Pharm -Study guides from book Flashcards
A patient diagnosed with chronic pain calls to request an oxycodone (Oxycontin) refill. Which action should the prescriber take initially?
a. Fax the renewal order to the pharmacy.
b. Arrange to schedule an appointment with the patient.
c. Verify the patient’s adherence to the prescribed drug regimen.
d. Determine the patient’s current medication dosage and pain level.
b. Arrange to schedule an appointment with the patient.
Schedule II medications are not eligible for refills, and prescriptions must be handwritten. It is important to verify the patient’s adherence to the drug regimen and determine the current dosage of medication and pain level; however, this can be accomplished by scheduling an appointment and evaluating the patient in person.
A metered-dose albuterol inhaler is prescribed for asthma management. The patient reports feeling jittery sometimes when taking the medication, and does not feel that the medication is always effective. Which action will the provider take to best minimize patient risks and maximize medication effectiveness?
a. Ask the patient to demonstrate use of the inhaler and assess effectiveness.
b. Assess the patient’s exposure to first- and second-hand tobacco smoke.
c. Auscultate the patient’s lung sounds and obtain other relevant vital signs.
d. Decrease the dosage to reduce side effects.
c. Auscultate the patient’s lung sounds and obtain other relevant vital signs.
Assessing and evaluating lung sounds as well as other vital signs helps determine the patient’s physical response to the medication and allows comparison to the patient’s baseline vital signs. Asking the patient to demonstrate inhaler use helps to evaluate the patient’s ability to administer the medication properly and is part of an effective evaluation, but is not a priority intervention based on the patient’s current report. Assessing tobacco smoke exposure helps determine whether nondrug therapies, such as smoke avoidance, can be used as an adjunct to drug therapy, but does not relate to the patient’s current problem. Rewriting the prescription to decrease the dosage may address the degree of jitteriness experienced, but does not address the patient’s concern that the drug is not always effective.
A patient is prescribed metronidazole for bacterial vaginosis. Which patient history finding would be most concerning to the provider?
a. The patient had a recent yeast infection.
b. There is a family history of cervical cancer.
c. The patient drinks two glasses of wine every night.
d. The patient is unemployed.
c. The patient drinks two glasses of wine every night.
Patients taking metronidazole should be educated not to drink alcohol to prevent a disulfiram-like reaction. It would be concerning that the patient drinks wine daily. History of a yeast infection may indicate increased risk for recurrence with administration of an antimicrobial. A family history of cervical cancer is not related to administration of metronidazole. Unemployment can indicate lack of insurance coverage, which may limit the patient’s ability to purchase medications; however, generic metronidazole is one of the less expensive medications.
The provider prepares a patient with newly diagnosed type 1 diabetes for hospital discharge. Which action by the provider will best support the patient’s ability to effectively manage medication therapy?
a. Asking the patient to demonstrate how to measure and administer insulin
b. Discussing methods of storing insulin and discarding syringes
c. Giving information about how diet and exercise affect insulin requirements
d. Teaching the patient about the long-term consequences of poor diabetes control
a. Asking the patient to demonstrate how to measure and administer insulin
Because insulin must be given correctly to control symptoms and prevent an overdose, it is most important for the patient to know how to measure and administer it. Asking for a demonstration of technique is the best way to determine whether the patient has understood the teaching. The other teaching points are important as well, but they are not as critical.
A patient reports that a medication prescribed for recurrent migraine headaches is not working. Which action is the prescriber’s priority when addressing the patient’s concern?
a. Ask the patient about the number and frequency of tablets taken.
b. Assess the patient’s headache pain on a scale from 1 to 10.
c. Prescribe a new medication for migraine management.
d. Suggest biofeedback as an adjunct to drug therapy.
a. Ask the patient about the number and frequency of tablets taken.
When evaluating the effectiveness of a drug, it is important to determine how often the patient is using the drug. Asking the patient to identify how many tablets are taken and how often helps the provider determine effective dosages and adherence to the medication regimen. The patient has already stated that the medication is not working; the actual level of pain may determine the degree to which it is not working, but it does not help the provider to determine why it is not working. The assessment process should gather as much information about compliance, symptoms, and drug effectiveness as possible before enacting a change in treatment. Biofeedback may be an effective adjunct to treatment, but it should not be recommended without complete information about drug effectiveness.
The drug manual states that older adult patients are at increased risk for hepatotoxicity. Which action is most important when prescribing this medication to an 80-year-old patient?
a. Obtaining baseline liver function studies
b. Ensuring that the drug is taken in the correct dose at the correct time
c. Discontinuing the order; the drug is contraindicated for this patient
d. Giving the medication intravenously to avoid first pass metabolism
a. Obtaining baseline liver function studies
The drug manual indicates that this drug increases risk of hepatotoxicity for elderly patients. Getting information about liver function before giving the drug establishes baseline data that can be compared with posttreatment data to determine whether the drug is affecting the liver. Taking the correct dose at the correct interval may minimize risk, but without baseline information, the effects cannot be determined. Drugs are not routinely contraindicated for an increased risk of adverse effects.
A patient with bipolar disorder is prescribed daily lithium. Which action is most important for the provider to take in order to determine if the therapeutic level is maintained?
a. Evaluate preadministration blood work.
b. Prescribe the lithium to be taken at regular intervals.
c. Order periodic laboratory testing.
d. Assess the patient for signs and symptoms of lithium toxicity.
c. Order periodic laboratory testing.
Therapeutic serum levels are determined through periodic laboratory testing. Preadministration blood work may be necessary to obtain baseline status prior to initiating treatment, but it will not determine therapeutic levels. Scheduling medication administration at regular intervals will help to ensure medication is absorbed and metabolized predictably, but it will not determine therapeutic blood levels. Assessing the patient for signs and symptoms of toxicity will help to determine if the therapeutic level has been exceeded, not maintained.
Which factor best supports an increase for full prescriptive authority for both advanced practice registered nurses (APRNs) and physician assistants (PAs)?
a. More patients will have access to health care.
b. Enrollment in medical schools is predicted to decrease.
c. Enrollment in both APRN and PA programs has increased.
d. Physician practices have become so large, quality care is in jeopardy.
a. More patients will have access to health care.
Implementation of the Affordable Care Act has increased the number of individuals with health care coverage, and thus the number who have access to health care services. The increase in the number of patients creates the need for more providers with prescriptive authority. APRNs and physical assistants can fill this practice gap. Enrollment in medical school has increased in recent years and shows no indication of decline. While some medical practices have increased in patient volume, there is no reason to believe care has suffered. While enrollment for both APRN and PA education has increased, that is not the primary factor associated with the need for increased prescriptive authority for these providers.
A pediatric patient prescribed ampicillin for streptococcal pharyngitis reports new onset of a pruritic, dull red, maculopapular rash on the chest and neck. Which action is most important for the provider to take to minimize this patient’s risk for injury?
a. Prescribe azithromycin to replace the ampicillin.
b. Discontinue the ampicillin.
c. Prescribe an antihistamine for the itching.
d. Flag all medical records with an “Allergic to Penicillin” notice.
b. Discontinue the ampicillin.
The priority action is to discontinue the medication to prevent a potential worsening of the patient’s symptoms. A different prescription may be indicated depending on the length of treatment. An antihistamine may be administered for pruritis. Rashes are a common side effect of ampicillin. Pruritic maculopapular rashes such as the one described occur in 5% to 10% of children taking ampicillin, especially in the presence of viral infections. They do not contraindicate future administration of penicillin antibiotics.
Which prescriber action will have the greatest impact on the patient’s commitment to adherence to any type of medication therapy?
a. Prescribing the medication in oral form whenever possible
b. Scheduling once a day administration
c. Providing medication education that the patient can easily understand
d. Assuring that the medication prescription will be covered by the patient’s
insurance
c. Providing medication education that the patient can easily understand
No other provider action assures the patient’s commitment to adhere to a medication plan more than effective medication education provided in a concise, understandable form. It is not always possible or appropriate to prescribe an oral form. While medication costs can present a barrier to compliance, insurance coverage is but one factor affecting costs.
Which patient statement suggests to the provider that the patient’s nonadherence with their medication plan is related to dissatisfaction with the therapy?
a. “This medication is too expensive; I can’t afford it any longer.”
b. “I’ve been taking this medication for well over a week and I lost only a half a
pound.”
c. “It’s too hard to remember to take the pill every other day; so, I’ve missedseveral
doses.”
d. “I have a very intense, fast paced job; it’s hard to make time to take the
medication like I should.”
b. “I’ve been taking this medication for well over a week and I lost only a half a
pound. ”
Dissatisfaction with drug therapy can take the form of a patient’s unrealistic expectation of desired results such as in the case of significant weight loss in a relatively short period of time. Medication costs, forgetfulness, and lack of planning are suggested by the other options.
How can the prescriber’s regular collaboration with a pharmacist improve positive outcomes for patients? (Select all that apply.)
a. Pharmacists can suggest foods that will help with the medications’ absorption.
b. Pharmacists have additional information on drug interactions.
c. The pharmacist can suggest adequate medication dosing.
d. Pharmacists have firsthand knowledge of the facility formulary.
e. Pharmacy can alter prescriptions when necessary to prevent patient harm.
b. Pharmacists have additional information on drug interactions.
c. The pharmacist can suggest adequate medication dosing.
d. Pharmacists have firsthand knowledge of the facility formulary.
Providers should collaborate with pharmacists because they will likely have additional information on formulary, drug interactions, and suggestions for adequate medication dosing. Dietitians can make food recommendations to treat the patient’s condition. The pharmacist can contact the prescriber about questionable prescriptions, but cannot alter the prescription without notification of and approval by the provider.
Which statements made by the prescriber demonstrate an understanding of effective medication education? (Select all that apply.)
a. “This medication needs to be stored in the refrigerator.”
b. “Take 3 tablets daily: 1 with breakfast, 1 with lunch, and one with dinner.”
c. “You need to take the medication as we discussed until all the tablets are gone.”
d. “Call the office immediately if you begin experiencing any itching, headache, or
difficulty breathing.”
e. “When you call about a medication refill, be sure to let the pharmacist know you
are talking about your heart pill.”
a. “This medication needs to be stored in the refrigerator.”
b. “Take 3 tablets daily: 1 with breakfast, 1 with lunch, and one with dinner.”
c. “You need to take the medication as we discussed until all the tablets are gone.”
d. “Call the office immediately if you begin experiencing any itching, headache, or
difficulty breathing.”
There are basic components that should be included when teaching about any new medication. They are (1) medication name, (2) purpose, (3) dosing regimen, (4) administration, (5) adverse effects, (6) any special storage needs, (7) associated laboratory testing, (8) food or drug interactions, and (9) duration of therapy. The statement suggesting referring to the medication as “your heart pill” is inappropriate since being familiar with the drug’s name is important in avoiding medication errors.
The patient who has been prescribed lithium for a diagnosis of bipolar disorder asks why blood tests are required on a regular basis. Which provider responses demonstrate an understanding of why the patient requires a variety of laboratory tests? (Select all that apply.)
a. “We need to monitor how your thyroid is functioning.”
b. “We need to monitor kidney function while you are on this drug.”
c. This medication can cause you to lose sodium, so we need to measure sodium
levels.”
d. “Your liver can be damaged by lithium; regular testing helps us monitor for that.”
e. “Lithium can cause you to lose potassium; so, we regularly monitor your blood
potassium level.”
a. “We need to monitor how your thyroid is functioning.”
b. “We need to monitor kidney function while you are on this drug.”
c. This medication can cause you to lose sodium, so we need to measure sodium
levels. ”
Lithium therapy can affect thyroid and renal function as well as deplete sodium levels. Regular laboratory testing is needed to monitor sodium levels and thyroid and renal function and so allows for modification of the lithium dose as needed. Lithium is not associated with altered liver function or potassium depletion.
When prescribing lovastatin, what will a provider advise to decrease the risk of developing muscle toxicity?
a. Avoid exercise for 2 hours after administration.
b. Substitute grapefruit juice with orange juice.
c. Monitor aspartate aminotransferase (AST) and alanine aminotransferase (ALT).
d. Take the medication with an NSAID or other anti-inflammatory drug.
b. Substitute grapefruit juice with orange juice.
Grapefruit juice can inhibit the metabolism of certain drugs including statins like lovastatin. The juice raises drug levels decreasing the intestinal metabolism of the drug resulting in increased drug levels which increases the risk for adverse effects such as muscle toxicity. Taking the drug with an anti-inflammatory drug and avoiding exercise after administration are not supported by science. Monitoring AST and ALT detects liver toxicity, not muscle toxicity.
When prescribing drugs with a narrow therapeutic index, what intervention does the provider take to decrease risk to the patient?
a. Schedule drug administration intervals that exceed the drug’s half-life.
b. Order the medication to be administered by the intravenous route.
c. Monitor the patient’s plasma drug levels at regular intervals.
d. Teach the patient that optimal outcomes will require adherence to themedication
regimen.
c. Monitor the patient’s plasma drug levels at regular intervals.
A drug with a narrow therapeutic range or index is more difficult to administer safely, because the difference between the minimum effective concentration and the toxic concentration is small. Patients taking these medications must have their plasma drug levels monitored closely to ensure that they are getting an effective dose that is not toxic. Administering medications at longer intervals risks increased periods of subtherapeutic levels. Drugs that have a narrow therapeutic range may be given by any route; intravenous administration is not preferable and in most cases will not be feasible. Medication regimen adherence is necessary; however, due to individual variation, for drugs with a narrow therapeutic range, what is an effective dose for one patient may be a lethal dose for another. For this reason, monitoring drug levels remains the primary method for decreasing risk.
A patient reports that a medication no longer effectively alleviates symptoms. What process informs the provider’s response to the patient’s concerns?
a. Endogenous antagonists compete with the drug for receptor sites.
b. Decreased selectivity for receptors results in a variety of effects.
c. Desensitization of receptor sites results from continual exposure to the drug.
d. Additional receptor sites are synthesized in response to the medication.
c. Desensitization of receptor sites results from continual exposure to the drug.
Continual exposure to an agonist would cause the cell to become less responsive or desensitized. The body does not produce antagonists as a response to a medication. Medication tolerance is not related to receptor selectivity. Medications do not cause more receptors to be produced.
A patient reports that Brand X tablets work faster than Brand Y tablets of the same amount of the same drug. Which statement informs the prescriber’s response when explaining this phenomenon to the patient?
a. Advertising by pharmaceutical companies can enhance patient expectations of
one brand over another, leading to a placebo effect.
b. Because the drug preparations are chemically equivalent, the actions of the two
brands must be identical.
c. Inactive ingredients used in composition can result in differing rates of
dissolution, which can alter the drug’s onset of action.
d. The bioavailability of a drug is determined by the amount of the drug in each
dose.
c. Inactive ingredients used in composition can result in differing rates of
dissolution, which can alter the drug’s onset of action.
Even if two brands of a drug are chemically equivalent (i.e., they have identical amounts of the same chemical compound), they can have different effects in the body if they differ in bioavailability. Tablets made by different manufacturers contain different binders and fillers, which disintegrate and dissolve at different rates and affect the bioavailability of the drug.
A patient receiving intravenous gentamicin has a toxic serum drug level. The prescriber confirms that the dosing is correct. Which possible cause of this situation will the provider explore?
a. Whether a loading dose was administered
b. If the drug was completely dissolved in the IV solution
c. Whether patient is taking a medication that binds to serum albumin
d. If the ordered dose frequency is longer than the gentamicin half-life
c. Whether patient is taking a medication that binds to serum albumin
Gentamicin binds to albumin, but only weakly, and in the presence of another drug that binds to albumin, it can rise to toxic levels in blood serum. A loading dose increases the initial amount of a drug and is used to bring drug levels to the desired plateau more quickly. A drug that is not completely dissolved carries a risk of causing embolism but this addresses a different concern. A drug given at a frequency longer than the drug half-life will likely be at subtherapeutic levels and not at toxic levels.
A patient takes a drug that is metabolized by CYP3A4 isoenzymes. If a CYP3A4 inducing drug is prescribed, what drug adjustment may be necessary to maintain a therapeutic level of CYP3A4 substrate?
a. Increase dosage of the CYP3A4 inducer.
b. Decrease dosage of the CYP3A4 inducer.
c. Increase dosage of the CYP3A4 substrate.
d. Decrease dosage of the CYP3A4 substrate.
c. Increase dosage of the CYP3A4 substrate.
A drug that acts as an inducing agent for an enzyme system increases the metabolism of drugs metabolized by that enzyme system, thereby lowering the level of those drugs in the body and requiring higher doses to maintain drug effectiveness. Although decreasing the dosage of the drug that induces metabolism may seem reasonable at first glance, this may decrease the therapeutic level of the drug making it ineffective in treating the condition for which it was prescribed.
