Midterm - Pharm

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

A patient with diabetes develops hypertension. Which type of medication will the provider prescribe to treat hypertension in this patient? A. Angiotensin-converting enzyme (ACE) inhibitors B. β blockers C. Direct-acting vasodilators D. Thiazide diuretics

ANS: A ACE inhibitors slow the progression of kidney injury in diabetic patients with renal damage. β blockers can mask signs of hypoglycemia and must be used with caution in diabetics. Direct-acting vasodilators are third-line drugs for chronic hypertension. Thiazide diuretics promote hyperglycemia.

A patient diagnosed with heart failure (HF) and taking an angiotensin-converting enzyme (ACE) inhibitor, has developed fibrotic changes in the heart and vessels. Which type of medication will the provider order to counter this development? A. Aldosterone antagonist B. Angiotensin II receptor blocker (ARB) C. β blocker D. Direct renin inhibitor (DRaI)

ANS: A Aldosterone antagonists are added to therapy for patients with worsening symptoms of HF. Aldosterone promotes myocardial remodeling and myocardial fibrosis, so aldosterone antagonists can help with this symptom. ARBs are given for patients who do not tolerate ACE inhibitors. β blockers do not prevent fibrotic changes. DRIs are not widely used.

A patient who has been taking sertraline for depression was prescribed azithromycin to treat an infection by a provider at an after-hours clinic. What action will the primary care provider take to address the risk this combination of medication has posed for the patient? A. Discontinue the azithromycin and write an order for an alternative antibiotic. B. Discontinue the sertraline and write an order for a different antidepressant medication. C. Reduce the sertraline dosage while taking azithromycin. D. Withhold the sertraline until the azithromycin therapy is completed.

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 and because the patient was already taking sertraline, 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. Additionally, it is important to reinforce the need to tell all providers that sertraline is being taken.

A patient who recently recovered from acute bronchitis reports a lingering dry cough that prevents sleep. Which over-the-counter medication will the provider recommend to best manage the symptoms? A. Diphenhydramine B. Fexofenadine/pseudoephedrine C. Guaifenesin D. Phenylephrine drops

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

A patient with severe, chronic COPD uses an inhaled long-acting inhaled β2 agonist (LABA)/glucocorticoid but continues to have frequent exacerbation of symptoms. What change in therapy will the provider discuss with the patient? A. Adding roflumilast B. Changing to oral theophylline C. Prescribing oral steroids D. Using an ipratropium/albuterol combination

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

Which factor best supports an increase for full prescriptive authority for both advanced practice registered nurses (APRNs) and physician assistants (PAs)? A. More patients will have access to health care. B. Enrollment in medical schools is predicted to decrease. C. Enrollment in both APRN and PA programs has increased. D. Physician practices have become so large, quality care is in jeopardy.

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 and physical assistants can fill this gap. Enrollment in medical school has increased in recent years and shows no indication of decline. While some medical practices have increased in patient volume, there is no reason to believe care has suffered. While enrollment for both APRN and PA education has increased, that is not the primary factor associated with the need for increased prescriptive authority for these providers.

A patient with a recent onset of nephrosclerosis has been taking an angiotensin-converting enzyme (ACE) inhibitor and a thiazide diuretic. The patient's initial blood pressure was 148/100 mm Hg. After 1 month of drug therapy, the patient's blood pressure is 130/90 mm Hg. What action will the provider take to address the patient's blood pressure? A. Add a calcium channel blocker to this patient's drug regimen. B. Lower doses of the antihypertensive medications. C. Order a high-potassium diet. D. Add spironolactone to the drug regimen

ANS: A In patients with renal disease, the goal of antihypertensive therapy is to lower the blood pressure to 130/80 mm Hg or less. Adding a third medication is often indicated. Lowering the dose of the medications is not indicated because the patient's blood pressure is not in the target range. Adding potassium to the diet and using a potassium-sparing diuretic are contraindicated.

A pregnant patient asks her provider about the safe use of medications during the third trimester. What will the provider tell her about drugs taken at this stage? 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. "Drugs are more likely to cause anatomical defects if they are taken during the second trimester.

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; therefore, drugs metabolized by the liver may need to be increased. Drugs are not less likely to cross the placenta. Anatomic defects are more likely to occur in the embryonic period which is in weeks 3 through 8 in the first trimester.

A patient with stable COPD is prescribed a bronchodilator by the provider. Which type of bronchodilator is preferred for this patient? A. A long-acting inhaled β2 agonist (LABA) B. An oral β2 agonist C. A short-acting β2 agonist (SABA) D. An intravenous methylxanthine

ANS: A LABAs are preferred over SABAs for COPD. Oral β2 agonists are not first-line therapy. Although theophylline, a methylxanthine, was once standard therapy in COPD, it is no longer recommended. It is used only if β2 agonists are not available.

A provider prescribes montelukast for a child with asthma. Which statement by the child's parent indicates understanding of this medication? A. "I may notice mood changes in my child." B. "This drug works like albuterol to open up my child's airways." C. "I will give my child this drug on days when his peak flow meter results are decreased." D. "This drug can alleviate symptoms during an acute attack."

ANS: A Montelukast is given as an adjunct to inhaled glucocorticoids to help prevent inflammation. Some patients have reported mood changes when taking this drug, so parents should be warned of this effect. The medication is given once daily. The drug is an antiinflammatory drug, not a bronchodilator. It should be taken on a regular schedule, not prn. The drug does not treat symptoms of an acute attack.

An older adult patient is admitted to the hospital for treatment of an exacerbation of a chronic illness. Admission laboratory work reveals an extremely low serum drug level of the drug used to treat this condition. The patient's renal and hepatic function tests are normal. What might the provider suspect as a likely cause of this finding? A. Nonadherence to the medical regimen B. Chronic constipation C. Increased tolerance to the drug's effects D. Concurrent administration of two highly protein-bound drugs

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

A patient reports mild nausea within an hour after taking the first two doses of a newly approved medication. Nausea is not listed among the known side effects of this drug. What instructions will the provider give the patient? A. "Take the next dose with food and call the office if the nausea reoccurs or if other symptoms develop." B. "Discontinue the medication and a substitute will be prescribed." C. "Reporting the situation to the MEDWATCH program will get us a recommendation about continuing the drug." D. "I'll write a prescription for an antiemetic to counter this drug's effects."

