines are safer than first-generation antihistamines. c. Antihistamines should not be taken during pregnancy but may be taken when breastfeeding. d. The margin of safety for antihistamines is clearly understood for pregnant patients.

ANS: A Antihistamines are pregnancy Category C, with debate currently occurring regarding degree of effects on the fetus. They should be avoided unless absolutely necessary. All antihistamines have adverse effects on the fetus. Antihistamines can be excreted in breast milk. The margin of safety of antihistamines in pregnancy is not clear, so these agents should be avoided unless a clear benefit of treatment outweighs any risks.

566. A nurse is teaching a group of nursing students about antihistamines. Which statement by a student indicates an understanding of the mechanism of action of the antihistamines? a. "Antihistamines block H1 receptors to prevent actions of histamine at these sites." b. "Antihistamines block release of histamine from mast cells and basophils." c. "H1 antagonists can bind to H1 receptors, H2 receptors, and muscarinic receptors." d. "First-generation antihistamines are more selective than second-generation antihistamines."

ANS: A Antihistamines block H1 receptors to prevent the actions of histamine. They do not block the release of histamine. H1 antagonists do not bind to H2 receptors; they do bind to muscarinic receptors. Second-generation antihistamines are more selective than first-generation antihistamines.

993. A patient has been diagnosed with fungal otitis externa (otomycosis). The nurse correctly explains that for the first course of treatment the patient should expect: a. acidifying drops for 1 week. b. antibiotic ear drops. c. intravenous (IV) antifungal agents. d. oral antibiotics.

ANS: A As a rule, otomycosis can be managed with thorough cleansing and application of acidifying drops (2% acetic acid solution applied three or four times a day for 7 days). If that does not work, an antifungal drug solution can be tried. If the infection fails to respond to the drug, oral antifungal therapy may be needed. Neither antibiotic ear drops nor oral antibiotics are indicated as the first course of treatment. IV antifungal agents are not indicated at all.

988. An adolescent has recently been experiencing pimples. The nurse notes several closed comedones across the patient's forehead and on the nose. The nurse will expect to teach this patient about the use of which medication? a. Benzoyl peroxide b. Topical clindamycin c. Topical erythromycin d. Topical retinoids

ANS: A Benzoyl peroxide is a first-line drug for mild to moderate acne. Other topical antibiotics and retinoids are used when first-line therapy fails.

961. A nurse is preparing to administer timolol [Timoptic] eye drops to a patient who has open- angle glaucoma. The nurse notes that the patient has a history of chronic obstructive pulmonary disease (COPD). The nurse will contact the provider to discuss changing to which medication? a. Betaxolol b. Carteolol c. Levobunolol d. Metipranolol

ANS: A Betaxolol is the only ophthalmic beta blocker that is beta1 selective, meaning that it has less chance of causing bronchial constriction. It is preferred for patients with asthma and COPD. The other agents are not beta1 selective.

653. A patient who has a viral upper respiratory infection reports having a runny nose and a cough that prevents sleep and asks the nurse to recommend an over-the-counter medication. Which medication will the nurse recommend? a. Diphenhydramine [Benadryl] b. Fexofenadine/pseudoephedrine [Allegra-D] c. Guaifenesin [Mucinex] d. Phenylephrine drops

ANS: A Diphenhydramine is effective in suppressing cough and also has sedative effects when used in doses to suppress cough. Fexofenadine/pseudoephedrine is a combination antihistamine/decongestant and will not help with cough. Guaifenesin helps make coughs more productive but will not suppress cough or help with sleep. Phenylephrine drops have decongestant properties.

639. A patient with severe, chronic COPD uses an inhaled LABA/glucocorticoid but continues to have frequent exacerbation of symptoms. The nurse will contact the provider to discuss: a. adding roflumilast [Daliresp] once daily. b. changing to oral theophylline twice daily. c. prescribing oral steroids once daily. d. Using an ipratropium/albuterol combination twice daily.

ANS: A For patients with chronic, severe COPD, the risk of exacerbations may be reduced with roflumilast. Theophylline is used only when other bronchodilators are not effective. Oral steroids are not indicated for this use. Ipratropium is used to treat bronchospasm in COPD.

633. A parent asks a nurse about growth suppression resulting from the use of an inhaled glucocorticoid in children. What will the nurse tell the parent? a. Growth may be slowed, but eventual adult height will not be reduced. b. The growth rate is not impaired, but overall height will be reduced. c. The growth rate slows while the drug is used and only resumes when the drug is stopped. d. Long-term use of the drug results in a decrease in adult height.

ANS: A Glucocorticoids can slow growth in children and adolescents, but they do not reduce the eventual adult height. The growth rate will return to normal within a year, even when the drug is continued. Long-term use does not affect the eventual adult height.

539. A nurse is teaching a group of nursing students about immunoglobulins. Which statement by a student indicates a need for further teaching? a. "IgD provides a first line of defense against microbes entering the body through the lungs." b. "IgE plays a role in hypersensitivity reactions and responses to parasites." c. "IgG and IgM participate in the complement response to promote target-cell lysis." d. "Neonatal immunity is the result of IgG crossing the placenta."

ANS: A IgD serves as a receptor for antigen recognition on B cells, which is the only place it is found. IgE is involved in hypersensitivity responses and responses to parasites. IgG and IgM are involved in complement responses. IgG crosses the placenta and confers passive immunity on the fetus.

630. A patient with stable COPD is prescribed a bronchodilator medication. Which type of bronchodilator is preferred for this patient? a. A long-acting inhaled beta2 agonist b. An oral beta2 agonist c. A short-acting beta2 agonist d. An intravenous methylxanthine

ANS: A LABAs are preferred over SABAs for COPD. Oral beta2 agonists are not first-line therapy. Although theophylline, a methylxanthine, was once standard therapy in COPD, it is no longer recommended. It is used only if beta2 agonists are not available.

965. A patient has been using latanoprost [Xalatan] ophthalmic drops. The patient tells the nurse, "My eyes used to be greenish-brown, but now they're brown." What will the nurse do? a. Reassure the patient that this is a harmless side effect. b. Report this toxic effect to the patient's provider. c. Tell the patient that this indicates an increased risk of migraine headaches. d. Tell the patient that this effect will reverse when the medication is withdrawn.

ANS: A Latanoprost can cause a harmless, heightened brown pigment of the iris that stops when the medication is discontinued but does not regress. It is not a sign of a toxic reaction. It does not indicate an increased risk of developing migraines. It will not reverse.

974. A female patient with baldness asks a nurse about the safety and efficacy of minoxidil [Rogaine]. What will the nurse tell the patient? a. Hair regrowth is most effective when baldness has developed recently. b. Minoxidil cannot be used by female patients. c. Once hair has been restored, minoxidil may be discontinued, because hair loss will stop. d. Systemic side effects, such as headaches and flushing, are common.

ANS: A Minoxidil is most effective at treating recent hair loss. It may be used in female patients. Hair loss may continue even with uninterrupted treatment. Systemic side effects are not common.

636. A 7-year-old child with asthma uses a daily inhaled glucocorticoid and an albuterol MDI as needed. The provider has added montelukast [Singulair] to the child's regimen. Which statement by the child's parent indicates understanding of this medication? a. "I may notice mood changes in my child." b. "I should give this medication twice daily." c. "I will give my child one 4-mg chewable tablet daily." d. "This drug can alleviate symptoms during an acute attack."

ANS: A Montelukast is given as an adjunct to inhaled glucocorticoids to help prevent inflammation. Some patients have reported mood changes when taking this drug, so parents should be warned of this effect. The medication is given once daily. The dose for a 7-year-old child is 5 mg daily. The drug does not treat symptoms of an acute attack.

973. To provide protection against the full range of ultraviolet (UV) radiation, an organic sunscreen must contain which agent? a. Avobenzone b. Para-aminobenzoic acid (PABA) c. Titanium dioxide d. Zinc oxide

ANS: A Only one organic sunscreen, avobenzone, absorbs the full range of UV radiation. The other agents do not protect against the full range of UV radiation. Titanium dioxide and zinc oxide are inorganic screens.

962. A patient with ocular hypertension will begin using brimonidine [Alphagan] for long-term reduction of increased ocular pressure (IOP). The nurse teaches the patient about this medication. Which statement by the patient indicates understanding of the teaching? a. "After using the drops, I should wait 15 minutes before putting in contacts." b. "Because this is a topical medication, drowsiness will not occur." c. "I will not have cardiovascular side effects when using this medication." d. "If my eyes begin to itch or turn red, it means I am allergic to this drug."

