week 2

A patient has urethritis. The primary care NP should prescribe: a. minocycline. b. doxycycline. c. tetracycline. d. demeclocycline.

ANS: A Minocycline is indicated to treat urethritis. DIF: Cognitive Level: Applying (Application) REF: 685

A primary care NP is preparing to prescribe a fluoroquinolone for a patient who has a history of alcohol abuse that has caused liver damage. The NP should choose: a. norfloxacin. b. levofloxacin. c. gemifloxacin. d. ciprofloxacin.

ANS: B Levofloxacin has less risk of hepatic adverse events than other fluoroquinolones. DIF: Cognitive Level: Understanding (Comprehension) REF: 696

A primary care nurse practitioner (NP) sees a 3-year-old child who has a history of recurrent otitis media. The child's parent tells the NP that the child is allergic to penicillin. The NP learns that the child developed an all-over rash 2 days after starting amoxicillin at age 2 years. The NP should: a. order a penicillin skin test. b. use cephalosporins when treating otitis media. c. order penicillin desensitization so the child can take penicillin when needed. d. use amoxicillin when needed because actual allergy correlates poorly with patient report.

ANS: A Although it is true that patient report correlates poorly with actual allergy, there is a risk of life-threatening anaphylaxis with a true penicillin allergy. The NP should order a penicillin skin test to verify allergy. If the skin test is positive, the patient should avoid b-lactam antimicrobials. Penicillin desensitization can be used for penicillin-allergic patients who need penicillins. DIF: Cognitive Level: Applying (Application) REF: 672

A primary care NP is planning to order a macrolide antibiotic for a patient who is experiencing an exacerbation of chronic obstructive pulmonary disease. The patient is taking a cytochrome (CYP) 3A medication. The NP should order: a. azithromycin. b. clarithromycin. c. erythromycin base. d. erythromycin estolate.

ANS: A Azithromycin does not interact with other CYP 3A medications. Erythromycin and clarithromycin do. DIF: Cognitive Level: Applying (Application) REF: 690

A school-age child comes to the clinic with a 5-day history of cough and low-grade fever. The primary care NP auscultates crackles and diminished breath sounds bilaterally. The NP should: a. order azithromycin. b. prescribe doxycycline. c. obtain a sputum culture. d. recommend symptomatic treatment.

ANS: A Community-acquired pneumonia in school-age children is commonly caused by Mycoplasma. Azithromycin is a first-line drug of choice to treat this type of pneumonia. DIF: Cognitive Level: Applying (Application) REF: 662

A primary care NP sees a 6-month-old patient who has a persistent staccato cough. The NP is aware that there is a pertussis outbreak in the community. The NP should obtain appropriate cultures and treat empirically with: a. erythromycin. b. azithromycin. c. clarithromycin. d. telithromycin.

ANS: A Erythromycin is a first-choice drug for the treatment of pertussis. DIF: Cognitive Level: Applying (Application) REF: 688

A patient is taking an aminoglycoside and a cephalosporin. The primary care NP should consider _____ the dose of _____. a. increasing; cephalosporin b. decreasing; cephalosporin c. increasing; aminoglycoside d. decreasing; aminoglycoside

ANS: D Cephalosporins can heighten aminoglycoside toxicity, so a decrease in the dose of the aminoglycoside should be considered. DIF: Cognitive Level: Applying (Application) REF: 682

Which antibiotic requires administration of a loading dose? a. Ilosone b. E-Mycin c. Erythrocin d. Zithromax

ANS: D It is important to give a loading dose, without which minimum plasma concentrations may take 5 to 7 days to reach steady state. DIF: Cognitive Level: Understanding (Comprehension) REF: 690

A 5-year-old child who has no previous history of otitis media is seen in clinic with a temperature of 100° F. The primary care NP visualizes bilateral erythematous, nonbulging, intact tympanic membranes. The child is taking fluids well and is playing with toys in the examination room. The NP should: a. prescribe azithromycin once daily for 5 days. b. prescribe amoxicillin twice daily for 10 days. c. prescribe amoxicillin-clavulanate twice daily for 10 days. d. initiate antibiotic therapy if the child's condition worsens.

