Test Bank for Pharmacotherapy Principles and Practice 5th Edition Chisholm-Burns, All 102 Chapters.

Pharmacotherapy Principles and Practice 5th Edition Chisholm-Burns Test Bank CHAPTER 1. Introduction 1. What is the name under which a drug is listed by the U.S. Food and Drug Administration (FDA)? a.

Brand b.

Nonproprietary

c.

Official

d.

Trademark 2. Which source contains information specific to nutritional supplements? a.

USP Dictionary of USAN & International Drug Names b.

Natural Medicines Comprehensive Database

c.

United States Pharmacopoeia/National Formulary (USP NF)

d.

Drug Interaction Facts 3. What is the most comprehensive reference available to research a drug interaction? a.

Drug Facts and Comparisons b.

Drug Interaction Facts

c.

Handbook on Injectable Drugs

d.

MartindaleThe Complete Drug Reference 4. The physician has written an order for a drug with which the nurse is unfamiliar. Which section of thePhysicians Desk Reference (PDR) is most helpful to get information about this drug? a.

Manufacturers section b.

Brand and Generic Name section

c.

Product Category section

d.

Product Information section 5. Which online drug reference makes available to health care providers and the public a standard, comprehensive, up to date look up and downloadable resource about medicines? a.

American Drug Index b.

American Hospital Formulary

c.

DailyMed

d.

Physicians Desk Reference (PDR) 6. Which legislation authorizes the FDA to determine the safety of a drug before its marketing? a.

Federal Food, Drug, and Cosmetic Act (1938) b.

Durham Humphrey Amendment (1952)

c.

Controlled Substances Act (1970)

d.

Kefauver Harris Drug Amendment (1962)

7. Meperidine (Demerol) is a narcotic with a high potential for physical and psychological dependency. Under which classification does this drug fall? a.I b.II c.III d.IV 8. What would the FDA do to expedite drug development and approval for an outbreak of smallpox, for which there is no known treatment? a.

List smallpox as a health orphan disease. b.

Omit the preclinical research phase.

c.

Extend the clinical research phase.

d.

Fast track the investigational drug.

9. Which statement is true about over the counter (OTC) drugs? a.

They are not listed in the USP NF. b.

A prescription from a health care provider is needed.

c.

They are sold without a prescription.

d.

They are known only by their brand names.

10. Which is the most authoritative reference for medications that are injected? a.

Physicians Desk Reference b.

Handbook on Injectable Drugs

c.

DailyMed

d.

Handbook of Nonprescription Drugs 11. The nurse is administering Lomotil, a Schedule V drug. Which statement is true about this drugs classification? a.

Abuse potential for this drug is low. b.

Psychological dependency is likely.

c.

There is a high potential for abuse.

d.

This drug is not a controlled substance.

12. The nurse is transcribing new orders written for a patient with a substance abuse history.

Choose the medication ordered that has the greatest risk for abuse. a.

Lomotil b.

Diazepam

c.

Phenobarbital

d.

Lortab 13. The nurse is caring for a patient newly diagnosed with type 1 diabetes mellitus. Which approach(es) to therapeutic methods would be considered in this patients treatment? (Select all that apply.) a.

Therapeutic drugs b.

Concentrated carbohydrate diet

c.

Family centered care

d.

Regular daily exercise and activity

e.

Daily baths

14. An older adult experiencing shortness of breath is brought to the hospital by her daughter.

While obtaining the medication history from the patient and her daughter, the nurse discovers that neither has a list of the patients current medications or prescriptions. All the patient has is a weekly pill dispenser that contains four different pills. The prescriptions are filled through the local pharmacy. Which resource(s) would be appropriate to use in determining the medication names and doses? (Select all that apply.) a.

MartindaleThe Complete Drug Reference b.

Physicians Desk Reference, Section 4

c.

Senior citizens center

d.

Patients home pharmacy 15. The nurse planning patient teaching regarding drug names would include which statement(s)? (Select all that apply.) a.

Most drug companies place their products on the market under generic names. b.

The official name is the name under which the drug is listed by the U.S. Food and Drug Administration (FDA).

c.

Brand names are easier to pronounce, spell, and remember.

d.

The first letter of the generic name is not capitalized.

e.

The chemical name is most meaningful to the patient.

16. When categorizing, the nurse is aware that which drug(s) would be considered Schedule II? (Select all that apply.) a.

Marijuana b.

Percodan

c.

Amphetamines

d.

Fiorinal

e.

Flurazepam Answers 1. C 2. C

3. B 4. B 5. C 6. A 7. B 8. D 9. C 10. B 11. A 12. D 13. A,B,D 14. B,D 15. B,C,D 16.B,C

CHAPTER 2. GERIATRICS 1. The following is an accurate description of the aging population: A. The number of older adults will reach 17 million in 2030 B. The ratio of women to men will no longer exist C. The surviving baby boomers will be more racially diverse than previous elders D. The surviving baby boomers will have less financial resources than previous elders E. The minority elder populations are projected to decrease in 2020 2. Education and health literacy in the older Americans can be described as: A. In 2007, 62% of Hispanic elders had high school degrees B. Nearly 20% of people 75 years and older have low health literacy C. In 2007, 62% of black elders had high school degrees D. Nearly 40% of people 75 years and older have low health literacy E. None of the above 3. Following are common chronic conditions older Americans have: A. Diabetes, hypertension, cancer B. Hypertension, Alzheimer disease, Parkinson disease C. Asthma, stroke, hypothyroidism D. Chronic lower respiratory diseases, Alzheimer disease, stroke E. Cancer, heart disease, Parkinson disease 4. The most important pharmacokinetic change that occurs with aging is: A. Reduced renal function B. Delayed gastric emptying C. Increased conjugation D. Phase II hepatic metabolism E. Deconditioning 5. All of the following are incorporated into the Cockcroft–Gault equation except: A. Age B. Gender C. Serum albumin D. Serum creatinine E. Weight 6. Because of pharmacodynamic changes, older adults have increased sensitivity to: A. Acetaminophen B. Metformin C. Aspirin D. Morphine E. Cyanocobalamin 7. Polypharmacy use in older adults does not result in: A. Increased adherence B. Increased drug–drug interaction C. Increased complex regimen D. Increased hospitalization E. Increased health care cost 8. According to the 2012 Beers criteria, the following drug should be avoided in older adults:

A. Diazepam B. Warfarin C. Aspirin D. Pravastatin E. Mirtazapine 9. The following statement about pain in older adults is true: A. Older adults do not feel as much pain as younger adults.

B. Older adults experience less addiction when using opioids for nerve pain.

C. Pain is not a quality indicator in long-term care facilities because it is not an objective measure.

D. Pain is frequently undertreated and underreported in elders.

E. Elders are more comfortable with opioid use because they are closer to end of life.

10. The predictors of adverse drug reactions include the following except: A. More than four medications B. Longer than 14 days of hospital stay C. More than four active medical problems D. Smoking history E. History of alcohol use 11. Medication nonadherence among older adults is influenced by: A. More than two prescribers B. Four or more medication changes in past 12 months C. History of more than two surgeries D. Having no caregiver help E. More than two chronic conditions for at least 10 years 12. Anticoagulation therapy in older adults: A. has proven benefit in atrial fibrillation B. should be withheld due to bleeding side effects C. should be withheld due to fall risks D. is more beneficial in the very sick E. is less beneficial in the community-dwelling ambulatory patient 13. Geriatric assessment: A. should only be performed by a board-certified geriatrician B. is an interprofessional collaborative process C. routinely includes a formal driving evaluation by occupational therapy D. includes history taking from the patient alone without family for maximum privacy E. is usually done at the hospital during an acute admission 14. Quality indicators: A. monitor costs related to pressure ulcer formation in long-term care facilities B. are used to measure the environmental quality of outpatient geriatric clinics C. do not include subjective complaints such as pain D. focus on physical health issues and do not include mental health issues E. are used by facility administrators and government overseers to identify problem areas 15. The following statement about pharmacotherapy in older adults is false: A. Renal function needs to be monitored for patients on digoxin.

B. Beers criteria indicate inappropriate medications.

C. Benzodiazepines may cause significant adverse effects.

D. Albumin needs to be monitored for patients on phenytoin.

E. Drug monitoring is often unnecessary due to multimorbidity.

Answers 1. C 2. D 3. A 4. A 5. C 6. D 7. A 8. A 9. D 10. D 11. B 12. A 13. B 14. E 15. E

CHAPTER 3. PEDIATRICS 1. AJ is a 14-day-old premature male infant, born at 30-week GA, started on ampicillin and gentamicin for neonatal sepsis. Which pharmacokinetic parameter affects the patient’s dosing frequency of gentamicin?

A. Absorption B. Protein binding C. Metabolism—Phase I reactions D. Metabolism—Phase II reactions E. Elimination half-life 2. Which is an appropriate maintenance fluid requirement for a 4-year-old boy with a weight of 40 pounds?

A. ~1400 mL/day B. ~1600 mL/day C. ~1800 mL/day D. ~2000 mL/day E. ~2200 mL/day 3. MM is a 6-month-old male infant who was born at 34-week GA. You are asked to evaluate his renal function in preparation for starting intravenous antibiotics. Which method for assessment is most appropriate?

A. “Bedside” Schwartz equation B. Cockcroft–Gault equation C. Schwartz (original) equation D. Modification of diet in renal disease (MDRD) equation E. Urine output alone 4. PG, a 1-week-old, 2.5-kg girl born at 30-week GA, is to be started on gentamicin for suspected neonatal sepsis. Which of the following is true regarding PG’s apparent volume of distribution (Vd) in milliliters per kilogram for gentamicin compared with adults and children with normal renal function?

A. Vd will be less than those used in adults and children.

B. Vd will be greater than those used in adults and children.

C. Vd will be less than those used in adults but similar to children.

D. Vd will be greater than those used in adults but less than in children.

E. Vd will be the same as adults and children.

5. NC is a 5-year-old boy who is to start carbamazepine, an antiepileptic medication, for seizure disorder. Which pharmacokinetic parameter affects his daily dose requirement of carbamazepine, by body weight?

A. Absorption B. Distribution C. Metabolism—Phase I reactions D. Metabolism—Phase II reactions E. Elimination 6. Which of the following is not an appropriate treatment of cold symptoms in a 1-year-old child?

A. Adequate oral fluid intake B. Dextromethorphan cough syrup C. Honey (orally)

D. Ibuprofen every 8 hours as needed for fever E. Saline nasal spray as needed 7. KC is a 3-week-old male infant born at 37-week GA with a urinary tract infection (UTI). Which age-dependent factor hinders the use of ceftriaxone for KC’s UTI? A. Gastric pH B. Glomerular filtration rate C. Intrapulmonary circulation D. Serum albumin E. Total body water 8. What is the estimated creatinine clearance for a 2-month-old term male infant whose weight is 4.5 kg, length 23.6 in (60 cm), and serum creatinine 0.5 mg/dL (or 44 µmol/L)?

A. 16 mL/min/1.73 m2 B. 21 mL/min/1.73 m2 C. 39 mL/min/1.73 m2 D. 54 mL/min/1.73 m2 E. 66 mL/min/1.73 m2 9. In the outpatient setting, which of the following is not a feasible factor to consider when assessing for potential illness in an infant?

