Pharmacology
A patient is to begin taking doxycycline to treat a rickettsial infection. Which statement by the patient indicates a need for further teaching by the provider about this drug?
"I should take this drug with food to ensure more complete absorption." Absorption of tetracyclines is reduced in the presence of food. The tetracyclines form insoluble chelates with calcium, iron, magnesium, aluminum, and zinc, so patients should not take tetracyclines with dairy products, calcium supplements, or drugs containing these minerals. Patients who experience diarrhea should stop taking the drug and notify the provider so they can be tested for C. difficile infection.
A young, nonpregnant female patient with a history of a previous urinary tract infection is experiencing dysuria, urinary urgency and frequency, and suprapubic pain of 3 days' duration. She is afebrile. A urine culture is positive for more than 100,000/mL of urine. The provider orders which treatment to assure the most effective treatment for this patient?
A 3-day course of trimethoprim/sulfamethoxazole Short-course therapy is recommended for uncomplicated, community-acquired lower urinary tract infections. The short course is more effective than a single dose, and compared with longer course therapies, it is less costly, has fewer side effects, and is more likely to foster compliance. Amoxicillin with clavulanic acid is a second-line drug used for pyelonephritis. Fosfomycin is a second-line drug and can be useful in patients with drug allergies.
A patient will be discharged home to complete treatment with intravenous cefotetan. The prescriber will include which instruction when teaching the patient about this drug treatment?
Abstain from alcohol consumption during therapy. Two cephalosporins, including cefotetan, can induce a state of alcohol intolerance and cause a disulfiram-like reaction when alcohol is consumed; therefore, patients should be advised to avoid alcohol. It is not necessary to avoid dairy products. Patients who experience a rash should report this to their provider. Cefotetan can also promote bleeding, so drugs that inhibit platelet aggregation should be avoided.
The nurse is preparing to administer amphotericin B intravenously. The provider will pretreat the patient with which medications?
Acetaminophen and diphenhydramine Optimum pretreatment before the administration of amphotericin B comprises acetaminophen and diphenhydramine [Motrin] is not suggested as pretreatment. Aspirin is an option, but it may increase kidney damage. Morphine is not indicated in the pretreatment regimen.
A patient who is taking nelfinavir reports moderate to severe diarrhea. What action will the provider recommend?
An over-the-counter antidiarrheal drug A dose-limiting effect of nelfinavir is moderate to severe diarrhea, which can be managed with OTC antidiarrheal medications. Unless the symptoms become severe, withdrawing the nelfinavir is not indicated. Reducing the dose by half or taking it with food is not indicated.
A young female patient is seen in a rural clinic after complaining of abdominal pain. The patient is wearing dirty clothing and is barefoot. The provider orders a complete blood count, which shows that the patient is anemic. The provider suspects that this patient has which of the following infestations?
Ancylostomiasis (hookworm) Ancylostomiasis is most common when hygiene is poor and the patient habitually goes barefoot. Symptomatic anemia may occur in menstruating women or undernourished individuals. Ascariasis is usually asymptomatic. Enterobiasis is characterized by perianal itching. Trichuriasis is usually asymptomatic but may cause rectal prolapse if the worm burden is very large.
During a routine screening, an asymptomatic, pregnant patient at 37 weeks' gestation learns that she has an infection caused by Chlamydia trachomatis. The provider will order which drug?
Azithromycin The preferred treatment for C. trachomatis infection during pregnancy is either azithromycin or amoxicillin. Doxycycline can be used for nonpregnant patients. Erythromycin is used for infants. Sulfisoxazole is not recommended for pregnant women near term, because it can cause kernicterus in the infant.
A patient is about to begin therapy with ethambutol. Before initiating treatment with this drug, the provider orders which test(s) to determine an accurate baseline?
Color vision and visual acuity Optic neuritis is a dose-related adverse effect of ethambutol. Patients receiving this drug should have color vision and visual acuity testing before therapy starts and periodically thereafter. A CBC, hearing evaluations, and hepatic function testing are not recommended.
A patient is HIV positive and the provider is about to prescribe zidovudine. Before the medication therapy is initialed the provider will review which of the patient's latest laboratory values?
Complete blood count (CBC) The patient's CBC should be reviewed to determine whether the patient has anemia and neutropenia. Ketones are not an adverse effect of zidovudine. Nothing indicates a need to monitor the immunoglobulin levels or serum lactate dehydrogenase.
Which side effect of clindamycin causes the provider the most concern and may warrant discontinuation of the drug?
Diarrhea Clostridium difficile-associated diarrhea (CDAD) is a serious, sometimes fatal suprainfection associated with clindamycin. Patients with diarrhea should notify their prescriber immediately and discontinue the drug until this condition has been ruled out. Headache, nausea, and vomiting do not warrant discontinuation of the drug and are not associated with severe side effects.
Before prescribing methenamine, it is important for the provider to review the patient's history for evidence of which problem?
Elevated blood urea nitrogen and creatinine Methenamine should not be given to patients with renal impairment, because crystalluria can occur. There is no cross-reactivity between methenamine and antibiotic agents. Methenamine is safe for use during pregnancy. There is no organism drug resistance to methenamine.
