Advanced Pharmacology Set One

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. b. Frequent use of this drug may lead to a decreased response. c. A hypersensitivity reaction to this drug may occur. d. Systemic steroids are more toxic in children.

ANS: A 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.DIF: Cognitive Level: ApplicationREF: p. 67TOP: Nursing Process: Evaluation MSC

17. A patient newly diagnosed with diabetes is to be discharged from the hospital. Which action should be taken first during medication education? a. Asking the patient to demonstrate how to measure and administer insulin b. Discussing methods of storing insulin and discarding syringes c. Giving information about how diet and exercise affect insulin requirements d. Teaching the patient about the long-term consequences of poor diabetes control

ANS: A Because insulin must be given correctly to control symptoms and because an overdose can be fatal, it is most important for the patient to know how to administer it. Asking for a demonstration of technique is the best way to determine whether the patient has understood the teaching. When a patient is receiving a lot of new information, the information presented first is the most likely to be remembered. The other teaching points are important as well, but they are not as critical and can be taught later.DIF: Cognitive Level: ApplicationREF: p. 11TOP: Nursing Process: Planning MSC: NCLEX Client Needs Category: Physiologic Integrity: Reduction of Risk Potential

42. A patient is taking sertraline [Zoloft] for depression, and the provider orders azithromycin [Zithromax] to treat an infection. What will the nurse do? a. Contact the provider to discuss an alternative to azithromycin. b. Request an order for a different antidepressant medication. c. Request an order to reduce the dose of sertraline. d. Withhold the sertraline while giving the azithromycin

ANS: A Both sertraline and azithromycin prolong the QT interval, and when taken together, they increase the risk of fatal dysrhythmias. Because the antibiotic is used for a short time, it is correct to consider using a different antibiotic. Reducing the dose of sertraline does not alter the combined effects of two drugs that lengthen the QT interval. Sertraline should not be stopped abruptly, so withholding it during antibiotic therapy is not indicated.DIF: Cognitive Level: ApplicationREF: p. 44TOP: Nursing Process: Planning MSC: NCLEX Client Needs Category: Physiologic Integrity: Pharmacologic and Parenteral Therapies

A nurse is teaching a group of nursing students about administering medications to older adult patients. Which statement by a student indicates a need for further teaching? a. "Alteration in hepatic function requires more frequent drug dosing." b. "Changes in GI function in older adult patients lead to lower serum drug levels." c. "Most adverse drug reactions in older adult patients are related to altered renal function." d. "Most nonadherence among older adult patients is intentional."

ANS: A Changes in hepatic function in older adult patients lead to decreased metabolism, meaning that drugs metabolized by the liver have prolonged half-lives and should be given less frequently. Altered GI function does not have much effect in this population, but most known effects from this cause are related to poor absorption and less available drug. Alterations in renal function are the cause of most adverse drug effects in the older adult. In most cases, nonadherence to drug regimens is intentional, usually because the patient does not believe that the drug is needed or that the dose prescribed is not necessary.DIF: Cognitive Level: AnalysisREF: p. 69TOP: Nursing Process: Diagnosis MSC: NCLEX Client Needs Category: Physiologic Integrity: Reduction of Risk Potential

An otherwise healthy child receives a varicella virus vaccine. Three weeks later the parent calls to report that the child has a mild case of chickenpox and wonders how this could happen after the vaccination. What will the nurse tell the parent? a. "A varicella-like rash can occur after the vaccine is given." b. "The vaccine was probably ineffective." c. "This represents a serious vaccine side effect." d. "Give the child aspirin to treat any fever that may occur."

ANS: A Children who receive the varicella vaccine may sometimes develop a mild, local varicella-like rash within a month of receiving the vaccine. This rash does not indicate that the vaccine was ineffective, and it is not a serious side effect. Because of the association with Reye syndrome, children should not take aspirin or other salicylates for 6 weeks after receiving the vaccine.DIF: Cognitive Level: ApplicationREF: p. 591TOP: Nursing Process: Implementation MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

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 dose is proportional for weight and size." b. "Infants metabolize drugs more quickly than do older children and adults." c. "Side effects of drugs in children are similar to side effects of drugs in adults." d. "The known differences in drug effects in children versus those in adults are related to the size of the patient."

ANS: A Drugs have different effects in children for many reasons besides simply the amount of drug per unit of weight. Because two-thirds of drugs used in children have never been tested in children, most of our knowledge of their effects is anecdotal and requires research. Infants metabolize drugs more slowly because of immaturity of organ systems that metabolize drugs. Because of differences in metabolism, absorption, and excretion of drugs in infants and children, side effects of drugs also differ. Again, the differences in drug effects are related to many factors, not just size and relative dose.DIF: Cognitive Level: ApplicationREF: p. 65TOP: Nursing Process: Diagnosis MSC: NCLEX Client Needs Category: Physiologic Integrity: Reduction of Risk Potential

2. Which factors increase the need for APRNs to have full prescriptive authority? a. More patients will have access to health care. b. Enrollment in medical schools is predicted to decrease. c. Physician's assistants are being utilized less often. d. APRN education is more complex than education for physicians.

ANS: A Implementation of the Affordable Care Act has increased the number of individuals with health care coverage, and thus the number who have access to health care services. The increase in the number of patients creates the need for more providers with prescriptive authority. APRNs can fill this practice gap.DIF: Cognitive Level: ComprehensionREF: p. 2TOP: Nursing Process: Implementation MSC: NCLEX Client Needs Category: Physiologic Integrity: Pharmacologic and Parenteral Therapies

A patient presents with delirium tremens requiring Ativan administration. The provider of care is not the facility. Which action by the nurse is the most appropriate? A. Obtain a telephone order. B. Contact the on-call hospitalist. C. Obtain an order from the charge nurse. D. Wait for a written Ativan order.

ANS: A In an emergency situation, such as delirium tremens with seizure activity, it is acceptable to provide a telephone order. Contacting the on-call hospitalist or waiting for a written order would take more time than available for a patient with high seizure risk. Writing an order is outside the scope of practice for the charge nurse.DIF: Cognitive Level: ApplicationREF: p. 7TOP: Nursing Process: Implementation MSC: NCLEX Client Needs Category: Physiologic Integrity: Reduction of Risk Potential

62. 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. b. They require lower doses if they are metabolized by the liver. c. They are less likely to cross the placenta and affect the fetus. d. They are more likely to cause anatomical defects if they are teratogenic.

ANS: A 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, 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.DIF: Cognitive Level: AnalysisREF: p. 60TOP: Nursing Process: Evaluation MSC: NCLEX Client Needs Category: Physiologic Integrity: Reduction of Risk Potential

The parent of a 2-month-old infant who has just received the first dose of DTaP asks the nurse about expected reactions to the vaccine. The nurse will respond by saying that: a. "mild reactions, including a low-grade fever, are common." b. "most children do not experience any reaction." c. "seizures are common and may require anticonvulsant medication." d. "the most common reaction is a rash that develops into itchy vesicles.

ANS: A Mild reactions to the first dose of the DTaP vaccine are common and most often are manifested by a low-grade fever, fretfulness, drowsiness, and local reactions of swelling and redness. At least 50% of children experience reactions. Seizures are not common. Itchy vesicles do not appear with the DTaP vaccine.DIF: Cognitive Level: ApplicationREF: p. 589TOP: Nursing Process: Implementation MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

40. A patient is given a new medication and reports nausea within an hour after taking the drug. The nurse consults the drug information manual and learns that nausea is not an expected adverse effect of this drug. When the next dose is due, what will the nurse do? a. Administer the drug and tell the patient to report further nausea. b. b. Hold the drug and notify the provider of the patient's symptoms. c. Report the symptoms of nausea to the MEDWATCH program. d. Request an order for an antiemetic to counter this drug's effects.

ANS: A Not all adverse drug reactions (ADRs) can be detected during clinical trials, and nurses should be alert to any effects that may result from drug administration. Because nausea is not a serious effect and because it is not yet known whether the drug is the cause of this patient's nausea, the nurse should administer the medication and observe the patient for recurrence of the symptom. It is not necessary to hold the drug, because nausea is not a serious side effect. The MEDWATCH program should be notified when there is a greater suspicion that the drug may have caused the nausea if the nausea occurs with subsequent doses. Until there is greater suspicion that the drug actually caused this patient's nausea, giving an antiemetic is not indicated.DIF: Cognitive Level: ApplicationREF: p. 42TOP: Nursing Process: Evaluation MSC: NCLEX Client Needs Category: Physiologic Integrity: Reduction of Risk Potential

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 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 b. Inability to open drug containers c. Increased tolerance to the drug's effects d. Patient's conviction that the drug is unnecessary

ANS: A 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. A patient unable to open the drug container would not get any medication and would not have a detectable serum drug level. A patient with increased tolerance to a drug's effects would require more of the drug to get effects. A patient convinced that the drug is not needed would probably not fill the prescription.DIF: Cognitive Level: AnalysisREF: p. 72TOP: Nursing Process: Evaluation MSC: NCLEX Client Needs Category: Physiologic Integrity: Reduction of Risk Potential

66. 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." b. "It is safer to recommend that pregnant women avoid medications while pregnant." c. "Most women are reluctant to admit taking medications while they are pregnant." d. "The relatively new MEPREP study will allow testing of medications during pregnancy in the future."

ANS: A 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. 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.DIF: Cognitive Level: AnalysisREF: p. 57TOP: Nursing Process: Evaluation MSC: NCLEX Client Needs Category: Physiologic Integrity: Physiologic Adaptation

18. The drug manual states that older adult patients are at increased risk for hepatic side effects. Which action is most important when prescribing this medication to an 80-year-old patient? a. Obtain pretreatment laboratory work. b. Ensure that the drug is given in the correct dose at the correct time to minimize the risk of adverse effects. c. Discontinue the order; the drug is contraindicated for this patient. d. Give the medication intravenously so that the drug does not pass through the liver.

