Introduction to Clinical Pharmacology 9th Edition

Introduction to Clinical Pharmacology 9th Edition

By Constance G Visovsky, Cheryl H. Zambroski , Shirley M. Hosler

Chapter 01: Pharmacology and the Nursing Process in LPN Practice Visovsky: Introduction to Clinical Pharmacology, 9th Edition MULTIPLE CHOICE 1. You are assessing the skin of a newly admitted patient and note a 2 inch area of redness at

the sacrum. Which type of data are you collecting with this information? a. Objective data b. Inspection c. Subjective data d. Alternative therapy ANS: A

Objective data are obtained by the healthcare provider during physical examination, or that are measurable (i.e., laboratory results).

DIF: Cognitive Level: Applying

REF: p. 3

2. Which part of the nursing process includes setting goals for the nursing care required when

giving drugs to a patient? a. Assessment b. Planning c. Evaluation d. Diagnosis ANS: B

The nursing process consists of five major steps in this order: assessment, diagnosis, planning, implementation, evaluation. It is in the planning step that the goals for nursing care related to drugs are set based upon data collected.

DIF: Cognitive Level: Remembering

REF: p. 4

3. When would it be appropriate to withhold a drug instead of giving it to a patient? a. When the order is written by hand b. When any part of the drug order is unclear c. When the drug improves the patient’s symptoms d. When the order contains both the generic and trade name of the drug ANS: B

You must use good judgment in carrying out a drug order. If, in your judgment, the order is unclear, or incorrect, it should be withheld (not given) until your concerns can be answered by the patient’s healthcare provider.

DIF: Cognitive Level: Applying

REF: p. 4

4. Which action would you take to ensure that an order for a drug is accurate? a. Check the drug record with the Kardex file. b. Compare the order with the drug history. c. Compare the order to the patient’s reason for admission. d. Check the drug record with the original healthcare provider’s order.

ANS: D

Once the healthcare provider orders the drug, you must verify that the order is accurate.

This is done by checking the drug chart or drug record with the healthcare provider’s original order.

DIF: Cognitive Level: Remembering

REF: p. 4

5. What do the nine “rights” of drug administration include? a. Right patient, drug, dose, route, time, reason, documentation, response, and right to

refuse b. Right drug, diagnosis, time, patient, route, drug history, documents, and right to

refuse c. Right drug, amount, route, time, nurse, reason, route, diagnosis, and

documentation d. Right dose, time, healthcare provider, patient, route, documentation, response, and

drug ANS: A

There are nine “rights” of drug administration: you must identify the right patient, give the right drug at the right dose, right route, right time, for the right reason, using the right documentation to record that the dose has been given, monitor the patient for the right response, and note that the patient has the right to refuse a drug.

DIF: Cognitive Level: Remembering

REF: p. 5

6. Which action should you take to ensure that you are giving a drug to the right patient? a. Verifying the drug record with the patient name on the chart b. Verifying the patient’s room and bed number with the chart c. Asking the patient to state his or her birthdate and Social Security number d. Asking the patient to state their name and birthdate, and then checking the patients

identification bracelet ANS: D

Before giving any drug, two forms of patient identifications should be used to identify the correct patient. Each patient should be asked his or her name, and another form of identification, such as birthdate; then you should check the patient’s identification bracelet.

DIF: Cognitive Level: Applying

REF: p. 5

7. Which category of drugs should be given exactly on schedule in order to maintain a

consistent level of the drug in the body? a. Steroids b. Diuretics c. Aspirin products d. Anticoagulants ANS: D

Certain drugs must be given at specific time interval (right time). Anticoagulants must be given at the same time each day to maintain a therapeutic blood level in order to prevent blood clots.

DIF: Cognitive Level: Applying

REF: p. 7

8. Which nursing action is not appropriate when giving drugs to a patient? a. Leaving the drug at the patient’s bedside to take when he/she awakens b. Asking the patient if he or she has any allergies to drugs c. Checking a drug reference to verify the action of the drug d. Explaining to the patient the possible side effects of the drug ANS: A

It is never permissible to leave drugs at the patient’s bedside. As the nurse, you are responsible for witnessing the patient taking the drug(s), or documentation of the patient’s refusal.

DIF: Cognitive Level: Applying

REF: p. 10

9. Which of the following nursing actions is an example of evaluating patient responses to

drug therapy? a. Documenting the fact that the patient refused the drug b. Making sure you have assembled all necessary equipment c. Taking the patient’s blood pressure before giving an antihypertensive d. Taking the temperature of a patient an hour after giving an antipyretic ANS: D

Evaluation is the process of determining the right response of the patient to the drug given.

The correct response to an antipyretic is a reduction in fever.

DIF: Cognitive Level: Knowing

REF: p. 9

10. Which statement is considered to be an example of objective data gathered in the

assessment of a patient who will be receiving drugs for the treatment of an injury? a. The patient’s skin is warm and dry to touch. b. The patient tells you “I have pain in my lower back.” c. The patient states he is having trouble catching his breath. d. The patient checks off “no history of drug allergies” on the health form.

ANS: A

Objective data are physical findings the nurse can see during careful inspection, palpation, percussion, and auscultation.

DIF: Cognitive Level: Knowing

REF: p. 3

11. You are interviewing a patient to obtain a current drug history. What information should

be part of this report? a. The color of each drug in pill form b. The names and dosages of each drug c. The major health conditions of the patient d. The nursing diagnoses that come from the collected information ANS: B

In the interview to obtain a current and accurate drug history, the names of each drug and, if possible, the dosage of each drug are recorded.

DIF: Cognitive Level: Applying

REF: p. 3

12. A patient you are caring for is prescribed 30 units of NPH insulin to be given

subcutaneously. You know that insulin is considered a “high-alert drug.” What nursing action would you perform to give a high-alert drug safely? a. Call the healthcare provider to double check the order. b. Ensure an insulin level is drawn before giving the drug. c. Have another nurse check the order and dosage before giving it. d. Refuse to give this drug, as it can only be given by a registered nurse.

ANS: C

Many institutions have policies that require two nurses to double check the order and dosages of high-alert drugs to reduce the risk of error and adverse effects for the patient.

This is especially important if the drug dose needs to be calculated.

DIF: Cognitive Level: Applying

REF: p. 8

13. You are about to give the prescribed drugs to a patient in your care. When you approach

the patient with the drugs, the patient refuses to take one of the drugs. What is your best action? a. Ask the pharmacy if there is a substitute drug for the one the patient refused. b. Acknowledge to patient’s right to refuse, no other action is needed. c. Let the patient know the consequences of refusing the drug. d. Notify the charge nurse or healthcare provider.

ANS: D

Never record drugs that were not given or record them before they are given. If a patient does not receive the drug for any reason, notify the nurse in charge or the healthcare provider according to your healthcare setting policies.

DIF: Cognitive Level: Applying

REF: p. 8

14. You have given the antibiotic penicillin as prescribed to a patient with no reported drug

allergies. Thirty minutes after receiving the drug, the patient notifies you that he/she has developed hives and swelling of the lips. What is your best first action? a. Call the pharmacy and report this as an adverse reaction to the drug. b. Immediately give epinephrine to counter the drug reaction. c. Reassure the patient that this is a typical side effect of the drug. d. Report the findings to the RN or healthcare provider and remain with the patient.

ANS: D

If you suspect the patient is having an adverse effect, such as an allergic reaction, report this immediately to the RN or healthcare provider. Remain with the patient, monitoring for changes in breathing or vital signs, until the RN or healthcare provider arrives with additional orders to be carried out.

DIF: Cognitive Level: Applying

REF: p. 9

15. You are working on a very busy 35-bed hospice unit. The RN you are working with just

got a new admission and hands you a syringe with “pain drug” in it. He/she asks you to give this drug to a specified patient. What is your most appropriate action? a. Assist the RN by giving the drug as requested for this one time only.

b. Refuse to give a drug that is not for a patient you are assigned to care for. c. Refuse, but prepare another dose of the drug yourself, and give as prescribed. d. Assist the RN as directed, as under the RN’s supervision, this practice is permitted.

ANS: C

You are never to give a drug prepared by another nurse, even during a busy time or during an emergency. To meet all the patient safety standards covered by the “9 Rights,” you are required to give only drugs you have prepared.

DIF: Cognitive Level: Applying

REF: p. 7

16. You are evaluating the response of a patient 30 minutes after receiving an antihypertensive

drug. Upon assessment of the patient’s blood pressure, you note the patient has become hypotensive. What type of drug effect is this patient experiencing? a. An adverse effect of the drug b. A side effect of the drug c. A therapeutic effect of the drug d. An allergic reaction to the drug ANS: A

An adverse effect is seen when patients do not respond to drugs in the way they should, or develop new signs or symptoms. When a patient has an adverse effect, you should report this immediately to the RN or healthcare provider.

DIF: Cognitive Level: Knowing

REF: p. 9

MULTIPLE RESPONSE 1. Before giving a drug to a patient which steps should you take to ensure safe drug

administration? (Select all that apply.) a. Use two forms of patient identification. b. Ask the patient about any drug allergies. c. Check the drug before removing it from the unit-dose cart. d. Check the dose before preparing or measuring the drug. e. Check the drug just before you open it and give it to the patient. f. Document the drug given before you enter into the patient’s room.

ANS: A, B, C, D, E

The nurse needs to use two forms of identification to ensure the drug is given to the right patient. The nurse should read the drug label at least three times: (1) before taking the drug from the unit-dose cart or shelf, (2) before preparing or measuring the prescribed dose of drug, and (3) before giving it to the patient. Asking about drug allergies is important if this information is not available, or if drugs associated with allergic reactions, such as antibiotics, are given.

DIF: Cognitive Level: Applying

REF: p. 10

2. You are taking the drug history from a patient. Which of the following information should

be collected as part of this interview? (Select all that apply.) a. Allergies to any drugs b. Alcohol or recreational drug use

c. d. e. f.

The time of day preferred for taking drugs The use of nutritional supplements or herbs The strategies you will use to care for the patient The illness or symptoms for which the drug is needed

ANS: A, B, D, F

The patient’s drug history consists of symptoms or diseases for which a drug is needed, the names, and dosages of all drugs, alcohol or recreational drug history, and alternative treatments, such as nutritional or herbal therapies.

DIF: Cognitive Level: Applying

REF: p. 3

3. When evaluating a patient’s response to s drug, which factors should you should consider?

(Select all that apply.) a. The clarity of all written drug orders b. The expected side effects of the drug c. The reason the drug was prescribed d. The therapeutic effects of the drug e. The timing of the prescribed drug f. The adverse effects of the drug ANS: B, D, E

The three factors to be considered in evaluating responses to drug therapy are the therapeutic effects, expected side effects, and adverse effects.

DIF: Cognitive Level: Remembering

REF: p. 9

Chapter 02: Legal, Regulatory, and Ethical Aspects of Drug Administration Visovsky: Introduction to Clinical Pharmacology, 9th Edition MULTIPLE CHOICE 1. Which of the following scenarios may be a sign of possible drug diversion on a unit? a. A patient is dissatisfied with the drug administration schedule. b. A patient receiving oral antibiotics has an excess amount of pills. c. A patient is unaware that the nurse mixed a drug in applesauce. d. A patient receiving opioids reports increased pain.

ANS: D

Drug diversion is defined as the illegal transfer of regulated drugs (like narcotics) from the patient for whom it was prescribed, to another person, such as a nurse, for their own (or others) use. Drug diversion should also be suspected if patients continually report pain despite appropriate drug treatment, and if inaccurate narcotic counts are noted.

DIF: Cognitive Level: Remembering

REF: pp. 13-14

2. Which of the following is an example of psychological dependence (addiction) to a drug? a. Symptoms of drug withdrawal b. Pain, confusion, and seizures c. An intense mental desire for certain drugs d. Shaking and an increased heart rate after taking a drug ANS: C

Psychological dependence, or addiction, is a mental desire associated with taking certain substances, such as cocaine or alcohol. Symptoms of mental dependence such as anxiety, anger, or depression can occur with psychological dependence.

DIF: Cognitive Level: Remembering

REF: p. 12

3. You have obtained a liquid narcotic for a patient in pain from the unit’s locked cabinet.

However, the dose was accidentally spilled before to giving it to the patient. What is the best action to take at this point? a. Ask another nurse to cosign the inventory record describing the situation. b. Immediately obtain another dose from the narcotic control system. c. Document the occurrence in the drug record. d. Clean up the spill and notify the supervisor.

ANS: A

Accounting for controlled substances is a legal requirement. If the drug is accidentally dropped, contaminated, or spilled two nurses must sign the inventory report and describe the situation.

DIF: Cognitive Level: Knowing

REF: p. 14

4. As you arrive to work, a nurse from the previous shift tells you that she has completed the

narcotic count for your shift. What action should be taken? a. There is no need for any additional action as this is the standard procedure.

b. Accept the keys to the narcotic cabinet and recount the drugs yourself. c. Recount the narcotics again with a nurse from the previous shift. d. Recount the drugs yourself at the end of your shift.

ANS: C

At the end of each shift, the contents of the locked cabinet are counted together by one nurse from each shift in order to verify the narcotics count. If not done properly, the nurse risks being held accountable for any shortages or discrepancies, and may be found guilty of falsifying the narcotic count records.

DIF: Cognitive Level: Applying

REF: p. 14

5. A one-time order for a controlled substance drug has been written for a patient you are

caring for. However, the drug ordered is available only in a larger dose than is needed.

What should you do with the remaining drug? a. Give the full dose that is available. b. Flush the remaining drug in the toilet of the patient’s bathroom. c. Save the remaining drug in case the patient needs it again. d. Have another nurse witness the wasting of the leftover drug, and document according to policy.

ANS: D

If the ordered dose is smaller than the dose provided (so that some drug must be discarded), two nurses witness the wasting of the drug and sign the controlled substance inventory report according to institution policy.

DIF: Cognitive Level: Knowing

REF: p. 14

6. An elderly patient in an assisted living home requests an over-the-counter cough

preparation for a mild couch she is experiencing. What is your best response? a. “I do not have any of this drug for you at this time, but can give you a dose from another patient’s supply.” b. “I will bring it to you right away, but I must keep it with your other prescription drugs.” c. “I will need to contact your healthcare provider for an order before I can give this drug to you.” d. “You may have this, but your family will need to bring it in for you.”

ANS: C

Over-the-counter (OTC) drugs do not require a prescription for purchase, but a healthcare provider’s order is required before it can be given by the LPN/LVN in an institutional setting. OTC drugs may interact with a patient’s prescribed drugs, especially in the elderly.

DIF: Cognitive Level: Applying

REF: p. 15

7. Which of the following orders is an example of a single drug order? a. Atenolol 50 mg orally daily b. Morphine sulfate 4 mg IV stat c. Cefazolin 1 g IV 8 a.m. before surgery d. Tramadol 50 mg orally as needed for pain ANS: C

A single drug order is a drug that is scheduled to be given at a specified time for one dose only.

DIF: Cognitive Level: Knowing

REF: p. 16

8. Diphenhydramine 50 mg IV push is ordered by the healthcare provider to be given “stat.”

When should this drug be given? a. Immediately b. As need upon the patient’s request c. Within one hour of receiving the order d. When you have completed giving the oral drugs first ANS: A

A stat order is a type of drug order that is to be given immediately.

DIF: Cognitive Level: Knowing

REF: p. 16

9. You are giving drugs to the patients assigned to you when you realize that you gave a drug

to the wrong patient. What action should you take? a. Evaluate the patient’s condition and notify the healthcare provider. b. Submit a report only if the patient has an adverse reaction. c. Inform the patient and complete an incident report. d. Document the occurrence in the patient record.

ANS: A

When it is discovered that an error has been made, you should immediately evaluate the patient for any adverse reactions and notify the healthcare provider as soon as possible. An incident report should be completed and the supervisor notified.

DIF: Cognitive Level: Applying

REF: p. 19

MULTIPLE RESPONSE 1. Which of the following drugs is considered a high-alert drug? (Select all that apply.) a. Percocet b. Insulin c. Heparin d. Herceptin e. Potassium f. Indomethacin ANS: B, C, E

Categories of common high-alert drugs can be remembered using the acronym “PINCH.” P is for potassium, I is for insulin, N is for narcotics (opioids), C is for cancer chemotherapy drugs, and H is for heparin or any drug type that interferes with blood clotting.

DIF: Cognitive Level: Remembering

REF: p. 19

2. Which of the following actions should you take before you give a drug mixed into food or

the mixing of drugs with food or drink must be documented in the patients care plan, and on the drug administration chart to address the legal aspects of this practice a drink?

(Select all that apply.) a. Check a drug handbook. b. Inform the patient or family. c. Inform the healthcare provider. d. Thoroughly crush pills with an enteric coating. e. Document the mixing of drugs in food or drink in the chart. f. Give the prescribed drug mixed in food during a regular patient meal.

ANS: A, B, C, E

Covert drug administration is discouraged. Therefore, nurses are under obligation to inform the healthcare provider, who ordered the drug, and the patient or family. Some drugs may not be mixed with certain foods or drinks, or may not be crushed, so checking the drug handbook is a necessary step to ensure patient safety. The mixing of drugs with food or drink must be documented in the patients care plan, and on the drug administration chart to address the legal aspects of this practice.

DIF: Cognitive Level: Applying

REF: p. 12

3. Which steps should you take to identify possible drug errors in a patient’s drug orders?

(Select all that apply.) a. Call the pharmacy. b. Clarify anything that is unreadable c. Ask the patient about the drug. d. Reconcile the drug list with an old drug record. e. Clarify vague orders with the healthcare provider. f. Check the original written order with the healthcare provider.

ANS: A, B, E, F

Checking with a reliable source, such as the pharmacist, clarifying vague orders or anything that is difficult to read (if handwritten) and checking the original written order are all ways to avoid drug errors.

DIF: Cognitive Level: Applying

REF: p. 17

4. Which levels of regulation must you adhere to when giving drugs to a patient? (Select all

that apply.) a. City Regulations b. State Regulations c. County Regulations d. Federal Regulations e. Institutional Regulations f. Health Insurance Regulations ANS: B, D, E

Nurses who are responsible for giving drugs to patients in their care have three levels of regulations to follow: federal (describes and controls), state (regulates who dispenses), and individual hospital or agency (additional guidelines or policies).

DIF: Cognitive Level: Remembering

REF: pp. 14-16

5. A narcotic control system is used in any hospital or agency. Which of the following are

special regulations applied for control of narcotics that you must follow? (Select all that apply.) a. Narcotics are stored in a special locked cabinet. b. Narcotic control is the responsibility of everyone on the unit. c. Narcotics may be borrowed from patient to patient for emergency use. d. You may return unused narcotics to the patient’s family upon discharge. e. You are responsible for signing out every narcotic drug used for a patient. f. An inventory of the narcotics on a unit must be kept and verified by two nurses.

ANS: A, E, F

Narcotics are stored in special, limited-access, locked cabinets. A nurse records all controlled substance drug during the shift. The inventory report form is completed before the drug is removed from the cabinet.

DIF: Cognitive Level: Applying

REF: pp. 12-13

6. A discrepancy in the narcotics inventory for morphine 5 mg/mL vials is discovered when

the narcotics count is performed. The count is short by one vial. Which of the following steps should you take to reconcile the count? (Select all that apply.) a. No action needs to be taken for small discrepancies. b. Notify the nursing supervisor and the pharmacy of the discrepancy. c. Identify if any nurse forgot to record any of the narcotics removed. d. Ask only the nurses who used narcotics about the drugs they have given. e. Check drug records to reconcile if narcotics given and not signed for. f. Notify the security department of the institution if drug diversion is suspected.

ANS: B, C, E, F

All nurses must be asked about narcotics that may have been given. Steps must be retraced to see if someone forgot to record any drug. Patient charts might also be checked to see if drug was given that was not signed for on the inventory report. If errors in the report cannot be found, both the pharmacy and the nursing service office must be notified. If drug diversion is suspected, the hospital administrator and security police are usually contacted.

DIF: Cognitive Level: Applying

REF: pp. 12-14

Chapter 03: Principles of Pharmacology Visovsky: Introduction to Clinical Pharmacology, 9th Edition MULTIPLE CHOICE 1. Which is always true regarding the generic name for a drug? a. It is the same in any country. b. It is capitalized when written. c. It is similar to the chemical name. d. It is assigned by a specific manufacturer.

ANS: A

The generic name is the common drug name used. This name is the same in all countries.

The generic drug name is written in lower-case letters, whereas the trade name or brand name of a drug is capitalized.

DIF: Cognitive Level: Remembering

REF: p. 23

2. What is the difference between the generic and the trade names of drugs? a. The generic name is approved and owned by the Federal Drug Standards

Committee. b. The generic name represents the proprietary name given by a drug company. c. The trade name is one that is registered to a specific drug manufacturer. d. The trade name, or chemical name, represents the chemicals in the drug.

ANS: C

The trade name is the proprietary or brand name for the drug, and is registered to a specific drug company.

DIF: Cognitive Level: Remembering

REF: p. 23

3. Which statement is true about the way drugs and receptor sites work? a. The drug attaches to a receptor site and activates it. b. The drug prevents activation of the receptor site. c. The receptor site is activated, allowing DNA replication to occur. d. The receptor sites are activated once the drug leaves the receptor site.

ANS: A

The drug attaches to the receptor site and activates the receptor.

DIF: Cognitive Level: Knowing

REF: p. 23

4. What response would you expect in a patient given a drug that is considered an antagonist? a. Positive and negative activation of cell receptors b. A complete activation of cell receptors c. A partial activation of cell receptors d. No activation of cell receptors ANS: D

When a drug attaches at a drug receptor site but does not activate or unlock it, there is no increase in cell activity and the drug is an antagonist.

DIF: Cognitive Level: Knowing

REF: p. 24

5. A patient is given a drug that is a known agonist. How would you expect this drug to

work? a. This drug works by attaching to the receptor site to activate it. b. This drug works by deactivation of all cellular receptor sites. c. This drug works to partially block receptor sites. d. This drug works by interacting with other drugs.

ANS: A

A drug agonist works by activating or unlocking receptors, and has the same actions as the body’s own chemicals.

DIF: Cognitive Level: Knowing

REF: p. 24

6. You are giving an oral drug to a patient. For this drug to be utilized by the body, which

mechanism is the first to be involved in that process? a. Excretion b. Absorption c. Metabolism d. Distribution ANS: B

Absorption involves the way a drug enters the body and passes into the body and tissues.

Drug absorption is the first step and it takes place through the processes of diffusion, filtration, and osmosis.

DIF: Cognitive Level: Knowing

REF: p. 24

7. You are giving an oral drug to a patient who asks you to explain the reason for taking

water with a tablet. What is your best response? a. “Water is important for proper metabolism.” b. “Juice or milk can keep it from dissolving.” c. “Water helps to dissolve the drug.” d. “Water keeps the drug potent.”

ANS: C

All drugs must be dissolved in body fluid before they enter body tissues. When the patient takes water with a tablet, it not only helps in swallowing but also helps dissolve the drug and increase its solubility.

DIF: Cognitive Level: Understanding

REF: p. 24

8. Which drug route would you expect to be the most rapidly absorbed? a. Subcutaneous injection b. Intravenous injection c. Rectal suppository d. Sublingual tablet ANS: B

Drugs injected intravenously into the bloodstream have the fastest action.

DIF: Cognitive Level: Remembering

REF: p. 24

9. What is the process by which molecules move from a region of higher concentration to

one of lower concentration? a. Diffusion b. Osmosis c. Filtration d. Solubility ANS: A

In diffusion, molecules move from a region of higher concentration to one of lower concentration.

DIF: Cognitive Level: Remembering

REF: p. 25

10. A 62-year old male patient with liver disease asks you why he is receiving a drug

intravenously rather than by mouth. What is your best response? a. “Many oral drugs are inactivated as you get older.” b. “Your liver disease impairs the transformation of a drug into its active form.” c. “Intravenous drugs reduce toxicity to the liver through first-pass metabolism.” d. “Individuals with liver disease have a genetic impairment that prevents drug activation.”

ANS: B

Many drugs must be activated by enzymes before they can be used in the body. This biotransformation happens in the liver. Liver disease impairs this process.

DIF: Cognitive Level: Applying

REF: pp. 25-26

11. A patient who is beginning a new cholesterol-lowering drug tells you he plans to take this

drug in the evening with his usual glass of grapefruit juice. What is your best response? a. “The vitamin C in grapefruit juice enhances the action of cholesterol-lowering drugs.” b. “The acid environment of grapefruit juice promotes drug metabolism.” c. “Taking grapefruit juice can reduce the effectiveness of the drug.” d. “Taking grapefruit juice can increase the absorption of the drug.”

ANS: C

Grapefruit juice affects (usually reduces) the absorption of many drugs such as antihistamines, cholesterol-lowering drugs, HIV drugs, and transplant drugs.

DIF: Cognitive Level: Applying

REF: p. 26

12. You give a patient 400 mg of an oral drug at noon. This drug has a half-life of 2 h. At what

time will 100 mg remain? a. 2:00 p.m. b. 6:00 p.m. c. 8:00 p.m. d. 4:00 p.m.

ANS: D

With a half-life of 2 h, the amount of drug remaining in the blood decreases by 50% every 2 h. So, when 400 mg are given at noon, by 2:00 p.m., 200 mg remain; by 4:00 p.m., 100 mg remain.

DIF: Cognitive Level: Understanding

REF: p. 26

13. When teaching a patient about a new drug that has been prescribed, the patient asks you to

explain the difference between a side effect and an adverse reaction. What is your best response? a. Both side effects and adverse reactions are mild. b. Both side effects and adverse reactions are severe. c. Side effects are mild, and adverse effects are severe. d. Side effects are severe, and adverse reactions are mild.

ANS: C

Side effects are usually seen as mild but annoying responses to a drug. Adverse reactions, or adverse effects, usually imply more severe symptoms or problems that develop because of the drug.

DIF: Cognitive Level: Applying

REF: p. 27

14. A patient tells you that she is experiencing sleepiness after taking a drug prescribed for

back pain. What is your best response? a. “You are having a severe drug interaction.” b. “You are having an expected drug side effect.” c. “You are having the desired effect of this drug.” d. “You are having an idiosyncratic response to this drug”.

ANS: B

Drugs may influence many body systems at the same time, so the effect of the drug is often not restricted to the desired action. Side effects are usually seen as mild but annoying responses to the drug. In the case of many drugs for pain, sleepiness is an expected side effect.

DIF: Cognitive Level: Applying

REF: p. 27

15. A patient who was given intravenous penicillin for a severe infection develops hives,

itching, and facial swelling immediately after the infusion. What type of drug reaction is this patient experiencing? a. An adverse reaction b. A paradoxical reaction c. An anaphylactic reaction d. A hypersensitivity reaction ANS: D

Some drugs (sulfa products, aspirin, and penicillin) can produce allergic (hypersensitivity) reactions that usually occur when an individual has taken the drug and the body has developed antibodies to it.

DIF: Cognitive Level: Knowing

REF: p. 27

16. What information should be included in the teaching plan for a young woman who has

begun on a 10-day course of oral antibiotic therapy for an infection? a. Antibiotics can mask the signs of allergic reactions. b. Antibiotics interfere with P-450 enzyme pathways in women. c. Antibiotics can have a synergistic effect when given with opiates. d. Antibiotics interact with birth control pills making them less effective.

ANS: D

Drug interactions can produce adverse effects. Many antibiotics make birth control tablets less effective, thus making it more likely that a woman will get pregnant while taking both drugs if she is sexually active.

DIF: Cognitive Level: Applying

REF: p. 28

17. Probenecid is sometimes given to patients taking penicillin to increase the amount of

penicillin absorbed. Which effect is this an example of? a. Additive effect b. Drug interaction c. Synergistic effect d. Antagonistic effect ANS: A

Some drugs are given together on purpose to produce an additive effect that is helpful in increasing the levels of penicillin in the blood. Probenecid does this by blocking penicillin’s elimination pathway via the kidneys (by inhibiting renal tubular secretion).

Maintaining high blood levels of penicillin is important in treating severe infections.

DIF: Cognitive Level: Knowing

REF: p. 28

18. A patient has been prescribed an antianxiety drug to be taken in the evening. He tells you

he has 2 to 3 beers with dinner each night. What is your best response? a. “The effect of alcohol on this drug is not a concern.” b. “Limit your alcohol use to 8 ounces a day with a meal.” c. “Eating a full meal before taking the drug will negate any side effects.” d. “Drinking any alcohol with this drug can have a harmful additive effect.”

ANS: D

When taken together with alcohol, drugs such as antianxiety agents can result in an additive effect.

DIF: Cognitive Level: Applying

REF: p. 28

19. You are caring for a patient with liver failure who will be starting on an anticoagulant for

the treatment of a deep vein thrombosis. What effect of this drug should you expect? a. The effect of the anticoagulant will be prolonged and pose a risk for bleeding. b. The effect of the anticoagulant will be reduced, requiring additional doses. c. The effect of the anticoagulant will result in an increased risk for infection. d. There will be no effect of the anticoagulant on the deep vein thrombosis.