ANS: A Not all adverse drug reactions (ADRs) are detected during clinical trials, and prescribers should be alert to any effects that may result from drug administration. The time of nausea onset suggests that this is drug-related. Unless contraindicated, taking drugs with food will usually relieve or decrease nausea. Because there is a possibility that the nausea is not drug-related, it is important to ask the patient to report the recurrence or worsening of the symptom or the addition of new symptoms. 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, e.g., if the nausea occurs with subsequent doses. Until there is greater suspicion that the drug caused this patient's nausea and because the patient is not vomiting, giving an antiemetic is not indicated.

A prescriber considers ordering propranolol for a patient with recurrent ventricular tachycardia. What information in the patient's medical history will be of greatest concern to the prescriber? A. Asthma B. Exercise-induced tachyarrhythmias C. Hypertension D. Paroxysmal atrial tachycardia associated with emotion

ANS: A Propranolol is to be used cautiously in patients with asthma because it is a nonselective β-adrenergic antagonist and can cause bronchoconstriction and exacerbate asthma. It is used to treat tachyarrhythmias and paroxysmal atrial tachycardia evoked by emotion, so it is not contraindicated for patients with these conditions. It lowers blood pressure, so it would be helpful in patients with hypertension.

The drug manual states that older adult patients are at increased risk for hepatotoxicity. Which action is most important when prescribing this medication to an 80-year-old patient? A. Obtaining baseline liver function studies B. Ensuring that the drug is taken in the correct dose at the correct time C. Discontinuing the order; the drug is contraindicated for this patient D. Giving the medication intravenously to avoid first pass metabolism

ANS: A The drug manual indicates that this drug increases risk of hepatotoxicity for elderly patients. Getting information about liver function before giving the drug establishes baseline data that can be compared with posttreatment data to determine whether the drug is affecting the liver. Taking the correct dose at the correct interval may minimize risk, but without baseline information, the effects cannot be determined. Drugs are not routinely contraindicated for an increased risk of adverse effects.

A medication prescribed for a neonate is eliminated primarily by hepatic metabolism. What action will the prescriber take to minimize risk to the infant? A. Prescribe a dose that is relatively lower than an adult dose when adjusted for body surface area. B. Prescribe a dose that is relatively higher than an adult dose when adjusted for body surface area. 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.

A patient is admitted to the hospital with a diagnosis of vitamin B12 deficiency, hypoxia and anemia. In addition to oxygen therapy, what will the provider order to address these problems? A. IM cyanocobalamin and folic acid B. IM cyanocobalamin and antibiotics C. PO cyanocobalamin and folic acid D. PO cyanocobalamin and blood transfusions

ANS: A The patient has anemia with associated hypoxia secondary to vitamin B12 deficiency; therefore, cyanocobalamin should be given parenterally along with folic acid. Antibiotics are indicated only when signs of infection are present. Oral cyanocobalamin is not recommended.

A provider is concerned about renal function in an 84-year-old patient who is taking several medications. What laboratory result will the provider order? 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 accurately reflect kidney function in older adults because lean muscle mass, which is the source of creatinine in serum, declines and may be low even with reduced kidney function.

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

A patient with asthma reports daily symptoms requiring a short-acting β2-agonist for relief. The patient has used oral glucocorticoids three times in the past 3 months and reports awakening at night with symptoms about once a week. The patient's forced expiratory volume in 1 second (FEV1) is 75% of predicted values. Which regimen does the provider determine is best for this patient? A. Daily low-dose inhaled glucocorticoid/LABA with a SABA as needed B. Daily low-dose inhaled glucocorticoid and a SABA as needed C. Daily medium-dose inhaled glucocorticoid/LABA combination D. No daily medications; continue a SABA as needed

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

A patient requests medication for insomnia. The provider notes that the patient is restless and anxious with a heart rate of 90 beats/minute, and blood pressure of 130/85 mm Hg. Current medications are the combination product loratadine/pseudoephedrine every 12 hours for allergic rhinitis. What action will the provider take? A. Discuss changing to an intranasal glucocorticoid and loratadine. B. Evaluate the patient for acute pseudoephedrine toxicity. C. Discuss changing to pseudoephedrine without loratadine. D. Suggest switching to a topical decongestant to minimize systemic symptoms.

ANS: A This patient is showing central nervous system (CNS) and cardiovascular side effects of the pseudoephedrine. A better option would be to use single-ingredient products for each symptom; an intranasal glucocorticoid and an oral antihistamine are considered first-line treatments. This patient is demonstrating adverse effects but not acute toxicity. Using pseudoephedrine only will not benefit the patient because the side effects are caused by pseudoephedrine. Topical decongestants are not first-line drugs for allergic rhinitis and, if used for more than a few days, can cause rebound congestion on attempts to discontinue them.

Verapamil is prescribed for the client who takes digoxin. The provider will monitor closely for which adverse reaction? A. AV blockade B. Gingival hyperplasia C. Migraine headaches D. Reflex tachycardia

ANS: A Verapamil and digoxin both suppress impulse conduction through the AV node; when the two drugs are used concurrently, the risk of AV blockade is increased. Gingival hyperplasia can occur in rare cases with verapamil, but it is not an acute symptom. Verapamil can be used to prevent migraine, although its use for this purpose is under investigation. Verapamil and digoxin both suppress the heart rate, so tachycardia is not anticipated. The calcium channel blocker nifedipine, not verapamil, causes reflex tachycardia.

A patient reports that a medication prescribed for recurrent migraine headaches is not working. Which action is the prescriber's priority when addressing the patient's concern? 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. Prescribe a new medication for migraine management. D. Suggest biofeedback as an adjunct to drug therapy.

ANS: A When evaluating the effectiveness of a drug, it is important to determine how often the patient is using the drug. Asking the patient to identify how many tablets are taken and how often helps the provider determine effective dosages and adherence to the medication regimen. The patient has already stated that the medication is not working; the actual level of pain may determine the degree to which is not working but it does not help the provider to determine why it is not working. The assessment process should gather as much information about compliance, symptoms, and drug effectiveness as possible before enacting a change in treatment. Biofeedback may be an effective adjunct to treatment, but it should not be recommended without complete information about drug effectiveness.

A provider considers prescribing tamoxifen for a woman with breast cancer. Upon reviewing results of genetic testing, the prescriber notes that the patient has variations in the CYP2Dy allele resulting in a deficiency of the CYP2D6 isoenzymes. What action will this deficiency warrant in the prescribing of tamoxifen, a CYP2D6 substrate? A. The tamoxifen will not be prescribed. B. The individual doses of tamoxifen will be increased. C. The tamoxifen will be ordered but in lower than normal dosage. D. The patient's serum tamoxifen level will be routinely monitored.

ANS: A Women with a deficiency of CYP2D6 isoenzymes 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.