ANS: A The drug manual indicates that this drug should be given with caution to elderly patients. Getting information about liver function before giving the drug establishes baseline data that can be compared with post-treatment data to determine whether the drug is affecting the liver. Giving the correct dose at the correct interval helps to minimize risk, but without baseline information, the effects cannot be determined. The drug is not contraindicated.DIF: Cognitive Level: AnalysisREF: p. 12TOP: Nursing Process: Implementation MSC: NCLEX Client Needs Category: Physiologic Integrity: Reduction of Risk Potential

A prescriber has ordered medication for a newborn. The medication is eliminated primarily by hepatic metabolism. The nurse expects the prescriber to: a. order a dose that is lower than an adult dose. b. order a dose that is higher than an adult dose. c. increase the frequency of medication dosing. d. discontinue the drug after one or two doses.

ANS: A 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.DIF: Cognitive Level: ApplicationREF: p. 66TOP: Nursing Process: Implementation MSC: NCLEX Client Needs Category: Physiologic Integrity: Reduction of Risk Potential

41. A nurse is preparing to give an antibiotic to a patient who reports being allergic to antibiotics. Before giving the medication, what will the nurse do first? a. Ask whether the patient has taken this antibiotic for other infections b. Question the patient about allergies to other medications c. Request an order for a lower dose of the antibiotic d. Request an order for an antihistamine

ANS: A The nurse needs to assess whether the patient is truly allergic to this drug. Allergic reactions require previous exposure to the drug, so the nurse should ask whether the patient has taken this antibiotic before. If a patient is allergic to a drug, lowering the dose will not decrease the risk of allergic reaction. Antihistamines sometimes are given when patients must take a drug to which they are allergic.DIF: Cognitive Level: ApplicationREF: p. 41TOP: Nursing Process: Assessment MSC: NCLEX Client Needs Category: Physiologic Integrity: Reduction of Risk Potential

A nurse is concerned about renal function in an 84-year-old patient who is taking several medications. What will the nurse assess? a. Creatinine clearance b. Sodium levels c. Potassium levels d. Serum creatinine

ANS: A 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 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.DIF: Cognitive Level: AnalysisREF: p. 70TOP: Nursing Process: Assessment MSC: NCLEX Client Needs Category: Physiologic Integrity: Reduction of Risk Potential

A pediatric nurse 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? a. "This formula helps approximate the first dose; other doses should be based on clinical observations." b. "This formula accounts for pharmacokinetic factors that are different in children." c. "Using this formula will prevent side effects of medications in children." d. "This formula can determine medication dosing for a child of any age."

ANS: A 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.DIF: Cognitive Level: ComprehensionREF: p. 67TOP: Nursing Process: Assessment MSC: NCLEX Client Needs Category: Physiologic Integrity: Reduction of Risk Potential

A clinic nurse receives a phone call from a parent who states that a 2-month-old infant has a severe cough, a low-grade fever, and a runny nose that have lasted over a week. What will the nurse ask the parent? a. Whether the infant has had the first set of vaccines b. Whether the infant received a hepatitis B vaccine as a newborn c. Whether the infant attends day care d. Whether there is a family history of respiratory disorders

ANS: A This infant may have pertussis, for which the primary symptoms are low-grade fever, persistent cough, and runny nose. Infants who have not received the first set of immunizations, including the DTaP vaccine, are especially vulnerable to this disease. The hepatitis B vaccine does not protect against these symptoms. Asking about day care may be important for evaluating exposure, but differentiating between the cough of pertussis and other coughs is best done by determining immunization status. A family history of respiratory disorders may indicate whether the symptoms are related to a chronic lung disease, but these do not usually manifest at 2 months of age.DIF: Cognitive Level: ApplicationREF: p. 584TOP: Nursing Process: Assessment MSC: NCLEX Client Needs Category: Physiologic Integrity: Health Promotion and Maintenance

6. A family nurse practitioner practicing in Maine is hired at a practice across state lines in Virginia. Which aspect of practice may change for the APRN? A. The APRN will have less prescriptive authority in the new position. B. The APRN will have more prescriptive authority in the new position. C. The APRN will have equal prescriptive authority in the new position. D. The APRN's authority will depend on federal regulations.

ANS: A Virginia allows limited prescriptive authority, while Maine gives full authority to certified nurse practitioners. The federal government does not regulate prescriptive authority.DIF: Cognitive Level: ComprehensionREF: p. 3TOP: Nursing Process: Implementation MSC: NCLEX Client Needs Category: Physiologic Integrity: Pharmacologic and Parenteral Therapies

59. 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? a. Ask the patient what she took and when she learned she was pregnant. b. Contact the patient's provider to request an ultrasound. c. Counsel the patient to consider termination of the pregnancy. d. Suggest to the patient that she go to a high-risk pregnancy center.

ANS: A When a pregnant patient is exposed to a known or potential teratogen, the first step is to find out when the drug was taken and when the pregnancy began to determine whether the drug was taken during the period of organogenesis, when the fetus is most vulnerable to teratogenic effects. If exposure occurred during this phase, the provider may order an ultrasound. Counseling the patient to terminate a pregnancy is not a nursing role. Until more is known about this patient's fetus, it is not necessary to refer her to another pregnancy center.DIF: Cognitive Level: ApplicationREF: p. 58TOP: Nursing Process: Evaluation MSC: NCLEX Client Needs Category: Physiologic Integrity: Physiologic Adaptation

Rosenthal: Lehne's Pharmacotherapeutics for Advanced Practice Providers, 1st Ed. Chapter 3: Promoting Positive Outcomes of Drug 14. A patient reports that a medication prescribed for recurrent migraine headaches is not working. Which action should be taken first? a. Ask the patient about the number and frequency of tablets taken. b. Assess the patient's headache pain on a scale from 1 to 10. c. Report the patient's complaint to the prescriber. d. Suggest biofeedback as an adjunct to drug therapy.

ANS: A When evaluating the effectiveness of a drug, it is important to determine whether the patient is using the drug as ordered. Asking the patient to tell the nurse how many tablets are taken and how often helps the nurse determine compliance. Assessing current pain does not yield information about how well the medication is working unless the patient is currently taking it. The nurse should gather as much information about compliance, symptoms, and drug effectiveness as possible before contacting the prescriber. Biofeedback may be an effective adjunct to treatment, but it should not be recommended without complete information about drug effectiveness.DIF: Cognitive Level: ApplicationREF: pp. 15-16TOP: Nursing Process: Evaluation MSC: NCLEX Client Needs Category: Physiologic Integrity: Pharmacologic and Parenteral Therapies

Rosenthal: Lehne's Pharmacotherapeutics for Advanced Practice Providers, 1st Ed. Chapter 6: Individual Variation in Drug Responses 48. A nurse is caring for a woman with breast cancer who is receiving tamoxifen. A review of this patient's chart reveals a deficiency of the CYP2D6 gene. The nurse will contact the provider to suggest: a. a different medication. b. an increased dose. c. a reduced dose. d. serum drug levels.

ANS: A Women with a deficiency of the CYP2D6 gene lack the ability to convert tamoxifen to its active form, endoxifen, and will not benefit from this drug. Another drug should be used to treat this patient's breast cancer. Increasing the dose, reducing the dose, or monitoring serum drug levels will not make this drug more effective in these women.DIF: Cognitive Level: ApplicationREF: p. 53TOP: Nursing Process: Planning MSC: NCLEX Client Needs Category: Physiologic Integrity: Reduction of Risk Potential

Which factors could be attributed to limited prescriptive authority for APRNs? Select all that apply. www.testbanktank.com A. Inaccessibility of patient care B. Higher health care costs C . Higher quality medical treatment D. Improved collaborative care E. Enhanced health literacy

ANS: A,B Limiting prescriptive authority for APRNs can create barriers to quality, affordable, and accessible patient care. It may also lead to poor collaboration among providers and higher health care costs. It would not directly impact patient's health literacy.DIF: Cognitive Level: ComprehensionREF: p. 2TOP: Nursing Process: Implementation MSC: NCLEX Client Needs Category: Physiologic Integrity: Pharmacologic and Parenteral Therapies

19. A patient recently diagnosed with HIV is prescribed several medications to treat the condition. Which factors could impact the patient's adherence to the treatment regimen?Select all that apply. a. The patient is uninsured b. The patient works three part-time jobs c. The medication regimen includes six different pills d. Patient has an eighth-grade reading comprehension level e. Medication regimen requires medication be taken at regular 4-hour intervals.

ANS: A,B,C,E Lack of insurance coverage can inhibit the patient from purchasing the medications, limiting his access to treatment. Having three part-time jobs indicates that the patient has a busy schedule, which contributes to forgetfulness and poor adherence. The more complex the medication regimen, the more difficult it is to maintain patient adherence. Although a patient with an eighth-grade reading comprehension level may have difficulty understanding professional medical language, medication teaching can be adjusted to meet the patient's learning needs.DIF: Cognitive Level: ComprehensionREF: pp. 13-14TOP: Nursing Process: Evaluation MSC: NCLEX Client Needs Category: Physiologic Integrity: Reduction of Risk Potential

13. A patient recently prescribed hydrocodone calls to report they are unable to fill the prescription. Which factors could contribute to the inability to fill the prescription?Select all that apply. a. DEA number missing from prescription B. Prescription sent via electronic messenger C. Dose higher than typically prescribed D. Prescriber license number not included E. Patient name and date of birth were handwritten

ANS: A,B,D In order to fill a hydrocodone prescription, the prescriber name, license number, DEA number, and contact information must be included. Schedule II medications, such as narcotics, must be prescribed using written prescriptions. Though the pharmacist may question the high dosing, that would not prevent filling the prescription. The patient's name and date of birth must be included on the prescription, but there are no regulations that the name cannot be handwritten.DIF: Cognitive Level: ComprehensionREF: pp. 6-8TOP: Nursing Process: Diagnosis MSC: NCLEX Client Needs Category: Physiologic Integrity: Reduction of Risk Potential.