A. Behavior such as lethargy and irritability B. Body temperature C. Diaper changes (urine output) D. Oral intake E. Mean arterial pressure 10. Which of the following items would be least appropriate to mix to mask the taste of medication for a 10-month-old infant?

A. Applesauce B. Chocolate syrup C. Honey D. Pear puree E. Strawberry gelatin 11. Which patient is at greatest risk for a medication error?

A. A 2-year-old girl (12 kg) who is started on amoxicillin suspension with dose rounded within 10% to meet a measurable volume.

B. A 3-day-old boy (2.8 kg) who is on a low concentration heparin drip to maintain his umbilical arterial catheter.

C. A 7-day-old premature female infant (1.5 kg) who is receiving gentamicin doses using a smart pump for infusion.

D. A 10-year-old girl (55 lb [24.9 kg]) started on an insulin drip for diabetic ketoacidosis.

E. A 12-year-old boy (34 kg) started on started on oxycodone for acute pain after surgery.

12. KT, an 18-month-old girl, swallowed some of her grandfather’s medications from his weekly pillbox. KT’s grandfather states that he is taking medications for blood pressure, sleep, and high cholesterol. He states that “she is a little

sleepy and not behaving like herself right now.” Which is the most appropriate action to manage the accidental ingestion for this child?

A. Administer ipecac syrup immediately and induce emesis until paramedics arrive B. Allow KT to “sleep off” the medication and contact her pediatrician tomorrow C. Direct her family to take KT to the emergency department and contact local/regional poison control center D. Give continuous oral fluids to dilute the medication’s effects E. Monitor the child’s blood pressure at home and go to the emergency department if it is too low 13. Which is false about medication use in pediatric patients?

A. Caregivers should be educated about measurement of liquid medication for each medication.

B. It is appropriate to recommend a tablet formulation for any child of age 5 years and younger.

C. Obtaining a child’s medication history should include prescription, over-the-counter, and complementary medications.

D. Suspendability, stability, uniformity, and palatability are important factors to consider when compounding a liquid formulation.

E. When using intravenous formulations, fluid status and comorbidities like congenital heart disease should be considered.

14. Which statement is false regarding complementary and alternative medicine (CAM) use in the pediatric population?

A. CAM is routinely disclosed in medication histories from parents/caregivers.

B. Common illnesses in which CAM may be used include cancer, asthma, and autism spectrum disorder.

C. Discussion of CAM use should be encouraged with parents/caregivers.

D. Drug interactions are possible with CAM use.

E. There are limited data regarding the use of ginger and echinacea in children.

15. Which statement is false regarding off-label use of medications: A. It includes use of a medication outside the licensed age range.

B. It is not permitted by law in the pediatric population due to lack of data.

C. It is based on limited data about the use in infants and children.

D. It is used in situations where there is no appropriate pediatric-approved alternative.

E. It includes dosing outside of those recommended by the manufacturer’s package insert.

Answers 1. E 2. A 3. C 4. B

5. C 6. B 7. D 8. D 9. E 10. C 11. D 12. C 13. B 14. A 15. B

CHAPTER 4. PALLIATIVE CARE 1. JP is being treated for lung cancer, and received his last chemotherapy infusion 3 weeks ago. He is currently reporting nausea and vomiting since he started taking morphine for his cancer-related pain. Which of the following antiemetics would be the best option to treat his uncontrolled nausea and vomiting?

A. Ondansetron B. Aprepitant C. Lorazepam D. Haloperidol E. Dolasetron 2. A patient diagnosed with advanced COPD is reporting dyspnea associated with thickened pulmonary secretions. The patient has a strong cough reflex and is adequately hydrated. Which of the following is the best option for this patient?

A. Oxygen therapy B. Low-dose oral morphine C. Scopolamine patches D. Nebulized saline E. Lorazepam 3. Delirium often presents gradually, with persistent decline in memory and global functioning.

A. True B. False 4. In a patient diagnosed with advanced heart failure, who is demonstrating excessive fluid overload symptoms, which of the following medication should be reduced or discontinued?

A. Digoxin B. Beta-adrenergic blocker C. Angiotensin-converting enzyme (ACE) inhibitor D. Loop diuretic E. Aspirin 5. Nausea secondary to gastroparesis is most appropriately treated by which of the following agents?

A. Lorazepam B. Haloperidol C. Metoclopramide D. Ondansteron E. Dolasteron 6. Which of the following adjuvant is often used in conjunction with standard opioid therapy for the treatment of severe bone pain?

A. Acetaminophen B. Corticosteroids C. Lorazepam D. Tricyclic antidepressants E. Alprazolam 7. Which of the following best describes the cause of death in patients diagnosed with

Lou Gehrig disease?

A. Opportunistic infections D. Anorexia E. Renal failure 8. A patient is eligible for the hospice Medicare benefit in the United States if they have a terminal diagnosis with of prognosis of less than: A. 1 month if the disease runs its usual course B. 3 months if the disease runs its usual course C. 6 months if the disease runs its usual course D. 12 months if the disease runs its usual course E. None of the above 9. Palliative care is considered appropriate care for which of the following: A. Breast cancer B. Chronic heart failure C. Alzheimer disease D. AIDS E. All of the above 10. Benzodiazepine as monotherapy in patients with delirium is the treatment of choice.

A. True B. False 11. The dose of short-acting opioids for the treatment of breakthrough pain should be equal to: A. 1%–2% of the daily maintenance dose B. 5%–20% of the daily maintenance dose C. 25%–35% of the daily maintenance dose D. Short-acting opioids should never be used in palliative care 12. Low-dose opioids may be effective in treating which of the following: A. Nausea B. Vomiting C. Dyspnea D. Terminal secretions 13. Due to questionable necessity of simvastatin therapy in hospice patients, this medication should be evaluated for discontinuation in end of life care.

A. True B. False 14. Which of the following agent(s) may be given sublingually?

A. Lorazepam B. Haloperidol C. Atropine D. All of the above 15. Methadone may be used to effectively manage which of the following?

A. Neuropathic pain B. Visceral pain C. Bone pain D. All of the above

Answers 1. D 2. D 3. B 4. B 5. C 6. B 7. B 8. C 9. E 10. False 11. B 12. C 13. A 14. D 15. D

CHAPTER 5. HYPERTENSION 1. A 55-year-old white man with seated office blood pressure (BP) readings of 144/92 mm Hg and 136/84 mm Hg is asked to return in 2 weeks for repeat measurements, which are 138/88 mm Hg and 134/82 mm Hg. Which of the following classifies DG’s BP per the American Society of Hypertension (ASH) and the International Society of Hypertension (ISH) joint Clinical Practice Guidelines for the Management of Hypertension in the Community?

A. Isolated systolic hypertension B. Stage 1 hypertension C. Prehypertension D. Optimal BP E. Stage 2 hypertension 2. Lupus-like syndrome is a possible side effect of which of the following drug(s)?

A. Clonidine B. Minoxidil C. Doxazosin D. Hydralazine E. Reserpine 3. A 55-year-old black woman has a history of left ventricular hypertrophy with a left ventricular ejection fraction of 55%. She has had hypertension for 10 years and is currently taking chlorthalidone 25 mg daily, metoprolol succinate 50 mg daily, and amlodipine 2.5 mg daily. Her averaged BP is 152/94 mm Hg with a heart rate of 54 beats/min. Her physical exam is unremarkable and basic metabolic panel reveals serum creatinine of 0.8 mg/dL [71 µmol/L] and potassium of 3.9 mEq/L (3.9 mmol/L). She reports allergies to fosinopril and aspirin. Which of the following represents the optimal course of action?

A. Increase amlodipine to 5 mg and have her take it at bedtime B. Increase metoprolol succinate to 100 mg daily C. Add lisinopril 5 mg daily D. Add spironolactone 50 mg daily E. A or B 4. A 34-year-old black man presents to your clinic with a BP of 160/94 mm Hg. Repeat readings over the next 2 weeks average 156/92 mm Hg. The patient has no past medical history with the exception of Crohn disease, which is currently treated with chronic steroid therapy. He is also taking an over-the-counter NSAID for ongoing back pain. Physical examination and laboratory tests are unremarkable.

Appropriate interventions at this time include: A. No intervention because patient most likely has drug-induced hypertension B. Discontinuation of the NSAID C. Reassessment of the dose and need for long-ter 5. A 68-year-old white man has resistant hypertension, prior myocardial infarction, and chronic kidney disease (CKD; serum creatinine 1.8 mg/dL [159 μmol/L], estimated creatinine clearance 40 mL/min [0.67 mL/s]). You are initiating ramipril today. What is the most appropriate timeframe for laboratory follow-up?

A. 1 to 2 days B. 1 to 2 weeks

C. 1 to 2 months D. 3 to 4 months E. 4 to 6 months 6. A 47-year-old Hispanic man has primary hypertension with an average BP of 172/98 mm Hg and heart rate of 70 beats/min. His most recent serum potassium is 4.5 mEq/L (4.5 mmol/L), serum creatinine is 1.1 mg/dL (97 µmol/L) and calculated creatinine clearance is 102 mL/min (1.70 mL/s). Which of the following antihypertensives would be most appropriate at this time?

A. Furosemide B. Atenolol C. Chlorthalidone and lisinopril initiated concurrently D. Amlodipine and lisinopril initiated concurrently E. C or D 7. A 67-year-old Asian man with a recent non-ST segment elevation MI (2 weeks ago) has an average BP of 148/86 mm Hg and a heart rate of 76 beats/min. Which of the following antihypertensive agents is preferred in this setting?

A. Metoprolol tartrate B. Acebutolol C. Hydrochlorothiazide D. Spironolactone E. A or B 8. Which of the following treatments is (are) the most appropriate for a hypertensive emergency?

A. Normalization of BP within hours B. Reduction in mean arterial pressure by 25% to 50% within minutes to hours C. Reduction in mean arterial pressure up to 25% within minutes to hours D. Administration of sublingual nifedipine E. C and D 9. A 65-year-old black man with history of hypertension, prior MI, and benign prostatic hypertrophy, is currently receiving amlodipine 5 mg QAM and metoprolol succinate 50 mg once daily. He has an average 24-hour Ambulatory Blood Pressure of 156/92 mm Hg and HR of 66 beats/min with notable nocturnal hypertension. He complains of nocturia but states that the swelling in his feet improved when his amlodipine dose was reduced. Which of the following presents the most clinically appropriate course of action?

A. Initiate tamsulosin 0.4 mg daily at bedtime B. Increase amlodipine to 10 mg daily and change to bedtime C. Increase metoprolol succinate to 50 mg twice daily D. Initiate chlorthalidone 50 mg daily at bedtime E. Initiate doxazosin 2 mg daily at bedtime 10. A 67-year-old black man has resistant hypertension. Past medical history is also significant for heart failure with left ventricular systolic dysfunction, dyslipidemia, and peripheral vascular disease. Medications currently include lisinopril, carvedilol, and furosemide. Current blood pressure is 146/88 mm Hg and when repeated 148/82 mm Hg. Which of the following additions to his medication regimen would be an inappropriate choice at this time?

