Pharmacology quizzes

A pregnant woman asks why more is not known about the teratogenic effects of maternal medication ingestion during pregnancy. Which response will the provider offer to address the patient's concern?

"Clinical trials to determine teratogenic effects would put the fetus at risk." One of the greatest challenges in identifying drug effects on a developing fetus has been the lack of clinical trials, which, by their nature, would put the developing fetus at risk of harm. Many pregnant women need prescription medications and not taking those would put the fetus at risk by compromising the health of the mother. The MEPREP study is a retrospective study to learn about possible outcomes related to known maternal drug exposure.

A provider teaches a patient who has been diagnosed with hypothyroidism about a new prescription for levothyroxine. Which statement by the patient indicates a need for further teaching?

"If I take calcium supplements, I may need to decrease my dose of levothyroxine." Patients taking calcium supplements should take these either 4 hours before or after taking levothyroxine, because they interfere with levothyroxine absorption. Many heartburn medications contain calcium, so patients should consult their provider before taking them. Insomnia, tremors, and tachycardia are signs of levothyroxine toxicity and should be reported. Iron also interferes with levothyroxine absorption, so dosing should be 4 hours apart.

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

"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 is increased, and drug clearance is accelerated. Hepatic metabolism increases; therefore, drugs metabolized by the liver may need to be increased. Drugs are not less likely to 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.

A pediatric provider is teaching nursing students to calculate medication doses for children using a formula based on body surface area. Which statement by a nursing student indicates understanding of the teaching?

"This formula helps approximate the first dose; other doses should be based on clinical observations." This formula helps determine an approximate 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. It may not be effective for all ages because of rapid changes in pharmacokinetics.

An adolescent had a serum glucose test at a health fair. The parent calls the clinic and says, "The level was 125 mg/dL. Does that mean my child has diabetes?" What is the provider's most accurate response?

"Unless your child were fasting for longer than 8 hours, this does not necessarily indicate diabetes." If a person has not fasted for 8 hours, a blood sugar level of 125 mg/dL would be considered normal, because it is less than 200 mg/dL for a random sampling. Also, a person must have positive outcomes on two separate days to be diagnosed with diabetes. This patient does not need to have an oral glucose tolerance test, because the 125 mg/dL reading is so far below 200 mg/dL, which would require further work-up. No conclusive evidence indicates that this patient has diabetes, because the random sample value is so low, and the patient has not had two separate tests on different days. However, this also is not conclusive evidence that the patient does not have diabetes.

A patient has a free T4 level of 0.6 ng/dL and a free T3 level of 220 pg/dL. When asked by the patient what these laboratory values mean, how will the provider respond?

"We will need to obtain a TSH level to better evaluate your diagnosis." A free T4 level of less than 0.9 ng/dL and a free T3 level of less than 230 pg/dL are consistent with hypothyroidism, but measurement of the thyroid-stimulating hormone (TSH) level is necessary to distinguish primary hypothyroidism from secondary hypothyroidism. Total T3 and T4 levels are not as helpful as free T3 and T4 levels. These laboratory values indicate hypothyroidism, not hyperthyroid conditions such as Graves disease.

A pregnant patient recently began treatment for hypothyroidism. What response will the provider give when the patient shares that she does not want to take medications while she is pregnant?

"Your baby will likely be born with permanent neuropsychologic deficits if the condition is not treated." Maternal hypothyroidism can result in permanent neuropsychologic deficits in the child. Hypothyroidism is not a normal effect of pregnancy and is a serious condition that can affect both mother and fetus. The greatest danger to the fetus occurs in the first trimester, because the thyroid does not fully develop until the second trimester. Early identification is essential. Symptoms often are vague. Treatment should begin as soon as possible, or intellectual disabilities and other developmental problems may occur.

A child attending daycare is prescribed 750 mg of an antibiotic for 10 days. The drug may be dosed in several ways and is available in two concentrations. Which dosing regimen will the provider consider to best assure drug adherence?

375 mg of a 500 mg/5 mL solution PO twice daily To promote adherence to a drug regimen in children, it is important to consider the size and timing of the dose. In this case the preparation containing 500 mg/5 mL means that a smaller volume can be given, which is more palatable to a child. Twice daily dosing is more convenient for parents, especially when a child is in daycare or school; it also helps prevent the problem of the medication being left either at home or at school.

The provider working on a high-acuity medical-surgical unit is prioritizing care for four patients who were just admitted. Which patient presents with needs that the provider should address first?