33.The nurse is administering morning medications. The nurse gives a patient multiple medications, two of which compete for plasma albumin receptor sites. As a result of this concurrent administration, the nurse can anticipate that what might occur?Select all that apply. a. Binding of one or both agents will be reduced. b. Plasma levels of free drug will rise. c. Plasma levels of free drug will fall. d. The increase in free drug will intensify effects. e. The increase in bound drug will intensify effects

ANS: A,B,D When two drugs bind to the same site on plasma albumin, co administration of those drugs produces competition for binding. As a result, binding of one or both agents is reduced, causing plasma levels of free drug to rise. The increase in free drug can intensify the effect, but it usually undergoes rapid elimination. The increase in plasma levels of free drug is rarely sustained.DIF: Cognitive Level: AnalysisREF: p. 36TOP: Nursing Process: Diagnosis MSC: NCLEX Client Needs Category: Physiologic Integrity: Pharmacologic and Parenteral Therapies

49. Which groups of people are especially sensitive to medication effects? Select all that apply. a. Older adults b. Caucasians c. Infants d. Minorities e. Women

ANS: A,C Older adults and infants are the two groups most sensitive to drugs because of differences in organs that absorb, metabolize, and excrete drugs. In the older adult, organ degeneration accounts for these differences, whereas in infants the differences are related to organ immaturity. Racial and gender differences tend to be related to genetic differences and not race and gender per se. These groups are more sensitive to drug effects in some cases and less sensitive in other cases.DIF: Cognitive Level: ComprehensionREF: p. 51TOP: Nursing Process: Diagnosis MSC: NCLEX Client Needs Category: Physiologic Integrity: Pharmacologic and Parenteral Therapies

4. Which aspects support the APRN's provision for full prescriptive authority? Select all that apply. A. Clinical education includes prescription of medications and disease processes. B. Federal regulations support the provision of full authority for APRNs. C. National examinations provide validation of the APRN's ability to provide safe care. D. Licensure ensures compliance with health care and safety standards. E. Limiting provision can decrease health care affordability.

ANS: A,C,D APRNs are educated to practice and prescribe independently without supervision. National examinations validate the ability to provide safe and competent care. Licensure ensures compliance with standards to promote public health and safety. Limited prescriptive authority creates numerous barriers to quality, affordable, and accessible patient care.DIF: Cognitive Level: ComprehensionREF: pp. 1-2TOP: Nursing Process: Implementation MSC:

A thin older adult woman 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? Select all that apply. a. Creatinine clearance b. Gastric pH c. Plasma drug levels d. Serum albumin e. Serum creatinine

ANS: A,C,D 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 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 do not reflect renal function.DIF: Cognitive Level: ApplicationREF: pp. 69-70TOP: Nursing Process: Assessment MSC: NCLEX Client Needs Category: Physiologic Integrity: Reduction of Risk Potential

37. Which patients are at increased risk for adverse drug events? Select all that apply. a. A 2-month-old infant taking a medication for gastroesophageal reflux disease b. A 23-year-old female taking an antibiotic for the first time c. A 40-year-old male who is intubated in the intensive care unit and taking antibiotics and cardiac medications d. A 7-year-old female receiving insulin for diabetes e. An 80-year-old male taking medications for COPD

ANS: A,C,E Patients at increased risk for adverse drug events include the very young, the very old, and those who have serious illnesses. Females, children, and young adults taking single medications do not have increased risk for adverse events.DIF: Cognitive Level: AnalysisREF: "pp. 42,46"TOP: Nursing Process: Assessment MSC: NCLEX Client Needs Category: Physiologic Integrity: Reduction of Risk Potential

44. Which are effective ways to help prevent medication errors? Select all that apply. a. Developing non-punitive approaches to track errors b. Focusing on caregivers who make errors c. Helping patients to be active, informed members of the healthcare team d. Naming, blaming, and shaming those who make errors e. Using electronic medical order entry systems

ANS: A,C,E To help prevent medication errors, it is important to create an environment for tracking errors that is non-punitive so that caregivers can learn from mistakes and work together to change systems appropriately. Helping patients be active, informed members of the healthcare team is a useful tool in this process. Using electronic order entry helps eliminate confusion from poor handwriting and allows built-in systems to warn caregivers about possible overdoses, side effects, and drug interactions; it also helps ensure the right dose at the right time to the right patient. An approach that focuses on those who make mistakes by naming, blaming, and shaming is not productive and often results in personnel who cover up mistakes instead of working to make things better.DIF: Cognitive Level: AnalysisREF: pp. 46-47TOP: Nursing Process: Assessment MSC: NCLEX Client Needs Category: Physiologic Integrity: Pharmacologic and Parenteral Therapies

36. A nurse is preparing to administer a drug. Upon reading the medication guide, the nurse notes that the drug has been linked to symptoms of Parkinson disease in some patients. What will the nurse do? a. Ask the patient to report these symptoms, which are known to be teratogenic effects. b. Observe the patient closely for such symptoms and prepare to treat them if needed. c. Request an order to evaluate the patient's genetic predisposition to this effect. d. Warn the patient about these effects and provide reassurance that this is expected.

ANS: B A drug that causes disease-like symptoms is known to be iatrogenic. Nurses should be prepared for this possibility and be prepared to withdraw the drug if necessary and treat the symptoms. Such effects are not teratogenic, since teratogenic effects affect the fetus. Patients with a genetic predisposition to respond differently to drugs are known to have idiosyncratic effects. Iatrogenic effects, even when known, are not typically expected side effects.DIF: Cognitive Level: ApplicationREF: pp. 41-42TOP: Nursing Process: Diagnosis MSC: NCLEX Client Needs Category: Physiologic Integrity: Pharmacologic and Parenteral Therapies

60. 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? a. That asthma medications will not affect the fetus b. That her baby's health is dependent on hers c. To avoid taking medications during her pregnancy d. To resume the medication in her second trimester

ANS: B Asthmatic women who fail to take medication have a doubled risk of stillbirth; therefore, the nurse should encourage the patient to use her medications. Because the health of the fetus depends on the health of the mother, all drugs must be considered in light of the benefits of treatment versus the risks to the fetus. Asthma medications may have effects on the fetus, but the risk of stillbirth presents a greater risk. In this case, the patient needs to take the medication to treat her asthma and not wait until the second trimester.DIF: Cognitive Level: ApplicationREF: p. 61TOP: Nursing Process: Implementation MSC: NCLEX Client Needs Category: Physiologic Integrity: Physiologic Adaptation

Chapter 9: Drug Therapy in Geriatric Patients 12. 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? a. Acetaminophen [Tylenol] and oxycodone b. Amitriptyline [Elavil] and diphenhydramine [Benadryl] c. Fexofenadine [Allegra] and an over-the-counter laxative d. Zolpidem [Ambien] and sertraline [Zoloft]

ANS: B 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.DIF: Cognitive Level: ApplicationREF: p. 71TOP: Nursing Process: Diagnosis MSC: NCLEX Client Needs Category: Physiologic Integrity: Physiologic Adaptation

A 41⁄2-year-old child who has been receiving high-dose systemic glucocorticoids for several months comes to a clinic for school immunizations, which usually include the DTaP vaccine; varicella virus vaccine [Varivax]; the measles, mumps, and rubella virus (MMR) vaccine; and the inactivated poliovirus vaccine (IPV). The clinic nurse will expect to administer which vaccines to this child? a. All four school immunizations b. DTaP and IPV only c. DTaP, OPV, and Varivax only d. DTaP and IPV, along with immunoglobulins

ANS: B Children who are immunocompromised should not receive live virus vaccines, including the MMR vaccine and Varivax. Children taking high-dose systemic glucocorticoids are immunocompromised and should not receive the vaccine until therapy is stopped and normal glucocorticoid production returns. The oral polio vaccine (OPV) contains live virus and is contraindicated. Immunoglobulins are not indicated unless children are exposed to the diseases themselves.DIF: Cognitive Level: ApplicationREF: p. 582TOP: Nursing Process: Planning MSC: NCLEX Client Needs Category: Physiologic Integrity: Reduction of Risk Potential

An infant has allergies and often develops a pruritic rash when exposed to allergens. The infant's parents ask the nurse about using a topical antihistamine. What should the nurse tell them? a. Antihistamines given by this route are not absorbed as well in children. b. Applying an antihistamine to the skin can cause toxicity in this age group. c. The child will also need oral medication to achieve effective results. d. Topical medications have fewer side effects than those given by other routes.

ANS: B 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.DIF: Cognitive Level: ApplicationREF: p. 66TOP: Nursing Process: Planning MSC: NCLEX Client Needs Category: Physiologic Integrity: Reduction of Risk Potential

25. A nurse is teaching a patient about a drug that induces P-glycoprotein. The nurse will explain that this drug may cause which effect on other drugs? a. Decreased absorption in the intestines b. Decreased elimination through the kidneys c. Increased brain exposure d. Increased fetal absorption

ANS: B Drugs that induce PGP can increase drug export from cells of the intestinal epithelium into the intestinal lumen, thus decreasing absorption of the drug. PGP inducers also increase drug elimination and decrease brain and fetal drug exposure.DIF: Cognitive Level: AnalysisREF: p. 36TOP: Nursing Process: Assessment MSC: NCLEX Client Needs Category: Physiologic Integrity: Pharmacologic and Parenteral Therapies

67. 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? a. Immediately before conception b. During the first trimester c. During the second trimester d. During the third trimester

ANS: B 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 unless the medication is a category X drug. Teratogen exposure during the second and third trimesters usually disrupts function rather than gross anatomy.DIF: Cognitive Level: ComprehensionREF: p. 61TOP: Nursing Process: Implementation MSC: NCLEX Client Needs Category: Physiologic Integrity: Reduction of Risk Potential

63. 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? a. Before she became pregnant b. During the first trimester c. During the second trimester d. During the third trimester

ANS: B Gross malformations typically are the result of teratogens consumed during the first trimester. Using teratogenic drugs before becoming pregnant is a risk because 50% of pregnancies are unintended, and a patient could become pregnant while taking the drug. Exposure to teratogens during the second or third trimester usually alters function, not gross anatomy.DIF: Cognitive Level: ApplicationREF: p. 58TOP: Nursing Process: Implementation MSC: NCLEX Client Needs Category: Physiologic Integrity: Physiologic Adaptation

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? a. Ask the patient if she has difficulty swallowing pills. b. Count the pills in the prescription bottle. c. Notify the provider to request more frequent dosing. d. Request an order for renal function tests.