ANS: D Signs and symptoms of otitis media that indicate a need for antibiotic treatment include otalgia, fever, otorrhea, or a bulging yellow or red tympanic membrane. This child has a low-grade fever, no history of otitis media, a nonbulging tympanic membrane, and no otorrhea, so watchful waiting is appropriate. When an antibiotic is started, amoxicillin is the drug of choice. DIF: Cognitive Level: Applying (Application) REF: 661

A young woman will begin taking minocycline. The primary care NP should tell this patient to: a. avoid taking antacids while taking this drug. b. expect headaches while taking this medication. c. always take the medication on an empty stomach. d. use a backup form of contraception if currently taking oral contraceptive pills.

ANS: D Tetracyclines may decrease the effects of oral contraceptive pills, so patients should use a backup form of contraception. Headaches are uncommon. Minocycline may be taken with food and is not affected by antacids. DIF: Cognitive Level: Applying (Application) REF: 684

A primary care NP provides teaching to a patient who will begin taking cefadroxil (Duricef). Which statement by the patient indicates a need for further teaching? a. "I should report any rash that occurs." b. "I will take this medication twice daily." c. "I should take this medication with food." d. "Gastrointestinal (GI) symptoms are common but not worrisome."

ANS: D The FDA advises that CDAD be considered in all patients who present with diarrhea after antibiotic use. Patients should be taught to report all GI symptoms. DIF: Cognitive Level: Applying (Application) REF: 680 - 681

A woman has a urinary tract infection (UTI) and has been taking TMP-SMX for 3 days along with increased fluids. She reports continued dysuria and urinary frequency and has a consistent, low-grade fever. The primary care NP should: a. prescribe ciprofloxacin twice daily for 3 days. b. order doxycycline twice daily for 7 to 14 days. c. prescribe amoxicillin-clavulanate twice daily for 7 days. d. order TMP-SMX DS twice daily for 7 days.

ANS: A Initial treatment of uncomplicated UTI is a 3-day course of TMP-SMX. Ciprofloxacin is used if the patient is still symptomatic. Doxycycline is a second-line treatment. Amoxicillin-clavulanate is used to treat pyelonephritis. DIF: Cognitive Level: Applying (Application) REF: 663 - 664

A patient is taking tetracycline for a rickettsial infection and reports having heartburn. The primary care NP should: a. ask the patient how the medication is taken. b. tell the patient to take the medication with food. c. tell the patient to use antacids when heartburn occurs. d. recommend drinking milk when taking the medication.

ANS: A Patients should sit up for at least 30 minutes after taking tetracycline to avoid the risk of esophageal ulceration. Tetracycline should not be taken with food, antacids, or milk. DIF: Cognitive Level: Applying (Application) REF: 684 - 685

A patient comes to the clinic with a history of fever of 102° F for several days, poor appetite, and cough. A sputum culture is pending, but Gram stain indicates a bacterial infection. The primary care nurse practitioner (NP) should: a. begin empirical antibiotic therapy. b. use a broad-spectrum antibiotic for initial treatment. c. prescribe an antibiotic when culture and sensitivity results are known. d. offer symptomatic treatment only unless the patient's condition worsens.

ANS: A Patients with signs and symptoms of a bacterial infection may be treated empirically, especially if Gram stain is positive. The antibiotic may need to be changed when culture and sensitivity results become available. It is best to use an antibiotic that is specific to the suspected organism and not a broad-spectrum antibiotic. DIF: Cognitive Level: Applying (Application) REF: 653

The primary care NP administers penicillin G (Bicillin) to a 75-year-old patient who has COPD and heart failure. The patient takes digoxin, warfarin, and spironolactone. To help prevent drug interactions, the NP should order: a. serum electrolytes. b. coagulation studies. c. creatinine clearance. d. liver transaminases aspartate aminotransferase and alanine aminotransferase.