A patient with diabetes who is NPO and has a blood glucose level of 80 mg/dl needs a change in diet status after receiving 20 units of 70/30 Novolin insulin. The NPO patient with hypoglycemia who just received 70/30 Novolin insulin takes priority, because this patient needs to consume a good source of glucose immediately or perhaps the NPO status will be discontinued for this shift. The digoxin may be withheld for the patient with a pulse of 58 beats/minute, but this is not a priority action. The patient with a headache needs to be followed up, and prescription for pain medication but because the blood pressure is 136/92 mm Hg, the headache is probably not caused by hypertension. The patient with an allergy to penicillin will not have a reaction to the vancomycin.

A provider obtains a drug history from an older adult who is a new patient. Of the multiple medications taken, which two, taken together, create a reason for concern?

Amitriptyline and diphenhydramine 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. Acetaminophen and oxycodone are both acceptable and may be given together. Fexofenadine is a second-generation antihistamine with fewer side effects, and it is not contraindicated for use with a laxative. Zolpidem is a sedative that has less risk of physical dependence and less risk of confusion, falls, and cognitive impairment; sertraline is a safer antidepressant, because it has a shorter half-life than others.

Four older adult patients are taking multiple medications. For which patient is the provider most concerned about the risk for adverse drug effects?

An underweight patient with a chronically low appetite The patient who is thin and has a poor appetite has an increased risk of malnutrition, with significant lowering of serum albumin. This can result in increased free drug levels of protein-bound drugs and can lead to drug toxicity. Obesity, which involves increased adipose tissue, would cause lipid-soluble drugs to deposit in adipose tissue, with a resulting reduction of drug effects. Creatinine levels do not adequately reflect kidney function in older adults and may be normal even though renal function is greatly reduced. Chronic diarrhea would accelerate the passage of medications through the GI tract and reduce absorption resulting in a decrease in both beneficial and adverse effects.

An infant developed a pruritic rash following exposure to an allergen. The infant's parents ask the provider about using a topical antihistamine. What information should the provider use to address the parents' question?

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. Because of increased drug absorption through the skin, infants should not be given additional drugs via other routes. If a drug is more likely to be absorbed rapidly, it will have more side effects.

An older adult patient with type 2 diabetes has a history of severe hypoglycemia. The patient's partner asks the provider what A1c level they should strive to achieve. What guideline will the prescriber provide?

Below 8.0 For patients with a history of severe hypoglycemia and those with a limited life expectancy or advanced micro- and macrovascular complications, the target A1c level should be below 8.0. For most other patients with diabetes, the target is 7.0 and below.

A patient who takes oral levothyroxine for hypothyroidism is admitted to the hospital. After the provider determines the patient has myxedema, what action will the provider take?

Change to intravenous levothyroxine. This patient is showing signs of severe hypothyroidism or myxedema. Intravenous administration of levothyroxine is used for myxedema coma. A β 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.

The parents of a child with asthma ask the provider why their child cannot use oral corticosteroids more often, because they are so effective. The provider will base the discussion with the parents on what fact concerning oral corticosteroids?

Chronic glucocorticoid use can inhibit physical growth. A specific age-related reaction to a drug is growth suppression caused by glucocorticoids. Children with asthma may need these from time to time for acute exacerbations, but chronic use is not recommended. None of the other three effects occurs in either adults or children.

A provider is concerned about renal function in an 84-year-old patient who is taking several medications. What laboratory result will the provider order?

Creatinine clearance The proper index of renal function in older adults is creatinine clearance, which indicates renal function in older patients whose organs are undergoing age-related deterioration. Sodium and potassium levels are not indicative of renal function. Serum creatinine levels do not accurately 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 provider speaking to a class or a group of pregnant patients correctly teaches that the highest risk of teratogen-induced gross malformations exists during which time period?

During the first trimester Gross malformations are caused by exposure to teratogens during the embryonic period, which is considered the first trimester. This is the time when the basic shape of internal organs and other structures is established. No risk exists immediately before conception. Teratogen exposure during the second and third trimesters usually disrupts function rather than gross anatomy.

An infant is prescribed a medication that has a narrow therapeutic range and is excreted by the kidneys. The provider will monitor closely for which effect?

Evidence of drug toxicity Renal drug excretion is lower in infants, so drugs that are eliminated primarily by renal excretion should be given in reduced doses or at longer intervals. Drugs with a narrow therapeutic range should be monitored closely for toxicity. This drug likely will have intensified effects and be present for a longer time. Nothing in the question indicates that unusual CNS effects will occur; these would depend on the drug prescribed.

What method will the provider consider the most reliable measure for assessing a patient's diabetes control over the preceding 3-month period?

