NMP exam sample questions Flashcards
Factors that affect absorption
- physico-chemical properties of drug
- drug formulation
- route of administration
what does ADME mean?
Absorption
Distribution
Metabolism
Excretion
Route of administration that will produce an enteral effect
Rectal
What is Bioavailability
The fraction of the dose which proceeds unaltered from the site of administration to the systemic circulation
Factors affecting bioavailability
- Poorly water soluble/slowly absorbed drug
- Malabsorption syndrome / GI surgery
- Increased gastric emptying time
- Complex formed e.g. tetracyclines and milk
- First pass effect
what is volume distribution?
pharmacokinetic parameter that represents the degree how a drug is distributed either remains in the plasma or redistribute to other tissues
It is the process of the body breaking down and converting medication into active chemical substances
Drug Metabolism
how many phase of metabolism is involved?
2 phases
What is phase 1 metabolism
- oxidation
- hydrolysis
- uses cytochome p450
- drug metabolite can still be chemically active
What is phase 2 metabolism
- conjugation
- attachment of an ionised group to the drug
- reduces drug effect
makes metabolite more water soluble for excretion
Factors affecting drug metabolism
- Enzyme induction
- Enzyme inhibition
- genetic deficiency
- age
- liver disease
What the drug does to the body
Pharmacodynamics
Examples of neurotransmitters
- Acetylcholine (ACh)
- Histamine (H)
- Dopamine (DA)
- Noradrenaline (NA)
- Adrenaline (Adr)
- 5-Hydroxytriptamine (5-HT) [serotonin]
Factors affecting drug excretion
- blood flow to kidney (normal 1500ml/min)
- glomerular filtration rate (normal 100mls/min)
- active secretion of drugs into the kidney tubule (e.g. penicillin)
- passive reabsorption back into the tubule
is an important consideration influencing distribution
Protein binding
Will plasma protein binding increase or decrease the volume of distribution?
decrease
what is half life
Half-life is the time taken for the concentration of drug in blood to fall by half
A patient showing toxic side effects of a drug has her plasma drug concentration measured. It is 100mg/L. The normal range is 20-30mg/L. If the half life is 24 hours how long before the level drops back to within the normal range?
Computation: 100mg half in 24hours
(First half life) 50mg = 24hours
(Second half life) 25mg = 48hours (normal range 20 to 30mg)
Answer:
2 days:
o After 24 hours the level will be 50mg/L
o After 48 hours the level will be 25mg/L
Recommend omit drug for 2 days, then re-start using lower dose.
is the amount of a medication between the quantity that gives the effective dose and the amount that gives more adverse than desired effects
Therapeutic window
The ability of a drug to produce an effect
Drug efficacy
Loss of response to a drug usually due to a decrease in number of receptors
Desensitisation
give 3 examples of narrow therapeutic index drugs
lithium
gentamycin
theophylline
digoxin
phenytoin
warfarin
The term for a drug that blocks the effects of a neurotransmitter at (or near) the receptor sites
Antagonist
Condition that may follow after repeated exposure to a drug in so that the effect produced by the original dose no longer occurs i.e. increasing doses required to achieve the same effect
Drug tolerance
what is does Peak level mean
the level of the drug in the patients body is at the highest
What is trough level
the lowest level of the drug in the patients body
Why do we need to assess drug plasma concentration levels
to determine dosing intervals, or how much time should pass between each new administration of the drug.
True/False
an agonist can bind reversibly to a competitive antagonist to block its action?
False
Antagonist blocks the action of the agonist
True/False
Ibuprofen inhibits enzymes
True
Ibuprofen inhibits the cyclooxygenase family of enzymes
True/False
plasma protein binding can delay excretion of drugs
True
Drugs binding in the protein will be held in the plasma and is not available for metabolism or excretion
Antagonist blocks the response to?
Agonist
An agonist bind to receptors to cause?
a biological response
is an active metabolite that when given to a person, does not have biological activity
Pro drug
They are naturally occurring chemicals in the body
agonist
chemicals that blocks responses to neurotransmitters
antagonist
chemical alteration of the drugs in the body
metabolism
What is potentiation
A drug interaction in which the addition of a second drug intensifies certain properties of the first drug administered.
controlled drug prescriptions are valid for how many days?