A. Amlodipine B. Felodipine C. Hydralazine/Isosorbide Dinitrate D. Minoxidil E. Spironolactone 11. A 32-year-old woman is 20 weeks pregnant and has a history of gestational diabetes. She presents with an average BP of 154/96 mm Hg and a heart rate of 60 beats/min. Her laboratory results are remarkable for proteinuria, elevated serum uric acid, and low potassium. Which of the following presents the most appropriate course of action?

A. Closely monitor her BP and provide supportive care B. Start Losartan 50 mg daily while monitoring BP C. Start methyldopa 250 mg every 6 hours while monitoring BP D. Start labetalol 100 mg every 12 hours while monitoring BP E. Start chlorthalidone 25 mg daily while monitoring BP 12. A 45-year-old black man has a past medical history significant only for hypertension. Despite therapy with lisinopril 40 mg daily, hydrochlorothiazide 12.5 mg daily, and amlodipine 10 mg daily, his home and office BPs over the last 2 weeks remain elevated with an average reading of 154/92 mm Hg. All laboratory results are within normal limits. Which of the following would be a reasonable change to his antihypertensive regimen?

A. Replace hydrochlorothiazide with chlorthalidone 25 mg daily B. Add aliskiren 150 mg daily C. Add spironolactone 50 mg daily D. Add losartan 25 mg daily E. B or D 13. A 29-year-old woman has had stage 1 hypertension for the past 2 years that has been well controlled (BP range of 100–110/60–65 mm Hg) on lisinopril 10 mg once daily. She has successfully implemented lifestyle modifications, losing 14 kg (31 lb) and obtaining a body mass index of 21 kg/m2 . She informs you she is going to start trying to get pregnant. What changes should be instituted with her antihypertensive therapy at this time?

A. Discontinuing lisinopril and monitoring BP closely with lifestyle modifications B. Discontinuing lisinopril and initiating methyldopa C. Continuing lisinopril because her BP is well controlled D. Reducing lisinopril dose to 2.5 mg daily and maintaining lifestyle modifications E. Discontinuing lisinopril and starting HCTZ 14. A 57-year-old white woman has type 2 diabetes, morbid obesity, and hypertension. She is currently taking only lisinopril 20 mg daily and her office blood pressures are consistently at goal < 140/90 mm Hg, but her home readings are significantly higher. Which of the following is a possible explanation for her elevated home readings?

A. Her home BP cuff is too small B. She has white coat hypertension C. Her home BP cuff is too large

D. She checks her blood pressure immediately after exercise E. All of the above 15. A 56-year-old black woman is currently on verapamil ER 360 mg once daily. She has a past medical history of hypertension and atrial fibrillation. Today, her office BP readings are 137/97 mm Hg and 144/96 mm Hg with a heart rate of 60 beats/min.

Which of the following is the most appropriate intervention?

A. Add amlodipine 5 mg daily B. Increase verapamil ER to 360 mg twice daily C. Add chlorthalidone 12.5 mg daily D. Add lisinopril 5 mg daily E. Either C or D ANSWERS 1. C 2. D 3. A 4. E 5. B 6. E 7. A 8. C 9. E 10. D 11. C 12. A 13. A 14. A 15. E

CHAPTER 6. HEART FAILURE 1. Which of the following finding, when reduced, indicates impaired systolic function in a patient with heart failure?

A. BNP B. SCr C. LVEF D. LVH E. Troponin 2. What is the most common etiology of heart failure?

A. Ischemic B. Idiopathic, unknown cause C. Viral cardiomyopathy D. Drug-induced E. Hypertension Use the following to answer questions 3–5: A 58-year-old man presents to the clinic today with complaints of increasing shortness of breath while dressing and carrying groceries and a 10 lb (4.5 kg) weight gain. A few months prior, he noticed episodes of waking in the middle of the night with shortness of breath, difficulty breathing after walking two flights of stairs, as well as ankle edema. The patient has a history of osteoarthritis × 10 years, hypertension × 4 years, diabetes mellitus × 5 years, dyslipidemia, and is status post myocardial infarction 2 years ago.

Physical exam reveals the following: BP 148/96 mmHg, pulse 98 beats/min, Ht: 5’11’’ (180 cm), Wt: 189 lb (86 kg; usual = 178 lb [ (+) JVD, (−) HJR or hepatomegaly (+) S3, (+) S4 ECG: regular rate/rhythm, evidence of old infarct ECHO: EF 33% (0.33) CXR: Crackles bilaterally and cardiomegaly (enlarged heart) Labs: Sodium: 142 mE/L (142 mmol/L) Potassium: 3.7 mEq/L (3.7 mmol/L) Magnesium: 1.8 mEq/L (0.90 mmol/L) BUN: 22 mg/dL (7.9 mmol/L) SCr: 1.3 mg/dL (115 µmol/L) BNP: 322 pg/mL (322 ng/L; 93 pmol/L) Current medications: Aspirin 81 mg daily Diltiazem 180 mg daily Glipizide 10 mg twice daily for diabetes Simvastatin 20 mg nightly at bedtime Acetaminophen 500 mg twice daily 3. Which of the patient’s medications can exacerbate systolic dysfunction heart failure?

A. Glipizide B. Diltiazem C. Acetaminophen D. b and c

E. All of the above 4. Which of the following is TRUE regarding the patient’s current NYHA functional class and stage of heart failure?

A. Class III, Stage B B. Class III, Stage C C. Class II, Stage B D. Class II, Stage C E. Class IV, Stage C 5. Which of the following is the MOST appropriate ACUTE treatment plan for the patient’s heart failure?

A. Add HCTZ 12.5 mg Qday, since creatinine clearance is above 30 mL/min (0.5 mL/s) B. Add HCTZ 25 mg Qday, increase dose of diltiazem to 240 mg Qday C. Add furosemide 20 mg BID and nesiritide infusion since BNP is elevated D. Add furosemide 20 mg BID and lisinopril 10 mg Qday, discontinue diltiazem E. Add furosemide 20 mg BID, and carvedilol 3.125 mg twice daily, discontinue diltiazem 6. What is the medical term for the symptom of “feels short of breath when she lies down at night”?

A. Orthopnea B. Hepatojugular reflux C. Paroxysmal nocturnal dyspnea D. Pulmonary congestion E. Peripheral edema 7. Which of the following is TRUE regarding ACE inhibitors in heart failure?

A. Should be used mainly in severe heart failure, NYHA functional class IV B. Efficacy of ACE inhibitors is a class effect C. May be used in place of hydralazine and isosorbide dinitrate in cases of renal dysfunction D. Can be replaced by angiotensin receptor blockers if the patient has hyperkalemia E. Should be discontinued if creatinine clearance decreases by more than 10% 8. Which of the following is TRUE regarding β-blockers in heart failure?

A. Ideally should be started in setting of congestion to aid in diuresis B. FDA-approved agents include carvedilol and metoprolol succinate C. Metoprolol tartrate is more efficacious than carvedilol for heart failure D. Chronic β-blockade increases ventricular mass E. Metoprolol has more potent blood pressure lowering effects compared to carvedilol 9. A 74-year-old woman presents to clinic for heart failure follow-up. She is classified as NYHA FC II. Her blood pressure is 144/82 mm Hg, and most recent EF is 26% (0.26).

Her current medication regimen includes lisinopril 20 mg Qday, carvedilol 25 mg BID, digoxin 0.125 mg Qday, and furosemide 20 mg BID. Which of the following would be the BEST choice to add at this time?

A. Metolazone B. Hydralazine and isosorbide C. Spironolactone

D. Hydrochlorothiazide E. Valsartan 10. Mineralocorticoid receptor antagonists (or aldosterone receptor antagonists) have been shown to reduce mortality in patients with heart failure. Which of the following is TRUE about MRAs? A. Spironolactone leads more frequently to gynecomastia compared to eplerenone B. Associated with hypokalemia C. Can only be used in NYHA functional class IV D. Used after maximizing ACE inhibitors, β-blockers, and digoxin E. Added to loop diuretic when a patient is resistant to its effects to enhance removal of fluid 11. A 76-year-old man is admitted to the hospital presenting with peripheral and pulmonary edema, decreased urinary output, hypotension, and altered mental status. Pertinent values: PCWP = 32 mm Hg (4.3 kPa), Cardiac index (CI) = 1.8 L/min/m2 . Based on his presentation, what hemodynamic subset is he in?

A. I B. II C. III D. IV E. II and IV 12. Which of the following diuretic combinations is used for the purpose of reducing congestion in the setting of diuretic resistance?

A. Hydrochlorothiazide and spironolactone B. Spironolactone and torsemide C. Furosemide and spironolactone D. Furosemide and metolazone E. Nesiritide and spironolactone 13. A 68-year-old African American woman is admitted to the hospital for new onset acute decompensated heart failure. Her current medications include felodipine 2.5 mg Qday and atorvastatin 20 mg Qday. Hemodynamic readings include a PCWP of 16 (2.1 kPa) and a CI of 1.8 L/min/m2 . Which of the following is the MOST appropriate treatment plan?

A. Fluids, inotropes B. Diuretics, vasodilators C. Fluids, inotropes, vasodilators D. Diuretics, fluids, inotropes E. Diuretics, inotropes, vasodilators 14. Which of the following statements is most appropriate for patient counseling on nonpharmacologic management of heart failure?

A. Supervised exercise is recommended including aerobic activity and weight lifting B. Contact health care provider if weight increases by more than 3 lb (1.4 kg) in a day or 5 lb (2.3 kg) in a week C. Lower dietary sodium intake to no more than 2 grams per day D. Maintain alcohol intake to no more than 2 drinks per day if diagnosed with

alcohol-induced cardiomyopathy E. Weight should be kept at 15% above ideal body weight to maintain adequate nutrition absorption 15. A 68-year-old woman is admitted for decompensated heart failure, hemodynamic subset IV. Her current medication regimen includes enalapril 10 mg BID, digoxin 0.125 mg Qday, carvedilol 12.5 mg BID, furosemide 80 mg BID, and potassium chloride (K-Dur) 40 mEq (40 mmol) BID. Which of the following is TRUE regarding using milrinone therapy in this patient?

A. Milrinone can interact with her β-blocker therapy due to its β-agonist mechanism B. Effects begin to wear off after 72 hours due to tolerance C. Dose needs to be adjusted in renal dysfunction D. Milrinone is not appropriate to use in subset IV E. a and c ANSWER S 1. C 2. A 3. B 4. B 5. D 6. A 7. B 8. B 9. C 10. A 11. D 12. D 13. A 14. B 15. C

CHAPTER 7. ISCHEMIC HEART DISEASE 1. A 50-year-old, nonsmoking woman has no significant past medical history. A physical exam and laboratory tests reveal the following: Height 5’4” (163 cm), weight 184 lb (83.6 kg), blood pressure 134/80 mm Hg, heart rate 70 beats/min, total cholesterol 184 mg/dL (4.76 mmol/L), LDL cholesterol 110 mg/dL (2.84 mmol/L), HDL cholesterol 46 mg/dL (1.19 mmol/L), and triglycerides 140 mg/dL (1.58 mmol/L). Which of the following are risk factors for IHD in this patient?

