Pharm Quiz 2 Study Guide

Promoting Adherance

- Simplified drug regimens - Clear and concise verbal and written instructions - Appropriate dosage form - Clearly labeled and easy-to-open containers - Daily reminders - Ability to afford drugs - Support system - Frequent monitoring

A child will receive 750 mg of an antibiotic for 10 days. The child attends day care. The drug may be dosed in several ways and his available in two concentrations. Which dosing regimen will the nurse discuss with the child's provider.

500 mg/5 ml to 375 mg PO twice daily To promote adherence to a drug regimen in children, it is important to consider the size and timing of the dose.

An older adult patient is admitted to the hospital for treatment of an exacerbation of a chronic illness. Admission laboratory work reveals an extremely low serum levels of the drug used to treat this condition. The patient has brought the medication to the hospital, along with other medications taken. The patient;s renal and hepatic function tests are normal. What might the nurse suspect as a likely cause of this finding?

A) Financial concerns Older adults patients who have financial concerns about paying for medications often taken less of the drug or take it less often to make the drug last longer.

A prescriber has ordered medication for a newborn. The medication is elimination primarily by hepatic metabolism. The nurse expects the prescriber to:

A) Order a dose that is lower than an adult dose The drug-metabolizing capacity of newborns is low. As a result, neonates are especially sensitive to drug that are eliminated primarily by hepatic metabolism.

A nurse is administering digoxin to a patient. To administration medication so that the drug is as effective as possible, the nurse needs to consider what?

B) Pharmacokinetics

An important concept taught by the nurse when providing medication teaching is the need to provide a complete list of medications taken to health care providers to avoid what?

C) Drug-drug interactions

A nurse is caring for an infant after surgical procedure. After ensuring that the ordered dose is appropriate for the infant's age and weight, the nurse administers a narcotic analgesic by IV. When assessing the infant 15 minutes later, the nurse notes respirations of 22 and a HR of 110. The infant is asleep in the parent's arms and does not awaken when vital signs are assessed. The nurse understands that these findings are the result of:

B) Immaturity of the blood-brain barrier in the infant The blood-brain barrier is not well developed in infants, making them more susceptible to CNS affects of medications.

A nurse is caring for a patient and her newborn immediately after delivery. The patient's medication history includes prenatal vitamins throughout pregnancy, one or two glasses of wine before knowing she was pregnant, occasional use of an albuterol inhaler in her last trimester, and intravenous morphine during labor. What will the nurse expect to do?

B) Monitor the infant's respirations and prepare to administer naxolone if needed

A woman who is breastfeeding her infant must take a prescription medication for 2 weeks. The medication is safe, but the patient wants to make sure her baby receives as little of the drug as possible. What will the nurse tell the patient to do?

B) Take the medication immediately after breastfeeding

A patient who has just learned she is pregnant has stopped using a prescription medication that she takes for asthma because she does not want to harm her baby. What will the nurse tell her?

B) That her baby's health is dependent of hers Asthmatic women who fail to take medication have a doubled risk of stillbirth; therefore, the nurse should encourage the patient to use her medications.

Based on changes in hepatic function in older adult patients, which adjustment should be nurse expect for oral medications that undergo extensive first pass metabolism?

B) The interval between doses should be increased The interval between doses of the medication should be increased in older adult patients, because drugs that undergo the first pass effect may no the broken down as well as in individual with with full liver function.

The nurse is teaching a group of nursing students about adherence to medication in older adults. Which statement by a student indicates understanding of the teaching?

D) "A majority of older patients who do not adhere to drug regimens do so intentionally"

A nurse is caring for a patient who has been receiving a drug by the IM route but will recieve the drug orally after discharge. How does the nurse explain the increased dosage prescribed for the oral dose?

D) First pass effect

A nurse is working as a member of a research team involved in exploring the unique response to drugs each individual displays based genetic make-up. What is this area of study called?

D) Pharmacogenomics

A nurse caring for a 5 yr old child notes that the child has discoloration of several teeth. When taking a medication history, the nurse will ask about which group of medications?

D) Tetracyclines Tetracyclines cause discoloration in developing teeth in children. Glucocorticoids are associated with growth suppression. Salicylates are associated with Reye syndrome. Sulfonamides are associated with kernicterus in newborns.

A nurse is preparing to give medications to four older patients who are all taking multiple medications. Which patient is most likely to have adverse drug reaction related to increased drug effects?