The provider prepares a patient with newly diagnosed type 1 diabetes for hospital discharge. Which action by the provider will best support the patient's ability to effectively manage medication therapy? 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 prevent an overdose, it is most important for the patient to know how to measure and administer it. Asking for a demonstration of technique is the best way to determine whether the patient has understood the teaching. The other teaching points are important as well, but they are not as critical.

A patient is brought to the emergency department with shortness of breath, a respiratory rate of 30 breaths/minute, intercostal retractions, and frothy, pink sputum. After the patient's provider renders a diagnosis of heart failure, which diuretic will be prescribed to address these assessment findings? A. Furosemide B. Hydrochlorothiazide C. Mannitol D. Spironolactone

ANS: A Furosemide, a potent diuretic, is used when rapid or massive mobilization of fluids is needed. This patient shows signs and symptoms of severe heart failure and needs immediate reduction of fluid overload. Hydrochlorothiazide and spironolactone are not indicated for pulmonary edema, because they are less efficacious, and diuresis is less rapid. Mannitol is indicated for patients with increased intracranial pressure and must be discontinued immediately if signs of pulmonary congestion or heart failure occur.

A pregnant woman asks why more is not known about the teratogenic effects of maternal medication ingestion during pregnancy. Which response will the provider offer to address the patient's concern? A. "Clinical trials to determine teratogenic effects 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 of harm. Many pregnant women need prescription medications and not taking those would put the fetus at risk by compromising the health of the mother. The MEPREP study is a retrospective study to learn about possible outcomes related to known maternal drug exposure.

A patient is found to have a genetic deficiency in the biomarker CYP2C19. The provider recognizes that prescribing clopidogrel will increase the patient's risk for developing what serious conditions? (Select all that apply.) A. Myocardial infarction B. Stroke C. Peptic ulcer D. Dementia E. Stomach cancer

ANS: A,B Clopidogrel, a drug that prevents platelet aggregation, is negatively affected by a variant in the genetic code of CYP2C19 resulting in a weak antiplatelet response, which increases their risk for stroke and myocardial infarction. The risk for the other options is not increased with this variant situation

The patient who has been prescribed lithium for a diagnosis of bipolar disorder asks why blood tests are required on a regular basis. Which provider responses demonstrate an understanding of why the patient requires a variety of laboratory tests? (Select all that apply.) A. "We need to monitor how your thyroid is functioning." B. "We need to monitor kidney function while you are on this drug." C. This medication can cause you to lose sodium, so we need to measure sodium levels." D. "Your liver can be damaged by lithium; regular testing helps us monitor for that." E. "Lithium can cause you to lose potassium; so, we regularly monitor your blood potassium level."

ANS: A,B,C Lithium therapy can affect thyroid and renal function as well as deplete sodium levels. Regular laboratory testing is needed to monitor sodium levels and thyroid and renal function and so allows for modification of the lithium dose as needed. Lithium is not associated with altered liver function or potassium depletion.

Which conditions will the provider consider as a therapeutic use for verapamil? (Select all that apply.) A. Angina of effort B. Cardiac dysrhythmias C. Essential hypertension D. Sick sinus syndrome E. Suppression of preterm labor

ANS: A,B,C Verapamil is used to treat both vasospastic angina and angina of effort. It slows the ventricular rate in patients with atrial flutter, atrial fibrillation, and paroxysmal supraventricular tachycardia. It is a first-line drug for the treatment of essential hypertension. It is contraindicated in patients with sick sinus syndrome. Nifedipine has investigational uses in suppressing preterm labor.

What will the provider consider when prescribing two drugs that compete for plasma albumin receptor sites? (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 cause sustained intensification of effects. E. The increase in bound drug will cause sustained intensification of effects

ANS: A,B,C When two drugs bind to the same site on plasma albumin, coadministration 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; therefore, the increase in plasma levels of free drug is rarely sustained. Drug that is bound to protein in the circulation is inactive; therefore, it cannot cause an effect.

When prescribing medications to infants, it is important for the provider to consider which fact? (Select all that apply.) A. Breast-feeding infants are more likely to develop toxicity when the mother is taking 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.

ANS: A,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. Oral medications may be given safely to infants as long as they are awake and can swallow the drug.

Which statements made by the prescriber demonstrate an understanding of effective medication education? (Select all that apply.) A. "This medication needs to be stored in the refrigerator." B. "Take 3 tablets daily: 1 with breakfast, 1 with lunch, and one with dinner." C. "You need to take the medication as we discussed until all the tablets are gone." D. "Call the office immediately if you begin experiencing any itching, headache, or difficulty breathing." E. "When you call about a medication refill, be sure to let the pharmacist know you are talking about your heart pill."

ANS: A,B,C,D There are basic components that should be included when teaching about any new medication. They are (1) medication name, (2) purpose, (3) dosing regimen, (4) administration, (5) adverse effects, (6) any special storage needs, (7) associated laboratory testing, (8) food or drug interactions, and (9) duration of therapy. The statement suggesting referring to the medication as "your heart pill" is inappropriate since being familiar with the drug's name is important in avoiding medication errors.

A frail older adult patient is admitted to the hospital after several days of vomiting, diarrhea, poor intake of foods and fluids, and anuria for 8 hours. What laboratory studies will the provider order to help guide medication administration? (Select all that apply.) 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 as important; most GI changes result in lowered absorption and less free drug. Serum creatinine levels are related to the amount of lean muscle mass, which may be low in older adult patients, and not reflective of renal function.

Amiodarone is prescribed for a patient. Which baseline tests will the prescriber order before this medication is started? (Select all that apply.) A. Chest radiograph B. Complete blood count with differential C. Ophthalmologic examination D. Pulmonary function tests E. Thyroid function tests

ANS: A,C,D,E Amiodarone has many potential toxic side effects, including pulmonary toxicity, ophthalmic effects, and thyroid toxicity, so these systems should be evaluated at baseline and periodically while the patient is taking the drug. A complete blood count is not indicated

A child with allergic rhinitis has used budesonide for several years. The parents are concerned that the child's rate of growth has slowed. What action will the provider take to address the parent's concerns? A. Reassure the parents that this is an expected side effect. B. Discuss changing to fluticasone with the parents. C. Advise the parents to administer budesonide only when symptoms are severe. D. Advise the parents that antihistamines work as well as intranasal glucocorticoids.

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

A provider obtains a drug history from an older adult who is a new patient. Of the multiple medications taken, which two, taken together, create a reason for concern? A. Acetaminophen and oxycodone B. Amitriptyline and diphenhydramine C. Fexofenadine and an over-the-counter (OTC) laxative D. Zolpidem and sertraline

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 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.