28 days
The primary legislation on the UK that came fully effect in 1973
Misuse of Drugs Act of 1971
How many months should clinical management plans be updated
6 months
a drug with the ability to bind to the receptor but do not initiate a change in cellular function
Antagonist
a drug with an affinity for a receptor resulting in stimulation of the receptor’s functional properties
Agonist
What are the 3 types of adrenaline receptors and their actions
“ß1 receptors - mainly on heart (Drugs that bind to beta receptors in the heart and increase the force of myocardial contraction)
ß2 receptors - mainly on bronchioles
Alpha receptors - mainly on blood vessels (to increase blood pressure)”
When a drug no longer has an effect as the dose increases
Ceiling effect
What is the difference between sympathetic and parasympathetic nervous system
“Sympathetic (adrenergic) releases Norepinephrine binds to adrenergic receptors: Stimulated by noradrenaline, “Fight or flight”, Have alpha and beta agonists
o Alpha contracts smooth muscle, dilates pupils
o Beta increases heart rate, opens airways
Parasympathetic (cholinergic) releases Acetylcholine (Ach): Stimulated by acetylcholine and binds to muscarinic receptors.
“Rest and digest”
o Contracts iris, Decreases heart rate, Increases gut activity”
This binds irreversibly to the receptor (or may be a different site) - high concentrations of agonist cannot completely overcome antagonism and maximal response cannot be obtained
Non-competitive antagonist
A patient has started taking herbal medications what will you consider?
- potential for allergic reactions
- some are toxic if used improperly or at high doses
- They may be dangerous in combination with other substances or drugs that have been prescribed adverse reactions related to the herbal medicines
- They may mask symptoms
- They may aggravate the patients current problem
What is First Pass effect?
the Metabolism of a drug before it enters the systemic circulation. The process of first pass metabolism occurs in the gut or in the liver and can only affect the oral route. The drug is absorbed from the GI tract and passes via the portal vein (portal circulation) into the liver where some of the drug undergo extensive biotransformation. This would mean that only a proportion of the drug reaches the circulation (decrease drug concentration).
What is concordance and why is it important in practice?
The decision about whether to take a medicine or not ultimately lies with the patient. It is crucial that health professionals and patients engage in ‘shared decision-making’ about medicines usage. Shared decision-making, requires health professionals to engage with patients as partners taking into account their beliefs and concerns. The shared decision making process with medicines is known as concordance and moves away from the medical/more autocratic idea of compliance.
Competency Framework for all UK prescribers
Royal Pharmaceutical Society - RPS 2021
True/False
Unlicensed medication prescribing is acceptable
True
All independent prescribers can prescribe off-licence/ off-label and unlicensed medicines within their sphere of competence.
unlicensed and off-label medicines are legally permitted only if satisfied that an alternative licensed medicine would not meet the patient’s clinical needs.
True/False
as an independent prescriber, you can issue a repeat prescription for a patients that somebody else has assessed and diagnosed the condition
True
The prescriber is accountable for any prescriptions made including repeat prescriptions for medicines initiated by colleagues.
You are asked to provide a repeat prescription, what should you do?
Prescriber needs to ensure that any repeat prescription you sign is safe and appropriate (right patient, correct prescription/dose), monitoring (usage and effects). Prescriber should properly assess patients’ needs for the repeat prescription. You should consider the benefits of prescribing with repeats, and where possible, reduce repeat prescribing. You have to agree on a review date with the patient and make clear records of these discussions and your reasons for repeat prescribing.
True/False
A prescriber is always allowed to prescribe for a friend or relative
False
You may be able to do so under exceptional circumstances where there are no other prescribers available. You must be able to justify what is considered an ‘exceptional circumstance’ and why, at the time, a prescription could not be issued by another independent prescriber.
Standards of
proficiency for
nurse and midwife
prescribers - Practice standard 11
What are the 4 ethical principles that underpins decisions on treatment
- Beneficence
- Non maleficence
- Autonomy
- Justice
Autonomy underpins the concept of?