Glycosylated hemoglobin level (A1c) The glycosylated hemoglobin level tells much about what the plasma glucose concentration has been, on average, over the previous 2 to 3 months. The SMBG graph report is done by the patient and indicates each blood sugar level the patient has on a daily basis. It is not as reliable as the glycosylated hemoglobin level, because the equipment used might not be accurate and the testing may not reflect actual measurements 100% of the time. Random blood sugar levels are not as accurate as the glycosylated hemoglobin level for the same reason that the SMBG is not. One fasting blood glucose level indicates the patient's blood sugar level for that one time when it was obtained but is not reflective of a 3-month period.

An admission history on an adult patient notes that the patient has a heart rate of 62 beats/minute, a blood pressure of 105/62 mm Hg, and a temperature of 96.2°F. The patient appears pale and reports always feeling cold and tired. The provider and patient will discuss tests to rule out what possible cause of these signs symptoms?

Hypothyroidism This patient is showing signs of hypothyroidism: a low heart rate, low temperature, pale skin, and feeling cold and tired. In adults, thyroid deficiency is called hypothyroidism. In children, thyroid deficiency is called cretinism. Graves disease and Plummer disease are conditions caused by thyroid excess.

Which type of medication prescribed to a pregnant patient is more likely to have effects on her fetus?

Lipid-soluble drugs Lipid-soluble drugs cross the placenta more readily. Drugs that are highly polar, ionized, or protein bound cross the placenta with difficulty.

A provider is reviewing an older adult patient's chart during a routine visit. Which patient information is of most concern regarding the renewing of medication prescriptions for highly protein-bound drugs?

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. The other options are not associated solely with protein-bound drugs. Additionally, altered gastrointestinal (GI) absorption is not a major factor of concern in the older adult, although delayed GI transit can delay drug responses. Increased body fat can alter drug distribution, causing reduced responses in lipid-soluble drugs; however, it is not the finding of greatest concern. Low serum creatinine may be an indicator of decreased lean muscle mass in older patients and does not necessarily reflect kidney function or drug excretion.

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 drug level of the drug used to treat this condition. The patient's renal and hepatic function tests are normal. What might the provider suspect as a likely cause of this finding?

Nonadherence to the medical regimen Nonadherence is the most common cause of a subtherapeutic drug level. For example, older adult patients who have financial concerns about paying for medications often take less of the drug or take it less often to make the drug last longer. Chronic constipation would be more likely to cause a slight elevation of drug level due to the prolonged time for drug absorption. A patient with increased tolerance to a drug's effects would require more of the drug to get effects. Concurrent administration of two highly protein-bound drugs would result in increased serum levels of one or both drugs.

Insulin glargine is prescribed by the provider for a hospitalized patient with type 1 diabetes. When will the provider order this medication to be administered?

Once daily at bedtime Glargine insulin is indicated for once-daily subcutaneous administration to treat adults and children with type 1 diabetes and adults with type 2 diabetes. According to the package labeling, the once-daily injection should be given at bedtime. Glargine insulin should not be given more than once a day, although some patients require bid dosing to achieve a full 24 hours of basal coverage.

A frail older adult patient is admitted to the hospital after several days of vomiting, diarrhea, poor intake of foods and fluids, and anuria for 8 hours. What laboratory studies will the provider order to help guide medication administration? (Select all that apply.)

Plasma drug levels Creatinine clearance 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 subtherapeutic 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. Gastric pH is not as important; most GI changes result in lowered absorption and less free drug. Serum creatinine levels are related to the amount of lean muscle mass, which may be low in older adult patients, and not reflective of renal function.

A medication prescribed for a neonate is eliminated primarily by hepatic metabolism. What action will the prescriber take to minimize risk to the infant?

Prescribe a dose that is relatively lower than an adult dose when adjusted for body surface area. The drug-metabolizing capacity of newborns is low. As a result, neonates are especially sensitive to drugs that are eliminated primarily by hepatic metabolism. When these drugs are used, dosages must be reduced. Because of the decreased ability of hepatic metabolism in the newborn, a lower dose is required, not a higher dose, and the frequency will not be increased. The medication dosage should be adjusted, not discontinued, for the newborn.

An older adult patient is entering into the immediate postoperative period after a total hip replacement. The patient's son concerned about related pain asks meperidine be prescribed since, "I had it for severe pain when I injured when I was younger." What action will the provider take to reduce the patient's risk for injury while addressing the patient's pain?