ANS: B Intentional non-adherence is common and may occur because older adult patients are not convinced that drugs are needed or that the dose prescribed is correct. Counting the pills would be an appropriate first step as the nurse determines the cause of the low serum drug level, because it provides information about adherence. If the pill count is correct and the patient has taken the drug as prescribed, other causes may have to be investigated. If it is clear that the patient has not been taking enough of the medication, asking about her ability to swallow may be a good follow-up question. The last two options would be steps to discuss with the provider if the patient is taking the medication as prescribed.DIF: Cognitive Level: ApplicationREF: p. 72TOP: Nursing Process: Evaluation MSC: NCLEX Client Needs Category: Physiologic Integrity: Reduction of Risk Potential

64. 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? a. Administer opioids to the infant to prevent withdrawal syndrome. b. Monitor the infant's respirations and prepare to administer naloxone if needed. c. Note a high-pitched cry and irritability in the infant and observe for seizures. d. Prepare the patient for motor delays in the infant caused by the alcohol use.

ANS: B Narcotics given for pain during labor cross the placenta and can cause respiratory depression in the infant. Nurses must be prepared to provide respiratory support and to give naloxone to reverse the narcotic effects if necessary. Exposure to opioids during labor is not sufficient to cause dependence, so withdrawal syndrome is not an issue. Infants withdrawing from drugs have a high- pitched cry and are irritable, which is not expected in this case. Any drug taken during the first weeks of pregnancy tends to have an "all or none" effect, meaning that it either causes death of the conceptus or, if sublethal, the conceptus recovers.DIF: Cognitive Level: ApplicationREF: p. 58TOP: Nursing Process: Implementation MSC: NCLEX Client Needs Category: Physiologic Integrity: Physiologic Adaptation

57. The U.S. Food and Drug Administration (FDA) recommends genetic testing of patients receiving certain medications. Genetic testing helps prescribers: a. better establish a drug's therapeutic index. b. determine whether a patient is a rapid or slow metabolizer of the drug. c. identify racial characteristics that affect psychosocial variation in drug response. d. produce a drug that is tailored to an individual patient's genetic makeup.

ANS: B Pharmacogenomics is the study of the ways genetic variations affect individual responses to drugs through alterations in genes that code for drug-metabolizing enzymes and drug receptors. For some drugs, the FDA requires genetic testing, and for others, this testing is recommended but not required. Genetic testing does not determine a drug's therapeutic index; this is a measure of a drug's safety based on statistics of the drug's use in the general population (see Chapter 5). Any distinct physiologic differences in drug response among various racial populations are related to genetic differences and do not affect psychosocial differences in drug responses. Genetic testing is recommended to identify how a patient will respond to a drug and not to design a drug specific to an individual.DIF: Cognitive Level: AnalysisREF: pp. 53-54TOP: Nursing Process: Assessment MSC: NCLEX Client Needs Category: Physiologic Integrity: Reduction of Risk Potential

11. A patient taking three medications for hypertension is diagnosed with COPD. Which action should be taken prior to prescribing medications to treat COPD? A. Obtain baseline laboratory values. B. Obtain a complete medication history. C. Assess liver enzyme levels. D. Determine if patient has insurance coverage.

ANS: B Prior to adding medications to the treatment regimen, it is essential to assess for any potential drug- drug interactions through a complete medical history. Baseline laboratory values are not necessary for COPD treatment. Liver enzyme levels may give insight into the possibility of altered metabolism but would not be the first action. The presence of insurance coverage would affect the patient's access to treatment but may not affect the type of medication prescribed.DIF: Cognitive Level: ApplicationREF: p. 6TOP: Nursing Process: Implementation MSC: NCLEX Client Needs Category: Physiologic Integrity: Reduction of Risk Potential

9. A patient with chronic pain calls the provider's office to request a refill on their oxycontin. Which action is most appropriate? A. Fax an order to the pharmacy. B. Schedule an appointment with the patient. C. Verify the patient's adherence to drug regimen. D. Determine the patient's current medication dosage.

ANS: B Schedule II medications are not eligible for refills, and prescriptions must be handwritten. It is important to verify the patient's adherence to the drug regimen and determine the current dosage of medication; however, this can be accomplished by scheduling an appointment and evaluating the patient in person.DIF: Cognitive Level: ApplicationREF: p. 8TOP: Nursing Process: Implementation MSC: NCLEX Client Needs Category: Physiologic Integrity: Reduction of Risk Potential

65. 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? a. Give the baby formula as long as the mother is taking the medication b. Take the medication immediately after breastfeeding c. Pump breast milk and feed the baby by bottle d. Take the medication 1 hour before breastfeeding

ANS: B 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.DIF: Cognitive Level: ApplicationREF: p. 63TOP: Nursing Process: Implementation MSC: NCLEX Client Needs Category: Physiologic Integrity: Reduction of Risk Potential

Rosenthal: Lehne's Pharmacotherapeutics for Advanced Practice Providers, 1st Ed. Chapter 1: Prescriptive Authority 1. An APRN works in a urology clinic under the supervision of a physician who does not restrict the types of medications the APRN is allowed to prescribe. State law does not require the APRN to practice under physician supervision. How would the APRN's prescriptive authority be described? A Full authority B Independent C Without limitation D Limited authority

ANS: B The APRN has independent prescriptive authority because the regulating body does not require that the APRN work under physician supervision. Full prescriptive authority gives the provider the right to prescribe independently and without limitation. Limited authority places restrictions on the types of drugs that can be prescribed.DIF: Cognitive Level: ComprehensionREF: p. 1TOP: Nursing Process: I MSC: NCLEX Client Needs Category: Physiologic Integrity: Pharmacologic and Parenteral Therapies

29. What occurs when a drug binds to a receptor in the body? a. It alters the receptor to become nonresponsive to its usual endogenous molecules. b. It increases or decreases the activity of that receptor. c. It gives the receptor a new function. d. It prevents the action of the receptor by altering its response to chemical mediators.

ANS: B When a drug binds to a receptor, it mimics or blocks the actions of the usual endogenous regulatory molecules, either increasing or decreasing the rate of the physiologic activity normally controlled by that receptor. It does not alter the activity of the receptor and does not give the receptor a new function.DIF: Cognitive Level: AnalysisREF: p. 29TOP: Nursing Process: Assessment MSC: NCLEX Client Needs Category: Physiologic Integrity: Pharmacologic and Parenteral Therapies

Chapter 53: Childhood Immunization "The nurse at a public health infant immunization clinic is acting as a preceptor for a nursing student. To assess the student's understanding of vaccinations, the nurse asks the student where the hepatitis B vaccine (HepB) should be administered. The student would be correct to respond that the hepatitis B vaccine should be administered in the: a. dorsogluteal muscle in an adult. b. anterolateral thigh in infants. c. ventrogluteal muscle in adolescents. d. deltoid of toddlers.

ANS: B The HepB vaccine should be administered in the anterolateral thigh in infants and children. The vaccine should be administered in the deltoid of adults and adolescents. The vaccine should not be administered in the deltoid of toddlers, because they have little muscle in that location.DIF: Cognitive Level: ApplicationREF: p. 587TOP: Nursing Process: Implementation MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

A 3-year-old child who has asthma is in the clinic for a well-child checkup. The nurse notes that the child is up to date for the DTaP, hepatitis A, hepatitis B, and the MMR vaccines but has only had one each of the Hib, the rotavirus, and the PCV13 vaccines. Which vaccine(s) will the nurse anticipate administering to this child? a. Hib and rotavirus vaccines b. PCV13 c. PCV13 and Hib d. Rotavirus

ANS: B The PCV13 should be given to all children under the age of 2 years and to all healthy children between ages 2 and 5 years, especially those who have conditions such as chronic lung disease that put them at high risk of serious pneumococcal disease. The Hib vaccine is only given up to age 15 months. The rotavirus vaccine is not given after 32 weeks of age.DIF: Cognitive Level: AnalysisREF: p. 592TOP: Nursing Process: Implementation MSC: NCLEX Client Needs Category: Physiologic Integrity: Pharmacologic and Parenteral Therapies

Chapter 8: Drug Therapy in Pediatric Patients 1. A nurse is caring for an infant after a surgical procedure. After ensuring that the ordered dose is appropriate for the infant's age and weight, the nurse administers a narcotic analgesic intravenously. When assessing the infant 15 minutes later, the nurse notes respirations of 22 breaths/minute and a heart rate of 110 beats/minute. 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: a. an allergic reaction to the medication. b. immaturity of the blood-brain barrier in the infant. c. toxic effects of the narcotic, requiring naloxone as an antidote. d. unexpected side effects of medications in infants.

ANS: B The blood-brain barrier is not as well developed in infants, making them more susceptible to CNS effects of medications. This assessment of the patient reveals no signs of an allergic reaction. Although this infant is somnolent, the vital signs are stable, so toxicity is not a concern. CNS effects are not unexpected with narcotic analgesics, but they may be more pronounced in infants.DIF: Cognitive Level: ApplicationREF: p. 65TOP: Nursing Process: Evaluation MSC: NCLEX Client Needs Category: Physiologic Integrity: Pharmacologic and Parenteral Therapies

50. A post-operative patient who is worried about pain control will be discharged several days after surgery. The nurse providing discharge teaching tells the patient that the prescribed Lortab is not as strong as the morphine the patient was given in the immediate post-operative period. Which response is the patient likely to experience? a. A decreased likelihood of filling the prescription for the drug b. A negative placebo effect when taking the medication c. An increased compliance with the drug regimen d. Optimistic, realistic expectations about the drug

ANS: B The full extent of placebo effects, if they truly occur, is not well documented or understood, although a decrease in pain as a placebo effect has been demonstrated to some extent. To foster a beneficial placebo effect, it is important for all members of the healthcare team to present an optimistic and realistic assessment of the effects of the drug the patient is taking. If the nurse tells an anxious patient that the medication being given is not as strong as what has been given, the patient is likely to have lowered expectations of the effectiveness of the drug, causing a negative placebo effect. Lowered expectations do not mean that the patient will give up on the drug entirely; in fact, the patient may actually fill the prescription and then take more drug than what is prescribed to get a better effect.DIF: Cognitive Level: ApplicationREF: p. 52TOP: Nursing Process: Planning MSC: NCLEX Client Needs Category: Physiologic Integrity: Pharmacologic and Parenteral Therapies

Based on changes in hepatic function in older adult patients, which adjustment should the nurse expect for oral medications that undergo extensive first pass metabolism? a. A higher dose should be used with the same time schedule. b. The interval between doses should be increased. c. No change is necessary; metabolism will not be affected. d. The interval between doses should be reduced.