Informed consent
Refers to the time it takes for a drug to achieve optimal plasma concentrations
Steady state
It equates to fairness and is to do with equal distribution of benefits and burdens
Justice
Give examples of sources of legislation that influences prescribing
- Convention on Human Rights
- United Kingdom parliament, e.g. Medicines Act 1968, Prescription by Nurses Act 1992
- Delegated legislation, e.g. NMC Code of Conduct
- Common or Case law as interpreted by the courts/judges,
- Bye laws/ supplementary legislation
This is when the amount of drug in the plasma has built up to a concentration level that is therapeutically effective and as long as regular doses are administered to balance the amount of drug being cleared the drug will continue to be active
Steady state
5 reliable sources for medication information
- BNF
- Trust Formulary
- Trust Medication Information Service
- NICE guidance
- Pharmacy service
- Electronic Medicines compendium
- National Library of Medicine
- Peer reviewed journals
the patient is experiencing an adverse reaction, what will you do?
- Remedy harm caused by the reaction
- Notify the prescriber
- Record in the patient’s notes
- Notify the MHRA via the Yellow Card Scheme
The gap between the desired effect of a drug and the point at which it exerts toxic
Therapeutic index
4 Common causes of risk when prescribing and how would you minimise the risk for each
ineligible handwriting - computerised - write legibly
incorrect doses - avoid trailing zeros (5.0, 6.0), avoid abbreviations (mcg, ng, u), use zero on doses less than 1 (0.5, 0.6)
failure to check interactions/contraindications - assess and always refer to BNF/EMC/Trust formulary if unsure
lack of knowledge of doses/strength - always refer to BNF/EMC/Trust formulary if unsure - ask other prescribers (medical, pharmacist)
Reduces the metabolic capacity of enzymes
Inhibitor
which of the following constitutes a pharmacokinetic interaction?
* Amiodarone & digoxin
* Atenolol & salbutamol
* Amitriptyline and
* Warfarin and vitamin
Amiodarone & digoxin
- Atenolol & salbutamol – reduces the action of each other (Pharmacodynamic)
- Amitriptyline and oxybutynin – increases parasympatholytic effects (Pharmacodynamic)
- Warfarin and vitamin K – Vitamin K antagonises warfarin (Pharmacodynamic)
which of the following is a pharmacodynamic interaction?
a. Warfarin & carbamazepine
b. Warfarin & cimetidine
c. Warfarin & danazol
d. Warfarin & clopidogrel
Warfarin & clopidogrel
a. Warfarin & carbamazepine – carbamazepine metabolism in CYP450 decreases plasma concentration of warfarin (Pharmacokinetics)
b. Warfarin & cimetidine – cimetidine inhibits metabolism of warfarin – increases bleeding tendencies (Pharmacokinetics)
c. Warfarin & danazol – danazol potentiates the hypoprothrombinemic response to warfarin – increases bleeding tendencies (Pharmacokinetics)
What are the 4 processes studied in pharmacokinetics?
Absorption
Distribution
Metabolism
Elimination
Which of the following neurotransmitters is most affected by citalopram?
* Noradrenaline
* Dopamine
* Serotonin
* GABA
Serotonin
Why are liquids absorbed quicker than tablets?
They don’t have to disintegrate & dissolve first
If an enzyme inducing drug is started will other drugs metabolised by the liver be metabolised faster or slower?
Faster – hence lower blood levels than expected
True/False
the bioavailability of an IV drug is higher an oral drug
TRUE
What is medication management
It is the clinical, cost-effective and safe use of medicines to ensure patients get the maximum benefit, from the medicines they need, while at the same time minimising potential harm.
What process needs to be followed when a drug error occurs
- Notify the patient
- Take action to remedy harm if necessary
- Report to pharmacy/prescriber
- Report to line manager
- Thorough and careful investigation at local level
What information is required to be on the drug chart before a registered nurse can administer a drug?
- Name
- DOB
- right Drug
- Dose
- Frequency (time given)
- Route
- Prescriber Signature
- MRN
- Formulation
A black triangle in the BNF means?
New drug / the drug preparation is being monitored intensively by the MHRA
Medicines that are being used outside the terms of the licence
off-labeled drug
True/False
The prescriber is not accountable for any issues that may occur if the prescriber will advise a patient for over the counter drug
False
prescriber is accountable for any advise given to patient regardless if it is an OTC drug. Prescriber should should fully assess patients for any possible interaction/reaction and provide adequate advice about the medication.