A. Age, hypertension, dyslipidemia B. Obesity C. Age, dyslipidemia D. Obesity, hypertension E. Hypertension, dyslipidemia 2. Which of the following is characteristic of an atherosclerotic lesion in a patient with chronic stable angina?

A. Thick fibrous cap B. Thrombosis C. Large lipid core D. Plaque rupture E. Platelet aggregation 3. A 47-year-old man has been prescribed sublingual nitroglycerin tablets for acute relief of angina symptoms. When counseling him on the proper use of sublingual nitroglycerin, which of the following statements is correct regarding when to call 9-1-1?

A. Call 9-1-1 if symptoms have not subsided 5 minutes after administration B. Call 9-1-1 if symptoms have not subsided 30 minutes after administration C. Call 9-1-1 prior to taking nitroglycerin D. Take 1 tablet every 5 minutes as needed for a maximum of three doses; call 9-1-1 if symptoms remain 5 minutes after the third dose E. Take one tablet every 8 to 12 hours; call 9-1-1 if dizziness occurs 4. A 65-year-old postmenopausal woman has a history of hypertension, dyslipidemia, and chronic stable angina. Her current medications are atenolol 50 mg PO daily, simvastatin 40 mg PO at bedtime, and SL nitroglycerin as needed. She has allergies/intolerances to aspirin (angioedema) and enalapril (cough). Which of the following should be added to her drug regimen to reduce her risk for cardiovascular events?

A. clopidogrel B. dipyridamole C. niacin D. nifedipine E. ticagrelor 5. A 45-year-old man diagnosed with hypertension, diabetes, and IHD was recently hospitalized for unstable angina. A coronary angiogram performed during hospitalization revealed single vessel disease not amenable to PCI. He is currently taking carvedilol 6.25 mg PO twice daily, lisinopril 10 mg PO daily, and metformin 500 mg PO twice daily. His blood pressure is 126/78 mm Hg and heart rate is 62 beats/min. A fasting lipid profile shows the following: LDL cholesterol 127 mg/dL (3.28 mmol/L), HDL cholesterol 36 mg/dL (0.93 mmol/L), and triglycerides 157 mg/dL (1.77 mmol/L). He is a current smoker. What additional therapy should be considered to treat this patient’s IHD and lower his risk of ischemic events?

A. Add low-intensity statin (eg, pravastatin 20 mg/day).

B. Add moderate-intensity statin (eg, lovastatin 40 mg/day) C. Add high-intensity statin (eg, atorvastatin 80 mg/day) D. Add prasugrel E. Add varenicline 6. A 53-year-old woman with a history of hypertension and dyslipidemia undergoes a thorough cardiac workup for new onset chest tightness and shortness of breath on exertion. A cardiac catheterization shows no significant coronary artery obstruction. She is believed to have microvascular disease. Her blood pressure is 148/90 mm Hg and heart rate is 74 beats/min. Her current medications include benazepril 10 mg PO daily and simvastatin 40 mg PO hs. What is the most appropriate therapy to manage her angina symptoms?

A. Increase benazepril to 20 mg daily B. Add metoprolol C. Add aspirin D. Add doxazosin E. Add hydralazine 7. What is the recommended treatment duration of dual antiplatelet therapy following implantation of a drug eluting stent?

A. 1 week B. 1 month C. 3 months D. 6 months E. At least 12 months 8. A 60-year-old obese woman with hypertension and dyslipidemia is being started on ranolazine for microvascular angina. Her current medications include aspirin 81 mg/day, lisinopril 10 mg daily, metoprolol 50 mg twice daily, and simvastatin 40 mg/day. A fasting lipid profile reveals the following: LDL cholesterol 65 mg/dL (1.68 mmol/L), HDL cholesterol 54 mg/dL (1.40 mmol/L), and triglycerides 108 mg/dL (1.22 mmol/L). What changes, if any, should be made to her statin regimen?

A. Change to a low-intensity statin (eg, pravastatin 20 mg/day) B. Change to a high-intensity statin (eg, rosuvastatin 20 mg/day.

C. Continue simvastatin 40 mg/day D. Reduce the dose of simvastatin to 20 mg/day E. Increase the dose of simvastatin to 80 mg/day 9. A 58-year-old woman with hypertension and coronary artery disease underwent percutaneous coronary intervention with placement of two drug eluting stents one week ago. Genotyping is done and reveals that she has the CYP2C19 poor metabolizer phenotype. Which of the following is the most appropriate antiplatelet therapy for this patient?

A. Clopidogrel plus aspirin B. Clopidogrel plus prasugrel C. Prasugrel plus aspirin D. High dose aspirin E. Dipyridamole plus aspirin 10. A 56-year-old woman was recently diagnosed with ischemic heart disease. Her current medications include conjugated estrogen 0.625 mg/day, fish oil 1 gm twice daily, aspirin 81 mg daily, atenolol 100 mg daily, lisinopril 20 mg daily, and rosuvastatin 20 mg daily. Which of the

following changes to the patient’s regimen are appropriate?

A. Add clopidogrel B. Add vitamin E C. Change rosuvastatin to pravastatin D. Discontinue conjugated estrogen E. Discontinue fish oil 11. A 60-year-old man with a history of hypertension, diabetes, and dyslipidemia is being treated with lisinopril 10 mg PO daily, simvastatin 20 mg PO daily, and metformin XR PO 500 mg daily. His current blood pressure is 150/88 mm Hg and heart rate is 80 beats/min. He presents with complaints of chest pressure and shortness of breath occurring with exertion. He is diagnosed with variant angina. In addition to sublingual nitroglycerin, what is the most appropriate change to his drug therapy?

A. Add amlodipine B. Add isosorbide mononitrate C. Add metoprolol D. Add ranolazine E. Add thiazide diuretic (eg, chlorthalidone) 12. A 55-year-old man with a history of dyslipidemia and ischemic heart disease had a myocardial infarction 3 months ago. His current medications are aspirin 81 mg PO once daily, metoprolol XL 200 mg PO daily, simvastatin 40 mg PO at bedtime, and sublingual nitroglycerin as needed. He continues to experience occasional symptoms of angina with exertion. His blood pressure is 124/70 mm Hg, and his pulse is 60 beats/min. What is the most appropriate pharmacologic intervention?

A. Taper off metoprolol and start verapamil B. Add isosorbide mononitrate C. Taper off metoprolol and start nifedipine D. Add diltiazem E. Switch metoprolol to atenolol 13. A 63-year-old woman with a past medical history of dyslipidemia and chronic stable angina treated with aspirin 81 mg PO once daily, atenolol 100 mg PO once daily, simvastatin 40 mg PO once daily, and sublingual nitroglycerin as needed. Her angina symptoms are currently well controlled. Her blood pressure is 148/90 mm Hg, and her pulse is 70 beats/min. What is the most appropriate addition to therapy to improve the management of this patient’s ischemic heart disease?

A. ramipril B. isosorbide dinitrate C. ranolazine D. verapamil E. bupropion 14. A 59-year-old man has a history of hypertension, dyslipidemia, ischemic heart disease, and pulmonary hypertension. He is currently taking aspirin 81 mg PO daily, atorvastatin 40 mg PO daily, ramipril 5 mg PO daily, metoprolol XL 100 mg PO daily, and sildenafil 20 mg PO thrice daily. His blood pressure is 102/76 mm Hg and heart rate is 60 beats/min. He continues to experience ischemic symptoms with minimal exertion. What is the most appropriate addition to therapy to improve the management of this patient’s ischemic heart disease?

A. Add felodipine

B. Add isosorbide mononitrate C. Add ranolazine D. Decrease metoprolol XL to 50 mg daily E. Increase metoprolol XL to 200 mg daily 15. A 68-year-old man with a history of hypertension, dyslipidemia, and chronic obstructive pulmonary disease was recently diagnosed with chronic stable angina. His current medications are chlorthalidone 25 mg PO daily, atorvastatin 40 mg PO at bedtime, salmeterol one inhalation every 12 hours, fluticasone MDI two puffs twice a day, and albuterol MDI one to two puffs every 4 hours prn. His vital signs are a heart rate of 86 beats/min and blood pressure of 150/90 mm Hg. In addition to sublingual nitroglycerin, what is the most appropriate change to his drug therapy?

A. Start propranolol B. Start ranolazine C. Start amlodipine D. Start isosorbide mononitrate E. Start verapamil ANSWERS 1. B 2. A 3. A 4. A 5. C 6. B 7. E 8. D 9. C 10. D 11. A 12. B 13. A 14. C 15. E

CHAPTER 8. ACUTE CORONARY SYNDROMES 1. A 68-year-old man with a history of ischemic heart disease develops severe chest pain (8/10 on a pain scale) with subsequent ECG depression in leads II, III, and aVF. Serum creatinine is 1.0 mg/dL (88 µmol/L) and troponin I is 3.4 ng/mL (3.4 mcg/L; 3400 ng/L). Which of the following differentiates MI from UA in this patient?

A. Location of the coronary artery blockade B. Quality of chest discomfort C. Severity of coronary artery disease D. Elevated plasma troponin concentration E. ECG changes 2. A 76-year-old man with prior history of coronary artery disease, hypertension, hyperlipidemia and stroke is found to have STEMI and receives a DES. Which dual antiplatelet regimen is most appropriate for him to receive at time of discharge?

A. Aspirin 325 mg and clopidogrel 75 mg daily B. Aspirin 325 mg and ticagrelor 90 mg twice daily C. Aspirin 325 mg and prasugrel 10 mg daily D. Aspirin 81 mg and prasugrel 10 mg daily E. Aspirin 81 mg and ticagrelor 90 mg twice daily 3. An 82-year-old man with STEMI was brought by ambulance to a small community hospital during nighttime (offpeak) hours. The nearest hospital with operating catheterization facilities is a 2.5-hour distance away. Which of the following addresses the appropriate reperfusion for this patient?

A. Fibrinolytic therapy B. An early invasive strategy C. A delayed invasive strategy D. An ischemia-guided approach E. A percutaneous strategy 4. A 54-year-old woman with a CrCl of 20 ml/min (0.33 mL/s) is being treated for ACS by utilizing an ischemiaguided strategy. In addition to aspirin 81 mg daily, which of the following medication combinations is most appropriate in this patient?

A. Clopidogrel, UFH, abciximab B Ticagrelor, enoxaparin, eptifibatide C. Prasugrel, fondaparinux D. Ticagrelor, UFH E. Clopidogrel, bivalirudin, tirofiban 5. A 62-kg (137-lb) man with CrCl of 55 mL/min (0.92 mL/s) is found to have a NSTE-ACS. Troponin levels, drawn at three separate intervals, are all negative. Which of the following is the preferred antithrombotic regimen, in addition to ASA and clopidogrel if an ischemia-guided strategy is chosen?

A. UFH infusion and eptifibatide IV infusion 2 mcg/kg/min B. Enoxaparin 60-mg SC twice daily C. Bivalirudin bolus plus infusion

D. Fondaparinux 2.5 mg SC twice daily E. Bivalirudin bolus plus eptifibatide IV infusion 2 mcg/kg/min 6. A 45-year-old patient with STEMI presents to a hospital without the capacity to perform primary PCI. It has been 2 hours since the onset of chest discomfort with BP mcg/L; 10,800 ng/L). In addition to ASA and IV NTG which early therapy option would be best to start within the first 24 hours to treat symptoms, and prevent long term complications?