ANS: B The interval between doses of the medication should be increased in older adult patients, because drugs that undergo the first pass effect may not be broken down as well as in an individual with full liver function. A higher dose of the medication is not indicated, because toxic effects could occur. A change in administration may be indicated in older adults, because their metabolism is affected. The interval between doses should not be reduced but increased.DIF: Cognitive Level: ApplicationREF: p. 69TOP: Nursing Process: Planning MSC: NCLEX Client Needs Category: Physiologic Integrity: Reduction of Risk Potential

10. A patient prescribed amoxicillin for streptococcal pharyngitis reports new onset of a flat, itchy red rash on the chest and neck. Which action is most important? A. Provide a different prescription. B. Discontinue the medication. C. Prescribe an antihistamine cream. D. Assess for respiratory compromise.

ANS: B The priority action is to discontinue the medication to prevent worsening of the patient's symptoms. A different prescription would be provided, topical antihistamine may be administered, and the patient would be assessed for respiratory involvement, but these actions would not be performed first.DIF: Cognitive Level: ApplicationREF: p. 6TOP: Nursing Process: Implementation MSC: NCLEX Client Needs Category: Physiologic Integrity: Reduction of Risk Potential

56. A nurse is teaching a group of women about medications. The women want to know why so many drugs have unpredictable effects in women. The nurse will tell them that: a. drugs usually have more toxic effects in women. b. most known drug effects are based on drug trials in men. c. women have varying responses to drugs during menstrual cycles. d. women metabolize drugs more slowly.

ANS: B Until 1997 almost all clinical drug trials were performed in men. Women may have more toxic effects with some drugs and fewer toxic effects with others. Not all drugs are influenced by hormonal changes. Women metabolize some drugs more slowly and other drugs more quickly. Unless drug trials are performed in both women and men, the effects of drugs in women will not be clear.DIF: Cognitive Level: ApplicationREF: p. 55TOP: Nursing Process: Implementation MSC: NCLEX Client Needs Category: Physiologic Integrity: Pharmacologic and Parenteral Therapies

34. When administering medications to infants, it is important to remember which of the following? Select all that apply. a. Breast-feeding infants are more likely to develop toxicity when given lipid-soluble drugs. b. Immaturity of renal function in infancy causes infants to excrete drugs less efficiently. c. Infants have immature livers, which slows drug metabolism. d. Infants are more sensitive to medications that act on the central nervous system (CNS). e. Oral medications are contraindicated in infants, because PO administration requires a cooperative patient.

ANS: B,C,D Immature renal function causes infants to excrete drugs more slowly, and infants are at risk for toxicity until renal function is well developed. Infants' livers are not completely developed, and they are less able to metabolize drugs efficiently. Because the blood-brain barrier is not well developed in infants, caution must be used when administering CNS drugs. Lipid-soluble drugs may be excreted in breast milk if the mother is taking them, but breastfeeding does not affect medications given directly to the infant. Oral medications may be given safely to infants as long as they are awake and can swallow the drug.DIF: Cognitive Level: ComprehensionREF: "pp. 20,22,24"TOP: Nursing Process: Assessment MSC: NCLEX Client Needs Category: Physiologic Integrity: Reduction of Risk Potential

Rosenthal: Lehne's Pharmacotherapeutics for Advanced Practice Providers, 1st Ed. Chapter 2: Rational Drug Selection 7. How can collaboration with a pharmacist improve positive outcomes for patients? Select all that apply. A. Pharmacists can suggest foods that will help with the patient's condition. B. Pharmacists have additional information on drug interactions. C. The pharmacist can suggest adequate medication dosing. D. Pharmacists have firsthand knowledge of the facility formulary. E. Pharmacy can alter prescriptions when necessary to prevent patient harm.

ANS: B,C,D Providers should collaborate with pharmacists because they will likely have additional information on formulary, drug interactions, and suggestions for adequate medication dosing. Dietitians can make foods recommendations to treat the patient's condition. The pharmacist can contact the prescriber about questionable prescriptions, but cannot alter the prescription without notification of and approval by the provider.DIF: Cognitive Level: ComprehensionREF: p. 9TOP: Nursing Process: Diagnosis MSC: NCLEX Client Needs Category: Physiologic Integrity: Reduction of Risk Potential

27. Two nurses are discussing theories of drug-receptor interaction. Which statements are true regarding the affinity of a drug and its receptor?Select all that apply. a. Affinity and intrinsic activity are dependent properties. b. Affinity refers to the strength of the attraction between a drug and its receptor. c. Drugs with high affinity are strongly attracted to their receptors. d. Drugs with low affinity are strongly attracted to their receptors. e. The affinity of a drug for its receptors is reflected in its potency.

ANS: B,C,E Affinity refers to the strength of the attraction between a drug and its receptor. Drugs with high affinity are strongly attracted to their receptors, and the affinity of a drug and its receptors is reflected in its potency. Affinity and intrinsic activity are independent properties. Drugs with low affinity are weakly attracted to their receptors.DIF: Cognitive Level: ComprehensionREF: pp. 30- 31TOP: Nursing Process: Diagnosis MSC: NCLEX Client Needs Category: Physiologic Integrity: Pharmacologic and Parenteral Therapies

47. Which actions occur in 90% of fatal medication errors? Select all that apply. a. Confusing drugs with similar packaging b. Giving a drug intravenously instead of intramuscularly c. Giving Nasarel instead of Nizoral d. Using an infusion device that malfunctions e. Writing a prescription illegibly

ANS: B,C,E Ninety percent of fatal medication errors fall into three categories: human factors, communication mistakes, and name confusion. Giving a drug IV (intravenously) instead of IM (intramuscularly) is an example of a human factor; writing a prescription so that it is illegible is an example of a communication mistake; and giving a drug with a name that sounds like the name of another drug is an example of name confusion. Confusion of drugs with similar packaging and using a faulty device also can cause fatal drug errors, but these factors do not fall into the categories that account for 90% of fatal errors.DIF: Cognitive Level: AnalysisREF: pp. 45-46TOP: Nursing Process: Assessment MSC: NCLEX Client Needs Category: Physiologic Integrity: Pharmacologic and Parenternal Therapies.

28. A patient receives a drug that has a narrow therapeutic range. The nurse administering this medication will expect to do what? a. Administer the drug at intervals longer than the drug half-life. b. Administer this medication intravenously. c. Monitor plasma drug levels. d. Teach the patient that maximum drug effects will occur within a short period.

ANS: C A drug with a narrow therapeutic range is more difficult to administer safely, because the difference between the minimum effective concentration and the toxic concentration is small. Patients taking these medications must have their plasma drug levels monitored closely to ensure that they are getting an effective dose that is not toxic. Administering medications at longer intervals only increases the time required to reach effective plasma drug levels. Drugs that have a narrow therapeutic range may be given by any route and do not differ from other medications in the amount of time it takes for them to take effect, which is a function of a drug's half-life and dosing frequency.DIF: Cognitive Level: ApplicationREF: p. 25TOP: Nursing Process: Evaluation MSC: NCLEX Client Needs Category: Physiologic Integrity: Reduction of Risk Potential

22. A patient is taking drug X and receives a new prescription for drug Y, which is listed as an inducing agent. The nurse caring for this patient understands that this patient may require __ doses of drug __. a. lower; X b. lower; Y c. higher; X d. higher; Y

ANS: C An inducing agent stimulates the synthesis of CYP isoenzymes, which may increase the metabolism of other drugs as much as two- to threefold, thereby lowering the level of those drugs in the body and requiring higher doses to maintain drug effectiveness.DIF: Cognitive Level: ApplicationREF: p. 36TOP: Nursing Process: Planning MSC: NCLEX Client Needs Category: Physiologic Integrity: Pharmacologic and Parenteral Therapies

16. A patient is using a metered-dose inhaler containing albuterol for asthma. The medication label instructs the patient to administer "two puffs every 4 hours as needed for coughing or wheezing." The patient reports feeling jittery sometimes when taking the medication, and she doesn't feel that the medication is always effective. Which action is most appropriate? a. Asking the patient to demonstrate use of the inhaler b. Assessing the patient's exposure to tobacco smoke c. Auscultating lung sounds and obtaining vital signs d. Suggesting that the patient use one puff to reduce side effects

ANS: C Asking the patient to demonstrate inhaler use helps to evaluate the patient's ability to administer the medication properly and is part of the nurse's evaluation, but is not a priority intervention based on the patient's current report. Assessing tobacco smoke exposure helps the nurse determine whether nondrug therapies, such as smoke avoidance, can be used as an adjunct to drug therapy, but does not relate to the patient's current problem. Performing a physical assessment helps the nurse evaluate the patient's response to the medication and identify the presence of other side effects.DIF: Cognitive Level: ApplicationREF: p. 13TOP: Nursing Process: Implementation MSC: NCLEX Client Needs Category: Physiologic Integrity: Pharmacologic and Parenteral Therapies

Rosenthal: Lehne's Pharmacotherapeutics for Advanced Practice Providers, 1st Ed. Chapter 5: Adverse Drug Reactions and Medication Errors 35. A nursing student is preparing to give a medication that has a boxed warning. The student asks the nurse what this means. What will the nurse explain about boxed warnings? a. They indicate that a drug should not be given except in life-threatening circumstances. b. They provide detailed information about the adverse effects of the drug. c. They alert prescribers to measures to mitigate potential harm from side effects. d. They provide information about antidotes in the event that toxicity occurs.

ANS: C Boxed warnings (also known as black box warnings) are used to alert providers to potential side effects and to ways to prevent or reduce harm from these side effects. A boxed warning is placed on any drug that, although useful, has serious side effects; this is a way to keep drugs on the market while protecting patients. Many of these drugs are used in situations that are not life-threatening. The boxed warning provides a concise summary and not a detailed explanation of drug side effects. The boxed warning does not include antidotes to toxicity.DIF: Cognitive Level: AnalysisREF: p. 45TOP: Nursing Process: Implementation MSC: NCLEX Client Needs Category: Physiologic Integrity: Reduction of Risk Potential

46. A patient is being discharged after surgery. During the admission history, the nurse learned that the patient normally consumes two or three glasses of wine each day. The prescriber has ordered hydrocodone with acetaminophen [Lortab] for pain. What will the nurse do? a. Request an order for acetaminophen without hydrocodone for pain. b. Suggest that the patient use ibuprofen for pain. c. Tell the patient not to drink wine while taking Lortab. d. Tell the patient to limit wine intake to one or two glasses per day.