The provider prescribes hydrocodone with acetaminophen for a patient’s postsurgical pain. What instruction will the prescriber include regarding alcohol intake?
a. “If you plan to drink alcohol, I will write an order for acetaminophen without
hydrocodone for your pain.”
b. “I’d suggest that you substitute ibuprofen for pain on days when you plan to drink
alcohol.”
c. “You should avoid drinking alcohol while you are taking the pain medication I’ve
ordered.”
d. “You should limit your alcohol intake to no more than two servings ofalcohol
daily while on the pain medication.”
c. “You should avoid drinking alcohol while you are taking the pain medicationI’ve
ordered. ”
Combining a hepatotoxic drug with other hepatotoxic agents increases the risk of hepatotoxicity. When even therapeutic doses of acetaminophen are taken with alcohol, the acetaminophen can cause liver damage. Patients should be cautioned not to drink alcohol; even two drinks with acetaminophen can produce this effect. Hydrocodone does not contribute to hepatotoxicity. Ibuprofen is not indicated for postoperative pain unless the pain is mild. Limiting alcohol intake to two servings per day still increases the risk of hepatotoxicity.
Which order for furosemide is written appropriately by the prescriber?
a. Furosemide [Lasix] 20 mg PO QD
b. Furosemide [Lasix] 20 mg PO qd
c. Furosemide [Lasix] 20 mg daily
d. Furosemide [Lasix] 20 mg PO daily
d. Furosemide [Lasix] 20 mg PO daily
The correct answer is a complete order; it contains the medication, dose, route, and time. “QD” and “qd” are no longer accepted abbreviations; it should be written out as “daily” or “every day.” The order of “20 mg daily” does not specify the route to be used.
A drug can cause symptoms that resemble those of Parkinson disease. What action should the prescriber take to minimize the potential patient risk?
a. Explain that these are teratogenic effects that must be reported immediately.
b. Thoroughly educate the patient about recognizing such symptoms and the need to
notify the office immediately.
c. Order an evaluation of the patient’s genetic predisposition to these effects.
d. Educate the patient about these symptoms and provide reassurance that the
condition is expected.
b. Thoroughly educate the patient about recognizing such symptoms and the need to
notify the office immediately.
Some drugs can cause iatrogenic conditions, which are conditions whose symptoms are the same as those of a known disease. The patient should be prepared for this possibility and be prepared to recognize and report the symptoms immediately. Such effects are not teratogenic, since teratogenic effects affect the fetus. Patients with a genetic predisposition to respond differently to drugs are
known to have idiosyncratic effects. Although reassurance may dispel some fear on the part of the patient, it does provide the patient with actions (e.g., notifying the provider) that can allow for symptom management.
A patient who has been taking sertraline for depression was prescribed azithromycin to treat an infection by a provider at an after-hours clinic. What action will the primary care provider take to address the risk this combination of medication has posed for the patient?
a. Discontinue the azithromycin and write an order for an alternative antibiotic.
b. Discontinue the sertraline and write an order for a different antidepressant
medication.
c. Reduce the sertraline dosage while taking azithromycin.
d. Withhold the sertraline until the azithromycin therapy is completed.
a. Discontinue the azithromycin and write an order for an alternative antibiotic.
Both sertraline and azithromycin prolong the QT interval, and when taken together, they increase the risk of fatal dysrhythmias. Because the antibiotic is used for a short time and because the patient was already taking sertraline, it is correct to consider using a different antibiotic. Reducing the dose of sertraline does not alter the combined effects of two drugs that lengthen the QT interval. Sertraline should not be stopped abruptly, so withholding it during antibiotic therapy is not indicated. Additionally, it is important to reinforce the need to tell all providers that sertraline is being taken.
A patient reports mild nausea within an hour after taking the first two doses of a newly approved medication. Nausea is not listed among the known side effects of this drug. What instructions will the provider give the patient?
a. “Take the next dose with food and call the office if the nausea reoccurs or if other
symptoms develop.”
b. “Discontinue the medication and a substitute will be prescribed.”
c. “Reporting the situation to the MEDWATCH program will get us a
recommendation about continuing the drug.”
d. “I’ll write a prescription for an antiemetic to counter this drug’s effects.”
a. “Take the next dose with food and call the office if the nausea reoccurs or if other
symptoms develop.”
Not all adverse drug reactions (ADRs) are detected during clinical trials, and prescribers should be alert to any effects that may result from drug administration. The time of nausea onset suggests that this is drug-related. Unless contraindicated, taking drugs with food will usually relieve or decrease nausea. Because there is a possibility that the nausea is not drug-related, it is important to ask the patient to report the recurrence or worsening of the symptom or the addition of new symptoms. It is not necessary to hold the drug, because nausea is not a serious side effect. The MEDWATCH program should be notified when there is a greater suspicion that the drug may have caused the nausea, e.g., if the nausea occurs with subsequent doses. Until there is greater suspicion that the drug caused this patient’s nausea and because the patient is not vomiting, giving an antiemetic is not indicated.
A patient develops shortness of breath shortly after taking the initial dose of a newly prescribed medication. The patient’s heartrate is 86 beats/minute, the respiratory rate is 24 breaths/minute, and the blood pressure is 120/70 mm Hg. The prescriber will discontinue the drug based on the assumption the patient experienced what medication induced effect?
a. An allergic reaction
b. An idiosyncratic effect
c. An iatrogenic response
d. A side effect
d. A side effect
A side effect is a secondary drug effect produced at therapeutic doses. This patient received the correct dose of the drug and developed shortness of breath, which, in this case, is a drug side effect. To experience an allergic reaction, a patient must have prior exposure to a drug and sensitization of the immune response. An idiosyncratic effect results from a genetic predisposition to an uncommon drug response. An iatrogenic response occurs when a drug causes symptoms of a disease.
A provider recommends genetic testing of a patient before prescribing a medication. What response should the provider give when asked by the patient about the purpose of genetic testing?
a. “Genetic testing better establishes the drug’s therapeutic index.”
b. “Such testing will tell us how quickly your body is likely to metabolize, or
process, the drug.”
c. “The testing helps identify any factors that could affect psychosocial variation in
the drug’s response.”
d. “It guides the production of a drug that is tailored to your individual genetic
makeup.”
b. “Such testing will tell us how quickly your body is likely to metabolize, or
process, the drug.”
Pharmacogenomics is the study of the ways genetic variations affect individual responses to drugs through alterations in genes that code for drug-metabolizing enzymes and drug receptors. For some drugs, the FDA requires genetic testing, and for others, this testing is recommended but not required. Genetic testing does not determine a drug’s therapeutic index; this is a measure of a drug’s safety based on statistics of the drug’s use in the general population (see Chapter 5). Any distinct physiologic differences in drug response among various racial populations are related to genetic differences and do not affect psychosocial differences in drug responses. Genetic testing is recommended to identify how a patient will respond to a drug and not to design a drug specific to an individual.
A patient is prescribed digoxin. Which screening will the provider order to monitor for potential adverse effects from this drug?
a. Albumin
b. Blood urea nitrogen (BUN) and creatinine
c. Hepatic enzymes
d. Serum electrolytes
d. Serum electrolytes
Patients with low serum potassium are at increased risk for fatal cardiac dysrhythmias when taking digoxin, and it is essential to know this level before this medication is administered. Knowing a patient’s albumin level would be important when giving drugs that are highly protein bound. The BUN and creatinine levels are indicators of renal function. Hepatic enzymes are important to know when drugs are metabolized by the liver.
A provider considers prescribing tamoxifen for a woman with breast cancer. Upon reviewing results of genetic testing, the prescriber notes that the patient has variations in the CYP2Dy allele resulting in a deficiency of the CYP2D6 isoenzymes. What action will this deficiency warrant in the prescribing of tamoxifen, a CYP2D6 substrate?
a. The tamoxifen will not be prescribed.
b. The individual doses of tamoxifen will be increased.
c. The tamoxifen will be ordered but in lower than normal dosage.
d. The patient’s serum tamoxifen level will be routinely monitored.
a. The tamoxifen will not be prescribed.
Women with a deficiency of CYP2D6 isoenzymes lack the ability to convert tamoxifen to its active form, endoxifen, and will not benefit from this drug. Another drug should be used to treat this patient’s breast cancer. Increasing the dose, reducing the dose, or monitoring serum drug levels will not make this drug more effective in these women.
A patient has taken a narcotic analgesic for chronic pain for several months. At a follow-up appointment, the provider notes that the patient has been taking more than the prescribed dosage. The patient has normal vital signs, is awake and alert, and reports mild pain. What does the provider suspect is responsible for the patient’s response?
a. This patient exhibits a negative placebo effect with a reduced response to the
drug.
b. This patient has developed tachyphylaxis because of repeated exposure to the
drug.
c. This patient has developed pharmacodynamic tolerance, which has increased the
minimal effective concentration (MEC) needed for analgesic effect.
d. This patient has increased hepatic enzyme production as a result of prolonged
exposure to the drug.
c. This patient has developed pharmacodynamic tolerance, which has increased the
minimal effective concentration (MEC) needed for analgesic effect.
Pharmacodynamic tolerance results when a patient takes a drug over a long period of time. Adaptive processes occur in response to chronic receptor occupation. The result is that the body requires increased drug, or an increased MEC, to achieve the same effect. This patient is getting adequate pain relief, so there is no negative placebo effect. Tachyphylaxis is a form of tolerance that can be defined as a reduction in drug responsiveness brought on by repeated dosing over a short time. Induced synthesis of hepatic enzymes increases metabolism of a drug, but it does not increase the MEC.
Which patient ethnic ancestry creates a risk factor that may result in minimal beneficial response to tamoxifen therapy?
a. African
b. French
c. Native American
d. Japanese
b. French
Between 8% and 10% of women of European ancestry have a gene variant that prevents the effective metabolism of tamoxifen that negatively affects the medication’s therapeutic effect. None of the other options present with a similar risk factor.
Before initiating cetuximab therapy, the provider will order epidermal growth factor receptor (EGFR) testing for the patient having which condition?
a. Breast cancer
b. Colorectal cancer
c. Bone cancer
d. Brain cancer
b. Colorectal cancer
Cetuximab is used mainly for metastatic colorectal cancer. The medication works only against tumors that express EGRF; all other tumors are unresponsive. This makes testing in advance of treatment required. Cetuximab is not appropriate for any of the other conditions listed.
When considering the benefit of pharmacogenomics, what information should the prescriber include when prescribing a new medication?
a. Stress the need to contact the primary health care prescriber immediately if side
effects occur.
b. Provide definitions and possible examples of related idiosyncratic responses to
this medication.
c. Explain any necessary precautions to take regarding medication administration.
d. Give a detailed explanation regarding the method for discontinuing the
medication, should it become necessary.
b. Provide definitions and possible examples of related idiosyncratic responses to
this medication.
A patient’s unique genetic makeup can lead to drug responses that are qualitatively and quantitatively different from those of the population at large. Adverse effects and therapeutic effects may be increased or reduced. Idiosyncratic responses to drugs may also occur. Educating the patient on the concept and examples of idiosyncratic responses should be included in the medication education provided. The other options are appropriate but not directly related to pharmacogenomics.
A provider has prescribed a female patient a medication that induces P-glycoprotein (PGP). The provider will be particularly concerned about which aspects of the patient’s medical history? (Select all that apply.)
a. Intestinal problems
b. Kidney function
c. Liver function
d. Pregnancy
e. Seasonal allergies
a. Intestinal problems
b. Kidney function
c. Liver function
Drugs that induce PGP can increase drug export from cells of the intestinal epithelium into the intestinal lumen, thus decreasing absorption of the drug. PGP inducers also increase drug elimination and decrease brain and fetal drug exposure. Seasonal allergies are not generally a concern.
When prescribing medications to infants, it is important for the provider to consider which fact? (Select all that apply.)
a. Breast-feeding infants are more likely to develop toxicity when the mother is
taking lipid-soluble drugs.
b. Immaturity of renal function in infancy causes infants to excrete drugs less
efficiently.
c. Infants have immature livers, which slows drug metabolism.
d. Infants are more sensitive to medications that act on the central nervous system
(CNS).
e. Oral medications are contraindicated in infants.
a. Breast-feeding infants are more likely to develop toxicity when the mother is
taking lipid-soluble drugs.
b. Immaturity of renal function in infancy causes infants to excrete drugs less
efficiently.
c. Infants have immature livers, which slows drug metabolism.
d. Infants are more sensitive to medications that act on the central nervous system
(CNS).
Immature renal function causes infants to excrete drugs more slowly, and infants are at risk for toxicity until renal function is well developed. Infants’ livers are not completely developed, and they are less able to metabolize drugs efficiently. Because the blood-brain barrier is not well developed in infants, caution must be used when administering CNS drugs. Lipid-soluble drugs may be excreted in breast milk if the mother is taking them. Oral medications may be given safely to infants as long as they are awake and can swallow the drug.
What will the provider consider when prescribing two drugs that compete for plasma albumin receptor sites? (Select all that apply.)
a. Binding of one or both agents will be reduced.
b. Plasma levels of free drug will rise.
c. Plasma levels of free drug will fall.
d. The increase in free drug will cause sustained intensification of effects.
e. The increase in bound drug will cause sustained intensification of effects.
a. Binding of one or both agents will be reduced.
b. Plasma levels of free drug will rise.
c. Plasma levels of free drug will fall.
When two drugs bind to the same site on plasma albumin, coadministration of those drugs produces competition for binding. As a result, binding of one or both agents is reduced, causing plasma levels of free drug to rise. The increase in free drug can intensify the effect, but it usually undergoes rapid elimination; therefore, the increase in plasma levels of free drug is rarely sustained. Drug that is bound to protein in the circulation is inactive; therefore, it cannot cause an effect.
Which actions occur in most of the fatal medication errors? (Select all that apply.)
a. Confusing drugs with similar packaging
b. Giving a drug intravenously instead of intramuscularly
c. Administering a drug that sounds like the prescribed drug
d. Using an infusion device that malfunctions
e. Writing a prescription illegibly
b. Giving a drug intravenously instead of intramuscularly
c. Administering a drug that sounds like the prescribed drug
e. Writing a prescription illegibly
Ninety percent of fatal medication errors fall into three categories: human factors, communication mistakes, and name confusion. Giving a drug IV (intravenously) instead of IM (intramuscularly) is an example of a human factor; writing a prescription so that it is illegible is an example of a communication mistake; and giving a drug with a name that sounds like the name of another drug is
an example of name confusion. Confusion of drugs with similar packaging and using a faulty device also can cause fatal drug errors, but these factors do not fall into the categories that account for most of fatal errors.
A patient is found to have a genetic deficiency in the biomarker CYP2C19. The provider recognizes that prescribing clopidogrel will increase the patient’s risk for developing what serious conditions? (Select all that apply.)
a. Myocardial infarction
b. Stroke
c. Peptic ulcer
d. Dementia
e. Stomach cancer
a. Myocardial infarction
b. Stroke
Clopidogrel, a drug that prevents platelet aggregation, is negatively affected by a variant in the genetic code of CYP2C19 resulting in a weak antiplatelet response, which increases their risk for stroke and myocardial infarction. The risk for the other options is not increased with this variant situation.
A provider speaking to a class or a group of pregnant patients correctly teaches that the highest risk of teratogen-induced gross malformations exists during which time period?
a. Immediately before conception
b. During the first trimester
c. During the second trimester
d. During the third trimester
b. During the first trimester
Gross malformations are caused by exposure to teratogens during the embryonic period, which is considered the first trimester. This is the time when the basic shape of internal organs and other structures is established. No risk exists immediately before conception. Teratogen exposure during the second and third trimesters usually disrupts function rather than gross anatomy.
A pregnant patient asks her provider about the safe use of medications during the third trimester. What will the provider tell her about drugs taken at this stage?
a. “They may need to be given in higher doses if they undergo renal clearance.”
b. “They require lower doses if they are metabolized by the liver.”
c. “They are less likely to cross the placenta and affect the fetus.”
d. “Drugs are more likely to cause anatomical defects if they are taken during the
second trimester.
a. “They may need to be given in higher doses if they undergo renal clearance.”
In the third trimester, drugs excreted by the kidneys may have to be increased, because renal blood flow is doubled, the glomerular filtration rate is increased, and drug clearance is accelerated. Hepatic metabolism increases; therefore, drugs metabolized by the liver may need to be increased. Drugs are not less likely to cross the placenta. Anatomic defects are more likely to occur in the embryonic period, which is in weeks 3 through 8 in the first trimester.
A woman who breastfeeds her infant must take a prescription medication for 2 weeks. The medication is safe, but the patient wants to make sure her baby receives as little of the drug as possible. What instructions will the prescriber give the patient to best address her concerns?
a. “Give the baby formula as long as you are taking the medication.”
b. “Take the medication immediately after breastfeeding your baby.”
c. “Pump your breast milk and feed the baby by bottle.”
d. “Take the medication 1 hour before breastfeeding.”
b. “Take the medication immediately after breastfeeding your baby.”
Taking the medication immediately after breastfeeding minimizes the drug concentration in the breast milk at the next feeding. Disrupting breastfeeding is not indicated. Pumping the breast milk will not diminish the drugs or drug concentration in the breast milk. Taking the medication 1 hour before breastfeeding will increase concentrations of the drug in the breast milk.
Which type of medication prescribed to a pregnant patient is more likely to have effects on her fetus?
a. Drugs that are highly polar
b. Ionized drugs
c. Lipid-soluble drugs
d. Protein-bound drugs
c. Lipid-soluble drugs
Lipid-soluble drugs cross the placenta more readily. Drugs that are highly polar, ionized, or protein bound cross the placenta with difficulty.