A. Clopidogrel, enoxaparin, ramipril, reteplase B. Clopidogrel, enoxaparin, tenecteplase C. Reteplase, UFH, metoprolol, enalapril D. Tenecteplase, bivalirudin, metoprolol E. Alteplase, bivalirudin, lisinopril 7. Which of the following is a contraindication to eplerenone in a patient with heart failure following MI? A. EF less than 40% (0.40) B. Persistent angina C. Angioedema to an ACE inhibitor D. Serum potassium of 5.6 mEq/L (5.6 mmol/L) E. Heart rate less than 60 beats/min 8. Which of the following represents the most appropriate antiplatelet regimen in a 55-year-old patient (weight 70 kg [154 lb]) administered tenecteplase 2 hours previously for STEMI? A. 600-mg clopidogrel loading dose, followed by 75 mg daily B. 300-mg clopidogrel loading dose, followed by 75 mg daily C. No clopidogrel load, followed by 75 mg daily D. 60-mg prasugrel loading dose, followed by 5 mg daily E. 60-mg prasugrel loading dose, followed by 10 mg daily 9. Which of the following patients is most likely to receive the most benefit from a GPI? A. A 47-year-old diabetic man with STEMI undergoing primary PCI receiving ticagrelor B A 68-year-old man with NSTE-ACS undergoing PCI receiving bivalirudin and prasugrel C. A 60-year-old woman with negative troponins, receiving clopidogrel D. An 82-year-old man with positive troponins, receiving ticagrelor E. A 53-year-old woman with positive troponins, receiving heparin 10. Which of the following anticoagulants is preferred for PCI in a patient with a history of heparin-induced thrombocytopenia and ACS? A. UFH B. Enoxaparin C. Bivalirudin D. Fondaparinux E. Dalteparin 11. Which of the following is the correct coagulation monitoring goal for a patient with ACS receiving enoxaparin?

A. Activated partial thromboplastin time (aPTT) 2.0 to 3.0 times control B. aPTT 50 to 70 seconds C. Activated clotting time less than 32 seconds

D. Anti-Xa levels greater than 1.5 IU/mL (1.5 kIU/L) E. No coagulation goal recommended 12. Which of the following best describes a patient with ACS who is a candidate for treatment with amlodipine added to β-blocker?

A. Continued chest discomfort despite nitrates and atenolol B. Acute heart failure while receiving metoprolol C. HR of 80 bpm and BP of 150/90 mm Hg while receiving low-dose metoprolol and enalapril D. Stable chronic obstructive pulmonary disease receiving a low-dose atenolol E. Contraindication to metoprolol receiving diltiazem 13. In patients undergoing coronary artery bypass graft (CABG) surgery, which of the following is a preferred antithrombotic strategy in addition to aspirin?

A. UFH, discontinue prasugrel 5 days prior to surgery B. Eptifibatide, discontinue clopidogrel 7 days prior to surgery C. UFH, discontinue ticagrelor 5 days prior to surgery D. Fondaparinux, discontinue clopidogrel 5 days prior to surgery E. Bivalirudin, discontinue prasugrel 24 hours prior to surgery 14. Which anticoagulant regimen would be most appropriate for a 76-year-old woman (weight 64 kg [141 lb]) with NSTE-ACS with an estimated CrCl of 50 ml/min (0.83 mL/s) undergoing PCI? A. UFH 3800 unit bolus, followed by 800 units/hour B. Enoxaparin 140-mg SC twice daily C. Fondaparinux 2.5-mg SC daily D. Bivalirudin 24.5-mg bolus, followed by 35 mg/kg/hour infusion E. No anticoagulant needed 15. Secondary interventions proven to reduce risk after ACS include all the following except: A. Pneumococcal vaccination in age older than 65 years B. Cardiac rehabilitation C. Nonsteroidal anti-inflammatory agents D. Cholesterol management E. Dual antiplatelet therapy ANSWERS 1. D 2. E 3. A 4. D 5. B 6. B 7. D 8. B 9. E 10. C 11. E 12. A 13. C 14. A 15. C

CHAPTER 9. ARRHYTHMIAS 1. Where in the heart is the atrioventricular (AV) node located?

A. High right atrium B. Low right atrium C. Junction of the atria and ventricles D. High right ventricle 2. Which phase of the ventricular action potential is most likely to be altered by a sodium channel blocking drug?

A. Phase 0 B. Phase 1 C. Phase 2 D. Phase 3 3. Which one of the following ECG intervals or durations corresponds most closely to phase 3 on the ventricular action potential?

A. PR interval B. QRS complex C. QT interval D. T wave 4. Which one of the following arrhythmias increases the risk of stroke two- to sevenfold?

A. Atrial fibrillation (AF) B. Paroxysmal supraventricular tachycardia (PSVT) C. Ventricular premature depolarizations (VPDs) Arrhythmias 2 D. Ventricular tachycardia (VT) 5. Which one of the following most accurately describes the mechanism of AF? A. Increased automaticity in the atria, triggering a single atrial reentrant circuit B. Increased automaticity in the atria, triggering multiple simultaneous atrial reentrant circuits C. Increased automaticity in the pulmonary veins, triggering a single atrial reentrant circuit D. Increased automaticity in the pulmonary veins, triggering multiple simultaneous atrial reentrant circuits 6. Which one of the following most accurately describes the mechanism of PSVT? A. A single reentrant circuit in the atrium B. Multiple simultaneous reentrant circuits in the atria C. Reentry involving the AV node D. Reentry occurring in the ventricles 7. Which of the following is the common myocardial pathology associated with hypertension, ischemic heart disease, heart failure, and valve disease that promotes the electrophysiological alterations that result in atrial fibrillation?

A. Fibrosis of the SA node B. Fibrosis of the AV node C. Left atrial hypertrophy D. Left ventricular hypertrophy 8. A 66-year-old man presents to the ED complaining of palpitations, dizziness, lightheadedness, and near-syncope. Past medical history is significant for hypertension for 10 years.

ECG reveals an irregularly irregular rhythm with no visible P waves and an undulating baseline.

Arrhythmias 3

His blood pressure in the ED is 99/63 mm Hg, and his heart rate is 125 beats/min. Which one of the following is the most appropriate treatment?

A. Immediate direct current cardioversion B. Amiodarone 300 mg IV administered over 1 hour C. Digoxin 0.25 mg IV, repeated every 2 hours up to a total dose of 1.5 mg D. Metoprolol 5 mg IV administered over 2 minutes 9. A 58-year-old woman presents to the ED complaining of dizziness. ECG reveals an irregularly irregular rhythm with no visible P waves and an undulating baseline. She has a past medical history of hypertension and heart failure (left ventricular ejection fraction 30% [0.30]). Her blood pressure in the ED is 105/65 mm Hg, and her heart rate is 145 beats/min. Which one of the following is the most appropriate treatment?

A. Immediate direct current cardioversion B. Amiodarone 300 mg IV administered over 1 hour C. Digoxin 0.25 mg IV, repeated every 2 hours up to a total dose of 1.5 mg D. Diltiazem 0.25 mg/kg IV bolus followed by 5 mg/hour IV continuous infusion 10. A 58-year-old woman presents to the ED complaining of dizziness and crushing chest pain.

ECG reveals an irregularly irregular rhythm with no visible P waves and an undulating baseline.

She has a past medical history of hypertension and heart failure (left ventricular ejection fraction 25% [0.25]). Her blood pressure in the ED is 85/65 mm Hg, and her heart rate is 160 beats/min.

Which one of the following is the most appropriate treatment?

A. Immediate direct current cardioversion B. Amiodarone 300 mg IV administered over 1 hour C. Digoxin 0.25 mg IV, repeated every 2 hours up to a total dose of 1.5 mg Arrhythmias 4 D. Diltiazem 0.25 mg/kg IV bolus followed by 5 mg/hour IV continuous infusion 11. A 56-year-old woman has paroxysmal atrial fibrillation and a history of hypertension. A recent exercise–stress test revealed no chest pain or evidence of ischemic changes on ECG, and she has no evidence of heart failure. She is currently receiving the maximum dose of the appropriate drug for ventricular rate control; however, she continues to complain of palpitations and dizziness approximately twice weekly, and these episodes last for approximately 3 to 4 hours. Which one of the following is the most appropriate therapy at this time?

A. Amiodarone B. Catheter ablation C. Procainamide D. No additional drug therapy is indicated 12. A 65-year-old man has a past medical history of hypertension and coronary artery disease, for which he is currently receiving hydrochlorothiazide 25 mg daily, enalapril 10 mg twice daily, and amlodipine 10 mg daily. He presents to his physician complaining of intermittent palpitations and light-headedness. An ambulatory ECG reveals 6 to 10 ventricular premature depolarizations per hour, intermittent couplets, and a heart rate of 82 beats/min. Which one of the following is the most appropriate course of action?

A. Amiodarone 400 mg daily B. Flecainide 150 mg every 12 hours C. Metoprolol 50 mg twice daily D. No treatment should be initiated Arrhythmias 5

13. A 65-year-old man was admitted to the cardiac intensive care unit today with an exacerbation of heart failure due to a hypertensive crisis. Echocardiogram reveals a left ventricular ejection fraction of 35% [0.35]. He also has a past history of hypertension and dyslipidemia. While in the cardiac intensive care unit, the patient complains of palpitations and light-headedness, and his blood pressure is 105/70 mm Hg. ECG reveals ventricular tachycardia at a rate of 125 beats/min, which lasts longer than 30 seconds and does not terminate on its own. Which one of the following is the most appropriate treatment?

A. No treatment is necessary B. Intravenous amiodarone C. Intravenous procainamide D. Immediate direct current cardioversion 14. Which one of the following best describes the role of drug therapy in patients with ventricular fibrillation?

A. Drugs cause termination of ventricular fibrillation and return of spontaneous circulation B. Drugs convert ventricular fibrillation into ventricular tachycardia, which can then be terminated by direct current cardioversion C. Drugs improve the likelihood of success of electrical defibrillation, but alone do not terminate ventricular fibrillation D. Drugs remove the need for cardiopulmonary resuscitation 15. Which one of the following is a risk factor for drug-induced torsades de pointes?

A. Age older than 55 years B. Female sex C. Hypertension Arrhythmias 6 D. Chronic obstructive pulmonary disease Arrhythmias 7 ANSWERS 1. B 2. A 3. D 4. A 5.

D 6. C 7. C 8. D 9. C 10. A 11.

B 12. C 13. B 14. C 15. B

CHAPTER 10. VENOUS THROMBOEMBOLISM 1. A 42-year-old Asian woman just returned from vacation in Ethiopia. She presents to the emergency department (ED) with shortness of breath and is subsequently diagnosed with pulmonary embolism (PE). She weighs 45 kg (100 lb; body mass index [BMI] 19 kg/m2 ).

