Chapter 04: Drug Calculation: Preparing and Giving Drugs

Visovsky: Introduction to Clinical Pharmacology, 9th Edition

Multiple Choice

1. Which of the following is an example of a drug given in units instead of milligrams?

a. Insulin b. Furosemide c. Normal saline d. Nitroglycerine

ANS: A

Insulin is a parenteral drug that is given in units, not milligrams. Insulin is drawn up using a unit-based syringe

DIF: Cognitive Level: Remembering REF: p. 37 a. The age of the child b. The weight of the child c. One-half of the adult dose d. The international standardized ratio

2. When calculating the dose of a drug to be given to a child, Clark’s rule is used. What measure is Clark’s rule based upon?

ANS: B

The Joint Commission now recommends that all dosages for children be weight-based. Clark’s rule: Pediatric child dose = (weight of child/150 lbs x adult dose).

DIF: Cognitive Level: Remembering REF: p. 39 a. Intravenous drugs must go through first-pass metabolism to be absorbed. b. Intravenous drugs are deposited directly into the blood stream. c. Intravenous drugs have lower rates of adverse events. d. Intravenous drugs are less effective than oral drugs.

3. Which statement is true regarding giving drugs by the IV route?

ANS: B

Drugs administered by the intravenous route are deposited directly into the bloodstream and have a higher incidence of chance for adverse events.

DIF: Cognitive Level: Knowing REF: p. 39 a. Crush and dilute it in warm water. b. Tell the patient to swallow it whole. c. Tell the patient to chew it completely. d. Pierce it with a needle and squeeze into the mouth.

4. Which represents the proper way to give an oral capsule?

ANS: B

Remain at the patient’s bedside until the drug is swallowed. Do not crush tablets or break capsules without checking with the pharmacist. Many drugs have special coatings that are essential for proper absorption.

DIF: Cognitive Level: Knowing REF: p. 41 a. Allow extra time to give all of the drugs. b. Crush all the drugs before giving them. c. Allow the patient to take only the drugs she can swallow. d. Leave the drugs at the bedside so the patient can take them slowly.

5. An elderly patient is scheduled to take six drugs each morning. What action should you take when giving these drugs?

ANS: A

Allow extra time to give drug to the elderly. These individuals often are slower at swallowing drugs and water. The nurse must be present for the administration of every drug.

DIF: Cognitive Level: Applying REF: p. 41 a. Take the vital signs. b. Check placement of the tube. c. Flush the tube with 30 mL of water. d. Ask the patient if the tube is painful.

6. When giving a drug through a nasogastric (NG) tube, which will you do first?

ANS: B

Make certain that the NG tube is in the stomach. Aspirate (take out) stomach contents with a syringe and test the pH of the stomach contents. If the pH is 0-5, the NG tube is most likely in the stomach.

DIF: Cognitive Level: Knowing REF: p. 42 a. The tube is reconnected to the suction. b. The tube is left off for 4 hours and then reconnected to suction. c. The tube is clamped for 10 minutes and then reconnected to suction. d. The tube is clamped for 30 minutes and then reconnected to suction.

7. Which is done after giving drug through a nasogastric tube that is connected to suction?

ANS: D

When the drug has passed through the tube, reclamp the tube for 30 minutes before reattaching the suction.

DIF: Cognitive Level: Knowing REF: p. 43 a. Recap the needle before disposal. b. Remove the needle from the syringe. c. Carry the needle with you until it can be disposed of. d. Immediately discard the needle and syringe in a puncture-proof container.

8. What precaution should you take to prevent injury from a needlestick?

ANS: D

Standard precautions recommend the use of puncture-resistant containers for disposal of all needles and sharps. Never recap a needle; most sticks happen this way.

DIF: Cognitive Level: Understanding REF: p. 45 a. IV route b. IM route c. Rectal route d. Subcutaneous route

9. When a patient is experiencing a life-threatening emergency, you may be given an order to give drug via which route?

ANS: A

IV injections or infusions may be needed when drug must go directly into the bloodstream, because the action of this method is rapid.

DIF: Cognitive Level: Understanding REF: p. 43 a. 18 G, 1-inch needle b. 20 G, 1/2-inch needle c. 25 G, 2-inch needle d. 21 G, 1 1/2-inch needle

10. Which is the correct needle for an intramuscular (IM) injection?

ANS: D

An IM injection is usually given with a 1- to 2-inch, 20- to 22-gauge needle.

DIF: Cognitive Level: Understanding REF: p. 45 a. Rotate sites among the upper arm, abdomen, and anterior thigh. b. Avoid injecting within 3 inches of a previous injection site. c. Insert the needle at a 30-degree angle to the skin. d. Use a 22-gauge, 5/8-inch needle.

11. Which principle of drug administration will you include in the teaching plan of a patient who will be administering his own subcutaneous injections?

ANS: A

The patient should be taught the principles of injection site rotation and be given a diagram to take home at discharge.

DIF: Cognitive Level: Applying REF: p. 49 a. Pallor and pain b. Pallor, warmth c. Pain, warmth, and burning d. Pain, swelling, and redness

12. What physical assessment findings would you observe when an IV becomes infiltrated?

ANS: D

Infiltration produces pain, swelling of the area, and redness. Pain with warmth and burning are signs of infection.

DIF: Cognitive Level: Understanding REF: p. 55 a. Draw up the exact amount of the drug adding 0.5 mL of air. b. Do not massage the injection site after giving the drug. c. Use the deltoid site for this injection. d. Pull the tissue upward and away.

13. Which correct step should you take when giving a Z-track injection?

ANS: B

The “Z-track technique” of IM injection uses the skin itself as a “door” to seal in the drug and prevent it from leaking back out from muscle tissue. 0.1-0.2 ml of air is added to the drug after it is drawn up. The tissue is pulled down and away, and the site is not massaged after the injection is given.

DIF: Cognitive Level: Applying REF: p. 51 a. Squeeze the nitroglycerine ointment onto the applicator paper and place it on the skin. b. Apply the nitroglycerine ointment to the medial aspect of the thigh. c. Massage the nitroglycerine ointment thoroughly into the skin. d. Shave the skin before to application.