ANS: A

A patient with liver or the kidney disease will retain a drug much longer, increasing the risk for adverse and toxic effects. In the case of an anticoagulant, the risk for bleeding is increased in a patient with liver disease.

DIF: Cognitive Level: Applying

REF: p. 29

20. Which statement concerning absorption of oral drugs is true for neonates? a. Oral prodrugs are activated most quickly in the neonate. b. Oral drugs are poorly absorbed for the gastrointestinal tract of the neonate. c. The overall low body metabolism results in increased toxicity in the neonate. d. The high percentage of total body water rapidly dilutes oral drugs in the neonate.

ANS: B

In neonates oral drugs are absorbed poorly from the GI tract because no gastric acid is present to help break down drugs, no intestinal bacteria or enzyme function is present to metabolize a drug, and the time it takes for a drug to move through the stomach and intestines is slow.

DIF: Cognitive Level: Knowing

REF: p. 30

MULTIPLE RESPONSE 1. Which of the following factors are known to influence drug distribution? (Select all that

apply.) a. Tissue type b. Drug binding c. Tissue perfusion d. Receptor site binding e. Electron displacement f. Cell membrane penetration ANS: A, B, C, F

Distribution of the drug depends upon tissue (perfusion), types of tissue (bone, fat, and muscle) and how easy it is for the drug to penetrate the cell membranes. Some drugs will also bind together with many blood substances and proteins such as albumin. This binding allows only “free” drug (that which is not bound) to penetrate the tissues.

DIF: Cognitive Level: Remembering

REF: p. 30

2. Which of the following routes are sites of excretion of drug metabolites from the body?

(Select all that apply.) a. Feces b. Urine c. Breast milk d. Bloodstream e. Lymph nodes f. Salivary glands ANS: A, B, C

All inactive chemicals, chemical by-products, and waste (metabolites) finally break down through metabolism and are removed from the body through the process of excretion in feces, urine, and breast milk.

DIF: Cognitive Level: Knowing

REF: pp. 31-32

3. What are the possible responses a patient can have to a drug’s actions? (Select all that

apply.) a. Desired action b. Bioequivalence c. Adverse effects d. Side effects e. Half-life f. Onset ANS: A, C, D

When a drug is given to a patient, the expected response of the drug is called the desired action. Other responses to drugs include side effects and adverse effects.

DIF: Cognitive Level: Applying

REF: p. 27

4. Which of the following issues related to drug therapy in the older patient are true? (Select

all that apply.) a. Drugs are secreted more slowly in older patients. b. Drug interactions are far less prevalent in older patients. c. Adverse drug reactions are more common in older patients. d. Dehydration can cause the blood level of drug to increase in older patients. e. Fat-soluble drugs are eliminated, and leave the body quickly in older patients. f. Loss of electrolytes due to diuretics can result in loss of electrolytes in older patients.

ANS: A, C, D, F

Drugs are absorbed, metabolized, and excreted more slowly and less completely in older adults. Adverse drug reactions (ADRs) are common in older adults. Issues such as falls, hypotension, delirium, kidney failure, and bleeding are common clinical manifestations.

Older adult patients may become dehydrated easily, thus allowing the amount of drug in the blood to increase. Diuretics lead to an increase in urination and this can lead to loss of electrolytes.

DIF: Cognitive Level: Knowing

REF: p. 30

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

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? a. The age of the child b. The weight of the child c. One-half of the adult dose d. The international standardized ratio 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

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

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

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

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

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

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

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

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

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

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

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

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

9. When a patient is experiencing a life-threatening emergency, you may be given an order to give drug via which route? a. IV route b. IM route c. Rectal route d. Subcutaneous 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

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

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

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

12. What physical assessment findings would you observe when an IV becomes infiltrated? a. Pallor and pain b. Pallor, warmth c. Pain, warmth, and burning d. Pain, swelling, and redness 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

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

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

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

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

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? 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.

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

DIF:

Cognitive Level: Applying

REF: p. 56

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

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

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? 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.

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

2. Which are examples of drugs given through mucous membranes? (Select all that apply.) a. Oral tablets b. Liquid drugs c. Intravenous drugs d. Transdermal drugs e. Rectal suppositories f. Metered-dose inhaler

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

2. A breast-feeding mother has been prescribed antimicrobial therapy for an infection.

What information should be included in her teaching plan? 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.

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

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

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

4. Which term refers to an antibiotic with a high degree of activity against many different organisms? a. Antimycotic b. Bacteriostatic c. Antimicrobial d. Broad-spectrum ANS: D Drugs that are effective against a variety of organisms are called broad-spectrum antibiotics.

DIF:

Cognitive Level: Remembering

REF: p. 67

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? a. Abdominal x-ray b. Blood chemistry c. Laparoscopic examination d. Culture and sensitivity studies 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

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? a. Cefazolin b. Penicillin c. Vancomycin d. Sulfamethoxazole/trimethoprim ANS: B Penicillin is effective in the treatment of the following susceptible organisms: group A beta-hemolytic streptococci and other less common organisms.

DIF:

Cognitive Level: Applying

REF: p. 69

7. You are teaching a patient about possible side effects when taking penicillin, a broad-spectrum antibiotic. What is the most common side effect you would stress in teaching the patient about this drug? a. Edema of the lower extremities b. Metallic taste in the mouth c. Ringing in the ears d. Loose stools 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

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

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

DIF:

Cognitive Level: Knowing

REF: p. 69

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

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

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? a. Lethargy b. Nephrotoxicity c. Peripheral edema d. Sleep disturbance 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

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? 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.

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

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

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

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

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

14. Which cell wall synthesis inhibitor drug is given in an oral form to treat Clostridium difficile? a. Gabapentin b. Vancomycin c. Doxycycline d. Clindamycin 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

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? a. 0.25 b. 0.5 c. 2 d. 4 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

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? 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.”

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

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? 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.”

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

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? 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.”

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

19. Which statement is true regarding macrolides? 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.

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

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? a. Complete blood count b. BUN and creatinine c. Troponin levels d. Liver enzymes 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

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? 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.

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

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? 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.”

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

23. In reviewing a patient’s reported drug allergies, which drug class sensitivity would suggest the patient should not be given a sulfonamide? a. Beta blockers b. ACE-inhibitors c. Thiazide diuretics d. Calcium channel blockers 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

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

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

DIF:

Cognitive Level: Applying

REF: p. 78

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? 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.”

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

26. A patient newly diagnosed with tuberculosis (TB) asks how this infection is transmitted.

What is your best response? 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.”

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

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? 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.”

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

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

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

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

DIF:

Cognitive Level: Applying

REF: p. 80

30. Which class of antifungal drugs works by altering the cell wall of the fungus? a. Azoles b. Polyenes c. Allylamines d. Antimetabolites 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

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? a. Hypoglycemia and dizziness. b. White plaques coating the tongue. c. Painful red or purple rash, and blisters. d. Decreased haemoglobin and hematocrit.

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

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? 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.”

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

33. For which condition would a patient receive the drug primaquine as a treatment? a. Malaria b. Pneumonia c. Strep infection d. Tuberculosis ANS: A Primaquine is a drug used in the treatment of malaria (antimalarial).

DIF:

Cognitive Level: Knowing

REF: p. 88

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? 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.

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

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

2. Which adverse reactions are associated with the use of broad-spectrum antibiotics?

(Select all that apply.) a. Bacterial changes in the bowel b. Overgrowth of yeast c. Loss of appetite d. Superinfection e. Nausea f. Edema 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

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.) 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.”

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

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

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

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.) 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.

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 Visovsky: Introduction to Clinical Pharmacology, 9th Edition 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

2. Which antiviral drug is only given by oral inhalation? a. Acyclovir (Zovirax) b. Zanamivir (Relenza) c. Oseltamivir (Tamiflu) d. Amantadine (Symmetrel) 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

3. Which antiviral drug is most likely to have more severe central nervous system side effects, including worsening of glaucoma? a. Acyclovir b. Amantadine c. Valacyclovir d. Zanamivir 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

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? a. “Antiviral drugs are not useful in combating 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.”

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

5. A patient who is asymptomatic comes into the clinic complaining of being exposed to a coworker who has the flu. What drug would be most appropriate for this patient? a. Flumadine (rimantadine) b. Valtrex (valacyclovir) c. Crixivan (indinavir) d. Ziagen (abacavir) 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

6. Which drug is the only approved treatment for RSV? a. Ribavirin (Virazole) b. Cidofovir (Vistide) c. Foscarnet (Foscavir) d. Lamivudine (Epivir) ANS: A The only drug approved for RSV treatment is ribavirin (Virazole).

DIF:

Cognitive Level: Knowing

REF: p. 96

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? a. 16-year-old brother b. 81-year-old grandmother c. 32-year-old pregnant mother d. 36-year-old father who has diabetes 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

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?

a. b. c. d.

Ask the patient if he/she is allergic to milk.

Wear a gown, mask, and gloves to give this drug.

Assess the patient for the presence of irregular pulse.

Inform the patient that this drug can cause excessive thirst.

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

9. Which of the following is a sign or symptom of an allergic or anaphylactic response to an antiviral drug? a. Nausea b. Insomnia c. Intolerance to fatty foods d. Swelling of the face or throat 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 heartbeat, a sense that something bad is happening, and light-headedness.

DIF:

Cognitive Level: Knowing

REF: p. 97

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? 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.

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

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

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

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

13. Which drug classification works to limit the progression of human immunodeficiency virus (HIV)? a. Antiretrovirals b. Antivirals c. Antibiotics d. Antifungals 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

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

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

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

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

16. You are teaching a patient about the action of a newly prescribed antiretroviral drug.

Which statement explains the action of antiretrovirals? 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.”

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

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? 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.”

ANS: D Most antiretrovirals react with other drugs. Antiretroviral drugs inhibit the cytochrome P-450 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

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? 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.”

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

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? a. Elevated glucose level b. Decreased hemoglobin c. Elevated liver enzymes d. Decreased amylase and lipase ANS: C Most antiretrovirals can also cause damage to the liver or kidneys (hepatotoxic or nephrotoxic).

DIF:

Cognitive Level: Understanding

REF: p. 102

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? a. Pancreatitis b. Kidney failure c. Vertebral fracture d. Acute gallbladder infection 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

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? 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.”

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

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? 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.

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

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? 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.”

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

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? 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.”

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

DIF:

Cognitive Level: Applying

REF: p. 101

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

ANS: A Efavirenz is a nonnucleotide analog reverse 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

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.) 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 a while.” f. “HIV is not currently curable, but drug therapy slows the advance of the disease.”

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

Chapter 07: Drugs for Allergy and Respiratory Problems Visovsky: Introduction to Clinical Pharmacology, 9th Edition MULTIPLE CHOICE 1. Which statement regarding the action of decongestants is true? a. Decongestants act by decreasing inflammation within the respiratory tract. b. Decongestants must be used cautiously as they can induce asthma attacks. c. Decongestants act primarily to reduce symptoms associated with allergy. d. Decongestants act by reducing the immune response of lymphocytes.

ANS: C

Decongestants are a class of drugs that are used to control the symptoms associated with allergy. They have no anti-inflammatory action.

DIF: Cognitive Level: Understanding

REF: p. 112

2. A patient with allergies has been prescribed an antihistamine. Which response by the

patient demonstrates understanding of the action of antihistamine drugs? a. “Antihistamines act by increasing the production of acetylcholine” b. “Antihistamines act by blocking histamine receptors in tissues” c. “Antihistamines act by increasing dilation of blood vessels” d. “Antihistamines act by blocking the release of histamine” ANS: B

Antihistamines do not block the release of histamine, but rather, block histamine receptors in target tissues which in turn limit the blood vessel vasodilation, capillary leak, swelling, and bronchoconstriction.

DIF: Cognitive Level: Applying

REF: p. 107

3. An older adult patient with glaucoma reports taking an antihistamine for allergy

symptoms. What adverse effect of antihistamines would you alert this patient about? a. Ototoxicity b. Ocular “floaters” c. Excessive tearing d. Increased intraocular pressure ANS: D

A rising intraocular pressure (pressure inside the eye) in patients with glaucoma can worsen the disease and could cause blindness.

DIF: Cognitive Level: Applying

REF: p. 110

4. Which statement would be true in teaching a patient with hypertension about taking

antihistamines? a. Antihistamines need to be taken 2 h apart. b. Antihistamines can cause the blood pressure to rise. c. Antihistamines can cause a slowing of the pulse rate. d. Antihistamines must be taken at the same time as antihypertensives.

ANS: B

A rise in blood pressure is an adverse action of antihistamines.

DIF: Cognitive Level: Applying

REF: p. 110

5. What is a common side effect of inhaled anti-inflammatory drugs for asthma? a. Anemia b. Bronchoconstriction c. Cutaneous itching d. Dry mouth ANS: D

Anti-inflammatory drugs reduce inflammation and dry all mucous membranes including those in the mouth and throat. They would reduce any cutaneous (skin) itching. They do not work on bronchial smooth muscles or the bone marrow (which produces red blood cells).

DIF: Cognitive Level: Remembering

REF: p. 110

6. Which type of asthma problem is helped most directly by anti-inflammatory drugs? a. Thick mucus b. Mucosal swelling c. Bronchoconstriction d. Large, flabby alveoli ANS: B

Anti-inflammatory drugs reduce inflammation and do not help bronchoconstriction. They directly inhibit mucosal swelling and, thus indirectly, reduce mucosal production of mucus. They do not affect mucous that has already formed. Flabby alveoli are not caused by inflammation.

DIF: Cognitive Level: Remembering

REF: p. 114

7. Which patient would not be a candidate for a leukotriene inhibitor as part of the treatment

plan for mild asthma? a. An adult patient with a history of liver disease b. An older patient with cognitive impairment c. An adolescent with allergic rhinitis d. A patient with depression ANS: A

Liver dysfunction is possible with long-term use. The leukotriene inhibitors interact with drugs that stimulate liver metabolism such as phenytoin, phenobarbital, and carbamazepine, and rifampin.

DIF: Cognitive Level: Applying

REF: p. 111

8. An adolescent with a history of asthma needs a drug to prevent exercise-induced asthma

while playing high school sports. Which drug would be appropriate for this use? a. Cromolyn sodium b. Theochron c. Sus-Phrine

d. Proventil ANS: A

Cromolyn sodium is used for prophylaxis in treating asthma. It works by slowing down the destruction of sensitized mast cells and inhaled specific antigens.

DIF: Cognitive Level: Applying

REF: p. 110

9. You are teaching a patient with newly diagnosed asthma about using the prescribed drugs

to manage acute asthma symptoms. Which of the following statements made by the patient would indicate your teaching was effective? a. “I will keep my short-acting bronchodilating inhaler with me at all times.” b. “I will take my cromolyn sodium 5 min after asthma symptoms begin.” c. “I will take montelukast (Singulair) at the first sign of an asthma attack.” d. “I will take my decongestant and corticosteroid nasal spray each day.”

ANS: A

Teach patients with asthma to always have their short-acting beta2-adrenergic agonists (SABAs) reliever drug with them at all times because an attack can occur anywhere and only a SABA can work fast enough to prevent a severe attack and death.

DIF: Cognitive Level: Applying

REF: p. 116

10. What is the most common route used to deliver short-acting beta-adrenergic agonists? a. Oral b. Intravenous c. Transdermal d. Inhalation ANS: D

Short-acting beta-adrenergic agonists work directly on the airways. They are delivered by oral inhalation so that their effects are exerted almost exclusively on the airway tissues.

DIF: Cognitive Level: Remembering

REF: p. 116

11. Why are long-acting beta-adrenergic agonists not useful during an actual acute asthma

attack? a. They are likely to cause allergies. b. They need time to build up an effect. c. They take too long to be absorbed by the intestinal tract. d. They reduce inflammation rather than relax bronchial smooth muscle.

ANS: B

Long-acting beta2-adrenergic agonists (LABAs) work in the same way as SABAs but need time to build up an effect. Therefore LABAs are used to prevent an asthma attack because their effects last longer but have no value during an acute attack.

DIF: Cognitive Level: Understanding

REF: p. 116

12. Which of the following patients is most at risk for overdose from the oral mucolytic drug

guaifenesin? a. A 38-year-old patient who had surgery 4 days ago

b. A 60-year-old with a history of COPD c. An adolescent with a history of asthma d. A 1-year-old child with a cold and cough ANS: D

Because of cases of overdosage, the FDA recommends that these products not be given to children under 2 years old and some products not to children under 6 years old.

DIF: Cognitive Level: Applying

REF: p. 120

13. Which statement made by the patient demonstrates understanding of the use of oral

mucolytics? a. “I will not use a humidifier while taking this drug.” b. “This drug will stop me from coughing.” c. “I will drink at least 2 quarts of water while taking this drug.” d. “This drug will cause my urine to change color.”

ANS: C

Patient instructions should include the use of a humidifier and instruct the patient to drink at least 2 quarts of water daily while taking a mucolytic unless there is a medical reason for fluid restriction. These actions will help get the mucus out.

DIF: Cognitive Level: Applying

REF: p. 120

14. What information should be included in the teaching plan for a patient who is prescribed

an antitussive agent? a. “This drug can cause drowsiness.” b. “This drug can be taken for long periods of time.” c. “This drug contains codeine, but is not habit forming.” d. “Do not give this drug to adults, as this drug is for children’s use only.”

ANS: A

Side effects of antitussives include drowsiness and dizziness. Antitussives should be used only for short periods of time because they can be addictive. They are prescribed for adults.

DIF: Cognitive Level: Applying

REF: p. 122

15. What symptom should you alert a patient taking a codeine-based antitussive to be aware

of? a. b. c. d.

Diarrhea Insomnia Paresthesia Constipation

ANS: D

Codeine-containing antitussives may cause severe constipation.

DIF: Cognitive Level: Knowing

REF: p. 122

16. Why are xanthine agents seldom used to treat asthma now? a. They increase bronchial secretions at the same time that they induce bronchial

dilation. b. They have no role in preventing bronchoconstriction or inflammation. c. They are all given intravenously. d. They have severe systemic side effects.

ANS: D

The xanthines are powerful systemic drugs that have a narrow therapeutic range. They have many dangerous and systemic side effects, especially for the cardiovascular and neurologic systems.

DIF: Cognitive Level: Understanding

REF: p. 116

MULTIPLE RESPONSE 1. You are teaching an older adult patient about the antihistamine that was prescribed for the

treatment of allergies. Which instructions would be appropriate to include? (Select all that apply.) a. Antihistamines can cause drowsiness. b. Avoid alcohol while taking antihistamines. c. Drink additional fluids when taking antihistamines. d. Antihistamines can lower blood pressure in older patients. e. Take antihistamines around the clock to stabilize drug blood levels. f. Older patients can develop memory problems when using antihistamines.

ANS: A, B, C, F

Most antihistamines cause drowsiness, so additional sedatives and alcohol should be avoided. If not contraindicated, additional fluids counteract the dryness of mucus membranes experienced with antihistamines. These drugs should only be taken when needed, and can raise the blood pressure in older adults. Older adults can develop memory problems due to antihistamine use.

DIF: Cognitive Level: Applying

REF: p. 110

2. Cromolyn is effective in which situations? (Select all that apply.) a. Prophylaxis for asthma b. Management of allergies c. Prophylaxis for pneumonia d. Management of allergic rhinitis e. Management of postexercise bronchospasm f. Management of an acute exacerbation of asthma ANS: A, B, D, E

Cromolyn is effective for asthma prophylaxis; in patients with food allergies to prevent GI reactions; in patients with allergic rhinitis; and in asthma patients with postexercise bronchospasm. This drug should not be used to manage acute attacks of asthma, or pneumonia.

DIF: Cognitive Level: Knowing

REF: p. 112

3. Which responses are possible side effects of inhaled beta2 adrenergic agonists? (Select all

that apply.)

a. b. c. d. e. f.

Bad taste in the mouth Increased salivation Difficulty sleeping Rapid heart rate Hypotension Diarrhea

ANS: A, C, D

Beta2 adrenergic agonists have actions similar to the sympathetic division of the autonomic nervous system. When these drugs are used heavily, they can have systemic effects, which include rapid heart rate, increased blood pressure, a feeling of nervousness, and difficulty sleeping. The inhaled drugs can dry the mouth and throat and also may leave a bad taste in the mouth. These drugs, even when absorbed systemically, do not cause diarrhea.

DIF: Cognitive Level: Remembering

REF: p. 116

4. Which side effects should you monitor for after a patient receives ipratropium (Atrovent)?

(Select all that apply.) a. Eye pain b. Sore throat c. Stuffy nose d. Constipation e. Decreased heart rate f. Increased urine output ANS: B, C, D

Ipratropium (Atrovent) is a cholinergic antagonist drug. Cholinergic antagonists are associated with sore throat, stuffy nose and constipation. Patients should be educated to expect these common side-effects.

DIF: Cognitive Level: Understanding

REF: p. 117

Chapter 08: Drugs Affecting theRenal/Urinary and Cardiovascular Problems Visovsky: Introduction to Clinical Pharmacology, 9th Edition MULTIPLE CHOICE 1. Which body system works with the renal/urinary system to maintain fluid balance and remove waste products from the body? a. Biliary system b. Cardiovascular system c. Central nervous system d. Gastrointestinal system ANS: B The renal/urinary system works together with the cardiovascular system to maintain adequate circulation to all parts of the body. The interactions between these two systems help maintain fluid balance, delivery of nutrients, and removal of waste products from cells, tissues, and organs. Most drugs that affect one system have an effect on the functioning of the other system.

DIF:

Cognitive Level: Remembering

REF: p. 126

2. Which category of diuretic drugs exerts its mechanism of action in the collecting duct? a. Loop diuretics b. Thiazide diuretics c. Potassium-sparing diuretics d. Thiazide-like sulfonamide diuretics ANS: C Loop diuretics work in the ascending limb of the Loop of Henle. Thiazide diuretics and thiazide-like diuretics work at the end of the ascending loop of Henle and the beginning of the distal convoluted tubule. Only the potassium-sparing diuretics work at the collecting duct.

DIF:

Cognitive Level: Understanding

REF: p. 126

3. How do thiazide and thiazide-like diuretic drugs reduce high blood pressure? a. Reducing blood volume and relaxing vascular smooth muscle b. Increasing potassium excretion and slowing heart contractions c. Releasing sodium from cellular storage sites and preventing heart block d. Reducing the thirst response and increasing the amount of urine the bladder can hold ANS: A Blood pressure is maintained by fluid volume in circulation, the force of heart contractions, and the constriction of blood vessels that provide resistance. All diuretics help lower blood pressure by reducing the amount of fluid (volume) in the blood.

Thiazide and thiazide-like diuretics also relax blood vessel smooth muscle, which decrease vascular resistance to blood flow. The reduced volume and decreased resistance result in lower blood pressure.

DIF:

Cognitive Level: Understanding

REF: p. 126

4. Which precaution is most important for the LPN/VN to teach a patient newly prescribed to take 10 mg of amiloride (Midamor) orally daily? a. “Avoid the use of salt substitutes.” b. “Avoid aspirin and aspirin-containing products.” c. “Eat plenty of bananas and oranges to prevent complications.” d. “Report a decrease in hearing to your healthcare provider immediately.

ANS: A Amiloride is a potassium-sparing diuretic, and patients can develop dangerously high blood potassium levels while taking this drug. They must avoid extra potassium. Salt substitutes contain high levels of potassium and so do bananas and citrus fruits.

Amiloride does not interact with aspirin or aspirin-containing drugs.

DIF:

Cognitive Level: Applying

REF: p. 129

5. Which health problem is a potential side effect or adverse reaction of any class of diuretic drug? a. Dehydration b. Heart failure c. Blurred vision d. Urinary tract infection ANS: A Diuretics work by increasing the excretion of water through urination. When water loss is excessive, dehydration of the circulatory system or even the whole body can occur.

Diuretic therapy actually helps improve the symptoms of heart failure and do not cause blurred vision. Although a urinary tract infection can occur in a patient taking a diuretic, the drug is not the direct cause.

DIF:

Cognitive Level: Understanding

REF: p. 129

6. Which statement made by a patient taking a loop diuretic indicates the need for more teaching? a. “Since I work nights, I take my drug when I first wake up rather than in the morning.” b. “If my hearing decreases, I will notify my healthcare provider.” c. “I make sure to space my fluid intake evenly throughout the day.” d. “When I travel by car, I always skip my diuretic that day.”

ANS: D Although taking the time to urinate while traveling is inconvenient, the patient needs to understand that the drug must be taken every day. Often, patients are told to take the drug in the morning; it should be taken at the time furthest away from when the patient usually goes to bed so there is less interference with his or her normal sleep patterns.

Spacing fluid intake evenly throughout the day helps prevent dehydration. Loop diuretics can cause hearing loss and the patient should notify the healthcare provider if this develops even though his or her health problem may require that the drug be continued.

DIF:

Cognitive Level: Applying

REF: p. 130

7. Why is it important to warn a patient prescribed to take finasteride (Proscar) for benign prostatic hyperplasia to wear a condom when having sex with a pregnant woman or one who could become pregnant? a. The drug contains a hormone that can greatly increase the risk for having twins when absorbed by a pregnant woman. b. The drug can be absorbed by the pregnant woman and cause birth defects in the fetus. c. The drug reduces local immunity and increases the risk for transmitting HIV. d. The drug increases the risk for vaginal infections in pregnant women.

ANS: B The drug is a synthetic hormone that can be absorbed through the skin and mucous membranes. When the fetus is exposed, birth defects are possible. The drug does not increase the risk for any type of infection development or transmission. The drug does not increase the risk for having twins.

DIF:

Cognitive Level: Understanding

REF: p. 131

8. How does phenazopyridine help reduce the symptoms of a bladder infection (cystitis)? a. Increasing the strength of the bladder contraction b. Changing the color and the smell of the urine c. Killing off the bacteria causing the infection d. Reducing the irritation of the bladder ANS: D The drug is a bladder anesthetic that reduces the irritation of the bladder (which causes pain and the sensation of needing to urinate immediately). Phenazopyridine is not an antibiotic and cannot kill or cure a urinary tract infection. Although it does turn the urine a deep orange-red color, this alone does not reduce symptoms. The drug does not increase the strength of bladder contractions, which would only worsen some of the symptoms.

DIF:

Cognitive Level: Understanding

REF: p. 130

9. You are teaching a patient about drug therapy for hyperlipidemia. Which statement made by the patient indicates that more teaching is needed? a. “I am so thankful that my high cholesterol has been cured by this drug.” b. “I always try to drink just about the same amount of fluid that I urinate each day.” c. “I have been taking this drug just before I go to bed so that it has the greatest effect.” d. “I will keep regular appointments with my healthcare provider to assess for any organ complications.”

ANS: A

Drugs for hyperlipidemia do not cure the high cholesterol blood levels; they only help control the problem. If the patient stops taking the drug, blood cholesterol levels will increase. The drugs do not increase urine output or the risk for dehydration. Drinking as much fluid as gets urinated each day is a good practice for anyone. Taking some of the drugs, especially the statins before bed is good because the body’s production of cholesterol generally occurs at night.

DIF:

Cognitive Level: Applying

REF: p. 135

10. Why are “statins” avoided during pregnancy and breast-feeding? a. These drugs cause hypotension in the fetus and infant. b. These drugs are associated with development of autism. c. They lower cholesterol levels in the fetus and infant. d. They can lead to miscarriage and early pregnancy loss.

ANS: C Statins can be dangerous to use during pregnancy because cholesterol is important for normal brain development. If taken during pregnancy, statins can lower the cholesterol levels in the fetus, which results in brain deformities.

DIF:

Cognitive Level: Knowing

REF: p. 135

11. A patient who has been taking atorvastatin for 6 months reports that he has stopped exercising because his muscles and joints are always so sore. What is the nurse’s best action? a. Document the report as the only action. b. Assess the patient’s range of joint motion. c. Hold the drug and notify the healthcare provider immediately. d. Suggest that the patient continue to exercise but take aspirin an hour before starting.

ANS: C Muscle weakness and joint soreness can signal the serious condition of muscle breakdown known as rhabdomyolysis. It may also be a mild issue. Only the healthcare provider will know whether the patient needs to discontinue the drug completely or continue the drug. Therefore, the best action is to notify the healthcare provider of this new and potentially serious complication.

DIF:

Cognitive Level: Applying

REF: p. 135

12. Which precaution is most important to teach patients who are taking any “statin” drug? a. “Eat plenty of bananas and oranges to prevent low blood potassium levels.” b. “Avoid using aspirin or any aspirin-containing products and drugs.” c. “Be sure to take this drug right before you eat a high fat meal.” d. “Avoid drinking alcohol and taking acetaminophen.”

ANS: D

All “statins” work in the liver to reduce liver production of cholesterol and all can cause liver impairment. Patients must be taught to avoid other drugs and agents that are harmful to the liver while they are taking these drugs. Two very common liver-damaging agents are alcohol and acetaminophen.