ANS: A Patients using this drug should wait 15 minutes before putting in contacts, because soft contacts can absorb the drug. Even though the medication is topical, it can be absorbed systemically, causing systemic side effects such as drowsiness or lowered blood pressure. Itching and hyperemia may occur and do not indicate allergy.

1001. A 12-month-old child attends day care and is seen in a clinic for a second middle ear infection since age 8 months. The parent calls the nurse to report that after the third day of giving amoxicillin [Amoxil], the child continues to have a temperature of 39.5° C and is unable to sleep well because of pain. What will the nurse do? a. Encourage the parent to discuss amoxicillin/clavulanate [Augmentin] with the child's provider. b. Recommend that the parent consider removing the child from day care to reduce exposure to infection. c. Schedule a clinic appointment for the child to receive ceftriaxone [Rocephin] IM. d. Tell the parent the child will probably need surgery for tympanostomy tubes to reduce infections.

ANS: A Resistant AOM is on the rise because of the emergence of resistant pathogens such as Haemophilus influenzae and Moraxella catarrhalis, which are resistant to beta-lactam antibiotics, and Streptococcus pneumoniae, which synthesizes altered penicillin-binding proteins. Resistance is treated with high-dose amoxicillin/clavulanate. The high dose of amoxicillin increases activity against amoxicillin-resistant S. pneumoniae, and the clavulanate component overcomes beta- lactam resistance of H. influenzae and M. catarrhalis. Removing a child from day care can help reduce the number of ear infections in infants and young children. This child has only experienced two episodes, and removing the child from day care may not be easy for this family, so this recommendation is not appropriate at this time. IM Rocephin is not recommended. Surgery for bilateral myringotomy tympanotomy tubes (BMTTs) is used to reduce the number of episodes in children with recurrent AOM.

561. A patient who has chronic allergies takes loratadine [Claritin] and develops a severe reaction to bee stings. The patient asks the nurse why the antihistamine did not prevent the reaction. What will the nurse say? a. "Allergy symptoms that are severe are caused by mediators other than histamine." b. "H1 blockers do not prevent the release of histamine from mast cells and basophils." c. "Second-generation H1 blockers contain less active drug and do not work in severe reactions." d. "Severe allergic reactions occur through actions on muscarinic receptors."

ANS: A Severe allergic reactions with symptoms of anaphylaxis are caused by mediators other than histamine, so the benefits of antihistamines are limited. H1 blockers do not block the release of histamine, but this is why they are not effective in anaphylaxis. Second-generation agents are as effective as first-generation agents in allergic reactions mediated by histamine; neither is effective for treating anaphylaxis.

645. A patient has just received a prescription for fluticasone/salmeterol [Advair Diskus]. What will the nurse include as part of the teaching for this patient about the use of this device? a. "You do not need good hand-lung coordination to use this device." b. "You will begin to inhale before activating the device." c. "You will need to use a spacer to help control the medication." d. "You will take two inhalations twice daily."

ANS: A The Advair Diskus is a dry powder inhaler and is activated by inhalation; therefore, hand-lung coordination is not required. There is no need for a spacer. Patients who use the Diskus take one inhalation twice daily.

557. A 5-year-old child with seasonal allergies has been taking 2.5 mL of cetirizine [Zyrtec] syrup once daily. The parents tell the nurse that the child does not like the syrup, and they do not think that the drug is effective. The nurse will suggest they discuss which drug with their child's health care provider? a. Cetirizine [Zyrtec] 5-mg chewable tablet once daily b. Loratadine [Claritin] 10-mg chewable tablet once daily c. Fexofenadine [Allegra] syrup 5 mL twice daily d. Desloratadine [Clarinex] 5-mg rapid-disintegrating tablet once daily

ANS: A The child is receiving a low dose of cetirizine and can receive up to 5 mg/day in either a single dose or two divided doses. Cetirizine is available in a chewable tablet, which this child may tolerate better, so the parents should be encouraged to explore this option with their provider. The loratadine 10-mg chewable tablet is approved for children 6 years and older. Fexofenadine would be safe for this child, but it is unlikely that the syrup would be any better than the cetirizine syrup. Desloratadine is not approved for children under the age of 12 years.

634. A patient who uses an inhaled glucocorticoid for chronic asthma calls the nurse to report hoarseness. What will the nurse do? a. Ask whether the patient is rinsing the mouth after each dose. b. Request an order for an antifungal medication. c. Suggest that the patient be tested for a bronchial infection. d. Tell the patient to discontinue use of the glucocorticoid.

ANS: A The most common side effects of inhaled glucocorticoids are oropharyngeal candidiasis and dysphonia. To minimize these, patients should be advised to gargle after each administration. Antifungal medications are used after a fungal infection has been diagnosed. Hoarseness is not a sign of a bronchial infection. There is no need to discontinue the glucocorticoid.

644. A patient who has been newly diagnosed with asthma is referred to an asthma clinic. The patient reports daily symptoms requiring short-acting beta2-agonist treatments for relief. The patient has used oral glucocorticoids three times in the past 3 months and reports awakening at night with symptoms about once a week. The patient's forced expiratory volume in 1 second (FEV1) is 75% of predicted values. The nurse will expect this patient to be started on which regimen? a. Daily low-dose inhaled glucocorticoid/LABA with a SABA as needed b. Daily low-dose inhaled glucocorticoid and a SABA as needed c. Daily medium-dose inhaled glucocorticoid/LABA combination d. No daily medications; just a SABA as needed

ANS: A This patient has moderate persistent asthma, which requires step 3 management for initial treatment. Step 3 includes daily inhalation of a low-dose glucocorticoid/LABA combination supplemented with a SABA as needed. A daily low-dose glucocorticoid with an as-needed SABA is used for step 2 management. A daily medium-dose glucocorticoid/LABA is used for step 4 management. Patients requiring step 1 management do not need daily medications.

963. An older adult patient comes to an ophthalmology clinic complaining of increased difficulty reading in dim light. The provider examines the patient and notes three large yellow deposits under the patient's cornea. The nurse will expect the provider to order which treatment for this patient? a. High doses of vitamins C and E, beta-carotene, and zinc b. Laser therapy c. Pegaptanib [Macugen] d. Photodynamic therapy

ANS: A This patient has three large drusen with minor vision changes, signs of intermediate age-related macular degeneration (ARMD). Patients with intermediate ARMD can significantly reduce their risk of developing advanced ARMD by taking high doses of vitamins C and E, beta-carotene, and zinc. Laser therapy, pegaptanib, and photodynamic therapy are used to manage wet, or neovascular, ARMD.

651. A patient with allergic rhinitis is taking a compound product of loratadine/pseudoephedrine [Claritin-D] every 12 hours. The patient complains of insomnia. The nurse notes that the patient is restless and anxious. The patient's heart rate is 90 beats/minute, and the blood pressure is 130/85 mm Hg. The nurse will contact the provider to: a. discuss using an intranasal glucocorticoid and loratadine [Claritin]. b. report acute toxicity caused by pseudoephedrine. c. suggest using an agent with a sympathomimetic drug only. d. suggest using a topical decongestant to minimize systemic symptoms.

ANS: A This patient is showing central nervous system (CNS) and cardiovascular side effects of the pseudoephedrine. A better option would be to use single-ingredient products for each symptom; an intranasal glucocorticoid and an oral antihistamine are considered first-line treatments. This patient is demonstrating adverse effects but not acute toxicity. Using a sympathomimetic agent would increase the adverse effects, because pseudoephedrine is a sympathomimetic drug. Topical decongestants are not first-line drugs for allergic rhinitis.

966. A patient begins using timolol [Timoptic] to treat primary open-angle glaucoma (POAG). The nurse gives a dose and notes that the patient develops shortness of breath. The nurse assesses the patient and auscultates wheezes in both lungs. The nurse will ask this patient about a history of which condition? a. Asthma b. Atrioventricular heart block c. Pulmonary hypertension d. Sinus bradycardia

ANS: A Timolol is a beta blocker and can precipitate bronchoconstriction when absorbed systemically. Patients with asthma will develop shortness of breath and wheezing. These symptoms are not associated with AV block, pulmonary hypertension, or sinus bradycardia.

654. A child with seasonal rhinitis has used budesonide [Rhinocort Aqua] for several years. The parents are concerned that the child's rate of growth has slowed. What will the nurse do? a. Reassure the parents that this is an expected side effect. b. Suggest that the parents discuss using fluticasone [Flonase] with the provider. c. Tell the parents to administer the drug only when symptoms are severe. d. Tell the parents that antihistamines work as well as intranasal glucocorticoids.