ANS: C Combining a hepatotoxic drug with certain other drugs may increase the risk of hepatotoxicity. When even therapeutic doses of acetaminophen are taken with alcohol, the acetaminophen can cause liver damage. Patients should be cautioned not to drink alcohol; even two drinks with acetaminophen can produce this effect. Hydrocodone does not contribute to hepatotoxicity. Ibuprofen is not indicated for post-operative pain unless the pain is mild. Limiting wine to one or two glasses per day still increases the risk of hepatotoxicity.DIF: Cognitive Level: ApplicationREF: p. 42TOP: Nursing Process: Diagnosis MSC: NCLEX Client Needs Category: Physiologic Integrity: Reduction of Risk Potential

31. A patient reports becoming "immune" to a medication because it no longer works to alleviate symptoms. The nurse recognizes that this decreased effectiveness is likely caused by: a. antagonists produced by the body that compete with the drug for receptor sites. b. decreased selectivity of receptor sites, resulting in a variety of effects. c. desensitization of receptor sites by continual exposure to the drug. d. synthesis of more receptor sites in response to the medication.

ANS: C Continual exposure to an agonist would cause the cell to become less responsive or desensitized. The body does not produce antagonists as a response to a medication. Receptor site selectivity is determined by physiologic factors and not by the substances that bind to them. Medications do not cause more receptors to be produced.DIF: Cognitive Level: AnalysisREF: p. 32-33TOP: Nursing Process: Diagnosis MSC: NCLEX Client Needs Category: Physiologic Integrity: Pharmacologic and Parenteral Therapies

3. 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? a. "Babies have a more rapid gastric emptying time and do not absorb drugs well." b. "Cough medicine tastes bad, and infants usually won't take it." c. "Infants are more susceptible to central nervous system effects than are adults." d. "Infants metabolize drugs too rapidly, so drugs are not as effective."

ANS: C Drugs cross the blood-brain barrier more readily in infants, making these patients more susceptible to central nervous system (CNS) side effects. Infants have a prolonged and irregular gastric emptying time and absorb drugs in the stomach more quickly. Although it may be true that cough medicines taste bad and are difficult to administer, this is not a contraindication to giving them. Infants metabolize drugs more slowly.DIF: Cognitive Level: AnalysisREF: p. 66TOP: Nursing Process: Implementation MSC: NCLEX Client Needs Category: Physiologic Integrity: Reduction of Risk Potential

55. A nurse administers the same medication in the same preparation in the same dose to several patients and notes that some patients have a better response to the drug than others. What is the most likely explanation for this phenomenon? a. Altered bioavailability of the drug b. Patient compliance with the therapeutic regimen c. Pharmacogenomic differences among individuals d. Placebo effects enhancing expectations of drug efficacy

ANS: C Each patient's genetic makeup can determine how that patient responds to drugs quantitatively and qualitatively, and this is the most likely cause of individual variation when the same drug is given at the same dose. The bioavailability of a drug is determined by the drug's composition and varies across formulations of the drug. The patients in this example were given the same drug. The nurse was administering the medication to the patients, so compliance is not an issue. Nothing in this example indicates that a placebo effect was in play.DIF: Cognitive Level: ComprehensionREF: p. 53TOP: Nursing Process: Evaluation MSC: NCLEX Client Needs Category: Physiologic Integrity: Pharmacologic and Parenteral Therapies

26. A patient claims to get better effects with a tablet of Brand X of a drug than with a tablet of Brand Y of the same drug. Both brands contain the same amount of the active ingredient. What does the nurse know to be most likely? a. Advertising by pharmaceutical companies can enhance patient expectations of one brand over another, leading to a placebo effect. b. Because the drug preparations are chemically equivalent, the effects of the two brands must be identical. c. Tablets can differ in composition and can have differing rates of disintegration and dissolution, which can alter the drug's effects in the body. d. The bioavailability of a drug is determined by the amount of the drug in each dose.

ANS: C Even if two brands of a drug are chemically equivalent (i.e., they have identical amounts of the same chemical compound), they can have different effects in the body if they differ in bioavailability. Tablets made by different manufacturers contain different binders and fillers, which disintegrate and dissolve at different rates and affect the bioavailability of the drug. Two brands may be chemically equivalent and still differ in bioavailability, which is not determined by the amount of drug in the dose.DIF: Cognitive Level: ApplicationREF: p. 19TOP: Nursing Process: Diagnosis MSC: NCLEX Client Needs Category: Physiologic Integrity: Pharmacologic and Parenteral Therapies

30. A patient is receiving intravenous gentamicin. A serum drug test reveals toxic levels. The dosing is correct, and this medication has been tolerated by this patient in the past. Which could be a probable cause of the test result? a. A loading dose was not given. b. The drug was not completely dissolved in the IV solution. c. The patient is taking another medication that binds to serum albumin. d. The medication is being given at a frequency that is longer than it's half-life

ANS: C Gentamicin binds to albumin, but only weakly, and in the presence of another drug that binds to albumin, it can rise to toxic levels in blood serum. A loading dose increases the initial amount of a drug and is used to bring drug levels to the desired plateau more quickly. A drug that is not completely dissolved carries a risk of causing embolism. A drug given at a frequency longer than the drug half-life will likely be at subtherapeutic levels and not at toxic levels.DIF: Cognitive Level: AnalysisREF: p. 21TOP: Nursing Process: Evaluation MSC: NCLEX Client Needs Category: Physiologic Integrity: Reduction of Risk Potential

A nurse is teaching nursing students about pediatric medication administration. What will the nurse include when discussing pediatric drug research? a. Early studies revealed that less than 10% of drugs known to be effective in adults were effective in children. b. Research findings show that drug doses may be safely calculated by extrapolating adult dosing. c. Studies showed a significant percentage of unanticipated and potentially lethal side effects in children. d. There is no need to continue with pediatric-specific drug research, since early studies were reassuring.

ANS: C In early studies, about 30% of drugs caused unanticipated side effects, some of them potentially lethal. These same studies revealed that about 20% of drugs were ineffective in children and that about 20% of drugs required doses different from those extrapolated from adult dosing. Because the early studies showed that there is much to learn, the BPCA and PREA were permanently reauthorized by Congress in 2012.DIF: Cognitive Level: AnalysisREF: p. 67TOP: Nursing Process: Evaluation MSC: NCLEX Client Needs Category: Physiologic Integrity: Reduction of Risk Potential

A nurse is caring for an older adult patient during the immediate postoperative period after a total hip replacement. The surgeon has ordered meperidine [Demerol] for severe pain. What will the nurse do? a. Administer the medication as prescribed and initiate a fall risk protocol. b. Ask for a PRN order for diphenhydramine [Benadryl] for the expected side effect of itching. c. Request an order for morphine instead of meperidine [Demerol]. d. Suggest to the surgeon that the patient receive diazepam [Valium] to reduce anxiety and the need for narcotics.

ANS: C In older adults, meperidine is not effective at usual doses and causes more confusion than in younger patients. Morphine is recommended for severe pain. 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.DIF: Cognitive Level: ApplicationREF: p. 71TOP: Nursing Process: Diagnosis MSC: NCLEX Client Needs Category: Physiologic Integrity: Physiologic Adaptation

Chapter 7: Drug Therapy During Pregnancy and Breast-Feeding Test 58. Which types of drugs taken by a pregnant patient are more likely to have effects on a fetus? a. Drugs that are highly polar b. Ionized drugs c. Lipid-soluble drugs d. Protein-bound drugs

ANS: C Lipid-soluble drugs cross the placenta more readily. Drugs that are highly polar, ionized, or protein bound cross the placenta with difficulty.DIF: Cognitive Level: AnalysisREF: p. 58TOP: Nursing Process: Evaluation MSC: NCLEX Client Needs Category: Physiologic Integrity: Reduction of Risk Potential

. A nurse is reviewing an older adult patient's chart before giving medications. Which patient information is of most concern? a. Chronic constipation b. Increased body fat c. Low serum albumin d. Low serum creatinine

ANS: C Low serum albumin reduces protein binding of drugs and can cause levels of free drug to rise, increasing the risk of toxicity. Altered gastrointestinal (GI) absorption is not a major factor in drug sensitivity in the older adult, although delayed gastric emptying 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 to the nurse. Low serum creatinine is a function of decreased lean muscle mass in older patients and does not reflect kidney function or drug excretion.DIF: Cognitive Level: ApplicationREF: p. 69TOP: Nursing Process: Diagnosis MSC: NCLEX Client Needs Category: Physiologic Integrity: Physiologic Adaptation

Rosenthal: Lehne's Pharmacotherapeutics for Advanced Practice Providers, 1 Chapter 4: Pharmacokinetics, Pharmacodynamics, and Drug Interactions 21. The nurse administers naloxone [Narcan] to a patient who has received a toxic dose of morphine sulfate. The nurse understands that the naloxone is effective because of which action? a. Countering the effects of morphine sulfate by agonist actions b. Increasing the excretion of morphine sulfate by altering serum pH c. Preventing activation of opioid receptors through antagonist actions d. Regulating the sensitivity of opioid receptors by neurochemical alterations

ANS: C Naloxone acts by blocking the action of opioids at opioid receptors. An opioid agonist would increase the effects of morphine. Naloxone does not affect serum pH or excretion of opioids. Naloxone does not alter the sensitivity of opioid receptors.DIF: Cognitive Level: AnalysisREF: p. 31TOP: Nursing Process: Implementation MSC: NCLEX Client Needs Category: Physiologic Integrity: Pharmacologic and Parenteral Therapies

15. A patient is prescribed metronidazole for bacterial vaginosis. Which patient history finding would be most concerning? a. Recent yeast infection b. Family history of cervical cancer c. Drinks two glasses of wine every night d. Patient is currently unemployed

ANS: C Patients taking metronidazole should be educated not to drink alcohol to prevent adverse reactions. It would be concerning that the patient drinks wine daily. History of a yeast infection may indicate increased risk for recurrence with administration of an antimicrobial. A family history of cervical cancer is not related to administration of metronidazole. Unemployment can indicate lack of insurance coverage, which may limit the patient's ability to purchase medications, but is not the most concerning patient finding.DIF: Cognitive Level: ApplicationREF: p. 12TOP: Nursing Process: Implementation MSC: NCLEX Client Needs Category: Physiologic Integrity: Reduction of Risk Potential

51. A patient has been taking narcotic analgesics for chronic pain for several months. The nurse caring for this patient notes that the prescribed dose is higher than the recommended dose. The patient has normal vital signs, is awake and alert, and reports mild pain. What does the nurse recognize about this patient? a. This patient exhibits a negative placebo effect with a reduced response to the drug. b. This patient has developed a reaction known as tachyphylaxis because of repeated exposure to the drug. c. This patient has developed pharmacodynamic tolerance, which has increased the minimal effective concentration (MEC) needed for analgesic effect. d. This patient produces higher than normal hepatic enzymes as a result of prolonged exposure to the drug.