DIF:

Cognitive Level: Applying

REF: p. 135

13. How do bile acid sequestrants work to lower blood lipids? a. Increasing the intestinal excretion of dietary fat b. Preventing the liver from making excess lipids c. Moving blood fats into blood vessel linings d. Increasing kidney excretion of blood lipids ANS: A Bile acids are present in the intestinal tract and contain large amounts of cholesterol. Bile acid sequestrants help the body lose cholesterol. The drugs are taken by mouth and work directly on dietary fats in the intestine. They bind with bile acids (and cholesterol) in the intestine, preventing them from being absorbed into the blood. This action then eliminates the cholesterol from the body through the stool. These drugs prevent liver production of cholesterol nor do they move blood fats into blood vessel linings. The kidney does not excrete blood lipids.

DIF:

Cognitive Level: Understanding

REF: p. 137

14. What are the most common side effects of any drug used to manage hypertension? a. Headache and an increased risk for nose bleeds b. Low blood pressure and an increased risk for falls c. Water retention and an increased risk for low sodium levels d. Low potassium levels and in increased risk for hearing loss ANS: B The main purpose of any drug category used to manage hypertension is to lower blood pressure by a variety of mechanisms. If the blood pressure drops rapidly, patients can become lightheaded and have an increased risk for falls, especially older adults. Some but not all drugs for hypertension alter sodium and potassium levels. The only drug category associated with hearing loss after chronic use is loop diuretics.

DIF:

Cognitive Level: Understanding

REF: p. 139

15. Which category of drugs for hypertension has the potential to make heart failure worse? a. Angiotensin receptor blockers b. Beta blockers c. Calcium channel blockers d. High ceiling “loop” diuretics ANS: C One mechanism of action for the calcium channel blockers is to relax vascular smooth muscle, causing vasodilation and some degree of fluid retention. Fluid retention makes heart failure worse. These drugs should be avoided in patients with heart failure.

DIF:

Cognitive Level: Understanding

REF: p. 142

16. A patient who has been taking lisinopril for 2 years calls the clinic to report that her tongue and lips are swelling, making it hard for her to talk and swallow. What is your priority action? a. Take a complete history of all her allergies over the phone. b. Suggest that she take 25 mg of diphenhydramine as soon as possible. c. Tell her to go to the nearest emergency department or call 911 right now. d. Tell her that you will notify her healthcare provider for more instructions.

ANS: C Tongue and lip swelling are indications of the serious adverse reaction of angioedema. It represents an allergic reaction that can continue to spread until the airway is completely blocked. Waste no time taking a history or notifying the healthcare provider. Send her to the nearest emergency department. Suggesting drugs is not in your scope of practice as an LPN/VN. DIF:

Cognitive Level: Applying

REF: p. 142

17. Which statement made by a patient who is prescribed to take clonidine twice daily indicates the need for more teaching? a. “When I get out of bed, I will take my time changing positions.” b. “If I forget my drug doses one day, I will take double doses the next day.” c. “If I get a cold, I will check with my healthcare provider before taking a cold drug.” d. “To determine how well my drugs are working, I will take my blood pressure every day.”

ANS: B Although rebound hypertension can occur with any antihypertensive drug, it is more common when doses of clonidine are missed. Taking twice as much the next day will cause severe hypotension. Even when both doses are missed on one day, the drug is taken when the patient remembers it at the prescribed dosage.

DIF:

Cognitive Level: Applying

REF: p. 147

18. A patient newly prescribed to take propranolol for hypertension has all of the following health problems. For which one will you check with the healthcare provider before giving? a. Asthma b. Cataracts c. Atrial fibrillation d. Benign prostatic hyperplasia ANS: A Propranolol is a nonselective beta blocking drug that blocks beta1 receptors (in the heart) and beta2 receptors (in the lungs and airways) equally. When beta2 receptors are blocked, airways are constricted, which can cause an asthma attack or worsen one already in progress. It should not be prescribed for patients who have asthma.

DIF:

Cognitive Level: Applying

REF: p. 141

19. When checking a patient’s blood pressure before giving a drug specifically prescribed for hypertension, the reading is 84/50 mm Hg. What is your best action? a. Change the patient’s position and reassess the blood pressure in 15 min. b. Document the finding as the only action and give the drug as usual. c. Assess the patient’s ankles for peripheral pulses and edema. d. Hold the dose and notify the healthcare provider.

ANS: D This patient’s blood pressure is quite low. If the patient is receiving this drug because he or she has hypertension and not for heart failure, another dose of the drug right now could make the patient's blood pressure dangerously low. Sometimes a patient may be prescribed an antihypertensive drug for another reason. You must check with the prescriber before giving this drug dose now.

DIF:

Cognitive Level: Applying

REF: p. 139

20. A nursing home patient who currently takes furosemide is now prescribed to receive the first dose of losartan. You are aware that both drugs are used to manage hypertension.

What is your best action? a. Give both drugs as prescribed. b. Give the drugs at least 6 h apart. c. Notify the healthcare provider that this patient already takes a drug for hypertension. d. Assess the patient’s blood pressure to determine whether his or her hypertension is classified as normal, prehypertension, stage I, or stage II. ANS: A Sometimes hypertension is not well controlled using only one antihypertensive agent.

Often two drugs from different classes are prescribed for better control. Losartan is an angiotensin II receptor blocker and furosemide is a “loop” diuretic. They have different mechanisms of action to lower blood pressure and can be taken together.

DIF:

Cognitive Level: Applying

REF: p. 139

21. By which mechanism or mechanisms do the nitrates help angina and heart failure? a. Increasing preload and increasing afterload b. Increasing preload and decreasing afterload c. Decreasing preload and increasing afterload d. Decreasing preload and decreasing afterload ANS: D Nitrates are a category of drugs that vasodilate (widen blood vessels) by relaxing vascular smooth muscle in the peripheral venous system and reducing resistance to blood flow in the arterial system. Relaxing the smooth muscle in the veins helps increase pooling of venous blood, thereby decreasing the amount of blood returned to the heart (preload). Relaxing the arterial system decreases the pressures the heart has to pump against (afterload). These effects work together to help the heart get more oxygen and pump more easily.

DIF:

Cognitive Level: Understanding

REF: p. 147

22. You are assessing the knowledge of a patient who has been using nitroglycerine for about a year as needed for angina. Which statement indicates the need for more teaching? a. “I always get my prescription refilled every 3 months even when there are tablets left in the bottle.” b. “I know that my nitroglycerine is working when it tingles under my tongue and my chest pain goes away.” c. “I always carry at least three tablets with me in a baggie my purse in case I have chest pains while I am out.” d. “I only drink one cup of coffee (decaffeinated) each day because caffeine can interfere with the effectiveness of the nitroglycerine.”

ANS: C Nitroglycerine tablets degrade quickly, especially when exposed to light and humidity.

They should always be stored in a dark glass bottle with a tight lid. A baggie could allow them to degrade so quickly they would not be effective when the patient needs them. The shelf life is 3 months. Caffeine can interfere with the drug’s effectiveness.

DIF:

Cognitive Level: Applying

REF: p. 148

23. Which factor or symptom is used to determine the most effective drug class to manage a patient’s cardiac dysrhythmia? a. The cause of the dysrhythmia b. The age of the patient c. Whether the patient has a pacemaker d. Which other drugs the patient takes daily ANS: A The cause of the dysrhythmia determines which drug class will be most effective for treatment. Whatever the abnormal rhythm, the goal is to restore the rhythm to normal and maintain adequate cardiac output.

DIF:

Cognitive Level: Remembering

REF: p. 150

24. What is the most important action to take or assessment to make before giving any drug for dysrhythmia to a patient? a. Taking the blood pressure in both arms b. Listening to the apical pulse for a full minute c. Assessing the legs and feet for peripheral edema d. Checking the results of the most recent ECG ANS: B Most, if not all, drugs for dysrhythmia can cause cardiac dysrhythmias as well as help them. Peripheral pulses are not reliable for checking the dysrhythmias. It is important to listen to the apical pulse with a stethoscope for a full minute to determine the accurate rate and rhythm.

DIF:

Cognitive Level: Applying

REF: p. 151

25. What specific effect on the heart does a drug with a positive inotropic action have? a. Increased heart rate b. Decreased heart rate c. Increased pumping action d. Decreased pumping action ANS: C The term inotrope is used to describe contractility of the heart. An inotropic drug affects contractility of the myocardium (heart muscle). A drug that is a positive inotrope increases contractility; a negative inotropic drug decreases contractility of the myocardium. In heart failure, positive inotropic drugs increase contractility of the heart (in other words, increases the ability of the heart to pump). Drugs that are inotropic may either increase or decrease heart rate. The heart rate is not the target of an inotropic agent.

DIF:

Cognitive Level: Understanding

REF: p. 153

26. What is the most common adult dosage of digoxin? a. 125 mg b. 12.5 mg c. 1.25 mg d. 0.125 mg ANS: D Digoxin is a powerful drug with a narrow therapeutic range. Normal dosages are much lower than that of other drugs. The most common usual adult dose is 0.125 mg.

DIF:

Cognitive Level: Knowing

REF: p. 153

MULTIPLE RESPONSE 1. A 70-year-old has been prescribed a “loop” diuretic to manage hypertension. Which side effects are most important to assess for in this patient? (Select all that apply.) a. High blood glucose levels b. Low blood glucose levels c. High blood potassium levels d. Low blood potassium levels e. High blood sodium levels f. Low blood sodium levels ANS: A, D, F Loop diuretics increase the loss of both sodium and potassium in the urine. In addition, these drugs can increase blood glucose levels, especially in older adults.

DIF:

Cognitive Level: Understanding

REF: p. 129

2. A woman taking tolterodine for overactive bladder tells you that she now has all the following changes noted below. Which ones will you report to the healthcare provider?

(Select all that apply.) a. Blurred vision b. Chest pain c. Drowsiness d. Dry mouth e. Irregular heart rate f. Swollen ankles ANS: B, E, F The drug can cause cardiac adverse reactions and heart failure. Chest pain, irregular heart rate, and swollen ankles are symptoms of serious cardiac problems and must be reported to the healthcare provider for immediate investigation. Tolterodine has anticholinergic side effects that are expected and are not indications of adverse events.

These include blurred vision, drowsiness, and dry mouth.

DIF:

Cognitive Level: Applying

REF: p. 132

3. Which symptoms are indicators of digoxin toxicity? (Select all that apply.) a. Bitter taste b. Blurred vision c. Nausea and vomiting d. Palpitations e. Tingling of the fingers and toes f. Urinary retention ANS: B, C, D Signs of digoxin overdose (toxicity) include nausea, vomiting, loss of appetite, diarrhea, and vision problems. Other signs include heart rate or rhythm changes, palpitations, and fainting. When these signs and symptoms occur, hold the dose and notify the healthcare provider.

DIF:

Cognitive Level: Knowing

REF: p. 154

4. Which precautions are most important to teach the caregiver of a home care patient who is prescribed nitroglycerine patches? (Select all that apply.) a. Remove old patches before applying new ones. b. Before applying a new patch, dab a little on your tongue to check for a tingling sensation that indicates the drug is active. c. If a rash develops under a patch, discontinue the drug. d. Rotate the placement of the patch to new areas. e. Use sterile technique when applying patches. f. Do not apply patches to areas where the skin is open or irritated. g. Keep the patches in the refrigerator until they are used. h. Return old patches back to the pharmacy for refilling.

ANS: A, D, F

Old patches are removed before new ones are applied to ensure correct drug dose. The caregiver should not touch the drug with his or her tongue or skin to prevent absorbing the drug and having it affect his or her own heart function. If a rash develops just under the patch, it is local irritation and not a reason to discontinue the drug (but should be reported to the healthcare provider). Patch placement should be rotated to prevent skin irritation. Clean technique, not sterile technique is used to apply transdermal patches. If patches are applied to skin areas that are open or irritated, drug absorption is not even.

Patches do not need to be refrigerated. Patches are discarded, not refilled.

DIF:

Cognitive Level: Applying

REF: p. 149

COMPLETION Drug Calculation Problems 1. The patient is prescribed to receive 40 mg of furosemide by IV push at a rate of 10 mg per minute. The vial of furosemide on hand has a concentration of 20 mg/mL. A. How many mL will you give for the correct dose?

ANS: 2 Want 40 mg Have 20 mg/mL 40 divided by 20 = 2 mL 2. The patient is prescribed to receive 40 mg of furosemide by IV push at a rate of 10 mg per minute. The vial of furosemide on hand has a concentration of 20 mg/mL. How many mL will you give per minute?

ANS: 0.5 If the concentration is 20 mg/mL, then 10 mg (maximum dosage per minute) is 0.5 mL (10 divided by 20 = 0.5) 3. The patient is prescribed to receive 40 mg of furosemide by IV push at a rate of 10 mg per minute. The vial of furosemide on hand has a concentration of 20 mg/mL. How many total minutes are required to give 40 mL at a rate of 10 mg/minute?

ANS: 4 40 mg divided by 10 mg (maximum dosage per minute) = 4 minutes 4. A patient who weighs 220 lb is to receive labetalol 0.25 mg/kg intravenously. The solution of labetalol on hand is 100 mg/20 mL. How many mL of labetalol will you prepare for a correct dose? _______

ANS: 5 1 kg = 2.2 lb 220 lb divided by 2.2 = 100 kg.

100 kg  0.25 mg = 25 mg 100 mg/20 mL = 5 mg/1 mL 25 divided by 5 = 5 mL

Chapter 09: Drug Therapy for Central Nervous System Problems Visovsky: Introduction to Clinical Pharmacology, 9th Edition MULTIPLE CHOICE 1. Which neurotransmitter has an inhibitory action within the central nervous system? a. Epinephrine b. Acetylcholine c. Norepinephrine d. Gamma-aminobutyric acid ANS: D Neurotransmitters can be excitatory or inhibitory. Excitatory neurotransmitters include acetylcholine (Ach), epinephrine, and norepinephrine. Inhibitory neurotransmitters include dopamine, some types of serotonin, and GABA (gamma-aminobutyric acid).

DIF:

Cognitive Level: Knowing

REF: p. 159

2. How does the drug tolcapone relieve the symptoms of Parkinson disease? a. Acts as a dopamine agonist, replacing the activity of dopamine b. Forces the substantia nigra to increase the production and release of natural dopamine c. Suppresses the activity of an enzyme that normally breaks down naturally occurring dopamine d. Increases the number of dopamine receptors sites throughout the central nervous system, thus increasing the effectiveness of dopamine and dopamine agonists ANS: C Catechol-O-methyltransferase (COMT) is an enzyme that breaks down (metabolizes) naturally occurring catecholamine-based neurotransmitters, including dopamine. It also breaks down dopamine agonist drugs. Catechol-O-methyltransferase (COMT) inhibitors are drugs that suppress the activity of the COMT enzyme so both naturally occurring dopamine and dopamine agonist drugs remain active in the body longer, helping to restore the acetylcholine–dopamine balance in the brain. Entacapone (Comtan) and tolcapone (Tasmar) are two COMT inhibitors that are used currently for PD. DIF:

Cognitive Level: Understanding

REF: p. 162

3. Why are carbidopa and levodopa usually given together? a. Carbidopa is a dopamine agonist and levodopa is a dopamine antagonist. b. Levodopa is a dopamine agonist and carbidopa is a dopamine antagonist. c. Carbidopa enhances the action of levodopa, and less drug is needed. d. Levodopa reverses or prevents the side effects of carbidopa.

ANS: C Carbidopa is usually given in combination with levodopa because it enhances the levodopa so lower doses of levodopa can be used, thus preventing the nausea and vomiting that accompanies the continual increasing of the levodopa dose to control disease symptoms.

DIF:

Cognitive Level: Understanding

REF: p. 163

4. When assessing a patient with Parkinson disease who takes a carbidopa/levodopa combination drug, you find that he now has almost constant muscle movements that look like uncoordinated dancing. What is your best action? a. Document the finding as the only action. b. Hold the next drug dose and report the finding to the healthcare provider. c. Give the next dose earlier than scheduled because the drugs are wearing off. d. Request that the healthcare provider prescribe a one-time dose of a muscle relaxant.

ANS: B The most common adverse reaction to carbidopa/levodopa is dyskinesia, involuntary muscle movements that look like uncoordinated dance movements. Dyskinesia is common in patients on long-term carbidopa/levodopa therapy (longer than 3 years).

Usually, this adverse effect requires the healthcare provider to adjust the drug therapy for Parkinson disease.

DIF:

Cognitive Level: Applying

REF: p. 163

5. A patient newly diagnosed with Parkinson disease is prescribed an oral dopamine agonist. Which precaution is most important to teach the patient and family about the timing for taking this drug? a. “Take the drug 30 to 60 min before meals on an empty stomach.” b. “Take the drug 30 to 60 min after eating a high protein meal.” c. “Take the drug first thing in the morning before getting out of bed.” d. “Take the drug when your symptoms are at their worst.”

ANS: A Dopamine agonists should be taken 30 to 60 minutes before a meal, so patients have an easier time swallowing. An empty stomach is best to enhance absorption. Patients must be taught to avoid taking the drug with or shortly after eating protein because protein reduces the effectiveness of these drugs.

DIF:

Cognitive Level: Applying

REF: p. 162

6. When asking the family of a patient with Alzheimer’s disease who takes the drug donepezil (Aricept) what other prescribed or over-the-counter drugs the patient takes, they list all the following drugs. Which one will you tell them to stop giving the patient? a. Aspirin b. Buspirone c. Vitamin C d. Dextromethorphan ANS: D Dextromethorphan, a common over-the-counter cough drug, can cause long Q-T syndrome. When taken with donepezil, a fatal dysrhythmia known as torsade de pointe, a form of ventricular tachycardia, can occur as a result of the interaction.

DIF:

Cognitive Level: Applying

REF: p. 167

7. When admitting a new patient with Alzheimer’s to a memory unit of a long-term care facility, you note that she is prescribed both memantine and rivastigmine. What is your best action? a. Give both drugs as prescribed. b. Ask the patient when she usually takes these drugs. c. Notify the prescriber that both drugs are for Alzheimer’s disease. d. Give the memantine one odd-numbered days and rivastigmine on even-numbered days.

ANS: A Although both drugs are used for Alzheimer’s disease, they have very different actions and both can be used at the same time. Memantine is usually given with rivastigmine and other cholinergic agonists because it increases the effectiveness of these other drugs.

DIF:

Cognitive Level: Applying

REF: p. 167

8. A family member of a patient using the rivastigmine patches reports that the patient keeps taking the patches off his chest. Where will you suggest the family member apply the patches to avoid this problem? a. On the forehead b. On the buttocks c. On the upper or lower back d. On the outer aspect of the thigh ANS: C Apply the patch to areas that the patient cannot see and would have a hard time reaching.

The recommended area is the upper or lower back to avoid removal by the patient.

DIF:

Cognitive Level: Applying

REF: p. 168

9. A patient is prescribed to receive memantine extended release (XR) 14 mg orally once daily. You have on hand memantine XR 7-mg capsule and memantine 28-mg capsule.

What is the best way to ensure the patient gets a 14-mg dose? a. Give the patient two 7-mg capsules every day. b. Give the patient one 28-mg capsule every other day. c. Cut the 28-mg capsule in half and give the patient one of the halves. d. Open a 28-mg capsule, empty it into a drug cup, divide the contents in half, and give one half to the patient.

ANS: A Whenever possible, it is best not to open an extended-release capsule. For some drugs, such as memantine, a capsule can be opened, and the entire contents sprinkled on food if the patient has difficulty swallowing the capsule whole. However, it is not possible to divide the contents well enough to ensure an accurate dose. So, the best action in this situation is to give two 7-mg capsules to equal the 14-mg prescribed dose.

DIF:

Cognitive Level: Understanding

REF: p. 168

10. When assessing a patient before starting the first dose of a newly prescribed antiepileptic drug, what is the most important nursing action to perform? a. Determine the type of aura a patient usually has before a seizure. b. Obtain an accurate weight because most drug dosages are based on weight. c. Ask the patient about all other prescribed or over-the-counter drugs he or she takes daily. d. Ensure that oxygen and suction equipment are in the patient’s room and in good working order.

ANS: C All actions are reasonable and helpful. The most important assessment information is determining all other drugs the patients take. Antiepileptic drugs have many drug interactions that can lead to adverse reactions.

DIF:

Cognitive Level: Applying

REF: p. 171

11. Why is intramuscular (IM) injection of phenytoin avoided? a. Rapid absorption can cause bradycardia. b. The drug is very irritating to the tissues. c. Gum hyperplasia is worsened by IM injection. d. The drug is a known teratogen that can induce birth defects.

ANS: B Giving phenytoin by the IM route results in pain and discomfort (and sometimes damaged tissue) because it is a severe tissue irritant. The best routes are oral and intravenous. All routes of this drug can cause bradycardia, gum hyperplasia, and birth defects.

DIF:

Cognitive Level: Understanding

REF: p. 172

12. When reviewing the preoperative laboratory results of a patient taking oxcarbazepine for seizure control, you note all of the following values. For which one will you notify the surgeon immediately? a. White blood cell count 8700 per mm3 b. Serum sodium level of 128 mEq/L c. International normalized ratio (INR) 0.9 d. Serum chloride level of 100 mEq/L ANS: B The serum sodium level is well below normal (136–145 mEq/L), which means the patient has hyponatremia. This problem is a common side effect of oxcarbazepine and must be corrected before surgery to prevent serious complications.

DIF:

Cognitive Level: Applying

REF: p. 174

13. Which precaution is most important to tell parents of young children prescribed lamotrigine for epilepsy? a. “Give this drug to your child at night only to prevent dizziness.” b. “Ensure that your child takes a multiple vitamin daily while he or she is on this drug.”

c. “Check your child daily for a rash and call your healthcare provider immediately if one develops.” d. “Weigh your child weekly and be sure to report a weight loss of 2 lb or more to your healthcare provider at your next visit.”

ANS: C Lamotrigine can cause life-threatening rashes (including Stevens–Johnson syndrome and toxic epidermal necrolysis). It has a black box warning that states to discontinue the drug immediately if any rash appears during treatment. Although this problem can occur at any age, it is more likely to occur in children. Although the drug interferes with the formation of folic acid, an important vitamin, and some patients may become folic acid deficient, a typical multiple vitamin does not contain enough folic acid to prevent this problem. Weight loss is not associated with this drug.

DIF:

Cognitive Level: Applying

REF: p. 175

14. A patient taking lacosamide tells you that he never forgets to take his prescribed doses because he feels so good and happy when he is on the drug. What is your best response? a. “Anything that helps you remember to take your drug on time is helpful in preventing seizures.” b. “Even though you feel good on this drug, do not increase the dose or number of times you take it.” c. “Probably knowing that you are less likely to have a seizure is contributing to these positive feelings.” d. It is important to remember that taking the drug at a different time of day may change your feelings.”

ANS: B Many people taking lacosamide experience euphoria, a feeling of intense well-being and happiness. This is considered an adverse reaction because it can lead to psychological dependence (but not addiction). Patients must be warned not to take more of the drug or take it more often to maintain these feelings.

DIF:

Cognitive Level: Applying

REF: p. 177

15. Which drug to manage multiple sclerosis should be avoided by patients who also have epilepsy? a. Beta-interferon b. Daclizumab c. Dalfampridine d. Tecfidera ANS: C Dalfampridine lowers the seizure threshold and increases the risk for seizure activity.

DIF:

Cognitive Level: Knowing

REF: p. 179

16. What is the most important precaution to teach patients taking any monoclonal antibody or neurologic drug to manage multiple sclerosis? a. “Avoid crowds and people who are sick.”

b. “Always wear protective clothing or sunscreen when outdoors.” c. “Report any weight loss immediately to your healthcare provider”. d. “Rest as much as possible and avoid any weight-bearing activities.”

ANS: A The monoclonal antibodies and neurologic drugs currently prescribed to help manage multiple sclerosis all reduce immunity and inflammation, increasing the risk for infection.

DIF:

Cognitive Level: Applying

REF: p. 180

MULTIPLE RESPONSE 1. Which symptoms in a patient taking levodopa for Parkinson disease indicate the drug is “wearing off?” (Select all that apply.) a. Decreased muscle tone b. Difficulty swallowing c. Dry mouth d. Increased appetite e. Increased tremors f. Slower gait ANS: B, E, F Levodopa is a dopamine agonist that restores balance between excitatory and inhibitory input to motor responses. When it wears off, the symptoms of Parkinson disease return or become worse. These include muscle movements that are hard to control and jerky with rigidity because they fail to relax sufficiently. The gait becomes slow and shuffling with short steps. Other common symptoms of PD include tremors, stooped posture, difficulty stopping motion once it has started, difficulty chewing and swallowing, and drooling.

DIF:

Cognitive Level: Applying or higher

REF: p. 163

2. Which changes are most important to assess for in a patient who is taking topirimate for seizure control? (Select all that apply.) a. Weight loss b. Decreased seizure activity c. Warm flushed skin d. Insomnia e. Pain at the IV site f. Decreased heart rate ANS: B, C, F Patients taking any antiepileptic drug should be assessed for changes in seizure activity to determine drug effectiveness. Topirimate can cause metabolic acidosis and the patient should be assessed for its symptoms on a regular basis. These symptoms include slow heart rate, hypotension, muscle weakness, and warm, flushed skin.

DIF:

Cognitive Level: Applying

REF: p. 175

COMPLETION 1. A patient in your long-term care facility is prescribed to receive a total of 24 mg of ropinirole daily in three divided doses. The drug on hand is ropinirole 4 mg/tablet. How many tablets will you give for one dose? _______ ANS: 2 24 mg/day in 3 divided doses = 24/3 or 8 mg/dose Want 8 mg Have 4 mg/tablet 8 mg divided by 4 mg = 2 tablets 2. The healthcare provider orders valproic acid at 10 mg/kg orally every 12 hours. The patient weighs 160 lb. How many mg will you give for each dose? How many mg is the total daily dose? _______ ANS: 1500 mg Patient weight in lb is 160. 1 kg = 2.2 lb. 160 lb divided by 2.2 kg = 74.7 kg, round up to 75 kg.

10 mg  75 kg = 750 mg/dose 750 mg  2 doses = 1500 mg total daily dose 3. Order: lamotrigine 250 mg orally twice daily.

Have: lamotrigine 100-mg tablets How many tablets of lamotrigine are needed for the correct dose? _______ ANS: 2.5 Want lamotrigine 250 mg; have lamotrigine 100 mg Divide 250 mg by 100 mg/tablet = 2.5 tablets

Chapter 10: Drug Therapy for Mental Health Visovsky: Introduction to Clinical Pharmacology, 9th Edition MULTIPLE CHOICE 1. Which drug category is useful in promoting sleep among patients with insomnia? a. Sedatives b. ACE inhibitors c. Atypical antipsychotics d. Selective serotonin reuptake inhibitors ANS: A Sedatives are drugs that have the main purpose of promoting sleep by changing signals in the central nervous system and reducing responses to stimulation.

DIF:

Cognitive Level: Knowing

REF: p. 184

2. You are preparing to give the benzodiazepine Valium to a patient as a premedication before surgery. The patient asks you how this drug works. What is your best response? a. “This drug works by binding to receptors acting with GABA to induce sleep.” b. “This drug is acts by preventing binding to the benzodiazepine receptors.” c. “This drug acts by inhibiting GABA responses to relax muscles.” d. “This drug acts by binding to opioid receptors.”

ANS: A Benzodiazepines are sedating hypnotic drugs that depress the CNS by binding to benzodiazepine (BNZ) receptors that act with gamma-aminobutyric acid (GABA) receptors to enhance GABA effects, resulting sleep and muscle relaxation.

DIF:

Cognitive Level: Applying

REF: p. 186

3. You are caring for a patient in the clinic setting who has been taking a benzodiazepine alprazolam (Xanax) for anxiety. What potential problem should you observe this patient for? a. Seizure activity b. Addiction c. Insomnia d. Anorexia ANS: B The benzodiazepines have a higher risk for addiction and dependency than do the nonbenzodiazepines. They also carry a black box warning for central nervous system depression. Overdoses are possible and serious.

DIF:

Cognitive Level: Understanding

REF: p. 185

4. Which drug would you anticipate will be given to a patient who experienced an overdose of a benzodiazepine? a. Rifampin

b. Naloxone c. Flumazenil d. Epinepherine ANS: C The drug flumazenil (Romazicon) is a benzodiazepine receptor antagonist and is an antidote used to reverse an overdose of either a benzodiazepine sedative or a nonbenzodiazepine sedative. For adults, it is given intravenously with an initial dose of 0.2 mg. If there is no response after 45 seconds, the dose can be repeated. After that, it can be repeated every minute for a total of 4 doses.

DIF:

Cognitive Level: Knowing

REF: p. 187

5. For which patient would benzodiazepines be contraindicated? a. A female with breast cancer. b. A woman who is 20 weeks pregnant. c. A male who has a history of smoking. d. A male who is about to undergo surgery.