Medications on admission include: estrogen-containing oral contraceptives, ibuprofen (prn), and ginseng tablets. She smokes one pack of cigarettes per day and drinks alcoholic beverages three to four times per week. Her sister died (age 41) of PE 4 years ago. The factors that most likely predisposed this patient for venous thromboembolism (VTE) include: A. Age, ibuprofen use, smoking B. Female sex, foreign travel, weight C. Asian ancestry, ginseng use, regular alcohol consumption D. Recent immobility, estrogen use, inherited disorder of hypercoagulability 2. The following is a recommended risk assessment model for estimating VTE risk specific to hospitalized medical patients: A. The CAPRINI Risk Prediction Score B. The WELLS Risk Prediction Score C. The PADUA Risk Prediction Score D. The PESCI Risk Prediction Score 3. Which VTE prevention strategy is the most appropriate for a 61-year-old patient who is undergoing a knee replacement surgery tomorrow, weighs 94 kg (207 lb), has an estimated creatinine clearance of 58 mL/min (0.97 mL/s), and has no known contraindications to anticoagulant drugs?

A. Rivaroxaban 15 mg given orally every 12 hours B. Fondaparinux 2.5 mg given SC every 24 hours C. Aspirin 81 mg given orally every 24 hours D. Early ambulation combined with graduated compression stockings (GCS) 4. Which of the following prophylactic strategies is most appropriate for a 62-year-old patient who is admitted to hospital with left-sided paralysis following an acute hemorrhagic stroke?

A. GCS B. Early ambulation C. Inferior vena cava (IVC) filter D. Intermittent pneumatic compression (IPC) 5. Which of the following anticoagulants would be an appropriate option as single therapy for the initial acute-phase treatment of patients diagnosed with acute lower extremity DVT? A. Apixaban B. Dabigatran C. Desirudin D. Warfarin 6. A patient is diagnosed with a left lower extremity deep vein thrombosis (DVT) and is initiated on intravenous unfractionated heparin (UFH) and warfarin therapy concurrently. How long should UFH and warfarin be overlapped?

A. For at least 4 days as long as the aPTT is greater than 50 seconds for 3 days B. For at least 5 days and only after the INR is greater than 2 C. For 7 days or until the INR is greater than 2.5 D. UFH can be discontinued once the aPTT is greater than 75 seconds, regardless of the length

of therapy 7. A patient had hip replacement surgery 2 weeks ago. He now presents with a right lower extremity DVT. He is admitted to the hospital for anticoagulation treatment. Following surgery, he received dalteparin 5000 units SC daily for 10 days. It was noted that his platelet count dropped from 390 × 103 /mm3 (390 × 109 /L) following the surgery to 160 × 103 /mm3 (160 × 109 /L) on the day of discharge. He has no previous history of thromboembolic events. Which of the following treatment options would be the best recommendation in this patient’s case?

A. Warfarin should be started now and continued for 6 months.

B. Unfractionated heparin (UFH) and warfarin should be started now and continued for 3 months.

C. Enoxaparin should be started now and the patient should be evaluated for thrombotic thrombocytopenic purpura.

D. Fondaparinux should be started now and the patient should be evaluated for heparin-induced thrombocytopenia.

8. The following statement is TRUE regarding drug interactions with the novel oral anticoagulants in patients with normal renal function: A. Avoid use of Rivaroxaban with combined strong CYP3A4 inhibitors and P-glycoprotein inhibitors B. Avoid use of Rivaroxaban with combined moderate CYP3A4 inhibitors and P-glycoprotein inhibitors C. Avoid use of Dabigatran with combined strong CYP3A4 inhibitors and P-glycoprotein inhibitors D. Avoid use of Dabigatran with combined moderate CYP3A4 inhibitors and P-glycoprotein inhibitors 9. In patients presenting with acute PE, thrombolytic therapy is recommended if: A. The patient has palpitations and hemoptysis B. Started within 4 hours of when patient first experiences symptoms C. The patient appears to be in shock (eg, systolic blood pressure < 90 mm Hg) D. The patient has elevated D-dimer concentration > 1000 ng/mL (1000 mcg/L) 10. A 47-year-old Caucasian man is being treated with warfarin 5 mg daily for PE diagnosed 6 weeks ago. Today, he presents to clinic for an INR check and is found to have an INR of 11.7.

His CBC is normal, and he has no complaints or signs/symptoms of bleeding. You take the following approach to manage his INR: A. Hold his warfarin until INR < 2 and then resume warfarin at 5 mg daily B. Give vitamin K 2.5 mg PO and hold his warfarin until INR < 2, then resume warfarin at 5 mg daily C. Give Vitamin K 2.5 mg IV and hold his warfarin until INR < 2, then resume warfarin at 5 mg daily D. Give Vitamin K 10 mg IV and admit patient to the hospital until INR < 2, then resume warfarin at 5 mg daily

11. An 82-year-old man was admitted to hospital and recently diagnosed with acute DVT. Treatment has been initiated with intravenous UFH. Twelve hours later, his aPTT is greater than 150 seconds and he is noted to have bright red blood per rectum. Which of the following is the best course of action in the management of this patient?

A. Hold heparin therapy for 60 minutes and then reduce infusion rate by 20% B. Hold heparin therapy and give vitamin K via slow IV infusion C. Hold heparin therapy and give recombinant factor VII D. Hold heparin therapy and give protamine sulfate via slow IV infusion 12. A 29-year-old woman is admitted for acute DVT. She reports that she had a PE last year, 2 weeks following the birth of her daughter. She was treated with enoxaparin and warfarin for 3 months. Her symptoms completely resolved. What is the recommended duration of anticoagulation therapy in this case now?

A. 3 months and then reevaluate risks and benefits B. 6 months and then discontinue C. 12 months and then reduce the dose by 50% for an additional 2 years D. Lifelong 13. Which of the following is the most appropriate treatment for a pregnant patient (first trimester) with a newly diagnosed acute PE? A. Enoxaparin SC 1 mg/kg twice daily B. Fondaparinux SC 2.5 mg daily C. UFH SC 333 units/kg followed by 250 units/kg twice daily D. Warfarin dose adjusted to achieve an INR goal of 2 to 3 14. Which of the following is the most appropriate initial treatment option in a patient with an acute DVT and a documented history of heparin-induced thrombocytopenia (HIT) 7 months ago but no history of prior VTE? A. Clopidogrel B. Dabigatran C. Dalteparin D. Warfarin 15. Which of the following statements accurately describes a potential advantage of the direct oral anticoagulants (apixaban, dabigatran, rivaroxaban) over warfarin in the treatment of VTE? A. More patients are able to tolerate the direct oral anticoagulants than warfarin.

B. Adherence with direct oral anticoagulants is 20%–30% better than adherence to warfarin.

C. When bleeding occurs, direct oral anticoagulants are more easily reversed than warfarin.

D. The onset of anticoagulant activity is more rapid with direct oral anticoagulants when compared to warfarin.

ANSWERS 1. D 2. C 3. B 4. D 5. A 6. B 7. D 8. A 9. C

10. B 11. D 12. A 13. A 14. B 15. D CHAPTER 11. STROKE 1. Which one of the following is true regarding the use of heparin and low–molecular weight heparins (LMWHs) in acute ischemic stroke?

A. Should be used emergently in all patients B. Increase the risk of hemorrhagic conversion C. Should be administered preferentially instead of IV alteplase D. Improve outcomes in most patients if dosed properly E. Should be used in the acute setting if IV alteplase is not an option 2. A 62-year-old Hispanic woman had a stroke 2 years ago. She presents to clinic complaining of several episodes of “not being able to get the words out” over the past 2 days. She has had gastrointestinal upset with ASA in the past and is currently being treated for peripheral arterial disease and arthritis. Which one of the following medications would be the most appropriate for stroke prevention in this patient?

A. Ticlopidine 250 mg twice daily B. Clopidogrel 75 mg daily C. ASA and ER dipyridamole 25/200 mg twice daily D. ASA 50 mg daily E. No treatment is necessary 3. A 64-year-old African American woman with a history of ischemic stroke several months ago was previously prescribed ASA 325 mg daily, but developed an allergy to ASA and stopped taking it 2 weeks ago. Which one of the following is the most appropriate recommendation at this time?

A. Make no change at this time B. Change the ASA dose from 325 mg daily to 50 mg daily C. Discontinue ASA and begin clopidogrel 75 mg daily D. Restart ASA 325 mg every other day E. Discontinue ASA and begin ticlopidine 250 mg twice daily 4. Which one of the following is the most important diagnostic test for ischemic and hemorrhagic stroke?

A. Carotid Doppler studies B. Transthoracic echocardiogram C. Transcranial Doppler D. CT scan of the head E. MRI of the neck 5. A 68-year-old male patient is admitted to the acute stroke unit for IV alteplase approximately 2.5 hours after his symptoms began. His blood pressure is 198/115 mm Hg on admission to the acute stroke unit. Which one of the following is the appropriate treatment at this time?

A. Administer IV alteplase immediately using recommended dosing B. Administer labetalol 10 mg IV and recheck BP in 10 minutes C. Hold IV alteplase and recheck BP in 30 minutes

D. Hold IV alteplase and complete a full neurologic examination E. Hold IV alteplase as patient is not an appropriate candidate for treatment 6. A 64-year-old African American man is diagnosed with ischemic stroke. He was taking ASA 81 mg daily at the time of his ischemic stroke and claims he never missed a dose. Which one of the following recommendations would be most appropriate for prevention of a recurrent stroke?

A. Continue aspirin; however, increase the dose to 325 mg po BID B. Continue his current aspirin regimen C. Discontinue aspirin and start clopidogrel 75 mg po daily D. Discontinue aspirin and start dipyridamole 100 mg po QID E. Discontinue aspirin and start warfarin with an INR goal of 2–3 7. A 54-year-old white woman has diabetes, hypertension and dyslipidemia. She gets little activity during her working hours as an administrative assistant and eats a normal diet. Which one of the following represents her combination of risk factors for stroke?

A. Inactivity, age, race, poor diet B. Hypertension, dyslipidemia C. Hypertension, dyslipidemia, race, gender D. Hypertension, dyslipidemia, diabetes, inactivity E. Hypertension, diabetes, gender 8. Carotid endarterectomy is recommended in which one of the following situations?

A.57-year-old man with symptomatic carotid artery occlusion of 47% B.73-year-old man with recent stroke and symptomatic carotid artery occlusion of 70% C.83-year-old woman with asymptomatic carotid artery occlusion of 65% D.62-year-old woman with asymptomatic carotid artery occlusion of 47% E.78-year-old man with high operative risk and symptomatic carotid artery occlusion of 65% 9. Recombinant factor VIIa has been studied in clinical trials of patients with ICH. Which one of the following is true regarding this agent?

A. Shown to increase mortality at 90 days B. Shown to decrease overall functioning at 90 days C. Increased the incidence of thromboembolic events D. Improved patient survival E. Improved functional outcome 10.Which of the following are risk factors for both ischemic stroke and hemorrhagic stroke?