ANS: A Penicillin G can cause hyperkalemia, which can increase digoxin toxicity, so serum electrolytes should be monitored. Penicillin G does not interact with warfarin or spironolactone. Coagulation studies, creatinine clearance, and LFTs are not indicated in this circumstance. DIF: Cognitive Level: Applying (Application) REF: 673

A woman has a Chlamydia infection. Before initiating treatment with a tetracycline antibiotic, the primary care nurse practitioner (NP) should: a. perform a pregnancy test. b. obtain baseline liver function and renal function tests. c. check her bilirubin and serum amylase levels. d. tell her she must stop using oral contraceptive pills.

ANS: A Tetracycline antibiotics can permanently stain teeth in children and in pregnant women. Before using a tetracycline in a woman who may be pregnant, the NP should perform a pregnancy test. Other laboratory tests are not indicated for short-term use. Women taking oral contraceptive pills should continue to take them. DIF: Cognitive Level: Applying (Application) REF: 683

A patient is taking cefadroxil (Duricef) and comes to the clinic complaining of loose stools for several days. The primary care NP notes normal vital signs; warm, pink skin with elastic turgor; and moist mucous membranes. The NP should: a. order tests for Clostridium difficile-associated disease (CDAD). b. discontinue the cefadroxil. c. reassure the patient that loose stools are common with antibiotics. d. recommend consuming lactobacillus-containing foods to minimize diarrhea.

ANS: A The U.S. Food and Drug Administration (FDA) advises that CDAD be considered in all patients who present with diarrhea after antibiotic use. This patient's symptoms are mild, so discontinuation of the drug is not warranted unless CDAD is present. DIF: Cognitive Level: Applying (Application) REF: 680 - 681

A patient comes to the clinic several days after an outpatient surgical procedure complaining of swelling and pain at the surgical site. The primary care NP notes a small area of erythema but no abscess or induration. The NP should: a. prescribe TMP-SMX. b. prescribe topical mupirocin four times daily. c. suggest that the patient apply warm soaks three times daily. d. refer the patient to the surgeon for further evaluation.

ANS: A This patient has cellulitis, so empirical treatment with TMP-SMX is indicated. Topical mupirocin is used for superficial skin infections, not cellulitis. Warm soaks may be used as an adjunct to antimicrobial treatment. Unless the cellulitis becomes worse, it is not necessary to refer the patient to the surgeon. DIF: Cognitive Level: Applying (Application) REF: 661

A patient was seen in a local emergency department and was treated empirically for pharyngitis with ampicillin and comes to the clinic 2 days later with an urticarial rash. The patient has no previous history of atopy and does not have respiratory symptoms. The primary care NP should suspect: a. scarlatina. b. mononucleosis. c. serum sickness. d. penicillin allergy.

ANS: B A nonallergic urticarial rash occasionally occurs with ampicillin and is common in patients with mononucleosis. This patient has pharyngitis, which was not diagnosed by throat culture. The NP should suspect mononucleosis and a nonallergic rash. Serum sickness and penicillin allergy are possible but less likely. A scarlatiniform rash is not urticarial. DIF: Cognitive Level: Applying (Application) REF: 674

A new patient comes to see the primary care NP with fever, mild dehydration, and dysuria with flank pain. The patient tells the NP that a previous provider always prescribed trimethoprim-sulfamethoxazole and wonders why a urine culture is necessary because this antibiotic has worked in the past. The NP should tell this patient that a culture is necessary to help determine: a. the correct dose of the antibiotic. b. whether antibiotic resistance is occurring. c. whether multiple organisms are causing infection. d. the length of antibiotic therapy needed to treat the infection.