ANS: B Pregnancy is an absolute contraindication for the benzodiazepines because they have a high risk for causing birth defects. Although the chemical structure of the nonbenzodiazepines (benzodiazepine agonists) is different, these drugs bind to the same receptors and have similar actions. As a result, they are not recommended during pregnancy.

DIF:

Cognitive Level: Applying

REF: p. 185

6. What specific information should be part of the teaching plan for a patient taking a nonbenzodiazepine sedative? a. These drugs can interact with many foods and beverages. b. These drugs can cause you to be physically active at night. c. These drugs must be takes for at least 6 weeks to see any effects. d. Excess caffeine intake can work to increase the effectiveness of these drugs.

ANS: B When taking a nonbenzodiazepine (benzodiazepine agonist), be aware that drugs from this class can cause you to be physically active at night, even going for a drive, without your knowledge or memory of the event. It is best to have a family member or friend watch out for these effects when you first start taking the drug.

DIF:

Cognitive Level: Applying

REF: p. 186

7. You are preparing to teach a patient with anxiety disorder about the actions of the nonbenzodiazepine drug buspirone. What would you inform the patient about how this drug works? a. “Buspirone acts by affecting the serotonin and dopamine neurotransmitters.” b. “Buspirone acts by inhibiting GABA pathways to decrease anxiety.” c. “Buspirone acts by affecting the monoamine oxidase pathway.” d. “Buspirone acts by inhibiting the action of dopamine receptors.”

ANS: A A newer drug from the nonbenzodiazepine class, buspirone, reduces anxiety through a variety of actions affecting the serotonin and dopamine neurotransmitters.

DIF:

Cognitive Level: Applying

REF: p. 187

8. Which drug is classified as a benzodiazepine? a. Lorazepam (Ativan) b. Buspirone (BuSpar) c. Benztropine (Cogentin) d. Chlorpromazine (Thorazine) ANS: A Lorazepam (Ativan) is a benzodiazepine.

DIF:

Cognitive Level: Knowing

REF: p. 186

9. The family members of a patient admitted for hallucinations and delusions tells you that the patient is currently taking chlorpromazine (Thorazine) for the treatment of schizophrenia. Which statement about this drug is true? a. Throazine is associated with a higher risk of extrapyramidal symptoms. b. Thorazine relieves anxiety symptoms associated with schizophrenia. c. Thorazine is used for acute schizoaffective disorders. d. Thorazine is used for chronic mental illness.

ANS: D Typical antipsychotics, such as Thorazine, are more commonly used for long-term management of chronic mental illnesses associated with psychosis.

DIF:

Cognitive Level: Understanding

REF: p. 190

10. The family of a patient who has been taking the antipsychotic fluphenazine (Prolixin) for the last 2 years. The patient’s family reports the patient has suddenly begun smacking her lips, and involuntarily sticking out her tongue. What would be your best first action? a. Call the healthcare provider to report these symptoms. b. Tell the family to hold the next dose of fluphenazine. c. Inform the family that these symptoms are expected, and of no concern. d. Tell the family that these symptoms will disappear over time as the drug dose stabilizes.

ANS: A The main adverse effects of typical antipsychotics are extrapyramidal symptoms (EPS), related to the decrease in dopamine, many are severe and some may be irreversible so it is important to recognize very early in treatment. The healthcare provider should be called immediately, and often, the drug is discontinued.

DIF:

Cognitive Level: Applying

REF: p. 193

11. You are about to begin teaching a patient with a psychosis about taking typical antipsychotic drugs. Which of the following statements would you include in your teaching plan? a. “Do not abruptly stop taking this drug.” b. “Take these drugs with a glass of grapefruit juice.” c. “Take these drugs at night with your sleep drug.” d. “You will experience the effects of these drugs within 30 minutes of taking them.”

ANS: A Continue to take the drugs as prescribed. It may take several weeks before significant changes occur. Do not suddenly stop taking these drugs as this can result in nausea, dizziness and tremors. You can take many of these drugs with food to avoid GI upset, but these drugs can interact with grapefruit juice. Do not drink alcohol or use any sedatives while using these drugs to prevent deep sedation and other dangerous side effects.

DIF:

Cognitive Level: Applying

REF: p. 193

12. A patient who has been taking the atypical antipsychotic risperidone (Risperdal) reports weight gain after taking the drug for 3 months. What would you tell this patient? a. “Stop this drug immediately.” b. “Weight gain can be an adverse effect of this drug.” c. “Weight gain is an expected side-effect of this drug.” d. “I will notify your healthcare provider, so the drug can be changed.”

ANS: C For patients taking atypical antipsychotics, weight gain is associated with these drugs.

DIF:

Cognitive Level: Applying

REF: p. 194

13. You are teaching a patient about the adverse effects associated with selective serotonin reuptake inhibitors (SSRIs). Which adverse effect would you inform your patient about? a. Metallic taste. b. Sexual dysfunction. c. Cardiovascular disease. d. Extrapyramidal symptoms.

ANS: B Expected side effects of SSRI’s include sexual side effects in men and women that include decreased sex drive and decreased ability to orgasm and erectile dysfunction.

Other adverse effects include nausea (during the first 2 weeks), drowsiness, insomnia, dry mouth, decreased appetite increased sweating and constipation.

DIF:

Cognitive Level: Applying

REF: p. 197

14. A patient who has been prescribed a serotonin norepinephrine reuptake inhibitor (SNRI) one week ago reports that she has not noticed any difference in her depression level since beginning this drug. What is your best response? a. “Begin taking two tablets daily to increase blood serum levels.” b. “Add a tablet of St, John’s Wort to increase the drug’s effects.”

c. “You should call your healthcare provider immediately.” d. “It may take several weeks for this drug to take effect.”

ANS: D The patient should see effects within a few weeks of taking the drug, with maximum effects at 6 to 8 weeks.

DIF:

Cognitive Level: Applying

REF: p. 200

15. A young adult patient taking an SSRI for the past 2 weeks comes in for an evaluation and follow-up appointment. Which potential side effect should you check for in this patient? a. Suicidal thoughts. b. Psychotic episodes. c. Delusional thinking. d. Schizo-affective disorders.

ANS: A SSRI’s may cause thoughts of suicide, most likely in children and young adults. Remind the patients and their families that this is just a side effect of the drug and should be reported to the healthcare providers immediately.

DIF:

Cognitive Level: Applying

REF: p. 197

16. Which of the following drugs classifications for the treatment of mental health problems is contraindicated for patients with vision problems? a. Antipsychotics. b. Tricyclic antidepressants. c. Selective serotonin reuptake inhibitors. d. Serotonin norepinephrine reuptake inhibitors.

ANS: B TCAs should not be used in patients with glaucoma because these drugs can increase intraocular pressure.

DIF:

Cognitive Level: Knowing

REF: p. 202

17. A patient who has been taking imipramine comes to the clinic for a routine follow-up appointment. Which of the following assessments would be appropriate to perform? a. Skin assessment. b. Hearing assessment. c. Elimination assessment. d. Vital signs and weight assessment.

ANS: D Assess vital signs including baseline weight. TCAs can cause hypotension and weight gain.

DIF:

Cognitive Level: Applying

REF: p. 202

18. You are caring for a patient who will begin treatment for anxiety and depression that has been unresponsive to other drugs with isocarboxazid. Which of the following statements made by the patient would indicate understanding of the teaching related to this drug? a. “I will take both my isocarboxazid and my SSRI drugs at the same time each day.” b. “I will avoid situations that cause me to lose fluids and become dehydrated.” c. “I will avoid eating foods containing tyramine that can increase blood pressure.” d. “I will take my isocarboxazid weekly, as this drug is long-acting” ANS: C Patients taking MAO-Is risk of hypertensive crisis from taking foods or drinks high in tyramine. Tyramine is an amino acid that is involved in the release of norepinephrine.

Normally, tyramine is broken down by monoamine oxidases (enzymes). When the patient is taking an inhibitor of the enzyme (MAO-Is), there is an increase in norepinephrine which can then significantly increase blood pressure. This can cause sudden and severe hypertension.

DIF:

Cognitive Level: Applying

REF: p. 199

19. Which of the following drugs would be appropriate for the treatment of bipolar illness? a. Lithium b. Sertoline c. Alprazolam d. Chlorpromazine ANS: A Lithium is specifically used for patients with bipolar disorder who are in an acute manic phase.

DIF:

Cognitive Level: Knowing

REF: p. 205

20. You have just completed teaching with a patient who is beginning lithium. Which of the following statements made by the patient demonstrates understanding of this drug? a. “I will need to increase my salt intake while taking this drug.” b. “I will need regular blood testing while taking this drug.” c. “I may develop mild memory loss while taking this drug.” d. “Lithium cannot be taken with tyrosine-containing foods.”

ANS: B Serum lithium levels need to be monitored frequently while the patient is taking the drug. Blood levels are checked 4 days after the patient starts taking lithium. Desired level for acute mania is 0.8 to 1.2 mEq/L. Any levels over 1.5 mEq are considered toxic.

Levels >3 mEq/L are associated with coma, organ failure, and even death.

DIF:

Cognitive Level: Applying

REF: p. 205

21. You are taking the history of a patient who is suspected of having lithium toxicity. What symptoms would you expect the patient to report? a. Increased drowsiness, weakness and nausea. b. Heart palpitations, seizures, and muscle spasm. c. Decreased urine output, vision loss and irritability.

d. Increased mania, excessive salivation and tachycardia.

ANS: A Signs and symptoms of lithium toxicity include nausea, vomiting, increased drowsiness, muscle weakness, severe hand tremor and incoordination. Report these symptoms to the RN or healthcare provider immediately.

DIF:

Cognitive Level: Knowing

REF: p. 205

MULTIPLE RESPONSE 1. Which symptoms would you expect a patient who is experiencing mania? (Select all that apply.) a. Catatonia b. CNS depression c. Increased energy d. Grandiose notions e. Poor judgement f. Excessive sleepiness ANS: C, D, E Symptoms of mania include: increased energy, grandiose notions, poor judgement, increased sexual desire, racing thoughts, irritability, increased energy, inappropriate social behavior & increased talking DIF:

Cognitive Level: Knowing

REF: p. 204

2. What disorders would a selective serotonin uptake inhibitor (SSRI) be prescribed for?

(Select all that apply.) a. Psychosis. b. Depression. c. General anxiety disorder. d. Traumatic stress disorder. e. Manic depressive disorder. f. Obsessive-compulsive disorder.

ANS: B, C, D, F SSRIs can be used in a variety of conditions including depression, premenstrual dysphoric disorder (PMDD), posttraumatic stress disorder, obsessive-compulsive disorder, and general anxiety disorder.

DIF:

Cognitive Level: Knowing

REF: p. 197

3. Too much serotonin can lead to the adverse effect known as serotonin syndrome. Which of the following symptoms are associated with serotonin syndrome? (Select all that apply.) a. Confusion. b. Restlessness c. Dilated pupils. d. Increased sweating.

e. Severe constipation. f. Extremely high blood pressure.

ANS: A, B, C, D, F Serotonin syndrome is a potentially life-threatening disorder characterized by confusion, restlessness, extremely high blood pressure, dilated pupils, increased sweating, seizures and tremors.

DIF:

Cognitive Level: Knowing

REF: p. 194

4. You are caring for a patient with schizophrenia who is taking antipsychotic drugs for the control of hallucinations and delusions. Which symptoms experienced by the patient would alert you to that the development of neuroleptic malignant syndrome? (Select all that apply.) a. Pinpoint pupils. b. Muscle rigidity. c. Elevated temperature. d. Unstable blood pressure. e. Increased white blood count. f. Extremely low creatinine kinase ANS: B, C, D, E Neuroleptic malignant syndrome is a potentially life-threatening condition characterized by muscle rigidity, elevated temperature, unstable blood pressure, increased white blood cell count, elevated creatinine kinase and hyperkalemia.

DIF:

Cognitive Level: Understanding

REF: p. 192

5. You are preparing to teach a patient about the drug amitriptyline. Which of the following statements should be included in your teaching plan? (Select all that apply.) a. “Use sugarless gum or candy to relieve dry mouth”. b. “Keep out of the sun while taking this drug.” c. “This drug can relieve depression quickly.” d. “Move slowly when changing positions.” e. “Avoid ripe cheeses and smoked meats.” f. “This drug can affect your sleeping.”

ANS: A, B, D, F TCAs can cause dry mouth, so using sugarless gum, candy or ice ships can help. Sun sensitivity can occur, so staying out of the sun and the use of sunscreen is recommended.

Orthostatic blood pressure changes can occur, so patients need to be told to change positions carefully. This drug can cause either drowsiness, or difficulty sleeping.

DIF:

Cognitive Level: Applying

REF: p. 202

Chapter 11: Drugs for Pain Management Visovsky: Introduction to Clinical Pharmacology, 9th Edition MULTIPLE CHOICE 1. What types of drugs have the main purpose of relieving pain? a. Anticholinergics b. Antagonists c. Analgesics d. Agonists ANS: C Analgesics have the specific purpose of relieving pain either by changing the patient’s perception of pain or by reducing painful stimulation at its source. Although some analgesics are opioid agonists, the term agonist is not specific for a pain-relieving drug.

DIF:

Cognitive Level: Knowing

REF: p. 213

2. The healthcare provider asks you to rate a patient’s postoperative pain. What is your best response? a. “He is asleep now, so his pain level is acceptable.” b. “I think we need to ask the patient to rate his own pain.” c. “His wife says he can still feel the incision when he turns or coughs.” d. “Since he received 15 mg of morphine an hour ago, his pain is probably minimal.”

ANS: B Pain is always a subjective experience; that is, pain is a sensation the patient feels and that cannot be felt or measured by someone else. Accurate pain assessment is best measured by the patient, if he or she is not unconscious or confused. Being asleep does not mean that pain is relieved.

DIF:

Cognitive Level: Applying

REF: p. 210

3. You are caring for a patient who is paralyzed from the waist down and has a large open wound on her right heel. When asked about her pain in that foot, she tells you it is a 0 on a 0 to 10 pain rating scale. What does this response indicate? a. The paralysis prevents her brain from perceiving the pain. b. The patient has chronic pain that does not trigger the stress response. c. She is afraid of becoming addicted if she takes the prescribed drug too often. d. This patient’s acute pain has been effectively managed by the prescribed pain drug.

ANS: A

Pain is felt or perceived in the brain rather than in the body area where it occurs. When a body part is injured, this injury stimulates pain nerve endings in the thumb that then send (transmit) electrical nerve impulses as a signal from the injury site along nerves to the spinal cord. At the spinal cord, the original signal is transferred to special pain nerve tracts up the spinal cord to the area of the brain where pain in that body site is perceived.

Paralysis from the waist down in the spinal cord prevents the transmission of a pain signal from the foot so that pain is not perceived no matter how deep or bad the heel wound is.

DIF:

Cognitive Level: Understanding

REF: p. 211

4. Why are natural and synthetic opioids considered “high-alert drugs?” a. They have an increased risk for causing a patient harm if given in error. b. They have a relatively high potential for addiction or abuse. c. There is wide variation in the dosages between opioid types. d. They can be given by a variety of routes.

ANS: A Although opioids can cause addiction or abuse, have different dosages ranges, and can be given by the oral, intravenous, intramuscular, and transdermal routes, these are not the reasons they are categorized as high-alert drugs. All natural and synthetic opioids are high-alert drugs because they have an increased risk for causing patient harm if given in error.

DIF:

Cognitive Level: Understanding

REF: p. 214

5. When you assess a patient’s pain level an hour after giving 2 mg of hydromorphone intravenously, you find the patient sleeping with a respiratory rate of 10 breaths per minute. What is your best first action? a. Give naloxone intravenously. b. Document the finding as the only action. c. Notify the healthcare provider immediately. d. Assess the patient’s oxygen saturation with pulse oximetry.

ANS: D Many patients have a reduced respiratory rate after receiving a dose of a strong morphine agonist. Although 10 breaths per minute may be a little lower than normal, it is not low enough to either notify the healthcare provider or give naloxone without further assessment. The best assessment is oxygen saturation by pulse oximetry to determine the effectiveness of the current respiratory rate. If oxygen saturation is lower than 94% or the patient’s usual percentage, awaken the patient and assess whether the patient’s respiratory rate increases.

DIF:

Cognitive Level: Applying

REF: p. 215

6. A patient being discharged to home is prescribed an oxycodone–acetaminophen combination for pain management. Which precaution is most important to teach this patient? a. “If you still need this drug after 48 hours, notify your healthcare provider immediately.”

b. “Be sure to drink plenty of water and eat foods high in fiber to prevent constipation.” c. “Always go to bed immediately after taking a dose of this drug.” d. “Avoid drinking alcohol while taking this drug.”

ANS: D Drinking alcohol while on a morphine agonist will make side effects worse and increase the risk for respiratory depression. Although preventing constipation is important, preventing respiratory depression is more important.

DIF:

Cognitive Level: Applying

REF: p. 216

7. You accidentally give a patient 30 mg orally of hydromorphone instead of the ordered hydrocodone. What is your first best action? a. Notify the RN in charge immediately. b. Induce the patient to vomit immediately. c. Assess the patient’s vital signs immediately. d. Follow your agency’s policy for documenting a drug error.

ANS: A The 30 mg oral dose of hydromorphone is six times the normal dose and could cause dangerous or even lethal effects. Get the RN to assess this patient immediately to determine the best course of action (naloxone or transporting the patient to the emergency department). The patient should not be made to vomit up the drug because he or she may already be so unalert that the risk for aspiration is increased. Assessing vital signs is important but having the RN perform a full assessment is more important. You can assess the vital signs after you call the RN. It is important to document the drug error, but this is not the first priority until the possible results to the patient have been addressed.

DIF:

Cognitive Level: Applying

REF: p. 217

8. When assessing the blood pressure of a patient receiving pentazocine 30 mg orally for pain control two days after surgery, the reading is 166/100, which is much higher than the patient’s presurgical blood pressure. What is your best action? a. Assess the patient for other symptoms of addiction or dependency. b. Give the next dose of the drug as prescribed. c. Assess the patient for other cardiac changes. d. Document the change as the only action.

ANS: C Pentazocine is an opioid agonist-antagonist that can have serious cardiac reactions.

Assessing the cardiac status is critical in preventing a heart attack or blood pressure crisis.

DIF:

Cognitive Level: Applying

REF: p. 218

9. How does tramadol help control pain? a. Binding to opioid receptors in the brain to reduce the perception of pain b. Reducing the inflammatory substances at the site of injury to inhibit the actual

cause of the pain c. Binding to adrenergic receptors in the spinal cord preventing pain signals from reaching the brain d. Inhibiting the generation of nerve impulses along the peripheral sensory nerves to alter the transmission of pain ANS: C Tramadol only weakly binds to opioid receptors and does not reduce pain in this way.

Instead, tramadol works for pain management by binding to specific receptors (alpha adrenergic receptors) in spinal cord and blocking their activity. This action keeps pain signals generated in the periphery from the source of the pain to be transmitted at the level of the spinal cord to the level of the brain.

DIF:

Cognitive Level: Understanding

REF: p. 218

10. Which health problem is a severe adverse reaction to chronic acetaminophen therapy? a. Asthma b. Diabetes c. Liver toxicity d. Excessive bleeding ANS: C When taken at higher doses or for prolonged periods, acetaminophen is toxic to the liver, which can be damaged or destroyed. The drug has a maximum daily dose to prevent liver toxicity and should not be taken with alcohol or other liver toxic drugs.

DIF:

Cognitive Level: Knowing

REF: p. 219

11. The postoperative orders for a large adult patient who has just arrived on your unit after major abdominal surgery reads morphine 15 mg IM every 4 to 6 h as needed for pain.

What is the best schedule for pain relief during the first postoperative day for this patient? a. Ask the patient every 4 to 6 h whether any drug for pain is needed. b. Give the drug automatically every 4 h around the clock for the 24 h. c. Give the drug automatically every 6 h around the clock for the first 24 h. d. Wait until the patient rates the pain at an 8 or higher on a 0 to 10 pain rating scale before giving any dose of the prescribed drug.

ANS: B Although asking a patient to rate the intensity of the pain is good, the day of abdominal surgery usually results in intense acute pain. The patient may be groggy from anesthesia.

Starting analgesics on a regular around the clock schedule provides the best pain management. This patient is a large adult and the 15 mg dosage is likely to be appropriate.

DIF:

Cognitive Level: Applying

REF: p. 213

12. Which of the following assessments is most important to perform on a patient newly prescribed to take cyclobenzaprine for severe muscle pain? a. Respiratory rate

b. Deep tendon reflexes c. Blood pressure and heart rate d. Muscle strength and coordination ANS: C Cyclobenzaprine can cause serious cardiac dysrhythmias, prolonged cardiac conduction, and high blood pressure.

DIF:

Cognitive Level: Applying

REF: p. 222

13. Which patient should be assessed closely for complications of pain management with methocarbamol? a. 75-year-old man with benign prostatic hyperplasia b. 55-year-old woman with type 2 diabetes c. 34-year-old woman with a peanut allergy d. 17-year-old teenager who is near-sighted ANS: A Methocarbamol often causes urinary retention, which could cause serious complications in a person who has difficulty emptying the bladder.

DIF:

Cognitive Level: Understanding

REF: p. 222

MULTIPLE RESPONSE 1. Indicate which analgesics are considered strong opioid agonists. (Select all that apply.) a. Codeine b. Fentanyl c. Hydrocodone d. Hydromorphone e. Morphine f. Oxycodone ANS: B, D, E Morphine is a strong opioid agonist against which all other analgesics are compared.

Fentanyl and hydromorphone are more powerful than morphine. Codeine, hydrocodone, and oxycodone are weaker opioid agonists.

DIF:

Cognitive Level: Knowing

REF: p. 214

2. Which drugs listed below help manage pain by acting at the tissue where pain starts and do not change the person’s perception of pain? (Select all that apply.) a. Acetaminophen b. Antidepressants c. Corticosteroids d. NSAIDs e. Opioid agonists f. Skeletal muscle relaxants ANS: C, D

Acetaminophen, antidepressants, opioid agonists, and skeletal muscle relaxants all work in the brain and or spinal cord to alter the perception and (occasionally) the transmission of pain signals in the spinal cord. Only corticosteroids and NSAIDs work to reduce mediators of pain and inflammation at the site of injury.

DIF:

Cognitive Level: Understanding

REF: p. 221

3. Which miscellaneous drugs are often prescribed to help with pain management? (Select all that apply.) a. Antibiotics b. Anticholinergics c. Anticonvulsants d. Antidepressants e. Antihistamines f. Anti-inflammatories ANS: C, D, F Anticonvulsants, antidepressants, and anti-inflammatories have all been found to reduce some types of pain effectively. Antibiotics, anticholinergics, and antihistamines have not been found to have a role in pain management.

DIF:

Cognitive Level: Knowing

REF: p. 220

COMPLETION 1. A 10-month-old infant who weighs 22 lb is prescribed to receive acetaminophen 8 mg/kg by oral liquid. The drug on hand is acetaminophen liquid with a concentration of 70 mg/mL. How many mL is the correct dose for this patient? _____ ANS: 1.1 1 kg = 2.2 lb. The infant’s weight in kg is 22 divided by 2.2 or 10 kg.

10 kg  8 mg = 80 mg The drug concentration is 70 mg/mL 80 mg divided by 70 mg/mL = 1.14 round down to 1.1 mL 2. A patient is prescribed to receive 0.6 mg of hydromorphone intravenously. The drug on hand is hydromorphone 2 mg/mL. How many mL will you prepare to give this drug? _____ ANS: 0.3 Want divided by have Want 0.6 mg Have 2 mg/mL. 0.6 divided by 2 = 0.3 mL

3. A patient is prescribed Vicodin for pain, two tablets every 4 h. The tablets contain 2.5 mg of hydrocodone and 325 mg acetaminophen. In addition, this patient takes an over-the-counter cold preparation that contains 650 mg of acetaminophen. How much total acetaminophen does this represent in a 24-h period? _____ ANS: 4550 Two Vicodin per dose = 650 mg acetaminophen times six doses = 3900 mg acetaminophen, plus the 650 mg taken with the cold preparation = 4550 mg acetaminophen in a 24-h period.

Chapter 12: Anti-inflammatory, Antiarthritis, and Antigout Drugs Visovsky: Introduction to Clinical Pharmacology, 9th Edition MULTIPLE CHOICE 1. A patient with joint inflammation is prescribed an anti-inflammatory drug. The patient asks you how this drug works to address this problem. What is your best response? a. “Anti-inflammatory drugs reduce pain and limit blood vessel responses to joint injury.” b. “Anti-inflammatory drugs contain antibacterial and anti-inflammatory properties.” c. “Anti-inflammatory drugs limit the body’s response to cortisol in the body.” d. “Anti-inflammatory drugs increase the release of TNF and other mediators.”

ANS: A Anti-inflammatory drug’s primary purpose is to reduce pain and prevent or limit the tissue and blood vessel responses to injury or invasion.

DIF:

Cognitive Level: Applying

REF: p. 227

2. A patient with a history of cardiovascular disease has been prescribed aspirin daily.

What specific risk should this patient be informed of because of taking aspirin? a. Risk of infection b. Risk of bleeding c. Risk of liver impairment d. Risk of cognitive impairment ANS: B Patients who take aspirin must be monitored for bleeding due to irreversible platelet inhibition for the lifespan of the platelet so as long as 7 to 8 days.

DIF:

Cognitive Level: Applying

REF: p. 228

3. A male patient taking daily aspirin for the prevention of cardiovascular complications informs you that he is planning to have a tooth extraction next week. What correct information should be provided to this patient? a. “Notify your healthcare provider and stop taking the aspirin before the dental procedure.” b. “You may require aspirin plus additional pain drug after the dental procedure.” c. “Taking enteric-coated aspirin ensures you will not be at risk for any complications.” d. “Aspirin is associated with tooth loss following dental surgery.”

ANS: A Patients who take aspirin must be monitored for bleeding due to irreversible platelet inhibition for the lifespan of the platelet as long as 7 to 8 days. This is very important if a patient is scheduled for an invasive procedure or surgery so make sure to notify the prescriber if the patient has an upcoming surgery.

DIF:

Cognitive Level: Applying

REF: p. 228

4. You are preparing a teaching plan for a patient prescribed the nonselective NSAID ibuprofen 800 mg orally daily. Which of the following instructions should be included in this teaching plan? a. Avoid eating excessive amounts of protein as this can interfere with the drug’s action. b. This drug can increase serum blood sugar levels in patients with diabetes. c. Taking this drug before bed can cause excessive night-time urination. d. Take this drug with food to prevent GI upset.

ANS: D If NSAIDS cause mild GI upset, the patient may take the drug with a small amount of food or milk. These drugs decrease blood sugar, making diabetics at high risk for hypoglycemia. NSAIDs can cause fluid retention.

DIF:

Cognitive Level: Applying

REF: p. 228

5. A patient reports ringing in her ears while taking aspirin four times a day to relieve arthritis pain. What action should you take? a. Instruct the patient to reduce the dose of aspirin by half until the ringing stops. b. No action is needed; this is an expected response to this dose of aspirin. c. Call the healthcare provider, as this is adverse reaction to the drug. d. Instruct the patient to take the full dose before bed.

ANS: C Tinnitus (ringing in the ears) is an adverse reaction to anti-inflammatory analgesics.

DIF:

Cognitive Level: Applying

REF: p. 230

6. A mother brings her febrile infant to the pediatric clinic for evaluation. The infant has a temperature of 102 degrees. The mother tells you that she wishes she had given the baby a dose of liquid aspirin before leaving the house to bring down the baby’s temperature.

What is your best response? a. “Aspirin can be dangerous, and should not be given to infants.” b. “We can give the baby a dose now before you leave the clinic.” c. “Give aspirin alternating with acetaminophen every 4 h for fever.” d. “Aspirin will need to be given with a proton-pump inhibitor to prevent bleeding.”

ANS: A Aspirin should not be given to infants or children who have an acute illness because of its association with development of a very serious problem known as Reye syndrome.

This disorder can lead to mental deficits, coma, or death.

DIF:

Cognitive Level: Applying

REF: p. 229

7. A patient with a history of alcoholism is taking aspirin on a regular basis for general aches and pains. The patient reports feeling weak and dizzy, and has developed abdominal pain 7 days ago, which is increasing in severity. What adverse drug effect might this patient be experiencing? a. Liver damage due to the combination of aspirin and alcohol

b. Reye syndrome due to the combination of aspirin and alcohol c. Gastrointestinal bleeding due to the combination of aspirin and alcohol d. Gastroesophageal reflux disease due to the combination of aspirin and alcohol ANS: C Alcohol taken with any of the anti-inflammatory analgesics greatly increases the risk for gastrointestinal bleeding.

DIF:

Cognitive Level: Applying

REF: p. 229

8. A patient with diabetes has been prescribed a course of prednisone to treat an acute exacerbation of asthma. Which of the following instructions should you give to the patient before he is discharged home? a. “Monitor your blood sugar regularly.” b. “Take this drug on an empty stomach.” c. “You may stop this drug when your symptoms improve.” d. “You may experience a change in the color of your urine.”