ANS: B A worrisome systemic effect of intranasal glucocorticoids is suppression of linear growth in children. Although rare, it can occur; however, it is less likely with fluticasone and mometasone, so these two preparations are better options for children. Reassuring parents that this is an expected side effect is incorrect. Intranasal glucocorticoids should be given daily and not as needed. Antihistamines are not as effective as glucocorticoids, because antihistamines work only against one mediator of allergic inflammation.

996. A nurse is discussing health maintenance with the parent of a newborn infant. Which statement by the parent indicates understanding of ways to reduce the incidence of otitis media? a. "I should hold my baby in an upright position during feeding." b. "I should keep my baby out of day care during cold and flu season." c. "My baby should not use a pacifier after 6 months of age." d. "The pneumococcal vaccine will prevent my baby from getting ear infections."

ANS: B Avoiding child care centers when respiratory infections are prevalent can significantly reduce the incidence of AOM. Holding infants in an upright position is an unproved recommendation. Avoiding pacifier use in the second 6 months of life is an unproved recommendation. The pneumococcal vaccine can slightly reduce the risk of AOM.

979. An adolescent has begun using benzoyl peroxide lotion twice daily to treat acne. The patient reports experiencing drying and burning of the skin. What will the nurse suggest? a. Applying lotion to the skin after applying the drug b. Reducing the frequency to one application a day c. Discontinuing the medication, because this is likely an allergic reaction d. Requesting a prescription for a gel formulation of the drug

ANS: B Benzoyl peroxide may cause drying and peeling of the skin. If signs of severe local irritation occur, such as burning or blistering, the frequency of application should be reduced. Applying lotion is not indicated. These symptoms are not consistent with an allergic reaction. There is no difference in skin reactions between the gel and the lotion formulations.

981. A 50-year-old patient receives botulinum toxin type A [Botox] injections for the first time on her forehead and around her eyes. One week later, she calls the clinic to report that she is experiencing droopy eyelids. The nurse will tell the patient that this effect: a. is normal and will resolve in a few days. b. may persist for 3 to 6 months but will resolve. c. may progress to cause drooling and dysphagia. d. represents an adverse effect that may be permanent.

ANS: B Botox is a neurotoxin that acts on cholinergic neurons to block the release of acetylcholine. Injection into the wrong site or diffusion from the correct site into surrounding tissues can weaken muscles not intended as targets. This patient's droopy eyelids are an example of the wrong site being affected. Weakening of muscles can last 3 to 6 months but will resolve. It is incorrect to tell the patient that it is a normal effect or that it will resolve in a matter of days. Drooling and dysphagia are likely when injections are around the mouth. It is not a permanent effect.

656. A 7-year-old child has a cough, runny nose, congestion, and fever, and the parents ask the nurse to recommend an over-the-counter product. Which response by the nurse is correct? a. "Any product will be effective when combined with vitamin C and zinc." b. "It is best to use single-agent medications to treat individual symptoms." c. "The fever indicates that your child may need an antibiotic; you should call your provider." d. "You should ask your provider to prescribe a combination product that will treat multiple symptoms."

ANS: B Combination medications may provide ingredients that are not needed or may provide ingredients that are either excessive or subtherapeutic. It is best to use single-agent drugs to treat individual symptoms. The efficacy of vitamin C and zinc for treating colds in children has not been established. Fever may accompany viral respiratory infections and not necessarily bacterial infections that need an antibiotic.

642. A nurse and a nursing student are reviewing the care of a 30-kg patient who will receive intravenous aminophylline. Which statement by the student indicates an understanding of the administration of this medication? a. "After the loading dose has been given, the patient will receive 6 mg/kg/hour." b. "Dosing is titrated based on the serum theophylline levels." c. "If the patient's serum theophylline level is less than 15 mcg/mL, the rate should be reduced." d. "The patient will receive a loading dose of 180 mg over 5 minutes."

ANS: B Dosing for aminophylline is based on each patient's serum theophylline levels. The loading dose usually is 6 mg/kg; after that, the maintenance infusion is titrated according to the theophylline levels. A serum theophylline level of 15 mcg/mL is within the therapeutic range, so dosing would not need to change. The patient's total loading dose will be 180 mg, but infusions should never be given at a rate faster than 25 mg/minute.

658. A patient with a cough has been advised to use guaifenesin. The patient asks the nurse to explain the purpose of the drug. The nurse will explain that guaifenesin: a. dries secretions to help suppress coughing so patients can rest. b. helps stimulate the flow of secretions to increase cough productivity. c. helps to relieve chest pain associated with a cough. d. stimulates the body's natural immune responses.

ANS: B Expectorants stimulate the flow of respiratory tract secretions to improve cough productivity. Guaifenesin does not dry secretions, because it does not have anticholinergic effects. Guaifenesin does not alleviate pain associated with cough. Guaifenesin does not stimulate immune responses.

565. A patient has seasonal allergies and needs an antihistamine to control symptoms. The patient likes to have wine with dinner occasionally and wants to know which antihistamine will be the safest to take. The nurse will tell the patient to discuss which medication with the provider? a. Cetirizine [Zyrtec] b. Fexofenadine [Allegra] c. Levocetirizine [Xyzal] d. Loratadine [Claritin]

ANS: B Fexofenadine is the least sedating of the second-generation antihistamines and so is the least likely to have synergistic effects with alcohol. Cetirizine, levocetirizine, and loratadine all have sedative side effects to some extent and thus would be less safe.

558. A patient will begin taking fexofenadine [Allegra] for hay fever. The nurse teaching this patient will tell the patient that: a. fexofenadine should be taken with food to prevent gastrointestinal (GI) symptoms. b. the medication may be taken once or twice daily. c. tolerance to sedation will occur in a few weeks. d. with renal impairment, this drug should be taken every other day.

ANS: B Fexofenadine may be given 60 mg twice daily or 180 mg once daily. Fexofenadine does not need to be given with food. Sedation is not a common side effect of fexofenadine. There is no caution to reduce the dosage or increase the dosing interval in patients with renal impairment who take fexofenadine.

647. A patient who takes oral theophylline [Theochron] twice daily for chronic stable asthma develops an infection and will take ciprofloxacin. The nurse will contact the provider to discuss: a. changing to a different antibiotic. b. reducing the theophylline dose. c. giving theophylline once daily. d. switching from theophylline to a LABA.

ANS: B Fluoroquinolone antibiotics increase theophylline levels, so the dose of theophylline may need to be reduced to prevent theophylline toxicity. Changing antibiotics, giving the theophylline once daily, and changing to a LABA are not indicated.

995. A 6-year-old child has otitis media and is being treated with amoxicillin [Amoxil] and ibuprofen [Motrin]. The child's parent calls the nurse to report that the child's pain is not relieved with the ibuprofen. The child is afebrile and there is no drainage from either ear. The nurse will discuss which additional treatment with the child's provider? a. Adding acetaminophen [Tylenol] to the pain medication regimen b. Applying antipyrine and benzocaine [Aurodex] solution to the ear canals c. Changing the antibiotic to amoxicillin/clavulanate [Augmentin] d. Performing a tympanostomy to relieve pressure in the middle ear

ANS: B For children over age 5 years, the AAP guidelines recommend topical anesthetic ear drops for pain relief; this is contraindicated if the TM is perforated. This child does not have drainage, indicating intact eardrums. Adding another oral analgesic will not be as effective as a topical anesthetic. The child is afebrile, so there is no concern about a resistant infection. Tympanostomy is not indicated.

971. A 14-year-old patient has moderate acne that has not responded to topical drugs. The nurse will suggest that the patient and her parents discuss which treatment with the provider? a. Combination oral contraceptive medication b. Doxycycline [Vibramycin] c. Isotretinoin [Accutane] d. Spironolactone

ANS: B For moderate to severe acne, oral antibiotics are indicated. Doxycycline is a drug of first choice. Hormonal agents, such as oral contraceptive pills (OCPs), are used in female patients who are at least 15 years old. Isotretinoin is used when other treatments fail and acne is severe. Spironolactone is used when OCPs fail.

980. A teenaged female patient has begun to develop acne and asks a nurse how to minimize pimple formation. What will the nurse recommend? a. Asking the provider about oral contraceptives b. Cleansing the face gently two to three times daily c. Eliminating greasy foods from the diet d. Using an abrasive agent to scrub the face

ANS: B Gentle cleansing two to three times a day can reduce surface oiliness and help minimize acne lesions. Oral contraceptives are not first-line treatment for acne. Eliminating greasy foods from the diet does not affect pimple formation. An abrasive agent is not indicated for mild acne.