ANS: B Antibiotic resistance can occur when bacteria are repeatedly exposed to antibiotic agents. Even though a particular antibiotic is effective for a certain type of infection, resistance can occur, and another antibiotic may be necessary. A culture and sensitivity test is essential for choosing the right antibiotic. The culture and sensitivity test does not help determine the dose or the length of therapy. DIF: Cognitive Level: Applying (Application) REF: 654

A primary care NP is preparing to prescribe a macrolide antibiotic for a patient who has a history of a prolonged QT interval on electrocardiogram. Which macrolide antibiotic should the NP prescribe? a. Erythromycin b. Azithromycin c. Clarithromycin d. Telithromycin

ANS: B Azithromycin does not cause a prolonged QT interval , unlike the other macrolides, so it would be safe for this patient. Visual disturbances have been found to occur with the use of telithromycin. Erythromycin has a wider range of adverse effects and can cause cardiac effects in patients who have a prolonged QT interval. The Ilosone, E-Mycin, and Erythrocin are all erythromycins. DIF: Cognitive Level: Understanding (Comprehension) REF: 689

A primary care NP sees a patient who has dysuria, fever, and urinary frequency. The NP orders a urine dipstick, which is positive for nitrates and leukocyte esterase, and sends the urine to the laboratory for a culture. The patient is allergic to sulfa drugs. The NP should: a. order cefaclor (Ceclor). b. prescribe cefixime (Suprax). c. administer intramuscular ceftriaxone (Rocephin). d. wait for culture results before ordering an antibiotic.

ANS: B Cephalosporins are useful for empirical treatment of many of the most common infections seen in primary care. Cefixime is a third-generation cephalosporin, which has greater activity against Escherichia coli and excellent penetration into body fluids, making it a good choice for empirical treatment of urinary tract infection. DIF: Cognitive Level: Applying (Application) REF: 678

A patient has a sore throat with fever. The primary care NP observes erythematous 4+ tonsils with white exudate. A rapid antigen strep test is negative, and a culture is pending. The NP orders amoxicillin as empiric treatment. The patient calls the next day to report a rash. The NP should suspect: a. penicillin drug allergy. b. a viral cause for the patient's symptoms. c. a serum sickness reaction to the penicillin. d. scarlatiniform rash from the streptococcal infection.

ANS: B Certain viral infections, such as mononucleosis, increase the frequency of rash in response to penicillin and is commonly attributed to penicillin allergy. DIF: Cognitive Level: Applying (Application) REF: 656

A primary care NP sees a patient who has fever, flank pain, and dysuria. The patient has a history of recurrent urinary tract infections (UTIs) and completed a course of trimethoprim-sulfamethoxazole (TMP/SMX) the week before. A urine test is positive for leukocyte esterase. The NP sends the urine for culture and should treat this patient empirically with: a. gemifloxacin. b. ciprofloxacin. c. azithromycin. d. TMP/SMX.

ANS: B Fluoroquinolones are effective in treatment of UTIs that are resistant to other antibiotics. Because this patient recently completed a course of TMP/SMX, the NP can assume that the bacterium causing the infection is resistant to TMP/SMX. Gemifloxacin is not indicated for UTI, but ciprofloxacin is. Azithromycin is not a fluoroquinolone. DIF: Cognitive Level: Applying (Application) REF: 693

A primary care NP provides teaching for a patient who is about to begin taking levofloxacin tablets to treat an infection. Which statement by the patient indicates a need for further teaching? a. "I should use sunscreen while taking this medication." b. "I should take this medication on an empty stomach." c. "I should use caution while driving when taking this medication." d. "I should take the tablet 2 hours before taking vitamins or an antacid."

ANS: B Levofloxacin tablets may be taken without regard to food, although levofloxacin solution must be taken on an empty stomach. Patients should be cautioned to use sunscreen and to avoid situations where drowsiness may impair function. Levofloxacin should not be taken with antacids or vitamins. DIF: Cognitive Level: Applying (Application) REF: 695

A patient who is taking a fluoroquinolone antibiotic for pyelonephritis develops Clostridium difficile-associated disease (CDAD). The primary care NP should treat for C. difficile and _____ fluoroquinolone. a. continue the b. discontinue the c. increase the dose of d. decrease the dose of

ANS: B Patients who develop CDAD while taking fluoroquinolones should stop taking the drug immediately DIF: Cognitive Level: Applying (Application) REF: 694

A primary care nurse practitioner (NP) is prescribing once-daily azithromycin to a 25-year-old woman. When teaching her about the drug, the NP should tell her to: a. take the medication on an empty stomach. b. use a backup contraception method other than oral contraceptive pills. c. expect severe gastrointestinal side effects while taking this drug. d. cut the pill in half and take twice daily if side effects are severe.