14. What step should be taken when applying a topical nitroglycerin ointment to a patient?

ANS: A

The correct number of inches of drug is squeezed onto the applicator paper as a small ribbon. The applicator paper is then laid on top of the skin where the drug is to be applied. A nonhairy area on the chest, upper arm, or flank area should be selected for application. Apply it to the paper because the nurse can receive some of the drug if it comes in contact with his or her fingers and is absorbed into the skin.

DIF: Cognitive Level: Applying REF: p. 57 a. Always wear gloves when giving transdermal drugs. b. To maintain blood levels, do not clean the skin. c. Remove all patches before showering. d. Keep all prior patches on the skin.

15. You are preparing to give a drug by the transdermal route to a patient. Which safety precaution should you use when giving this type of drug?

ANS: A

Always wear gloves to avoid drug absorption onto your own skin.

DIF: Cognitive Level: Applying REF: p. 56 a. Never shake the inhaler drug before use. b. Hold the head back while inhaling the drug. c. Exhale while squeezing the canister to deliver the drug. d. Sit upright, exhale, then activate the inhaler as the next inhalation begins.

16. Metered-dose inhalers are used to deliver specific amounts of drug. The nurse gives the patient which instructions?

ANS: D

The patient should exhale and then activate the inhaler as the next inspiration begins. This will carry drug down into the lungs.

DIF: Cognitive Level: Applying REF: p. 58 a. The drug must go into the back of the nose. b. The drug must go directly into the throat. c. The drug must go onto the tongue. d. The drug must go into the lungs.

17. You are instructing a clinic patient on how to use an inhaler during an asthma attack. Which statement is correct about the use of an inhaler?

ANS: C

If using inhalers, patients must be carefully instructed so the drug goes all the way into the lungs, not just to the back of the nose or throat. Take a deep breath first, exhale, and then inhale the drug.

DIF: Cognitive Level: Applying REF: p. 58

Multiple Response

1. You discover that an IV infusion is failing to flow properly. Which actions should you take? (Select all that apply.)

a. Change the IV tubing b. Check IV pole height c. Check the IV solution type d. Check the position of needle e. Check the IV tubing for kinks f. Examine IV site for infiltration

ANS: B, D, E, F

Failure of an IV to infuse properly warrants the following nursing actions: check for bent or kinked tubing, check the needle position- it should be against a vein wall, the IV pole may be too low, or the needle may be out of the vein and infiltrated.

DIF: Cognitive Level: Applying REF: p. 55 a. Oral tablets b. Liquid drugs c. Intravenous drugs d. Transdermal drugs e. Rectal suppositories f. Metered-dose inhaler

2. Which are examples of drugs given through mucous membranes? (Select all that apply.)

ANS: D, E, F

Percutaneous drugs are given through mucous membranes. Transdermal drugs, rectal suppositories and inhalers are examples of percutaneous drugs.

DIF: Cognitive Level: Knowing REF: p. 57

Chapter 05: Anti-infective Drugs: Antibacterial, Antitubercular, and Antifungal Agents

Visovsky: Introduction to Clinical Pharmacology, 9th Edition

Multiple Choice

1. A patient receiving antibiotics for the treatment of a bacterial wound infection develops a secondary fungal infection. The patient asks you to explain why the fungal infection developed. What is your best response?

a. “Antibiotics can upset the balance of normal flora and allow yeast or fungus to grow.” b. “Antibiotic resistance has allowed the bacteria in your wound to become a fungus.” c. “Genetic changes induced by antibiotics lead to this fungal infection.” d. “There is no known cause for this secondary fungal infection.”

ANS: A

Antibiotic use can upset the normal flora balance in the body and cause yeast or fungal infections to occur. Candida is a common body yeast and often overgrows to cause a fungal infection. When a person is given antibiotics to kill infectious bacteria, the normal flora is killed off as well.

DIF: Cognitive Level: Applying REF: p. 65 a. Breast-feeding is permitted during antimicrobial therapy and should be continued. b. Breast-feeding can continue if the breast milk is pumped, and given by bottle. c. Breast-feeding should be avoided during antimicrobial therapy. d. Breast-feeding during antimicrobial therapy can lead to mastitis.

2. A breast-feeding mother has been prescribed antimicrobial therapy for an infection. What information should be included in her teaching plan?

ANS: C

Breast-feeding should be avoided during antimicrobial therapy because most of these drugs are excreted into breast milk and the infant (who may not have an infection) will be exposed to the actions, side effects, and adverse effects.

DIF: Cognitive Level: Applying REF: p. 66 a. Bacteriostatic drugs kill the bacteria. b. Bacteriostatic drugs slow the growth of bacteria. c. Bacteriostatic drugs are only effective against gram-positive organisms. d. Bacteriostatic drugs are only effective against gram-negative organisms.

3. What is the action of an antibiotic that is classified as bacteriostatic?

ANS: B

Bacteriostatic drugs limit or slow the growth of the bacteria, weakening or eventually leading to the death of the bacteria.

DIF: Cognitive Level: Remembering REF: p. 66 a. Antimycotic b. Bacteriostatic c. Antimicrobial d. Broad-spectrum

4. Which term refers to an antibiotic with a high degree of activity against many different organisms?

ANS: D

Drugs that are effective against a variety of organisms are called broad-spectrum antibiotics.

DIF: Cognitive Level: Remembering REF: p. 67 a. Abdominal x-ray b. Blood chemistry c. Laparoscopic examination d. Culture and sensitivity studies

5. You are caring for an elderly patient who is newly admitted with a suspected urinary tract infection requiring antimicrobial therapy. Which of the following tests would you expect the healthcare provider to order before initiating treatment?

ANS: D

The organisms present in the urine must be carefully cultured and tested to see which drugs are effective against them (drug sensitivity).