560. A patient tells a nurse that antihistamines help relieve cold symptoms and wants to know why they are not recommended or prescribed for this purpose. The nurse tells the patient that antihistamines provide only mild relief from some cold symptoms by: a. anticholinergic properties that decrease rhinorrhea. b. blocking H1 receptors in nasal passages. c. reducing secretions at H2 receptor sites. d. having sedative effects, which help patients rest and sleep.

ANS: B Histamine does not mediate cold symptoms, so antihistamines do not provide relief through H1 blockade. Their anticholinergic effects at muscarinic receptor sites can moderately reduce rhinorrhea, so some patients may experience some relief of this symptom. H1-receptor sites do not play a role in cold symptoms. H2-receptor sites do not play a role in cold symptoms. Sedative side effects do not alleviate cold symptoms.

968. A patient with severe allergic conjunctivitis who has been using cromolyn ophthalmic drops for 2 days calls the nurse to report persistence of the symptoms. When the nurse explains that it takes several weeks for maximum benefit to occur, the patient asks if there is something else to use in the meantime. The nurse will suggest that the patient discuss which drug with the provider? a. An ophthalmic demulcent b. H1-receptor antagonists c. Glucocorticoid drops d. Ocular decongestants

ANS: B Histamine receptor antagonists can be used to provide immediate symptom relief, so until the cromolyn has provided relief, they may be useful for treating symptoms. Demulcents only add moisture to the eye and do not prevent chemical mediators from causing symptoms. Glucocorticoids are used for inflammatory disorders of the eye but are not first-line agents. Ocular decongestants are used to treat redness caused by minor irritants.

998. The nurse is administering ear drops to a patient with acute bacterial otitis externa. Which procedure would assist drug penetration into the ear canal? a. Administering refrigerated drops b. Inserting a sponge wick into the ear canal and then administering the drops c. Cleaning out the earwax with a cotton-tipped swab before giving the drops d. Inserting earplugs after administering the drops

ANS: B Insertion of a sponge wick can aid delivery of the ear drops to the epithelium of the ear canal. Medication is absorbed into the wick, which delivers the drug to the epithelium. Ear drops should be warmed before administration to prevent dizziness, which may occur with instillation of cold drops. Cerumen should not be removed. Inserting cotton-tipped swabs may damage the epithelium. The use of earplugs may lead to further problems with bacterial otitis externa.

660. A patient asks the nurse what type of medications would be most effective for treating seasonal and perennial rhinitis. Which response by the nurse is correct? a. Pseudoephedrine [Sudafed] b. Fluticasone propionate [Fluticasone] c. Loratadine [Claritin] d. Intranasal cromolyn sodium [Atrovent]

ANS: B Intranasal glucocorticoids, such as fluticasone propionate, are the most effective drugs for prevention and treatment, because they prevent or suppress all the major symptoms of allergic rhinitis (congestion, rhinorrhea, sneezing, nasal itching, and erythema). Pseudoephedrine is an oral sympathomimetic used to reduce nasal congestion associated with allergic rhinitis. It has no effect on other symptoms. Loratadine, an oral antihistamine, reduces sneezing, rhinorrhea, and nasal itching only and is less effective than intranasal glucocorticoids. Intranasal cromolyn sodium is moderately effective in the treatment of allergic rhinitis, but the benefits are much less than those of intranasal glucocorticoids.

661. What is ipratropium bromide [Atrovent]? a. A cholinergic agent used for perennial rhinitis b. An anticholinergic used for allergic rhinitis and colds c. A medication that is used only in patients with asthma d. A drug that is inappropriate for use in patients with allergic rhinitis

ANS: B Ipratropium bromide is an anticholinergic that is indicated for allergic rhinitis, asthma, and the common cold. The drug reduces rhinorrhea. Ipratropium bromide is an anticholinergic. In addition to asthma, ipratropium bromide can be used for allergic rhinitis and the common cold. Ipratropium bromide can be used for allergic rhinitis.

635. A young adult woman will begin using an inhaled glucocorticoid to treat asthma. The nurse will teach this patient about the importance of which action? a. Lowering her calcium intake and increasing her vitamin D intake b. Participating in weight-bearing exercises on a regular basis c. Taking oral glucocorticoids during times of acute stress d. Using two reliable forms of birth control to prevent pregnancy

ANS: B Like oral glucocorticoids, inhaled glucocorticoids can promote bone loss in premenopausal women. Patients should be encouraged to participate in weight-bearing exercises to help minimize this side effect. Patients should increase both their calcium and vitamin D intakes. Patients taking oral glucocorticoids need increased steroids in times of stress. It is not necessary to use two reliable forms of birth control.

976. A patient has actinic keratosis and is unable to tolerate the effects of fluorouracil. The provider orders the nonsteroidal anti-inflammatory drug diclofenac sodium [Solaraze] 3% gel. What will the nurse include when teaching this patient about this medication? a. "Apply this medication three times daily for 30 days." b. "Dry skin, itching, and rash are common local side effects." c. "This drug has the same risk of GI side effects as with oral NSAIDs." d. "You do not need to protect your skin from sunlight with diclofenac."

ANS: B Localized skin reactions are common effects with diclofenac. The medication is applied twice daily for 60 to 90 days. The risk of GI side effects is very low. Diclofenac causes sensitization to UV radiation, so patients should be taught to avoid exposure and to use sunscreen.

652. A child who has perennial allergic rhinitis has been using an intranasal glucocorticoid. The provider has ordered montelukast [Singulair] to replace the glucocorticoid because the child has frequent nosebleeds. When teaching this child's parents about montelukast, the nurse will include which statement? a. "Montelukast is also effective for treating infectious rhinitis." b. "Montelukast may cause behavior changes in your child." c. "Montelukast will treat both congestion and rhinitis." d. "Montelukast works best when combined with a topical decongestant."

ANS: B Montelukast can cause rare but serious neuropsychiatric effects in patients, and parents should be warned of this possibility. It is not useful for treating infectious rhinitis. It does not affect congestion. It is not necessary to add a topical decongestant when using this drug for allergic rhinitis.

999. A nurse is teaching a parent about the observation strategy for managing a 3-year-old child's ear infection. Which statement by the parent indicates understanding of the teaching? a. "I should not give analgesics, because they may mask important symptoms." b. "I will give ibuprofen or acetaminophen for pain or fever as needed." c. "I will let my provider know if the symptoms are not better in 1 week." d. "There is a slight risk of mastoiditis if antibiotic therapy is delayed."

ANS: B Observation is defined as management by symptomatic relief alone for 48 to 72 hours to allow time for AOM to resolve on its own. Parents should be taught to administer analgesics/antipyretics. Providing pain relief does not mask an important symptom. Parents should notify the provider if symptoms worsen or do not improve in 48 to 72 hours. There is no significant difference in the risk of developing mastoiditis.

990. A patient will begin initial treatment for severe acne. Which regimen will the nurse expect the provider to order? a. Clindamycin/benzoyl peroxide [BenzaClin] and tretinoin [Retin-A] b. Doxycycline [Vibramycin] and tretinoin [Retin-A] c. Erythromycin [Ery-Tab) and benzoyl peroxide d. Topical clindamycin and isotretinoin [Accutane]

ANS: B Oral antibiotics are used for moderate to severe acne and are usually combined with a topical retinoid. Combination clindamycin/benzoyl peroxide and tretinoin are used for mild to moderate acne. Erythromycin can be used as an oral antibiotic but would need to be combined with a topical retinoid. Isotretinoin is used for severe acne that has not responded to other treatments.

650. A nurse provides teaching to a patient with allergic rhinitis who will begin using an intranasal glucocorticoid. Which statement by the patient indicates understanding of the teaching? a. "If the glucocorticoid causes burning or itching, I should use it every other day." b. "I should use a decongestant if necessary before using the glucocorticoid." c. "I should use the glucocorticoid whenever I have symptoms." d. "I will probably develop systemic effects from the topical glucocorticoid."

ANS: B Patients using intranasal glucocorticoids should be taught to use a decongestant to unblock nasal passages if needed before using the medication. Intranasal glucocorticoids should be used regularly on a daily basis to achieve optimal effects and not every other day or as needed. Systemic effects from intranasal glucocorticoids can occur but are not likely.

982. A patient is using a high-concentration keratolytic agent containing 20% salicylic acid to remove warts. What will the nurse teach this patient? a. Peeling and drying are desired effects of this drug. b. Systemic effects may occur with this medication. c. Tinnitus is a common side effect of little concern. d. Tissue injury is unlikely at this dose.

ANS: B Salicylic acid is readily absorbed through the skin, and systemic toxicity can result. Peeling and drying are not desired effects of salicylic acid. Tinnitus is a symptom of systemic toxicity. Tissue injury is likely in any concentration above 6%.