A 6-week-old infant who has not yet received immunizations develops a severe cough. While awaiting nasopharyngeal culture results, the provider will prescribe which antibiotic?
Erythromycin ethylsuccinate Erythromycin is the drug of first choice for infections caused by Bordetella pertussis, the causative agent of whooping cough. Infants who have not received their first set of immunizations are at increased risk of pertussis. Clindamycin, doxycycline, and penicillin are not recommended.
A patient who is being treated for HIV infection has a 5-mm area of induration after a routine TB skin test. The patient's chest radiograph is normal, and there are no other physical findings. The provider will prescribe which medications to begin treatment?
Isoniazid and rifabutin Rifabutin is used off-label as an alternative to rifampin to treat TB in patients with HIV, because it has less impact on the metabolism of protease inhibitors. The effects of rifapentine on protease inhibitors are similar to those of rifampin. Pyrazinamide is not indicated.
A patient with HIV who takes protease inhibitors develops tuberculosis and will begin treatment. Which drug regimen will the provider prescribe for this patient?
Isoniazid, pyrazinamide, ethambutol + rifabutin Patients with HIV who take protease inhibitors are susceptible to drug interactions with rifampin, which accelerates the metabolism of protease inhibitors. Rifabutin can be substituted for rifampin in patients with HIV, because the degree of acceleration of this metabolism is less. A three-drug regimen would increase drug resistance, as would a two-drug regimen.
A patient who takes an ACE inhibitor and an angiotensin receptor blocker (ARB) medication will begin taking TMP/SMZ to treat a urinary tract infection. Which serum electrolyte will the provider monitor closely?
Potassium Trimethoprim suppresses renal excretion of potassium, increasing the risk of hyperkalemia. Patients at greatest risk are those taking high doses of trimethoprim and those taking other drugs that elevate potassium, including ACE inhibitors and ARB medications. Trimethoprim does not affect other serum electrolytes.
A female patient who has hepatitis C is being treated with pegylated interferon α and ribavirin. It will be important for the provider to discuss what topic with the patient?
She will need a monthly pregnancy test during her treatment. Ribavirin causes severe fetal injury and is contraindicated during pregnancy. Women taking ribavirin must rule out pregnancy before starting the drug, monthly during treatment, and monthly for 6 months after stopping treatment. Inhaled ribavirin is also embryo lethal and teratogenic. Adding a protease inhibitor will reduce the efficacy of oral contraceptives. Women using ribavirin should use two reliable forms of birth control.
What medication will the provider prescribe for a patient with an Enterococcus faecium associated infection who has proven to be ampicillin resistant? (Select all that apply.)
Tigecycline, Linezolid, An alternative treatment for an enterococcus faecium-realated infection diagnosed in a patient who is ampicillin resistant includes linezolid. None of the other options are known to be effective in the case of an enterococcus faecium infection.
Which condition is generally treated with oral antifungal agents?
Tinea capitis Tinea capitis must be treated with oral agents for 6 to 8 weeks. Tinea corporis, tinea cruris, and tinea pedis may be treated topically.
A patient has an invasive aspergillosis infection. Which antifungal agent will the prescriber consider the drug of choice for this infection?
Voriconazole Voriconazole has replaced amphotericin B as the drug of choice for treating invasive aspergillosis. Fluconazole, which is fungistatic, is not used to treat aspergillosis. Posaconazole is used for prophylaxis of aspergillosis in immunocompromised patients.
A patient comes to the clinic and receives valacyclovir for a herpes-zoster virus. When will the provider instruct the patient to take the medication?
Without regard to meals The patient may take the medication without regard to meals. The patient does not need to avoid dairy products, take the pill only in the morning, or take it on an empty stomach.
A patient has a localized skin infection, which is most likely caused by a gram-positive cocci. Until the culture and sensitivity results are available, the provider will order a ____-spectrum ____ agent.
narrow, topical When infections are treated before the causative agent has been identified, and after cultures have been obtained, antibiotics may be used based on the knowledge of which microbes are most likely to cause infection at that particular site. Because this is a localized infection, a topical agent is recommended. Unless the infection is very serious, a narrow-spectrum antibiotic is best.
Quinolone antibiotics
produce QT prolongation
A patient who is taking didanosine reports nausea, vomiting, and abdominal pain. What will the provider recommend to this patient?
"You will need laboratory tests to determine if these are serious effects of the drug." As with all NRTIs, pancreatitis may occur and may manifest as nausea, vomiting, and abdominal pain. The patient will need evaluation of serum amylase, triglycerides, and calcium. Taking the drug with food or at a different time of day is not indicated. It is not correct to discontinue the drug and to resume it when symptoms subside, since pancreatitis may be fatal.
A patient received 500 mg of azithromycin at 0800 as a first dose. What order will the provider write for the amount and time of the second dose of azithromycin?
250 mg at 0800 the next day Azithromycin generally is given as 500 mg on the first day and then 250 mg/day for the next 4 days, so the second dose would be 24 hours after the first dose.