ANS: B Patients who use oral contraceptive pills for birth control should be advised that macrolides can reduce their efficacy and that they should consider using a backup method of contraception. Azithromycin can be taken without regard to food. Severe gastrointestinal side effects are uncommon. The tablets should not be chewed, crushed, or cut. DIF: Cognitive Level: Applying (Application) REF: 689

The primary care NP sees a child in the clinic who has a 5-day history of cough, poor fluid intake, and fever of 103° F. A chest radiograph shows areas of consolidation in the child's lungs. The child's cough is nonproductive, and the NP is unable to get a sputum specimen. The NP should: a. prescribe a broad-spectrum antibiotic to cover any possible causative organism. b. ask colleagues in the clinic about children they have treated and what they have prescribed. c. give the child's parents a specimen cup and ask that they try to bring in a sputum specimen for culture. d. refer the child to a pulmonologist or infectious disease specialist to help determine the proper treatment.

ANS: B The child shows signs of a bacterial infection, but getting a sputum culture is not likely. The NP should ask colleagues about similar cases and treat according to those patterns. Broad-spectrum antibiotics increase the incidence of resistance. If this child's symptoms do not respond to empiric therapy, referral may be warranted. DIF: Cognitive Level: Applying (Application) REF: 654

The primary care NP sees a patient who has a 1-week history of nasal congestion; red, watery eyes; cough; and a temperature ranging from 99.1° F to 100.5° F. The NP notes thin, white nasal discharge and an erythematous oropharynx without swelling or exudates. The NP should: a. begin empiric antibiotic therapy to treat sinusitis. b. reassure the patient that this is likely a viral infection. c. prescribe antiviral medications and decongestants. d. obtain a nasal culture and consider antibiotic therapy.

ANS: B The patient does not have severe symptoms indicating a bacterial infection. Unless symptoms worsen, reassurance is indicated. Empiric antibiotic therapy is contraindicated for viral infections. Antiviral medications are not routinely used. A nasal culture is not indicated. DIF: Cognitive Level: Applying (Application) REF: 653

A female patient presents with grayish, odorous vaginal discharge. The primary care NP performs a gynecologic examination and notes vulvar and vaginal erythema. Testing of the discharge reveals a pH of 5.2 and a fishy odor when mixed with a solution of 10% potassium hydroxide. The NP should: a. order topical fluconazole. b. order metronidazole 500 mg twice daily for 7 days. c. withhold treatment until culture results are available. d. prescribe a clotrimazole vaginal suppository for 7 days.

ANS: B This patient has classic symptoms of bacterial vaginosis. The treatment of choice is metronidazole. Fluconazole is used to treat fungal infections. Cultures are generally not helpful in the diagnosis of bacterial vaginosis. Clotrimazole is used to treat Candida infections. DIF: Cognitive Level: Applying (Application) REF: 666

A patient with group A b-hemolytic streptococcal pharyngitis is treated with penicillin V. At a follow-up visit 2 weeks later, the patient presents with edema of the hands and feet, blood pressure of 140/85 mm Hg, and cola-colored urine. A urine dipstick shows proteinuria. The primary care NP should: a. perform a repeat throat culture. b. prescribe 10 more days of penicillin V. c. obtain an ASO titer and creatinine clearance. d. order oral amoxicillin-clavulanate for 14 days.