ANS: C Pharmacodynamic tolerance results when a patient takes a drug over a period of time. Adaptive processes occur in response to chronic receptor occupation. The result is that the body requires increased drug, or an increased MEC, to achieve the same effect. This patient is getting adequate pain relief, so there is no negative placebo effect. Tachyphylaxis is a form of tolerance that can be defined as a reduction in drug responsiveness brought on by repeated dosing over a short time; this occurs over several months. Barbiturates induce synthesis of hepatic enzymes that cause increased metabolism of the drug, but it does not increase the MEC.DIF: Cognitive Level: ApplicationREF: p. 52TOP: Nursing Process: Evaluation MSC

12. A patient with diabetes reports losing their job and an inability to purchase required medications. Which action is most appropriate? A. Provide a 7-day sample pack. B. Decrease the daily dose by half. C. Contact a different pharmacy. D. Prescribe a different medication.

ANS: C Providing a 7-day sample will address the patient's immediate need, but will not help with the patient's long-term need for medication. Decreasing the daily dose will diminish the effectiveness of the medication. Selecting a different pharmacy could decrease the cost of the medication, as costs vary based on the location and the pharmacy dispensing the medication. Prescribing a different medication would be the last option.DIF: Cognitive Level: ApplicationREF: p. 5TOP: Nursing Process: Implementation MSC: NCLEX Client Needs Category: Physiologic Integrity: Reduction of Risk Potential

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: a. decreased effectiveness of the drug. b. shorter period of the drug's effects. c. signs of drug toxicity. d. unusual CNS effects.

ANS: C 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 indicates that unusual CNS effects will occur because of this alteration in excretion.DIF: Cognitive Level: ApplicationREF: p. 66TOP: Nursing Process: Evaluation MSC: NCLEX Client Needs Category: Physiologic Integrity: Reduction of Risk Potential

A 1-year-old child receives the MMR vaccine. The next day, the child's parent calls the nurse to report that the child has a temperature of 103°F. What will the nurse do? a. File an adverse event report with the Vaccine Adverse Event Reporting System (VAERS). b. Notify the child's provider that thrombocytopenia is likely to occur. c. Reassure the parent that fever can occur with the MMR vaccine. d. Tell the parent to take the child to the emergency department.

ANS: C The MMR vaccine can have several adverse effects, including fever up to 103°F; this is not considered a serious effect and does not warrant filing an adverse event report with VAERS. Thrombocytopenia is a rare but serious side effect of the MMR vaccine but is not associated with fever. There is no need to have the parent take the child to the emergency department.DIF: Cognitive Level: ApplicationREF: p. 586TOP: Nursing Process: Implementation MSC: NCLEX Client Needs Category: Physiologic Integrity: Reduction of Risk Potential

52. A patient asks a nurse why a friend who is taking the same drug responds differently to that drug. The nurse knows that the most common variation in drug response is due to differences in each patient's: a. drug receptor sites. b. hypersensitivity potential. c. metabolism of drugs. d. psychosocial response.

ANS: C The most common source of genetic variation in drug response is related to alterations in drug metabolism and is determined by genetic codes for various drug-metabolizing isoenzymes. There are known genetic differences in codes for drug target sites, but these are not as numerous as those for metabolic isoenzymes. Hypersensitivity potential is also genetically determined, but variations produce differences in adverse reactions to drugs and not in drug effectiveness. Psychosocial responses vary for many less measurable reasons, such as individual personalities and variations in cultures.DIF: Cognitive Level: AnalysisREF: p. 53TOP: Nursing Process: Evaluation MSC: NCLEX Client Needs Category: Physiologic Integrity: Pharmacologic and Parenteral Therapies

61. 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? a. Passivity and flat affect b. Diarrhea and salivation c. A shrill cry and irritability d. Restless sleep and seizures

ANS: C The newborn of an active heroin addict experiences a withdrawal syndrome that includes shrill crying, vomiting, and extreme irritability. The newborn will not experience passivity or a flat affect, diarrhea, or salivation, or continuous restless sleep as a result of being born to an active heroin addict.DIF: Cognitive Level: ApplicationREF: p. 58TOP: Nursing Process: Assessment MSC: NCLEX Client Needs Category: Physiologic Integrity: Reduction of Risk Potential

The parents of an infant who will be attending day care tell the nurse that they do not want their child vaccinated against rotavirus because an older cousin developed intussusception after receiving this vaccine. Which response by the nurse is correct? a. "Intussusception is much less serious than getting the disease." b. "It was probably just a coincidental reaction to the vaccine." c. "The newer vaccines for rotavirus are not associated with intussusception." d. "Your child will have herd immunity and will not need the vaccine."

ANS: C The rotavirus vaccine product RotaShield was withdrawn because of the high rate of intussusception associated with it. The two products currently on the market—RotaTeq and Rotarix—do not carry a risk for intussusception. Intussusception can be life-threatening, so telling parents it is less serious than the disease is incorrect. Intussusception was not merely a coincidental reaction. Herd immunity is not guaranteed.DIF: Cognitive Level: ApplicationREF: p. 594TOP: Nursing Process: Implementation MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

20. A patient diagnosed with bipolar disorder is prescribed daily lithium. Which action is most important to determine if the therapeutic level is maintained? a. Obtain preadministration blood work. b. Administer medication at regular intervals. c. Ensure periodic laboratory testing is completed. d. Assess the patient for adverse effects.

ANS: C Therapeutic serum levels are determined through periodic laboratory testing. Preadministration blood work may be necessary to determine the patient's physical condition but will not determine therapeutic levels. Scheduling medication administration at regular intervals will help to ensure medication is absorbed and metabolized predictably, but will not determine therapeutic blood levels. Assessing the patient for physical signs of adverse effects does not determine if a therapeutic level has been obtained.DIF: Cognitive Level: ApplicationREF: p. 12TOP: Nursing Process: Evaluation MSC: NCLEX Client Needs Category: Physiologic Integrity: Reduction of Risk Potential

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? a. Ask the patient to share the teaching with a neighbor or friend soon after discharge. b. Give the patient detailed written information about each drug. c. Cluster medication administration times as much as possible. d. Make sure the patient understands the actions and side effects of each drug.

ANS: C 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 teaching. Asking the patient to share what is learned may not be a reasonable expectation of a forgetful patient. 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.DIF: Cognitive Level: ApplicationREF: p. 72TOP: Nursing Process: Implementation MSC: NCLEX Client Needs Category: Physiologic Integrity: Reduction of Risk Potential

45. A patient is taking a drug that has known toxic side effects. What will the nurse do? a. Discontinue the drug at the first signs of toxicity. b. Ensure that complete blood counts are ordered periodically. c. Monitor the function of all organs potentially affected by the drug. d. Teach the patient how to treat the symptoms if they develop.

ANS: C When a drug is administered that has known toxic side effects, the nurse is responsible for monitoring all organ systems potentially affected by the drug. Not all toxic side effects warrant discontinuation of the drug, and a nurse cannot discontinue a drug without an order from the provider. Complete blood counts are indicated only for drugs that affect the blood. Some drugs need to be discontinued, so teaching a patient to treat symptoms is not correct in all cases.DIF: Cognitive Level: ApplicationREF: pp. 42-43TOP: Nursing Process: Planning MSC: NCLEX Client Needs Category: Physiologic Integrity: Reduction of Risk Potential

43. A patient is given a drug for the first time and develops shortness of breath. The patient's heart rate is 76 beats/minute, the respiratory rate is 20 breaths/minute, and the blood pressure is 120/70 mm Hg. The nurse checks a drug administration manual to make sure the correct dose was given and learns that some patients taking the drug experience shortness of breath. The nurse will contact the provider to report what? a. An allergic reaction b. An idiosyncratic effect c. An iatrogenic response d. A side effect

ANS: D A side effect is a secondary drug effect produced at therapeutic doses. This patient received the correct dose of the drug and developed shortness of breath, which, in this case, is a drug side effect. To experience an allergic reaction, a patient must have prior exposure to a drug and sensitization of the immune response. An idiosyncratic effect results from a genetic predisposition to an uncommon drug response. An iatrogenic response occurs when a drug causes symptoms of a disease.DIF: Cognitive Level: ApplicationREF: p. 41TOP: Nursing Process: Implementation MSC: NCLEX Client Needs Category: Physiologic Integrity: Reduction of Risk Potential

38. A nurse provides teaching to a patient who will begin taking a drug with a known risk of hepatotoxicity. Which statement by the patient indicates a need for further teaching? a. "I should avoid taking acetaminophen while taking this drug." b. "I will need periodic evaluation of aspartate aminotransferase and alanine aminotransferase levels." c. "If I experience nausea, vomiting, or abdominal pain, I should call my provider." d. "Routine testing and early detection of problems will prevent liver failure."