A pregnant woman asks why more is not known about the teratogenic effects of maternal medication ingestion during pregnancy. Which response will the provider offer to address the patient’s concern?
a. “Clinical trials to determine teratogenic effects would put the fetus at risk.”
b. “It is safer to recommend that pregnant women avoid medications while
pregnant.”
c. “Most women are reluctant to admit taking medications while they are pregnant.”
d. “The relatively new MEPREP study will allow testing of medications during
pregnancy in the future.”
a. “Clinical trials to determine teratogenic effects would put the fetus at risk.”
One of the greatest challenges in identifying drug effects on a developing fetus has been the lack of clinical trials, which, by their nature, would put the developing fetus at risk of harm. Many pregnant women need prescription medications and not taking those would put the fetus at risk by compromising the health of the mother. The MEPREP study is a retrospective study to learn about possible outcomes related to known maternal drug exposure.
An infant developed a pruritic rash following exposure to an allergen. The infant’s parents ask the provider about using a topical antihistamine. What information should the provider use to address the parents’ question?
a. Antihistamines given by this route are not absorbed as well in children.
b. Applying an antihistamine to the skin can cause toxicity in this age group.
c. The child will also need oral medication to achieve effective results.
d. Topical medications have fewer side effects than those given by other routes.
b. Applying an antihistamine to the skin can cause toxicity in this age group.
Drug absorption through the skin is more rapid in infants, because their skin is thinner and has greater blood flow; therefore, infants are at increased risk of toxicity from topical drugs. Because of increased drug absorption through the skin, infants should not be given additional drugs via other routes. If a drug is more likely to be absorbed rapidly, it will have more side effects.
The parents of a child with asthma ask the provider why their child cannot use oral corticosteroids more often, because they are so effective. The provider will base the discussion with the parents on what fact concerning oral corticosteroids?
a. Chronic glucocorticoid use can inhibit physical growth.
b. Frequent use of this drug may lead to a decreased response.
c. A hypersensitivity reaction to this drug may occur.
d. Systemic steroids are more toxic in children.
a. Chronic glucocorticoid use can inhibit physical growth.
A specific age-related reaction to a drug is growth suppression caused by glucocorticoids. Children with asthma may need these from time to time for acute exacerbations, but chronic use is not recommended. None of the other three effects occurs in either adults or children.
An infant is prescribed a medication that has a narrow therapeutic range and is excreted by the kidneys. The provider will monitor closely for which effect?
a. Decreased drug effectiveness
b. Tachyphylaxis
c. Evidence of drug toxicity
d. Unusual CNS effects
c. Evidence of drug toxicity
Renal drug excretion is lower in infants, so drugs that are eliminated primarily by renal excretion should be given in reduced doses or at longer intervals. Drugs with a narrow therapeutic range should be monitored closely for toxicity. This drug likely will have intensified effects and be present for a longer time. Nothing in the question indicates that unusual CNS effects will occur; these would depend on the drug prescribed.
A medication prescribed for a neonate is eliminated primarily by hepatic metabolism. What action will the prescriber take to minimize risk to the infant?
a. Prescribe a dose that is relatively lower than an adult dose when adjusted for body
surface area.
b. Prescribe a dose that is relatively higher than an adult dose when adjusted for
body surface area.
c. Increase the frequency of medication dosing.
d. Discontinue the drug after one or two doses.
a. Prescribe a dose that is relatively lower than an adult dose when adjusted for body
surface area.
The drug-metabolizing capacity of newborns is low. As a result, neonates are especially sensitive to drugs that are eliminated primarily by hepatic metabolism. When these drugs are used, dosages must be reduced. Because of the decreased ability of hepatic metabolism in the newborn, a lower dose is required, not a higher dose, and the frequency will not be increased. The medication dosage should be adjusted, not discontinued, for the newborn.
A pediatric provider is teaching nursing students to calculate medication doses for children using a formula based on body surface area. Which statement by a nursing student indicates understanding of the teaching?
a. “This formula helps approximate the first dose; other doses should be based on
clinical observations.”
b. “This formula accounts for pharmacokinetic factors that are different in children.”
c. “Using this formula will prevent side effects of medications in children.”
d. “This formula can determine medication dosing for a child of any age.”
a. “This formula helps approximate the first dose; other doses should be based on
clinical observations.”
This formula helps determine an approximate first dose for a child that is extrapolated from an adult dose; subsequent doses should be adjusted based on clinical outcome and serum plasma levels. The formula accounts only for differences in weight and not for differences in pharmacokinetic factors. The formula helps determine an effective dose but cannot account for unusual side effects that may occur in children. It may not be effective for all ages because of rapid changes in pharmacokinetics.
A child attending daycare is prescribed 750 mg of an antibiotic for 10 days. The drug may be dosed in several ways and is available in two concentrations. Which dosing regimen will the provider consider to best assure drug adherence?
a. 375 mg of a 250 mg/5 mL solution PO twice daily
b. 250 mg of a 250 mg/5 mL solution PO three times daily
c. 250 mg of a 500 mg/5 mL solution PO three times daily
d. 375 mg of a 500 mg/5 mL solution PO twice daily
d. 375 mg of a 500 mg/5 mL solution PO twice daily
To promote adherence to a drug regimen in children, it is important to consider the size and timing of the dose. In this case the preparation containing 500 mg/5 mL means that a smaller volume can be given, which is more palatable to a child. Twice daily dosing is more convenient for parents, especially when a child is in daycare or school; it also helps prevent the problem of the medication being left either at home or at school.
A 5-year-old has gray teeth. When taking a medication history, the provider will ask about previous use of which group of medications?
a. Glucocorticoids
b. Salicylates
c. Sulfonamides
d. Tetracyclines
d. Tetracyclines
Tetracyclines cause discoloration in developing teeth in children. Glucocorticoids are associated with growth suppression. Salicylates are associated with Reye syndrome. Sulfonamides are associated with kernicterus in newborns.
A provider is concerned about renal function in an 84-year-old patient who is taking several medications. What laboratory result will the provider order?
a. Creatinine clearance
b. Sodium levels
c. Potassium levels
d. Serum creatinine
a. Creatinine clearance
The proper index of renal function in older adults is creatinine clearance, which indicates renal function in older patients whose organs are undergoing age-related deterioration. Sodium and potassium levels are not indicative of renal function. Serum creatinine levels do not accurately reflect kidney function in older adults because lean muscle mass, which is the source of creatinine in serum, declines and may be low even with reduced kidney function.
An older adult patient with a history of forgetfulness will need to take multiple drugs after discharge from the hospital. What provider action will most successfully promote medication adherence in a forgetful patient?
a. Ask the patient to share the medication teaching with a neighbor or friend soon
after discharge.
b. Give the patient detailed written information about each drug.
c. Schedule medications to be taken at the same times as much as possible.
d. Make sure the patient understands the actions and side effects of each drug.
c. Schedule medications to be taken at the same times as much as possible.
Unintentional nonadherence often is the result of confusion and forgetfulness. Grouping medications to reduce the number of medication times per day can simplify the regimen and help the patient remember medication times. Enlisting a neighbor, relative, or friend is a good idea, but this person should be included in the original teaching sessions. Asking the patient to share what is learned may not be a reasonable expectation of a patient who is forgetful. Detailed written information may just be more confusing; verbal and written information should be clear and concise. Making sure the patient understands the actions and side effects of medications helps when intentional nonadherence is an issue, but in this case it may just add to the patient’s confusion.
A provider is reviewing an older adult patient’s chart during a routine visit. Which patient information is of most concern regarding the renewing of medication prescriptions for highly protein-bound drugs?
a. Chronic constipation
b. Increased body fat
c. Low serum albumin
d. Low serum creatinine
c. Low serum albumin
Low serum albumin reduces protein binding of drugs and can cause levels of free drug to rise, increasing the risk of toxicity. The other options are not associated solely with protein-bound drugs. Additionally, altered gastrointestinal (GI) absorption is not a major factor of concern in the older adult, although delayed GI transit can delay drug responses. Increased body fat can alter drug distribution, causing reduced responses in lipid-soluble drugs; however, it is not the finding of greatest concern. Low serum creatinine may be an indicator of decreased lean muscle mass in older patients and does not necessarily reflect kidney function or drug excretion.
Four older adult patients are taking multiple medications. For which patient is the provider most concerned about the risk for adverse drug effects?
a. An obese patient
b. A patient with decreased serum creatinine
c. A patient who experiences chronic diarrhea
d. An underweight patient with a chronically low appetite
d. An underweight patient with a chronically low appetite
The patient who is thin and has a poor appetite has an increased risk of malnutrition, with significant lowering of serum albumin. This can result in increased free drug levels of protein-bound drugs and can lead to drug toxicity. Obesity, which involves increased adipose tissue, would cause lipid-soluble drugs to deposit in adipose tissue, with a resulting reduction of drug effects. Creatinine levels do not adequately reflect kidney function in older adults and may be normal even though renal function is greatly reduced. Chronic diarrhea would accelerate the passage of medications through the GI tract and reduce absorption resulting in a decrease in both beneficial and adverse effects.
An older adult patient is entering into the immediate postoperative period after a total hip replacement. The patient’s son concerned about related pain asks meperidine be prescribed since, “I had it for severe pain when I injured when I was younger.” What action will the provider take to reduce the patient’s risk for injury while addressing the patient’s pain?
a. Prescribe meperidine and request the initiation of the fall risk protocol.
b. Provide a PRN order for diphenhydramine for the expected side effect of itching.
c. Prescribe morphine and discuss the rationale with the patient’s son.
d. Offer to prescribe diazepam to reduce the patient’s anxiety and thus reduce the
need for narcotics.
c. Prescribe morphine and discuss the rationale with the patient’s son.
In older adults, meperidine is not effective at usual doses and causes more confusion, delirium, and neurotoxicity than in younger patients. Morphine is recommended for severe pain among the older population. A fall risk protocol is appropriate, but the drug ordered is not. Diphenhydramine is not recommended for older adult patients, because it causes blurred vision. Both diphenhydramine and diazepam have central nervous system (CNS) sedative effects, which will compound the CNS effects of the narcotic. Diazepam also produces prolonged sedation in older adults.
An older adult patient is admitted to the hospital for treatment of an exacerbation of a chronic illness. Admission laboratory work reveals an extremely low serum drug level of the drug used to treat this condition. The patient’s renal and hepatic function tests are normal. What might the provider suspect as a likely cause of this finding?
a. Nonadherence to the medical regimen
b. Chronic constipation
c. Increased tolerance to the drug’s effects
d. Concurrent administration of two highly protein-bound drugs
a. Nonadherence to the medical regimen
Nonadherence is the most common cause of a subtherapeutic drug level. For example, older adult patients who have financial concerns about paying for medications often take less of the drug or take it less often to make the drug last longer. Chronic constipation would be more likely to cause a slight elevation of drug level due to the prolonged time for drug absorption. A patient with increased tolerance to a drug’s effects would require more of the drug to get effects. Concurrent administration of two highly protein-bound drugs would result in increased serum levels of one or both drugs.
A provider obtains a drug history from an older adult who is a new patient. Of the multiple medications taken, which two, taken together, create a reason for concern?
a. Acetaminophen and oxycodone
b. Amitriptyline and diphenhydramine
c. Fexofenadine and an over-the-counter (OTC) laxative
d. Zolpidem and sertraline
b. Amitriptyline and diphenhydramine
Both amitriptyline and diphenhydramine are on the BEERS list, amitriptyline for anticholinergic effects and diphenhydramine because it causes blurred vision. Additionally, they both have CNS effects that can compound each other when the drugs are given together. Acetaminophen and oxycodone are both acceptable and may be given together. Fexofenadine is a second-generation antihistamine with fewer side effects, and it is not contraindicated for use with a laxative. Zolpidem is a sedative that has less risk of physical dependence and less risk of confusion, falls, and cognitive impairment; sertraline is a safer antidepressant, because it has a shorter half-life than others.
A frail older adult patient is admitted to the hospital after several days of vomiting, diarrhea, poor intake of foods and fluids, and anuria for 8 hours. What laboratory studies will the provider order to help guide medication administration? (Select all that apply.)
a. Creatinine clearance
b. Gastric pH
c. Plasma drug levels
d. Serum albumin
e. Serum creatinine
a. Creatinine clearance
c. Plasma drug levels
d. Serum albumin
Creatinine clearance is the best way to evaluate renal function in the older adult. Plasma drug levels are important for determining if the patient has toxic or subtherapeutic drug levels. Serum albumin may be decreased, especially in patients who are thin, are chronically undernourished, or have been vomiting, and the decreased level may result in higher levels of drugs that normally bind to proteins. Gastric pH is not as important; most GI changes result in lowered absorption and less free drug. Serum creatinine levels are related to the amount of lean muscle mass, which may be low in older adult patients, and not reflective of renal function.
A patient is wheezing and short of breath with a heart rate of 88 beats/minute, a respiratory rate of 24 breaths/minute, and a blood pressure of 124/78 mm Hg. The primary health care prescriber orders a nonselective β agonist medication. Besides evaluating the patient for a reduction in respiratory distress, which side effect is of primary concern?
a. Hypotension
b. Tachycardia
c. Tachypnea
d. Urinary retention
b. Tachycardia
β agonists are used for asthma because of their β2 effects on bronchial smooth muscle, causing dilation. Nonselective β agonists also have β1 effects. β1 effects cause tachycardia and hypertension. β receptors do not exert effects on the bladder.
A pregnant patient is in premature labor. Which class of drug will her provider prescribe in an attempt to stop the contractions?
a. α1 agonist
b. Anticholinergic
c. β2 agonist
d. β2 antagonist
c. β2 agonist
β2 agonists cause relaxation of uterine muscle, slowing or stopping the contractions that precipitate labor. An α1 agonist would have effects on the heart and arterioles. Anticholinergic drugs generally are given for their effects on the urinary and GI tracts and do not affect uterine muscle. A β2 antagonist would cause increased constriction of uterine muscle.
Which assessment finding would be of greatest concern for a provider who is attempting to determine the appropriateness of prescribing the patient a nonselective β agonist?
a. Pulse oximetry reading of 88%
b. Blood pressure of 100/60 mm Hg
c. Respiratory rate of 28 breaths/minute
d. Heart rate of 110 beats/minute
d. Heart rate of 110 beats/minute
Nonselective β agonists activate both β1 and β2 receptors. A nonselective β agonist dilates respiratory smooth muscle, but as a side effect, it can stimulate the heart. A heart rate of 110 beats/minute is a concern, because this medication may further increase the already elevated heart rate. A pulse oximetry reading of 88% is a concern, but the medication causes bronchodilation and improves oxygenation; this should increase the pulse oximetry reading. A blood pressure of 100/60 mm Hg is on the low side, but this medication may actually cause an increase in blood pressure as a side effect; this should not concern the nurse before administration of the medication. A respiratory rate of 28 breaths/minute is elevated; however, this medication should improve oxygenation by bronchodilation, and the patient’s respiratory rate should decrease once oxygenation has improved. Therefore, this should not concern the nurse.
For what purpose will a provider prescribe pilocarpine?
a. To reduce excessive secretions in a postoperative patient
b. To lower intraocular pressure in a patient with glaucoma
c. To inhibit muscular activity in a patient with an overactive bladder
d. To prevent a hypertensive crisis in a patient with chronic hypertension
b. To lower intraocular pressure in a patient with glaucoma
Pilocarpine is a muscarinic agonist used mainly for topical therapy of glaucoma to reduce intraocular pressure. Pilocarpine is not indicated for the treatment of excessive secretions and mucus; in fact, pilocarpine is used to treat dry mouth. Pilocarpine does not inhibit muscular activity in the bladder. Pilocarpine is not used to prevent hypertensive crisis.
A provider reviews the patient’s chart before prescribing bethanechol for postoperative urinary retention. Which preexisting condition would be a contraindication to using this drug?
a. Asthma
b. Gastroesophageal reflux
c. Hypertension
d. Hypothyroidism
a. Asthma
Bethanechol is contraindicated in patients with active or latent asthma because activation of muscarinic receptors in the lungs causes bronchoconstriction. It increases the tone and motility of the gastrointestinal (GI) tract and is not contraindicated in patients with reflux. It causes vasodilation and would actually lower blood pressure in a hypertensive patient. It causes dysrhythmias in hyperthyroid patients, not hypothyroid patients.
An older adult patient who lives alone and admits to being “somewhat forgetful” has an overactive bladder (OAB) and occasional constipation. The patient has tried behavioral therapy to treat the OAB without success. Which treatment will the provider likely prescribe for this patient?
a. Oxybutynin short-acting syrup
b. Oxybutynin [Ditropan XL] extended-release tablets
c. Oxybutynin [Oxytrol] transdermal patch
d. Percutaneous tibial nerve stimulation (PTNS)
c. Oxybutynin [Oxytrol] transdermal patch
The transdermal patch is applied weekly and may be the best option for a patient who is more likely to forget to take a daily medication. The transdermal preparation has fewer side effects than the systemic dose, so it is less likely to increase this patient’s constipation. The syrup has a high incidence of dry mouth and other anticholinergic side effects. The extended-release tablets must be given daily, and this patient may not remember to take them. PTNS is used after behavioral and drug therapies have failed.