564. A family is preparing for travel and the parents report that their 5-year-old child has frequent motion sickness. The nurse will tell the parents to ask the provider about which antihistamine to help prevent symptoms? a. Desloratadine [Clarinex] b. Dimenhydrinate [Dramamine] c. Hydroxyzine [Vistaril] d. Promethazine [Phenergan]

ANS: B Some antihistamines, including dimenhydrinate and promethazine, are labeled for use in motion sickness. Promethazine, however, is contraindicated in children under age 2 years and should be used with caution in children older than 2 years because of the risks for severe respiratory depression. Desloratadine and hydroxyzine are not used for motion sickness.

978. A nurse is discussing the use of tazarotene [Tazorac] with a patient who has psoriasis. Which statement by the patient indicates a need for further teaching? a. "I should use a sunscreen when using this medication." b. "I understand the gel can cause staining of clothing." c. "I will apply this once daily in the evening." d. "I will apply the medication to dry skin."

ANS: B Tazarotene will not stain clothing. It is true that patients should use sunscreen while using this drug. It should be applied once daily in the evening to dry skin.

649. A patient admitted to the hospital has been using phenylephrine nasal spray [Neo- Synephrine], 2 sprays every 4 hours, for a week. The patient complains that the medication is not working, because the nasal congestion has increased. What will the nurse do? a. Request an order for an oral decongestant to replace the intranasal phenylephrine. b. Request an order for an intranasal glucocorticoid to be used while the phenylephrine is withdrawn. c. Tell the patient to increase the dose of phenylephrine to 4 sprays every 4 hours. d. Tell the patient to stop using the phenylephrine and begin using an intranasal antihistamine.

ANS: B This patient is experiencing rebound congestion, which develops when topical sympathomimetics are used for longer than a few days. Abrupt withdrawal can stop the cycle of rebound congestion but is uncomfortable, so using an intranasal glucocorticoid, beginning 1 week before discontinuing the decongestant, while withdrawing the decongestant, is recommended. An oral decongestant is not recommended. Increasing the dose of the intranasal decongestant will only compound the problem of rebound congestion. Stopping the intranasal decongestant will only increase the congestion; using an intranasal antihistamine will not help with congestion.

984. An infant has a severe contact diaper dermatitis. The provider orders triamcinolone acetonide [Kenalog] 0.1% cream to be applied three times daily. When teaching the infant's parents about this medication, the nurse will instruct them to apply: a. a thick layer and massage the cream into the skin. b. a thin layer and leave the diaper open as much as possible. c. the cream and place an occlusive dressing over the area. d. the cream and put the infant's diaper on tightly.

ANS: B Topical glucocorticoids can be absorbed systemically and cause adverse effects. To minimize systemic and local adverse effects, the medication should be applied sparingly. Parents should be taught to avoid tight-fitting diapers. The cream should be rubbed gently into the skin. Occlusive dressings increase the risk of adverse effects. Putting the diaper on tightly creates an occlusive dressing.

987. A patient has severe acne that has been refractory to treatment. The patient is taking tetracycline and using topical tretinoin [Retin-A] and has been applying benzoyl peroxide twice daily. The provider asks the nurse to teach this patient about isotretinoin [Accutane], which the patient will begin taking in a few weeks. The nurse will include which statement when teaching this patient about this drug? a. "Alcohol may be consumed in moderation when taking this drug." b. "Skin rash, headache, and hair loss are common with this drug." c. "Tetracycline must be discontinued before beginning the isotretinoin." d. "Two pregnancy tests are required before each monthly refill of your prescription."

ANS: C Adverse effects of isotretinoin can be increased by tetracycline, so tetracycline must be discontinued before therapy is started. Alcohol should be avoided, since it can potentiate hypertriglyceridemia. Skin rash, headache, and hair loss are not common side effects, although they can occur. Two pregnancy tests are required at the beginning of therapy; at each refill, only one pregnancy test is required.

960. A patient has had dilation of the eyes with an anticholinergic agent. What will the nurse say when preparing this patient to go home after the examination? a. "Systemic side effects will not occur with this agent." b. "You may experience an increased heart rate, but this is a harmless side effect." c. "You may need to wear dark glasses until this medication wears off." d. "You will be able to read as soon as the examination is completed."

ANS: C Because the agent causes cycloplegia, which paralyzes the iris sphincter, the eyes are unable to respond to bright light, so patients should be advised to wear sunglasses until this effect wears off. Systemic side effects do occur with these agents. Tachycardia is a systemic effect and may indicate toxicity. Mydriasis is an effect of this drug, causing the eye to be unable to focus; patients will have blurred vision until this effect wears off.

655. A parent asks a nurse to recommend an intranasal decongestant for a 6-year-old child. Which response by the nurse is correct? a. "Decongestants are too sedating for children and should not be used." b. "Decongestants should not be given to children under 7 years old." c. "Decongestant drops are recommended instead of decongestant sprays." d. "Decongestant sprays should be used no longer than 5 to 10 days."

ANS: C Decongestant drops are recommended for children, because the number of drops can be controlled precisely. When sprays are used, the amount given is not well controlled. Decongestants cause CNS excitation. Decongestants may be given to children over the age of 4 years. Intranasal decongestants should not be used for longer than 5 days.

538. Which statement is true about helper T cells? a. They are useful but are not essential to immune responses. b. They do not play a role in antibody production. c. They have highly specific receptors to antigens on their surface. d. They prevent CD4 molecules from attaching to antigens.

ANS: C Helper T cells have highly specific cell surface receptors that recognize individual antigens. Helper T cells play an essential role in several functions of the immune response. They have an essential role in the production of antibodies by B cells. They carry CD4 molecules on their surface and are also referred to as CD4 cells.

563. A prescriber orders hydroxyzine [Vistaril] for a patient with acute urticaria. The nurse will include which information when teaching the patient about this drug? a. The drug will reduce redness and itching but not edema. b. This antihistamine is not likely to cause sedation. c. The patient should avoid drinking alcohol while taking the drug. d. The patient should report shortness of breath while taking the drug.

ANS: C Hydroxyzine is a first-generation antihistamine and has sedative effects, so patients should be cautioned not to consume alcohol while taking the drug. In capillary beds, antihistamines reduce edema, itching, and redness. This antihistamine causes sedation. It is not associated with respiratory depression at therapeutic doses.

975. A child with eczema has been treated unsuccessfully with a topical glucocorticoid for a year and has skin atrophy and hypopigmentation. The nurse will suggest discussing which drugs with the provider? a. Higher potency topical glucocorticoids b. Topical keratolytic agents c. Topical immunosuppressants d. Topical nonsteroidal anti-inflammatory drugs (NSAIDs)

ANS: C If topical glucocorticoids fail to treat eczema without causing skin atrophy and hypopigmentation, topical immunosuppressants may be used. Higher potency glucocorticoids will only compound the adverse effects. Topical keratolytic agents are not indicated. Topical NSAIDs are not indicated.

531. A patient who breastfeeds her infant asks the nurse about the immunity the infant receives from breast milk. What does the nurse tell the patient about immunity through breastfeeding? a. "The immunity protects the infant from hypersensitivity reactions." b. "The immunity provides phagocytes to help the infant fight infections." c. "The immunity results from the transfer of IgA through the breast milk." d. "The immunity protects the infant from respiratory and gastrointestinal (GI) microbes."

ANS: C IgA crosses breast milk and, in the GI tract, where it is not absorbed, provides passive immunity to microbes. Infants do not receive protection from hypersensitivity reactions through breast milk. Phagocytes are not transmitted through breast milk. Infants are not protected from respiratory microbes via breast milk.

556. A 5-year-old child is brought to the emergency department after ingesting diphenhydramine [Benadryl]. The child is uncoordinated and agitated. The nurse observes that the child's face is flushed, the temperature is 37.1°C, and the heart rate is 110 beats/minute. The nurse will expect to: a. administer atropine to reverse the adverse effects. b. apply ice packs to stop the flushing. c. give activated charcoal to absorb the drug. d. prepare to provide mechanical ventilation.

ANS: C In acute toxicity, patients present with agitation, a flushed face, tachycardia, and uncoordinated movements. There is no specific antidote, so drug removal is the focus of treatment, starting with activated charcoal to absorb the drug, followed by a cathartic to enhance excretion. Atropine would cause an increase in the heart rate. Application of ice packs is recommended for hyperthermia and not for flushing. The child's temperature is normal. Mechanical ventilation is not indicated with this presentation of symptoms, although cardiovascular collapse may eventually develop.