ANS: D Drug-induced liver injury can progress from undetectable to advanced between routine tests; therefore, routine testing does not always prevent liver failure. Patients taking known hepatotoxic drugs should avoid other drugs, such as acetaminophen, that can cause liver damage. Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) are liver enzymes that are routinely monitored when a patient is taking hepatotoxic drugs. Nausea, vomiting, and abdominal pain are signs of liver injury and should be reported.DIF: Cognitive Level: ApplicationREF: p. 44TOP: Nursing Process: Implementation MSC: NCLEX Client Needs Category: Physiologic Integrity: Reduction of Risk Potential

A nurse is preparing to administer vaccines to a 1-year-old child. The parents ask the nurse to give the child acetaminophen before administering the vaccine to reduce the pain. Which response by the nurse is correct? a. "Children do not remember pain, so it is not necessary to give acetaminophen." b. "The small needles used to inject the vaccines cause hardly any discomfort." c. "You can apply a topical anesthetic when you get home to reduce pain from the injection." d. "Your child's immune response may not be as effective if I give acetaminophen before the vaccine."

ANS: D Giving analgesic/antipyretic medications before or shortly after vaccines can reduce the immune response, so giving them to prevent pain or fever is not recommended. Children do remember pain, and it is important to provide other comfort measures and to give the injections rapidly. Small needles cause less discomfort, and it is important to reassure the parents about this; however, it is more important to explain why acetaminophen is not recommended. Topical anesthetics are useful before giving the injections, not afterwards.DIF: Cognitive Level: ApplicationREF: p. 582TOP: Nursing Process: Implementation MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

24. Which statement about food and drug interactions is true? a. Foods alter drug absorption and metabolism but not drug action. b. Medications are best absorbed on an empty stomach. c. Patient discomfort is the food and drug interaction of most concern. d. Some foods can inhibit CYP isoenzymes and alter drug metabolism.

ANS: D Grapefruit juice inhibits CYP3A4, which lowers the metabolism of some drugs, leading to toxic effects of drugs affected by these isoenzymes. Foods can alter all pharmacokinetic and pharmacodynamic processes. Not all medications are absorbed better on an empty stomach; some require certain foods to enhance absorption. Patient comfort is a concern, but it is not as important as more severe and possibly life-threatening food and drug interactions.DIF: Cognitive Level: AnalysisREF: p. 39TOP: Nursing Process: Assessment MSC: NCLEX Client Needs Category: Physiologic Integrity: Reduction of Risk Potential

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? a. "An inability to pay for medications contributes to most intentional non-adherence among older adults." b. "Most issues associated with non-adherence among older adults would be resolved with simplified drug regimens." c. "Most non-adherence in older adults results in drug toxicity and adverse drug effects." d. "A majority of older patients who do not adhere to drug regimens do so intentionally."

ANS: D Intentional non-adherence is common. It accounts for 75% of non-adherence among older adults and may occur because older adult patients are not convinced that drugs are needed or that the dose prescribed is correct. The inability to pay for medications and complicated drug regimens result in non-intentional non-adherence. Although non-adherence may result in therapeutic failure and drug toxicity, subtherapeutic dosing is by far the most common result.DIF: Cognitive Level: AnalysisREF: p. 72TOP: Nursing Process: Evaluation MSC: NCLEX Client Needs Category: Physiologic Integrity: Reduction of Risk Potential

32. A patient who is taking morphine for pain asks the nurse how a pain medication can also cause constipation. What does the nurse know about morphine? a. It binds to different types of receptors in the body. b. It can cause constipation in toxic doses. c. It causes only one type of response, and the constipation is coincidental. d. It is selective to receptors that regulate more than one body process.

ANS: D Morphine is a medication that is selective to receptor type that regulates more than one process. Because it is selective to receptor type, it does not bind to different types of receptors. Constipation is a normal side effect and is not significant for toxicity.DIF: Cognitive Level: AnalysisREF: p. 35TOP: Nursing Process: Implementation MSC: NCLEX Client Needs Category: Physiologic Integrity: Pharmacologic and Parenteral Therapies

53. The nurse is assessing a newly admitted older patient who has recently lost 15 pounds. The nurse notes that the patient is taking warfarin (Coumadin). Which laboratory tests will the nurse discuss with this patient's provider? a. Blood glucose and C-reactive protein b. Complete blood count and hepatic function tests c. Renal function tests and serum electrolytes d. Serum albumin and coagulation studies

ANS: D Older patients and those who are malnourished are at increased risk for low serum albumin. Since warfarin binds to albumin, such patients are at increased risk for elevated warfarin levels, which can cause increased bleeding. The nurse should request albumin levels and coagulation studies.DIF: Cognitive Level: AnalysisREF: p. 54TOP: Nursing Process: Assessment MSC: NCLEX Client Needs Category: Physiologic Integrity: Pharmacologic and Parenteral Therapies

54. A nurse is preparing to care for a patient who is receiving digoxin. When screening for potential adverse effects from this drug, the nurse will review which of this patient's laboratory results? a. Albumin b. Blood urea nitrogen (BUN) and creatinine c. Hepatic enzymes d. Serum electrolytes

ANS: D Patients with low serum potassium are at risk for fatal cardiac dysrhythmias when taking digoxin, and it is essential to know this level before this medication is administered. Knowing a patient's albumin level would be important when giving drugs that are protein bound. The BUN and creatinine levels are indicators of renal function. Hepatic enzymes are important to know when drugs are metabolized by the liver.DIF: Cognitive Level: ApplicationREF: p. 51TOP: Nursing Process: Assessment MSC: NCLEX Client Needs Category: Physiologic Integrity: Reduction of Risk Potential

23. The nurse is preparing to administer penicillin G intramuscularly to a child. The child's parents ask why the drug cannot be given in an oral liquid form. What is the nurse's reply? a. "This drug causes severe gastric upset if given orally." b. "This drug has a narrow therapeutic range, and the dose must be tightly controlled." c. "This drug is absorbed much too quickly in an oral form." d. "This drug would be inactivated by enzymes in the stomach."

ANS: D Penicillin G is inactivated by digestive enzymes in the stomach and cannot be given orally. It does not have a narrow therapeutic range.DIF: Cognitive Level: ApplicationREF: p. 20TOP: Nursing Process: Implementation MSC: NCLEX Client Needs Category: Physiologic Integrity: Pharmacologic and Parenteral Therapies

4. A nurse caring for a 5-year-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? a. Glucocorticoids b. Salicylates c. Sulfonamides d. Tetracyclines

ANS: D 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.DIF: Cognitive Level: ApplicationREF: p. 67TOP: Nursing Process: Evaluation MSC: NCLEX Client Needs Category: Physiologic Integrity: Reduction of Risk Potential

An immigrant child is in the clinic for MMR vaccination. The nurse learns that the child has recently received an immune globulin injection for a viral infection, currently has an upper respiratory infection with a temperature of 100°F, and has a recent history of thrombocytopenia, which has resolved. What does the nurse tell the child's parents? a. "The vaccine is contraindicated in this child because of the history of thrombocytopenia." b. "The child should be brought back for the vaccine when the temperature is back to normal." c. "The child is at increased risk of developing autism from this vaccine." d. "The vaccine must be postponed for 3 months after administration of the immune globulin."

ANS: D The MMR vaccine should be postponed in children who have received immunoglobulins, because the immunoglobulin contains antibodies against the viruses in the vaccine. Thrombocytopenia is not a contraindication to the MMR vaccine. A low-grade temperature is not a contraindication. There is no link between receiving the MMR vaccine and the development of autism.DIF: Cognitive Level: ApplicationREF: p. 589TOP: Nursing Process: Implementation MSC: NCLEX Client Needs Category: Physiologic Integrity: Reduction of Risk Potential

39. A nurse is reviewing a medication administration record before administering medications. Which order will the nurse implement? a. Furosemide [Lasix] 20 mg QD PO b. Furosemide [Lasix] 20 mg qd PO c. Furosemide [Lasix] 20 mg daily d. Furosemide [Lasix] 20 mg PO daily

ANS: D The correct answer is a complete order; it contains the medication, dose, route, and time. "qd" is no longer an accepted abbreviation; it should be written out as "daily" or "every day." The order of "20 mg daily" does not specify the route to be used.DIF: Cognitive Level: AnalysisREF: p. 48TOP: Nursing Process: Planning MSC: NCLEX Client Needs Category: Physiologic Integrity: Reduction of Risk Potential

A nurse is preparing to give medications to four older patients who are all taking multiple medications. Which patient is most likely to have an adverse drug reaction related to increased drug effects? a. Obese patient b. Patient with decreased serum creatinine c. Patient with chronic diarrhea d. Thin patient with a chronically low appetite

ANS: D 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. Decreased serum creatinine in an older adult patient may just be a function of a decrease in lean body mass and not of renal function. Chronic diarrhea would accelerate the passage of medications through the GI tract and reduce absorption.DIF: Cognitive Level: AnalysisREF: p. 69TOP: Nursing Process: Diagnosis MSC: NCLEX Client Needs Category: Physiologic Integrity: Physiologic Adaptation

A nurse at an immunization clinic is providing vaccines to children. The parent of a child waiting to receive vaccines tells the nurse that the child has an immune deficiency disorder. The nurse understands which vaccine should not be administered to this child? a. Diphtheria and tetanus toxoids and acellular pertussis (DTaP) vaccine b. Haemophilus influenzae type b (Hib) vaccine c. Polio injection d. Varicella virus vaccine

ANS: D The varicella vaccine should be avoided by individuals who are immunocompromised, which includes those infected with the human immunodeficiency virus (HIV) and those who have a congenital immunodeficiency. The DTaP vaccine, Hib vaccine, and polio injection may be administered to immunocompromised individuals, because these are not live vaccines.DIF: Cognitive Level: AnalysisREF: p. 591TOP: Nursing Process: Planning MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

2. 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 is available in two concentrations. Which dosing regimen will the nurse discuss with the child's provider? a. 250 mg/5 mL to 375 mg PO twice daily b. 250 mg/5 mL to 250 mg PO three times daily c. 500 mg/5 mL to 250 mg PO three times daily d. 500 mg/5 mL to 375 mg PO twice daily

ANS: D 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 day care or school; it also helps prevent the problem of the medication being left either at home or at school.DIF: Cognitive Level: ApplicationREF: p. 68TOP: Nursing Process: Implementation MSC: NCLEX Client Needs Category: Physiologic Integrity: Reduction of Risk Potential