A patient who has taken warfarin for a year has now been prescribed carbamazepine. What additional action will the provider take to assure the patient's safety? A. Decrease the usual dose of carbamazepine B. Increase the dose of warfarin. C. Order more frequent activated partial thromboplastin time (aPTT) monitoring. D. Order extra dietary vitamin K.

ANS: B Carbamazepine is a powerful inducer of hepatic drug-metabolizing enzymes and can accelerate warfarin degradation. The warfarin dose should be increased if the patient begins taking carbamazepine. Decreasing the dose of carbamazepine is not indicated. It is not necessary to perform more frequent aPTT monitoring or to add extra vitamin K.

Which patient statement suggests to the provider that the patient's nonadherence with their medication plan is related to dissatisfaction with the therapy? A. "This medication is too expensive; I can't afford it any longer." B. "I've been taking this medication for well over a week and I lost only a half a pound." C. "It's too hard to remember to take the pill every other day; so, I've missed several doses." D. "I have a very intense, fast paced job; it's hard to make time to take the medication like I should."

ANS: B Dissatisfaction with drug therapy can take the form of a patient's unrealistic expectation of desired results such as in the case of significant weight loss in a relatively short period of time. Medication costs, forgetfulness and lack of planning are suggested by other options.

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

A patient with a cough has been advised to use guaifenesin. When the patient asks why this particular drug, what response will the provider provide? A. "It dries secretions to help suppress coughing so you can rest." B. "It stimulates the flow of secretions so they are easier to cough up. C. "It helps to relieve the chest pain caused by frequent coughing." D. "It stimulates the body's natural immune responses."

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

A patient takes oral theophylline twice daily for chronic stable asthma. After developing an infection, the patient went to an after-hours clinic where ciprofloxacin was prescribed. What action will the patient's primary provider take when the patient follows up the next day? A. Prescribe a different antibiotic. B. Reduce the theophylline dose. C. Increase the theophylline dose D. Discontinue the theophylline and prescribe a long-acting β agonist.

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

When prescribing lovastatin, what will a provider advise to decrease the risk of developing muscle toxicity? A. Avoid exercise for 2 hours after administration. B. Substitute grapefruit juice with orange juice. C. Monitor aspartate aminotransferase (AST) and alanine aminotransferase (ALT). D. Take the medication with an NSAID or other anti-inflammatory drug.

ANS: B Grapefruit juice can inhibit the metabolism of certain drugs including statins like lovastatin. The juice raises drug levels decreasing the intestinal metabolism of the drug resulting in increased drug levels which increases the risk for adverse effects such as muscle toxicity. Taking the drug with an anti-inflammatory drug and avoiding exercise after administration are not supported by science. Monitoring AST and ALT detects liver toxicity, not muscle toxicity.

A provider speaking to a class or a group of pregnant patients correctly teaches that the highest risk of teratogen-induced gross malformations exists during which time period? 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. Teratogen exposure during the second and third trimesters usually disrupts function rather than gross anatomy.

A patient with seasonal and perennial rhinitis requests a prescription for the most effective drug for treating this condition. Which medication will the provider recommend? A. Pseudoephedrine B. Fluticasone propionate C. Loratadine D. Intranasal cromolyn sodium

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

A child with perennial allergic rhinitis has been using an intranasal glucocorticoid. After the child develops frequent nosebleeds, the provider orders montelukast to replace the inhaler. What statement will the provider include when teaching the child's parents about montelukast? A. "Montelukast is effective for treating allergic and infectious rhinitis." B. "This drug will help prevent inflammation without causing nosebleeds." C. "Montelukast will treat both congestion and rhinitis." D. "Montelukast works best when combined with a topical decongestant."

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

A provider recommends genetic testing of a patient before prescribing a medication. What response should the provider give when asked by the patient about the purpose of genetic testing? A. "Genetic testing better establishes the drug's therapeutic index." B. "Such testing will tell us how quickly your body is likely to metabolize, or process, the drug." C. "The testing helps identify any factors that could affect psychosocial variation in the drug's response." D. "It guides the production of a drug that is tailored to your individual 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(seeChapter5). Any distinct physiologic differences in drug response 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.

The provider is discussing the management of prescribed, controlled substances with a patient. Which statement by the patient indicates understanding of the information provided? A. "If there is a difference between state and federal laws governing a scheduled drug, the federal law takes precedence." B. "Prescriptions for drugs in Schedules III and V may be written to include up to 5 refills." C. "Schedule I drugs may only be given to hospitalized patients." D. "To reduce the possibility of abuse of a drug that is Schedule II, the prescriber should call the prescription to the pharmacy."

ANS: B Providers may prescribe Schedule III and IV drugs orally by phone, written as a prescription, or electronically, and may provide up to 5 refills. When state and federal laws differ, the more restrictive law takes precedence, whether it is the state or the federal law. Schedule I drugs have no approved uses. Schedule II drugs must be typed or written in indelible ink or pencil and signed by the provider or may be submitted electronically. They may be called in an emergency but must be followed by a written prescription within 72 hours.

A patient diagnosed with chronic pain calls to request an oxycodone (Oxycontin) refill. Which action should the prescriber take initially? A. Fax the renewal order to the pharmacy. B. Arrange to schedule an appointment with the patient. C. Verify the patient's adherence to the prescribed drug regimen. D. Determine the patient's current medication dosage and pain level.

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 and pain level; however, this can be accomplished by scheduling an appointment and evaluating the patient in person.

A drug can cause symptoms that resemble those of Parkinson disease. What action should the prescriber take to minimize the potential patient risk? A. Explain that these are teratogenic effects that must be reported immediately. B. Thoroughly educate the patient about recognizing such symptoms and the need to notify the office immediately. C. Order an evaluation of the patient's genetic predisposition to these effects. D. Educate the patient about these symptoms and provide reassurance that the condition is expected.

ANS: B Some drugs can cause iatrogenic conditions, which are conditions whose symptoms are the same as those of a known disease. The patient should be prepared for this possibility and be prepared to recognize and report the symptoms immediately. 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. Although reassurance may dispel some fear on the part of the patient, it does provide the patient with actions (e.g., notifying the provider) that can allow for symptom management.

A woman who breastfeeds her infant must take a prescription medication for 2 weeks. The medication is safe, but the patient wants to make sure her baby receives as little of the drug as possible. What instructions will the prescriber give the patient to best address her concerns? A. "Give the baby formula as long as you are taking the medication." B. "Take the medication immediately after breastfeeding your baby." C. "Pump your 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.