476. A patient with hypothyroidism begins taking PO levothyroxine [Synthroid]. The nurse assesses the patient at the beginning of the shift and notes a heart rate of 62 beats/minute and a temperature of 97.2°F. The patient is lethargic and difficult to arouse. The nurse will contact the provider to request an order for which drug? a. Beta blocker b. Increased dose of PO levothyroxine c. Intravenous levothyroxine d. Methimazole [Tapazole]

ANS: C Intravenous administration of levothyroxine is used for myxedema coma. This patient is showing signs of severe hypothyroidism, or myxedema. A beta blocker is useful in patients who show signs of hyperthyroidism to minimize cardiac effects. Because the half-life of oral levothyroxine is so long, increasing the PO dose will not provide immediate relief of this patient's symptoms. Methimazole is used to treat hyperthyroidism.

958. A nurse administers timolol [Timoptic] ophthalmic drops to a patient who has glaucoma. The patient reports stinging of the eyes shortly after the drops were administered. What will the nurse do? a. Monitor the patient's heart rate, respiratory rate, and blood pressure. b. Notify the provider that the patient shows signs of angle-closure glaucoma. c. Reassure the patient that these are localized, reversible effects of the drug. d. Request an order for an antihistamine to treat this allergic response to the drug.

ANS: C Local effects of timolol and other beta blockers are generally minimal, but transient ocular stinging can occur. There is no need to monitor vital signs, because this does not represent a systemic reaction. This is not a sign of angle-closure glaucoma. Antihistamines will not help.

540. A nurse is discussing the role of antibodies in the complement system with a group of nursing students. Which statement by a student is correct? a. "Antibodies activate the complement cascade by turning on the alternative pathway." b. "Antibodies that are free in solution can activate the complement system." c. "Antibodies flag target cells to be lysed by membrane attack complexes." d. "Antibody receptors are nonspecific to antigenic determinants."

ANS: C Lysis of target cells that have been tagged with antibodies is the most dramatic effect of the complement system. Antibodies activate the complement cascade by turning on the classical pathway. C1 cannot bind with free antibodies. Antibody receptors are specific to antigen determinants.

629. A patient with asthma is admitted to an emergency department with a respiratory rate of 22 breaths/minute, a prolonged expiratory phase, tight wheezes, and an oxygen saturation of 90% on room air. The patient reports using fluticasone [Flovent HFA] 110 μg twice daily and has used 2 puffs of albuterol [Proventil HFA], 90 mcg/puff, every 4 hours for 2 days. The nurse will expect to administer which drug? a. Four puffs of albuterol, oxygen, and intravenous theophylline b. Intramuscular glucocorticoids and salmeterol by metered-dose inhaler c. Intravenous glucocorticoids, nebulized albuterol and ipratropium, and oxygen d. Intravenous theophylline, oxygen, and fluticasone (Flovent HFA) 220 mcg

ANS: C Patients using inhaled glucocorticoids should be given IV or oral glucocorticoids for acute exacerbations. During asthma flares, nebulized albuterol with ipratropium may be better tolerated and more effective. Oxygen is indicated, because oxygen saturations are low despite the increased work of breathing. Increasing the dose of albuterol and giving theophylline are not indicated. Salmeterol is a long-term beta agonist and is not useful in an acute attack.

555. A provider has ordered intravenous promethazine [Phenergan] for an adult patient postoperatively to prevent nausea and vomiting (N/V). What will the nurse do? a. Administer the drug at a rate of 25 mg/minute or more to achieve maximum effects. b. Contact the provider to suggest using dimenhydrinate [Dramamine] instead. c. Ensure that the IV is infusing freely through a large-bore needle. d. Monitor the patient closely for cardiac dysrhythmias.

ANS: C Promethazine can cause severe local tissue injury if it extravasates into tissues, so the medication should be administered in an IV that is flowing freely through a large-bore needle. The drug should be administered at a rate of 25 mg/minute or less. Dimenhydrinate is indicated for motion sickness, not postoperative N/V. Cardiac dysrhythmias were a concern with two antihistamines no longer on the market, astemizole and terfenadine.

562. An 18-month-old child develops an urticarial reaction after a transfusion. The prescriber orders intravenous promethazine [Phenergan]. What will the nurse do? a. Give the medication as ordered. b. Monitor the child for bronchoconstriction. c. Question the order. d. Request an order to give the drug orally.

ANS: C Promethazine can cause severe respiratory depression, especially in very young patients; it is contraindicated in children younger than 2 years. The medication should not be given as ordered. It is not safe to give the drug and then monitor for bronchoconstriction. The drug is not safe in this age group when given orally.

997. A 2-year-old child is seen in the clinic in July with otalgia, erythematous, bulging tympanic membranes (TMs), and rupture of the right TM. The child also has a temperature of 39.4° C. The child's parent tells the nurse, "This is the fifth ear infection this year. What can we do?" The nurse will expect the provider to: a. administer ceftriaxone [Rocephin] IM and give the influenza vaccine. b. begin prophylactic antibiotic therapy with trimethoprim/sulfamethoxazole [Septra]. c. prescribe amoxicillin/clavulanate [Augmentin] and refer the child to an otolaryngologist. d. prescribe high-dose amoxicillin [Amoxil] and administer the influenza vaccine.

ANS: C Recurrent AOM is defined as AOM that occurs three or more times within 6 months or four or more times in a year. Giving an antibiotic, such as Augmentin, is appropriate for each episode, and referral to an ENT specialist is recommended to help reduce risk. IM Rocephin might be an appropriate treatment for an episode, but a flu vaccine is not recommended in July. Prophylactic antibiotic therapy is not recommended. High-dose amoxicillin might be an appropriate treatment for an episode, but a flu vaccine is not recommended in July.

970. A nurse is teaching a group of lifeguards about safe sunning. Which statement by a lifeguard indicates understanding of the teaching? a. "Sunscreen should be applied 30 minutes before going outside." b. "I do not need sunscreen when it is cloudy outside." c. "I should reapply sunscreen after swimming." d. "UV radiation does not penetrate through water."

ANS: C Sunscreens should be reapplied after swimming and with profuse sweating. Most sunscreens should be applied at least 30 minutes before going outdoors, but some require application 2 hours before exposure. Clouds do not protect from all UV rays. UV radiation can penetrate at least several centimeters of clear water.

964. A nurse is teaching a patient who will begin using a fixed-dose preparation of dorzolamide and timolol [Cosopt] for open-angle glaucoma. Which statement by the patient indicates a need for further teaching? a. "Blurred vision, tearing, or eye dryness may occur with this medication." b. "I may experience a bitter taste in my mouth after instilling these eye drops." c. "I will need to instill two eye drops three times daily in each eye." d. "If I notice redness in my eyes or eyelids, I should stop using these drops."

ANS: C The fixed-dose preparation of dorzolamide and timolol is given as 1 drop twice daily. Blurred vision, tearing, eye dryness, and a bitter aftertaste are the expected side effects. Redness in the eyes or eyelids indicates an allergic conjunctivitis and means that the drops should be discontinued.

994. A provider has told a parent that a 3-year-old child has a minor ear infection and that an antibiotic would be prescribed in a couple of days if the child's symptoms worsened. The parent asks the nurse why the child cannot get an antibiotic today. Which response by the nurse is correct? a. "If the eardrum ruptures, we can culture the fluid to determine which antibiotic is best." b. "Most ear infections are caused by viruses, so antibiotics are not effective." c. "Most ear infections will resolve on their own without antibiotics." d. "Your child will develop tolerance to antibiotics if they are prescribed too often."

ANS: C The vast majority of acute otitis media (AOM) episodes resolve without treatment, so unless the child is very ill, observation is the initial choice. Spontaneous rupture of the tympanic membrane can occur, but clinicians do not wait for it to happen to obtain a culture that will guide treatment. About 70% to 90% of AOM episodes are bacterial in origin. Patients do not develop tolerance to antibiotic effects; overuse of antibiotics can lead to resistant organisms.

537. A nurse is teaching a group of nursing students about antibodies. The nurse correctly explains which type of response is triggered when antigens bind to antibodies on mast cells or basophils? a. Acquired immune response b. Autoimmune response c. Hypersensitivity reaction d. Transplant rejection

ANS: C When antigens bind to antibodies on mast cells and basophils, chemical mediators of hypersensitivity reactions are released. Although hypersensitivity is an acquired response, mast cells and basophils do not play a role in other acquired responses. An autoimmune response occurs when the immune system fails to discriminate between self and nonself. Transplant rejection occurs when the MHC molecules of the donor are different from those of the patient.

967. A nurse in an ophthalmology clinic instills an anticholinergic agent into a patient's eyes. The nurse provides teaching when the patient asks the reason for the drops. Which statement by the patient indicates a need for further teaching? a. "The drops help prevent my lenses from moving during the examination." b. "The drops will cause me to have blurred vision and sensitivity to light." c. "These drops allow the ophthalmologist to see inside my eyes." d. "This medication anesthetizes my eyes so that the examination won't be painful."