A patient is receiving tobramycin three times daily. The provider has ordered a trough level with the 8:00 AM dose and will expect the level to be drawn at what time?
7:45 AM When a patient is receiving divided doses of an aminoglycoside, the trough level should be drawn just before the next dose; therefore, 7:45 AM would be the appropriate time. It would not be appropriate to draw a trough at the other times listed.
A patient complains of painful urination. A physical examination reveals vesicles on her labia, vagina, and the foreskin of her clitoris. Which medication will the provider prescribe?
Acyclovir Genital herpes can be treated with acyclovir, famciclovir, or valacyclovir, which are antiviral medications. Azithromycin, metronidazole, and tinidazole are antibiotics and do not have antiviral effects.
Which cephalosporin may the prescriber order to treat meningitis?
Cefotaxime Cefotaxime has increased ability to reach the cerebrospinal fluid (CSF) and to treat meningitis. Cefaclor, cefazolin, and cefoxitin do not reach effective concentrations in the CSF.
The nurse is caring for a patient who is taking a protease inhibitor (PI). Upon review of the laboratory test results, the nurse notes that the patient has newly elevated plasma triglycerides and cholesterol. Upon being notified of the test results, what action will the provider take?
Discuss diet modification and exercise. All PIs can elevate plasma levels of cholesterol and triglycerides. Potential interventions for hyperlipidemia include modified diet, exercise, and lipid-lowering agents. Lovastatin and simvastatin should be avoided, because they can accumulate to dangerous levels. Pancreas is not indicated to lower triglycerides and cholesterol.
A patient is given a new prescription for potassium penicillin G given intravenously (IV) every 8 hours and gentamicin given IV every 12 hours. Which is the best schedule for administering these drugs?
Give the penicillin at 0800, 1600, and 2400; give the gentamicin [Garamycin] at 1800 and 0600.Gentamicin should never be administered concurrently with penicillin, because they will interact, and the penicillin may inactivate the aminoglycoside. All the other options show concurrent administration.
A nurse is preparing to administer oral ofloxacin to a patient. While taking the patient's medication history, the nurse learns that the patient takes warfarin and theophylline. Upon learning this information, what action will the provider take?
Order daily coagulation levels. Ofloxacin increases plasma levels of warfarin, so coagulation tests should be monitored. The ofloxacin dose should not be reduced or increased. Ofloxacin does not affect theophylline levels.
A patient with an infection caused by Pseudomonas aeruginosa is being treated with piperacillin. The nurse providing care reviews the patient's laboratory reports and notes that the patient's blood urea nitrogen and serum creatinine levels are elevated. What action will the provider take when notified of the elevated lab results?
Reduces the dosage of piperacillin Patients with renal impairment should receive lower doses of piperacillin than patients with normal renal function. Aminoglycosides are nephrotoxic. Penicillin G and nafcillin are not effective against Pseudomonas infections.
A patient is about to receive penicillin G for an infection that is highly sensitive to this drug. While obtaining the patient's medication history, the nurse learns that the patient experienced a rash when given amoxicillin as a child 20 years earlier. What action will the provider take when made aware of the patient's past reaction to amoxicillin?
Request an order for a skin test to assess the current risk. Allergy to penicillin can decrease over time; therefore, in patients with a previous allergic reaction who need to take penicillin, skin tests can be performed to assess the current risk. Until this risk is known, changing to a cephalosporin is not necessary. Reassuring the patient that allergic responses will diminish is not correct, because this is not always the case; the occurrence of a reaction must be confirmed with skin tests. Desensitizing schedules are used when patients are known to be allergic and the drug is required anyway.
A patient starting therapy with efavirenz asks about the timing of the medication with regard to meals. What patient education about the administration of this medication should the prescriber provide?
The drug should be taken once daily on an empty stomach. The nurse should advise the patient that the medication should be taken once daily on an empty stomach. Thirty minutes after a meal is too soon to take the medication. The medication is taken on an empty stomach, because high-fat meals increase plasma levels by 39% with capsules and by 79% with tablets. The medication must not be taken with high-fat meals.
A provider determines that a patient requires a prescription for a narrow spectrum antibacterial drug to treat a gram-positive cocci-related infection. What option will the provider consider? (Select all that apply.)
Vancomycin, Penicillin G, Erythromycin Examples of narrow spectrum antibacterial drugs include penicillin G, erythromycin, and vancomycin. Trimethoprin and tetracycline are broad spectrum antibiotics.
Which patient will the provider determine should begin treatment for tuberculosis?
A recent immigrant from a country with a high prevalence of TB with a 10-mm region of induration The immigrant is considered to be at moderate risk, meaning that a 10-mm area of induration on a tuberculin skin test (TST) is considered a positive result. After being evaluated for active TB, this patient should be treated for latent TB. A patient with HIV is considered high risk, but this patient has a negative TST result of less than 5 mm. For a low-risk patient receiving a screening TST for a job, the area of induration must be 15 mm or greater to be considered a positive result. An IV drug abuser is in the moderate-risk category; an area of induration of 10 mm or greater is needed to be considered a positive TST result.