D) Thin patient with chronically low appetite

Other considerations

- Implications - Ethics - Guidelines

Chapter 10

Drug Therapy in Geriatric

Pharmacokinetics: Neonates and Infants

- Determining the concentration of a drug at its sites of action - Determining the intensity of the duration of response

Predisposing ADR Factors

- Drug accumulation secondary to reduced renal function - Polypharmacy - Greater severity of illness - Presence of comorbidities - Use of drugs that have a low therapeutic index (e.g., digoxin) - Increased individual variation secondary to altered pharmacokinetics - Inadequate supervision of long-term therapy - Poor patient adherence

Pharmacogenomics

- How genes affect a person's response to drugs - Provides safe drugs to patients - Genomics education and competencies - Biomarkers - Genetic variants that alter drug metabolism

Barriers to Pharmacogenomics

- Lack of education - Financial cost for testing

Pharmacokinetics: Children Age 1 Year and Older

- Most pharmacokinetic parameters are similar to those of adults - Drug sensitivity more like that of adults than for children younger than 1 year old One important difference: - Children in this age group metabolize drugs faster than adults • Markedly faster until the age of 2 years, then a gradual decline • Sharp decline at puberty • May need to increase dosage or decrease interval between doses

Measure to Reduce ADRs

- Obtain a thorough drug history that includes over-the-counter medications - Consider pharmacokinetic and pharmacodynamic changes due to age - Monitor the patient's clinical response and plasma drug levels - Use the simplest regimen possible - Monitor for drug-drug interactions and iatrogenic illness - Periodically review the need for continued drug therapy - Encourage the patient to dispose of old medications - Take steps to promote adherence and to avoid drugs on the Beers list

Drug Therapy During Pregnancy

- Two thirds of pregnant patients take at least one medication; most take more - Physiologic changes during pregnancy and their impact on drug disposition and dosing - Placental drug transfer - Adverse reactions during pregnancy

A nurse is teaching a group of nursing students about administering medications to older adult patients. Which statement by student indicates a need for further teaching?

A) "Alteration in hepatic function requires more frequent drug dosing" Changes in hepatic function in older patient lead to decreased metabolism, meaning that drugs metabolized by the liver have prolonged half-lives and should be given less frequently.

A nursing student asks the nurse why more is not known about the teratogenic effects of maternal medication ingestion during pregnancy. Which response by the nurse is correct?

A) "Clinical trials to assess this risk would put the fetus at risk"

A pediatric nurse is teaching nursing students about medication administration in children. Which statement by a student indicates an understanding of the teaching?

A) "Drugs effective in adults may not work in children, even if the the dose is proportional for weight and size" Drugs have different effects in children for many reasons besides simply the amount of drug per unit of weight.

A pediatric nurse is teaching nursing students to calculate medication doses for children using a formula based on BSA. Which statement by a nursing student indicated understanding of the teaching?

A) "This formula helps approximate the first dose; other doses should be based on clinical observations" This formula helps determine an appropriate first dose for a child that is extrapolated from an adult dose; subsequent doses should be adjusted based on clinical outcome and serum plasma levels. The formula accounts only for differences in weight and not for differences in pharmacokinetic factors. The formula helps determine an effective dose but cannot account for unusual side effects that may occur in children.

The parents of a child with asthma ask the nurse why their child cannot use oral corticosteroids more often, because they are so effective. The nurse will offer which information that is true for children?

A) Chronic steroid use can inhibit growth A specific age-related reaction to a drug is growth suppression caused by glucocorticosteroids. Children with asthma may need these from time to time for acute exacerbations, but chronic use i s not recommended.

A then older adult women is admitted to the hospital after several days of vomiting, diarrhea, and poor intake of foods and fluids. She has not voided since admission. In preparing to care for this patient, the nurse will look for what laboratory values to help guide medication administration?

A) Creatinine clearance C) Plasma drug levels D) Serum Albumin Creatinine clearance is the best way to evaluate renal function in the older adult. Plasma drug levels are important for determining if the patient has toxic or sub-therapeutic drug levels. Serum albumin may be decreased, especially in patients who are thin, are chronically undernourished, or have been vomiting, and the decreased level may result in higher levels of drugs that normally bind to proteins.

A nurse is concerned about renal function in an 84 year old patient who is taking several medications. What will the nurse assesss?

A) Creatinine clearance The proper index of renal function in older adults is creatinine clearance, which indicates renal function in older patient whose organs are undergoing are-related deterioration. Sodium and potassium levels are not indicative of renal function. Serum creatinine levels do not reflect kidney function in older adults because lean muscle mass, which is the source of creatinine in serum, declines and may be low even with reduced kidney function.

A nurse uses what term to describe the drug level required to have a therapeutic effect?

A) Critical concentration

Several processes enable a drug to reach a specific concentration in the body. Together they are called dynamic equilibrium. What are these processes?