Bethanechol is being investigated for inclusion in treatment for which diagnosis?
a. Gastric ulcers
b. Gastroesophageal reflux
c. Hypotension
d. Intestinal obstruction
b. Gastroesophageal reflux
Bethanechol is being investigated for the treatment of gastroesophageal reflux disease (GERD) because of its effects on esophageal motility and the lower esophageal sphincter. Bethanechol stimulates acid secretion and could intensify ulcer formation. Bethanechol can cause hypotension. Because bethanechol increases the motility and tone of intestinal smooth muscle, the presence of an obstruction could lead to bowel rupture.
The prescriber has ordered neostigmine for a patient with myasthenia gravis. What physiological process would be assessed to best assure patient safety and the long-term effectiveness of the medication therapy?
a. The patient’s ability to raise the eyelids
b. The level of fatigue the patient generally experiences
c. Current skeletal muscle strength the patient possesses
d. The patient’s current swallowing ability
d. The patient’s current swallowing ability
Many patients hospitalized for myasthenia gravis do not have the muscle strength to swallow well and need a parenteral form of the medication; therefore, assessing the patient’s ability to swallow is an important initial safety measure. Evaluating the patient’s ability to raise the eyelids, level of fatigue, and skeletal muscle strength are important assessments before drug administration and during drug treatment, because they indicate the effectiveness of the drug and help determine subsequent doses.
A patient experiences delirium and hallucinations after beginning atropine treatment for bradycardia. Which medication will the provider prescribe to address these signs of possible atropine toxicity?
a. Donepezil
b. Edrophonium
c. Neostigmine
d. Physostigmine
d. Physostigmine
Physostigmine is the drug of choice for treating poisoning from atropine and other drugs that cause muscarinic blockade. Donepezil is used to treat Alzheimer disease. Edrophonium is used to distinguish between a myasthenic crisis and a cholinesterase inhibitor overdose. Neostigmine does not cross the blood-brain barrier and would not effectively treat this patient’s CNS symptoms.
The provider is assessing an older adult male patient prior to beginning a prescribed anticholinergic drug. Which question concerning preexisting conditions demonstrates the provider’s understanding of possible contraindications to this therapy?
a. “Would you say that diarrhea is a problem you deal with regularly?”
b. “Do you have any vision problems that require a prescribed medication?”
c. “Have you ever been treated for prostate cancer?”
d. “Do you have problems with urinary incontinence?”
b. “Do you have any vision problems that require a prescribed medication?”
Anticholinergic drugs have been designated as potentially inappropriate for use in geriatric patients. They can cause confusion, blurred vision, tachycardia, urinary retention, and constipation. Many of these complicate preexisting conditions (e.g., urinary retention secondary to benign prostatic hyperplasia) and increase the risk for other conditions (e.g., narrow-angle glaucoma risk secondary to pupil dilation and heat-related illness secondary to hyperthermia and impaired sweating mechanisms).
A client with a history of motion sickness asks the provider about medication to manage this condition during a planned cruise. What medication will the provider likely prescribe?
a. Ipratropium
b. Scopolamine
c. Dicyclomine
d. Atropine
b. Scopolamine
Scopolamine is an anticholinergic drug with actions much like those of atropine, but with an exception. Scopolamine suppresses emesis and motion sickness, whereas atropine does not. Ipratropium is an anticholinergic drug used to treat asthma, COPD, and rhinitis caused by allergies or the common cold. Dicyclomine is indicated for irritable bowel syndrome (spastic colon, mucous colitis). It is also used for functional bowel disorders such as diarrhea and hypermotility. Neither dicyclomine nor ipratropium have antiemetic properties.
A client is about to begin anticholinergic medication therapy. What instructions will the provider give to best minimize common side effects?
a. Wear dark glasses both indoors and outdoors.
b. Void just prior to taking the medication.
c. Minimize fiber intake to avoid diarrhea.
d. Hydrate well before engaging in outdoor exercise.
b. Void just prior to taking the medication.
Advise patients that urinary retention can be minimized by voiding just before taking anticholinergic medication. Dark glasses are of value with outdoors if experiencing photophobia, but are unnecessary indoors. Constipation rather than diarrhea is associated with anticholinergic medication and so fiber consumption is important. Avoidance of outside exercise especially in warm/hot environments is related to impaired sweat production and hyperthermia rather than hydration issues.
Dopamine is administered to a patient who has hypotension. Other than an increase in blood pressure, which indicator would the provider use to evaluate a successful response?
a. Decrease in pulse
b. Increase in urine output
c. Weight gain
d. Improved gastric motility
b. Increase in urine output
Dopamine will cause an increase in urine output, because cardiac output is increased as a result of the increase in blood pressure. The effectiveness of dopamine would not be measured by a decrease in pulse, because dopamine’s primary effect is to increase blood pressure. Dopamine’s effectiveness would not be evaluated by a weight gain. Dopamine’s effectiveness would not be evaluated by improved gastric motility.
A patient with asthma uses albuterol for wheezing. The provider notes current vital signs of HR, 96 beats/minute; RR, 18 breaths/minute; and BP, 116/78 mm Hg. The patient has clear breath sounds and fine hand tremors. What action will the provider take initially to treat this patient effectively?
a. Ask how often the patient uses the inhaler.
b. Check the patient’s blood glucose level.
c. Prescribe isoproterenol to reduce side effects.
d. Substitute isoproterenol to minimize the tremors.
a. Ask how often the patient uses the inhaler.
Tachycardia is a response to activation of β1 receptors. It can occur when large doses of albuterol are used and selectivity decreases. The nurse should question the patient about the number of inhalations used. Isoproterenol can cause hyperglycemia in diabetic patients. Isoproterenol has more side effects than albuterol. Tremors are an expected side effect and are not an indication for stopping the drug.
The provider is discussing home management with a patient who will begin taking an α-adrenergic antagonist for hypertension. Which statement by the patient indicates understanding of the teaching?
a. “I need to stop the medication if my heart rate increases.”
b. “I should not drive while taking this medication.”
c. “I should take the first dose at bedtime.”
d. “I will stop taking the medication if I feel dizzy.”
c. “I should take the first dose at bedtime.”
Orthostatic hypotension is a common side effect of this class of drugs and is most severe with the first dose. Administering the first dose at bedtime eliminates the risk associated with this first-dose effect. Tachycardia is an expected side effect; if severe, it can be treated with other medications. Patients should not drive during the first 12 to 24 hours after taking these agents, because fainting and dizziness may occur, but they may drive after that. Dizziness is not an indication for stopping the drug; patients who experience dizziness are instructed to sit or lie down until symptoms pass.
A patient prescribed phentolamine to treat pheochromocytoma now has a blood pressure of 76/52 mm Hg and a heart rate of 90 beats/minute. Which action will the provider take to provide effective care?
a. Prescribe epinephrine.
b. Ask to be notified if the heart rate increases.
c. Prescribe a β blocker.
d. Prescribe norepinephrine.
d. Prescribe norepinephrine.
Phentolamine overdose can produce profound hypotension. When this occurs, blood pressure can be elevated with norepinephrine. Epinephrine should not be used because, in the presence of α1 blockade, the ability of epinephrine to promote vasodilation by activation of β2 receptors may outweigh its ability to cause vasoconstriction, causing further lowering of blood pressure. Norepinephrine does not activate β2 receptors. β blockers may be used to treat severe reflex tachycardia. This patient has significant hypotension, so it is not correct to continue to monitor rather than providing treatment.
A patient who takes a β blocker reports experiencing shortness of breath and has respirations of 28 breaths/minute, a blood pressure of 78/50 mm Hg, a pulse of 68 beats/minute, and crackles are auscultated in all lung fields. The provider begins treatment for what condition based on the assessment data?
a. Bronchoconstriction
b. Left-sided heart failure
c. Rebound cardiac excitation
d. Sinus bradycardia
b. Left-sided heart failure
β blockers can exacerbate symptoms in patients with acute decompensated heart failure or in those with preexisting myocardial dysfunction and borderline compensation, since the maintenance of cardiac output in such patients depends in part upon sympathetic drive. The signs and symptoms describe left-sided heart failure, in which the blood normally handled by the left ventricle and forced out through the aorta into the body backs up into the lungs, producing respiratory signs and symptoms. The patient’s signs and symptoms are not indicative of bronchoconstriction, which would cause wheezing and diminished breath sounds. Rebound cardiac excitation occurs when the β blocker is withdrawn, not during administration of the drug. The patient’s heart rate is not lowered to the point of sinus bradycardia.
A male patient with benign prostatic hyperplasia (BPH) has stopped taking his α-adrenergic antagonist medication because of ejaculatory difficulties. Which medication will the provider to prescribe to best address the BPH and the patient’s concerns?
a. Alfuzosin
b. Prazosin
c. Silodosin
d. Tamsulosin
a. Alfuzosin
Alfuzosin is used for BPH and does not interfere with ejaculation. All of the other drugs have ejaculatory related side effects. Prazosin may be useful for BPH, but it is not approved for this use.
A patient will begin taking propranolol for hypertension. Which statement made by the prescriber is important when teaching this patient about the medication?
a. “Notify the clinic if you start waking at night with shortness of breath or have
difficulty lying flat.”
b. “It is safe to take this medication with your calcium channel blocker.”
c. “Stop taking the drug if you become short of breath.”
d. “Take your pulse and do not take the medication if your heart rate is fast.”
a. “Notify the clinic if you start waking at night with shortness of breath or have
difficulty lying flat.”
Patients taking propranolol can develop heart failure because of the suppression in myocardial contractility. Symptoms typically begin with left heart failure, so patients should be taught to report onset of paroxysmal nocturnal dyspnea, orthopnea, and night coughs. Use of these agents with calcium channel blockers is contraindicated, because the effects are identical and excessive cardiosuppression can occur. Abrupt cessation of the drug can cause rebound cardiac excitability; therefore, shortness of breath should be reported rather than stopping the drug. Propranolol reduces the heart rate and should not be given if the pulse is less than 60 beats/minute.
A provider prescribed methyldopa for a patient with hypertension. The patient is educated about drug actions, adverse effects, and the ongoing blood tests necessary with this drug. What additional statement should the provider include during the teaching?
a. “If you have a positive Coombs test result, you will need to discontinue the
medication, because this means you have hemolytic anemia.”
b. “Methyldopa can be used for its analgesic effects and for its hypertensive
effects.”
c. “Xerostomia and orthostatic hypotension are serious side effects and indications
for withdrawing the medication.”
d. “You will need to contact the office immediately and stop taking the medication if
your eyes look yellow.”
d. “You will need to contact the office immediately and stop taking the medication if
your eyes look yellow.”
Hepatotoxicity is a serious adverse effect of methyldopa and is an indication for withdrawal of the drug to prevent fatal hepatic necrosis. Jaundice is a sign of liver toxicity. Patients should undergo periodic liver function tests while taking the drug. Liver function usually improves when the drug is withdrawn. A positive Coombs test result is not an indication for withdrawal of the drug in itself. About 5% of patients with a positive Coombs test result develop hemolytic anemia; withdrawal of the drug is indicated for those patients. Methyldopa does not have analgesic effects. Xerostomia and orthostatic hypotension are known side effects of methyldopa but usually are not serious. Additionally, drug education should be provided using terms the patient can easily understand; most patients will not know the meaning of xerostomia or a positive Coombs test.
A patient reports that the clonidine recently prescribed for hypertension is causing drowsiness. Which response by the provider to this concern is appropriate?
a. “Drowsiness is a common side effect initially, but it will lessen with time.”
b. “You may also experience hypotension when you stand along with the
drowsiness. ”
c. “You may be at risk for addiction if you have central nervous systemside
effects. ”
d. “You should discontinue the medication and I’ll prescribe analternative
medication. ”
a. “Drowsiness is a common side effect initially, but it will lessen with time.”
CNS depression, evidenced in this patient by drowsiness, is common in about 35% of the population. These responses become less intense with continued drug use. Orthostatic hypotension is less likely with clonidine, because its antihypertensive effects are not posture dependent. The experience of drowsiness does not indicate abuse potential. The patient should not discontinue the medication abruptly because of the potential for rebound hypertension; there is no need to change prescriptions.
A prescriber orders clonidine ER (Kapvay ER) tablets for a 12-year-old child to treat which condition?
a. ADHD
b. Hypertension
c. Severe pain
d. Tourette syndrome
a. ADHD
Kapvay ER is used to treat ADHD. This form of clonidine is not used for hypertension, severe pain, or treatment of Tourette syndrome.
A patient is prescribed both a diuretic and a dobutamine in the immediate postoperative period. What adverse drug reactions will the prescriber consider as possible in this patient? (Select all that apply.)
a. Angina
b. Dysrhythmias
c. Hypotension
d. Oliguria
e. Tachycardia
b. Dysrhythmias
d. Oliguria
e. Tachycardia
Hypertension, dysrhythmias, and tachycardia are the most common adverse effects of dopamine; general anesthetics can increase the likelihood of dysrhythmias. Dopamine elevates blood pressure by increasing cardiac output. Diuretics complement the beneficial effects of dopamine on the kidney, so urine output would be increased, not decreased.
A prescriber has ordered methyldopa for a female patient diagnosed with hypertension. The nurse understands that which laboratory tests are important before beginning therapy with this drug? (Select all that apply.)
a. Coombs test
b. Hemoglobin and hematocrit (H&H)
c. Liver function tests
d. Pregnancy test
e. Urinalysis
a. Coombs test
b. Hemoglobin and hematocrit (H&H)
c. Liver function tests
A positive Coombs test result occurs in 10% to 20% of patients who take methyldopa chronically. A few of these patients (5%) develop hemolytic anemia. Blood should be drawn for a Coombs test and an H&H before treatment is started and at intervals during treatment. Because methyldopa is associated with liver disorders, liver function tests should be performed before therapy is started and periodically during treatment. Methyldopa is one of the hypertensives recommended during pregnancy, so pregnancy testing is not needed. A urinalysis is not indicated.
Clonidine is approved for the treatment of which conditions? (Select all that apply.)
a. ADHD
b. Hypertension
c. Opioid withdrawal
d. Severe pain
e. Smoking cessation
a. ADHD
b. Hypertension
d. Severe pain
Clonidine has three approved uses: treatment of ADHD, hypertension, and severe pain. It has investigational (off-label) uses for management of opioid withdrawal and for smoking cessation.
A patient diagnosed with Parkinson disease (PD) begins treatment with levodopa/carbidopa. After several months of therapy, the patient reports no change in symptoms. The provider will implement what action?
a. Prescribing the patient a dopamine agonist
b. Discussing the effects of the “on-off” phenomenon with the patient
c. Increasing the daily dose of levodopa/carbidopa
d. Ordering tests to reevaluate the patient’s diagnosis
d. Ordering tests to reevaluate the patient’s diagnosis
Patients beginning therapy with levodopa/carbidopa should expect therapeutic effects to occur after several months of treatment. Levodopa/carbidopa is so effective that a diagnosis of PD should be questioned if the patient fails to respond in this time frame. Adding a dopamine agonist is not indicated. The “on-off” phenomenon occurs when therapeutic effects are present. Increasing the dose of levodopa/carbidopa is not indicated.
A patient who takes levodopa/carbidopa for Parkinson disease reports periods of lost drug effect lasting from minutes to several hours with no relationship to the timing of drug administration. What course of action will the provider take?
a. Prescribe a COMT inhibitor, such as entacapone.
b. Add the DA-releasing agent amantadine to the regimen.
c. Prescribe a direct-acting dopamine agonist.
d. Shorten the dosing interval of levodopa/carbidopa.
a. Prescribe a COMT inhibitor, such as entacapone.
This patient is describing abrupt loss of effect, or the “off” phenomenon, which is treated with entacapone or another COMT inhibitor. Amantadine is used to treat dyskinesias. A direct-acting dopamine agonist is useful for gradual loss of effect, which occurs at the end of the dosing interval as the dose is wearing off. Shortening the dosing interval does not help with abrupt loss of effect.
When selecting a dopamine agonist for a patient with Parkinson disease, the provider identifies which side effect associated with pramipexole as being less likely to occur than with other dopamine agonists?
a. Sleep attacks
b. Dizziness
c. Hallucinations
d. Dyskinesias
a. Sleep attacks
A few patients taking pramipexole have experienced sleep attacks, or an overwhelming and irresistible sleepiness that comes on without warning. Dizziness, hallucinations, and dyskinesias are listed as side effects of all dopamine agonists
A patient has been newly diagnosed with Parkinson disease. Before beginning therapy with pramipexole, the provider will ask the patient which assessment question in order to minimize risk for injury?
a. “Do you have any history of alcohol abuse or compulsive behaviors?”
b. “Have you have any previous history of hypertension?”
c. “Do you have any difficulty falling asleep or staying asleep?”
d. “Do you have family history associated with psychoses?”
a. “Do you have any history of alcohol abuse or compulsive behaviors?”
Pramipexole has been associated with impulse control disorders, and this risk increases in patients with a history of alcohol abuse or compulsive behaviors. Pramipexole increases the risk of hypotension and sleep attacks, so a history of hypertension or insomnia would not be cautionary. Unlike with levodopa, the risk of psychoses is not increased.