A patient is diagnosed with a lung infection caused by P. aeruginosa. The culture and sensitivity report shows sensitivity to all aminoglycosides. The provider knows that the rate of resistance to gentamicin is common in this hospital. What provider will order which medication?
Amikacin When resistance to gentamicin and tobramycin is common, amikacin is the drug of choice for initial treatment of aminoglycoside-sensitive infections. Gentamicin would not be indicated, because resistance is more likely to develop. Paromomycin is used only for local effects within the intestine and is given orally. Tobramycin is not indicated, because organisms can more readily develop resistance.
A child with an ear infection is not responding to treatment with amoxicillin. What alternative medication will the provider order?
Amoxicillin-clavulanic acid β-lactamase inhibitors are drugs that inhibit bacterial β-lactamases. These drugs are always given in combination with a penicillinase-sensitive penicillin. Augmentin contains amoxicillin and clavulanic acid and is often used when patients fail to respond to amoxicillin alone. Ampicillin is similar to amoxicillin, but amoxicillin is preferred and, if drug resistance occurs, ampicillin is equally ineffective. Pharmaceutical chemists have developed a group of penicillins that are resistant to inactivation by β-lactamases (e.g., nafcillin), but these drugs are indicated only for penicillinase-producing strains of staphylococci. Penicillin G would be as ineffective as amoxicillin if β-lactamase is present.
A patient diagnosed with hepatitis B begins treatment with adefovir and asks how long the drug therapy will last. What time frame will the prescriber give the patient?
An indefinite, prolonged period of time Current guidelines recommend treatment only for patients at highest risk; it is unknown whether treatment should continue lifelong. Treatment is usually prolonged, without a specific period of time. Nephrotoxicity is common but is not the deciding factor when determining length of effective treatment.
Which patient diagnosed with a urinary tract infection will be hospitalization and prescribed intravenous antibiotics?
An older adult man with a low-grade fever, flank pain, and an indwelling catheter The patient with an indwelling catheter and signs of pyelonephritis shows signs of a complicated UTI, which is best treated with intravenous antibiotics. Three other patients show signs of uncomplicated urinary tract infections that are not severe and can be treated with oral antibiotics.
A patient who is being treated with medication for both HIV and tuberculosis but a four-drug regimen taken for 3 months has shown no improvement in symptoms. Which drug will the provider add to this patient's regimen?
Bedaquiline Bedaquiline is a newer, highly effective anti-TB drug that does not accelerate the metabolism of HIV drugs and is sued for multidrug-resistant TB. Capreomycin is a second-line drug used for drug-resistant TB, but is not as effective as bedaquiline. Ethionamide is a second-line drug that is less well tolerated of all anti-TB agents and is used only when there is no alternative. Pyridoxine is given to prevent peripheral neuritis in patients taking isoniazid.
A patient has a skin infection and the culture reveals methicillin-resistant Staphylococcus aureus (MRSA). What medication treatment should the provider prescribe for this patient?
Ceftaroline Ceftaroline is a fifth-generation cephalosporin with a spectrum similar to third-generation cephalosporins but also with activity against MRSA. Cefaclor is a second-generation cephalosporin. Cefazolin is a first-generation cephalosporin. Cefotaxime is a third-generation cephalosporin.
An adolescent patient with mild cervicitis is diagnosed with gonorrhea. The provider will order which treatment regimen?
Ceftriaxone, 250 mg IM once, and azithromycin, 1 g PO once The only options for treating cervical infection with gonorrhea are cefixime and ceftriaxone. Ceftriaxone is recommended over cefixime because of antibiotic resistance to cefixime. Because a high percentage of patients with gonorrhea also have chlamydial infections, they should be treated with either doxycycline or azithromycin until a chlamydial infection has been ruled out. Azithromycin combined with doxycycline would not treat gonorrhea. Ceftriaxone would treat gonorrhea only. Doxycycline would treat chlamydia only.
A patient comes to a clinic for tuberculosis medications 2 weeks after beginning treatment with a four-drug induction phase. The patient's sputum culture remains positive, and no drug resistance is noted. At this point, the provider will take what action?
Continue the four-drug regimen and recheck the sputum in 2 weeks. In patients with positive pretreatment sputum test results, sputum should be evaluated every 2 to 4 weeks until cultures are negative and then monthly thereafter. In the absence of drug resistance, treatment with the same regimen should continue. Sputum cultures should become negative in over 90% of patients in 3 or more months. The induction phase should last 2 months, so this patient should remain on a four-drug regimen. It is not necessary to order a chest radiograph or to add another drug at this stage of treatment. The patient is stable and has not developed symptoms that cause concern, so the patient does not need to be questioned about adherence.
A provider would prescribe which antibiotic to a patient diagnosed with methicillin-resistant Staphylococcus aureus (MRSA)?
Daptomycin Daptomycin is active against MRSA. Levofloxacin and norfloxacin are not approved to treat MRSA. Ciprofloxacin is a poor choice for staphylococcal infections, including MRSA.