ANS: D Anticholinergic agents are used to provide mydriasis and cycloplegia. They do not affect the sensation of pain and do not provide anesthesia. Cycloplegia refers to paralysis of the ciliary muscle and prevents the lens from moving during the examination. The desired effects, which facilitate eye examinations, do not allow the eye to focus or to respond to light, so blurred vision and photophobia occur. Mydriasis prevents the iris sphincter from contracting, allowing the examiner to see inside the eye.

648. A patient who has seasonal allergies in the spring and fall asks the nurse about oral antihistamines. Which response by the nurse is correct? a. "Anticholinergic effects are more common with second-generation antihistamines." b. "First-generation antihistamines, such as diphenhydramine [Benadryl], are more effective." c. "Make sure you take antihistamines only when you have symptoms to minimize side effects." d. "You should take oral antihistamines daily during each allergy season to get maximum effects.

ANS: D Antihistamines are most effective when they are taken prophylactically, and they should be administered on a regular basis throughout the allergy season, even when symptoms are not present. They are less helpful when taken after symptoms appear. Second-generation antihistamines have fewer anticholinergic effects than first-generation antihistamines. First- generation antihistamines are not more effective than second-generation antihistamines. Oral antihistamines are not as effective when given on a PRN basis.

969. A nurse is teaching a patient diagnosed with wet ARMD who will begin receiving bevacizumab [Avastin]. Which statement by the patient indicates a need for further teaching? a. "I should be able to improve my visual acuity by using this drug." b. "I should report eye pain and photophobia to my provider if they occur." c. "This drug will help suppress the growth of new blood vessels." d. "This medication will not reduce the risk of blindness."

ANS: D Bevacizumab can help reduce the risk of further impairment and progression to blindness. It can help improve visual acuity. Eye pain and photophobia are signs of endophthalmitis, which is an inflammation caused by infection; they should be reported to the provider. Bevacizumab works by suppressing the development of new blood vessels.

972. A patient with psoriasis has been using a high-potency glucocorticoid. Because of skin atrophy, the provider has ordered a switch to calcitriol [Vectical], a vitamin D3 analog. What will the nurse teach this patient? a. "Calcitriol causes severe photosensitivity." b. "Itching, erythema, and irritation are indications of an allergic reaction." c. "Systemic effects do not occur with this topical agent." d. "You may apply calcitriol to all areas of the skin except the face."

ANS: D Calcitriol may be applied twice daily to all areas except the face. It does not cause severe photosensitivity. Skin irritation does not occur. Systemic effects may occur.

977. A patient with actinic keratoses has received a prescription for fluorouracil [Carac]. Which statement by the patient indicates understanding of this medication? a. "Healing should occur 6 weeks after beginning treatment." b. "I will apply this drug twice daily." c. "Severe inflammation is an indication for stopping treatment." d. "Tissue ulceration and necrosis are desired effects."

ANS: D Fluorouracil causes tissue disintegration, erosion, ulceration, and necrosis as part of the normal course of desired effects. Complete healing may take several months, although treatment lasts 2 to 6 weeks. Carac is applied once daily. Severe inflammation is part of the course of treatment and not an indication for discontinuing the medication.

659. A parent asks a nurse about giving diphenhydramine [Benadryl] to a child to relieve cold symptoms. Which response by the nurse is correct? a. "Benadryl must be given in higher doses to provide relief for cold symptoms." b. "Intranasal glucocorticoids are more effective for treating cold symptoms." c. "Nasal antihistamines are more effective for treating cold symptoms." d. "Because histamine does not cause cold symptoms, Benadryl would not be effective."

ANS: D Histamine does not contribute to symptoms of infectious rhinitis; therefore, antihistamines are of no use in treating cold symptoms. Giving antihistamines in higher doses does not provide relief for infectious rhinitis. Intranasal glucocorticoids are not useful for infectious rhinitis. Nasal antihistamines are not effective for treating infectious rhinitis.

535. A nurse is reviewing the immune system with a group of nursing students. One student asks about the difference between cell-mediated immunity and humoral immunity. What should the nurse reply? a. "Humoral immunity does not involve helper T cells in the immune response." b. "Humoral immunity does not have a role in hypersensitivity reactions." c. "Humoral immunity requires cytolytic T cells that attack antigens directly." d. "Humoral immunity uses cells produced by B lymphocytes in the immune response."

ANS: D Humoral immunity refers to immunity mediated by antibodies, which are produced by B lymphocytes. Helper T cells have an essential role in antibody production by B cells. The antibody immunoglobulin E plays a role in hypersensitivity reactions. Cytolytic T cells do not produce antibodies; they are key players in cellular immunity.

638. A patient with stable COPD receives prescriptions for an inhaled glucocorticoid and an inhaled beta2-adrenergic agonist. Which statement by the patient indicates understanding of this medication regimen? a. "I should use the glucocorticoid as needed when symptoms flare." b. "I will need to use the beta2-adrenergic agonist drug daily." c. "The beta2-adrenergic agonist suppresses the synthesis of inflammatory mediators." d. "The glucocorticoid is used as prophylaxis to prevent exacerbations."

ANS: D Inhaled glucocorticoids are used daily to prevent acute attacks. They are not used PRN. The beta2- adrenergic agonist drugs should not be used daily; they are used to treat symptoms as needed. They do not suppress mediators of inflammation.

643. A patient with persistent, frequent asthma exacerbations asks a nurse about a long-acting beta2-agonist medication. What will the nurse tell this patient? a. LABAs are safer than short-acting beta2 agonists. b. LABAs can be used on an as-needed basis to treat symptoms. c. LABAs reduce the risk of asthma-related deaths. d. LABAs should be combined with an inhaled glucocorticoid.

ANS: D LABAs can increase the risk of asthma-related deaths when used improperly; this risk is minimized when LABAs are combined with an inhaled glucocorticoid. LABAs are not safer than SABAs, and they are not used PRN. LABAs increase the risk of asthma-related deaths.

1000. A child has been diagnosed with otitis media with effusion (OME), and the child's parent asks the nurse what this means. The nurse will explain that OME is: a. a condition with a heightened risk of acute otitis media. b. an acute ear infection with fluid in the middle ear. c. an infection of the skin and tissues of the outer ear. d. fluid in the middle ear without localized or systemic infection.

ANS: D OME occurs in many children after an episode of AOM. It is characterized by fluid in the middle ear without evidence of local or systemic illness. It does not necessarily pose a heightened risk of AOM. OME is not an acute ear infection or an infection of the outer ear.

657. Which medication used for asthma has off-label uses to treat allergic rhinitis? a. Diphenhydramine [Benadryl] b. Fexofenadine/pseudoephedrine [Allegra-D] c. Guaifenesin [Mucinex] d. Omalizumab [Xolair]

ANS: D Omalizumab is a monoclonal antibody directed against IgE that plays a role in the release of inflammatory mediators from mast cells and basophils. It is currently only approved for allergy mediated asthma but is being used off-label to treat other allergic symptoms. Diphenhydramine, fexofenadine/pseudoephedrine, and guaifenesin are not used to treat asthma.

641. A nurse is teaching a group of nursing students about the different formulations of beta2- adrenergic agonist medications. Which statement by a student indicates understanding of the teaching? a. "Beta2-adrenergic agonists provide quick relief via any formulation." b. "Long-acting beta2 agonists may be used alone to prevent attacks." c. "Short-acting beta2 agonists are usually given by nebulizer." d. "Oral beta2 agonists are not useful for short-term treatment."

ANS: D Oral beta2 agonists are used only for long-term control. All formulations vary; long-acting beta2 agonists (LABAs) and oral preparations are used for long-term control, whereas short-acting beta2 agonists (SABAs) are useful for acute episodes. LABAs are used in conjunction with inhaled glucocorticoids to prevent attacks. SABAs may be given by MDI or nebulizer and usually are given by MDI.

640. Which medication should be used for asthma patients as part of step 1 management? a. Combination inhaled glucocorticoids/long-acting beta2 agonists b. Inhaled low-dose glucocorticoids c. Long-acting beta2 agonists d. Short-acting beta2 agonists

ANS: D Patients needing step 1 management have intermittent, mild symptoms and can be managed with a SABA as needed. Combination inhaled glucocorticoids/LABAs are used for step 3 management. Inhaled low-dose glucocorticoids are used for step 2 management. LABAs, along with inhaled glucocorticoids, are used for step 3 management.