A hospitalized patient newly diagnosed with Parkinson disease is prescribed apomorphine but develops medication-related nausea and vomiting. What drug will the provider prescribe to manage these side effects effectively?
a. Levodopa
b. Ondansetron
c. Prochlorperazine
d. Trimethobenzamide
d. Trimethobenzamide
Trimethobenzamide can be used as an antiemetic in patients treated with apomorphine. Serotonin receptor agonists (e.g., ondansetron) and dopamine receptor antagonists (e.g., prochlorperazine) cannot be used, because they increase the risk of serious postural hypotension. Levodopa only increases nausea and vomiting.
The provider prescribes bromocriptine for a patient who takes levodopa/carbidopa. Afterward, the patient becomes agitated and has frequent nightmares. What action will the provider take to manage the patient’s symptoms?
a. Add an antipsychotic medication to the patient’s medication regimen.
b. Discontinue the bromocriptine and prescribe cabergoline.
c. Reduce the dose of bromocriptine.
d. Reduce the dose of levodopa/carbidopa.
c. Reduce the dose of bromocriptine.
Bromocriptine is used to treat levodopa-induced dyskinesias and has dose-dependent psychological side effects. Reducing the dose of this drug can minimize these side effects. Adding an antipsychotic medication is not indicated. Cabergoline is not approved for this use. Reducing the dose of levodopa/carbidopa is not indicated.
An infant is prescribed a central nervous system (CNS) drug. The parents are concerned that the child exhibits unusual drowsiness and sedation. The provider explains these effects based on an understanding of which difference in the physiology of infants and adults?
a. Blood-brain barrier
b. First-pass effect
c. Gastrointestinal absorption
d. Renal filtration
a. Blood-brain barrier
The blood-brain barrier is not fully developed at birth, making infants much more sensitive to CNS drugs than older children and adults. CNS symptoms may include sedation and drowsiness. The first-pass effect and GI absorption affect metabolism and absorption of drugs, and renal filtration affects elimination of drugs, all of which may alter drug levels.
A patient reports stopping baclofen the day before being admitted to the hospital. The provider instructs the hospital staff to monitor the patient for which withdrawal effects?
a. Dizziness
b. Fatigue
c. Hallucinations
d. Dyspnea
c. Hallucinations
Abrupt discontinuation of baclofen is associated with visual hallucinations, paranoid ideation, and seizures. Adverse effects (not withdrawal effects) of baclofen include weakness, dizziness, fatigue, and drowsiness. Respiratory depression is a result of overdose of baclofen.
When a patient with a lower back injury begins experiencing muscle spasms, the provider orders cyclobenzaprine 10 mg three times a day. What information will the provider include when teaching this patient about this drug?
a. “This drug carries some risk of developing hallucinations and psychotic
symptoms. ”
b. “This medication may cause your urine to turn brown, black, or dark green.”
c. “You may experience blurred vision, dry mouth, or constipation.”
d. “You will need to have liver function tests performed while taking this
medication. ”
c. “You may experience blurred vision, dry mouth, or constipation.”
Cyclobenzaprine has significant anticholinergic effects and patients should be warned about dry mouth, blurred vision, and constipation. Tizanidine, not cyclobenzaprine, can cause hallucinations and psychotic symptoms. Methocarbamol, not cyclobenzaprine, may turn urine brown, black, or green, which is a harmless side effect. Tizanidine and metaxalone, not cyclobenzaprine, can cause liver toxicity and require monitoring.
A provider is considering prescribing tizanidine for patient who is experiencing localized muscle spasms after an injury. What information in the patient’s health history will be concerning enough to the provider to warrant selecting a different drug?
a. Chronic use of aspirin
b. A history of hepatitis
c. A history of malignant hyperthermia
d. Occasional use of alcohol
b. A history of hepatitis
Hepatotoxicity is a serious potential problem in a patient receiving tizanidine. Baseline liver enzymes should be obtained before dosing and periodically thereafter. Analgesic anti-inflammatory drugs commonly are used in conjunction with centrally acting muscle relaxants, so using aspirin is not a concern. This drug does not contribute to malignant hyperthermia. Patients should be advised to avoid alcohol when taking this drug, but a history of occasional alcohol use is not a contraindication.
A provider has prescribed dantrolene for the following patients. Which patient will the provider monitor most closely for risk of injury?
a. A 20-year-old woman with a spinal cord injury
b. A 45-year-old man with a history of malignant hyperthermia
c. A 55-year-old woman with multiple sclerosis
d. An 8-year-old child with cerebral palsy
c. A 55-year-old woman with multiple sclerosis
Dose-related liver damage is the most serious adverse effect of dantrolene and is most common in women older than 35 years. Dantrolene is used to treat spasticity associated with multiple sclerosis, cerebral palsy, and spinal cord injury, so all of these patients would be candidates for this agent. Dantrolene also is used to treat malignant hyperthermia.
A patient with cerebral palsy has severe muscle spasticity and muscle weakness which makes it difficult to take anything by mouth. The provider will prescribe and educate the patient on which medication for home therapy?
a. Baclofen
b. Dantrolene
c. Diazepam
d. Metaxalone
a. Baclofen
Baclofen is used to treat muscle spasticity associated with multiple sclerosis, spinal cord injury, and cerebral palsy. It does not reduce muscle strength, so it will not exacerbate this patient’s muscle weakness. It can be given intrathecally, via an implantable pump, and therefore is a good choice for patients who cannot take medications by mouth. Dantrolene causes muscle weakness and must be given by mouth or intravenously, so it would not be a good option for this patient. Diazepam is not the first-line drug of choice. Metaxalone is used to treat localized muscle spasms caused by injury and is not used for cerebral palsy.
A patient with cerebral palsy who has been receiving baclofen for 3 months is admitted to the hospital for evaluation of new-onset seizures. What assessment question will the provider ask to help identify the most likely cause of these seizures?
a. “Have you taken any extra doses of baclofen?”
b. “Are you aware of the most common adverse effect of baclofen?”
c. “Did you know that seizures are an idiopathic response to baclofen?”
d. “Have you missed any doses of baclofen?”
d. “Have you missed any doses of baclofen?”
Baclofen does not appear to cause physical dependence, but abrupt discontinuation has been associated with adverse reactions. Abrupt withdrawal of oral baclofen can cause visual hallucinations, paranoid ideation, and seizures and should be considered when a patient develops these symptoms. Seizures are not a symptom of baclofen toxicity.
A provider provides teaching for a patient with a newly diagnosed partial complex seizure disorder who will begin therapy with an antiepileptic drug (AED). Which statement by the patient indicates to the provider an understanding of the teaching?
a. “I may need to try several drugs before finding one is effective.”
b. “I will know that the drug is effective if I am seizure-free for two months.”
c. “Serious side effects may occur, and if they do, I should stop taking the
medication.”
d. “When the drug level is maintained at therapeutic levels, I can expect to be
seizure free.”
a. “I may need to try several drugs before finding one is effective.”
Even with an accurate diagnosis of seizures, many patients have to try more than one AED to find a drug that is effective and well tolerated. Unless patients are being treated for absence seizures, which occur frequently, monitoring of the clinical outcome is not sufficient for determining effectiveness, because patients with convulsive seizures often have long seizure-free periods. Serious side effects may occur, but withdrawing a drug precipitously can induce seizures. Not all patients have seizure control with therapeutic drug levels, because not all medications work for all patients.
A patient who has been taking an antiepileptic drug for several weeks reports little change in seizure frequency, what action will the provider take to provide effective care?
a. Ask the patient to complete a seizure frequency chart for the past few weeks.
b. Write an order for serum drug levels.
c. Reinforce to the patient the need to take the medications as prescribed.
d. Increase the dose of the antiepileptic drug.
b. Write an order for serum drug levels.
If medication therapy is not effective, it is important to measure serum drug levels of the medication to determine whether therapeutic levels have been reached. Patients should be asked at the beginning of therapy to keep a seizure frequency chart to help deepen their involvement in therapy; asking for historical information is not helpful. Until it is determined that the patient is not complying, the nurse should not reinforce the need to take the medication. Until the drug level is known, increasing the dose is not indicated.
A provider counsels a patient who is prescribed phenytoin for epilepsy. Which statement by the patient indicates understanding of the teaching?
a. “I should brush and floss my teeth regularly.”
b. “Once therapeutic blood levels are reached, they are easy to maintain.”
c. “I can consume alcohol in moderation while taking this drug.”
d. “Rashes are a common side effect but are not serious.”
a. “I should brush and floss my teeth regularly.”
Gingival hyperplasia occurs in about 20% of patients who take phenytoin. It can be minimized with good oral hygiene, so patients should be encouraged to brush and floss regularly. Because small fluctuations in phenytoin levels can affect response, maintaining therapeutic levels is not easy. Patients should be cautioned against consuming alcohol while taking phenytoin. Rashes can be serious and should be reported immediately.
A patient who takes phenytoin for seizures asks the provider for a prescription for oral contraceptives. What recommendation will the provider make to help assure the effectiveness of the contraception method?
a. She may need to increase her dose of phenytoin while taking oral contraceptives.
b. She should consider a different form of birth control while taking phenytoin.
c. She should adhere strictly to oral contraceptive schedules because phenytoin
causes birth defects.
d. She should not take oral contraceptives, because they reduce the effectiveness of
phenytoin.
b. She should consider a different form of birth control while taking phenytoin.
Because phenytoin can reduce the effects of oral contraceptive pills (OCPs) and because avoiding pregnancy is desirable when taking phenytoin, patients should be advised to increase the dose of oral contraceptives or use an alternative method of birth control. Increasing the patient’s dose of phenytoin is not necessary; OCPs do not affect phenytoin levels. Phenytoin is linked to birth defects; OCPs have decreased effectiveness in patients treated with phenytoin, and the patient should be advised to increase the OCP dose or to use an alternative form of birth control. OCPs do not alter the effects of phenytoin.
A patient with a seizure disorder is admitted to the hospital after an increase in seizure frequency. The prescriber considers adding carbamazepine 100 mg twice daily to the patient’s medication regimen, but notes that the patient is already taking lamotrigine 375 mg twice daily. What changes will the prescriber make to the patient’s medication regimen?
a. Reduce the carbamazepine dose to 50 mg twice daily.
b. Reduce the lamotrigine dose to 225 mg twice daily.
c. Increase the carbamazepine dose to 200 mg twice daily.
d. Increase the lamotrigine dose to 500 mg twice daily.
d. Increase the lamotrigine dose to 500 mg twice daily.
Carbamazepine induces hepatic drug-metabolizing enzymes and can increase the rate at which lamotrigine is metabolized; therefore, the lamotrigine dosage will need to be increased. Reducing the dose of either drug is not indicated. Increasing the dose of carbamazepine may be necessary but only after serum drug levels have been checked.
The patient who is on memantine therapy has a slight elevation in the creatinine clearance. What action will the provider take in response to this laboratory result?
a. Add sodium bicarbonate to the patient’s drug regimen.
b. Order a serum creatinine level to validate the creatinine clearance.
c. Discontinue the memantine.
d. Reduce the dose of memantine.
d. Reduce the dose of memantine.
Patients with severe renal impairment may require discontinuation, but with a slight elevation, a dosage reduction is indicated. Adding sodium bicarbonate would alkalinize the urine and increase memantine levels, causing toxicity. It is not necessary to discontinue or decrease the dose of the memantine with mild or moderate renal impairment. A serum creatinine level is less sensitive than creatinine clearance for monitoring renal function in older adults and it cannot be used to validate creatinine clearance findings.
The spouse of a patient with Alzheimer disease asks the provider for more information about the rivastigmine transdermal patch that is being used. After the discussion with the provider, which statement by the spouse indicates a need for further explanation?
a. “Doses are lower but more steady with the transdermal patch.”
b. “Reduced side effects occur with the transdermal patch.”
c. “We only need to change the patch every 2 weeks.”
d. “We should remove the old patch before applying the new one.”
c. “We only need to change the patch every 2 weeks.”
The rivastigmine transdermal patch needs to be changed daily. Sites used should not be reused for 14 days. Transdermal dosing provides lower, steady levels of the drug. Intensity of side effects is lower with the transdermal patch. The old patch must be removed prior to applying the new patch to prevent toxicity.
An older adult patient displays confusion, memory loss, and disorientation in familiar surroundings. Although the patient has been taking donepezil 10 mg once daily for 6 months, the symptoms have begun to worsen, and the patient’s spouse asks if the medication dose can be increased. What response will the prescriber provide to best address the spouse’s concerns?
a. “The dose can be increased, because the patient has been taking the drug for
longer than 3 months.”
b. “The dose can be increased to twice daily dosing instead of once daily dosing.”
c. “The increase in symptoms is the result of hepatotoxicity from the medication’s
side effects.”
d. “The patient must take the drug for longer than 1 year before the dose can be
increased.”
a. “The dose can be increased, because the patient has been taking the drug for
longer than 3 months.”
Donepezil is given for mild, moderate, and severe Alzheimer disease (AD), and dosing may be increased, although it must be titrated up slowly. For patients with moderate to severe AD who have taken 10 mg once daily for at least 3 months, the dose can be increased to 23 mg once daily. Donepezil is not given twice daily. Donepezil does not cause hepatotoxicity; hepatotoxicity occurs with tacrine, the first acetylcholinesterase (AChE) inhibitor, which now is rarely used. Dosing is increased after 3 months, not 1 year.
An older adult patient with Alzheimer disease is prescribed a cholinesterase inhibitor drug. When providing medication education to the care giver, the prescriber will prioritize which possible side effects? (Select all that apply.)
a. Confusion
b. Memory impairment
c. Constipation
d. Slowed heart rate
e. Lightheadedness
d. Slowed heart rate
e. Lightheadedness
Cardiovascular effects of cholinesterase inhibitor drugs are uncommon but cause the most concern. Bradycardia and fainting can occur when cholinergic receptors in the heart are activated. Confusion and memory impairment are signs of the disease and are not side effects of the drug. Diarrhea, not constipation, is an expected adverse effect.
A patient who has infrequent migraine headaches wants to prevent them from occurring. What intervention will the provider take?
a. Prescribe prochlorperazine.
b. Prescribe amitriptyline.
c. Ask the patient to keep a headache diary to help determine possible triggers.
d. Schedule the abortive medication to be taken regularly instead of PRN.
c. Ask the patient to keep a headache diary to help determine possible triggers.
Keeping a headache diary to try to identify triggers to migraines can be helpful when a patient is trying to prevent them and is the first step in managing headaches. Prochlorperazine is an antiemetic and does not prevent or abort migraine headaches. Prophylactic medications such as amitriptyline are used when headaches are more frequent. To prevent medication-overuse headache, abortive medications should not be used more than 1 to 2 days at a time.
A patient who has recurrent migraine headaches is prescribed sumatriptan. Which condition in this patient’s history is of concern to the prescriber?
a. Asthma
b. Coronary artery disease
c. Diabetes
d. Renal disease
b. Coronary artery disease
Serotonin receptor agonists can cause vasoconstriction and coronary vasospasm and should not be given to patients with coronary artery disease, current symptoms of angina, or uncontrolled hypertension. There is no contraindication for asthma, diabetes, or renal disease.
A provider considers prescribing sumatriptan for a patient experiencing a migraine headache. Before prescribing this drug, what is the most important information to obtain?
a. Is there a family history of migraines?
b. Has acetaminophen been taken in the past 3 hours?
c. Has the patient taken ergotamine in the past 24 hours?
d. Is the patient allergic to sulfa compounds?
c. Has the patient taken ergotamine in the past 24 hours?
Triptans and ergot alkaloids cause vasoconstriction and, if combined, excessive and prolonged vasospasm could result. Sumatriptan should not be used within 24 hours of an ergot derivative. A family history is important, but it is not vital assessment data as it relates to this scenario. Acetaminophen has no drug-to-drug interaction with sumatriptan. Sulfa is not a component of sumatriptan and, therefore, is not relevant.
A patient reports numbness in the extremities. The assessment history notes that the patient’s hands and feet are cool and pale and that the patient has a history of migraine headaches. The provider focuses on further assessing for what likely cause of the symptoms?
a. Ergotamine withdrawal
b. Ergotism
c. Severe migraine symptoms
d. Sumatriptan side effects
b. Ergotism
Ergotism is a serious toxicity caused by acute or chronic overdose of ergotamine. The toxicity results in ischemia, causing the extremities to become cold, pale, and numb. Symptoms associated with ergotamine withdrawal include headache, nausea, vomiting, and restlessness. These are not symptoms of a severe migraine or side effects of sumatriptan.
A young female adult who has recently begun taking sumatriptan reports a sensation of chest pressure, without pain, and arm heaviness. What action will the provider take?
a. Focus on identifying any history of hypertension or coronary artery disease.
b. Determine whether the patient might be pregnant.
c. Reassure the patient that this is a transient, reversible side effect of the
medication.
d. Discontinue the sumatriptan.
c. Reassure the patient that this is a transient, reversible side effect of the
medication.