A patient recently began receiving clindamycin to treat an infection. After 8 days of treatment, the patient reports having 10 to 15 watery stools per day. What action will the provider take to address the patient's diarrhea?
Discontinue the clindamycin immediately. Clostridium difficile-associated diarrhea (CDAD) is the most severe toxicity of clindamycin; if severe diarrhea occurs the patient should be told to stop taking clindamycin immediately and to contact the provider so that treatment with vancomycin or metronidazole can be initiated. Increasing the dose of clindamycin will not treat this infection. Consuming extra fluids while still taking the clindamycin is not correct, because CDAD can be fatal if not treated. Taking Lomotil or bulk laxatives only slows the transit of the stools and does not treat the cause.
A patient who has been receiving intravenous gentamicin for several days reports having had a headache for 2 days. What action will the provider take?
Discontinue the gentamicin. A persistent headache may be a sign of developing ototoxicity, and since ototoxicity is largely irreversible, gentamicin should be withdrawn at the first sign of developing ototoxicity. A gentamicin trough should be obtained before the next dose is given when high gentamicin levels are suspected. Analgesics are not indicated until a serious cause of the headache has been ruled out. A headache is an early sign of ototoxicity, not nephrotoxicity.
A patient receiving a cephalosporin develops a secondary intestinal infection caused by Clostridium difficile. What action will the provider take to provide effective care for this patient?
Discontinuing the cephalosporin and beginning metronidazole Patients who develop C. difficile infection (CDI) as a result of taking cephalosporins or other antibiotics need to stop taking the antibiotic in question and begin taking either metronidazole or vancomycin. Adding one of these antibiotics without withdrawing the cephalosporin is not indicated. CDI must be treated with an appropriate antibiotic, so stopping all antibiotics is incorrect. Increasing the cephalosporin dose would only aggravate the CDI.
A patient is diagnosed with pelvic inflammatory disease (PID). Which treatment regimen is most appropriate for reducing the risk of sterility in this patient?
Doxycycline, 100 mg IV twice daily, and cefoxitin, 2 g IV every 6 hours in the hospital Many experts recommend that all patients with PID receive IV antibiotics in the hospital to minimize the risk of sterility and other complications. Medications used intravenously can be cefoxitin or cefotetan combined with doxycycline; when symptoms resolve, IV therapy may be discontinued but must be followed by PO doxycycline. Outpatient regimens are not recommended. Oral medications are not recommended for initial treatment.
A patient will be discharged from the hospital with a prescription for TMP/SMZ. When providing teaching for this patient, the provider will discuss the importance of what action while taking this medication?
Drinking 8 to 10 glasses of water every day TMP/SMZ can injure the kidneys, because it causes deposition of sulfonamide crystals in the kidneys. Patients should be advised to drink 8 to 10 glasses of water a day to maintain a urine flow of 1200 mL in adults. Trimethoprim can cause hyperkalemia, so consuming extra potassium is unnecessary. The medication should be taken on an empty stomach. It is not necessary to consume extra folic acid, because mammalian cells use dietary folate and do not have to synthesize it; it is the process of folic acid synthesis that is altered by sulfonamides.
A patient is to undergo orthopedic surgery, and the prescriber will order a cephalosporin to be given preoperatively as prophylaxis against infection. Which generation of cephalosporin will the provider order?
First First-generation cephalosporins are widely used for prophylaxis against infection in surgical patients, because they are effective, less expensive, and have a narrower antimicrobial spectrum than second-, third-, and fourth-generation cephalosporins.
A patient with a history of congestive heart failure and renal impairment is diagnosed with esophageal candidiasis. Which antifungal agent will the provider prescribe this patient?
Fluconazole Fluconazole is a drug of choice for treating systemic candidal infections. Amphotericin is nephrotoxic and should not be used in patients with existing renal disease. Itraconazole is a possible alternative agent for treating candidiasis but has serious cardiac side effects. Voriconazole is a drug of first choice for treating aspergillosis but not for candidiasis.
A patient reporting burning on urination and increased frequency has a history of frequent urinary tract infections (UTIs). The patient is going out of town in 2 days and the provider wants to treat the infection quickly. What medication will the provider order?
Fosfomycin Fosfomycin has been approved for single-dose therapy of UTIs in women. Vancomycin and aztreonam are not indicated for UTIs. Bactrim is indicated for UTIs, but administration of a single dose is not therapeutic.
A patient is given a new prescription for potassium penicillin G given intravenously (IV) every 8 hours and gentamicin given IV every 12 hours. Which is the best schedule for administering these drugs?
Give the penicillin at 0800, 1600, and 2400; give the gentamicin [Garamycin] at 1800 and 0600. Gentamicin should never be administered concurrently with penicillin, because they will interact, and the penicillin may inactivate the aminoglycoside. All the other options show concurrent administration.
A patient is HIV positive and has a previous history of drug and alcohol abuse. The patient is being treated with combination therapies, including didanosine. Which laboratory findings would most concern the provider?