ANS: C A minimum of 10 days of treatment is recommended for any infection caused by group A b-hemolytic streptococcus to prevent the occurrence of rheumatic fever or acute glomerulonephritis. This patient shows signs of acute glomerulonephritis, so the NP should obtain an ASO titer and creatinine clearance to help confirm the diagnosis. It is not necessary to repeat the throat culture. Treatment involves controlling blood pressure and maintaining renal function, not giving antibiotics. DIF: Cognitive Level: Applying (Application) REF: 673

A sexually active woman is being treated for streptococcal pharyngitis. The patient takes oral contraceptive pills (OCPs). Which penicillin should the primary care NP prescribe for this patient? a. Ampicillin b. Penicillin V c. Penicillin G d. Dicloxacillin

ANS: C Although penicillin V is the drug of choice, ampicillin and penicillin G can be used to treat streptococcal pharyngitis. Penicillin G is the only penicillin that does not interfere with OCPs. Dicloxacillin is not recommended to treat streptococcal pharyngitis. DIF: Cognitive Level: Applying (Application) REF: 674

A primary care nurse practitioner (NP) sees a child who has several honey-colored crusted lesions around the nose and mouth. The NP notes that no other lesions are present. The NP should prescribe: a. dicloxacillin. b. clarithromycin. c. mupirocin topical. d. trimethoprim-sulfamethoxazole (TMP-SMX).

ANS: C Although systemic antibiotics are often required to treat impetigo, mupirocin can be used for topical treatment of mild impetigo. Because this is a localized infection, mupirocin can be ordered empirically. Dicloxacillin and clarithromycin are used when systemic empirical treatment is indicated. TMP-SMX is used to treat cellulitis. DIF: Cognitive Level: Applying (Application) REF: 658 - 659

A patient who has had two recent urinary tract infections is in the clinic with dysuria and fever. The primary care NP reviews the patient's chart and notes that in both previous cases the causative organism and sensitivity were the same. The NP should: a. treat the patient empirically without a culture. b. order a microscopic evaluation of the urine and an antibiotic. c. order a urine culture and treat empirically pending culture results. d. order a urine culture and sensitivity and wait for results before treating.

ANS: C Because this patient has had similar infections in the past, treating empirically is acceptable. The NP must still obtain a culture and sensitivity so that appropriate antibiotic therapy can be provided, even though it is likely that this is a recurrence of the same organism. A culture should always be obtained when possible. A microscopic evaluation is used to determine whether or not a culture should be performed and is not diagnostic. DIF: Cognitive Level: Applying (Application) REF: 653

A primary care NP sees a patient who reports a 2-week history of nasal congestion and runny nose. The NP performs a history and learns that the nasal discharge has changed from yellow to green in the past few days, accompanied by a fever of 102° F and unilateral facial pain. To treat this patient, the NP should: a. order azithromycin daily for 5 days. b. prescribe cefdinir twice daily for 10 days. c. prescribe amoxicillin-clavulanate twice daily for 10 days. d. recommend symptomatic treatment because this is probably a viral infection.

ANS: C Evidence of a bacterial sinus infection includes prolonged symptoms without improvement for 10 to 14 days, fever greater than 102° F, and unilateral pain. A bacterial infection should be suspected if nasal discharge turns from yellow to green. Amoxicillin-clavulanate is a recommended first-line drug to treat sinusitis. DIF: Cognitive Level: Applying (Application) REF: 661

A patient has had severe diarrhea for 2 weeks. Laboratory testing reveals Clostridium difficile. The primary care NP should prescribe: a. erythromycin. b. azithromycin. c. fidaxomicin. d. clarithromycin.

ANS: C Fidaxomicin is indicated only for treatment of C. difficile-associated diarrhea. The other macrolides are not used for this purpose. DIF: Cognitive Level: Understanding (Comprehension) REF: 690

An adult patient has cellulitis. The patient is a single parent with health insurance who works and is attending classes at a local university. To treat this infection, the primary care nurse practitioner (NP) should prescribe: a. cefdinir (Omnicef). b. cephalexin (Keflex). c. cefadroxil (Duricef). d. ceftriaxone (Rocephin).