Some patients taking sumatriptan experience unpleasant chest symptoms, usually described as “heavy arms” or “chest pressure.” These symptoms are transient and are not related to heart disease. Patients experiencing angina-like pain when taking sumatriptan, as a result of coronary vasospasm, should be asked about hypertension or coronary artery disease (CAD); they should not take sumatriptan if they have a history of either of these. The symptoms this patient describes are not characteristics of pregnancy. There is no need to stop taking the medication.
A patient with a history of asthma experiences three or four migraine headaches each month, uses sumatriptan as an abortive medication but has developed medication-overuse headaches. When asked what can be done to prevent migraines, the provider suggests prescribing which medication?
a. Botulinum toxin
b. Meperidine
c. Timolol
d. Topiramate
d. Topiramate
Topiramate can be used for migraine prophylaxis, and its benefits appear equal to those of the first-line β blockers. Botulinum toxin can be used for migraine prophylaxis in patients who have 15 or more headaches a month. Meperidine may be used as abortive therapy, not prophylaxis. Timolol is a β blocker; this patient has asthma, and because β blockers cause bronchoconstriction, these agents are not recommended.
A patient who has migraine headaches has been using sumatriptan with good initial results but now reports frequent migraine recurrence 24 hours later. Which medication will the provider order for this patient?
a. Aspirin
b. Ergotamine
c. Naratriptan
d. Zolmitriptan
c. Naratriptan
Naratriptan has effects that persist longer than other triptans, and the 24-hour recurrence rate may be reduced when taking this formulation. Aspirin has a shorter half-life than the triptans.
A patient has been taking oxycodone to manage severe, chronic pain for the last 6 months but now reports that it is no longer effective. The provider will discuss prescribing which medication for the patient?
a. Fentanyl transdermal patch
b. Hydrocodone PO
c. Meperidine PO
d. Pentazocine PO
a. Fentanyl transdermal patch
Transdermal fentanyl is indicated only for persistent, severe pain in patients already opioid tolerant. Hydrocodone, a combination product, has actions similar to codeine and is not used for severe, chronic pain. Meperidine is not recommended for continued use because of the risk of harm caused by the accumulation of a toxic metabolite. Pentazocine is an agonist–antagonist opioid and is less effective for pain; moreover, when given to a patient who is already opioid tolerant, it can precipitate an acute withdrawal syndrome.
A patient has been taking methadone for 5 months to overcome an opioid addiction. The provider will monitor the patient for which electrocardiographic change?
a. Prolonged QT interval
b. Prolonged P-R interval
c. Bundle branch block
d. Elevated ST segment
a. Prolonged QT interval
Methadone prolongs the QT interval. It does not prolong the P-R interval, cause a bundle branch block, or produce an elevated ST segment.
A patient receives an epidural anesthetic during labor and delivery. What effect in the newborn in the immediate postpartumperiod must the provider be prepared to address?
a. Bradycardia
b. Hypoglycemia
c. Jitteriness
d. Tachypnea
a. Bradycardia
Local anesthetics can cross the placenta, causing bradycardia and central nervous system (CNS) depression in the infant. They do not affect blood glucose. Jitteriness is a sign of CNS excitation, not depression. Increased respirations are not an adverse effect in the newborn.
A provider has prescribed the topical anesthetic lidocaine for a patient who has a second-degree burn on one arm. Which statement by the patient indicates understanding of the teaching regarding this treatment?
a. “I will apply a thin layer of the medication to only the burned area.”
b. “I will cover the burn with a dressing after applying the medication.”
c. “Applying an occlusive dressing is needed to increase absorption to relieve pain.”
d. “I need to limit use of the medication to areas where the blisters have ruptured.”
a. “I will apply a thin layer of the medication to only the burned area.”
Topical anesthetics can be absorbed in sufficient amounts to cause serious and even life-threatening systemic toxicity, so they should be applied in the smallest amount needed to as small an area as possible. Covering the site increases the skin’s temperature, which increases absorption, so this should be avoided. Applying the medication to broken skin increases systemic absorption and should be avoided.
Within a few minutes of administration of a local anesthetic, the patient has a pulse of 54 beats/minute, respirations of 18 breaths/minute, and a blood pressure of 90/42 mm Hg. The provider should monitor the patient for further signs of what condition?
a. Heart block
b. Anaphylaxis
c. Central nervous system excitation
d. Respiratory depression
a. Heart block
When absorbed in a sufficient amount, local anesthetics can affect the heart and blood vessels. These drugs suppress excitability in the myocardium and conduction system and can cause hypotension, bradycardia, heart block, and potentially cardiac arrest. Anaphylaxis would be manifested by hypotension, bronchoconstriction, and edema of the glottis. Central nervous system excitation would be manifested by hyperactivity, restlessness, and anxiety and may be followed by convulsions. No evidence indicates respiratory depression; this patient’s respirations are within normal limits.
The provider used lidocaine with epinephrine as a local anesthetic when suturing a laceration on a patient’s hand. Following the procedure, which patient symptom causes the most concern?
a. Difficulty moving the fingers of the affected hand
b. Inability to feel pressure at the suture site
c. Nervousness and tachycardia
d. Sensation of pain returning to the wound
c. Nervousness and tachycardia
Absorption of the vasoconstrictor can cause systemic effects, including nervousness and tachycardia. Local anesthetics are nonselective modifiers of neuronal function and also can block motor neurons, so it is expected that patients may have difficulty with movement. The sensation of pressure also is affected and is an expected effect. As the local anesthetic wears off, the sensation of the pain will return.
Which medications would a provider prescribe to treat menstrually associated migraine? (Select all that apply.)
a. Amitriptyline
b. Estrogen
c. Ergotamine
d. Frovatriptan
e. Naproxen
b. Estrogen
d. Frovatriptan
e. Naproxen
Menstrual migraines may be treated with estrogen, some perimenstrual triptans, such as frovatriptan, and Naproxyn. Neither amitriptyline nor ergotamine are used for that purpose
The provider has prescribed a vasoconstrictor to be given in combination with a local anesthetic. What is the expected goal for this action? (Select all that apply.)
a. Enhanced absorption of the anesthetic
b. A reduction of the risk of anesthetic toxicity
c. The prevention of bradycardia
d. A shortened duration of action
e. A prolonging of the anesthesic effect
b. A reduction of the risk of anesthetic toxicity
e. A prolonging of the anesthesic effect
Vasoconstrictors, when combined with local anesthetics, reduce the risk of toxicity and prolong the anesthetic effects. Vasoconstrictors, when combined with local anesthetics, slow down the absorption process. They do not prevent bradycardia or shorten the duration of action.
A patient is brought to the emergency department with shortness of breath, a respiratory rate of 30 breaths/minute, intercostal retractions, and frothy, pink sputum. After the patient’s provider renders a diagnosis of heart failure, which diuretic will be prescribed to address these assessment findings?
a. Furosemide
b. Hydrochlorothiazide
c. Mannitol
d. Spironolactone
a. Furosemide
Furosemide, a potent diuretic, is used when rapid or massive mobilization of fluids is needed. This patient shows signs and symptoms of severe heart failure and needs immediate reduction of fluid overload. Hydrochlorothiazide and spironolactone are not indicated for pulmonary edema, because they are less efficacious, and diuresis is less rapid. Mannitol is indicated for patients with increased intracranial pressure and must be discontinued immediately if signs of pulmonary congestion or heart failure occur.
The provider orders furosemide for a patient who takes digoxin and is admitted to the hospital for treatment of heart failure. The morning assessment identifies an irregular heart rate of 86 beats/minute, a respiratory rate of 22 breaths/minute, and a blood pressure of 130/82 mm Hg. Crackles are heard in both lungs. Which laboratory result will be of greatest concern to the provider?
a. Blood glucose level of 120 mg/dL
b. Oxygen saturation of 90%
c. Potassium level of 3.4 mEq/L
d. Sodium level of 140 mEq/L
c. Potassium level of 3.4 mEq/L
This patient has an irregular, rapid heartbeat that might be caused by a dysrhythmia. This patient’s serum potassium level is low, which can trigger fatal dysrhythmias, especially in patients taking digoxin. Furosemide contributes to loss of potassium through its effects on the distal nephron. Potassium-sparing diuretics often are used in conjunction with furosemide to prevent this complication. This patient’s serum glucose and sodium levels are normal and of no concern at this point, although they can be affected by furosemide. The oxygen saturation is somewhat low and needs to be monitored, although it will likely improve with diuresis.
Verapamil is prescribed for the client who takes digoxin. The provider will monitor closely for which adverse reaction?
a. AV blockade
b. Gingival hyperplasia
c. Migraine headaches
d. Reflex tachycardia
a. AV blockade
Verapamil and digoxin both suppress impulse conduction through the AV node; when the two drugs are used concurrently, the risk of AV blockade is increased. Gingival hyperplasia can occur in rare cases with verapamil, but it is not an acute symptom. Verapamil can be used to prevent migraine, although its use for this purpose is under investigation. Verapamil and digoxin both suppress the heart rate, so tachycardia is not anticipated. The calcium channel blocker nifedipine, not verapamil, causes reflex tachycardia.
Which medication will the provider prescribe for a patient admitted with severe hypertensive crisis?
a. Captopril PO
b. Hydralazine PO
c. Minoxidil PO
d. Sodium nitroprusside IV
d. Sodium nitroprusside IV
Sodium nitroprusside, the drug of choice for hypertensive emergencies, is given intravenously. ACE inhibitors, such as captopril, are not used. Hydralazine may be used but should be given IV instead of PO. Minoxidil is effective, but its severe side effects make it a second-line drug.
A patient had a blood pressures of 150/95 mm Hg and 148/90 mm Hg on two separate office visits. This is consistent with a blood pressure of 145/92 mm Hg taken in an ambulatory setting. The patient’s diagnostic tests are all normal. What will the patient’s provider order to best manage the patient’s hypertension?
a. A β blocker
b. A loop diuretic and spironolactone
c. A thiazide diuretic
d. An α1 blocker
c. A thiazide diuretic
This patient has primary, or essential, hypertension as evidenced by systolic pressure greater than 140 and diastolic pressure greater than 90, along with normal tests ruling out another primary cause. Thiazide diuretics are first-line drugs for hypertension. β blockers are effective but are most often used to counter reflex tachycardia associated with reduced blood pressure caused by therapeutic agents. Loop diuretics cause greater diuresis than is usually needed and so are not first-line drugs. α1 blockers are not drugs of first choice.
A patient with diabetes develops hypertension. Which type of medication will the provider prescribe to treat hypertension in this patient?
a. Angiotensin-converting enzyme (ACE) inhibitors
b. β blockers
c. Direct-acting vasodilators
d. Thiazide diuretics
a. Angiotensin-converting enzyme (ACE) inhibitors
ACE inhibitors slow the progression of kidney injury in diabetic patients with renal damage. β blockers can mask signs of hypoglycemia and must be used with caution in diabetics. Direct-acting vasodilators are third-line drugs for chronic hypertension. Thiazide diuretics promote hyperglycemia.
A patient reports a family history of hypertension and cardiovascular disease but has no other risk factors. Current blood pressure is 126/82 mm Hg and the patient has a normal weight and body mass index for height and age. What will be the provider’s focus when providing patient education?
a. Angiotensin-converting enzyme (ACE) inhibitors and calcium channel blocker
medications
b. The DASH diet, sodium restriction, and exercise
c. Increased calcium and potassium supplements
d. Thiazide diuretics and lifestyle changes
b. The DASH diet, sodium restriction, and exercise
This patient has elevated hypertension without other risk factors. Lifestyle changes are indicated at this point. If blood pressure rises to hypertensive levels, other measures, including drug therapy, will be initiated. Calcium and potassium supplements are not indicated.
A patient taking an angiotensin-converting enzyme (ACE) inhibitor to treat hypertension tells the provider that she wants to become pregnant. What response will the provider give to the patient?
a. “Controlling your blood pressure will decrease your risk of preeclampsia.”
b. “We need to consider changing you to an angiotensin receptor blocker during
pregnancy. ”
c. “It will be safe to continue taking the ACE inhibitor during your pregnancy.”
d. “Let’s discuss using methyldopa instead of the ACE inhibitor while you are
pregnant. ”
d. “Let’s discuss using methyldopa instead of the ACE inhibitor while you are
pregnant. ”
Methyldopa has limited effects on uteroplacental and fetal hemodynamics and does not adversely affect the fetus or neonate. Controlling blood pressure does not lower the risk of preeclampsia. ACE inhibitors and ARBs are specifically contraindicated during pregnancy.
A patient with a recent onset of nephrosclerosis has been taking an angiotensin-converting enzyme (ACE) inhibitor and a thiazide diuretic. The patient’s initial blood pressure was 148/100 mm Hg. After 1 month of drug therapy, the patient’s blood pressure is 130/90 mm Hg. What action will the provider take to address the patient’s blood pressure?
a. Add a calcium channel blocker to this patient’s drug regimen.
b. Lower doses of the antihypertensive medications.
c. Order a high-potassium diet.
d. Add spironolactone to the drug regimen.
a. Add a calcium channel blocker to this patient’s drug regimen.
In patients with renal disease, the goal of antihypertensive therapy is to lower the blood pressure to 130/80 mm Hg or less. Adding a third medication is often indicated. Lowering the dose of the medications is not indicated because the patient’s blood pressure is not in the target range. Adding potassium to the diet and using a potassium-sparing diuretic are contraindicated.
A patient with chronic hypertension is admitted to the hospital. During the admission assessment, the nurse notes a heart rate of 96 beats/minute, a blood pressure of 150/90 mm Hg bibasilar crackles, 2+ pitting edema of the ankles, and distention of the jugular veins. What will the provider order in response to this assessment data?
a. Angiotensin-converting enzyme (ACE) inhibitor
b. Digoxin
c. Furosemide
d. Spironolactone
c. Furosemide
This patient shows signs of fluid volume overload and needs a diuretic. Furosemide is a loop diuretic, which can produce profound diuresis very quickly even when the glomerular filtration rate (GFR) is low. An ACE inhibitor will not reduce fluid volume overload. Digoxin has a positive inotropic effect on the heart, which may improve renal perfusion, but this is not its primary effect. Spironolactone is a potassium-sparing diuretic with weak diuresis effects; it is used in conjunction with other diuretics to improve electrolyte balance.
A patient with heart failure who takes an angiotensin-converting enzyme (ACE) inhibitor, a thiazide diuretic, and a β blocker for several months comes to the clinic for evaluation. As part of the ongoing assessment of this patient, the provider will focus on which evaluation?
a. Complete blood count
b. Ejection fraction
c. Maximal exercise capacity
d. Serum electrolyte levels
d. Serum electrolyte levels
Patients taking thiazide diuretics can develop hypokalemia, which can increase the risk for dysrhythmias; therefore, the serum electrolyte levels should be monitored closely. A complete blood count is not recommended. This patient is taking the drugs recommended for patients with Stage C heart failure; although the patient’s quality of life and ability to participate in activities should be monitored, routine measurement of the ejection fraction and maximal exercise capacity is not warranted at this time.
A patient diagnosed with heart failure (HF) and taking an angiotensin-converting enzyme (ACE) inhibitor, has developed fibrotic changes in the heart and vessels. Which type of medication will the provider order to counter this development?
a. Aldosterone antagonist
b. Angiotensin II receptor blocker (ARB)
c. β blocker
d. Direct renin inhibitor (DRI)
a. Aldosterone antagonist
Aldosterone antagonists are added to therapy for patients with worsening symptoms of HF. Aldosterone promotes myocardial remodeling and myocardial fibrosis, so aldosterone antagonists can help with this symptom. ARBs are given for patients who do not tolerate ACE inhibitors. β blockers do not prevent fibrotic changes. DRIs are not widely used.
A patient taking a thiazide diuretic for hypertension and quinidine to treat a dysrhythmia, is now prescribed digoxin 0.125 mg to improve cardiac output. Which action will the provider take to best assure the patient’s safety?
a. Add spironolactone.
b. Reduce the dose of digoxin.
c. Discontinue the quinidine.
d. Give potassium supplements.
c. Discontinue the quinidine.
Quinidine can cause plasma levels of digoxin to rise; concurrent use of quinidine and digoxin is contraindicated. There is no indication for adding spironolactone in this scenario. The dose of digoxin ordered is a low dose. Potassium supplements are contraindicated with digoxin.
Which effect will the provider expect when prescribing a cardiac glycoside?
a. Decreased cardiac output
b. Decreased force of contraction
c. Decreased heart rate
d. Positive inotropic effects
c. Decreased heart rate
Digoxin slows the heart rate and increases the force of contraction. It does not decrease cardiac output or result in positive inotropic effects.
A prescriber considers ordering propranolol for a patient with recurrent ventricular tachycardia. What information in the patient’s medical history will be of greatest concerned to the prescriber?
a. Asthma
b. Exercise-induced tachyarrhythmias
c. Hypertension
d. Paroxysmal atrial tachycardia associated with emotion
a. Asthma
Propranolol is to be used cautiously in patients with asthma because it is a nonselective β-adrenergic antagonist and can cause bronchoconstriction and exacerbate asthma. It is used to treat tachyarrhythmias and paroxysmal atrial tachycardia evoked by emotion, so it is not contraindicated for patients with these conditions. It lowers blood pressure, so it would be helpful in patients with hypertension.