A pediatric patient prescribed ampicillin for streptococcal pharyngitis reports new onset of a pruritic, dull red, maculopapular rash on the chest and neck. Which action is most important for the provider to take to minimize this patient's risk for injury? A. Prescribe azithromycin to replace the ampicillin. B. Discontinue the ampicillin C. Prescribe an antihistamine for the itching. D. Flag all medical records with an "Allergic to Penicillin" notice.

ANS: B The priority action is to discontinue the medication to prevent a potential worsening of the patient's symptoms. A different prescription may be indicated depending on the length of treatment. An antihistamine may be administered for pruritis. Rashes are a common side effect of ampicillin. Pruritic maculopapular rashes such as the one described occur in 5% to 10% of children taking ampicillin, especially in the presence of viral infections. They do not contraindicate future administration of penicillin antibiotics.

A patient reports a family history of hypertension and cardiovascular disease but has no other risk factors. Current blood pressure is 126/82 mm Hg and the patient has a normal weight and body mass index for height and age. What will be the provider's focus when providing patient education? A. Angiotensin-converting enzyme (ACE) inhibitors and calcium channel blocker medications B. The DASH diet, sodium restriction, and exercise C. Increased calcium and potassium supplements D. Thiazide diuretics and lifestyle changes

ANS: B This patient has elevated hypertension without other risk factors. Lifestyle changes are indicated at this point. If blood pressure rises to hypertensive levels, other measures, including drug therapy, will be initiated. Calcium and potassium supplements are not indicated.

A patient with new-onset exertional angina has taken three nitroglycerin sublingual tablets at 5-minute intervals, but the pain has intensified. The patient has a heart rate of 76 beats/minute and a blood pressure of 120/82 mm Hg. The electrocardiogram is normal. The patient's lips and nail beds are pink, and there is no respiratory distress. The provider will prescribe what intervention? A. An angiotensin-converting enzyme (ACE) inhibitor B. Intravenous nitroglycerin and a β blocker C. Ranolazine and quinidine STAT D. Supplemental oxygen and intravenous morphine

ANS: B This patient has unstable angina, and the next step, when pain is unrelieved by sublingual nitroglycerin, is to give intravenous nitroglycerin and a β blocker. ACE inhibitors should be given to patients with persistent hypertension if they have left ventricular dysfunction or heart failure (HF). Ranolazine is a first-line angina drug, but it should not be given with quinidine because of the risk of increasing the QT interval. Supplemental oxygen is indicated if cyanosis or respiratory distress is present. IV morphine may be given if the pain is unrelieved by nitroglycerin.

A patient with a cold used phenylephrine nasal spray, 2 sprays every 4 hours, for a week. Since then it has become impossible to discontinue the medication because the nasal congestion has increased. What action will the provider take? A. Prescribe an oral decongestant to replace the intranasal phenylephrine. B. Order an intranasal glucocorticoid to be used while the phenylephrine is withdrawn. C. Increase the dose of phenylephrine to 4 sprays every 4 hours. D. Stop the phenylephrine and discuss using an intranasal antihistamine.

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

A patient has been receiving iron replacement therapy for 2 days after hip replacement surgery. The provider is alerted to the following assessment data: Patient's stools appear black. Patient is pale and reports feeling tired. Patient's heart rate is 98 beats/minute, respirations are 20 breaths/minute, and the blood pressure is 100/50 mm Hg. What order will the provider take initially to best assure appropriate care for this patient? A. Packed red blood cells B. Hemoglobin and hematocrit (H&H) C. A stool guaiac D. Hypertonic fluid bolus

ANS: B This patient is showing signs of iron deficiency anemia, as manifested by tachycardia and pallor. Because this patient's blood pressure is low, the anemia probably has occurred secondary to blood loss, a common occurrence with hip replacement surgery. The first response should be to obtain an H&H to compare baseline and posttreatment levels. This should be done before an intervention is ordered. A stool guaiac is not indicated because black stools are an expected effect oafboriarlbiro.ncaodmini/streatsiont. If the patient has blood loss that is causing hypotension, an isotonic fluid bolus and packed red blood cells (PRBCs) are indicated to treat this

How can the prescriber's regular collaboration with a pharmacist improve positive outcomes for patients? (Select all that apply.) A. Pharmacists can suggest foods that will help with the medications' absorption. B. Pharmacists have additional information on drug interactions. D. 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 food 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.

Which actions occur in most of the fatal medication errors? (Select all that apply.) A. Confusing drugs with similar packaging B. Giving a drug intravenously instead of intramuscularly C. Administering a drug that sounds like the prescribed drug 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 most of fatal errors.

A patient takes a drug that is metabolized by CYP3A4 isoenzymes. If a CYP3A4 inducing drug is prescribed, what drug adjustment may be necessary to maintain a therapeutic level of CYP3A4 substrate? A. Increase dosage of the CYP3A4 inducer. B. Decrease dosage of the CYP3A4 inducer. C. Increase dosage of the CYP3A4 substrate. D. Decrease dosage of the CYP3A4 substrate

ANS: C A drug that acts as an inducing agent for an enzyme system increases the metabolism of drugs metabolized by that enzyme system, thereby lowering the level of those drugs in the body and requiring higher doses to maintain drug effectiveness. Although decreasing the dosage of the drug that induces metabolism may seem reasonable at first glance, this may decrease the therapeutic level of the drug making it ineffective in treating the condition for which it was prescribed.

When prescribing drugs with a narrow therapeutic index, what intervention does the provider take to decrease risk to the patient? A. Schedule drug administration intervals that exceed the drug's half-life. B. Order the medication to be administered by the intravenous route. C. Monitor the patient's plasma drug levels at regular intervals. regimen. D. Teach the patient that optimal outcomes will require adherence to the medication

ANS: C A drug with a narrow therapeutic range or index 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 risks increased periods of subtherapeutic levels. Drugs that have a narrow therapeutic range may be given by any route; intravenous administration is not preferable and in most cases will not be feasible. Medication regimen adherence is necessary; however, due to individual variation, for drugs with a narrow therapeutic range, what is an effective dose for one patient may be a lethal dose for another. For this reason, monitoring drug levels remains the primary method for decreasing risk.

A metered-dose albuterol inhaler is prescribed for asthma management. The patient reports feeling jittery sometimes when taking the medication, and does not feel that the medication is always effective. Which action will the provider take to best minimize patient risks and maximize medication effectiveness? A. Ask the patient to demonstrate use of the inhaler and assess effectiveness. B. Assess the patient's exposure to first- and second-hand tobacco smoke. C. Auscultate the patient's lung sounds and obtain other relevant vital signs. D. Decrease the dosage to reduce side effects.