ANS: A The patient should be instructed to monitor blood sugar regularly because corticosteroids reduce the sensitivity of insulin receptors and increase blood glucose levels. Adjustments to oral antidiabetic drug or insulin may be needed while taking corticosteroids. Warn patients to not stop taking the oral drug suddenly (without the guidance of the healthcare provider) to prevent possible adrenal insufficiency. Corticosteroids should be taken with food or milk to reduce the risk for gastric ulcers. There is no effect of corticosteroids on the color of urine.

DIF:

Cognitive Level: Applying

REF: p. 231

9. A patient with a chronic inflammatory condition has been taking corticosteroids for several months. Which of the following side effects should you monitor this patient for? a. Weight loss b. Hypotension c. Fat redistribution d. Increased muscle mass ANS: C After a month of therapy, patients taking corticosteroids experience fat redistribution (moon face and “buffalo hump” between the shoulders), weight gain, hypertension (after 1 week), and decreased muscle mass.

DIF:

Cognitive Level: Applying

REF: p. 231

10. A patient on long-term corticosteroid therapy appears to have frequent colds and upper respiratory infections and is concerned that something may be wrong. What is your best response? a. “Corticosteroids affect the production of protective mucous.” b. “Taking corticosteroids for a long time can reduce your immunity.” c. “Corticosteroids increase adrenal gland function and result in infections.” d. “There is no relationship between the treatment for your condition and frequent

colds.”

ANS: B The most important problems are associated with long-term use and include adrenal gland suppression and reduced immunity that can make patients susceptible to infections.

DIF:

Cognitive Level: Applying

REF: p. 233

11. A patient with severe asthma who has been taking systemic corticosteroids for 2 weeks tells you he is feeling better and would like to stop taking this drug today. What is your best response? a. “Take the last dose today, and then you can stop the drug.” b. “As long as your asthma symptoms have resolved, you can stop the drug.” c. “Skip the drug on the days you feel better and take it only if symptoms reoccur.” d. “The dose of this drug will need to be tapered down over time to prevent complications.”

ANS: D To prevent adrenal insufficiency, doses of systemic corticosteroids must be tapered rather than stopped abruptly. Tapering of the drug allows the atrophied adrenal gland cells to gradually begin producing cortisol again and prevents acute adrenal insufficiency.

DIF:

Cognitive Level: Applying

REF: p. 233

12. A patient who has been prescribed a topical corticosteroid cream for the treatment of a rash tells you that he now has a small, reddened, open wound located on the anterior aspect of the right foot. He asks you if he can apply this same cream to this new wound to reduce the redness. What is your best response? a. “You may use the same topical steroid on this wound but apply it with a gloved hand.” b. “Dispose of at least inch of the topical steroid before applying it elsewhere.” c. “Mix the topical steroid with an antibiotic cream for the best effect.” d. “You should not apply topical steroids to open wounds.”

ANS: D Topical steroids should not be applied to open wounds. They should be avoided if there are any signs of infection as they may increase the risk of the infection spreading due to their effect on the immune/inflammatory response.

DIF:

Cognitive Level: Applying

REF: p. 234

13. What would be an appropriate nursing action to prevent complications in an elderly person taking long-term corticosteroid therapy? a. Protect the skin from skin tears. b. Bathe the patient twice daily. c. Check the patient’s blood pressure before giving the drug. d. Ask the patient about the presence of constipation.

ANS: A Make sure to carefully protect skin of patients who are taking corticosteroids while transferring or positioning to prevent skin tears.

DIF:

Cognitive Level: Applying

REF: p. 234

14. A patient is beginning a prescribed disease-modifying antirheumatic drug (DMARD) for the treatment of rheumatoid arthritis. The patient asks you how these drugs work to help this condition. What is your best response? a. “These drugs modify the immune system by decreasing T-cell response.” b. “These drugs act to increase the body’s immune response to rheumatoid factor.” c. “These drugs work by inhibiting the inflammatory mediator tumor necrosis factor.” d. “These drugs reduce the amount of an enzyme that controls the production of purines.”

ANS: C DMARDS inhibit the inflammatory mediator tumor necrosis factor (TNF). They bind to the TNF molecules produced by white blood cells (WBCs) and prevent them binding to TNF receptor sites on inflammatory cells and other cells. This prevents the cells from continuing to produce even more TNF and other substances that enhance the inflammatory responses and cause direct tissue destruction.

DIF:

Cognitive Level: Applying

REF: p. 235

15. You are teaching a patient with rheumatoid arthritis about giving subcutaneous adalimumab (Humira) at home. What instructions should be included in this patient’s teaching plan? a. Before drawing up drug, shake the vial well to distribute the drug. b. Rotate the injection site of the thighs and abdomen frequently. c. Do not discontinue this drug if you have an infection. d. Rub the injection site well to prevent bleeding.

ANS: B Instruct the patient to rotate injection sites on the front of the thighs and the abdomen to ensure best absorption and prevent skin problems. Avoid giving within 2 inches of the umbilicus because this area has many blood vessels and absorption can be too rapid.

DIF:

Cognitive Level: Applying

REF: p. 235

16. For which patients may the use of disease-modifying antirheumatic drug (DMARD) be contraindicated? a. A patient with pre-existing heart failure b. A patient who has a history of a depressive disorder c. A patient with diabetes mellitus controlled with insulin d. A patient who has chronic obstructive pulmonary disease ANS: A

Heart failure can occur with DMARDs. The heart failure may be new or, if the patient already has heart failure, it can become more severe while taking DMARDs. DMARDs should not be used in anyone who has severe heart failure.

DIF:

Cognitive Level: Understanding

REF: p. 236

17. A patient reports a history of gout in the right big toe. A previous aspiration of the joint revealed uric acid crystals to be present in the joint. Which of the following drugs would be most appropriate to treat this patient? a. Demerol b. Colchicine c. Allopurinol d. Enteric-coated aspirin ANS: C Allopurinol helps prevent gout attacks by reducing the amount of an enzyme that converts the purines in protein into uric acid so less uric acid available to form. This drug helps patients to maintain a lower blood uric acid level.

DIF:

Cognitive Level: Understanding

REF: p. 237

18. Which laboratory value is most likely to be elevated in a patient presenting with acute gout? a. Potassium b. Uric acid c. Calcium d. Glucose ANS: B High serum uric acid levels lead to the formation of uric acid crystals, usually in the kidneys and joint spaces. These crystals are long and jagged and cause the swelling, inflammation, and severe pain of gout.

DIF:

Cognitive Level: Understanding

REF: p. 237

19. A patient with acute gout asks you why allopurinol cannot be used at this time. What is your best response? a. “Allopurinol does not lower uric acid levels.” b. “Allopurinol is useful in rheumatoid arthritis, but not gout.” c. “Allopurinol is used only for the prevention of gout attacks.” d. “Allopurinol can cause swelling of the feet, worsening your gout symptoms”.

ANS: C Allopurinol is used to prevent gout attacks by reducing the amount of an enzyme that converts the purines in protein into uric acid, and to maintain a lower blood uric acid level.

DIF:

Cognitive Level: Applying

REF: p. 237

20. A patient with gout requires dietary teaching to help control flare ups of the illness. What should be included in the diet teaching for this patient? a. Increase your intake of organ meats for protein. b. Avoid foods that are high in purine, such as tuna. c. Avoid drinking fruit juices while taking antigout drugs. d. Increase your intake of vegetables such as cauliflower and asparagus.

ANS: B Avoid foods that are high in purines as those foods may precipitate an acute attack. High purine foods are organ meats (liver, kidneys), and certain vegetables such as cauliflower, asparagus, mushrooms, and spinach.

DIF:

Cognitive Level: Applying

REF: p. 237

MULTIPLE RESPONSE 1. Inflammation is the result of tissue and blood vessel reactions to white blood cells. What are the symptoms associated with inflammation? (Select all that apply.) a. Pain b. Warmth c. Redness d. Swelling e. Elevated temperature f. Bacteria in the bloodstream ANS: A, B, C, D Inflammation is a predictable set of tissue and blood vessel actions caused by white blood cells (leukocytes) and their products as a response to injury or infection. These tissue and blood vessel actions cause the five major symptoms of inflammation; pain, redness, warmth, swelling, and loss of function.

DIF:

Cognitive Level: Knowing

REF: p. 225

2. When caring for a patient who is taking anti-inflammatory drugs, what should be included in the patient’s teaching plan? (Select all that apply.) a. You should take this drug without food. b. Take this drug with a full glass of water. c. Only take this drug when you have pain. d. This drug may interact with anticoagulants. e. Contact your healthcare provider if you develop dark stools.

ANS: B, D, E These drugs should be taken exactly as ordered on a regular schedule to keep blood levels of the drug stable. Dark stools can be a sign of GI bleeding, and adverse effect of the drug. To decrease stomach upset, take with a full glass of water. These drugs can be taken with food or milk. Anti-inflammatory drugs can interact with anticoagulants and cause bleeding.

DIF:

Cognitive Level: Applying

REF: p. 228

3. A patient taking anti-inflammatory drugs tells you that some doses of the drug have been missed. What should you teach this patient to do when drug doses are missed? (Select all that apply.) a. Skip all missed drug dosages. b. Never take a double dose of this drug. c. If it is close to the next time the drug is due, skip the missed dose. d. If possible, take the missed dose within an hour of the scheduled time. e. Once you have missed a dose, double up on the drug dose at the next time it is due. f. All missed doses of the drug should be returned to the pharmacy.

ANS: B, C, D Never take a double dose of this drug. If a drug dose is missed, it may be taken within an hour of when it was scheduled. If the patient remembers the missed dose close to the time when the next dose is to be taken, he should take the regular dose and miss the skipped dose.

DIF:

Cognitive Level: Applying

REF: p. 228

4. Anti-inflammatory analgesics should not be used by patients with which of the following conditions? (Select all that apply.) a. Stroke b. Cachexia c. Liver disease d. Heart disease e. Severe migraine f. Transient ischemic attacks ANS: A, C, F Anti-inflammatory analgesics should not be used in patients with hepatic (liver) disease, stroke, or when patients have symptoms of TIAs. DIF:

Cognitive Level: Applying

REF: p. 229

5. Corticosteroids are a class of drugs that are used to manage inflammation. What are the properties or actions associated with corticosteroids? (Select all that apply.) a. Corticosteroids decrease inflammatory mediators. b. Corticosteroids act only within the cells that are inflamed. c. Corticosteroids can be used to manage chronic inflammation. d. Corticosteroids slow the production of WBCs in the bone marrow. e. Corticosteroids have few adverse effects due to their localized action. f. Corticosteroids increase arachidonic acid production of inflammatory mediators.

ANS: A, C, D Corticosteroids are very useful in managing chronic inflammation. They are very powerful in decreasing the production of all known mediators that trigger inflammation.

Corticosteroids inhibit enzymes and proteins that start and continue the arachidonic acid production of inflammatory mediators. They also slow the production of white blood cells (WBCs) in the bone marrow. The actions of corticosteroids occur in all cells, not just those involved in inflammation. As a result, their therapeutic effects, side effects, and adverse effects are wide-spread.

DIF:

Cognitive Level: Knowing

REF: p. 230

6. A patient has been diagnosed with acute adrenal insufficiency. Which of the following symptoms would you expect this patient to present with? (Select all that apply.) a. Joint pain b. Increased thirst c. Peeling of the skin d. Severe hypertension e. Lethargy and headache f. Agitation and sleeplessness ANS: A, C, E Symptoms of acute adrenal insufficiency include anorexia, nausea and vomiting, lethargy, headache, fever, joint pain, skin peeling, myalgia (widespread muscle pain), weight loss, and hypotension.

DIF:

Cognitive Level: Knowing

REF: p. 230

7. You are preparing to teach a patient and family member about long-term corticosteroid therapy. Which instructions should be included in the patient’s teaching plan? (Select all that apply.) a. You may increase the dose of this drug by one-half if your symptoms worsen. b. Consult your healthcare provider before getting any vaccinations. c. Stop this drug immediately if you develop nausea or vomiting. d. Take your dose of this drug early in the morning. e. Take this drug with food to prevent GI upset. f. Eat a diet low in potassium-containing foods.

ANS: B, D, E Only the healthcare provider should adjust the dose of corticosteroids. Patients with normal adrenal gland function should take corticosteroids early in the morning; this is the time when the adrenal glands are normally secreting the most cortisol, so the corticosteroid dose more closely mimics the body’s usual actions. Never stop corticosteroids abruptly. Take these drugs with food to prevent GI upset. Teach the patient to eat a diet rich in potassium-containing foods and low in sodium.

DIF:

Cognitive Level: Applying

REF: p. 234

Chapter 13: Drugs for Gastrointestinal Problems Visovsky: Introduction to Clinical Pharmacology, 9th Edition MULTIPLE CHOICE 1. What types of drugs prevent or control nausea and vomiting? a. Antiemetic drugs b. Antimotility drugs c. Antidiarrheal drugs d. Antipropulsion drugs ANS: A Antiemetic drugs control nausea and prevent vomiting. Nausea and vomiting often occur together, and the same drugs are used for both problems.

DIF:

Cognitive Level: Remembering

REF: p. 242

2. Which common drug for nausea and vomiting is a 5-HT3 receptor antagonist? a. Ondansetron b. Promethazine c. Scopolamine d. Metoclopramide ANS: A Ondansetron (Zofran, Zuplenz) is a 5-HT3 receptor antagonist that reduces or halts nausea and vomiting by blocking serotonin (5-HT3) receptors in the intestinal tract.

DIF:

Cognitive Level: Knowing

REF: p. 243

3. What specific problem can develop in a patient who has been prescribed both a 5-HT3 receptor antagonist and a phenothiazine? a. Bleeding b. Muscular tremors c. Serotonin syndrome d. Cardiac dysrhythmias ANS: D When combined with phenothiazine drugs, the patient may experience cardiac dysrhythmias.

DIF:

Cognitive Level: Knowing

REF: p. 244

4. You are caring for a patient who is taking a substance P/neurokinin1 (NK1) receptor antagonist. Which laboratory finding would suggest the patient is experiencing an adverse reaction to this class of drugs? a. Decreased magnesium level b. Increased blood glucose level c. Increased serum creatinine level d. Decreased white blood cell count

ANS: D Neutropenia is one of the most common adverse reactions associated with substance P/neurokinin1 (NK1) receptor antagonists. Other blood abnormalities include anemia and thrombocytopenia; so, monitor laboratory values carefully.

DIF:

Cognitive Level: Knowing

REF: p. 245

5. A patient who developed vomiting has been given 10 mg of prochlorperazine IM. What instructions should you provide to this patient? a. “Your temperature may increase today.” b. “Call for assistance when getting out of bed.” c. “Bruising and bleeding at the injection site may occur.” d. “Avoid eating green, leafy vegetables while taking this drug.”

ANS: B Make sure to assess the vital signs carefully in patients who are taking phenothiazines because they can cause a drowsiness and dizziness & orthostatic hypotension. The patients call light should be available to call for assistance to get out of bed.

DIF:

Cognitive Level: Applying

REF: p. 245

6. Which drug for nausea and vomiting can cause decreased sweating and increased risk for overheating? a. Meclizine (Antivert) b. Ondansetron (Zofran) c. Trimethobenzamide (Tigan) d. Prochlorperazine (Compazine) ANS: D Prochlorperazine (Compazine) can cause a decrease in sweating, increasing the risk for overheating of the patient’s body. Check body temperature every 4 to 8 hours while a patient is taking this drug.

DIF:

Cognitive Level: Remembering

REF: p. 244

7. Which antiemetic drug class is reserved for patients with severe nausea and vomiting? a. Cannabinoids b. Phenothiazines c. Serotonin (5-HT3) receptor antagonists d. Substance P/neurokinin1 (NK1) receptor antagonists ANS: A The use of cannabinoids as antiemetics is typically reserved for patients with severe nausea and vomiting that has not been relieved by other antiemetics due to the potential for addiction (rare but possible) and other perceived side effects.

DIF:

Cognitive Level: Remembering

REF: p. 244

8. You are teaching a patient who has been prescribed dronabinol for severe nausea. What information should be included in the patient teaching plan?

a. b. c. d.

“This drug may turn your urine pink.”

“This drug is only available by injection.”

“Avoid drinking alcohol while taking this drug.”

“Avoid activities that may cause injury and increase risk for bleeding.”

ANS: C Patients who take dronabinol should avoid drinking alcohol because it can increases the risk for sedation.

DIF:

Cognitive Level: Applying

REF: p. 244

9. A patient prescribed metoclopramide (Reglan) reports having difficulty sleeping, difficulty concentrating, tiredness, and feeling hopeless. What is your best action? a. Instruct the patient that these are expected side effects of the drug. b. Document these findings as the only action. c. Check the patient’s chart history of depression. d. Hold the drug and notify the prescriber.

ANS: D Difficulty sleeping and concentrating, tiredness, and feeling hopeless are signs of depression. Metoclopramide can cause mild to severe depression. You should hold the drug and notify the prescriber. This drug should not be prescribed for patients with a history of depression.

DIF:

Cognitive Level: Applying

REF: p. 248

10. A patient taking metoclopramide (Reglan) for the last 6 months develops uncontrolled rhythmic movement of the face, lip smacking, and rapid or wormlike movements of the tongue. What is your best action? a. Obtain a serum drug level immediately. b. Document the findings and contact the prescriber. c. Ask if the patient has any drug, pet, or food allergies. d. Make arrangements to transfer the patient to the ICU. ANS: B Metoclopramide (Reglan) can cause tardive dyskinesia, a chronic disorder of the nervous system. Signs and symptoms include uncontrolled rhythmic movement of the mouth, face, or extremities; lip smacking or puckering; puffing of cheeks; uncontrolled chewing; and rapid or wormlike movements of the tongue. This adverse effect usually occurs after a year or more of continued use of these drugs and is often irreversible. If diagnosed early, tardive dyskinesia may be reversed by stopping the drug.

DIF:

Cognitive Level: Applying

REF: p. 248

11. Which drug classification would you expect a patient who was just diagnosed with a duodenal ulcer to be prescribed? a. A laxative b. An antacid c. A phenothiazine d. A proton pump inhibitor

ANS: D Proton pump inhibitors are used in the short-term treatment of active duodenal ulcers, usually after adequate courses of H2-receptor antagonists have not been successful.

DIF:

Cognitive Level: Applying

REF: p. 250

12. A patient with gastrointestinal upset has been prescribed an antacid. What information regarding this drug classification would be appropriate to provide to the patient? a. “Other drugs should be taken 1 hour before or 2 hours after an antacid.” b. “Antacids work to relieve GI upset and prevent future attacks.” c. “Antacids should be taken with meals for maximum benefit.” d. “Chewable antacids should be taken with a full glass of milk.”

ANS: A A major concern for all antacids is the impact on absorption of other drugs. For this reason, timing of administration of the antacids related to meals and other drugs is very important. Other drugs should be taken 1 hour before or 2 hours after taking the antacid.

DIF:

Cognitive Level: Applying

REF: p. 250

13. Which statement made by a patient taking a H2-receptor blocker for peptic ulcer disease leads you to suspect the patient needs additional teaching regarding taking this class of drugs? a. “This type of drug may cause dizziness.” b. “I will avoid smoking while taking this drug.” c. “I will report any unusual bleeding or signs of infection.” d. “I will take my daily dose of this drug first think in the morning.”

ANS: D Once a day dosing of H2-receptor blockers is best taken at bedtime to reduce symptoms of acid reflux at night.

DIF:

Cognitive Level: Applying

REF: p. 252

14. A patient with a peptic ulcer who has been prescribed sucralfate asks you to explain how this drug works to heal the ulcer. What is your best response? a. “This drug works by neutralizing gastric acid in the stomach.” b. “This drug works by preventing the secretion of gastric acids.” c. “This drug works by providing a protective layer over the ulcer.” d. “This drug works by blocking the H2-receptor for gastric secretions.”

ANS: C Sucralfate is a cytoprotective drug that aids in the healing of ulcers by forming a protective layer at the ulcer site, providing a barrier to injury from the gastric acids.

DIF:

Cognitive Level: Applying

REF: p. 251

15. An elderly patient taking a loop diuretic comes in for a routine visit. During your interview with the patient, she informs you that she frequently uses a stimulant laxative.

Which of the following problems may arise from frequent laxative use?

a. b. c. d.

Infection Duodenal ulcer Electrolyte imbalance Inflammatory bowel disorder

ANS: C Excessive use of stimulant laxatives may cause excessive fluid loss and electrolyte imbalance, particularly hypokalemia, especially when taking loop diuretics.

DIF:

Cognitive Level: Applying

REF: p. 256

16. A patient has been scheduled for a routine colonoscopy. Which of the following laxatives would be most appropriate to use for preparing the colon for this procedure? a. A bulk-forming laxative b. A lubricant laxative c. An osmotic laxative d. A stimulant laxative ANS: C Osmotic or saline laxatives are used to cleanse the bowel in preparation for, or following, endoscopic or colonoscopic examination or surgery.

DIF:

Cognitive Level: Knowing

REF: p. 255

17. You suspect an older adult patient of using excessive amounts of laxatives. Which would be an appropriate intervention for this patient to help reduce chronic laxative use and dependency? a. Advise the patient to take a stool softener plus laxative preparation. b. Instruct the patient to use a fleet-type enema instead of a laxative. c. Instruct the patient to drink six to eight glasses of water each day. d. Advise the patient to take a laxative only once weekly.

ANS: C Older adult patients should be taught nondrug measures to prevent constipation, such as increasing fluid intake to six to eight glasses of water a day, increasing fiber intake, and increasing physical activity.

DIF:

Cognitive Level: Applying

REF: p. 256

18. You are providing instruction to a patient about the use of a bulk-forming laxative for the treatment of constipation. Which statement should be included in the teaching plan for this patient? a. “Take this drug with a full glass of water.” b. “These drugs contain mineral oil and must be swallowed carefully.” c. “Take this drug with dairy products, such as milk.” d. “These drugs are used for the rapid relief of constipation.”

ANS: A Patients who do not take bulk-forming laxatives with enough water (need at least 8–12 ounces of fluid) are at risk for esophageal obstruction.

DIF:

Cognitive Level: Applying

REF: p. 256

MULTIPLE RESPONSE 1. What information about proton pump inhibitors is correct? (Select all that apply.) a. These drugs can cause dizziness. b. These drugs can cause neutropenia. c. These drugs should only be taken as needed. d. These drugs can increase the risk for osteoporosis. e. These drugs heal ulcers by reducing acid in the stomach. f. These drugs work by ‘sticking’ to ulcerated areas of the stomach.

ANS: A, D, E Proton pump inhibitors (PPIs) can cause dizziness, so use of heavy machinery and driving should be avoided. PPIs should be taken as scheduled to heal the ulcer. These drugs can cause osteoporosis, so vitamin D should be added to the patient’s regimen.

PPIs work to heal ulcers by reducing stomach acid.

DIF:

Cognitive Level: Knowing

REF: p. 253

2. What problems may a patient with nausea and vomiting be at risk for? (Select all that apply.) a. Weight loss b. Constipation c. Dehydration d. Fluid retention e. Electrolyte imbalance f. Chemoreceptor zone malfunction ANS: A, C, E Patients with nausea and vomiting are at risk for dehydration, weight loss, and electrolyte imbalance. Monitor and report any changes in fluid balance, food intake, and lab abnormalities.

DIF:

Cognitive Level: Knowing

REF: p. 242

3. A patient reports constipation. Which high-fiber foods would the nurse instruct the patient to add to his diet? (Select all that apply.) a. Apple juice b. Oranges c. Bran cereals d. Figs e. Kiwi ANS: B, C, D High-fiber foods increase the transit of food through the GI tract and have a mild laxative effect. Oranges, bran, and figs are high in fiber.

DIF:

Cognitive Level: Applying

REF: p. 258

4. A patient with gastritis asks why the healthcare provider prescribed an antacid when she has already been eating well. Which would be the best response made by the nurse?

(Select all that apply.) a. “Antacids are used to neutralize the acidity in your stomach between meals.” b. “Antacids will help to neutralize stomach acid and reduce your discomfort.” c. “All drugs should be taken with an antacid.” d. “Antacids are also used to treat constipation.” e. “Antacids will help you digest your food.”

ANS: A, B Antacids neutralize gastric acid in patients and provide relief from heartburn and indigestion that accompanies gastritis.

DIF:

Cognitive Level: Applying

REF: p. 249

5. You are giving discharge instructions to a patient who will be taking an antacid for gastric problems. Which instructions should be provided to this patient? (Select all that apply.) a. Antacids must be taken with a lower fiber diet. b. Antacids must be taken between meals. c. Antacids should be taken at bedtime. d. Antacids serve as a gastric buffer. e. Antacids must be taken with food. f. Antacids can cause diarrhea.

ANS: B, C, D, F Antacid neutralizes gastric acid; thus antacids are most beneficial if given between meals and at bedtime. They may also cause diarrhea.

DIF:

Cognitive Level: Applying

REF: p. 251

6. Which are classified as one of the five major categories of laxatives? (Select all that apply.) a. Bulk-forming laxatives b. Lubricant laxatives c. Stimulant laxatives d. Antispasmodic laxatives e. Stool softeners ANS: A, B, C, E Laxatives are classified into five major categories, based on their mechanism of action.

These categories are bulk-forming agents, fecal (stool) softeners, hyperosmolar or saline solutions, lubricants, and stimulant or osmotic laxatives.

DIF:

Cognitive Level: Knowing

REF: p. 256

Chapter 14: Drugs Affecting the Hematologic System Visovsky: Introduction to Clinical Pharmacology, 9th Edition MULTIPLE CHOICE 1. A patient with a clotting disorder is prescribed an anticoagulant and asks you to explain the purpose of anticoagulant therapy. What is your best response? a. Anticoagulants are used to lyse existing clots. b. Anticoagulants are used to increase the flow of blood. c. Anticoagulants are used to prevent new clot formation. d. Anticoagulants are used to thin the viscosity of the blood.

ANS: C Anticoagulants are drugs that interfere with the clotting process, so they are used to reduce existing clots or to prevent new clots from forming.

DIF:

Cognitive Level: Remembering

REF: p. 266

2. An older patient who takes a daily NSAID for arthritis pain has been prescribed aspirin as an antiplatelet agent. What information regarding risks associated with aspirin use should be included in this teaching plan? a. The risk for urinary retention b. The risk for cognitive decline c. The risk for gastrointestinal bleeding d. The risk for peripheral arterial disease ANS: C Most drugs that affect the blood clotting system, such as antiplatelet drugs, have the potential to cause bleeding, especially in older patients.

DIF:

Cognitive Level: Applying

REF: p. 268

3. Which statement made by a patient with a recent coronary artery stent placement who is taking clopidogrel informs you that the patient requires further teaching about this drug? a. “I will avoid herbal supplements while taking this drug.” b. “I will need to take this drug every day for 3 months.” c. “I will report any abnormal bleeding.” d. “I will take this drug with food.”

ANS: B For patients who have had a stent placed into the coronary artery as a result of severe narrowing or blockage of the artery, clopidogrel prevents platelets from sticking to the stent mesh. For these patients, clopidogrel must be taken daily for a year or longer to prevent clots from developing and plugging up the stent.

DIF:

Cognitive Level: Applying

REF: p. 268

4. Which symptom when reported by a patient taking aspirin alerts you to a possible adverse reaction to the drug?

a. b. c. d.

Nausea Itching and hives Decreased vision Increased urination

ANS: B Allergic reactions to aspirin and NSAIDs generally occur within a few hours of taking the drug. Symptoms of allergic reactions include itching, hives, and runny nose, with more severe reactions causing swelling of the lips, tongue, or face.

DIF:

Cognitive Level: Applying

REF: p. 268

5. You are taking the drug history of a patient who will be starting on an anticoagulant.

Which of the following drug categories from this patients’ drug list would potentially interfere with an anticoagulant? a. Beta blockers b. Loop diuretics c. Oral contraceptives d. Inhaled corticosteroids ANS: C Oral contraceptives decrease the effects of anticoagulants.

DIF:

Cognitive Level: Knowing

REF: p. 269

6. A patient prescribed an anticoagulant asks you about potential drug interactions with this new drug. Which of the following drugs would you advise this patient to avoid while taking anticoagulants? a. Vitamin C b. Thiazide diuretics c. Proton pump inhibitor d. Nonsteroidal anti-inflammatory analgesics ANS: D Nonsteroidal anti-inflammatory drugs (NSAIDs) will increase the risk of bleeding and hemorrhage in a patient receiving anticoagulants.

DIF:

Cognitive Level: Applying

REF: p. 269

7. You are reviewing the laboratory values of an outpatient who is on anticoagulant therapy. The laboratory tests show a less than desired level of anticoagulation. The patient states that the drug has been taken as prescribed. Which food would you advise the patient to avoid while on anticoagulant therapy? a. Spinach b. Bananas c. Tomatoes d. Sweet potatoes ANS: A The patient should avoid excessive amounts of foods high in vitamin K (spinach, broccoli, cabbage, kale, dark leafy greens, and asparagus).