ANS: C First-generation cephalosporins, such as cephalexin and cefadroxil, are used for skin and soft tissue infections. Cefadroxil is preferred in this case because it can be given twice daily instead of four times daily, and this patient will be more likely to comply with the drug regimen. Cefdinir and ceftriaxone are both third-generation cephalosporins. DIF: Cognitive Level: Understanding (Comprehension) REF: 678

A child with a febrile illness is taking a cephalosporin. While in the clinic for a follow-up visit, the child has a tonic-clonic seizure. The primary care NP should: a. administer acetaminophen because this is likely a febrile seizure. b. reassure the parent that seizures can occur while taking cephalosporins. c. ask the child's parent how much of the cephalosporin the child has taken. d. suspect the development of a secondary central nervous system infection.

ANS: C Seizures can occur with an overdose of cephalosporins, so the NP should determine whether this has occurred. It is not correct to assume that the seizure is fever-related or that it is a normal side effect of the cephalosporin. DIF: Cognitive Level: Applying (Application) REF: 682

A patient is taking levofloxacin to treat sinusitis. The patient calls the primary care NP to report pain just above the heel of the right foot. The NP should: a. change to ofloxacin. b. change to ciprofloxacin. c. discontinue the levofloxacin. d. reassure the patient that this is a common side effect.

ANS: C Warnings have been issued for the fluoroquinolone antibiotics for the increased risk of tendon ruptures. Ruptures have occurred unilaterally and bilaterally, and have involved the Achilles tendon; however, ruptures in the shoulder joint, hand, biceps, thumb, and other tendon sites have been reported. The risk of tendon rupture is further increased in those over age 60, those receiving concomitant steroid therapy, and in kidney, heart, and lung transplant recipients. Reasons for tendon ruptures also include physical activity or exercise, kidney failure, and tendon problems in the past. These ruptures may occur during therapy or up to several months after discontinuation of drugs. DIF: Cognitive Level: Applying (Application) REF: 693

A patient with otitis media is treated for 10 days with amoxicillin. At the follow-up visit, the primary care NP notes bilateral erythematous, bulging tympanic membranes. The NP should prescribe: a. intramuscular injection of penicillin G (Bicillin). b. amoxicillin for 10 more days. c. oral dicloxacillin (Dynapen) for 10 days. d. oral amoxicillin-clavulanate (Augmentin) for 10 days.

ANS: D Antibiotic resistance to penicillins occurs through three mechanisms, the most important being bacteria producing b-lactamase, which breaks down the b-lactam ring and renders the penicillin inactive. Clavulanic acid, used in combination with penicillins, prevents this inactivation. The NP should prescribe amoxicillin-clavulanate. Giving 10 more days of amoxicillin would not be effective. Dicloxacillin is used when resistance is caused by penicillinase-resistant staphylococcal infection. Penicillin G is not used to treat otitis media. DIF: Cognitive Level: Applying (Application) REF: 672

A patient has recently returned from travel in Central America and reports having seven to eight liquid stools each day with severe tenesmus. The primary care NP notes a temperature of 102° F. A stool specimen is Hemoccult positive with leukocytes present. The NP will: a. order tests for Clostridium difficile. b. prescribe tinidazole 2000 mg for 3 days. c. give 750 mg of ciprofloxacin one time only. d. order a stool culture and begin therapy with a fluoroquinolone.

ANS: D By history, this patient likely has traveler's diarrhea. The NP should obtain a culture and should start a fluoroquinolones antibiotic empirically. C. difficile is suspected in patients who have been taking antibiotics, which is not true in this case. Tinidazole is used for amebiasis or giardiasis. Ciprofloxacin may be given as a single dose for mild traveler's diarrhea. DIF: Cognitive Level: Applying (Application) REF: 663

A patient who has been taking ciprofloxacin for 14 days for treatment of a UTI is seen in the clinic for a follow-up urinalysis. The urinalysis reveals crystalluria. The primary care NP should: a. discontinue the ciprofloxacin. b. decrease the dose of ciprofloxacin. c. change the antibiotic to norfloxacin. d. counsel the patient to increase fluid intake.