A) Distribution to the active sites B) Biotransformation D) Excretion

The patient is taking a drug that affects the body by increasing cellular activity. Where does this drug work on the cell?

A) Receptor sites

A pregnant patient asks the nurse about the safe use of medications during the third trimester. What will the nurse tell her about drugs taken at this stage?

A) They may need to be given in higher doses if they undergo renal clearance. In the third trimester, drugs excreted by the kidneys may have to be increased, because renal blood flow is doubled, the glomerular filtration rate increased, and drug clearance is accelerated. Hepatic metabolism increases, meaning that drugs metabolized by the liver must be increased. All drugs can cross the placenta. Anatomic defects are more likely to occur in the embryonic period, which is in weeks 3 through 8 in the first trimester.

FDA Pregnancy Risk Factors

A: Safest B: More dangerous than A C: More dangerous than A and B D: More dangerous than A, B, and C X: Most dangerous; known to cause fetal harm

A nurse is teaching nursing students about pediatric medication administration. What will the nurse include when discussing pediatric drug research?

C) Studies showed a significant percentage of unanticipated and potentially lethal side effects in children. In early studies, about 30% of drugs caused unanticipated side effects, some of them potentially lethal.

A nurse is making a home visit to an older adult woman who was recently discharged home from the hospital with a new prescription. The nurse notes that a serum drug level drawn the day before was subtherapeutic. What will the nurse do next?

B) Count the pills in the prescription bottle

Pediatric Patients

All patients up to age 16 years old Pediatric patients respond differently to drugs than the rest of the population - Absorption - Distribution - Hepatic metabolism - Renal excretion

A patient has just given birth to a baby boy with a cleft palate. The nurse will review the patient's medication history with special emphasis on drugs taken during which period?

B) During the first semester Gross malformations typically are the result of teratogens consumed during the first trimester.

A nurse is teaching a class to a group of pregnant patients. The nurse correctly teaches that the highest risk of teratogen-induced gross malformations exists during which time?

B) During the first trimester Gross malformations are caused by exposure to teratogens during the embryonic period, which is considered the first trimester.

A patient in her second trimester of pregnancy tells the nurse she is worried that a medication she took before knowing she was pregnant might have harmed the fetus. What will the nurse do?

Ask the patient what she took and when she learned she was pregnant

A patient presents to the emergency department with a drug level of 50 unites/ml. The half life of this drug is 1 hour. With this drug, concentrations above 25 units/ml are considered toxic and no more drug is given. How long will it take for the blood level to reach the non-toxic range?

B) 1 hour Half life is the time required for the serum concentration of a drug to decrease by 50%.

A nurse is obtaining a drug history from an older adult patient who is taking multiple medications prescribed by different providers. Which two medications taken together create a reason for concern?

B) Amitriptyline (Elavil) and diphenhydramine (Benedyrl) Both amitriptyline and diphenhydramine are on the BEERS list, amitriptyline for anticholinergic effects and diphenhydramine because it causes blurred vision. Additionally, they both have CNS effects that can compound each other when the drugs are given together.

An infant has allergies and often develops a pruritic rash when exposed to allergens. The infant's parents ask the nurse about using topical antihistamine. What should the nurse tell them?

B) Applying an antihistamine to the skin can cause toxicity in this age group. Drug absorption through the skin is more rapid in infants, because their skin is thinner and has greater blood flow; therefore, infants are at increased risk of toxicity from topical drugs.

A nurse is caring for a patient who is supposed to receive two drugs at the same time. What is the nurses priority action?

B) Consult a drug guide for compatibility

An infant is receiving a medication that has a narrow therapeutic range. The nurse reviews the medication information and learns that the drug is excreted by the kidneys. When giving the medication, the nurse will assess the infant for:

C) signs of drug toxicity Renal drug excretion in lower in infants, so drugs that are eliminated primarily by renal excretion should be given reduced doses or at longer intervals. Drugs with a narrow therapeutic range should be monitored closely for toxicity.

A patient has recently moved from Vermont to Southern Florida. The patient presents to the clinic complaining of dizzy spells and weakness. While conducting the admission assessment, the patient tells the nurse that he have been on the same anti-hypertensive drug for 6 years and had stable blood pressures and no adverse effects. Since his move, he has been having problems and he feels that the drug is no longer effective. The clinic nurse knows that one possible reason for the change in the effectiveness of the drug could be what?

C) The impact of the warmer environment on the patients physical status.

Drugs do not metabolize the same way in all people. For what patient would a nurse expect to assess for an alteration in drug metabolism?

C) A 50 year old man with cirrhosis of the liver

A pharmacology student asks the instructor what an accurate descriptions of a drug agonist is. What is the instructors best response?