992. An 18-month-old child is seen in the clinic with a temperature of 40° C. The child's parents tell the nurse that the child developed the fever the previous evening and was inconsolable during the night. The provider examines the child and notes a bulging, erythematous tympanic membrane. The nurse will expect to: a. ask the parent to return to the clinic in 2 days to see whether antibiotics need to be started. b. discuss a referral to an ear, nose, and throat specialist for follow-up treatment. c. teach the parent to give analgesics for 3 days while observing for worsening symptoms. d. tell the parent to administer amoxicillin at 45 mg/kg/dose twice daily.

ANS: D Patients with severe symptoms of AOM should begin treatment with antibiotics upon diagnosis. For children 6 months to 2 years of age, treatment should begin when the diagnosis is certain, as evidenced by erythema of the tympanic membrane (TM) and distinct discomfort. Amoxicillin 45 mg/kg/dose twice daily is indicated. Observation for 2 days is not recommended for this child, because the diagnosis is certain; therefore, asking the parent to return in 2 days or to give only symptomatic treatment is incorrect. Referral to an ear, nose, and throat (ENT) specialist is not recommended unless the child has recurrent AOM or if treatments repeatedly fail.

959. A nursing student asks the nurse to discuss the differences between POAG and angle- closure glaucoma. Which statement by the nurse is correct? a. "Angle-closure glaucoma may be asymptomatic until irreversible damage has occurred." b. "Both types are more common in African-American patients." c. "Drug therapy is the definitive treatment for angle-closure glaucoma." d. "Early treatment with prostaglandin analogs can stop the progression of POAG."

ANS: D Prostaglandin analogs are first-line agents for treating POAG, and early treatment can stop the progression. Angle-closure glaucoma has a rapid onset of painful symptoms. POAG is more common in African Americans but angle-closure glaucoma is not. Surgery, not drugs, is the definitive treatment for angle-closure glaucoma.

536. A nurse is caring for a patient who has undergone organ transplantation. Because the sequence of amino acids in the major histocompatibility complex (MHC) molecules of the donor is different from that of the patient, the nurse will expect to administer which class of drugs? a. Antibiotics b. Antihistamines c. Immune globulins d. Immunosuppressants

ANS: D The MHC molecules from one individual are recognized as foreign by the immune system of another individual; therefore, when an attempt is made to transplant organs between individuals who are not identical twins, immune rejection of the transplant is likely. Immunosuppressants are given to counter this response. Antibiotics are used to destroy bacteria. Antihistamines block hypersensitivity reactions. Immune globulins are given to confer passive immunity when specific acquired immunity has not yet developed a response.

637. A child is receiving a combination albuterol/ipratropium [DuoNeb] inhalation treatment. The patient complains of a dry mouth and sore throat. What will the nurse do? a. Contact the provider to report systemic anticholinergic side effects. b. Discontinue the aerosol treatment immediately. c. Notify the provider of a possible allergic reaction. d. Reassure the patient that these are expected side effects.

ANS: D The most common adverse effects of this combination drug are dry mouth and irritation of the pharynx. The patient should be reassured that these are common and minor effects. Systemic anticholinergic side effects are rare. It is not necessary to discontinue the medication. Patients with peanut allergy may have severe anaphylactic reactions, but the patient's symptoms are not those associated with anaphylaxis.

532. A nurse is caring for a patient infected with the human immunodeficiency virus (HIV). Which finding would most concern the nurse? a. High level of macrophages b. Low neutrophil count c. Low red blood cell (RBC) count d. Very low helper T lymphocyte count

ANS: D The nurse understands that this patient may be vulnerable to opportunistic infections, especially if there were an indication of the HIV conversion to acquired immunodeficiency syndrome (AIDS). A very low helper T lymphocyte count would most concern the nurse, because the helper T cells are essential to the immune system, and people with AIDS have a low or deficient count. A high level of macrophages could indicate an inflammatory response. A low RBC count may indicate anemia. A low neutrophil count can be caused by multiple conditions, but a high count most likely indicates an infection.

534. A patient has a Type IV hypersensitivity (delayed-type hypersensitivity) response to an infection. The nurse understands which two types of cells are necessary for this response? a. Antigen-presenting cells and mast cells b. Cytolytic T lymphocytes and target cells c. Immunoglobulin cells and dendritic cells d. Infected macrophages and CD4 helper T cells

ANS: D The object of Type IV hypersensitivity (delayed-type hypersensitivity) is to rid the body of bacteria that replicate within macrophages. The macrophage activates the CD4 cell, which in turn activates the macrophage. The other cells listed are not a part of this response.

533. A nurse is teaching a nursing student about a specific acquired immunity system. Which statement by the student indicates a need for further teaching? a. "Cell-mediated immunity and humoral immunity are both types of specific acquired immune responses." b. "Each exposure to an antigen causes a faster, more intense response." c. "Immune responses occur only after exposure to a foreign substance." d. "The skin is a factor in specific acquired immunity."

ANS: D The skin is a physical barrier that confers natural immunity. It is not a factor in specific acquired immunity. Cell-mediated and humoral immunity are both types of specific acquired immunity. In specific acquired immunity, each exposure to an antigen evokes a more intense response more quickly. Specific acquired immunity occurs only after initial exposure to an antigen.

631. A patient with COPD is prescribed tiotropium [Spiriva]. After the initial dose, the patient reports only mild relief within 30 minutes. What will the nurse tell the patient? a. "You may have another dose in 4 hours." b. "You may need to take two inhalations instead of one." c. "You should have peak effects in about 6 hours." d. "You should see improved effects within the next week."

ANS: D Tiotropium shows therapeutic effects in about 30 minutes, with improved bronchodilation occurring with subsequent doses, up to 8 days. The medication is given once daily, with inhalation of one capsule. Peak effects occur in 3 hours.

632. A patient with asthma comes to a clinic for treatment of an asthma exacerbation. The patient's medication history lists an inhaled glucocorticoid, montelukast [Singulair], and a SABA as needed via MDI. The nurse assesses the patient and notes a respiratory rate of 18 breaths/minute, a heart rate of 96 beats/minute, and an oxygen saturation of 95%. The nurse auscultates mild expiratory wheezes and equal breath sounds bilaterally. What will the nurse do? a. Contact the provider to request a systemic glucocorticoid. b. Contact the provider to suggest using a long-acting beta2 agonist. c. Evaluate the need for teaching about MDI use. d. Question the patient about how much albuterol has been used.

ANS: D To determine the next course of action, it is important to assess the drugs given before these symptoms were observed. Patients who continue to wheeze after using a SABA need systemic glucocorticoids and nebulized albuterol. If a SABA has not been used, that will be the first intervention. LABAs are not used for exacerbations. If a patient reports using a SABA without good results, evaluating the MDI technique may be warranted.

985. An adolescent patient with moderate acne has begun a regimen consisting of combination clindamycin/benzoyl peroxide [BenzaClin] and tretinoin [Retin-A]. Which statement by the patient indicates understanding of this medication regimen? a. "I should apply the Retin-A immediately after bathing." b. "I should apply the Retin-A twice daily." c. "I should augment this therapy with an abrasive soap." d. "I should use sunscreen every day."

ANS: D Tretinoin increases susceptibility to sunburn, so patients should be warned to apply a sunscreen and wear protective clothing. Before applying Retin-A, the skin should be washed, toweled dry, and allowed to dry fully for 15 to 30 minutes. Retin-A is applied once daily. Abrasive soaps intensify localized reactions to Retin-A and should not be used.

986. A 50-year-old patient asks about using tretinoin [Renova] to minimize wrinkles. What will the nurse tell the patient? a. The drug may be discontinued once results are obtained. b. Results may be visible within a few weeks of starting therapy. c. Systemic toxicity is a common side effect in patients with sensitive skin. d. The drug is not effective on coarse wrinkles or sun-damaged skin.

ANS: D Tretinoin is used to treat fine wrinkles, not coarse wrinkles, and does not repair sun-damaged skin. Treatment with Renova must continue to maintain the response to the drug. Results are not visible for up to 6 months after beginning therapy. Systemic toxicity is not common.

646. A patient with asthma will be using a metered-dose inhaler (MDI) for delivery of an inhaled medication. The provider has ordered 2 puffs to be given twice daily. It is important for the nurse to teach this patient that: a. the patient should inhale suddenly to receive the maximum dose. b. the patient should activate the device and then inhale. c. the patient should store the MDI in the refrigerator between doses. d. the patient should wait 1 minute between puffs.

ANS: D When two puffs are needed, an interval of at least 1 minute should separate the first puff from the second. Sudden inhalation can cause bronchospasm. The patient should begin inhaling and then activate the device. There is no need to store the drug in the refrigerator.