Azithromycin is prescribed for a patient who develops an infection. The patient’s only other medication is simvastatin. Which patient symptom will create the greatest concern for the provider?
a. Nausea
b. Tiredness
c. Muscle pain
d. Headache
c. Muscle pain
Statins can injure muscle tissue, causing muscle aches and pain known as myopathy/rhabdomyolysis. Azithromycin also can cause myopathy and therefore should be used with caution in patients concurrently taking simvastatin. Nausea, tiredness, and headache would not cause the provider as much concern as the likelihood of myopathy.
A patient with new-onset exertional angina has taken three nitroglycerin sublingual tablets at 5-minute intervals, but the pain has intensified. The patient has a heart rate of 76 beats/minute and a blood pressure of 120/82 mm Hg. The electrocardiogram is normal. The patient’s lips and nail beds are pink, and there is no respiratory distress. The provider will prescribe what intervention?
a. An angiotensin-converting enzyme (ACE) inhibitor
b. Intravenous nitroglycerin and a β blocker
c. Ranolazine and quinidine STAT
d. Supplemental oxygen and intravenous morphine
b. Intravenous nitroglycerin and a β blocker
This patient has unstable angina, and the next step, when pain is unrelieved by sublingual nitroglycerin, is to give intravenous nitroglycerin and a β blocker. ACE inhibitors should be given to patients with persistent hypertension if they have left ventricular dysfunction or heart failure (HF). Ranolazine is a first-line angina drug, but it should not be given with quinidine because of the risk of increasing the QT interval. Supplemental oxygen is indicated if cyanosis or respiratory distress is present. IV morphine may be given if the pain is unrelieved by nitroglycerin.
A patient who uses transdermal nitroglycerin for angina reports occasional periods of tachycardia. What intervention will the prescriber order?
a. Order digoxin to slow the heart rate.
b. Discontinue the nitroglycerin.
c. Recommend periods of rest when the heart rate increases.
d. Prescribe verapamil as an adjunct to nitroglycerin therapy.
d. Prescribe verapamil as an adjunct to nitroglycerin therapy.
Nitroglycerin lowers blood pressure by reducing venous return and dilating the arterioles. The lowered blood pressure activates the baroreceptor reflex, causing reflex tachycardia, which can increase cardiac demand and negate the therapeutic effects of nitroglycerin. Treatment with a β blocker or verapamil suppresses the heart to slow the rate. Digoxin is not recommended. Discontinuation of the nitroglycerin is not indicated. Resting does not slow the heart when the baroreceptor reflex is the cause of the tachycardia.
A patient presents to the emergency department after accidentally taking too much prescribed warfarin. The patient’s heart rate is 78 beats/minute and the blood pressure is 120/80 mm Hg. A dipstick urinalysis is normal. The patient does not have any obvious hematoma or petechiae and does not report any pain. What will the provider order initially to address the patient’s current condition?
a. Vitamin K
b. Protamine sulfate
c. An activated partial thromboplastin time (aPTT)
d. A prothrombin time (PT) and an international normalized ratio (INR)
d. A prothrombin time (PT) and an international normalized ratio (INR)
This patient does not exhibit any signs of bleeding from a warfarin overdose. The vital signs are stable, there are no hematomas or petechiae, and the patient does not have pain. A PT and INR should be drawn to evaluate the anticoagulant effects. Vitamin K may be given if laboratory values indicate overdose. Protamine sulfate is given for heparin overdose. PTT evaluation is used to monitor heparin therapy.
A patient who has taken warfarin for a year has now been prescribed carbamazepine. What additional action will the provider take to assure the patient’s safety?
a. Decrease the usual dose of carbamazepine.
b. Increase the dose of warfarin.
c. Order more frequent activated partial thromboplastin time (aPTT) monitoring.
d. Order extra dietary vitamin K.
b. Increase the dose of warfarin.
Carbamazepine is a powerful inducer of hepatic drug-metabolizing enzymes and can accelerate warfarin degradation. The warfarin dose should be increased if the patient begins taking carbamazepine. Decreasing the dose of carbamazepine is not indicated. It is not necessary to perform more frequent aPTT monitoring or to add extra vitamin K.
A patient has been receiving iron replacement therapy for 2 days after hip replacement surgery. The provider is alerted to the following assessment data:
Patient’s stools appear black.
Patient is pale and reports feeling tired.
Patient’s heart rate is 98 beats/minute, respirations are 20 breaths/minute, and the blood pressure is 100/50 mm Hg. What order will the provider take initially to best assure appropriate care for this patient?
a. Packed red blood cells
b. Hemoglobin and hematocrit (H&H)
c. A stool guaiac
d. Hypertonic fluid bolus
b. Hemoglobin and hematocrit (H&H)
This patient is showing signs of iron deficiency anemia, as manifested by tachycardia and pallor. Because this patient’s blood pressure is low, the anemia probably has occurred secondary to blood loss, a common occurrence with hip replacement surgery. The first response should be to obtain an H&H to compare baseline and posttreatment levels. This should be done before an intervention is ordered. A stool guaiac is not indicated because black stools are an expected effect of oral iron administration. If the patient has blood loss that is causing hypotension, an isotonic fluid bolus and packed red blood cells (PRBCs) are indicated to treat this.
A patient is admitted to the hospital with a diagnosis of vitamin B12 deficiency, hypoxia and anemia. In addition to oxygen therapy, what will the provider order to address these problems?
a. IM cyanocobalamin and folic acid
b. IM cyanocobalamin and antibiotics
c. PO cyanocobalamin and folic acid
d. PO cyanocobalamin and blood transfusions
a. IM cyanocobalamin and folic acid
The patient has anemia with associated hypoxia secondary to vitamin B12 deficiency; therefore, cyanocobalamin should be given parenterally along with folic acid. Antibiotics are indicated only when signs of infection are present. Oral cyanocobalamin is not recommended.
Which conditions will the provider consider as a therapeutic use for verapamil? (Select all that apply.)
a. Angina of effort
b. Cardiac dysrhythmias
c. Essential hypertension
d. Sick sinus syndrome
e. Suppression of preterm labor
a. Angina of effort
b. Cardiac dysrhythmias
c. Essential hypertension
Verapamil is used to treat both vasospastic angina and angina of effort. It slows the ventricular rate in patients with atrial flutter, atrial fibrillation, and paroxysmal supraventricular tachycardia. It is a first-line drug for the treatment of essential hypertension. It is contraindicated in patients with sick sinus syndrome. Nifedipine has investigational uses in suppressing preterm labor.
Amiodarone is prescribed for a patient. Which baseline tests will the prescriber order before this medication is started? (Select all that apply.)
a. Chest radiograph
b. Complete blood count with differential
c. Ophthalmologic examination
d. Pulmonary function tests
e. Thyroid function tests
a. Chest radiograph
c. Ophthalmologic examination
d. Pulmonary function tests
e. Thyroid function tests
Amiodarone has many potential toxic side effects, including pulmonary toxicity, ophthalmic effects, and thyroid toxicity, so these systems should be evaluated at baseline and periodically while the patient is taking the drug. A complete blood count is not indicated.
A patient receiving heparin postoperatively to prevent deep vein thrombosis has a blood pressure of 90/50 mm Hg and a heart rate of 110 beats/minute. The patient’s most recent aPTT is greater than 90 seconds. The patient reports lumbar pain. The provider will order what interventions initially? (Select all that apply.)
a. A repeat aPTT to be drawn immediately
b. Analgesic medication
c. Changing heparin to aspirin
d. Protamine sulfate
e. Discontinue heparin
d. Protamine sulfate
e. Discontinue heparin
Heparin overdose may cause hemorrhage, which can be characterized by low blood pressure, tachycardia, and lumbar pain. Protamine sulfate should be given, and the heparin should be discontinued. An aPTT may be drawn later to monitor the effectiveness of protamine sulfate. Analgesics are not indicated because the lumbar pain is likely caused by adrenal hemorrhage. Not only will aspirin increase the risk of hemorrhage, but antiplatelet drugs are used to prevent excessive arterial clotting while anticoagulants are used to prevent excessive venous clotting; therefore, they are not used interchangeably.
A provider caring for a patient infected with the human immunodeficiency virus (HIV) will be most concerned about which lab result?
a. High level of eosinophils
b. Low neutrophil count
c. Decreased red blood cell (RBC) count
d. Very low helper T lymphocyte count
d. Very low helper T lymphocyte count
The provider understands that this patient may be vulnerable to opportunistic infections, especially if there were an indication of the HIV conversion to acquired immunodeficiency syndrome (AIDS). A very low helper T lymphocyte count would most concern the nurse, because the helper T cells are essential to the immune system, and people with AIDS have a low or deficient count. A high level of eosinophils likely indicates an allergy. A decreased RBC count is unrelated to HIV infection and is only a concern ifit is low. A high neutrophil count, not a low count, indicates infection. Low counts often reflect an increased percentage of another WBC in the differential.
A provider is caring for a patient who has undergone organ transplantation. Because the major histocompatibility complex (MHC) molecules of the donor are different from those of the patient, the provider will prescribe a drug from which drug class?
a. Antibiotics
b. Antihistamines
c. Immune globulins
d. Immunosuppressants
d. Immunosuppressants
The MHC molecules from one individual are recognized as foreign by the immune system of another individual; therefore, when an attempt is made to transplant organs between individuals who are not identical twins, immune rejection of the transplant is likely. Immunosuppressants are given to counter this response. Antibiotics are used to destroy bacteria. Antihistamines block hypersensitivity reactions. Immune globulins are given to confer passive immunity when specific acquired immunity has not yet developed a response.
A provider prescribing vaccines to a child with an immune deficiency disorder will avoid ordering which vaccination?
a. Diphtheria and tetanus toxoids and acellular pertussis (DTaP) vaccine
b. Haemophilus influenzae type b (Hib) vaccine
c. Polio injection
d. Varicella virus vaccine
d. Varicella virus vaccine
Live vaccines, such as the varicella vaccine, should be avoided by individuals who are immunocompromised. The DTaP vaccine, Hib vaccine, and polio injection may be administered to immunocompromised individuals, because these are not live vaccines.
A 2-month-old infant is scheduled to receive the first dose of DTaP. What information will the provider include in instructions given to the parents?
a. “Usually reactions are mild; a low-grade fever is most common.”
b. “Most children do not experience any reaction.”
c. “Seizures are common and may require anticonvulsant medication.”
d. “The most common reaction is a rash that develops into itchy blisters.”
a. “Usually reactions are mild; a low-grade fever is most common.”
Mild reactions to the first dose of the DTaP vaccine are common and most often are manifested by a low-grade fever, fretfulness, drowsiness, and local reactions of swelling and redness. At least 50% of children experience reactions. Seizures are not common. Itchy vesicles do not appear with the DTaP vaccine.
A 1-year-old child receives the MMR vaccine. The next day, the child’s parent calls to report that the child has a temperature of 102.8°F. What action will the provider take?
a. File an adverse event report with the Vaccine Adverse Event Reporting System
(VAERS).
b. Order a lab test to rule out thrombocytopenia.
c. Reassure the parent that fever can occur with the MMR vaccine.
d. Advise the parent to take the child to the emergency department.
c. Reassure the parent that fever can occur with the MMR vaccine.
The MMR vaccine can have several adverse effects, including fever up to 103°F. This is not considered a serious effect and does not warrant filing an adverse event report with VAERS. Thrombocytopenia is a rare but serious side effect of the MMR vaccine that would take longer than 24 hours to develop and is not associated with fever. There is no need to have the parent take the child to the emergency department.
A 2-month-old infant presents with a low-grade fever, runny nose, and severe bursts of coughing resulting in transient cyanosis. When taking a history, the provider will specifically inquire about the vaccination history for which condition?
a. Pertussis
b. Hepatitis B
c. Measles, mumps, and rubella (MMR)
d. Influenza
a. Pertussis
This infant may have pertussis, for which the primary symptoms are low-grade fever, persistent cough, and runny nose. Infants who have not received the first set of immunizations, including the DTaP vaccine, are especially vulnerable to this disease. The hepatitis B vaccine does not protect against these symptoms. The influenza and MMR vaccines are not given to children this young.
A 3-year-old child who has asthma is in the clinic for a well-child checkup. The nurse notes that the child is up to date for the DTaP, hepatitis A, hepatitis B, and the MMR vaccines but has only had one each of the Hib, the rotavirus, and the PCV13 vaccines. Which vaccine will the provider prescribe for this child?
a. Hib
b. PCV13
c. PCV13 and Hib
d. Rotavirus
b. PCV13
The PCV13 should be given to all children under the age of 2 years and to all healthy children between ages 2 and 5 years, especially those who have conditions that put them at high risk of serious pneumococcal disease. The Hib vaccine is only given up to age 15 months. The rotavirus vaccine is not given after 32 weeks of age.
A 5-year-old child with seasonal allergies has been taking 2.5 mL of cetirizine syrup once daily. The parents tell the provider that the child does not like the syrup, and they do not think that the drug is effective. The provider will discuss which change in medication therapy?
a. Cetirizine 5-mg chewable tablet once daily
b. Loratadine 10-mg chewable tablet once daily
c. Fexofenadine syrup 5 mL twice daily
d. Desloratadine 5-mg rapid-disintegrating tablet once daily
a. Cetirizine 5-mg chewable tablet once daily
The child is receiving a low dose of cetirizine and can receive up to 5 mg/day in either a single dose or two divided doses. Cetirizine is available in a chewable tablet, which this child may tolerate better, so the parents should explore this option with their provider. The loratadine 10-mg chewable tablet is approved for children 6 years and older. Fexofenadine would be safe for this child, but it is unlikely that the syrup would be any better than the cetirizine syrup. Desloratadine is not approved for children under the age of 12 years.
A patient who has seasonal allergies works as a truck driver and needs the least sedating antihistamine to control symptoms. Which medication will the provider recommend?
a. Cetirizine
b. Fexofenadine
c. Levocetirizine
d. Loratadine
b. Fexofenadine
Fexofenadine is the least sedating of the second-generation antihistamines and so is the least likely to have synergistic effects with alcohol. Cetirizine, levocetirizine, and loratadine all have sedative side effects to some extent and thus would be less safe.
A provider orders hydroxyzine for a patient with acute urticaria. What information will the provider include when teaching the patient about this drug?
a. The drug will reduce redness and itching but not edema.
b. This antihistamine is not likely to cause sedation.
c. Alcohol should be avoided while taking the drug.
d. Shortness of breath may occur while taking the drug.
c. Alcohol should be avoided while taking the drug.
Hydroxyzine is a first-generation antihistamine and has sedative effects, so patients should be cautioned not to consume alcohol while taking the drug. In capillary beds, antihistamines reduce edema, itching, and redness. This antihistamine causes sedation. It is not associated with respiratory depression or shortness of breath at therapeutic doses.
Parents report that their 5-year-old child has frequent motion sickness. Which antihistamine will the provider recommend?
a. Desloratadine
b. Dimenhydrinate
c. Hydroxyzine
d. Promethazine
b. Dimenhydrinate
Some antihistamines, including dimenhydrinate and promethazine, are labeled for use in motion sickness. Promethazine, however, is contraindicated in children under age 2 years and should be used with caution in children older than 2 years because of the risks for severe respiratory depression. Desloratadine and hydroxyzine are not approved for motion sickness.
A patient who takes aspirin daily is scheduled for surgery in 1 week. What action will the provider suggest to minimize the patient’s risk for injury?
a. Continue to use aspirin as scheduled.
b. Reduce the aspirin dosage by half until after surgery.
c. Stop taking aspirin immediately.
d. Stop taking aspirin 3 days before surgery.
c. Stop taking aspirin immediately.
Aspirin should be withdrawn at least 1 week before surgery. Aspirin cannot be continued as scheduled, because the risk for bleeding is too great. An interval of 3 days is not long enough for the bleeding effects of aspirin to be reversed. Cutting the dose in half would not reduce the effects of bleeding associated with aspirin use.
A patient who takes aspirin for rheumatoid arthritis develops a headache and tinnitus. The patient’s lab result includes a plasma salicylate level of 300 μg/mL, and a urine pH of 6.0. What action will the provider take?
a. Increase the aspirin dose to better treat the patient’s headache.
b. Order lab work to identify possible renal toxicity.
c. Prepare to provide respiratory support, related to a possible overdose.
d. Withhold the aspirin until the patient’s symptoms have subsided.
d. Withhold the aspirin until the patient’s symptoms have subsided.
This patient shows signs of salicylism, which occurs when ASA levels climb above the therapeutic level. Salicylism is characterized by tinnitus, sweating, headache, and dizziness. Tinnitus is an indication that the maximum acceptable dose has been achieved. Toxicity occurs at a salicylate level of 400 mcg/mL or higher. ASA should be withheld until the symptoms subside and then should be resumed at a lower dose. Increasing the dose would only increase the risk of toxicity. Signs of renal impairment include oliguria and weight gain, which are not present in this patient. This patient has salicylism, not salicylate toxicity, so respiratory support measures are not indicated.