DIF:

Cognitive Level: Applying

REF: p. 269

8. A patient who is taking an anticoagulant informs you that the herbal supplement St. John’s wort is taken daily for depression. What should you teach the patient about the use of herbal supplements with anticoagulant therapy? a. Herbal drugs may decrease clotting times. b. Herbal drugs may increase the risk of bleeding. c. There are no risks associated with this drug combination. d. They are safe to take together if you take them an hour apart.

ANS: B St. John’s wort, as well as other herbal drugs, may increase the risk of bleeding in patients on anticoagulants.

DIF:

Cognitive Level: Applying

REF: p. 269

9. A patient with atrial fibrillation has been prescribed the drug dabigatran (Pradaxa). The patient asks you what the advantage of this drug may be over warfarin (Coumadin).

What is your best response? a. “This drug is taken only once daily.” b. “This drug does not carry a risk for excessive bleeding.” c. “This drug does not require frequent laboratory testing.” d. “This drug does not interact with other drugs you may be taking.”

ANS: C The advantage of direct thrombin inhibitors (DTIs) is that they do not require the frequent laboratory blood testing as part of the monitoring process that is required by warfarin.

DIF:

Cognitive Level: Applying

REF: p. 270

10. You are caring for a patient who is taking an indirect thrombin inhibitor following surgery. What laboratory value should you monitor for possible adverse effects of this therapy? a. Platelet count b. Potassium level c. Serum calcium level d. White blood cell count ANS: A The most common adverse reactions from indirect thrombin inhibitors are excessive bleeding and thrombocytopenia, so monitoring of the patient’s platelet count is needed.

DIF:

Cognitive Level: Applying

REF: p. 271

11. A patient taking a direct thrombin inhibitor (DTI) tells you he is going on vacation and will be taking his anticoagulant drug with him. What advice should you give to this patient related to this specific class of drugs? a. “Keep this drug in its original bottle while traveling.”

b. “Stop this drug while on vacation to avoid the risk of bleeding.” c. “Take this drug with only a few sips of water to avoid GI upset.” d. “Make sure you eat plenty of green vegetables while on vacation.”

ANS: A Instruct patients to keep DTIs in the original bottle to protect the drug from moisture and light. Teach them not to put DTIs in pill boxes or pill organizers.

DIF:

Cognitive Level: Applying

REF: p. 270

12. You are teaching a patient who has been prescribed apixaban (Eliquis) about symptoms of drug overdose. What symptom should you alert the patient to report? a. Abnormal pulse rate b. Gastric upset after eating c. Excessive sleepiness during the day d. Bleeding from the gums while brushing the teeth ANS: D Early signs of overdose or internal bleeding include bleeding from the gums while brushing teeth, excessive bleeding or oozing from cuts, unexplained bruising or nosebleeds, and unusually heavy or unexpected menses in women.

DIF:

Cognitive Level: Knowing

REF: p. 270

13. What category of anticoagulant drugs works by increasing the amount of the protein antithrombin III? a. Fibrinolytics b. Vitamin K antagonists c. Direct thrombin inhibitors d. Indirect thrombin inhibitors ANS: D Indirect thrombin inhibitors (ITIs) are anticoagulant drugs that decrease clot formation by increasing the amount and action of a protein called antithrombin III. This protein inhibits thrombin from doing its job in the blood clotting cascade, and clot formation is reduced.

DIF:

Cognitive Level: Remembering

REF: p. 271

14. A patient with a history of deep vein thrombosis is prescribed subcutaneous heparin before surgery. The patient asks you if the heparin can be taken orally instead of by injection. What is your best response? a. “Oral heparin is quite expensive, and not covered by insurance.” b. “Heparin is given by injection because it cannot be absorbed orally.” c. “Heparin is given by injection before surgery because it works faster.” d. “Heparin cannot be given orally because you are fasting for your surgery.”

ANS: B Heparin is given only by injection because it cannot be absorbed orally.

DIF:

Cognitive Level: Applying

REF: p. 271

15. You are reviewing the laboratory values of a patient whose heparin dose has been changed by the healthcare provider. Which laboratory value will inform you about effect of the dose change on this anticoagulant therapy? a. PT b. INR c. aPTT d. DIC panel ANS: C Therapy with heparin sodium must be monitored for its anticoagulation effect by a blood test known as the activated partial thromboplastin time (aPTT). The prescriber maintains or adjusts dosages according to this test result.

DIF:

Cognitive Level: Remembering

REF: p. 272

16. A patient is suspected of having an overdose of heparin. What drug should you prepare for the healthcare provider to give? a. Naloxone b. Warfarin c. Acetylcysteine d. Protamine sulfate ANS: D Protamine sulfate is a strongly basic (alkaline) protein that acts as an antagonist to neutralize (reverse) the actions of heparin.

DIF:

Cognitive Level: Remembering

REF: p. 272

17. A patient prescribed subcutaneous heparin tells you that her menstrual bleeding is heavier than usual. What is your best response? a. “I will hold the drug and notify your healthcare provider.” b. “This is a fairly common and expected side effect of the drug.” c. “Heavy menstrual bleeding indicates the drug is working properly.” d. “I will have to give you a shot of protamine sulfate to reverse the drug’s action.”

ANS: A Watch for signs of abnormal bleeding and teach patients to report abnormal bleeding, including heavy menses, to the healthcare provider because these may indicate overdosage.

DIF:

Cognitive Level: Applying

REF: p. 267

18. You are preparing to draw up a dose of heparin to give subcutaneously to a patient.

Which of the following represents the best procedure in preparing this injection? a. Roll the vial between your hands in order to distribute the solution. b. Insert the needle, then turn the vial upside down to distribute the drug. c. Shake the vial vigorously to adequately distribute the drug molecules. d. Carefully draw the solution up from the vial without disturbing the contents.

ANS: A

Do not shake the bottle containing the heparin; only roll it carefully between your hands before inserting the needle. If the heparin solution is discolored or contains a precipitate or particles at the bottom of the bottle, do not use it.

DIF:

Cognitive Level: Remembering

REF: p. 272

19. The aPTT of a patient who is prescribed continuous intravenous (IV) heparin is two times the control value. What is your best action? a. Increase the IV rate as ordered. b. Decrease the IV rate as ordered. c. Leave the rate unchanged. d. Stop the infusion and notify the prescriber.

ANS: C The goal of continuous heparin therapy is to keep the aPTT within a therapeutic range of 1.5 to 2.5 times greater than the laboratory-established control value. Two times the control value is within this range. The prescriber should be notified, but the infusion rate, which is therapeutic, will not change at this time.

DIF:

Cognitive Level: Applying

REF: p. 272

20. A patient taking an oral anticoagulant has had an international normalized ratio (INR) drawn to check the therapeutic drug response. Which range represents the therapeutic INR range for a patient taking an oral anticoagulant? a. 1.0 to 2.0 b. 2.0 to 3.0 c. 3.0 to 4.0 d. 4.0 to 5.0 ANS: B The normal range for the INR is 0.8 to 1.2, with a therapeutic target range of 2.0 to 3.0.

For patients with mechanical heart valves, this therapeutic range is slightly higher at 2.5 to 3.5, because of the high risk for clots forming within the valve itself.

DIF:

Cognitive Level: Knowing

REF: p. 272

21. A young mother who is breast-feeding now requires treatment with heparin. The patient asks you if she should continue breast-feeding during her treatment. What is your best response? a. “You will need to stop breast-feeding during treatment with heparin.” b. “Heparin is not found in breastmilk, so you may continue breast-feeding.” c. “The half-life of heparin is short, so breastfeed before your daily heparin injection.” d. “Pump your breasts to keep breastmilk flowing so you can resume breast-feeding later.”

ANS: B Breast-feeding is safe during heparin therapy because the drug is not found in breastmilk.

DIF:

Cognitive Level: Applying

REF: p. 272

22. An obese, menopausal woman is beginning warfarin (Coumadin) therapy. Which adverse effect should you monitor this patient for in the first 10 days of drug therapy? a. Neutropenia b. Skin necrosis c. Severe diarrhea d. Pulmonary edema ANS: B Warfarin can cause skin necrosis (death) that can occur within the first 10 days of therapy and is associated with larger dosages. Obese, menopausal women are at greatest risk for this rare adverse reaction.

DIF:

Cognitive Level: Knowing

REF: p. 273

23. You are assessing a patient who is on long-term warfarin (Coumadin) therapy who has been diagnosed with a warfarin overdosage. What drug would you anticipate would be needed as the antidote for warfarin overdose? a. Paroxetine b. Phytonadione c. Protamine sulfate d. Prothrombin factor ANS: B In response to some bleeding disorders or warfarin overdosage, vitamin K, phytonadione (AquaMEPHYTON), may be given either orally or parenterally to help stimulate the liver to resume manufacture of prothrombin and serve as an anticoagulant antagonist.

However, this clotting activity may not return for 48 to 72 hours.

DIF:

Cognitive Level: Knowing

REF: p. 273

24. A patient has been prescribed a fibrinolytic drug. What response to the patient best describes the action of this class of drug? a. “This drug works to prevent blood clot formation.” b. “This drug acts to reverse the effects of heparin.” c. “This drug works to lyse existing blood clots.” d. “This drug thins out the blood.”

ANS: C Fibrinolytic drugs convert plasminogen to the enzyme plasmin, which breaks down fibrin clots, fibrinogen, and other plasma proteins, and thus, they dissolve and break down existing blood clots.

DIF:

Cognitive Level: Knowing

REF: p. 275

25. Which statement about fibrinolytic drugs is true? a. These high-alert drugs are given by IV infusion. b. These drugs can be used in the outpatient setting. c. These drugs increase cellular damage from clots blocking the arteries.

d. These drugs are contraindicated in patients diagnosed with an acute MI. ANS: A All fibrolytic drugs are given IV and are high-alert drugs, and are used for several purposes, including acute MI. These drugs decrease cellular damage and are used only in a critical care setting.

DIF:

Cognitive Level: Knowing

REF: p. 275

26. A patient is brought to the hospital with chest pain and shortness of breath is suspected of having an acute MI. Which assessment is a priority for this patient with a suspected acute MI who may be given a fibrinolytic drug as treatment? a. Ask the patient or family when the symptoms first began. b. Ask the patient or family for a list of all drugs taken that day. c. Ask the patient or family when the last meal took was eaten. d. Ask the patient or family to report any history of kidney disease present.

ANS: A Timing is a critical factor in using these drugs. If fibrinolytics are begun within 12 hours of a heart attack, or 3 hours of the onset of a stroke, the blood clot blocking the artery can be dissolved, and blood flow restored.

DIF:

Cognitive Level: Applying

REF: p. 275

27. You are preparing to give an injection of an erythropoietin stimulating agent to a patient.

The patient asks you to explain the expected side effects of this injection. What is your best response? a. “Thickening of the blood” b. “Infection at the injection site” c. “Pain at the site of the injection” d. “Drowsiness and lack of concentration” ANS: C Pain at the injections site is the most common side effect of ESAs. Generalized body aches and pain, skin rash, redness, or warmth at the injection site can occur. Thickening of the blood leading to hypertension or stroke is an adverse effect, not a common side effect.

DIF:

Cognitive Level: Applying

REF: p. 276

28. A patient is about to begin treatment with epoetin alfa. Which patient assessment parameter should you monitor closely to prevent complications from this drug? a. The patient’s urine output b. The patient’s blood pressure c. The patient’s blood glucose level d. The patient’s serum potassium level ANS: B The use of ESAs is not without significant risks. As RBC production increases, the blood itself becomes thicker. This can result in a higher risk for hypertension, blood clots, stroke, and MI.

DIF:

Cognitive Level: Applying

REF: p. 276

MULTIPLE RESPONSE 1. What signs or symptoms would you expect to see in a patient who develops bleeding as a result of anticoagulant therapy? (Select all that apply.) a. Hypertension b. Easy bruising c. Bleeding gums d. Tarry-colored stool e. Shortness of breath f. Decreased pulse rate ANS: B, C, D, E For any patient who is taking anticoagulants, watch for early signs of bleeding: easy bruising of knuckles, elbows, or any body part experiencing pressure (e.g., under watch band), new or excessive bleeding of gums when brushing teeth, blood in the urine or stool, or tarry-colored stool, tachycardia, hypotension, shortness of breath, and gastrointestinal pain.

DIF:

Cognitive Level: Remembering

REF: p. 269

2. You are preparing to give an injection of heparin to a patient. Which of the following steps represent the correct procedure? (Select all that apply.) a. Insert the needle, pull back the plunger, and aspirate before injecting. b. Give subcutaneous heparin in the same general area each time. c. Do not massage the injection site after injecting the heparin. d. Draw up the heparin and check the dose with another nurse. e. Use a 25-gauge needle to give heparin subcutaneously. f. Give the heparin IM ventrogluteal muscle.

ANS: C, D, E When injecting subcutaneous heparin, do not pull back on the syringe to aspirate for blood or move the needle in the tissue during the injection. Do not massage the injection site. All of these actions increase the risk for bleeding, bruising, and tissue damage at the injection site. Heparin is not given IM. DIF:

Cognitive Level: Knowing

REF: p. 271

3. You suspect a patient taking warfarin (Coumadin) has developed internal bleeding. What symptoms of this condition would you expect the patient to exhibit? (Select all that apply.) a. Abdominal pain b. Dizziness c. Tachycardia d. Warm, flushed skin e. Hypertension ANS: A, B, C

Signs that suggest internal bleeding include: abdominal pain or swelling, back pain, or constipation (resulting from paralytic ileus or intestinal obstruction); bloody or tarry stools, bloody or dark-colored urine, coughing up or vomiting blood or “coffee-ground” substance; dizziness or cold, clammy skin; severe or continuous headache; and tachycardia (fast pulse), hypotension (low blood pressure), and tachypnea (rapid breathing).

DIF:

Cognitive Level: Knowing

REF: p. 273

4. For which conditions would the use of fibrinolytic drugs be appropriate? (Select all that apply.) a. Ischemic stroke b. Hypotensive crisis c. Acute arterial occlusion d. Acute pulmonary embolism e. Cellular damage from an MI f. Treatment of warfarin overdose ANS: A, C, D, E Fibrinolytic drugs are used in acute myocardial infarction for lysis of thrombi that block coronary arteries, in acute pulmonary embolism for clot lysis when the patient is hemodynamically unstable, in acute ischemic stroke, and in acute arterial occlusion.

These drugs reduce the extent of cellular damage from blockage.

DIF:

Cognitive Level: Remembering

REF: p. 275

Chapter 15: Drugs for Immunization and Immunomodulation Visovsky: Introduction to Clinical Pharmacology, 9th Edition MULTIPLE CHOICE 1. Which type of immunity serves to protect against day-to-day pathogen exposure? a. Innate immunity b. Natural immunity c. Acquired immunity d. Supplemental immunity ANS: A

Innate immunity helps protect you from smaller day-to-day exposures to pathogenic organism but cannot provide long-term immunity to any single specific disease-causing microorganism.

DIF: Cognitive Level: Remembering

REF: p. 280

2. In acquired immunity, what is the body’s response to antigen exposure? a. The body initiates the clotting cascade. b. The body produces additional antigens. c. The body produces an antibody response. d. The body increases antigen response through lymphocyte action.

ANS: C

Exposure to antigens is the trigger for lymphocytes to begin producing antibodies. These antibodies can be made in such high amounts that, when you are re-infected by the same microorganism, they attack and destroy it or rid the body of it before it can make you sick again.

DIF: Cognitive Level: Knowing

REF: p. 281

3. Which of the following is an example of acquired passive immunity? a. Immunity developed from microorganism exposure through vaccination. b. Premade antibodies are transferred to you by another person or an animal. c. Microorganism exposure that makes you sick, and then develop antibodies. d. A pregnant woman who transfers antibodies to her baby during breast-feeding.

ANS: D

Natural acquired passive immunity is composed of the antibodies that a woman transfers to her fetus during pregnancy and to her infant during breast-feeding. This immunity is short-term but critically important in preventing young infants from many illnesses during the first 6 months after birth.

DIF: Cognitive Level: Knowing

REF: p. 282

4. Which type of vaccine contains antigens that are killed by heat, radiation, or chemicals? a. A toxoid b. An antiserum c. Inactivated vaccine

d. Attenuated vaccine ANS: C

Laboratories can produce inactivated vaccines that contain dead antigens so that people can be immunized to prevent them from getting the disease.

DIF: Cognitive Level: Remembering

REF: p. 283

5. The parent of an infant you are caring for asks you for the correct schedule for the

diphtheria, tetanus, and pertussis (DTaP) vaccine schedule. What is your best response? a. “DTaP is given at 2, 4, and 6 months of age.” b. “DTaP is given at 1, 3, and 5 months of age.” c. “DTaP is given at 6, 12, and 18 months of age.” d. “DTaP is given to children when they are ready to begin school.”

ANS: A

The correct schedule for the DTaP is at 2, 4, and 6 months of age, with a booster at 15 to 18 months.

DIF: Cognitive Level: Applying

REF: p. 283

6. Which statement made by an adult patient demonstrates understanding of the

recommended Tdap vaccine booster schedule? a. “I will need a booster every 5 years” b. “I will need a booster every 7 years.” c. “I will need a booster every 10 years.” d. “I will need a booster every 15 years.”

ANS: C

For adults aged 19 and older, Tdap boosters are recommended every 10 years.

DIF: Cognitive Level: Applying

REF: p. 283

7. An adult patient scheduled for a seasonal influenza vaccine presents to the clinic with

complaints of an upper respiratory infection. He is also there for a flu shot. What is your best action? a. Give a ‘test dose’ of the vaccine to observe if a reaction is present. b. Give the influenza vaccine to avoid more severe infection. c. Have the patient sign a consent for the vaccine. d. Hold the vaccine until the infection resolves.

ANS: D

Vaccines should not be given to patients with active infection, severe febrile illness, or history of a serious side effect from previous vaccinations.

DIF: Cognitive Level: Applying

REF: p. 285

8. Which of the following patients should receive a yearly influenza virus vaccine? a. An adolescent b. A young mother c. A middle-aged man d. An older adult woman

ANS: D

Older adults are at high risk for influenza, so it is recommended that this patient population receive the annual flu vaccine to prevent infection.

DIF: Cognitive Level: Knowing

REF: p. 286

9. A pregnant woman presents for her regular obstetric appointment and requests to have the

seasonal influenza vaccine. What is your best response? a. “This vaccine contains a live virus, so cannot be given during pregnancy.” b. “This vaccine can be given safely anytime during your pregnancy.” c. “You may only receive this vaccine during your last trimester.” d. “You may only receive this vaccine during your first trimester.”

ANS: B

Vaccinations that are recommended during pregnancy include seasonal influenza and Tdap.

DIF: Cognitive Level: Applying

REF: p. 286

10. You are preparing to give an 18-month-old child the measles, mumps, and rubella (MMR)

vaccine. The child’s mother informs you that a relative who is HIV-positive has just moved into the home with this family. What is your best action? a. Withhold the vaccine, as it contains live microorganisms. b. Give the vaccine as ordered; there is no effect on the HIV-positive person. c. Give one-half of the vaccine dose now and schedule the remaining dose at a later date. d. Have the HIV-positive person contact his/her healthcare provider before giving the vaccine.

ANS: D

People who are immunocompromised are at increased risk for an adverse reaction after administration of live attenuated vaccines because they have less of an ability to build up an effective immune response. Before receiving a vaccination with a live vaccine, the household member’s healthcare provider should be consulted because the patient with reduced immunity may be at increased risk for contracting the virus the vaccine is designed to prevent.

DIF: Cognitive Level: Applying

REF: p. 286

11. An adult patient who has received the series of vaccines against hepatitis B asks you if

immunity is now present against this disease. What is your best response? a. “Immunity can only be determined by obtaining a blood titer.” b. “You are considered immune if you have completed all three vaccines.” c. “You will be considered immune one month after your last injection.” d. “The health department will review the dates of your vaccines and let you know.”

ANS: A

Antibody blood titers taken after the hepatitis B vaccine series can confirm the presence of antibodies and immunity.

DIF: Cognitive Level: Applying

REF: p. 284

12. An adult patient who is the recipient of a kidney transplant is prescribed the antirejection

drug mycophenolate. What potential problem should you monitor this patient for? a. Fluid retention and edema b. Signs and symptoms of infection c. Changes in cognition and memory d. Decreased pulse rate and hypotension ANS: B

All selective immunosuppressants reduce immunity to some extent and increase the patient’s risk for infection. With reduced immunity and inflammation, the symptoms of infection may not be present even when the patient has a significant infection.

DIF: Cognitive Level: Applying

REF: p. 287

13. You are teaching a patient who is beginning an antiproliferative drug about potential

toxicities associated with this class of drugs. Which statement should be included in the teaching plan for this patient? a. “Stay out of the sun and use sunscreen daily.” b. “Eat high-fiber foods and increase your fluid intake.” c. “Avoid drinking alcohol and taking acetaminophen.” d. “These drugs can cause bleeding at the administration site.”

ANS: C

Liver toxicity and liver failure have occurred with all of the antiproliferatives and the calcineurin inhibitors. The risk is increased if the patient has other liver problems or is exposed to other substances that are liver toxic, such as alcohol and acetaminophen.

DIF: Cognitive Level: Applying

REF: p. 289

14. A woman of childbearing age has just been prescribed an antiproliferative drug. What

statement made by this patient alerts you to the need for additional teaching? a. “I can plan to become pregnant after I am on this drug for a minimum of 6 months.” b. “I will use two reliable forms of birth control while taking this drug.” c. “I will report any yellowing of my eyes or skin.” d. “I will take my temperature daily.”

ANS: A

Pregnancy is an absolute contraindication for the use of antiproliferative drugs because they are associated with birth defects and other severe problems. Tell sexually active women of childbearing age to use two reliable methods of contraception during this therapy and for at least 12 weeks after the therapy is discontinued.

DIF: Cognitive Level: Applying

REF: p. 290

MULTIPLE RESPONSE 1. Which of the following are examples of a toxoid that has been modified to be used as a

vaccine? (Select all that apply.) a. Human papilloma virus

b. c. d. e. f.

Hepatitis B Pertussis Tetanus Rubella Polio

ANS: A, B, C, D

Disease for which toxoid vaccines are commonly used include tetanus, diphtheria, pertussis (whooping cough), human papilloma virus (HPV), and hepatitis B (HVB).

DIF: Cognitive Level: Remembering

REF: p. 283

2. Which statements made about vaccinations for artificial acquired active immunity are

true? (Select all that apply.) a. These vaccines require more than one injection. b. These vaccines require smaller, booster doses. c. These vaccines are only given during childhood. d. These vaccines can cause reactions at the injection site. e. These vaccines can be given during episodes of fever or illness. f. These vaccines are not used to immunize populations against disease.

ANS: A, B, D

Vaccinations for artificial acquired active immunity usually require more than one injection to ensure there are enough B cells to the specific antigen and can begin making antibodies. Additional vaccinations (boosters) containing smaller doses of the original antigens are needed to continue immunity. These vaccines are given to adults and children, and are used to protect the population against disease outbreak. Reactions at the injection site are common and usually mild.

DIF: Cognitive Level: Knowing

REF: p. 283

3. Which of the following selective immunosuppressants can cause an increase in serum

cholesterol levels? (Select all that apply.) a. Mycophenolate b. Methotrexate c. Cyclosporine d. Everolimus e. Tacrolimus f. Sirolimus ANS: C, D, E, F

Sirolimus and everolimus, and the calcineurin inhibitors cyclosporine and tacrolimus all increase blood cholesterol levels, which leads to hypertension.

DIF: Cognitive Level: Remembering

REF: p. 288

4. What instructions should be included in the teaching plan for patients taking the oral

suspensions of sirolimus or cyclosporine? (Select all that apply.) a. Mix the solution in a glass container. b. Mix oral preparations together using only water. c. Take this drug with grapefruit juice for the best absorption.

d. Rinse the container with the same solution used to prepare it. e. Mix each drug with the recommended solution of milk or juice. f. Allow the prepared mixture to stand for one hour before taking the drug.

ANS: A, D, E

If you are taking the oral suspensions of sirolimus or cyclosporine, mix the drug exactly as directed, using the recommended solution (milk, orange juice, apple juice) not water. After drinking the suspension, rinse the container with the same solution and drink the rinse for better drug effectiveness. Remember that cyclosporine must be mixed in a glass container, not a plastic one.

DIF: Cognitive Level: Applying

REF: p. 290

5. Which illnesses do the pneumococcal vaccine produce immunity against in infants and

children? (Select all that apply.) a. Rubella b. Pertussis c. Influenza d. Meningitis e. Pneumonia f. Pneumonitis ANS: D, E

Pneumococcal vaccine provides active immunization for infants and children against pneumonia and meningitis caused by Streptococcus pneumoniae.

DIF: Cognitive Level: Remembering

REF: p. 283

6. Which diseases are infants and children immunized against? (Select all that apply.) a. Polio b. Rabies c. Varicella d. Hepatitis B e. Hepatitis C f. Lyme disease ANS: A, C, D

Infants and children can be immunized against hepatitis B, polio, and varicella in addition to several other conditions.

DIF: Cognitive Level: Remembering

REF: p. 283

7. Which statements are correct concerning vaccines and toxoids? (Select all that apply.) a. They are biologic agents that produce active immunization. b. They are biologic agents that produce passive immunization. c. They are prepared with animal serum. d. They are considered a blood product. e. They are only used in children. f. They are not routinely used.

ANS: A, C

Vaccines and toxoids are biologic agents used in the routine schedule of active immunization for adults and children. Many biologic agents are prepared with animal serum.

DIF: Cognitive Level: Knowing

REF: p. 283

Chapter 16: Hormones and Drugs for Osteoporosis Visovsky: Introduction to Clinical Pharmacology, 9th Edition MULTIPLE CHOICE 1. A patient diagnosed with hypothyroidism has been prescribed treatment with a thyroid hormone agonist. The patient asks you how long this drug will need to be taken. What is your best response? a. “You will need to take this drug for the rest of your life.” b. “You will need to take this drug until your symptoms improve.” c. “You will need to take this drug until your thyroid hormone level normalizes.” d. “You will need to take this drug incrementally until you reach the maximum tolerated dose.”

ANS: A Hypothyroidism is a common problem in which the thyroid gland produces little or no thyroid hormones, slowing all aspects of metabolism, and is treated with thyroid hormone agonists. Usually this therapy is needed for the rest of the person’s life.

DIF:

Cognitive Level: Applying

REF: p. 293

2. A patient taking levothyroxine sodium is pregnant and tells you she plans to breastfeed her baby. What should you tell this patient? a. “While it is safe to breastfeed, this drug will limit your milk supply over time.” b. “Breast-feeding is safe when taking this drug, but not with other thyroid hormones.” c. “You should not breastfeed your infant because this drug passes into your breastmilk.” d. “You may breastfeed while hospitalized and your thyroid hormone levels can be checked.”

ANS: C Women taking thyroid hormone agonists are advised not to breastfeed, as the drug can be found in the mother’s breast milk.

DIF:

Cognitive Level: Applying

REF: p. 294

3. The action of which drug is known to be increased by thyroid hormone replacement drugs? a. Warfarin (Coumadin) b. Acetaminophen (Tylenol) c. Diphenhydramine (Benadryl) d. Fiber supplements (FiberCon) ANS: A

Thyroid agonists used for thyroid hormone replacement therapy enhance the action of drugs that reduce blood clotting (anticoagulants), especially warfarin. Acetaminophen is a pain reliever. Diphenhydramine is an antihistamine. And fiber supplements are dietary supplements, not drugs, and are unaffected by thyroid hormone replacement therapy although their use can inhibit intestinal uptake of thyroid agonists.

DIF:

Cognitive Level: Remembering

REF: p. 294

4. Which assessment is most important to perform before giving an elderly patient who is prescribed levothyroxine (Synthroid) the first dose of the drug? a. Measuring heart rate and rhythm b. Determining level of consciousness c. Asking about an allergy to “sulfa” drugs d. Checking intake and output for the last 24 hours ANS: A Adults over 65 years are usually prescribed a lower initial dose of thyroid hormone agonists because they are more likely to have serious adverse cardiac and nervous system effects. For this reason, doses are increased more slowly in older adults than in younger adults until an appropriate maintenance dose is reached.

DIF:

Cognitive Level: Applying

REF: p. 295

5. How do thyroid replacement drugs work to treat hypothyroidism? a. Forcing the thyroid gland to secrete more thyroid hormones b. Inhibiting the enzymes that break down thyroid hormones c. Preventing damage to thyroid endocrine cells d. Providing thyroid hormones ANS: D Hypothyroidism is low thyroid functioning, which is demonstrated by very low production of thyroid hormones. Thyroid replacement drugs are thyroid hormone agonists. Taking these drugs provides an exogenous source of thyroid hormones.