DIF: Cognitive Level: Remembering REF: p. 67 a. Cefazolin b. Penicillin c. Vancomycin d. Sulfamethoxazole/trimethoprim

6. You are caring for a patient with an upper respiratory infection from group A beta-hemolytic streptococci. The patient asks you what antimicrobial drug is effective for this infection. What is your best response?

ANS: B

Penicillin is effective in the treatment of the following susceptible organisms: group A betahemolytic streptococci and other less common organisms.

DIF: Cognitive Level: Applying REF: p. 69 a. Edema of the lower extremities b. Metallic taste in the mouth c. Ringing in the ears d. Loose stools

7. You are teaching a patient about possible side effects when taking penicillin, a broadspectrum antibiotic. What is the most common side effect you would stress in teaching the patient about this drug?

ANS: D

The most common side effect of penicillin (and many other antibiotics) is simple diarrhea of two to four loose stools daily.

DIF: Cognitive Level: Applying REF: p. 69 a. The antibiotic should be acid stable. b. The antibiotic should be penicillinase resistant. c. The antibiotic should have an extended-release formulation. d. The antibiotic should be a narrow-spectrum preparation.

8. Which statement is true of any antibiotic used to treat an infection caused by a penicillinaseproducing organism?

ANS: B

Penicillins come in different forms; one class is natural penicillinase-resistant penicillin.

DIF: Cognitive Level: Knowing REF: p. 69 a. “Ampicillin can reduce the effect of oral contraceptives.” b. “Ampicillin is given only to patients allergic to penicillin.” c. “Taking ampicillin can upset your menstrual cycle for the next month.” d. “NSAIDS taken for menstrual pain can decrease serum levels of ampicillin.”

9. Which effect or drug interaction of ampicillin would be important to teach to female patient of childbearing age?

ANS: A

Ampicillin reduces the effectiveness of oral contraceptives, which can lead to an unplanned pregnancy. Teach women of childbearing age to use two reliable methods of birth control while taking any penicillin to prevent unplanned pregnancy.

DIF: Cognitive Level: Applying REF: p. 72 a. Lethargy b. Nephrotoxicity c. Peripheral edema d. Sleep disturbance

10. You are caring for an elderly patient in a long-term care facility who has been prescribed a cephalosporin. Which adverse effect should you monitor the patient for while taking this drug?

ANS: B

Nephrotoxicity (kidney toxic effects) has been reported with some cephalosporins, and the incidence is greater in older adult patients and in patients with poor renal function.

DIF: Cognitive Level: Applying REF: p. 72 a. Inform the healthcare provider immediately. b. Inform the patient that he can take the prescribed drug safely. c. Instruct the patient to call the healthcare provider only if a rash appears. d. Instruct the patient to take a dose in your presence to observe for adverse effects.

11. A patient who was prescribed a cephalosporin for the treatment of an infection states he has an allergy to penicillin. What action should you take before giving this drug to the patient?

ANS: A

Patients who are allergic to penicillin are often allergic to the cephalosporins because the chemical structures are similar. Inform the prescriber about a penicillin allergy.

DIF: Cognitive Level: Applying REF: p. 72 a. Ask the patient whether he or she has ever developed a rash while taking another drug. b. Reassure the patient that many people have this expected reaction to antibiotic therapy. c. Ask the patient whether the rash itches, burns, or causes other types of discomfort. d. Document the report as the only action.

12. A patient receiving antibiotics for 3 days reports a skin rash over the chest, back, and arms. What is your first action?

ANS: A

A rash is an indication that the patient is allergic to the drug; however, at this time it is not an emergency. First explore the patient’s response further and hold the dose; then notify the prescriber of this problem.

DIF: Cognitive Level: Applying REF: p. 72 a. Inject the penicillin into the dorsal gluteal site by deep IM injection; do not aspirate. b. Inject the penicillin using the Z-track method; aspirate before injecting the drug. c. Inject subcutaneously as a bleb; if no reaction, then proceed to inject IM. d. Penicillin is not permitted to be given by IM injection, but by IV only.

13. Which of the following methods is the correct procedure for giving IM penicillin?

ANS: B

Penicillin is given by the Z-track method and aspiration is performed before injecting the drug. If blood appears in the syringe, remove the syringe, dispose of the drug, and prepare another dose.

DIF: Cognitive Level: Knowing REF: p. 70 a. Gabapentin b. Vancomycin c. Doxycycline d. Clindamycin

14. Which cell wall synthesis inhibitor drug is given in an oral form to treat Clostridium difficile?

ANS: B

Vancomycin has an oral form of a cell wall synthesis inhibitor that is used to combat the pseudomembranous colitis caused by Clostridium difficile.

DIF: Cognitive Level: Remembering REF: p. 71 a. 0.25 b. 0.5 c. 2 d. 4

15. A patient is to receive penicillin G benzathine (Bicillin LA) 2,400,000 units intramuscularly. The drug on hand is penicillin G benzathine 600,000 units/mL. How many milliliters should you prepare for the correct dose?

ANS: D

Want 2,400,000 units/have 600,000 units per mL. 2,400,000/600,000 = 24/6 = 4 mL.

DIF: Cognitive Level: Applying REF: p. 70 a. “Yes, these problems indicate an allergic reaction.” b. “Yes, these side effects eventually lead to difficulty breathing.” c. “No, these uncomfortable problems are an expected drug side effect.” d. “No, the problems are caused by the presence of the infection and are not related to the drug.”

16. A patient prescribed vancomycin (Vancocin) has developed redness on the face, neck, chest, back, and arms. The family asks the nurse if the drug should be stopped because of this response. What is your best answer?

ANS: C

Vancomycin is a powerful antibacterial drug that has many side effects, including “red man syndrome.” This problem is caused by a histamine release that dilates blood vessels, giving a red appearance to the face, neck, chest, back, and arms. Sometimes this reaction can be reduced by slowing the infusion rate; however, it is not an indication to stop the drug.

DIF: Cognitive Level: Applying REF: p. 71 a. “Tetracycline can cause sun sensitivity, so protect yourself from sun exposure.” b. “Tetracycline alters blood clotting; avoid injury while taking this drug. c. “Tetracycline should be taken with food to avoid stomach upset.” d. “Tetracycline may cause irritation to the vein when it is injected.”