ANS: C Assessing and evaluating lung sounds as well as other vital signs helps determine the patient's physical response to the medication and allows comparison to the patient's baseline vital signs. Asking the patient to demonstrate inhaler use helps to evaluate the patient's ability to administer the medication properly and is part of an effective evaluation, but is not a priority intervention based on the patient's current report. Assessing tobacco smoke exposure helps 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. Rewriting the prescription to decrease the dosage may address the degree of jitteriness experienced, but does not address the patient's concern that the drug is not always effective.

The provider prescribes hydrocodone with acetaminophen for a patient's postsurgical pain. What instruction will the prescriber include regarding alcohol intake? A. "If you plan to drink alcohol, I will write an order for acetaminophen without hydrocodone for your pain." B. "I'd suggest that you substitute ibuprofen for pain on days when you plan to drink alcohol." C. "You should avoid drinking alcohol while you are taking the pain medication I've ordered" D. "You should limit your alcohol intake to no more than two servings of alcohol daily while on the pain medication."

ANS: C Combining a hepatotoxic drug with other hepatotoxic agents increases 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 postoperative pain unless the pain is mild. Limiting alcohol intake to two servings per day still increases the risk of hepatotoxicity.

A patient reports that a medication no longer effectively alleviates symptoms. What process informs the provider's response to the patient's concerns? A. Endogenous antagonists compete with the drug for receptor sites. B. Decreased selectivity for receptors results in a variety of effects. C. Desensitization of receptor sites results from continual exposure to the drug. D. Additional receptor sites are synthesized 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. Medication tolerance is not related to receptor selectivity. Medications do not cause more receptors to be produced.

Which effect will the provider expect when prescribing a cardiac glycoside? A. Decreased cardiac output B. Decreased force of contraction C. Decreased heart rate D. Positive inotropic effects

ANS: C Digoxin slows the heart rate and increases the force of contraction. It does not decrease cardiac output or result in positive inotropic effects.

A patient reports that Brand X tablets work faster than Brand Y tablets of the same amount of the same drug. Which statement informs the prescriber's response when explaining this phenomenon to the patient? 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 actions of the two brands must be identical. C. Inactive ingredients used in composition can result in differing rates of dissolution, which can alter the drug's onset of action. 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.

A patient receiving intravenous gentamicin has a toxic serum drug level. The prescriber confirms that the dosing is correct. Which possible cause of this situation will the provider explore? A. Whether a loading dose was administered B. If the drug was completely dissolved in the IV solution C. Whether patient is taking a medication that binds to serum albumin D. If the ordered dose frequency is longer than the gentamicin 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 os causing embolism but this addresses a different concern. A drug given at a frequency longer than the drug half-life will likely be at subtherapeutic levels and not at toxic levels.

An older adult patient is entering into the immediate postoperative period after a total hip replacement. The patient's son concerned about related pain asks meperidine be prescribed since, "I had it for severe pain when I injured when I was younger." What action will the provider take to reduce the patient's risk for injury while addressing the patient's pain? A. Prescribe meperidine and request the initiation of the fall risk protocol. B. Provide a PRN order for diphenhydramine for the expected side effect of itching. C. Prescribe morphine and discuss the rationale with the patient's son. D. Offer to prescribe diazepam to reduce the patient's anxiety and thus reduce the need for narcotics.

ANS: C In older adults, meperidine is not effective at usual doses and causes more confusion, delirium, and neurotoxicity than in younger patients. Morphine is recommended for severe pain among the older population. A fall risk protocol is appropriate, but the drug ordered is not. Diphenhydramine is not recommended for older 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.

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

A provider is reviewing an older adult patient's chart during a routine visit. Which patient information is of most concern regarding the renewing of medication prescriptions for highly protein-bound drugs? 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. The other options are not associated solely with protein-bound drugs. Additionally, altered gastrointestinal (GI) absorption is not a major factor of concern in the older adult, although delayed GI transit can delay drug responses. Increased body fat can alter drug distribution, causing reduced response in libid-sobuble drugs; however, it is not the finding of greatest concern. Low serum creatinine may be an indicator of decreased lean muscle mass in older patients and does not necessarily reflect kidney function or drug excretion.

Which prescriber action will have the greatest impact on the patient's commitment to adherence to any type of medication therapy? A. Prescribing the medication in oral form whenever possible B. Scheduling once a day administration C. Providing medication education that the patient can easily understand D. Assuring that the medication prescription will be covered by the patient's insurance

ANS: C No other provider action assures the patient's commitment to adhere to a medication plan more than effective medication education provided in a concise, understandable form. It is not always possible or appropriate to prescribe an oral form. While medication costs can present a barrier to compliance, insurance coverage is but one factor affecting costs.

A patient is prescribed metronidazole for bacterial vaginosis. Which patient history finding would be most concerning to the provider? A. The patient had a recent yeast infection. B. There is a family history of cervical cancer. C. The patient drinks two glasses of wine every night. D. The patient is unemployed.

ANS: C Patients taking metronidazole should be educated not to drink alcohol to prevent a disulfiram-like reaction. 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; however, generic metronidazole is one of the less expensive medications.

A patient has taken a narcotic analgesic for chronic pain for several months. At a follow-up appointment, the provider notes that the patient has been taking more than the prescribed dosage. The patient has normal vital signs, is awake and alert, and reports mild pain. What does the provider suspect is responsible for the patient's response? A. This patient exhibits a negative placebo effect with a reduced response to the drug. B. This patient has developed 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 has increased hepatic enzyme production as a result of prolonged exposure to the drug. abirb.com/test

ANS: C Pharmacodynamic tolerance results when a patient takes a drug over a long 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. Induced synthesis of hepatic enzymes increases metabolism of a drug, but it does not increase the MEC.

A patient taking a thiazide diuretic for hypertension and quinidine to treat a dysrhythmia, is now prescribed digoxin 0.125 mg to improve cardiac output. Which action will the provider take to best assure the patient's safety? A. Add spironolactone. B. Reduce the dose of digoxin. C. Discontinue the quinidine D. Give potassium supplements

ANS: C Quinidine can cause plasma levels of digoxin to rise; concurrent use of quinidine and digoxin is contraindicated. There is no indication for adding spironolactone in this scenario. The dose of digoxin ordered is a low dose. Potassium supplements are contraindicated with digoxin.

An infant is prescribed a medication that has a narrow therapeutic range and is excreted by the kidneys. The provider will monitor closely for which effect? A. Decreased drug effectiveness B. Tachyphylaxis C. Evidence of drug toxicityabirb.com/test 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 in the question indicates that unusual CNS effects will occur; these would depend on the drug prescribed.