C) A drug that interacts directly with receptor sites to cause the same activity that a natural chemical would cause at that site.

A pregnant patient in active labor is admitted to the emergency department. A toxicology screen and a physical assessment reveal that the patient is an active heroin addict. The nurse who cares for the neonate after delivery should anticipate which clinical manifestations?

C) A shrill cry and irritability A newborn of an active heroin addict experiences a withdrawal syndrome that includes shrill crying, vomiting, and extreme irritability.

A nurse is preparing to teach a forgetful older adult patient about a multiple drug regimen to follow after discharge from the hospital. To help promote adherence, what will the nurse do?

C) Cluster medication administration times as much as possible Unintentional nonadherence often is the result of confusion and forgetfulness. Grouping medications to reduce the number of medication times.

The nurse is talking with a group of nursing students who are doing clinical hours of the unit. A student asks if all IM drugs are absorbed the same. What factor would the floor nurse tell the students to affect absorptions of ther IM administration of the drugs?

C) Environmental temperature

Parents ask the nurse why an over-the-counter cough suppressant with sedative side effects is not recommended for infants. Which response by the nurse is correct?

C) Infants are more susceptible to CNS affects than are adults Drugs cross the blood=brain barrier more readily in infants, making these patients more susceptible to CNS side effects.

Which types of drugs taken by a pregnant patient are more likely to have effects on a fetus?

C) Lipid-soluble drugs

A nurse is reviewing an older adult's patient't chart before giving medications. Which patient information is of most concern?

C) Low serum albumin Low serum albumin reduces protein binding of drugs and can cause levels of free drug to rise, increasing the risk of toxicity.

A nurse is caring for an older patient during the immediate postoperative period after a total hip replacement. The surgeon has ordered meperidine (Demerol) for severe pain. What will the nurse so?

C) Request an order for morphine instead of meperidine (Demerol) In older adults, meriperidine is not effective at usual doses and causes more confusion than in younger patients.

Adverse Drug Reactions

Children are vulnerable to unique adverse effects related to organ immaturity and ongoing growth and development Age-related effects: • Growth suppression (caused by glucocorticoids) • Discoloration of developing teeth (tetracyclines) • Kernicterus (sulfonamides)

End of Life Care

Comfort measures for -Constipation - Delirium - Dyspnea - Fatigue - Nausea and vomiting - Pain - Respiratory secretions

Older Adult Patients

Disproportionately high prescription drug use exists in the older adult population Older adult patients experience more adverse drug reactions and drug-drug interactions than younger patients do Pharmacokinetic changes - Absorption - Distribution - Metabolism - Excretion

Dosage Determination

Dosage is most commonly based on body surface area - Child's BSA x Adult dosage / 1.73 m2 = child dosage Initial pediatric dosing is, at best, an approximation Subsequent doses need to be adjusted

Chapter 9

Drug Therapy in Pediatric Patients

Genetic Variants That Alter Drug Targets

Drug targets on normal cells - ADRB1 - VKORC1 Drug targets on cancer cells and viruses - HER2 - EGFR - CCR5 Genetic variants that alter immune responses to drugs - HLAs

Chapter 8

Drug therapy during pregnancy and breastfeeding

Drug Therapy During Breastfeeding

Drugs can be excreted in breast milk, and effects can occur in the infant How to decrease risk to the infant: - Take drugs immediately after breastfeeding - Avoid drugs that have long half-lives - Choose drugs that tend to be excluded from milk and that are least likely to affect the infant - Avoid drugs that are known to be hazardous - Use the lowest dose for shortest time - Abandon breastfeeding if drug is dangerous

Chapter 7

Genetic and Genomic considerations in pharmacotherapeutics

Genetic and Pharmacogenomic Testing

Genetic biomarkers - Blood - Saliva - Urine - Amniotic fluid - Tissue - Hair Genetic test kits

Teratogenesis

Incidence and causes of congenital anomalies Identification of teratogens very difficult - Birth defects are rare - Animal tests may not apply to humans As a result, only a few drugs are considered proven teratogens Minimizing the risk for teratogenesis - Pregnant patients should avoid unnecessary drug use (e.g., alcohol, cocaine) Responding to teratogen exposure

Promoting Adherence

Provide patient education in writing Demonstration techniques should be included as appropriate Effective education should include the following: - Dosage size and timing - Route and technique of administration - Duration of treatment - Drug storage - The nature and time course of desired responses - The nature and time course of adverse responses

Adverse Drug Reactions (ADRs)

Seven times more likely in the elderly Account for 16% of hospital admissions Account for 50% of all medication-related deaths Majority are dose related rather than idiosyncratic Symptoms in older adults often nonspecific - May include dizziness and cognitive impairment