17. You are counseling a patient who is to begin a course of tetracycline for the treatment of Lyme disease. What instructions would be important to provide to this patient?

ANS: A

The tetracyclines increase the sensitivity of the skin to the sun and severe sunburns are possible, even among people with dark complexions.

DIF: Cognitive Level: Applying REF: p. 73 a. “Tetracycline can impair the development of teeth and bones in young children.” b. “Tetracycline is a large pill and difficult for a young child to swallow.” c. “Tetracycline can cause severe headaches in young children.” d. “Tetracycline can cause seizures in young children.”

18. The mother of a 6-year-old child with a skin infection asks why her child is not being treated with tetracycline as she was for a similar infection. What is your best response?

ANS: A

Tetracycline interferes with bone development and the development of tooth enamel. Exposure to tetracycline can cause permanent tooth staining.

DIF: Cognitive Level: Applying REF: p. 74 a. Macrolides are the first treatment for MRSA infection. b. Macrolides always require a longer course of treatment. c. Macrolides cannot be used for patients with a penicillin allergy. d. Macrolides are effective against the same organisms as penicillin.

19. Which statement is true regarding macrolides?

ANS: D

Macrolides are effective against the same infectious organisms that are sensitive to penicillin and are used for patients who have a penicillin allergy. These drugs are not effective against MRSA.

DIF: Cognitive Level: Remembering REF: p. 74 a. Complete blood count b. BUN and creatinine c. Troponin levels d. Liver enzymes

20. You are caring for a hospitalized patient receiving gentamycin IV, an aminoglycoside, for the treatment of Pseudomonas pneumonia. Which laboratory values would be important to monitor to avoid adverse effects from drugs of this classification?

ANS: B

Patients who are given aminoglycosides must be monitored for nephrotoxicity (kidney damage) as well as ototoxicity. The nurse should monitor BUN and creatinine during treatment, and report elevations to the healthcare provider.

DIF: Cognitive Level: Applying REF: p. 76 a. Take the drug on a full stomach. b. Drink milk when taking the drug. c. Take the drug at night before going to bed. d. Drink large amounts of water with this drug.

21. A sulfonamide, Bactrim, is ordered for a patient with a urinary tract infection. What should you include in the teaching plan for the patient who is taking this drug?

ANS: D

To prevent crystals in the urine, the patient should be told to drink large amounts of water while taking this drug.

DIF: Cognitive Level: Applying REF: p. 77 a. “I will need to watch for symptoms of low blood glucose levels.” b. “I will need to restrict the amount of fluids I drink to prevent edema.” c. “I will need to take the Bactrim on an empty stomach to increase drug absorption.” d. “I will need to add additional salt to my food to replace sodium excreted with this drug.”

22. You are caring for a patient with type 2 diabetes who has been prescribed a course of a sulfonamide (Bactrim) for a urinary tract infection. Which statement by the patient reflects understanding of potential drug interactions?

ANS: A

Sulphonamides can interact with some type 2 diabetic drugs, such as sulfonylureas that can cause symptoms of hypoglycemia (fatigue, shakiness, anxiety, and irritability).

DIF: Cognitive Level: Applying REF: p. 77 a. Beta blockers b. ACE-inhibitors c. Thiazide diuretics d. Calcium channel blockers

23. In reviewing a patient’s reported drug allergies, which drug class sensitivity would suggest the patient should not be given a sulfonamide?

ANS: C

Patients with an allergy or sensitivity to thiazide diuretics, oral sulfonylureas, or carbonic anhydrase inhibitors may exhibit the same allergy or sensitivity to sulfonamides.

DIF: Cognitive Level: Remembering REF: p. 77 a. “There are no drug interactions associated with fluoroquinolones.” b. “I should take this drug with food to decrease GI upset.” c. “I can take this drug with caffeine such as a cup of coffee.” d. “I can discontinue this drug once I feel better.”

24. You are providing education for a patient prescribed a fluoroquinolone. Which response made by the patient indicates that teaching has been effective?

ANS: B

Fluoroquinolones should be taken with food to decrease adverse GI effects.

DIF: Cognitive Level: Applying REF: p. 78 a. “I will report the development of pain, redness, or swelling around any joint.” b. “I will call my healthcare provider if I develop abnormal bruising or bleeding.” c. “I will call my healthcare provider if I develop lower leg swelling.” d. “I will report the development of a chronic, irritating cough.”

25. A patient who is a marathon runner requires treatment with the fluoroquinolone levofloxacin (Levaquin) for the treatment of a severe infection. What statement by the patient ensures understanding of the potential adverse effects of this drug?

ANS: A

Fluoroquinolones can cause rupture of tendons. Teach patients to notify the healthcare provider for tendonitis symptoms that might occur (ache, pain, redness, and swelling in a joint or area where a tendon attaches to a bone).

DIF: Cognitive Level: Applying REF: p. 78 a. “TB is a sexually transmitted disease.” b. “TB is transmitted by living in unsanitary conditions.” c. “TB is transmitted by inhaling droplets from coughing or sneezing.” d. “TB is transmitted from one person to another by infected blood.”

26. A patient newly diagnosed with tuberculosis (TB) asks how this infection is transmitted. What is your best response?

ANS: C

TB is transmitted by infected humans, cows (bovine), and birds (avian). Droplets ejected during coughing or sneezing are inhaled by an uninfected host. Once the bacterium is inhaled it rapidly multiplies in the oxygen-rich lung tissue.

DIF: Cognitive Level: Applying REF: p. 79 a. “INH disrupts blood flow in TB cells depriving them of oxygen.” b. “INH inhibits enzymes needed for reproduction and growth of TB.” c. “INH is a bacteriostatic drug that works directly in the lung when inhaled.” d. “INH works by increasing the elimination of tubercular bacteria through the urine.”