Azithromycin is prescribed for a patient who develops an infection. The patient's only other medication is simvastatin. Which patient symptom will create the greatest concern for the provider? A. Nausea B. Tiredness C. Muscle pain D. Headache

ANS: C Statins can injure muscle tissue, causing muscle aches and pain known as myopathy/rhabdomyolysis. Azithromycin also can cause myopathy and therefore should be used with caution in patients concurrently taking simvastatin. Nausea, tiredness, and headache would not cause the provider as much concern as the likelihood of myopathy.

A patient with bipolar disorder is prescribed daily lithium. Which action is most important for the provider to take in order to determine if the therapeutic level is maintained? A. Evaluate preadministration blood work. B. Prescribe the lithium to be taken at regular intervals. C. Order periodic laboratory testing. D. Assess the patient for signs and symptoms of lithium toxicity.

ANS: C Therapeutic serum levels are determined through periodic laboratory testing. Preadministration blood work may be necessary to obtain baseline status prior to initiating treatment, but it will not determine therapeutic levels. Scheduling medication administration at regular intervals will help to ensure medication is absorbed and metabolized predictably, but it will not determine therapeutic blood levels. Assessing the patient for signs and symptoms of toxicity will help to determine if the therapeutic level has been exceeded, not maintained.

A patient had a blood pressures of 150/95 mm Hg and 148/90 mm Hg on two separate office visits. This is consistent with a blood pressure of 145/92 mm Hg taken in an ambulatory setting. The patient's diagnostic tests are all normal. What will the patient's provider order to best manage the patient's hypertension? A. A β blockerc. B. A loop diuretic and spironolactone C. A thiazide diuretic D. An α1 blocker

ANS: C This patient has primary, or essential, hypertension as evidenced by systolic pressure greater than 140 and diastolic pressure greater than 90, along with normal tests ruling out another primary cause. Thiazide diuretics are first-line drugs for hypertension. β blockers are effective but are most often used to counter reflex tachycardia associated with reduced blood pressure caused by therapeutic agents. Loop diuretics cause greater diuresis than is usually needed and so are not first-line drugs. α1 blockers are not drugs of first choice.

A patient with chronic hypertension is admitted to the hospital. During the admission assessment, the nurse notes a heart rate of 96 beats/minute, a blood pressure of 150/90 mm Hg bibasilar crackles, 2+ pitting edema of the ankles, and distention of the jugular veins. What will the provider order in response to this assessment data? A. Angiotensin-converting enzyme (ACE) inhibitor B. Digoxin C. Furosemide D. Spironolactone

ANS: C This patient shows signs of fluid volume overload and needs a diuretic. Furosemide is a loop diuretic, which can produce profound diuresis very quickly even when the glomerular filtration rate (GFR) is low. An ACE inhibitor will not reduce fluid volume overload. Digoxin has a positive inotropic effect on the heart, which may improve renal perfusion, but this is not its primary effect. Spironolactone is a potassium-sparing diuretic with weak diuresis effects; it is used in conjunction with other diuretics to improve electrolyte balance.

An older adult patient with a history of forgetfulness will need to take multiple drugs after discharge from the hospital. What provider action will most successfully promote medication adherence in a forgetful patient? A. Ask the patient to share the medication teaching with a neighbor or friend soon after discharge. B. Give the patient detailed written information about each drug. C. Schedule medications to be taken at the same 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 original teaching sessions. Asking the patient to share what is learned may not be a reasonable expectation of a patient who is forgetful. Detailed written information may just be more confusing; verbal and written information should be clear and concise. Making sure the patient understands the actions and side effects of medications helps when intentional nonadherence is an issue, but in this case it may just add to the patient's confusion.

The provider orders furosemide for a patient who takes digoxin and is admitted to the hospital for treatment of heart failure. The morning assessment identifies an irregular heart rate of 86 beats/minute, a respiratory rate of 22 breaths/minute, and a blood pressure of 130/82 mm Hg. Crackles are heard in both lungs. Which laboratory result will be of greatest concern to the provider? A. Blood glucose level of 120 mg/dL B. Oxygen saturation of 90% C. Potassium level of 3.4 mEq/L D. Sodium level of 140 mEq/L

ANS: C This patient has an irregular, rapid heartbeat that might be caused by a dysrhythmia. This patient's serum potassium level is low, which can trigger fatal dysrhythmias, especially in patients taking digoxin. Furosemide contributes to loss of potassium through its effects on the distal nephron. Potassium-sparing diuretics often are used in conjunction with furosemide to prevent this complication. This patient's serum glucose and sodium levels are normal and of no concern at this point, although they can be affected by furosemide. The oxygen saturation is somewhat low and needs to be monitored, although it will likely improve with diuresis.

A patient taking an angiotensin-converting enzyme (ACE) inhibitor to treat hypertension tells the provider that she wants to become pregnant. What response will the provider give to the patient? A. "Controlling your blood pressure will decrease your risk of preeclampsia." B. "We need to consider changing you to an angiotensin receptor blocker during pregnancy." C. "It will be safe to continue taking the ACE inhibitor during your pregnancy." D. "Let's discuss using methyldopa instead of the ACE inhibitor while you are pregnant."

ANS: D Methyldopa has limited effects on uteroplacental and fetal hemodynamics and does not adversely affect the fetus or neonate. Controlling blood pressure does not lower the risk of preeclampsia. ACE inhibitors and ARBs are specifically contraindicated during pregnancy.

A patient who uses transdermal nitroglycerin for angina reports occasional periods of tachycardia. What intervention will the prescriber order? A. Order digoxin to slow the heart rate. B. Discontinue the nitroglycerin. C. Recommend periods of rest when the heart rate increases. D. Prescribe verapamil as an adjunct to nitroglycerin therapy.

ANS: D Nitroglycerin lowers blood pressure by reducing venous return and dilating the arterioles. The lowered blood pressure activates the baroreceptor reflex, causing reflex tachycardia, which can increase cardiac demand and negate the therapeutic effects of nitroglycerin. Treatment with a β blocker or verapamil suppresses the heart to slow the rate. Digoxin is not recommended. Discontinuation of the nitroglycerin is not indicated. Resting does not slow the heart when the baroreceptor reflex is the cause of the tachycardia.