An adolescent is brought to the emergency department after consuming a bottle of extended-release acetaminophen tablets between 8 and 10 hours ago. Which intervention will the provider order?
a. Acetylcysteine administration
b. Activated charcoal administration
c. Hemodialysis
d. Gastric lavage
a. Acetylcysteine administration
Acetylcysteine is the specific antidote for acetaminophen overdose. It is 100% effective when given within 8 to 10 hours after ingestion and may still have some benefit after this interval. Activated charcoal and gastric lavage are effective only if given before the medication is absorbed. Hemodialysis is not indicated.
An older male patient takes furosemide and low-dose aspirin. Urine output is low despite the diuretic. Today’s blood pressure is 140/80 mm Hg and the serum creatinine and blood urea nitrogen (BUN) levels are elevated. The patient has also gained 10-pounds over the past 3 months. What action will the provider discuss with the patient?
a. Adding an antihypertensive medication
b. Recheck the serum creatinine and BUN
c. Ordering a potassium-sparing diuretic
d. Withdrawing the aspirin
d. Withdrawing the aspirin
This patient shows signs of renal impairment, as evidenced by weight gain despite the use of diuretics, decreased urine output, hypertension, and elevated serum creatinine and BUN. Aspirin can cause acute, reversible renal impairment and should be withdrawn. Hypertensive medications do not treat the underlying cause. Rechecking the serum creatinine and BUN are not indicated because elevated values are typical for the situation presented. Addition of a potassium-sparing diuretic is not indicated.
A pregnant patient in her third trimester asks the nurse whether she can take aspirin for headaches. Which response by the nurse is correct?
a. “Yes, but it is safe during only the second and third trimesters of pregnancy.”
b. “Aspirin may cause premature closure of the ductus arteriosus in your baby so
should be avoided.”
c. “Aspirin may induce premature labor and should be avoided in the third
trimester.”
d. “No, you should use a first-generation nonsteroidal anti-inflammatory
medication.”
b. “Aspirin may cause premature closure of the ductus arteriosus in your baby so
should be avoided.”
Aspirin poses risks to the pregnant patient and her fetus, including premature closure of the ductus arteriosus. ASA is not safe, especially in the third trimester, because it can cause anemia and can contribute to postpartum hemorrhage. ASA does not induce labor but can prolong labor by inhibiting prostaglandin synthesis. NSAIDs have similar effects and also should be avoided.
A provider is about to prescribe prednisone to a patient for tendonitis. What item in the patient’s medical history would cause the provider to reconsider that action?
a. Allergic rhinitis
b. Gouty arthritis
c. Seborrheic dermatitis
d. Systemic fungal infection
d. Systemic fungal infection
Glucocorticoids are contraindicated in patients with a history of systemic fungal infections. Glucocorticoids are used to treat, allergic rhinitis, gout, and seborrheic dermatitis.
A 60-year-old female patient is about to begin long-term therapy with a glucocorticoid. Which intervention will the provider prescribe to help minimize the patient’s risk of developing osteoporosis?
a. Baseline vitamin D level
b. Calcium and vitamin D supplements
c. Estrogen therapy
d. Skeletal x-rays before treatment
b. Calcium and vitamin D supplements
Calcium and vitamin D supplements can help minimize the patient’s risk of developing osteoporosis. A baseline vitamin D level is not recommended. Estrogen therapy can help in postmenopausal women, but its risks outweigh its benefits at this patient’s age. Patients should undergo evaluation of the bone mineral density of the lower spine, not skeletal x-rays.
A patient taking high doses of a glucocorticoid develops weakness in the muscles of the upper arms and in the legs. What action will the provider take?
a. Reducing the dose of the glucocorticoid medication
b. Encourage the patient to restrict sodium intake.
c. Reassure the patient that this is an expected side effect.
d. Discontinue the medication immediately.
a. Reducing the dose of the glucocorticoid medication
High-dose glucocorticoid therapy can cause myopathy, manifesting as weakness. If muscle weakness occurs, the dose should be reduced. Reducing the sodium intake is recommended to minimize sodium and water retention, not to decrease muscle weakness. Muscle weakness is not an expected side effect, because it indicates myopathy. It is incorrect to tell the patient to stop taking the drug, because a glucocorticoid must be withdrawn slowly to allow time for recovery of adrenal function.
A patient taking a glucocorticoid for arthritis reports feeling bloated and peripheral edema is noted. Which action by the provider is relevant to the care of this patient?
a. Asking the patient about sodium intake
b. Obtaining a blood glucose level
c. Suggesting the patient limit potassium intake
d. Discontinuing the drug
a. Asking the patient about sodium intake
Because of their mineralocorticoid activity, glucocorticoids can cause sodium and water retention and potassium loss. Asking about the sodium intake can help the nurse evaluate this patient. Although glucocorticoids can affect glucose tolerance, this patient does not have signs of hyperglycemia. Patients with sodium and water retention should be encouraged to increase their potassium intake. Telling a patient to stop taking the drug is incorrect, because this side effect can be managed and this action does not take into consideration the benefits versus the risks.
A patient who has been taking a glucocorticoid for several months arrives in the clinic. The patient’s cheeks appear full and there is a prominent hump of fat present on the upper back. The provider will order which test?
a. Liver function tests
b. Serum electrolytes
c. Tuberculin skin test
d. Vitamin D levels
b. Serum electrolytes
This patient shows signs of iatrogenic Cushing syndrome, which may include serum electrolyte disturbances; therefore, the electrolyte levels should be monitored. Liver function tests, tuberculin skin testing, and vitamin D levels are not indicated.
A provider is teaching a patient who has taken glucocorticoids for over a year about glucocorticoid withdrawal. Which statement by the patient indicates a need for further teaching?
a. “I should reduce the dose by half each day until I stop taking the drug.”
b. “I will need to have cortisol levels monitored during the withdrawal process.”
c. “The withdrawal schedule may take several months.”
d. “If I have surgery, I may need to take the drug for a while, even after I have
stopped. ”
a. “I should reduce the dose by half each day until I stop taking the drug.”
Glucocorticoid therapy can suppress adrenal function, so withdrawal should be done slowly to allow recovery of adrenal function. Reducing the dose of a glucocorticoid by half each day is not recommended. Patients should have their cortisol levels monitored to determine when therapy can be stopped. The withdrawal schedule may take several months. Patients who have stopped the drug may still experience adrenal insufficiency in times of physiologic stress, such as surgery.
A patient who takes a glucocorticoid reports having tarry stools but denies gastric pain. After ruling out anemia and determining that the patient is not in danger, which action will the provider take?
a. Prescribing an antiulcer medication.
b. Counseling the patient to use over-the-counter antacids.
c. Reassuring the patient not to worry unless there is gastric pain.
d. Discontinuing the glucocorticoid immediately.
a. Prescribing an antiulcer medication.
Glucocorticoid therapy can increase the risk of gastric ulcer and possibly GI bleeding. Treatment with antiulcer medications is indicated, but not with OTC antacids. Gastric pain is usually decreased because of the glucocorticoids, so absence of gastric pain is not reassuring. The glucocorticoid should be withdrawn slowly, not immediately.
A patient will begin taking fexofenadine for hay fever. What information will the provider include in patient teaching?
a. Fexofenadine should be taken with food to prevent gastrointestinal symptoms.
b. The medication may be taken once or twice daily.
c. Tolerance to sedation will occur in a few weeks.
d. With renal impairment, this drug should be taken every other day.
b. The medication may be taken once or twice daily.
Fexofenadine may be given 60 mg twice daily or 180 mg once daily. Fexofenadine does not need to be given with food. Sedation is not a common side effect of fexofenadine. There is no caution to reduce the dosage or increase the dosing interval in patients with renal impairment who take fexofenadine.
An 11-year-old boy received all childhood immunizations before attending kindergarten. Which vaccines will the provider recommended for this child at his current age? (Select all that apply.)
a. Hepatitis B
b. PCV-23
c. Tdap
d. MCV4
e. HPV
c. Tdap
d. MCV4
e. HPV
At age 11, both males and females should receive a booster of diphtheria, tetanus, and pertussis (Tdap); the Menactra vaccine against meningitis (MCV4); and the human papillomavirus (HPV) vaccine. The PCV-23 vaccine is indicated only in high-risk patients. The MMR is not given at this age. The hepatitis B vaccine is not given at this age.
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?
a. Order a sputum culture and prescribe an antibiotic based on the results.
b. Order an empiric antibiotic while waiting for sputum culture results.
c. Treat symptomatically, because antibiotics are usually ineffective against
bronchitis.
d. Treat the patient with more than one antibiotic without obtaining cultures.
b. 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 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.
a. broad; systemic
b. broad; topical
c. narrow; systemic
d. narrow; topical
d. 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.
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?
a. Give the penicillin at 0800, 1600, and 2400; give the gentamicin [Garamycin] at
1800 and 0600.
b. Give the penicillin at 0800, 1600, and 2400; give the gentamicin [Garamycin] at
1200 and 2400.
c. Give the penicillin at 0600, 1400, and 2200; give the gentamicin [Garamycin] at
0600 and 1800.
d. Give the penicillin every 8 hours; give the gentamicin [Garamycin]
simultaneously with two of the penicillin doses.
a. 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 child with an ear infection is not responding to treatment with amoxicillin. What alternative medication will the provider order?
a. Amoxicillin–clavulanic acid
b. Ampicillin
c. Nafcillin
d. Penicillin G
a. 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 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?
a. Order an immediate assessment of the skin at the infusion site for signs of tissue
necrosis.
b. Order that the patient be closely observed for confusion and other neurotoxic
effects.
c. Order a serum electrolyte test and cardiac monitoring STAT.
d. Request immediate notification of any bizarre behaviors demonstrated by the
patient.
c. 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.
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?
a. Order a cephalosporin.
b. Reassure the patient that allergic responses diminish over time.
c. Request an order for a skin test to assess the current risk.
d. Order a desensitization schedule to be used to administer the drug safely.
c. 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 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?
a. Prescribes an aminoglycoside
b. Discontinues the piperacillin and orders penicillin G
c. Reduces the dosage of piperacillin
d. Discontinues the piperacillin and prescribes nafcillin
c. 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 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?
a. Take one pill twice daily.
b. Take a daily dose for 28 days.
c. Inhale the powdered drug as ordered three times each day.
d. Use the nebulizer to administer the drug three times daily.
d. 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.
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?
a. Cefaclor
b. Cefazolin
c. Cefotaxime
d. Ceftaroline
d. 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.
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?
a. Adding an additional antibiotic to the patient’s regimen
b. Discontinuing the cephalosporin and beginning metronidazole
c. Discontinuing all antibiotics and providing fluid replacement
d. Increasing the dose of the cephalosporin and providing isolation measures
b. 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 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?
a. First
b. Second
c. Third
d. Fourth
a. 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 will be discharged home to complete treatment with intravenous cefotetan. The prescriber will include which instruction when teaching the patient about this drug treatment?
a. Abstain from alcohol consumption during therapy.
b. Avoid dairy products while taking this drug.
c. Take an antihistamine if a rash occurs.
d. Use nonsteroidal anti-inflammatory drugs (NSAIDs), not acetaminophen, for
pain.
a. 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.
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?
a. Aztreonam
b. Fosfomycin
c. Trimethoprim/sulfamethoxazole
d. Vancomycin
b. 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.
Which cephalosporin may the prescriber order to treat meningitis?
a. Cefaclor
b. Cefazolin
c. Cefoxitin
d. Cefotaxime
d. 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.
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?
a. Reassure the patient that this is a harmless side effect of this drug.
b. Tell the patient that blindness rarely occurs with this drug.
c. Tell the patient that this symptom is reversible when the drug is discontinued.
d. Suggest the patient take tyramine supplements to minimize this effect.
c. 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 develops Clostridium difficile–associated diarrhea (CDAD). Which antibiotic will the prescriber order to treat this infection?
a. Chloramphenicol
b. Clindamycin
c. Linezolid
d. Vancomycin
d. Vancomycin
Vancomycin and metronidazole are the drugs of choice for treating CDAD.
Which side effect of clindamycin causes the provider the most concern and may warrant discontinuation of the drug?
a. Diarrhea
b. Headache
c. Nausea
d. Vomiting
a. 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.
A patient received 500 mg of azithromycin at 0800 as a first dose. What order will the provider write for the amount and time ofthe second dose of azithromycin?
a. 250 mg at 2000 the same day
b. 500 mg at 2000 the same day
c. 250 mg at 0800 the next day
d. 500 mg at 0800 the next day
c. 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 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?
a. Clindamycin
b. Doxycycline
c. Erythromycin ethylsuccinate
d. Penicillin G
c. 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 taking doxycycline for a serious infection reports anal itching. What action will the provider take?
a. Prescribing an antihistamine to the patient’s existing drug regimen
b. Ordering liver function tests to test for hepatotoxicity
c. Prescribing an antifungal drug to treat a superinfection
d. Testing the patient for a C. difficile secondary infection
c. 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.
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?
a. “I should consult my provider before using laxatives or antacids while taking this
drug. ”
b. “I should not take a calcium supplement or consume dairy products with this
drug. ”
c. “I should take this drug with food to ensure more complete absorption.”
d. “If I get diarrhea, I should stop taking the drug and let my provider know
immediately. ”
c. “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 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?
a. Increase the clindamycin dose to aggressively treat this infection.
b. Assure the patient this is known side effect of clindamycin, and suggest
consuming extra fluids.
c. Discontinue the clindamycin immediately.
d. Prescribe Lomotil or a bulk laxative to minimize the diarrheal symptoms.
c. 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.
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?
a. Discuss an increased risk of aminoglycoside toxicity with the patient.
b. Continue the aminoglycoside as ordered.
c. Prescribe a different class of antibiotic.
d. Add a penicillin to the patient’s drug regimen.
c. 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 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?
a. Amikacin
b. Gentamicin
c. Paromomycin
d. Tobramycin
a. 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 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?
a. Antibiotic resistance
b. Interpatient variation
c. Liver disease
d. Renal disease
d. 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 who has been receiving intravenous gentamicin for several days reports having had a headache for 2 days. What action will the provider take?
a. Discontinue the gentamicin.
b. Order a gentamicin trough before the next dose is given.
c. Prescribe an analgesic to control headache discomfort.
d. Order renal function tests to evaluate for potential nephrotoxicity.
a. 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 shows signs and symptoms of conjunctivitis. Which aminoglycoside will the provider order?
a. Amikacin
b. Kanamycin
c. Neomycin
d. Paromomycin
c. 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 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?
a. 4:00 AM
b. 7:00 AM
c. 7:45 AM
d. 8:45 AM
c. 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 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?
a. Drinking 8 to 10 glasses of water every day
b. Eating foods that are high in potassium
c. Taking the medication with food
d. Taking a folic acid supplement
a. 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 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?
a. Prescribe a different antibiotic for this patient.
b. Order daily blood glucose determinations while giving TMP/SMZ.
c. Suggest that the patient take a potassium supplement while taking TMP/SMZ.
d. Suggest that the patient avoid excessive fluid intake while taking TMP/SMZ.
a. 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 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?
a. Change the antibiotic to TMP/SMZ.
b. Increase the dose of the glipizide.
c. Order daily lab testing of the patient’s electrolytes.
d. Order daily coagulation levels to be drawn.
d. 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 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?
a. Calcium
b. Chloride
c. Potassium
d. Sodium
c. 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 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?
a. Acute cystitis
b. Urinary tract infection
c. Pyelonephritis
d. Prostatitis
c. 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.
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?
a. Acute cystitis
b. Urinary tract infection
c. Pyelonephritis
d. Prostatitis
d. 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 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?
a. Uncomplicated lower urinary tract infection treatable with short-course therapy
b. Complicated lower urinary tract infection treatable with single-dose therapy
c. Uncomplicated upper urinary tract infection requiring 14 days of oral antibiotics
d. Complicated upper urinary tract infection requiring parenteral antibiotics
a. 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 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. A 14-day course of amoxicillin with clavulanic acid
b. A 7-day course of ciprofloxacin
c. A single dose of fosfomycin
d. A 3-day course of trimethoprim/sulfamethoxazole
d. 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 with a history of renal calculi has fever, flank pain, and bacteriuria. What action will the provider take?
a. Prescribe antibiotic therapy after urine culture and sensitivity results are available.
b. Order an prophylactic antibiotic for 6 weeks after the acute infection has cleared.
c. Initiate immediate treatment with a prescription for a broad-spectrum antibiotic.
d. Refer the patient for intravenous antibiotics and hospitalization.
a. 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 has a positive urine culture 1 week after completion of a 3-day course of antibiotics. What action will the prescriber take?
a. Prescribe a 2-week course of antibiotics.
b. Order tests to evaluate for a structural abnormality of the urinary tract.
c. Prescribe long-term prophylaxis with low-dose antibiotics.
d. Treat the patient with intravenous antibiotics.
a. 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 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?
a. Cephalexin
b. Fosfomycin
c. Methenamine
d. Nitrofurantoin
c. 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.
Which patient diagnosed with a urinary tract infection will be hospitalization and prescribed intravenous antibiotics?
a. A 5-year-old child with a fever of 100.5°F, dysuria, and bacteriuria
b. A pregnant woman with bacteriuria, suprapubic pain, and fever
c. A young man with dysuria, flank pain, and a previous urinary tract infection
d. An older adult man with a low-grade fever, flank pain, and an indwelling catheter
d. 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.