Increased serum amylase and triglycerides and decreased serum calcium The nurse should be concerned about increased serum amylase triglycerides and a decrease in serum calcium, which are symptoms of pancreatitis, the major adverse effect of didanosine. The other laboratory test results and assessment findings are not consistent with pancreatitis and are not a concern.
A pregnant female patient diagnosed with bacteriuria, suprapubic pain, urinary urgency and frequency, and a low-grade fever is allergic to sulfa, ciprofloxacin, and amoxicillin. The provider will prescribe which alternative medication to treat this patient?
Methenamine Methenamine is an excellent second-line drug for this patient and is indicated because of the patient's multiple drug sensitivities. It is safe in pregnancy, and there is no drug resistance. Nitrofurantoin has potential harmful effects on the fetus and should not be used during pregnancy. Single-dose regimens are not recommended in pregnant women. Cephalexin can have cross-reactivity with amoxicillin.
A patient is about to begin treatment with isoniazid. When the provider learns that the patient also takes phenytoin for seizures what action will be taken?
Monitoring phenytoin levels Isoniazid is a strong inhibitor of three cytochrome P450 enzymes, and inhibition of these enzymes can raise the levels of other drugs, including phenytoin. Patients taking phenytoin should have the levels of this drug monitored, and the dose should be reduced if appropriate. Reducing the dose of isoniazid is not indicated. It is not necessary to monitor isoniazid levels.
A patient diagnosed with histoplasmosis is being treated with itraconazole. The provider will teach this patient to report which symptoms?
Nausea, vomiting, and anorexia Itraconazole is associated with rare cases of liver failure, some of which were fatal. Patients should be instructed to report signs of liver toxicity, including nausea, vomiting, and anorexia. Ketoconazole is associated with gynecomastia and libido changes. Headache and rash are associated with fluconazole. Visual disturbances may occur with voriconazole
A patient shows signs and symptoms of conjunctivitis. Which aminoglycoside will the provider order?
Neomycin Neomycin is used for topical treatment of infections of the eye, ear, and skin. Amikacin, kanamycin, and paromomycin are not topical treatments and are not indicated for eye infections.
A patient diagnosed with HIV and mucocutaneous HSV is being treated with foscarnet after failing treatment with acyclovir. After 2 weeks, the patient's dose is increased to 90 mg/kg over 2 hours from 40 mg/kg over 1 hour. The patient reports numbness in the extremities and perioral tingling. What action will the provider take?
Order a serum calcium level. Foscarnet frequently causes hypocalcemia and other electrolyte and mineral imbalances. Paresthesias, numbness in the extremities, and perioral tingling can indicate hypocalcemia, so a calcium level should be drawn. These are not signs of foscarnet overdose. Nephrotoxicity may occur, but these are not signs of renal complications, so a creatinine clearance is not indicated. If nephrotoxicity occurs, prehydration with IV saline is indicated to reduce the risk of renal injury.
A patient is receiving intravenous potassium penicillin G, 2 million units to be administered over 1 hour. At 1900, the nurse notes that the dose hung at 1830 has infused completely. What action will the provider take when notified of this medication error?
Order a serum electrolyte test and cardiac monitoring STAT. Although penicillin G is the least toxic of all antibiotics, certain adverse effects may be caused by compounds coadministered with penicillin. When large doses of potassium penicillin G are administered rapidly, hyperkalemia can occur, which can cause fatal dysrhythmias. When penicillin G is administered IM, tissue necrosis occurs with inadvertent intraarterial injection. Confusion, seizures, and hallucinations can occur if blood levels of the drug are too high. Bizarre behaviors result with large IV doses of procaine penicillin G.
An older adult patient with a history of chronic obstructive pulmonary disease (COPD) develops bronchitis. The patient has a temperature of 39.5°C. What action will the provider initially take to assure effective care for this patient?
Order an empiric antibiotic while waiting for sputum culture results. Patients with severe infections should be treated while culture results are pending. If a patient has a severe infection or is at risk of serious sequelae if treatment is not begun immediately, it is not correct to wait for culture results before beginning treatment. Until a bacterial infection is ruled out, treating symptomatically is not indicated. Treating without obtaining cultures is not recommended.
A drug history from a patient about to receive sulfadiazine identifies that the patient takes warfarin, glipizide, and a thiazide diuretic. Based on this information, what action will the provider take?
Order daily coagulation levels to be drawn. Sulfonamides interact with several drugs and through metabolism-related interactions can intensify the effects of warfarin. Patients taking both should be monitored closely for bleeding tendencies. Changing to the combination product will not help, because sulfonamides are still present. Sulfonamides intensify glipizide levels, so this drug may actually need to be reduced. Trimethoprim, not sulfonamides, raises potassium levels
A patient with HIV contracts herpes simplex virus (HSV), and the prescriber orders acyclovir 400 mg PO twice daily for 10 days. After 7 days of therapy, the patient reports having an increased number of lesions. What action will the provider take?