27. A patient with a confirmed active tuberculosis (TB) exposure asks how the first-line drugs such as isoniazid (INH) work to prevent infection. What response demonstrates your understanding of the action of isoniazid?

ANS: B

Isoniazid (INH) is a bactericidal drug that inhibits the enzymes of the TB organisms needed for reproduction and growth. INH can inhibit the enzymes of the TB bacteria that are in an infectious as well as a dormant state.

DIF: Cognitive Level: Understanding REF: p. 81 a. Prophylactic treatment with isoniazid (INH) only b. Rifampin for 10 days or until the cough is resolved c. Long-term treatment with several antitubercular drugs d. Ethambutol plus a course of broad-spectrum antibiotics

28. Which type of treatment would you expect to be used for a patient with active tuberculosis?

ANS: C

Antitubercular drugs are classified as primary or secondary agents to describe the way they are used in treating tuberculosis. The combination of drugs helps to slow the development of bacterial resistance in active TB.

DIF: Cognitive Level: Remembering REF: p. 79 a. “Avoid taking acetaminophen and alcohol while taking this drug.” b. “Take this drug with milk or an antacid to avoid stomach upset.” c. “Your stools may be darker than normal when taking this drug.” d. “Take this drug with food.”

29. You are teaching a patient prescribed rifampin for the treatment of tuberculosis. What instruction should be included in the treatment plan?

ANS: A

Rifampin can cause liver damage that is potentiated by acetaminophen and alcohol.

DIF: Cognitive Level: Applying REF: p. 80 a. Azoles b. Polyenes c. Allylamines d. Antimetabolites

30. Which class of antifungal drugs works by altering the cell wall of the fungus?

ANS: A

Azoles work by altering the cellular membrane of the fungus by depleting a lipid-like substance (ergosterol), which damages the fungus and will not allow it to reproduce.

DIF: Cognitive Level: Knowing REF: p. 85 a. Hypoglycemia and dizziness. b. White plaques coating the tongue. c. Painful red or purple rash, and blisters. d. Decreased haemoglobin and hematocrit.

31. Your patient has been prescribed a course of fluconazole for the treatment of a fungal infection. Which symptoms would indicate a medical emergency due to an adverse reaction to the drug?

ANS: C

Painful red or purple rash with flu-like symptoms are signs of Steven’s Johnson Syndrome, a medical emergency.

DIF: Cognitive Level: Applying REF: p. 84 a. “Take care not to shake the suspension before pouring it.” b. “Take this drug after having a fatty meal to increase absorption.” c. “Keep the suspension in your mouth several minutes before swallowing.” d. “Check your pulse before taking this drug, report a heart rate of 100 or greater.”

32. A patient with candida infection in the mouth has been prescribed nystatin suspension. Which instruction should be included in the teaching plan for this patient?

ANS: C

Patients should be taught to retain the suspension in the mouth for several minutes before swallowing to ensure the drug comes into contact with the oral fungus.

DIF: Cognitive Level: Applying REF: p. 85 a. Malaria b. Pneumonia c. Strep infection d. Tuberculosis

33. For which condition would a patient receive the drug primaquine as a treatment?

ANS: A

Primaquine is a drug used in the treatment of malaria (antimalarial).

DIF: Cognitive Level: Knowing REF: p. 88 a. Wash the toilet seat weekly. b. There are special diet requirements before taking this drug. c. There is no need to test other family members for this condition. d. You may have diarrhea and abdominal pain while taking this drug.

34. A patient is being treated for pinworms with anthelmintics. In addition to taking the drug, what else should be included in the patient’s teaching plan?

ANS: D

Some people have diarrhea and abdominal discomfort while taking the drug. During the initial period of illness, patients must remember that they are contagious. Every effort must be made to protect those nearby.

DIF: Cognitive Level: Understanding REF: p. 89 a. Prophylactically when people travel to areas in which malaria is common b. Prophylactically when people return from malaria-infested areas c. For treatment of malaria once the acute illness is over d. Prophylactically in acute cases of malaria

35. In which situation should drugs for malaria be given?

ANS: A

People in the military or those traveling to or living in areas where malaria is endemic can use antimalarials to prevent malaria and to treat the symptoms.

DIF: Cognitive Level: Understanding REF: p. 89

Multiple Response

1. Under which circumstances may the body’s normal flora cause infection? (Select all that apply.)

a. When normal flora are present in greater amounts than normal b. When normal flora are within immunocompromised persons c. When normal flora present in an unusual place in the body d. When normal flora are exposed to probiotics e. When normal flora are exposed to antibiotics f. When normal flora undergo genetic mutations

ANS: A, B, C, E

Conditions in which normal flora cause infection include: when a person has very little immunity, if the organisms are present in excessive amounts and overwhelm the body, or they are located in the wrong place. Antibiotic use can upset the normal flora balance in the body and cause yeast or fungal infections to occur.

DIF: Cognitive Level: Understanding REF: p. 65 a. Bacterial changes in the bowel b. Overgrowth of yeast c. Loss of appetite d. Superinfection e. Nausea f. Edema

2. Which adverse reactions are associated with the use of broad-spectrum antibiotics? (Select all that apply.)

ANS: A, B, D

Several types of adverse reactions are seen with broad-spectrum antibiotics. Adverse reactions include: changes in the normal bacteria in the bowel, an overgrowth of yeast, and superinfections.

DIF: Cognitive Level: Knowing REF: p. 66 a. “Notify your prescriber immediately if you vomit.” b. “Stop taking the drug if you develop hives or a rash.” c. “Call 911 if you experience any difficulty breathing.” d. “Avoid drinking caffeinated beverages with the drug.” e. “If you notice diarrhea be sure to stop taking the drug.” f. “Continue taking the drug even if you are feeling well.”

3. A patient is being discharged home on antibacterial drug therapy. What instructions should you teach the patient about allergic reactions? (Select all that apply.)