A. Hypertension, cigarette smoking, male gender B. Cocaine use, arteriovenous malformation C. Trauma, hypertension, cigarette smoking D. Male gender, trauma E. Cocaine use, cigarette smoking, trauma 11.An 84-year-old woman with a history of TIAs and ischemic stroke experiences difficulty speaking that lasts over 2 hours. She presents acutely to the ED 3.5 hours after her symptoms started. She is currently on aspirin 81 mg daily. Which one of the following is a contraindication to alteplase therapy for this patient?

A. Symptoms started greater than 3 hours ago B. History of TIAs C. History of aspirin use D. Age more than 80 years old E. History of previous ischemic stroke

12. Of the following, who would have the highest risk for an ischemic stroke?

A. 35-year-old pregnant woman B. 69-year-old Japanese man C. 72-year-old Caucasian woman D. 52-year-old African American woman E. 80-year-old African American man 13.A patient is brought in to the emergency department with suspected ischemic stroke. His symptoms started approximately 3 hours ago. Which one of the following is true regarding the use of alteplase in this patient?

A. It is too late to administer alteplase as the first hour after symptom onset is past.

B. Alteplase would need to be administered within the next 1.5 hours if the patient is found to be a candidate for treatment.

C. Alteplase must be administered within 6 hours of symptom onset.

D. Alteplase must be administered within 12 hours of symptom onset.

E. Alteplase is only used within the first 90 minutes after symptom onset.

14. A 63-year-old African American woman is being discharged after a stroke. She has a history of hypertension, dyslipidemia and smoking. Which one of the following discharge plans is appropriate?

A. Blood pressure control, statin therapy, referral to smoking cessation program, aspirin B. Blood pressure control, statin therapy C. Statin therapy, referral to smoking cessation program, aspirin D. Referral to a smoking cessation program E. Blood pressure control 15.Vasospasm is a complication of subarachnoid hemorrhage. Which one of the following is the drug of choice to decrease morbidity secondary to vasospasm?

A. Nifedipine B. Aminocaproic acid C. Nimodipine D. Diltiazem E. Labetalol ANSWERS 1. B 2.B 3. C 4. D 5. B 6. C 7. D 8. B 9. C 10.A 11.D 12.E 13.B 14. A 15.C

CHAPTER 12. DYSLIPIDEMIAS 1. A 38-year-old woman presents to your clinic today with new onset chest pain that occurs after walking a few blocks. Her father had a heart attack at age 40. Her diet is low in saturated fats and cholesterol. The patient is otherwise healthy and does not smoke. Her lipid panel today is: total cholesterol 350 mg/dL (9.05 mmol/L), HDL cholesterol 40 mg/dL (1.03 mmol/L), and triglycerides 120 mg/dL (1.36 mmol/L). What is her non-HDL cholesterol and LDL cholesterol?

A. 310 mg/dL (8.02 mmol/L) and 286 mg/dL (7.40 mmol/L) B. 390 mg/dL (10.09 mmol/L) and 334 mg/dL (8.64 mmol/L) C. 310 mg/dL (8.02 mmol/L) and unable to calculate D. 350 mg/dL (9.05 mmol/L) and 286 mg/dL (7.40 mmol/L) E. 310 mg/dL (8.02 mmol/L) and 230 mg/dL (5.95 mmol/L) 2. What is this patient’s primary target for intervention?

A. Triglycerides B. LDL cholesterol C. Non-HDL cholesterol D. HDL cholesterol E. Non-HDL and LDL cholesterol 3. What is your assessment of this patient’s lipid disorder?

A. She has hypercholesterolemia and is likely polygenic B. She has hypercholesterolemia and heterozygous familial hypercholesterolemia C. She has hypertriglyceridemia D. She has a combined dyslipidemia E. She has homozygous familial hypercholesterolemia 4. According to the ACC/AHA guidelines, what intervention would be most appropriate for this patient?

A. Start simvastatin 80 mg daily B. Start prescription omega-3 fatty acid esters 4 g daily C. Start ezetimibe 10 mg daily D. Start a high-intensity statin E. Start gemfibrozil 600 mg twice daily 5. The patient returns to clinic after 4 months for follow-up and post percutaneous coronary intervention of her left anterior descending coronary artery with the following lipid panel: total cholesterol 230 mg/dL (5.95 mmol/L); triglycerides 100 mg/dL (1.13 mmol/L); HDL cholesterol 44 mg/dL (1.14 mmol/L); LDL cholesterol 166 mg/dL (4.29 mmol/L). According to the NLA guidelines, what are the non-HDL cholesterol and LDL cholesterol goals for this patient?

A. Less than 160 mg/dL (4.14 mmol/L) and less than 130 mg/dL (3.36 mmol/L) B. Less than 130 mg/dL (3.36 mmol/L) and less than 100 mg/dL (2.59 mmol/L) C. Less than 100 mg/dL (2.59 mmol/L) and less than 70 mg/dL (1.81 mmol/L) D. At least a 50% reduction in atherogenic cholesterol E. Cholesterol goals are not recommended 6. What would be the next appropriate intervention for this patient?

A. Lomitapide 5 mg daily B. Fenofibrate 160 mg daily C. Ezetimibe 10 mg daily D. Prescription omega-3 fatty acid esters E. Change to atorvastatin 20 mg daily

7. Which type of therapy would be most appropriate for a 58-year-old woman with type 2 DM, evidence of end-organ damage and total cholesterol 210 mg/dL (5.43 mmol/L), HDL cholesterol 45 mg/dL (1.16 mmol/L), triglycerides 850 mg/dL (9.61 mmol/L), and non-HDL cholesterol 165 mg/dL (4.27 mmol/L)?

A. Atorvastatin 10 mg daily B. Pravastatin 20 mg daily C. Cholestyramine one scoop twice daily D. Gemfibrozil 600 mg twice daily E. Alcohol and carbohydrate restriction 8. According to the NLA, which risk category does this patient best fit?

A. Very High Risk B. High Risk C. Moderate Risk D. Low Risk E. Need more information to determine 9. Which of the following is not a secondary cause of dyslipidemia?

A. Hypothyroidism B. Hyperthyroidism C. Diabetes D. Renal failure E. Protease inhibitors 10. For which patients would you consider calculating a quantitative risk score?

A. Patients with three major ASCVD risk factors B. Patients with preexisting ASCVD C. Patients with HDL exceeding 50 mg/dL (1.29 mmol/L) D. Patients with two major ASCVD risk factors and not very high-risk or high-risk conditions.

E. Patients with triglycerides exceeding 500 mg/dL (5.65 mmol/L) 11. A patient diagnosed with metabolic syndrome and CHD is taking atorvastatin 20 mg daily.

His non-HDL cholesterol is 118 mg/dL (3.05 mmol/L) and LDL cholesterol is 78 mg/dL (2.02 mmol/L). His primary care physician has tried to increase atorvastatin to 40 mg; however, the patient complains of muscle pain and weakness shortly after the dose is escalated. His triglycerides are currently 198 mg/dL (2.24 mmol/L), HDL cholesterol is 39 mg/dL (1.01 mmol/L), and total cholesterol is 157 mg/dL (4.06 mmol/L). What would be the most appropriate intervention?

A. Continue current therapy and monitor his progress B. Add ezetimibe 10 mg daily C. Add gemfibrozil 600 mg twice daily D. Add niacin ER 500 mg at bedtime E. Switch to pravastatin 20 mg at bedtime 12. Which lipoprotein particle is not considered to be atherogenic A. LDL B. IDL C. VLDL D. Small-dense LDL E. HDL 13. A 56-year-old woman who smokes two packs of cigarettes per day is admitted to the

emergency room with severe left-sided chest pain and numbness down her left arm. She is diagnosed with acute coronary syndrome and undergoes percutaneous coronary intervention of her right coronary artery. Her lipid profile obtained in the emergency room reveals the following: total cholesterol 229 mg/dL (5.92 mmol/L), non-HDL cholesterol 181 mg/dL (4.68 mmol/L), LDL cholesterol 152 mg/dL (3.93 mmol/L), HDL cholesterol 48 mg/dL (1.24 mmol/L), and triglycerides 147 mg/dL (1.66 mmol/L). What would be the most appropriate initial therapy?

A. Mipomersen 200 mg once weekly B. Pravastatin 40 mg daily C. Atorvastatin 80 mg daily D. Rosuvastatin 20 mg daily E. Pitavastatin 4 mg daily 14. Which side effect can be caused by statin therapy?

A. Fatty liver B. New onset diabetes C. Gout D. Flushing E. None of the above 15. Choose the best answer that explains the difference in liver toxicity between IR niacin and sustained-release niacin.

A. Sustained-release preparations result in higher blood levels of nicotinuric acid B. Sustained-release preparations quickly saturate the low-affinity, high capacity metabolic pathway C. Sustained-release preparations have a slow absorption rate allowing more niacin to be metabolized by the amidation pathway D. Sustained-release niacin only causes liver toxicity when used in doses exceeding 4 g E. None of the above ANSWERS 1. A 2. E 3. B 4. D 5. C 6. C 7. D 8. A 9. B 10. D 11. B 12. E 13. E 14. B 15. C

CHAPTER 13. HYPOVOLEMIC SHOCK 1. Which of the following is the key goal of therapy in the first hour of hypovolemic shock?

A. MAP greater than 90 mm Hg B. SBP greater than 90 mm Hg C. SBP greater than 60 mm Hg D. Hematocrit is at least 30% (0.30) using transfusions E. Normalization of urine output and base deficit 2. What should be the first pharmacologic/fluid intervention in an adult patient with an SBP less than 90 mm Hg or MAP less than 60 mm Hg? A. Administer 2 units of Type O PRBCs B. Administer 1000 to 2000 mL of 0.9% NaCl or LR C. Begin dopamine or norepinephrine infusion D. Administer 5% albumin infusion E. Begin stress ulcer prophylaxis and antithrombotic therapy 3. What is the primary reason that hetastarch products are no longer recommended for initial resuscitation in hypovolemic shock?

A. Crystalloids clearly result in lower mortality B. Hetastarch has a higher risk of infections C. Hetastarch is more effective but avoided due to high cost D. Hetastarch is associated with acute kidney injury E. Crystalloids require a smaller administration volume 4. What potential adverse event requires caution if using dextran in hemorrhagic hypovolemic shock?

A. Hemolytic reaction B. Risk of infection from contamination C. Drug-induced pancreatitis D. Inhibition of the coagulation cascade E. Electrolyte abnormalities 5. What are some primary indications for whole blood/PRBC administration in the acute resuscitation phase in adults?

A. All patients should receive 2 units of Type O PRBCs B. Blood losses exceeding 750 mL or ongoing bleeding C. Blood losses exceeding 1500 mL or ongoing bleeding D. Administer in patients with a PA catheter and vasopressors E. Administer in all patients requiring mechanical ventilation 6. When should a norepinephrine infusion be started?

A. Only in patients with hemorrhagic hypovolemic shock B. In all patients with hypovolemic shock C. If patient’s BP responds well to the initial fluid bolus D. In all patients who require Type O PRBCs E. If there is evidence of cerebral or myocardial ischemia 7. What is the reason why norepinephrine is generally recommended as the first choice vasopressor over dopamine or epinephrine in patients with hypovolemic shock?