Order intravenous foscarnet every 8 hours for 2 to 3 weeks. Foscarnet is active against all known herpesviruses and is used in immunocompromised patients with acyclovir-resistant HSV or VZV. This patient is demonstrating resistance to acyclovir, so extending acyclovir therapy or increasing the acyclovir dose will not be effective. Valacyclovir is not approved for use in immunocompromised patients because of the risk for thrombotic thrombocytopenic purpura/hemolytic uremic syndrome.
A patient taking isoniazid for 4 months for latent tuberculosis reports bilateral tingling and numbness of the hands and feet, as well as feeling clumsy. What action will the provider take?
Order pyridoxine 100 mg per day. Patients sometimes develop peripheral neuropathy, characterized by paresthesias, clumsiness, and muscle aches. If these occur, they may be reversed by administering pyridoxine (vitamin B6). It is not necessary to discontinue the isoniazid. Lowering the isoniazid dose and adding rifampin is not indicated. Rechecking the TST is not indicated.
A patient will begin taking an immunosuppressant medication. The provider learns that a patient about to begin immunosuppressant medication has a history of frequent candidal infections. The provider will order which drug as prophylaxis?
Posaconazole Posaconazole is used as prophylaxis for invasive Aspergillus and Candida infections in immunocompromised patients. Fluconazole, ketoconazole, and voriconazole are not used prophylactically.
A patient has a positive urine culture 1 week after completion of a 3-day course of antibiotics. What action will the prescriber take?
Prescribe a 2-week course of antibiotics. Patients who develop a subsequent urinary tract infection after treatment are treated in a stepwise fashion, beginning with a longer course of antibiotics. The next steps would be to begin a 4- to 6-week course of therapy, followed by a 6-month course of therapy if that is unsuccessful. If urinary tract infections are thought to be caused by other complicating factors, an evaluation for structural abnormalities may be warranted. Unless the infections are severe or are complicated, intravenous antibiotics are not indicated.
A patient with a urinary tract infection is given a prescription for TMP/SMZ. When reviewing the drug with the patient, the provider learns that the patient has type 1 diabetes mellitus and consumes alcohol heavily. What action will the provider take?
Prescribe a different antibiotic for this patient. Alcoholics are likely to be folate deficient and have an increased risk of megaloblastic anemia when taking TMP/SMZ, so withholding this drug in this population is recommended. TMP/SMZ shares hypersensitivity reactions with oral sulfonylurea-type hypoglycemics that are used with type 2 diabetes mellitus, so it is not necessary to assess the blood glucose level more often. TMP/SMZ can cause hyperkalemia, so potassium supplements are contraindicated. Patients taking TMP/SMZ should consume more fluids to maintain renal blood flow and prevent renal damage.
A provider has ordered oral voriconazole for a patient who has a systemic fungal infection. The nurse obtains a medication history and learns that the patient takes phenobarbital for seizures. When the nurse contacts the provider what action will the provider take?
Prescribe a different antifungal agent. Voriconazole can interact with many drugs. It should not be combined with drugs that are powerful P450 inhibitors, including phenobarbital, because these can reduce the levels of voriconazole. Administering the voriconazole IV will not increase the serum level. It is not correct to reduce the dose of either drug.
The provider is reviewing the culture results of a patient receiving an aminoglycoside. The report reveals an anaerobic organism as the cause of infection. What action will the provider take?
Prescribe a different class of antibiotic. Aminoglycosides are not effective against anaerobic microbes, so another class of antibiotics is indicated. There is no associated increase in aminoglycoside toxicity with anaerobic infection. The aminoglycoside will not be effective, so continuing to administer this drug is not indicated. Adding another antibiotic is not useful, because the aminoglycoside is not necessary.
A patient with a history of renal calculi has fever, flank pain, and bacteriuria. What action will the provider take?
Prescribe antibiotic therapy after urine culture and sensitivity results are available. Patients with renal calculi are more likely to have complicated urinary tract infections that have less predictable microbiologic etiologies. Because the symptoms are mild, it is important first to obtain a culture and sensitivity to assist with antibiotic selection. If symptoms worsen, a broad-spectrum antibiotic may be started until sensitivity information is available. Intravenous antibiotics are indicated for severe pyelonephritis. Long-term prophylaxis is not indicated unless this patient develops frequent reinfection.
A patient who is receiving intravenous ciprofloxacin for pneumonia develops diarrhea. A stool culture is positive for Clostridium difficile. What action will the provider take?
Prescribe metronidazole. C. difficile is resistant to fluoroquinolones; metronidazole is the drug of choice to treat this infection. Metronidazole is lethal only to anaerobic organisms, so the ciprofloxacin should be continued to treat the pneumonia. Increasing the dose of ciprofloxacin is not indicated, because C. difficile is resistant to ciprofloxacin. Gemifloxacin is approved for use in respiratory infections. Dairy consumption will have little effect on the diarrhea.
A patient who is taking doxycycline for a serious infection reports anal itching. What action will the provider take?
Prescribing an antifungal drug to treat a superinfection A superinfection occurs secondary to suppression of drug-sensitive organisms. Overgrowth with fungi, especially Candida albicans, is common and may occur in the mouth, pharynx, vagina, or bowel. Anal itching is a sign of such an infection, not a sign of hepatotoxicity. Antihistamines will not treat the cause. C. difficile infection is characterized by profuse, watery diarrhea.