ANS: B, C

GI upset, vomiting, and diarrhea are common side effects of antibacterial drugs and are not signs of allergic reactions. When a patient experiences an allergic reaction, he or she should be taught to stop taking the drug if rash or hives develop and to call the prescriber immediately. A patient should also be taught to call 911 immediately for difficulty breathing or a feeling of a lump in the throat because these are signs of a serious allergic reaction.

DIF: Cognitive Level: Understanding REF: p. 69 a. Fluoroquinolones interact with antidiabetic drugs. b. Fluoroquinolones increase the anticoagulant action of warfarin. c. The most common side effect of fluoroquinolones is temporary incontinence. d. Fluoroquinolones should be taken 2 hours before or 4 hours after multivitamins. e. Dairy products and enteral tube feedings reduce the absorption of fluoroquinolones. f. Fluoroquinolones are the only safe antibiotics for patients taking antidysrhythmics.

4. Which of the following statements are true regarding fluoroquinolones? (Select all that apply.)

ANS: A, B, D, F

Nausea, vomiting, diarrhea, abdominal pain, and headache are the most common side effects. Fluoroquinolones are generally contraindicated in patients on antidysrhythmics. Fluoroquinolones should be taken 2 hours before or 4 hours after multivitamins, minerals, antacids and iron because these agents reduce the absorption of the antibiotic by as much as 90%. When taken with warfarin, fluoroquinolones increase warfarin’s anticoagulant effects. Dairy products and enteral tube feedings reduce the absorption of fluoroquinolones. In patients taking antidiabetic drugs, hyper or hypoglycemia may occur.

DIF: Cognitive Level: Remembering REF: p. 78 a. Report weight loss to your healthcare provider. b. Avoid alcohol for the duration of this treatment. c. Sleep with your head elevated using two pillows. d. Take each drug at a different time throughout the day. e. Report the appearance of dark colored urine and light-colored stools. f. You will need to have weekly blood draws to assess for neutropenia.

5. Which of the following instructions should be part of a teaching plan for all patients receiving treatment with antitubercular drugs? (Select all that apply.)

ANS: A, B, E, F

Weight loss is an indication of worsening disease and should be reported to the healthcare provider. These drugs can cause liver damage as evidenced by clay-colored stools, dark urine, and jaundice. Because these drugs affect the liver, all alcohol should be avoided.

DIF: Cognitive Level: Applying REF: p. 83

Chapter 06: Antivirals and Antiretrovirals

Multiple Choice

1. Which statement about antiviral drugs is true?

a. Antiviral drugs kill viruses by altering viral DNA.

b. Antiviral drugs work by stopping viral replication.

c. Antiviral drugs alter the host immune system.

d. Antiviral drugs are considered virucidal.

ANS: B

Antiviral drugs must enter the infected cell and act at the site of infection to be effective. Antivirals do not kill the virus but rather stop viral reproduction. This action means that all antivirals are only virustatic, not virucidal.

DIF: Cognitive Level: Knowing REF: p.94 a. Acyclovir (Zovirax) b. Zanamivir (Relenza) c. Oseltamivir (Tamiflu) d. Amantadine (Symmetrel)

2. Which antiviral drug is only given by oral inhalation?

ANS: B

Zanamivir is given only by oral inhalation. Acyclovir is given intravenously or as an orally swallowed drug. Oseltamivir and amantadine are swallowed orally.

DIF: Cognitive Level: Knowing REF: p.95 a. Acyclovir b. Amantadine c. Valacyclovir d. Zanamivir

3. Which antiviral drug is most likely to have more severe central nervous system side effects, including worsening of glaucoma?

ANS: B

Amantadine crosses the blood-brain barrier and concentrates in the brain tissues. None of the other drugs concentrate in brain tissues.

DIF: Cognitive Level: Knowing REF: p.95 a. “Antiviral drugs are not useful incombating influenza.” b. “Antiviral drugs are only used for prevention of influenza.” c. “Antiviral drugs can only be given to people who are immunocompromised.” d. “Antiviral drugs work best when given within 48 hours of the start of symptoms.”

4. A patient presents to the clinic with flu symptoms that began 3 days ago. The patient is wondering why the flu cannot be treated with an antiviral. What is your best response?

ANS: D

All the antiviral drugs for influenza are used to either prevent an infection in a patient who has been exposed to the virus or to reduce the symptoms of an existing influenza infection. They work best when given after exposure and before symptoms start or within 48 hours of the onset of symptoms.

DIF: Cognitive Level: Applying REF: p.94 a. Flumadine (rimantadine) b. Valtrex (valacyclovir) c. Crixivan (indinavir) d. Ziagen (abacavir)

5. A patient who is a symptomatic comes into the clinic complaining of being exposed to a coworker who has the flu. What drug would be most appropriate for this patient?

ANS: A

Flumadine (rimantadine) is used for prophylaxis and treatment of illness caused by various strains of influenza virus.

DIF: Cognitive Level: Applying REF: p.95 a. Ribavirin (Virazole) b. Cidofovir (Vistide) c. Foscarnet (Foscavir) d. Lamivudine (Epivir)

6. Which drug is the only approved treatment for RSV?

ANS: A

The only drug approved for RSV treatment is ribavirin (Virazole).

DIF: Cognitive Level: Knowing REF: p.96 a. 16-year-old brother b. 81-year-old grandmother c. 32-year-old pregnant mother d. 36-year-old father who has diabetes

7. A 2-year-old patient with respiratory syncytial virus is prescribed aerosolized ribavirin (Virazole). Which visitor should you ensure is not in the patient’s room during the aerosol treatments?

ANS: C

A major adverse effect of ribavirin is that it is a teratogen, an agent that has a very high likelihood of increasing the risks for birth defects and fetal damage. It should not be given to pregnant or breast-feeding women, and it should not be handled or inhaled by anyone who is pregnant.

DIF: Cognitive Level: Applying REF: p.96 a. Ask the patient if he/she is allergic to milk. b. Wear a gown, mask, and gloves to give this drug. c. Assess the patient for the presence of irregular pulse. d. Inform the patient that this drug can cause excessive thirst.

8. The oral antiviral drug acyclovir (Zovirax) has been ordered for a patient with genital herpes. What is your best action before giving this drug?