DIF:

Cognitive Level: Knowing

REF: p. 294

6. A patient who has been prescribed propylthiouracil (Propacil) asks you how this drug works to reduce thyroid hormone levels. What is your best response? a. “This drug combines with the enzyme that connects iodine to tyrosine.” b. “This drug works by activating thyroid hormone in the pituitary gland.” c. “This drug activates the gene for metabolism, speeding up cellular work.” d. “This drug works by interfering with the thyroid hormone feedback loop.”

ANS: A Antithyroid drugs work by entering the thyroid gland and combining with the enzyme responsible for connecting iodine (iodide) with tyrosine. Without this iodide–tyrosine connection, thyroid hormone production is suppressed.

DIF:

Cognitive Level: Applying

REF: p. 294

7. You are caring for a patient who is taking an antithyroid drug for the treatment of hyperthyroidism. Which assessment should be performed before giving this drug? a. Check the pulse rate for irregular rate and rhythm. b. Check the blood pressure for hypertension. c. Check the skin and sclera for yellowing. d. Check the lower extremities for edema.

ANS: C These drugs are hepatotoxic. Check the patient’s liver function tests before giving these drugs. Both thyroid-suppressing drugs are hepatotoxic. Check the patient daily for yellowing of the skin or sclera for jaundice.

DIF:

Cognitive Level: Applying

REF: p. 298

8. A patient taking an antithyroid drug for one week calls you and states that the symptoms of hyperthyroidism have not improved yet. What is your best response? a. “You will need to have your blood level of the drug checked.” b. “This drug must be taken for 3 to 4 weeks to start being effective.” c. “This may mean you have formed thyroid antibodies against this drug.” d. “I will let your healthcare provider know so your dose can be adjusted.”

ANS: B Teach patients that thyroid-suppressing drugs must be taken for 3 to 4 weeks to start being effective because they have no effect on thyroid hormones already stored in the thyroid gland.

DIF:

Cognitive Level: Applying

REF: p. 296

9. You are caring for an elderly patient taking an antithyroid drug. Which of the following conditions is associated with an adverse effect in this patient? a. Decreased complete blood count b. Increased urine output c. Decreased blood pressure d. Increased platelet count ANS: A Older adults taking antithyroid drugs are more likely to have more severe adverse effects. The older patient’s immune system is already lower than that of a younger person, which increases the older person’s risk for infection. Bone marrow suppression from these drugs increases the risk for severe infection.

DIF:

Cognitive Level: Knowing

REF: p. 297

10. A patient you are caring for develops a goiter. What does the appearance of a goiter mean? a. Hypothyroidism b. Hyperthyroidism c. Thyroid problem d. Premature menopause ANS: C

Although a goiter is a distinct swelling of the thyroid gland and the neck, it only indicates a thyroid problem. It is associated with some forms of hypothyroidism and some forms of hyperthyroidism.

DIF:

Cognitive Level: Remembering

REF: p. 296

11. A patient with adrenal hypofunction has a known aldosterone deficiency and has been prescribed Fludrocortisone (Florinef). The patient asks you how this drug works to treat this problem. What is your best response? a. “This drug acts like natural aldosterone in the body.” b. “This drug permits potassium to be retained in the body.” c. “This drug acts to retain glucose for action within the body.” d. “This drug permits the excretion of sodium from the body.”

ANS: A Fludrocortisone (Florinef) is a synthetic drug that acts like natural aldosterone. With the use of this drug, more sodium is retained to prevent excessive sodium wasting, and more potassium is excreted to prevent dangerously high blood potassium levels.

DIF:

Cognitive Level: Applying

REF: p. 298

12. A patient prescribed Fludrocortisone (Florinef) calls to report a weight gain of 3 lb. in the last week to you. What is your best response to this patient? a. “You will need to cut all salt from your diet for a few days to see if this resolves.” b. “Your diet may contain too many carbohydrates for your body to process.” c. “I will notify your healthcare provider right away and get back to you.” d. “This is an expected side effect of this drug.”

ANS: C Congestive heart failure (CHF) is a serious adverse effect of fludrocortisone. It requires that the drug dose be either reduced or stopped. A weight gain of 2 lb. in a day or 3 lb. in a week should be reported to the healthcare provider immediately.

DIF:

Cognitive Level: Applying

REF: p. 298

13. Which side effects are most common when taking any drug to manage adrenal gland hyperfunction? a. Decreased urine output and increased sweating b. Blurred vision and dry mouth c. Headache and mouth sores d. Nausea and vomiting ANS: D The most common side effects for any drug used to manage adrenal gland function are nausea and vomiting. They also cause many other gastrointestinal upsets. They are not associated with blurred vision, dry mouth, headache, mouth sores, or increased sweating.

Urine output is usually increased, not decreased.

DIF:

Cognitive Level: Remembering

REF: p. 299

14. Which drug is used only for patients with type 2 diabetes and hypercortisolism? a. Mitotane (Lysodren) b. Mifepristone (Korlym) c. Liothyronine sodium (Cytomel) d. Methimazole (Northyx, Tapazole) ANS: B A specialized drug for hypercortisolism is Mifepristone (Korlym). This drug works by blocking corticosteroid receptors. Although this does not reduce cortisol levels, it does inhibit cortisol responses in different tissues. It is approved for use only in people who have type 2 diabetes and hypercortisolism.

DIF:

Cognitive Level: Remembering

REF: p. 299

15. A patient experiencing symptoms related to menopause asks you to explain the cause of her symptoms. What is your best response? a. “Symptoms of menopause are caused by low levels of estrogen and high levels of FSH.” b. “Symptoms of menopause are caused by high levels of estrogen and low levels of FSH.” c. “Symptoms of menopause are caused by low levels of estrogen and low levels of FSH.” d. “Symptoms of menopause are caused by high levels of estrogen and high levels of FSH.” ANS: A Symptoms of menopause are caused by low levels of estrogen and high levels of FSH. DIF:

Cognitive Level: Applying

REF: p. 300

16. What is one of the adverse effects of hormone replacement therapy for menopause? a. Pregnancy b. Blood clots c. Miscarriage d. Decreased mental concentration ANS: B Hormone replacement therapy for perimenopausal symptoms uses different types of estrogens and sometimes progesterone. Exogenous use of these drugs increases the risk for forming blood clots where they are not needed, leading to the potential venous thromboembolism complications of deep vein thrombosis, strokes, and heart attacks.

DIF:

Cognitive Level: Remembering

REF: p. 302

17. Which side effects are most common among women taking hormone replacement therapy for menopause? a. Nausea, vomiting, and diarrhea b. Skin itching and dark-colored urine c. Breast tenderness and fluid retention d. Increased vaginal dryness and constipation

ANS: C The most common side effects of hormone replacement therapy for perimenopausal symptoms are breast tenderness, breakthrough bleeding, fluid retention, weight gain, and acne. Vaginal dryness is reduced, not increased. Skin itching is reduced, not increased.

Dark urine would be a symptom of the adverse effect of liver toxicity. These drugs are not commonly a cause of any gastrointestinal problems.

DIF:

Cognitive Level: Remembering

REF: p. 302

18. Which type of oral contraceptive drug must be taken every day of the month to be effective? a. An estrogen–progestin combination. b. A progestin–drospirenone combination. c. An estrogen only “mini” pill d. A progestin only “mini” pill ANS: D Progestin only mini pills contain very low concentrations of only one hormone. As the hormone levels are low, they must be taken daily, without any time off, to be effective.

DIF:

Cognitive Level: Remembering

REF: p. 303

19. Which of the following patients is most at risk for adverse effects related to the use of oral contraceptives? a. A 37-year-old woman who has a history of smoking b. A 25-year-old woman who had a baby 2 months ago c. A 32-year-old woman who has never been pregnant d. A 16-year-old female who has just become sexually active ANS: A Oral contraceptives increase the risk for blood clot formation. This problem can lead to deep vein thrombosis, pulmonary embolism, myocardial infection, and stroke. The risk increases among women who smoke and in those older than 35 years.

DIF:

Cognitive Level: Understanding

REF: p. 304

20. Which oral contraceptive can increase serum potassium levels and potentially lead to irregular heart rhythm? a. Yasmin b. Camila c. Ovral d. Zovia ANS: A Oral contraceptives that use drospirenone as the progestin (Ocella, Yasmin, YAZ28) can increase the serum potassium level, which can lead to heart block and other irregular heart rhythms. Women who have kidney, liver, or adrenal disease and those who are taking other drugs that increase potassium levels (e.g., angiotensin-converting enzyme (ACE) inhibitors for hypertension, potassium-sparing diuretics) are not recommended to use contraceptives containing drospirenone.

DIF:

Cognitive Level: Understanding

REF: p. 304

21. You are teaching a young female patient about the oral contraceptive she has been prescribed. What instructions should be included in the teaching plan for this patient? a. “Take oral contraceptives exactly as prescribed.” b. “You may take over-the-counter drugs with oral contraceptives.” c. “You may miss up to two doses in a row and still be protected from pregnancy.” d. “You may use nicotine patches, but stop smoking when taking oral contraceptives.”

ANS: A Oral contraceptives are only effective at preventing pregnancy when taken exactly as prescribed.

Patients should not smoke or use nicotine in any form to reduce the risk for blood clots, heart attacks, and strokes. If more than one dose within a cycle is missed, especially two doses in a row, continue not only to use it for the rest of the cycle but also to use another method of contraception for the rest of the cycle. Instruct the patient not to take any over-the-counter drug without checking with your healthcare provider who prescribed the contraceptive to prevent possible interactions.

DIF:

Cognitive Level: Applying

REF: p. 304

22. A male patient is prescribed androgen therapy with testosterone 100 mg IM every 4 weeks. What finding will you teach the patient to report to the prescriber immediately? a. Blood pressure decrease of 10 mm Hg systolic b. Urine output increase of 200 mL/day c. Fluid retention d. Increased prostate size ANS: C Teach patients to check weight every day to assess for fluid retention and report weight gain of 5 or more pounds (indicating significant fluid retention) to the prescriber.

DIF:

Cognitive Level: Applying

REF: p. 305

23. Which bone or joint is most likely to be adversely affected by bisphosphonates? a. Eye orbit b. Jawbone c. Big toe d. Wrist ANS: B The most serious adverse effect of the bisphosphonates is the development of jawbone necrosis (osteonecrosis), especially with tooth extraction or other invasive dental procedures involving the jawbone in which the bone is damaged. The exact mechanism by which these drugs cause osteonecrosis is not known but is thought to occur because the drugs interfere with bone healing.

DIF:

Cognitive Level: Knowing

REF: p. 306

24. A patient is to receive a subcutaneous injection of denosumab (Prolia) for severe osteoporosis. What action should you take before giving this injection? a. Place emergency equipment in the room with the patient. b. Assess for circulation in the umbilical area. c. Assess the patient’s ability to walk. d. Monitor the patient’s liver function tests.

ANS: A Assess the patient for an allergic reaction during and after subcutaneous injection of denosumab (Prolia). Keep emergency equipment in the room with the patient.

DIF:

Cognitive Level: Applying

REF: p. 307

MULTIPLE RESPONSE 1. Which findings indicate that thyroid hormone drug dose is appropriate and effective in a patient with hypothyroidism? (Select all that apply.) a. The patient’s vital signs are within normal limits. b. The patient reports an increase in activity levels. c. The patient’s body weight remains consistent. d. The patient reports mild, bilateral edema. e. The patient has a bowel movement daily. f. The patient’s goiter is reduced in size.

ANS: A, C, E These changes indicate that the drug is effective and the dose is appropriate: The patient’s vital signs (body temperature, heart rate, blood pressure, and respiratory rate) are within normal limits. Patient’s activity level and mental status are normal for him or her.

Patient’s body weight is consistent with the amount of calories he or she eats and his or her activity level. Patient’s bowel habits are what they were before the thyroid problem occurred.

DIF:

Cognitive Level: Applying

REF: p. 295

2. Which statements about the adrenal glands are true? (Select all that apply.) a. Adrenal hormones differ by age and gender. b. Glucocorticoid hormones are necessary for life. c. Aldosterone controls sodium and water balance. d. Low levels of adrenal hormones can lead to stroke. e. The adrenal cortex secretes aldosterone and cortisol. f. When adrenal hormones are overproduces, cancer can result.

ANS: B, C, E

The adrenal cortex secretes aldosterone and cortisol. Aldosterone controls sodium and water balance. Cortisol, of which there are many types, has many more functions that are essential for life. Cortisol helps maintain critical blood glucose levels, the stress response, excitability of cardiac muscle, immunity, and blood sodium levels. Since cortisol was first discovered to affect blood glucose levels, it is also known as a glucocorticoid.

DIF:

Cognitive Level: Remembering

REF: p. 297

3. You are teaching a patient with adrenal gland hyperfunction taking Mitotane (Lysodren) about this drug. What signs and symptoms of adrenal insufficiency should you teach this patient to report? (Select all that apply.) a. Craving for salty food b. Hyperglycemia c. Feeling weak d. Hypertension e. Fatigue f. Nausea ANS: A, C, E Teach patients the signs and symptoms of adrenal insufficiency: hypoglycemia, salt craving, muscle weakness, hypotension, and fatigue.

DIF:

Cognitive Level: Applying

REF: p. 299

4. Which drugs belong to the bisphosphonate class of drug? (Select all that apply.) a. Alendronate (Fosamax) b. Denosumab (Prolia) c. Estrogen/bazedoxifene (Duavee) d. Ibandronate (Boniva) e. Raloxifene (Evista) f. Risedronate (Actonel) g. Zoledronic acid (Reclast) ANS: A, D, F, G Alendronate, ibandronate, risedronate, and zoledronic acid all belong to the bisphosphonate class of drug. Denosumab is a monoclonal antibody.

Estrogen/bazedoxifene and raloxifene are from the estrogen agonist/antagonist class of drugs.

DIF:

Cognitive Level: Remembering

REF: p. 306

Chapter 17: Drug Therapy for Diabetes Visovsky: Introduction to Clinical Pharmacology, 9th Edition MULTIPLE CHOICE 1. What is the main role of insulin in the body? a. Conversion of complex carbohydrates into glucose b. Movement of glucose from blood into the cells c. Prevention of kidney excretion of glucose d. Prevention of the formation of fat cells ANS: B Many body cells have membranes that do not allow glucose to move into the cells to participate in metabolism. When insulin binds to membrane insulin receptors, the membranes become more open to glucose, allowing it to enter.

DIF:

Cognitive Level: Remembering

REF: p. 310

2. In what way does insulin work to lower blood glucose levels? a. Enhancing the enzymes that break down glucose b. Helping glucose to move from the blood into cells c. Converting glucose into proteins in the liver and brain d. Converting glycogen into glucose in the liver and brain ANS: B When insulin binds to insulin receptors on cells, the cells’ membranes become more open (permeable) to glucose and glucose transport proteins in the cell membranes become more active. The overall result is movement of glucose into the cells, which lowers blood glucose levels.

DIF:

Cognitive Level: Remembering

REF: p. 310

3. Which term means an elevated blood sugar (glucose) level? a. Glycogen b. Euglycemia c. Hypoglycemia d. Hyperglycemia ANS: D Glycogen is a stored form of human carbohydrate. Euglycemia means a blood sugar level within the normal range. Hypoglycemia is a lower than normal blood sugar level.

DIF:

Cognitive Level: Remembering

REF: p. 311

4. Which hormone has an action opposite to the action of insulin? a. Glycogen b. Glucagon c. Hemoglobin A1c d. Adenosine triphosphate

ANS: B Glucagon, which is known as the hormone of starvation, is secreted from the alpha cells of the pancreas when blood glucose levels are lower than normal. Glucagon goes to the liver and triggers the breakdown of glycogen and release of glucose into the blood, raising the blood glucose level. These actions are exactly the opposite of insulin’s actions.

DIF:

Cognitive Level: Remembering

REF: p. 310

5. What is the main reason that insulin is needed as drug therapy for people who have type 1 diabetes? a. The beta cells of the pancreas no longer make insulin. b. The alpha cells of the pancreas no longer make insulin. c. The beta cells of the pancreas make too much glucagon. d. The alpha cells of the pancreas make too much glucagon.

ANS: A With type 1 diabetes, the beta cells of the pancreas are destroyed and no longer produce any insulin. Insulin is necessary for life, so drug therapy for type 1 diabetes requires insulin. People who have type 2 diabetes often continue to secrete insulin from their beta cells; thus extra insulin may not be needed. Drugs for this condition often work by forcing the beta cells to release the patient’s own insulin.

DIF:

Cognitive Level: Remembering

REF: p. 311

6. Which statement regarding diabetes mellitus (DM) type 2 is true? a. Some people with DM type 2 will need insulin. b. This type of diabetes is found in children less than 1 year of age. c. Drug therapy for DM type 2 eliminates the need for diet and exercise. d. DM type 2 is characterized by sudden, complete shutdown of the pancreas.

ANS: A Insulin may also be necessary for some people with DM type 2, although diet, weight reduction, and noninsulin antidiabetic drugs are often effective in maintaining good blood glucose control.

DIF:

Cognitive Level: Remembering

REF: p. 311

7. You are preparing to discuss a newly prescribed insulin stimulator with a patient. What condition would need to be present for this drug to work effectively for a diabetic patient? a. The patient would need to be able to self-inject the drug. b. The patient would need to be in ketoacidosis to begin this drug. c. The patient would need to have diabetes mellitus type 2 to use this drug. d. The patient needs to have some functioning beta cells for this drug to work.

ANS: C Insulin stimulators are oral drugs that lower blood glucose levels by stimulating the release of insulin stored in the beta cells of the pancreas. Therefore the patient must have some functioning beta cells if these drugs are to work.

DIF:

Cognitive Level: Knowing

REF: p. 312

8. A patient with diabetes mellitus type 2 is prescribed glipizide (Glucotrol). Which of the following nursing actions would be the best action when giving this drug? a. Give this drug with milk. b. Give this drug with a meal. c. Assess the patient for signs of pancreatitis. d. Take the patient’s pulse before giving this drug.

ANS: B These drugs with, or just before, meals prevent hypoglycemia. If you must skip a meal, also skip the drug dose.

DIF:

Cognitive Level: Applying

REF: p. 313

9. Which oral antidiabetic drug belongs to the biguanide class? a. Acarbose (Precose) b. Nateglinide (Starlix) c. Pioglitazone (Actos) d. Metformin (Glucophage) ANS: D There is only one drug in the biguanide class, and it is metformin.

DIF:

Cognitive Level: Remembering

REF: p. 313

10. For which patient would a biguanide antidiabetic drug be contraindicated? a. A female patient who is pregnant b. A newly diagnosed type 2 diabetic c. A patient with known kidney disease d. A diabetic patient with some functioning pancreatic beta cells ANS: C Metformin should not be given to patients with kidney disease as it can cause kidney failure.

DIF:

Cognitive Level: Understanding

REF: p. 314

11. A patient taking metformin (Glucophage) is scheduled for a radiographic scan with contrast dye. What instructions should you provide to this patient? a. “Take the metformin as soon as the scan is completed.” b. “Stop taking the metformin at least 24 h before your scan.” c. “Stop taking the metformin for 3 days before and after the scan.” d. “Take your metformin the night before the scan, and resume after the test is completed.”

ANS: B Metformin is to be stopped at least 24 h before radioactive dye is used and not started again until 48 h after the test is completed.

DIF:

Cognitive Level: Applying

REF: p. 314

12. You are teaching a patient prescribed rosiglitazone about this drug. Which statement should you include in the patient’s teaching plan? a. “Call if you develop swelling of the legs, or weight gain.” b. “If you miss a dose of this drug, take two tablets for your next dose.” c. “You will not need to check your blood sugar when using this drug.” d. “Vision changes are expected with this drug, and are not of a concern.”

ANS: A The thiazolidinediones have been associated with severe cardiovascular side effects and must be used with care. Rosiglitazone can also cause fluid retention, liver problems, and macular edema. Teach patients to report swelling of the feet or ankles, or rapid weight gain to the healthcare provider.

DIF:

Cognitive Level: Applying

REF: p. 314

13. Which precaution is most important to teach patients who have any type of diabetes about alcohol use? a. “Be sure to take your antidiabetic drug or drugs 15 min before drinking any alcohol. b. “Only drink alcohol right before bedtime because it will make you drowsy.” c. “Increase your water intake whenever you drink alcohol.” d. “Only drink alcohol with a meal or shortly after a meal.”

ANS: D Drinking alcoholic beverages leads to hypoglycemia. To prevent hypoglycemia, alcohol consumption should be limited to no more than one serving per day and should be taken either with a meal or very shortly after a meal.

DIF:

Cognitive Level: Applying

REF: p. 315

14. How does acarbose (Precose) prevent blood glucose levels from rising too high? a. It limits the intestinal enzyme that converts complex carbohydrates into glucose. b. It blocks the absorption of carbohydrates and glucose in the intestines. c. It enhances the binding of insulin to its membrane receptors. d. It releases more insulin from pancreatic beta cells.

ANS: A Acarbose is an alpha-glucosidase inhibitor. Drugs from this class work by slowing the digestion of dietary starches and other carbohydrates by inhibiting an enzyme that breaks them down into glucose. The result of this action is that blood glucose does not rise as far or as fast after a meal.

DIF:

Cognitive Level: Remembering

REF: p. 315

15. You are about to give miglitol (Glyset) to a patient with diabetes mellitus type 2. Which nursing action is most important for this patient? a. Rotate the injection site on a weekly basis. b. Give this drug with the first bite of a meal.”

c. Do not mix this drug in the same syringe as insulin. d. Assess the patient for signs and symptoms of heart failure.

ANS: B Miglitol is an oral antidiabetic drug from the alpha-glucosidase inhibitor class. Its action is to slow the digestion of starches and other carbohydrates in the intestinal tract. In order to be effective, it must be taken at the beginning of a meal.

DIF:

Cognitive Level: Applying

REF: p. 315

16. Which complaint by a patient taking a DPP-4 inhibitor would alert you to a potential complication from this drug? a. Diarrhea b. Abdominal pain c. Nasopharyngitis d. Swelling of the lower extremities ANS: B Symptoms of acute pancreatitis include: upper abdominal radiating to the back, nausea and vomiting, fever, rapid pulse, and should be reported to the healthcare provider immediately, as this is a serious adverse effect of the drug.

DIF:

Cognitive Level: Knowing

REF: p. 318

17. A young, female patient with diabetes mellitus who is taking an oral antidiabetic drug comes in for a regularly scheduled clinic appointment. She tells you that is currently taking an oral contraceptive agent for birth control. What is your best response? a. “Oral contraceptives are contraindicated for diabetics.” b. “Oral contraceptives can be taken only if you are on insulin.” c. “Oral contraceptives can be safely taken with oral antidiabetic agents.” d. “Oral contraceptives reduce their effectiveness of oral antidiabetic agents.”

ANS: D Oral contraceptives and antibiotics can interact with drugs for diabetes, reducing their effectiveness.

DIF:

Cognitive Level: Applying

REF: p. 318

18. You are teaching a patient who has been prescribed a sodium-glucose cotransport inhibitor for the treatment of diabetes mellitus type 2. The patient asks you to explain how this drug works. What is your best response? a. “This drug works by inactivating normal gut hormones.” b. “This drug works by preventing the kidney from reabsorbing glucose.” c. “This drug works by making insulin receptors more sensitive to insulin.” d. “This drug works by preventing enzymes from breaking down starches into glucose.”

ANS: B

Sodium-glucose cotransport inhibitors are a new category of noninsulin antidiabetic drug that lower blood glucose levels by preventing the kidney from reabsorbing glucose that was filtered from the blood into the urine. This glucose then remains in the urine and is excreted rather than moved back into the blood.

DIF:

Cognitive Level: Applying

REF: p. 319

19. A patient who is taking dapagliflozin (Farxiga) for diabetes mellitus type 2 has also been prescribed furosemide (Lasix) for another condition. What potential risk should you monitor for on this patient? a. Risk for infection b. Risk for bleeding c. Risk of dehydration d. Risk for fluid retention ANS: C Combining sodium-glucose cotransport inhibitors with diuretics increases the frequency of urination increases and can result in dehydration.

DIF:

Cognitive Level: Knowing

REF: p. 320

20. A patient is taking a sodium-glucose cotransport inhibitor for the treatment of diabetes.

Which of the following laboratory values should you monitor in this patient? a. Serum potassium b. Serum amylase and lipase c. Hemoglobin and hematocrit d. Cholesterol and triglycerides ANS: A Patients with diabetes are at increased risk for hyperkalemia due to the presence of renal impairment, and potential use of diuretics and antihypertensives used in this population.

Hyperkalemia is also potential serious adverse effect of sodium-glucose cotransport inhibitors. Monitor the patient’s serum potassium level, and check for symptoms of hyperkalemia (muscle twitching, numbness and tingling, irregular heart rate).

DIF:

Cognitive Level: Knowing

REF: p. 320

21. A patient is started on exenatide (Byetta), an injectable incretin mimetic. The patient asks you how this drug will help lower blood glucose. Which is your best response? a. “This drug restores insulin secretion.” b. “This drug increases insulin secretion.” c. “This drug works to increase the duration of insulin.” d. “This drug works by increasing the action of glucagon.”

ANS: B Incretin mimetics act like the natural gut hormones (e.g., GLP-1) secreted in response to food in the stomach, increasing insulin secretion, decreasing glucagon secretion, and slowing the rate of gastric emptying. This results in an increase in insulin secretion, a decrease in glucagon secretion, and a slower the rate of gastric emptying.

DIF:

Cognitive Level: Applying

REF: p. 316

22. A patient is taking insulin each morning. When the insulin peaks, the patient should be observed for which signs of hypoglycemia? a. Tachycardia and acetone breath b. Nervousness, hunger, weakness, pallor, and confusion c. Tachycardia, loss of consciousness, and Kussmaul respirations d. Serum glucose greater than 150 mg/dL hunger, and confusion ANS: B Symptoms of hypoglycemia include nervousness; hunger; weakness; cold, clammy skin; and change in the level of consciousness.

DIF:

Cognitive Level: Applying

REF: p. 324

23. Which condition is the most dangerous adverse effect of insulin? a. Hypoglycemia b. Hyperglycemia c. Severe hypotension d. Development of insulin allergy ANS: A The main adverse effect of insulin is the lowering of blood glucose levels below normal (hypoglycemia). This response, also called insulin shock, is dangerous because brain cells are very sensitive to low blood glucose levels and the patient can become nonresponsive very quickly. If the problem is not corrected immediately, the patient can die or have irreversible brain damage.

DIF:

Cognitive Level: Remembering

REF: p. 324

24. What makes insulin a “high-alert” drug? a. Many people are very allergic to insulin. b. Serious harm can occur if the wrong dose is given. c. If too much insulin is given, the respiratory system is depressed. d. If too much insulin is given, the blood glucose level could climb to dangerously high levels.

ANS: B Insulin as a drug works very quickly. Great harm can come to a patient who receives it and does not have diabetes. Also, if too much of it is given to a patient who does have diabetes, the patient can become severely hypoglycemic and die. If too little insulin is given to a patient who has diabetes, blood glucose levels remain too high and cause organ damage.

DIF:

Cognitive Level: Remembering

REF: p. 321

25. You are preparing to teach a patient about the use of short-acting insulin. Which instruction should be stressed to the patient regarding this drug? a. “Place pressure on the injection site for 5 full minutes.” b. “You should always aspirate before injecting this drug.”

c. “You may store your insulin for 6 months at room temperature.” d. “You should eat a meal within 15 minutes of giving yourself the injection.”

ANS: D Whenever short-acting insulin is given before a meal, the patient will need to eat the meal within 15 minutes of receiving the injection to prevent hypoglycemia.

DIF:

Cognitive Level: Applying

REF: p. 321

26. Why is insulin only given by injection and not as an oral drug? a. Injected insulin works faster than oral drugs to lower blood glucose levels. b. Insulin is a small protein that is destroyed by stomach acids and intestinal enzymes. c. Insulin is a “high-alert drug” and be easily be abused if it were available as an oral agent. d. Oral insulin has a high “first pass loss” rate in the liver and would require very high dosages to be effective.

ANS: B Since insulin is a small protein that is easily destroyed by stomach acids and intestinal enzymes, it cannot be used as an oral drug. Most commonly it is injected subcutaneously.

DIF:

Cognitive Level: Understanding

REF: p. 321

27. Which precaution is most important to teach patients who have any type of diabetes about alcohol use? a. “Be sure to take your antidiabetic drug or drugs 15 minutes before drinking any alcohol.” b. “Only drink alcohol right before bedtime because it will make you drowsy.” c. “Increase your water intake whenever you drink alcohol.” d. “Only drink alcohol with a meal or shortly after a meal.”

ANS: D Drinking alcoholic beverages leads to hypoglycemia. To prevent hypoglycemia, alcohol consumption should be limited to no more than one serving per day and should be taken either with a meal or very shortly after a meal.

DIF:

Cognitive Level: Applying

REF: p. 315

MULTIPLE RESPONSE 1. Which of the following conditions are associated with poorly controlled diabetes?