Which medication for asthma can a provider prescribe off-label to treat allergic rhinitis? A. Diphenhydramine B. Fexofenadine/pseudoephedrine C. Guaifenesin D. Omalizumab

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

Which medication will a provider prescribe for an asthma patient as part of step 1 management? A. Combination inhaled glucocorticoids/long-acting β2 agonists B. Inhaled low-dose glucocorticoids C. Long-acting β2 agonists D. Short-acting β2 agonists

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

A provider, prescribing pain medication to each patient, will be most concerned about which patient developing a substance use disorder? A. A college student with migraine headaches who reports having experimented with marijuana in the past year. B. An older adult patient with terminal cancer who requires twice the normal dose of morphine for pain relief. C. A patient in moderate to severe pain after a total hip replacement who asks for pain medication an hour before the next dose is due. D. A patient whose history indicates the use of prescription narcotic analgesics for back and headache pain.

ANS: D Patients who use narcotics for minor pains are more likely to be compulsive drug seekers. A college student who experiments with an illegal substance is not necessarily going to develop a substance use disorder. An elderly patient with terminal cancer pain has most likely developed physical dependence and tolerance to morphine but is not a substance abuser. Patients with significant pain who ask for more frequent dosing are not showing substance use disorder.

A patient is prescribed digoxin. Which screening will the provider order to monitor for potential adverse effects from this drug? A. Albumin B. Blood urea nitrogen (BUN) and creatinine C. Hepatic enzymes D. Serum electrolytes

ANS: D Patients with low serum potassium are at increased 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 highly 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.

Which medication will the provider prescribe for a patient admitted with severe hypertensive crisis? A. Captopril PO B. Hydralazine PO C. Minoxidil PO D. Sodium nitroprusside IV

ANS: D Sodium nitroprusside, the drug of choice for hypertensive emergencies, is given intravenously. ACE inhibitors, such as captopril, are not used. Hydralazine may be used but should be given IV instead of PO. Minoxidil is effective, but its severe side effects make it a second-line drug.

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

Which order for furosemide is written appropriately by the prescriber? A. Furosemide [Lasix] 20 mg PO QD B. Furosemide [Lasix] 20 mg PO qd 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" and "qd" are no longer accepted abbreviations; it should be written out as "daily" or "every day." The order of "20 mg daily" does not specify the route to be used.

Four older adult patients are taking multiple medications. For which patient is the provider most concerned about the risk for adverse drug effects? A. An obese patient B. A patient with decreased serum creatinine C. A patient who experiences chronic diarrhea D. An underweight 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. Creatinine levels do not adequately reflect kidney function in older adults and may be normal even though renal function is greatly reduced. Chronic diarrhea would accelerate the passage of medications through the GI tract and reduce absorption resulting in a decrease in both beneficial and adverse effects.

A patient presents to the emergency department after accidentally taking too much prescribed warfarin. The patient's heart rate is 78 beats/min and the blood pressure is 120/80mmHg. A dipstick urinalysis is normal. The patient does not have any obvious hematoma or petechiae and does not report any pain. What will the provider order initially to address the patient's current condition? A. Vitamin K B. Protamine sulfate C. An activated partial thromboplastin time (aPTT) D. A prothrombin time (PT) and an international normalized ratio(INR)

ANS: D This patient does not exhibit any signs of bleeding from a warfarin overdose. The vital signs are stable, there are no hematomas or petechiae, and the patient does not have pain. A PT and INR should be drawn to evaluate the anticoagulant effects. Vitamin K may be given if laboratory values indicate overdose. Protamine sulfate is given for heparin overdose. PTT evaluation is used to monitor heparin therapy.

A patient develops an asthma exacerbation. The patient's medication history lists an inhaled glucocorticoid, montelukast, and a short-acting β2 agonist as needed via a metered-dose inhaler (MDI). The patient's respiratory rate is 18 breaths/minute, heart rate is 96 beats/minute, and oxygen saturation is 95%. The provider auscultates mild expiratory wheezes bilaterally. What action will the provider take first? A. Prescribe a systemic glucocorticoid. B. Prescribe a long-acting β2 agonist. C. Evaluate the need for teaching about MDI use. D. Question the patient about how much albuterol has been used

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

A patient develops shortness of breath shortly after taking the initial dose of a newly prescribed medication. The patient's heart rate is 86 beats/minute, the respiratory rate is 24 breaths/minute, and the blood pressure is 120/70 mm Hg. The prescriber will discontinue the drug based on the assumption the patient experienced what medication induced effect? 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.

A patient with heart failure who takes an angiotensin-converting enzyme (ACE) inhibitor, a thiazide diuretic, and a β blocker for several months comes to the clinic for evaluation. As part of the ongoing assessment of this patient, the provider will focus on which evaluation? A. Complete blood count B. Ejection fraction C. Maximal exercise capacity D. Serum electrolyte levels

ANS: D Patients taking thiazide diuretics can develop hypokalemia, which can increase the risk for dysrhythmias; therefore, the serum electrolyte levels should be monitored closely. A complete blood count is not recommended. This patient is taking the drugs recommended for patients with Stage C heart failure; although the patient's quality of life and ability to participate in activities should be monitored, routine measurement of the ejection fraction and maximal exercise capacity is not warranted at this time.

A child attending daycare is prescribed 750 mg of an antibiotic for 10 days. The drug may be dosed in several ways and is available in two concentrations. Which dosing regimen will the provider consider to best assure drug adherence? A. 375 mg of a 250 mg/5 mL solution PO twice daily B. 250 mg of a 250 mg/5 mL solution PO three times daily C. 250 mg of a 500 mg/5 mL solution PO three times daily D. 375 mg of a 500 mg/5 mL solution 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 daycare or school; it also helps prevent the problem of the medication being left either at home or at school.

A patient receiving heparin postoperatively to prevent deep vein thrombosis has a blood pressure of 90/50 mm Hg and a heart rate of 110 beats/minute. The patient's most recent aPTT is greater than 90 seconds. The patient reports lumbar pain. The provider will order what interventions initially? (Select all that apply.) A. A repeat aPTT to be drawn immediately B. Analgesic medication C. Changing heparin to aspirin D. Protamine sulfate E. Discontinue heparin

ANS: D,E Heparin overdose may cause hemorrhage, which can be characterized by low blood pressure, tachycardia, and lumbar pain. Protamine sulfate should be given, and the heparin should be discontinued. An aPTT may be drawn later to monitor the effectiveness of protamine sulfate. Analgesics are not indicated because the lumbar pain is likely caused by adrenal hemorrhage. Not only will aspirin increase the risk of hemorrhage, but antiplatelet drugs are used to prevent excessive arterial clotting while anticoagulants are used to prevent excessive venous clotting; therefore, they are not used interchangeably.