ANS: A

Before giving acyclovir ask patients whether they have a true milk allergy because this is a contraindication to acyclovir therapy as there is cross-reactivity of the antibodies.

DIF: Cognitive Level: Applying REF: p.95 a. Nausea b. Insomnia c. Intolerance to fatty foods d. Swelling of the face or throat

9. Which of the following is a sign or symptom of an allergic or an aphylactic response to an antiviral drug?

ANS: D

Allergic and anaphylactic symptoms include swelling of the face or throat, hives, itching, redness, low blood pressure, feeling a lump in the throat, an irregular heart beat, a sense that something bad is happening, and light-headedness.

DIF: Cognitive Level: Knowing REF: p.97 a. Assess the respiratory rate and pulse. b. Assess for signs of abnormal bleeding. c. Assess for yellowing of the skin and sclera. d. Assess for signs of lower extremity edema.

10. You are giving a patient who has hepatitis B an oral dose of the antiviral drug adefovir (Hepsera). What assessment should you perform before giving this drug to the patient?

ANS: C

Assess patients for yellowing of the skin and sclera, and elevated liver enzymes because DNA polymerase inhibitors are liver toxic. Liver enzyme levels should also be monitored.

DIF: Cognitive Level: Applying REF: p.97 a. Retroviruses lack specialized enzymes. b. Retroviruses use DNA instead of RNA in their genes. c. Retroviruses cannot leave the cell to infect new cells. d. Retroviruses transmit their own information into the cell’s DNA.

11. In what way does a retrovirus differ from other common viruses?

ANS: D

Retroviruses are organisms that differ from viruses in that instead of merely hijacking a cell’s DNA or RNA to reproduce, they transmit their own information into the cell’s DNA.

DIF: Cognitive Level: Understanding REF: p.98 a. “I may be more susceptible to opportunistic infections.” b. “By taking the antiretrovirals over time, I will be cured of HIV.” c. “I understand that I may take several different drugs for my HIV.” d. “Antiretrovirals interfere with the ability of the retrovirus to reproduce.”

12. Which statement when made by a human immunodeficiency virus (HIV positive patient informs you that the patient needs additional teaching?

ANS: B

Once a person has become infected with HIV he or she will have the virus for life. All antiretroviral drugs are virustatic rather than virucidal. None of these drugs kill the virus.

DIF: Cognitive Level: Applying REF: p.99 a. Antiretrovirals b. Antivirals c. Antibiotics d. Antifungals

13. Which drug classification works to limit the progression of human immunodeficiency virus (HIV)?

ANS: A

Antiretrovirals are an important group of drugs that slow the growth or prevent the duplication of retroviruses; they are used to limit the advance of HIV and AIDS.

DIF: Cognitive Level: Knowing REF: p.99 a. “This infection is a toxic effect of the virus.” b. “This infection is from drug-related toxicities.” c. “This infection is a first-generation metabolic infection.” d. “This infection is from damage to the body’s immune system.”

14. A patient diagnosed with human immunodeficiency virus (HIV) asks you about opportunistic infections. What is your best response?

ANS: D

An opportunistic infection develops because of the damage to the body’s immune system, leaving the body unable to protect itself from certain other infections.

DIF: Cognitive Level: Applying REF: p.98 a. They are counterfeit bases that prevent reverse transcriptase from synthesizing the DNA needed for viral replication. b. They inactivate the enzyme that allows the viral genetic material to be integrated into the human host’s cellular DNA. c. They prevent the production of proteins needed for viral particles to leave the cell and infect other cells. d. They prevent initial infection by blocking the receptor the virus uses to enter target cells.

15. How do protease inhibitor (PI) drugs prevent viral replication?

ANS: C

Protease inhibitors prevent viral replication and release of viral particles. Human immunodeficiency virus produces its proteins, including those needed to move viral particles out of the host cell, in one long (human immunodeficiency virus, HIV) strand. For the proteins to be active, this large protein must be broken down into separate smaller proteins through the action of the viral enzyme HIV protease. Protease inhibitors, when taken into an HIV-infected cell, make the protease enzyme work on the drug rather than on the initial large protein. Thus active proteins are not produced and viral particles cannot leave the cell to infect other cells.

DIF: Cognitive Level: Understanding REF: p.100 a. “These drugs act by boosting the body’s T-cell production.” b. “These drugs act by interfering with replication of the retrovirus.” c. “These drugs act by using the DNA of the host cell kill the virus.” d. “These drugs act by producing artificially acquired active immunity.”

16. You are teaching a patient about the action of a newly prescribed antiretroviral drug. Which statement explains the action of antiretrovirals?

ANS: C

Antiretroviral agents act to stop more retroviruses from being made by interfering with the ability of a retrovirus to reproduce, or replicate.

DIF: Cognitive Level: Applying REF: p.99 a. “The antiretroviral and other drugs must be taken together.” b. “The antiretroviral and other drugs must be taken with milk.” c. “The antiretroviral should be taken with water 30 min before eating.” d. “The antiretroviral should be taken alone and not with other drugs.”

17. A patient beginning antiretroviral therapy for HIV infection asks you why it is important to report all other drugs that the patient is taking. What is your best response?

ANS: D

Most antiretrovirals react with other drugs. Antiretroviral drugs inhibit the cytochrome P450 enzyme system involved in the metabolism of drugs in the liver. For this reason, they should not be taken at the same time as other drugs.

DIF: Cognitive Level: Applying REF: p.103 a. “Keep taking the drug regimen exactly as ordered throughout your pregnancy.” b. “Stop the drug regimen during the first trimester, as this is when the fetus forms.” c. “This drug regimen is only given the last trimester to protect the baby during birth.” d. “Keep taking the drug regimen as prescribed until delavirdine or efavirenz is added.”

18. A female with human immunodeficiency virus (HIV) who is taking a combination of a nucleoside reverse transcriptase inhibitor, nonnucleoside reverse transcriptase inhibitor, and protease inhibitor tells you she is now pregnant. What advice regarding her drug therapy would be appropriate?