(Select all that apply.) a. Stroke b. Blindness c. Kidney failure d. Cognitive deficits e. Deep vein thrombosis f. Cardiovascular disease

ANS: A, B, C, F DM that is not well controlled can reduce the function of all organs and tissues.

Complications of uncontrolled or poorly controlled DM include hypertension, high blood lipid levels, early-onset cardiovascular disease, kidney failure, strokes, and blindness to name only the more serious ones. The complications of DM can be delayed or reduced with good blood glucose (glycemic) control along with keeping blood pressure and blood cholesterol levels as close to normal as possible.

DIF:

Cognitive Level: Knowing

REF: p. 311

2. You are taking the history of a new clinic patient whom you suspect of having undiagnosed diabetes. Which of the following symptoms would you expect this patient to report? (Select all that apply.) a. Petechiae b. Increased thirst c. Increased hunger d. Increased urination e. Decreased blood pressure ANS: B, C, D The classic symptoms of DM are polydipsia (increased fluid intake), polyuria (excessive urination), and polyphagia (hunger with excessive eating).

DIF:

Cognitive Level: Remembering

REF: p. 311

3. A patient has been admitted to the hospital with a potential hypoglycemic reaction to an insulin stimulator. What symptoms would you expect to observe in this patient? (Select all that apply.) a. Headache b. Clammy skin c. Slow heart rate d. Lack of appetite e. Anxiety and confusion f. Nervousness and tremors ANS: A, B, E, F Signs of hypoglycemia include tremors, sweating, confusion, and rapid heart rate, hunger, headache, nervousness, and inability to concentrate.

DIF:

Cognitive Level: Knowing

REF: p. 312

Chapter 18: Drugs for Ear and Eye Problems Visovsky: Introduction to Clinical Pharmacology, 9th Edition MULTIPLE CHOICE 1. A child has been diagnosed with an infection with inflammation in the right ear canal.

Which drug route would be most appropriate for treating this condition? a. Oral route b. Topical route c. Ophthalmic route d. Intramuscular route ANS: B

Since the external ear can be reached from the outside, infections and inflammation of the pinna and the ear canal are most often managed by topical drug application.

DIF: Cognitive Level: Knowing

REF: p. 330

2. You are preparing to instill otic drops into the ear canal of an adult. What is the correct

technique for giving otic drugs to an adult? a. Pull the external ear down and back. b. Press the pinna against the mastoid bone. c. Pull the pull the external ear up and back. d. Press the upper portion of the ear until the eustachian tube is seen.

ANS: C

When instilling eardrops into an adults’ ear, gently pull the external ear up and back.

DIF: Cognitive Level: Applying

REF: p. 331

3. A parent tells you that a 4-year-old child has some clear drainage coming from the right

ear. This drainage is sometimes tinged with blood. The parent asks if the ear canal should be irrigated. What is your best response? a. “Use a small amount of sterile saline instilled into the ear to flush out the fluid and blood.” b. “You may use over-the-counter ear drops in this ear to clear up this new infection.” c. “The ear will need to be irrigated, and then an antibiotic for the ear instilled.” d. “The ear should not be irrigated when there is drainage present.”

ANS: D

Never place a drug into the ear canal or irrigate the ear canal if there is drainage present because it could enter the middle ear and cause an infection. The healthcare provider should be notified.

DIF: Cognitive Level: Applying

REF: p. 331

4. Which term refers to constriction of the pupil of the eye? a. Miosis b. Punctum c. Glaucoma

d. Mydriasis ANS: A

Miosis means constriction of the pupil; mydriasis means dilation of the pupil; glaucoma is an eye disease that is caused by increased intraocular pressure; and punctum is the opening in the lower lid that drains tears into systemic circulation.

DIF: Cognitive Level: Remembering

REF: p. 333

5. What is the main problem that comes accompanies glaucoma? a. Cloudiness of the lens b. Cloudiness of the cornea c. Increased intraocular pressure d. Increased intracranial pressure ANS: C

Glaucoma is a problem related to increased intraocular pressure that can put so much pressure on ocular blood vessels, photoreceptors, and the optic nerve that blindness results.

It does not affect the lens, the cornea, or the intracranial pressure.

DIF: Cognitive Level: Remembering

REF: p. 334

6. Which drug group for glaucoma has the side effect of darkening the iris color? a. Adrenergic agonists b. Beta blockers c. Cholinergics d. Prostaglandin agonists ANS: D

Two side effects of the prostaglandins agonists are making the lashes grow and darkening the iris color, sometimes changing a blue iris to one that appears browner. No other drugs for glaucoma have these side effects.

DIF: Cognitive Level: Remembering

REF: p. 335

7. A patient with glaucoma reports a possible infection in the affected eye and asks if the

usual dose of latanoprost (Xalatan) drops should be instilled. What is your best response? a. “Do not take this dose until your healthcare provider is notified.” b. “Rinse the affected eye with sterile saline and then instill the eye drops.” c. “You should not put the eye drops in today but can resume them tomorrow.” d. “Missing a dose of this drug will increase intraocular pressure and worsen your vision.”

ANS: A

Never instill prostaglandin agonists into an eye that has been scratched or has an infection.

Contact the healthcare provider for instructions about continuing glaucoma therapy.

DIF: Cognitive Level: Applying

REF: p. 336

8. Which drug for glaucoma is a beta blocker? a. Timolol (Timoptic) b. Travoprost (Travatan)

c. Apraclonidine (Iopidine) d. Pilocarpine (Adsorbocarpine) ANS: A

Timolol is a beta blocker, travoprost is a prostaglandins agonist, apraclonidine is an adrenergic agonist; and pilocarpine is a cholinergic drug.

DIF: Cognitive Level: Remembering

REF: p. 339

9. Which drug group for glaucoma can worsen underlying respiratory conditions? a. Cholinergics b. Beta blockers c. Adrenergic agonists d. Prostaglandin agonists ANS: B

Beta blockers that are absorbed systemically cause constriction of bronchiolar smooth muscle and can make asthma worse.

DIF: Cognitive Level: Remembering

REF: p. 336

10. Which maneuver serves to lessen the possibility of systemic absorption of an ophthalmic

beta-blocker? a. Instill the eye drop in the corner of the eye. b. Perform punctal opening of the affected eye. c. Ask the patient to close their eyes for 2 minutes. d. Ask the patient to take a deep breath while the eye drops are instilled.

ANS: C

After giving the drops, ask the patient to close their eyes for 2 minutes. Closing the eyes for 2 minutes reduces the amount of drug absorbed systemically. Another option to reduce systemic absorption of the drug is digital nasolacrimal occlusion (this technique has also been called “punctal occlusion”).

DIF: Cognitive Level: Applying

REF: p. 337

11. Which precaution is most important to teach a patient who is prescribed any type of eye

drug given as eye drops? a. Apply only the number of drops prescribed. b. Stop the drug immediately if eye redness occurs. c. Wear dark glasses for 1 h after placing the eye drops. d. Apply pressure to the corner of the eye after the drug has been placed.

ANS: A

Not only can eye drops enter the circulatory system and have systemic effects, excessive drops for some types of drugs for glaucoma can reduce intraocular pressure to dangerously low levels. Many patients do not consider any topical drug, including eye drops, to be “real” drug and believe that more drug is better. Patients must be taught to use all eye drugs exactly as prescribed, and not use more drug than is prescribed.

DIF: Cognitive Level: Applying

REF: p. 338

12. A patient who has been prescribed timolol (Timoptic) for the last month reports that his

asthma is worse. What is your best first response? a. Check the patient’s breath sounds and pulse rate. b. Hold the dose and notify the prescriber immediately. c. Ask the patient what drugs he takes to control his asthma. d. Reassure the patient that this is an expected response and requires no action.

ANS: A

Timolol is a nonspecific beta blocker that can have systemic effects. It can cause bronchoconstriction and can make heart failure worse with backing of fluid into the lungs.

The first action is to determine whether the patient needs immediate attention for either bronchoconstriction or possible heart failure. This is done by assessing breath sounds with a stethoscope and checking the pulse for rate, strength, and regularity. If a pulse oximeter is available, it should be used to assess the patient’s degree of oxygen saturation. The results of this assessment along with the patient’s report are then provided to the prescriber. It is likely that the class of drugs used to control this patient’s glaucoma will need to be changed.

DIF: Cognitive Level: Applying

REF: p. 339

13. Which class of drugs for glaucoma therapy generally is used short term to prevent or

reduce increases in intraocular pressure (IOP) after eye surgery rather than for long-term IOP control? a. Cholinergic drugs b. Adrenergic agonists c. Prostaglandins agonists d. Beta-adrenergic blockers ANS: B

The adrenergic agonists generally are used short term for 1 to 4 weeks to prevent or reduce increases in IOP. They are more likely to cause severe, systemic side effects if used long term. The other three drug classes are used long term for IOP control.

DIF: Cognitive Level: Remembering

REF: p. 340

14. You are about to give apraclonidine (Iopidine) eye drops to a patient with glaucoma. What

assessment should you perfume before giving this drug? a. Check the patient’s urinary output. b. Check the patient’s pulse and blood pressure. c. Check the patient’s pupils for responsiveness. d. Check the patient’s level of orientation to time, place, and person.

ANS: B

Adverse effects of adrenergic agonists include bradycardia or tachycardia and decreased blood pressure. These can result from giving too many drops of the drug causing systemic absorption.

DIF: Cognitive Level: Applying

REF: p. 340

15. What safety instructions would be appropriate to give to a patient starting glaucoma

treatment with carbachol (Isopto Carbachol)?

a. b. c. d.

Avoid driving at night due to decreased vision.

You may develop drowsiness, fatigue, or irritability.

Do not rub your eye even if it feels as though something is in it.

Check your blood sugar daily; these drops can cause hypoglycemia.

ANS: A

Patients may develop decreased night vision, so patients may need to avoid night driving due to side effects of the cholinergic agonists.

DIF: Cognitive Level: Applying

REF: p. 341

16. Which drug reduces the production of aqueous humor to the greatest degree? a. Acetazolamide (Diamox) b. Pilocarpine (Isopto) c. Dipivefrin (AK-Pro) d. Travosprost (Travatan) ANS: A

Acetazolamide is a carbonic anhydrase inhibitor that can reduce production of aqueous humor by 60% or more. Although drugs from some other classes can reduce the production of aqueous humor, this effect is much less than that of acetazolamide.

DIF: Cognitive Level: Knowing

REF: p. 342

17. You are taking the history from a patient who may be prescribed a carbonic anhydrase

inhibitor for the treatment of glaucoma. What information would indicate this category of drug may not be appropriate for this patient? a. The patient is a diabetic. b. The patient has mydriasis. c. A history of sulfa drug allergy d. The patient has unequal pupil size.

ANS: C

Never give a carbonic anhydrase inhibitor to a patient who has a “sulfa” allergy because these drugs are a type of sulfonamide.

DIF: Cognitive Level: Applying

REF: p. 342

MULTIPLE RESPONSE 1. Which drugs for glaucoma cause marked mydriasis? (Select all that apply.) a. Apraclonidine (Iopidine) b. Bimatoprost (Lumigan) c. pilocarpine (Isopto Carpine, Pilopine) d. Carbachol (Carboptic) e. Cartelolol (Ocupress) f. Dipivefrin (AK-Pro) g. Levobunolol (Betagan) ANS: A, F

Apraclonidine and dipivefrin are adrenergic agonists that cause pupillary dilation (mydriasis). This action allows aqueous humor to flow more freely through the pupil and be absorbed. The others either do not affect pupillary size to any degree or cause pupillary constriction.

DIF: Cognitive Level: Remembering

REF: p. 341

Chapter 19: Over-the-Counter Products, Herbal and Alternative Drugs, and Vitamins and Minerals Visovsky: Introduction to Clinical Pharmacology, 9th Edition MULTIPLE CHOICE 1. You are teaching a patient about taking over-the-counter (OTC) drugs. Which important

safety information should you include in your teaching plan? a. “OTC drugs will only maintain their potency months after the expiration date.” b. “OTC drugs often interact with other drugs, and with food or alcohol” c. “Be sure to take all the pills in the bottle.” d. “Adjust the dosage to your specific needs.”

ANS: B

OTC drugs often interact with other drugs, and with food or alcohol, or they might affect other existing health problems the patient has. Ask a pharmacist or the healthcare provider if you are unsure. Also, the health care professional must be aware of all over-the-counter drugs being taken because of the dangers of interaction.

DIF: Cognitive Level: Applying

REF: p. 346

2. A patient informs you that she is buying over-the-counter (OTC) drugs online from

another country because they are cheaper. What is your best response? a. “I agree with you, it is important to save money on expensive drugs when you can.” b. “There is no difference between generic OTC drugs from different countries.” c. “Avoid buying OTC drugs online, as they may be counterfeit or dangerous.” d. “Only buy OTC drugs online if your insurance company covers them.”

ANS: C

Patients should avoid buying these products online, outside of well-known Internet insurance company sites, because many OTC preparations sold through the Internet are counterfeit products and may be dangerous.

DIF: Cognitive Level: Applying

REF: p. 348

3. What information is important to include when teaching parents about giving

over-the-counter (OTC) drugs to children? a. Do not give drugs containing alcohol to children. b. OTC drugs are safe for children younger than 2 years of age. c. When giving OTC drugs to a child, always give one-half of the adult dose. d. Refrain from using a child-resistant cap in the event the drug must be given quickly.

ANS: A

One of the most important considerations in reading OTC product labels is to notice the hidden chemicals (used for various purposes) in the products. Drugs containing alcohol (such as some cough preparations) should not be given to children.

DIF: Cognitive Level: Applying

REF: p. 348

4. Which of the following drug types is not regulated by the Food and Drug Administration? a. Opioids b. Vitamins c. Hormones d. Herbal supplements ANS: D

The FDA does not regulate herbal supplements but protects consumers from misleading health claims by the supplement industry.

DIF: Cognitive Level: Remembering

REF: p. 349

5. During your assessment of a clinic patient, the patient asks you if using expired

over-the-counter (OTC) drugs would cause harm. What is your best answer? a. “These drugs are safer than prescription drugs, so using expired OTC drugs is harmless.” b. “Disposing of expired drugs is only necessary if you have several drug allergies.” c. “You should always safely dispose all expired or discolored drugs.” d. “The chemical preservatives in OTC drugs prevent drug expiration.”

ANS: C

You should always tell patients to safely dispose of old, discolored, or expired drugs or any drug that has lost its label instructions. Your pharmacist can tell you about the ways to safely dispose of drugs.

DIF: Cognitive Level: Applying

REF: p. 348

6. A patient with depression tells you she is using St. John’s wort to treat her symptoms

because she would rather use a natural product, as she already takes many prescription drugs. What is your best response? a. “St. John’s wort has been proven effective in treating mild to moderate depression.” b. “You may take St. John’s wort with your other prescription drugs without concern.” c. “Avoid taking St. John’s wort because it interferes with many prescription drugs.” d. “Avoid using St. John’s wort unless you have weekly blood levels drawn.”

ANS: C

St. John’s wort may improve mild to moderate depression but has potentially dangerous interactions with many prescription drugs.

DIF: Cognitive Level: Applying

REF: p. 350

7. Which statement about multivitamins is true? a. Most people will take multivitamins without consulting a healthcare professional. b. Many multivitamins are used with prescription drugs to prevent disease. c. Multivitamins are drug preparations that do not expire. d. Multivitamins do not pose a risk for adverse effects.

ANS: A

People take vitamins to maintain health or to correct specific nutritional deficiencies. Most people decided to take vitamins on their own without the advice of a health care professional.

DIF: Cognitive Level: Knowing

REF: p. 350

8. A patient with a severe upper respiratory infection tells you she is taking mega-doses of

vitamin C to help her get rid of the infection quicker. What is your best response? a. “Taking high doses of vitamin C is recommended for this purpose.” b. “Taking high doses of vitamin C is not effective because it is excreted quickly.” c. “Vitamin C is a fat-soluble vitamin, and high doses can be dangerous’” d. “Vitamin C is only useful in treating malabsorption syndromes.”

ANS: B

Vitamin C is a water-soluble vitamin that is quickly excreted and thus mega-doses of this vitamin produce no additional benefit.

DIF: Cognitive Level: Applying

REF: p. 354

9. A patient in the clinic asks you if she should purchase an expensive brand-name

multivitamin because cheaper vitamins may not be as good. What is your best response to this patient? a. “All over-the-counter multivitamin preparations are the same.” b. “There is a price–quality relationship to the vitamin product you buy.” c. “The cost of the vitamin preparation is not an indication of effectiveness.” d. “The cost of multivitamins is related to the bioavailability of the vitamins in the formula.”

ANS: C

The costs for some products are high because of the claims made about their effectiveness, but few of the manufacturer claims can be substantiated by evidence.

DIF: Cognitive Level: Applying

REF: p. 350

10. A newly pregnant patient is taking oral vitamin A to encourage embryo growth. What

would you include in your teaching plan for this patient? a. “Vitamin A is a water-soluble vitamin, so it is safe for the fetus.” b. “Take only the amount prescribed; high doses can cause birth defects.” c. “Taking vitamin A during the first 12 weeks of pregnancy is recommended.” d. “Only take vitamin A in the last trimester of pregnancy to encourage fetal growth.”

ANS: B

Excess vitamin A ingestion during pregnancy can cause birth defects of the central nervous system.

DIF: Cognitive Level: Applying

REF: p. 351

11. A patient has been admitted for suspected vitamin A overdose. What symptoms would you

expect the patient to exhibit? a. Diarrhea and fever b. Constipation and changes in taste c. Ecchymosis of the lower extremities

d. Yellowing of the skin on the nose and ears ANS: D

An early indication of vitamin A overdose is anorexia, abdominal pain, malaise, and yellowing of the skin, especially on the nose and ears.

DIF: Cognitive Level: Applying

REF: p. 352

12. You are getting ready to give an intravenous preparation containing vitamin B1 (thiamine)

to a patient with alcoholism. What is the rationale for giving thiamine in an IV solution containing glucose? a. Glucose is necessary to assist thiamine in entering the cells. b. Glucose prevents the thiamine from being excreted. c. Glucose prevents precipitation of the IV fluid d. Glucose is needed for thiamine absorption.

ANS: C

If giving thiamine to an alcoholic or thiamine deficient patient, intravenous glucose should also be given to prevent precipitation or worsening of Wernicke’s encephalopathy.

DIF: Cognitive Level: Knowing

REF: p. 352

13. You are teaching a patient with a dietary deficiency of riboflavin about foods that contain

riboflavin that should be part of the patient’s diet. Which of the following foods would be recommended? a. Enriched flour b. Dairy products c. Whole grains such as barley d. Orange-colored vegetables such as carrots ANS: B

Teach patients that common food sources of riboflavin include dairy products, eggs, green leafy vegetables, organ meats, and peanuts.

DIF: Cognitive Level: Applying

REF: p. 352

14. A patient you are caring for has been started on niacin as part of a regimen to reduce

hyperlipidemia. Which unpleasant side effects of niacin should you teach this patient to expect? a. Skin warmth and flushing b. Yellow-tinged skin and sclera c. Beefy-red tongue d. Watery eyes ANS: A

Expected side effects of niacin supplementation are skin warmth, flushing, and itching that can be relieved when giving niacin with aspirin.

DIF: Cognitive Level: Applying

REF: p. 352

15. Which drug category is associated with pyridoxine deficiency? a. Antibiotics

b. Beta blockers c. Antilipidemics d. Oral contraceptives ANS: D

Oral contraceptives may induce pyridoxine deficiency.

DIF: Cognitive Level: Remembering

REF: p. 352

16. A newly pregnant woman placed on folic acid states she does not want to take any drugs

during her pregnancy. What is your best response? a. “Folic acid is crucial to the development of the sex organs of the fetus.” b. “Folic acid is crucial to the development of the cardiovascular system.” c. “Folic acid is given to prevent neural tube defects of the spinal cord.” d. “Folic acid will prevent nausea and vomiting during pregnancy.”

ANS: C

The US Public Health Service has issued an official recommendation that all women of childbearing age in the United States who are pregnant should consume folic acid for reducing their risk of having a pregnancy affected with spina bifida or other neural tube defects.

DIF: Cognitive Level: Applying

REF: p. 353

17. You are evaluating a patient’s understanding of a newly prescribed drug regimen for the

prevention of heart disease. Which response made by the patient demonstrates understanding of the drug regimen? a. “I will take folic acid every other day.” b. “I will take calcium supplements daily with meals.” c. “I will take a daily dose of folic acid and vitamins B6 and B12.” d. “I will take a quality multivitamin and additional ferrous sulfate daily.”

ANS: C

Folic acid and vitamins B6 and B12 have been shown to reduce homocysteine levels.

Modestly elevated homocysteine levels in the blood are a risk factor for heart disease.

DIF: Cognitive Level: Applying

REF: p. 353

18. Which patient would be most likely to develop a vitamin B12 deficiency? a. A patient who takes ibuprofen daily for arthritis b. A patient who smokes cigarettes daily c. A patient who is on a vegetarian diet d. A patient with sickle cell anemia ANS: C

A patient who is on a strict vegetarian diet may develop vitamin B12 deficiency because vitamin B12 is found only in animal products.

DIF: Cognitive Level: Knowing

REF: p. 353

19. A patient with multiple vitamin deficiencies is prescribed oral vitamin C as part of a

vitamin supplementation treatment. Which of the following instructions regarding vitamin C should be given to this patient? a. “Keep vitamin C tablets away from heat and light sources.” b. “Only take vitamin C when you are unable to eat citrus fruits.” c. “There are no interactions of vitamin C with other drugs you may be taking.” d. “Vitamin C is a fat-soluble vitamin primarily used to treat blood clotting disorders.”

ANS: A

Vitamin C is easily destroyed by air, heat, and light. This drug should be kept tightly capped in its own container.

DIF: Cognitive Level: Applying

REF: p. 354

20. You are caring for a patient who has a family history of cancer. The patient reports taking

vitamin E daily for cancer prevention. What is your best response? a. “Recent evidence shows that vitamin E is safe and effective for cancer prevention.” b. “You may take vitamin E for cancer prevention as long as it is the prescription form.” c. “There is currently no evidence that taking vitamin E will prevent cancer.” d. “Vitamin E is only useful in the prevention of heart disease.”

ANS: C

Many suggested uses of vitamin E are controversial and unproved. New evidence suggests that vitamin E supplements do not reduce the risk for cancer or major cardiovascular disease and may even increase the risk of heart failure.

DIF: Cognitive Level: Applying

REF: p. 355

21. Which drug overdosage would you expect vitamin K to be given as an antidote? a. Warfarin b. Heparin c. Pyridoxine d. Ascorbic acid ANS: A

Vitamin K is the antidote for warfarin (Coumadin) overdose.

DIF: Cognitive Level: Knowing

REF: p. 355

22. For which condition would you expect the healthcare provider to prescribe iron

supplementation? a. Esophageal reflux b. Constipation c. Osteoporosis d. Anemia ANS: D

Iron is necessary for people with anemia caused by blood loss secondary to surgery or other conditions resulting in iron-deficiency anemia.

DIF: Cognitive Level: Knowing

REF: p. 356

23. A patient with a chronic malabsorption syndrome has been admitted to the hospital with a

severe magnesium deficiency. What complication of magnesium deficiency should you be alert for? a. Ventricular tachycardia b. Vasoconstriction c. Severe diarrhea d. Pancreatitis ANS: A

Magnesium is important in cardiac function, and only slight deficiencies may prolong the Q-T interval and lead to a very dangerous form of ventricular tachycardia (rapid heartbeat) called torsades de pointes.

DIF: Cognitive Level: Knowing

REF: p. 357

MULTIPLE RESPONSE 1. You are caring for a patient with a suspected vitamin B2 (riboflavin) deficiency. What

symptoms would you expect to see in this patient? (Select all that apply.) a. Sore throat b. Low blood counts c. Upper quadrant abdominal pain d. Burning of the tongue and lips e. Cracks in the corners of the mouth f. Confusion and short-term memory loss ANS: A, D, E

Symptoms of riboflavin deficiency may include cracks in the corner of the mouth, soreness and burning of the tongue and lips, and sore throat.

DIF: Cognitive Level: Applying

REF: p. 352

2. The teaching plan for a patient with vitamin B6 deficiency includes eating foods high in

vitamin B6 (pyridoxine). Which foods would you recommend the patient include in his/her diet? (Select all that apply.) a. Eggs b. Liver c. Bananas d. Soybeans e. Orange juice f. Whole grain breads ANS: A, B, D, F

Food sources of vitamin B6 include yeast, wheat, corn, egg yolk, liver, kidney, and muscle meats, soybeans, cereals, whole grain bread, and soybeans. Limited amounts are available from milk and vegetables.

DIF: Cognitive Level: Applying

REF: p. 353

3. You are taking a diet history from a patient who has a vitamin B12 deficiency from

pernicious anemia. Which of the following foods demonstrates understanding of an appropriate dietary choice for this patient? (Select all that apply.) a. Fermented cheeses such as Camembert b. Organ meats, such as liver or kidneys c. Shellfish, such as clams or scallops d. Whole grain foods such as barley e. Leafy greens, such as spinach f. Nonfat milk ANS: A, B, C, F

Food sources of B12 include organ meats, clams and oysters; nonfat dry milk; fermented cheese such as Camembert and Limburger; and seafood such as lobster, scallops, flounder, haddock, swordfish, and tuna.

DIF: Cognitive Level: Knowing

REF: p. 354

4. Which of the following represent the effects of calcium on the body? (Select all that

apply.) a. Large doses of calcium will not harm the body when taken on a full stomach. b. Calcium can limit the absorption of iron and other trace elements. c. Calcium can cause constipation and reduce kidney function. d. Calcium may prevent bone loss in older men. e. Calcium can reduce kidney function.

ANS: B, C, D, E

Large doses of calcium can limit the absorption of iron and other trace elements. Calcium can cause constipation and reduce kidney function. Older men, as well as older women, need calcium in their diet to prevent bone loss.

DIF: Cognitive Level: Knowing

REF: p. 356

5. Which herbs, although considered generally safe and effective (in recommended dosages)

by non-U.S. regulatory authorities, should be avoided in patients also taking aspirin, ibuprofen, or warfarin? (Select all that apply.) a. Garlic b. Ginkgo c. Flaxseed d. Feverfew e. Goldenseal f. Multivitamins with iron ANS: A, B, D

Garlic, ginkgo, and feverfew all inhibit platelet aggregation and therefore could increase the risk of bleeding when taken concomitantly with NSAIDs like aspirin and ibuprofen, or with the blood thinner warfarin (Coumadin). Patients should be cautioned accordingly.

Patients should make sure their healthcare providers know they are taking these herbal products before having surgery or general anesthesia due to the increased risk of intraoperative bleeding.

DIF: Cognitive Level: Applying

REF: p. 350

6. While collecting information on a new patient’s drug history, including the use of

over-the-counter (OTC) drugs, the patient asks you why this is important. Which statements are true regarding OTC drugs? (Select all that apply.) a. Patients often neglect to tell healthcare providers about OTC drugs routinely taken. b. Assessment of OTC drugs is not necessary unless the patient has an acute event. c. The insurance company needs to determine the monthly costs of all drugs taken. d. There may be unsafe interactions of OTC drugs with prescription drugs. e. OTC preparations have been proven safe for infants and children. f. OTC drugs may worsen existing medical problems.

ANS: A, D, F

Nurses should always assess the patient’s use of OTC products, as many patients do not disclose the use of OTC products to healthcare providers. Some of the active chemicals in OTC products may make existing medical problems worse or interact with a patient’s prescribed drugs.

DIF: Cognitive Level: Knowing

REF: p. 346

7. What patient teaching points should be included in the care of a patient taking iron for the

treatment of iron deficiency anemia? (Select all that apply.) a. Liquid iron solutions can discolor teeth. b. Take the iron tablets on an empty stomach. c. Expect to take iron for a period of 4 to 6 months. d. Do not eat foods high in iron while on iron supplements. e. Calcium should be given along with iron for maximal absorption. f. Iron supplements can cause the stool to appear dark green or black in color.

ANS: A, B, C, F

Patients taking iron should be instructed that liquid iron solutions can discolor teeth. They should take the iron tablets on an empty stomach. Most iron regimens last for 4 to 6 months. Iron supplements can cause the stool to appear dark green or black in color.

DIF: Cognitive Level: Applying

REF: p. 357

8. A patient taking a diuretic asks you to suggest potassium-rich foods that can be eaten to

supplement potassium loss form the diuretic. What foods would you include in your dietary teaching plan for this patient? (Select all that apply.) a. Nuts b. Dried fruits c. Citrus fruits d. Cruciferous vegetables e. Green, leafy vegetables f. Cantaloupe and watermelon ANS: A, B, C, F

A potassium-rich diet includes foods such as bananas, citrus fruits (especially tomatoes and oranges), apricots, and dried fruits such as raisins, prunes, and dates. Fresh cantaloupe and watermelon, nuts, dried beans, beef, and fowl also contain ample quantities of potassium.

DIF: Cognitive Level: Knowing

REF: p. 358