An older male patient comes to the clinic with reports of chills, malaise, myalgia, localized pain, dysuria, nocturia, and urinary retention. The provider will suspect what cause for the patient's symptomology?
Prostatitis The provider should suspect prostatitis, which is manifested by high fever, chills, malaise, myalgia, and localized pain, and may also be manifested by dysuria, nocturia, and urinary urgency, frequency, and retention. Clinical manifestations of acute cystitis include dysuria, urinary urgency and frequency, suprapubic discomfort, pyuria, and bacteriuria. Urinary tract infections are very general and are classified by their location. Pyelonephritis is characterized by fever, chills, severe flank pain, dysuria, and urinary frequency and urgency, as well as by pyuria and bacteriuria.
A patient presents to the emergency department with chills, severe flank pain, dysuria, and urinary frequency. The patient has a temperature of 102.9°F, a pulse of 92 beats/minute, respirations of 24 breaths/minute, and a blood pressure of 119/58 mm Hg. The provider suspects that the patient is showing signs and symptoms of what pathology?
Pyelonephritis The provider should suspect pyelonephritis. Pyelonephritis is characterized by fever, chills, severe flank pain, dysuria, urinary urgency and frequency, and pyuria and bacteriuria. Clinical manifestations of acute cystitis include dysuria, urinary urgency and frequency, suprapubic discomfort, pyuria, and bacteriuria. Urinary tract infections (UTIs) are very general and are classified by their location. These symptoms are specific to pyelonephritis. Prostatitis is manifested by high fever, chills, malaise, myalgia, localized pain, and various UTI symptoms, but not by severe flank pain.
A provider has ordered intravenous gentamicin at a dose that is half the usual dose for an adult patient. What factor noted in the patient's medical history would be a likely reason for this action?
Renal disease The aminoglycosides are eliminated primarily by the kidneys, so in patients with renal disease, doses should be reduced or the dosing interval should be increased to prevent toxicity. Patients with antibiotic resistance would be given amikacin. Interpatient variation may occur but cannot be known without knowing current drug levels. Aminoglycosides are not metabolized by the liver, so liver disease would not affect drug levels.
A patient develops Clostridium difficile-associated diarrhea (CDAD). Which antibiotic will the prescriber order to treat this infection?
Vancomycin Vancomycin and metronidazole are the drugs of choice for treating CDAD.
A patient is taking oral ketoconazole for a systemic fungal infection. The medication administration record notes that the patient is also taking omeprazole for reflux disease. What instructions will the provider give the patient to maximize medication effectiveness?
Take the omeprazole at least 2 hours after the ketoconazole. The nurse should administer the omeprazole at least 2 hours after the ketoconazole to prevent a drug-to-drug interaction. Drugs that reduce gastric acidity should be administered no sooner than 2 hours after ingestion of ketoconazole, because they reduce absorption of the drug. There is no need to restrict dairy products or wear sun glasses because neither ketoconazole nor omeprazole have a potential to require such measures.
A patient who has been taking linezolid for 6 months develops vision problems and is worried about blindness. What response will the provider give to address the patient's concern?
Tell the patient that this symptom is reversible when the drug is discontinued. Linezolid is associated with neuropathy, including optic neuropathy. This is a reversible effect that will stop when the drug is withdrawn. Reassuring the patient that this is a harmless side effect is not correct. It is not an indication that blindness will occur. Tyramine supplements are not indicated.
A patient who is taking nitrofurantoin reports experiencing several side effects. Which side effect would cause the provider the most concern and would require discontinuation of the medication?
Tingling of the fingers Tingling of the fingers can indicate peripheral neuropathy, which can be an irreversible side effect of nitrofurantoin. The other side effects are not serious and can be reversed.
A 20-year-old female patient presents with suprapubic discomfort, pyuria, dysuria, and bacteriuria greater than 100,000/mL of urine. Which are the most likely diagnosis and treatment?
Uncomplicated lower urinary tract infection treatable with short-course therapy These are symptoms of uncomplicated cystitis, which is a lower urinary tract infection that can be treated with a short course of antibiotics. Short-course therapy is more effective than single-dose therapy and is preferred. A complicated lower urinary tract infection would be associated with some predisposing factor, such as renal calculi, an obstruction to the flow of urine, or an indwelling catheter. Upper urinary tract infections often include severe flank pain, fever, and chills.
A patient diagnosed with cystic fibrosis has a Pseudomonas aeruginosa infection and the provider has ordered aztreonam. What instruction will the provider give the patient regarding the administration of this drug?
Use the nebulizer to administer the drug three times daily. Cayston is a form of aztreonam formulated for inhalation administration for patients with cystic fibrosis who have P. aeruginosa lung infections. The reconstituted powder is given using a nebulizer system three times daily for 28 days followed by 28 days off. This form of the drug is not given IM. The dose is three times daily. The drug is reconstituted and administered via a nebulizer.