ANS: A

Antiretroviral drugs (except delavirdine or efavirenz) are recommended to be taken by pregnant women who are known to be HIV positive because the virus can cross the placenta and infect the fetus. These drugs, when taken as prescribed, can reduce the chances of fetal infection from about 30% to about 8%.

DIF: Cognitive Level: Applying REF: p.102 a. Elevated glucose level b. Decreased hemoglobin c. Elevated liver enzymes d. Decreased amylase and lipase

19. You suspect that a patient on antiretroviral therapy may have drug-related toxicity. Which of the following laboratory tests would alert you to a drug toxicity?

ANS: C

Most antiretrovirals can also cause damage to the liver or kidneys (hepatotoxic or nephrotoxic).

DIF: Cognitive Level: Understanding REF: p.102 a. Pancreatitis b. Kidney failure c. Vertebral fracture d. Acute gallbladder infection

20. A patient taking cART therapy for human immunodeficiency virus (HIV) infection develops severe upper abdominal pain that radiates to the back. What complication of this therapy may this patient be experiencing?

ANS: A

Upper abdominal pain and/or pain that radiates to your back, pain that worsens after eating, fever, rapid pulse, increased nausea, and vomiting may indicate a pancreatitis which is a medical emergency.

DIF: Cognitive Level: Understanding REF: p.103 a. “I will let your healthcare provider know so your regimen can be changed.” b. “You need only take the drug regimen 50% of the time for it to be effective.” c. “You can stop the drugs for a short 2-week “drug holiday” then resume them.” d. “You should always take your drug therapy as prescribed or it may not be effective.”

21. A patient with human immunodeficiency virus (HIV) infection tells you that she has been only partially compliant with cART drugs because she is tired of taking so many pills. What is your best response?

ANS: D

These drugs must be taken exactly as ordered every day to ensure the drugs work properly and to avoid drug resistance. Taking too little of the drugs or skipping doses leads to drug resistance and disease advancement. It is imperative not to skip doses or decrease the dosage. To be most effective in preventing HIV infection and slowing HIV reproduction, cART drugs must be taken correctly and on time at least 90% of the time.

DIF: Cognitive Level: Applying REF: p.103 a. Document the report as the only action. b. Hold the dose and notify the prescriber. c. Remind the patient to take a multiple vitamin daily. d. Reassure the patient that this is an expected drug side effect.

22. A patient who has been taking subcutaneous enfuvirtide (Fuzeon) for 6 months reports reduced sensation in the fingers and toes. What is your best action?

ANS: D

Peripheral neuropathy with loss of sensation in the extremities is a common and expected side effect of therapy. Drug therapy is not stopped for this effect. The patient needs to implement precautions to prevent injury from not having full sensation for touch, temperature, and pressure.

DIF: Cognitive Level: Applying REF: p.101 a. “Take this drug only with fruit juice.” b. “Be sure to chew this drug thoroughly.” c. “Take your pulse daily before taking this drug.” d. “Change positions carefully as this drug can lower your blood pressure.”

23. You are teaching a patient who has been prescribed atazanavir (Reyataz) about this drug. What should be included in this patient’s teaching plan?

ANS: C

Teach patients taking atazanavir and ritonavir to check their pulse daily and report low heart rate to the prescriber because these two drugs can impair electrical conduction and lead to heart block.

DIF: Cognitive Level: Applying REF: p.100 a. “This drug will not interact with your diabetic drugs.” b. “You will need to increase your carbohydrate intake while on this drug.” c. “Monitor your glucose levels, as this drug can increase blood glucose levels.” d. “Keep hard candy with you at all times, as this drug can cause hypoglycemia.”

24. A diabetic patient who is receiving treatment for HIV with raltegravir (Isentress) asks you how this drug may affect his diabetes. What is your best response?

ANS: C

Teach patients with diabetes to closely monitor blood glucose levels because these drugs increase hyperglycemia.

DIF: Cognitive Level: Applying REF: p.101 a. Hold the dose and notify the prescriber. b. Document the report as the only action. c. Remind the patient that these are symptoms of opportunistic infection. d. Reassure the patient that these are common and expected side effects of the drug.

25. A patient who has been taking efavirenz (Sustiva) reports a sore throat, fever, and blisters. What is your best action?

ANS: A

Efavirenz is a nonnucleotide analogreverse transcriptase inhibitor (NNRTI). A sore throat, fever, different types of rashes, blisters, or multiple bruises are all signs of serious adverse effects of drugs from this class. The drug should be stopped and the prescriber contacted.

DIF: Cognitive Level: Applying REF: p.100

Multiple Response

1. Which drug classes are used in the treatment of hepatitis B virus? (Select all that apply.)

a. Interferon b. Uncoating inhibitors c. Neuraminidase inhibitors d. DNA polymerase inhibitors e. Nucleoside reverse transcriptase inhibitors f. Nonnucleoside reverse transcriptase inhibitors

ANS: A, D, E

The major drugs used to treat HBV fall into three classes, the nucleoside reverse transcriptase inhibitors (NRTIs), the DNA polymerase inhibitors, and interferon.

DIF: Cognitive Level: Knowing REF: p.96 a. “You started the drug early enough to be cured.” b. “Taking St. John’s Wort will help you feel even better.” c. “Taking the drug prevents more virus from being produced.” d. “You are not cured of HIV; however, you will not be able to spread the virus.” e. “You are having a good response to the drugs, so you can stop them for awhile.” f. “HIV is not currently curable, but drug therapy slows the advance of the disease.”

2. A patient diagnosed with human immunodeficiency virus (HIV) infection taking antiretroviral therapy appears less depressed and more talkative. The patient tells you the drugs seem to be working, and she is certain she is now cured. What are your best responses? (Select all that apply.)

ANS: C, F

Antiretrovirals do not cure HIV infection, but taking the drug regimen as prescribed prevents resistant strains of HIV and slows the progression of the disease.

DIF: Cognitive Level: Applying REF: p.98