Prescribe morphine and discuss the rationale with the patient's son. In older adults, meperidine is not effective at usual doses and causes more confusion, delirium, and neurotoxicity than in younger patients. Morphine is recommended for severe pain among the older population. A fall risk protocol is appropriate, but the drug ordered is not. Diphenhydramine is not recommended for older adult patients, because it causes blurred vision. Both diphenhydramine and diazepam have central nervous system (CNS) sedative effects, which will compound the CNS effects of the narcotic. Diazepam also produces prolonged sedation in older adults.

A patient arrives in the emergency department with a heart rate of 128 beats/minute and a temperature of 105°F. The patient's skin feels hot and moist. The free T4 level is 4 ng/dL, the free T3 level is 685 pg/dL, and the TSH level is 0.1 microunits/mL. The provider caring for this patient will give what intervention priority?

Propylthiouracil (PTU) Propylthiouracil is used for patients experiencing thyroid storm, and this patient is showing signs of that condition. Levothyroxine is given IV for hypothyroidism. 131I is used in patients over 30 years of age who have not responded to other therapies for hyperthyroidism. Methimazole is used long term to treat hyperthyroidism, but PTU is more useful for emergency treatment.

A patient is admitted to the hospital and is prescribed levothyroxine. Assessment data show that the patient also takes warfarin. The provider will make what medication dosage-related change?

Reducing warfarin Levothyroxine accelerates the degradation of vitamin K-dependent clotting factors, which enhances the effects of warfarin. Patients taking warfarin who start taking levothyroxine may need to have their warfarin dose reduced. It is not correct to increase or decrease the levothyroxine dose or to increase the warfarin dose.

An older adult patient with a history of forgetfulness will need to take multiple drugs after discharge from the hospital. What provider action will most successfully promote medication adherence in a forgetful patient?

Schedule medications to be taken at the same times as much as possible. Unintentional nonadherence often is the result of confusion and forgetfulness. Grouping medications to reduce the number of medication times per day can simplify the regimen and help the patient remember medication times. Enlisting a neighbor, relative, or friend is a good idea, but this person should be included in the original teaching sessions. Asking the patient to share what is learned may not be a reasonable expectation of a patient who is forgetful. Detailed written information may just be more confusing; verbal and written information should be clear and concise. Making sure the patient understands the actions and side effects of medications helps when intentional nonadherence is an issue, but in this case it may just add to the patient's confusion.

The provider is assessing a newly diagnosed patient for short-term complications of diabetes. What evaluation does this assessment include?

Serum blood sugar results for hyperglycemia High blood sugar, low blood sugar, and ketoacidosis are short-term complications of diabetes. Microvascular and macrovascular complications, such as peripheral neuropathy, are long-term complications of diabetes. Arterial insufficiency and atherosclerosis also are long-term complications of diabetes.

A patient with type 1 diabetes recently became pregnant. What blood glucose testing schedule will the provider recommended during the pregnancy?

Six or seven times a day A pregnant patient with type 1 diabetes must have frequent blood sugar monitoring (e.g., six or seven times a day) to manage the patient's glucose levels and to ensure that no harm occurs to the fetus. Monitoring the blood sugar level before meals and at bedtime is not significant enough to provide the necessary glycemic control. Morning and 4:00 PM monitoring is not enough to provide glycemic control. Urine glucose testing is not sensitive enough to aid glycemic control, and monitoring three times a day is not enough.

A woman who breastfeeds 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 instructions will the prescriber give the patient to best address her concerns?

Take the medication immediately after breastfeeding your baby." Taking the medication immediately after breastfeeding minimizes the drug concentration in the breast milk at the next feeding. Disrupting breastfeeding is not indicated. Pumping the breast milk will not diminish the drugs or drug concentration in the breast milk. Taking the medication 1 hour before breastfeeding will increase concentrations of the drug in the breast milk.

A 5-year-old has gray teeth. When taking a medication history, the provider will ask about previous use of which group of medications?

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 patient with type 1 diabetes reports taking propranolol for hypertension. What concern does this information present for the provider?

The β blocker can mask the symptoms of hypoglycemia. β blockers can delay awareness of and response to hypoglycemia by masking signs associated with stimulation of the sympathetic nervous system (e.g., tachycardia, palpitations) that hypoglycemia normally causes. Furthermore, β blockade impairs glycogenolysis, which is one means by which the body can counteract a fall in blood glucose; β blockers, therefore, can worsen insulin-induced hypoglycemia. Propranolol does not cause insulin resistance. The incidence of DKA is not increased by concurrent use of propranolol and insulin. Insulin requirements are not increased because of receptor blocking by propranolol.