True/False
The use of amitriptylline for migraine is an off-license prescribing
True
What are the legal requirement of a prescription under Medicines Act 1968
Wet signature
Full name of patient
Full address of patient
Full address of prescriber
date of prescription
True/False
Unlicensed prescribing is acceptable as long as it is considered best practice and where no equivalent alternative is available
True
Controlled drugs that can be prescribed by nurse independent prescribers
All CD schedules 2-5
True/False
Unlicensed medications cannot be prescribed in a PGD (patient Group direction)
True
Unlicensed medication can be prescribed through a CMP
The use of controlled drugs as medications is regulated by?
Misuse of drugs regulations 2001
True/False
There is an increased risk of ventricular arrhythmias when tricyclic antidepressants are given with amiodarone
True
As per BNF drug interaction
POM symbol in BNF indicates what?
Prescription Only Medicine (POM).
Only available on a prescription issued by an appropriately trained practitioner
True/False
Non medical prescribers should only prescribe unlicensed medication under a CMP
False
Medicines for Human Use Act amendments 2009 - independent non medical prescribers are allowed to prescribe unlicensed medicines
Liability for one’s own action
accountability
Responsibility to tell the truth
Veracity
True/False
Drug absorption is not affected by the acidity of the GI tract
False
A written instructions for the supply or administration of named medicines to specific groups of patients
Patient Group Directions
(PGD)
Therapeutic drug monitoring is usually done when a drug?
has a narrow therapeutic window
The collection, monitoring, and evaluation of unexpected and unintended effects of medicines
Pharmacovigilance
True/False
Most non concordance is intentional
True
It results from conscious decisions by the patient about illness, medication experience, culture, lifestyle, religion, and education
What percentage of patients with asthma take their medications as prescribed
20%
The extent to which a persons behaviour corresponds with agreed recommendations from healthcare provider
Adherence
T/F
Patients on long term medications for chronic illness are most likely to have the best concordance
False
only 50%
It is the term for multiple medications used to treat many different disease and can cause drug interactions and ADRs
Polypharmacy
True/False
All prescriptions are valid for 6 moths
False
CD prescriptions are valid for 28 days
all other prescriptions are valid for 6 months
It is the principal site of drug metabolism
Liver
True/False
A nurse prescriber can write a prescription for a patient assessed by a nursing colleague who is not a prescriber
True
This should however be avoided as per NMC standards of proficiency for nurse and midwife prescribers 2006
True/False
Dieticians can prescribe through a CMP
False
at present, dieticians are not part of the list of professionals who can become prescribers
True/False
Pharmacist were always allowed to prescribe since before
False
it was only on 2003 where pharmacists became eligible to train as supplementary prescribers
True/False
Private prescriptions can be issued by supplementary prescribers
True
Independent and Supplementary prescribers are able to provide private prescriptions
True/False
Prescribers should be able to provide medicine administration directions to non prescribers
True
Supplementary prescribing is most useful for?
long-term conditions
Who is responsible and liable for the actions of supplementary prescribers
The supplementary prescriber and their employer
The UK parliament act which governs the manufacture and supply of medicines
Medicines Act of 1968
What is pharmacovigilance?
it is the process of monitoring of all medicine safety throuout their marketed life
It is also known as the recommended international non-proprietary name (rINN) of a drug
Generic name
the data sheet submitted to the MHRA which contains the drug information by the manufacturer
summary of product characteristics (SPC)
True/False
Mixing 2 licensed medicines together in a syringe results in an unlicensed used of medication
True
BNF section 5 relates to what type of medicines?
Antimicrobials
Appendix 4 in the BNF relates to?
Wound management
True/False
A prescription is considered a legal document
True
as per Medicined Act of 1968
It is the right of the individual to make choices for themselves
Autonomy
True/False
Lipid solubility is an important factor affecting drug absorption
True
Lipophilic drugs can easily pass into the cell membrane because they are not charged or ionised. This makes them easily absorbed.
A group of antibiotics that inhibits protein synthesis
Macrolides
A type of antibiotics that inhibits bacterial cell wall synthesis
Penicillins
The organisation responsible for identifying the drugs that may be prescribed on the NHS budget
NICE
National Institute for health and Clinical Excellence