ANS: D Fluoroquinolones can cause renal irritation and urine crystals. Patients should be advised to maintain proper hydration to avoid this. It is not necessary to discontinue the ciprofloxacin or to decrease the dose. DIF: Cognitive Level: Applying (Application) REF: 695

A 70-year-old patient will begin taking cefdinir (Omnicef) for an acute exacerbation of COPD. Before initiating therapy, the primary care NP should order: a. liver function tests (LFTs). b. coagulation studies. c. an electrocardiogram (ECG). d. a creatinine clearance test.

ANS: D Geriatric patients may need adjusted doses based on creatinine clearance testing, so obtaining a creatinine clearance test before initiating therapy is indicated. LFTs, coagulation studies, and an ECG are not indicated. DIF: Cognitive Level: Applying (Application) REF: 681

A patient has been taking ciprofloxacin for 3 days and calls the primary care nurse practitioner (NP) to report having headaches and dizziness. The NP should: a. change to levofloxacin. b. decrease the dose of ciprofloxacin. c. change to an antibiotic in another drug class. d. reassure the patient that these are common side effects.

ANS: D Headaches and dizziness are common side effects of fluoroquinolones. It is not necessary to change to another fluoroquinolone, decrease the dose, or change to another antibiotic class. DIF: Cognitive Level: Understanding (Comprehension) REF: 694

During a gynecologic examination of a sexually active adolescent girl, the primary care NP notes mucopurulent cervicitis. A culture is positive for Neisseria gonorrhoeae. The NP should: a. give a single dose of 2 g of oral azithromycin. b. administer benzathine penicillin G 2.4 million units intramuscularly. c. prescribe oral doxycycline 100 mg daily for 7 days. d. give intramuscular ceftriaxone and a single dose of 1 g of azithromycin.

ANS: D Many patients who present with one sexually transmitted disease (STD) have other concomitant STDs. When gonorrhea or urethritis/cervicitis is diagnosed, the NP should treat for both N. gonorrhoeae and Chlamydia. A single-dose treatment ensures compliance. A single, 2-g dose of azithromycin is indicated to treat chancroid. Benzathine penicillin G is indicated to treat syphilis. A 7-day regimen of doxycycline is used to treat Chlamydia, but not gonorrhea. DIF: Cognitive Level: Applying (Application) REF: 664 - 665

A patient is taking dicloxacillin (Dynapen) 500 mg every 6 hours to treat a severe penicillinase-resistant infection. At a 1-week follow-up appointment, the patient reports nausea, vomiting, and epigastric discomfort. The primary care NP should: a. change the medication to a cephalosporin. b. decrease the dose to 250 mg every 6 hours. c. reassure the patient that these are normal adverse effects of this drug. d. order blood cultures, a white blood cell (WBC) count with differential, and liver function tests (LFTs).

ANS: D When giving penicillinase-resistant penicillins, it is important to monitor therapy with blood cultures, WBC with differential cell counts, and LFTs before treatment and weekly during treatment. This patient may have typical gastrointestinal side effects, but the symptoms may also indicate hepatic damage. Changing the medication is not indicated, unless serious side effects are present. Decreasing the dose is not indicated. DIF: Cognitive Level: Applying (Application) REF: 673

A patient has confirmed Rocky Mountain spotted fever, and the infectious disease specialist is treating the patient with doxycycline 100 mg orally for 7 days. The patient comes to the clinic for follow-up care with the primary care NP at the end of therapy and reports continued fever, headache, and myalgia. The NP will consult with the infectious disease specialist and order: a. 7 more days of doxycycline. b. erythromycin 250 mg four times daily for 7 days. c. amoxicillin 500 mg three times daily for 10 to 14 days. d. hospital admission for intravenous chloramphenicol.

ANS: D With treatment, the patient's condition should start to improve in 2 to 3 days. Continued elevation of the temperature may indicate lack of efficacy or drug fever. Chloramphenicol is used to treat Rocky Mountain spotted fever. It is not correct to continue therapy with doxycycline because treatment failure is likely. Erythromycin is used to treat Lyme disease. Amoxicillin is not indicated. DIF: Cognitive Level: Applying (Application) REF: 666