A. Lower mortality B. Lower costs C. Fewer tachyarrhythmias

D. More inotropic activity E. More powerful BP elevation 8. A patient with a history of severe heart failure is in hypovolemic shock from massive gastrointestinal fluid losses. The patient’s BP is improving with fluids and dopamine 25 mcg/kg/min, but his cardiac index is 1.8 L/min/m2 (0.03 L/s/m 2 ) and PAOP is 18 mm Hg. What should be done to improve cardiac index?

A. Administer 2 L of normal saline over 1 hour B. Start dobutamine infusion C. Administer 5 mL/kg of hetastarch D. Administer 2 units of Type O PRBCs E. Intubate patient and start mechanical ventilation 9. A patient with a history of type 2 diabetes, uncontrolled hypertension, and rheumatoid arthritis is in hypovolemic shock from bleeding after a lawnmower accident. Home medications include metoprolol 100 mg twice daily, hydrochlorothiazide 25 mg daily, amlodipine 10 mg daily, metformin 500 mg twice daily, and prednisone 20 mg daily.

Which of the following drug-related issues is most likely to contribute to hypotension over the next few days?

A. Long-acting antihypertensive effects of metoprolol B. Long-acting antihypertensive effects of amlodipine C. Hypovolemia exacerbated by previous hydrochlorothiazide use D. The risk of metformin-associated metabolic acidosis E. Adrenal suppression from using systemic prednisone 10. Which of the following is an important goal of therapy at 24 hours after the onset of hypovolemic shock that may improve mortality?

A. Normalization of blood pressure and heart rate B. Normalization of urine output and base deficit C. Discontinuation of vasopressors and inotropes D. Ensuring the hematocrit is at least 30% (0.30) E. Normalization of body and skin temperature 11. What should be done for a patient who is still hypotensive (MAP 50 mm Hg) after an initial bolus of 2000 mL of LR, 2 units of PRBCs (current hematocrit 32% [0.32]), and norepinephrine at 2 mcg/min?

A. Administer 1000 to 2000 mL of NS or LR B. Increase norepinephrine to 4 mcg/min C. Add dobutamine at 10 mcg/kg/min D. Give 2 more units of PRBCs E. Begin stress ulcer prophylaxis and antithrombotic therapy 12. A patient who presented with hypovolemic shock and confusion from severe vomiting and diarrhea has received a total of four liters of LR over the past 3 hours. Her mental status is back to normal and her current vital signs are BP 95/65 mm Hg, HR 93, RR 14.

What is the most appropriate treatment at this time?

A. Administer 1000 to 2000 mL of IV lactated Ringer B. Begin norepinephrine IV infusion at 2 mcg/min

C. Continue to monitor, no fluids or vasopressors needed D. Administer 5 to 10 mL/kg of Type O negative PRBCs E. Place a pulmonary artery catheter for more intensive monitoring 13. A patient with hemorrhagic hypovolemic shock has responded well to fluid resuscitation and no longer has signs of active bleeding. What is the most appropriate threshold for administering a transfusion of PRBCs at this time?

A. Hemoglobin less than 7 g/dL (70 g/L or 4.34 mmol/L) B. Hemoglobin less than 8.5 g/dL (85 g/L or 5.3 mmol/L) C. Hemoglobin less than 10 g/dL (100 g/L or 6.2 mmol/L) D. Platelets less than 20 × 103 /mm3 (20 x 109 /L) E. If the patient has ongoing organ dysfunction 14. Which statement is true regarding the use of recombinant activated factor VII (rFVIIa) for hemorrhagic hypovolemic shock?

A. Provides clinical benefits if given within 3 hours of the onset of bleeding B. Should not be used because of concerns about cost and thromboembolic events C. Should only be used in patients who require blood transfusions D. Decreases mortality in patients with, or at risk of, significant bleeding E. Should not be used because of increased mortality, especially in older patients 15. Based on a recent clinical trial, which of the following represents the most appropriate use of tranexamic acid as an adjunctive antifibrinolytic agent in hypovolemic shock?

A. All trauma patients regardless of blood loss and timing B. Within 3 hours in all trauma patients with shock C. In all trauma patients who require blood transfusions D. In all trauma patients with significant bleeding E. Within 3 hours in trauma patients with significant bleeding ANSWERS 1. B 2. B 3. D 4. D 5. C 6. E 7. C 8. B 9. E 10. B 11. A 12. C 13. A 14. B 15. E

CHAPTER 14. ASTHMA 1. Which one of the following is a common symptom of chronic asthma?

A. Cyanosis B. Wheezing C. Hypoxemia D. Edema E. Nasal congestion 2. Which one of the following comorbid conditions may worsen asthma control?

A. Obesity B. Hypertension C. Diabetes D. Hyperlipidemia E. Otitis media 3. Which one of the following situations indicates controlled asthma?

A. Using one canister of albuterol each month B. Exercising with SABA use before the activity C. Waking at night only three times a week with a cough D. Visiting the emergency department one time in the past year for asthma E. Missing school once a month because of asthma symptoms 4. An 11-year-old boy with asthma reports using albuterol once or twice in the past month. He is able to play soccer well by using albuterol before games. He denies waking at night, and his last spirometry reading FEV1/FVC was 88% (0.88). What additional asthma treatment is appropriate for this patient?

A. Montelukast B. Salmeterol C. Prednisone D. Ciclesonide E. No additional medication needed 5. Which one of the following educational strategies may help an asthma patient with worsening asthma from cats, strong odors, gastroesophageal reflux disease (GERD), cold air, and upper respiratory infections?

A. Have pets groomed monthly B. Use bleach to clean the bathroom once a week C. Take medication for GERD as needed for symptoms D. Wear a scarf to cover the nose and mouth during cold winter months E. Obtain an influenza vaccine after the age of 65 6. The optimal delivery method of albuterol for a typical 16-year-old asthma patient is: A. Nebulization B. Oral solution C. MDI with a valved-holding chamber and mask D. MDI E. Oral tablet 7. Which one of the following medications requires monitoring of growth in children?

A. Montelukast B. Zileuton C. Theophylline

D. Fluticasone E. Omalizumab 8. During pregnancy, which one of the following medications is preferred as the longterm control medication?

A. Budesonide B. Theophylline C. Montelukast D. Omalizumab E. Zafirlukast 9. Dosing for omalizumab is based on which of the following criteria?

A. Age B. Renal function C. Baseline IgE levels D. Liver function E. Baseline severity of asthma 10. A 25-year-old woman is taking levalbuterol and formoterol for her poorly controlled asthma. Which one of the following therapeutic recommendations is most appropriate for her?

A. Switch formoterol to tiotropium B. Add fluticasone DPI to her regimen C. Switch formoterol alone to budesonide/formoterol MDI D. Add montelukast to her regimen E. Discontinue levalbuterol and continue formoterol 11. Proper use of inhaled corticosteroids includes: A. Priming the inhaler before each use B. Checking to see if the inhaler is empty by shaking the inhaler C. Discontinuing inhaled corticosteroids while oral corticosteroids are being used D. Waiting to use the medication until an acute asthma exacerbation occurs E. Rinsing the mouth after each use 12. Which one of the following medications may worsen asthma control?

A. Carvedilol B. Furosemide C. Losartan D. Varenicline E. Atorvastatin 13. A 15-year-old boy with a diagnosis of moderate, persistent asthma returns to his physician’s office. He has had no exacerbations in the last 2 years, and he has no complaints about his current regimen of fluticasone 220 mcg, 1 puff twice daily, montelukast 10 mg daily, and albuterol as needed. After 3 months of well-controlled asthma, which one of the following therapeutic recommendations is recommended?

A. Discontinue albuterol B. Lower the dose of fluticasone C. Switch fluticasone to salmeterol D. Lower the dose of montelukast E. Switch albuterol to levalbuterol 14. A 21-year-old woman with asthma calls the clinic very short of breath and wondering

if she should initiate prednisone. She has been using her albuterol via nebulization every 2 hours with minimal relief of her wheezing and shortness of breath. Her peak flow is 180 L/min and her personal best is 400 L/min. What therapeutic recommendation is best in this situation?

A. Stop all medications and call 9-1-1 B. Start prednisone at home and continue albuterol nebulization until her peak flow is greater than 70% of her personal best C. Double the dose of her ICS/LABA inhaler D. Discontinue albuterol and start ipratropium nebulization E. Initiate prednisone at home, continue albuterol MDI, and proceed to the emergency department 15. Which one of the following statements is true about treatment of an asthma exacerbation in the hospital?

A. Corticosteroids are administered intravenously for the fastest onset of action B. Oxygen therapy is initiated for all patients C. Albuterol may be administered continuously via nebulization D. Inhaled corticosteroids are discontinued while in the hospital E. Corticosteroid dosing in the hospital is double that of outpatient use ANSWERS 1. B 2. A 3. B 4. E 5. D 6. D 7. D 8. A 9. C 10. C 11. E 12. A 13. B 14. E 15. C

CHAPTER 15. CHRONIC OBSTRUCTIVE PULMONARY DISEASE 1. All of the following play a role in the pathophysiology of COPD except: A. Chronic inflammation from repeated exposure to noxious particles and gases B. An imbalance between proteinases and antiproteinases C. Inflammation similar to what is seen in asthma, which is mainly mediated through eosinophils and mast cells D. Oxidative stress E. Impairment of the normal protective and repair mechanisms in the lungs 2. In COPD, where in the lungs is the primary site of obstruction?

A. Large bronchi B. Large bronchioles C. Mucus glands D. Small bronchi and bronchioles E. Trachea 3. A 67-year-old man presents to his primary care physician complaining of productive cough and dyspnea on exertion for the past 6 months; COPD is suspected. Which of the following further supports the diagnosis of COPD? A. A 45 pack–year history of smoking B. FEV1/FVC of 60% (0.60) C. Family history of AAT deficiency D. Fifteen years of employment in a plastics plant with exposure to talc E. All of the above 4. Which of the following is an adverse effect of tiotropium?

A. Hypokalemia B. Dry mouth C. Insomnia D. Irritability E. Seizures 5. A 66-year-old man was admitted to the hospital 4 days ago for an acute COPD exacerbation.

During this hospitalization, he has been treated with albuterol 2.5 mg via nebulizer every 4 hours, ipratropium 0.5 mg via nebulizer every 8 hours, prednisone 30 mg orally once daily, and cefuroxime axetil 500 mg orally twice daily, as well as fluticasone 110 mcg inhaled twice daily and theophylline 200 mg orally twice daily (fluticasone and theophylline were continued from outpatient treatment). Today he complains of restlessness and feeling like his heart is racing, which he attributes to being unable to smoke since being admitted to the hospital. Which of the following is/are alternative causes of these symptoms?

A. Theophylline toxicity secondary to reduced metabolism B. Adverse effect of albuterol C. Adverse effect of fluticasone D. All of the above E. A and B only 6. A 65-year-old woman with emphysema is seen in clinic today for a checkup. Her current COPD pharmacotherapy includes tiotropium 18 mcg once daily, an albuterol MDI as needed and formoterol 12 mcg every 12 hours. She is adherent with medications and uses her inhalers correctly. She reports increasing use of albuterol over the last 3 months and increased breathlessness; she denies any recent changes in sputum. Her postbronchodilator FEV1 today is