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1. Which of the following has influenced an emphasis on primary care education in medical schools? a. Changes in Medicare reimbursement methods recomm... [Show More] ended in 1992 b. Competition from nonphysicians desiring to meet primary care shortages c. The need for monopolistic control in the marketplace of primary outpatient care d. The recognition that nonphysicians have variable success providing primary care ANS: A The Physician Payment Review Commission in 1992 directly increased financial reimbursement to clinicians who provide primary care. Coupled with a shortage of primary care providers, this incentive led medical schools to place greater emphasis on preparing primary care physicians. Competition from nonphysicians increased coincidentally as professionals from other disciplines stepped up to meet the needs. Nonphysicians have had increasing success at providing primary care and have been shown to be safe and effective. DIF: Cognitive Level: Remembering (Knowledge) REF: 2 2. Which of the following statements is true about the prescribing practices of physicians? a. Older physicians tend to prescribe more appropriate medications than younger physicians. b. Antibiotic medications remain in the top five classifications of medications prescribed. c. Most physicians rely on a “therapeutic armamentarium” that consists of less than 100 drug preparations per physician. d. The dominant form of drug information used by primary care physicians continues to be that provided by pharmaceutical companies. ANS: D Even though most physicians claim to place little weight on drug advertisements, pharmaceutical representatives, and patient preference and state that they rely on academic sources for drug information, a study showed that commercial rather than scientific sources of drug information dominated their drug information materials. Younger physicians tend to prescribe fewer and more appropriate drugs. Antibiotics have dropped out of the top five classifications of drugs prescribed. Most physicians have a therapeutic armamentarium of about 144 drugs. DIF: Cognitive Level: Remembering (Knowledge) REF: 3 3. As primary care nurse practitioners (NPs) continue to develop their role as prescribers of medications, it will be important to: a. attain the same level of expertise as physicians who currently prescribe medications. b. learn from the experiences of physicians and develop expertise based on evidencebased practice. c. maintain collaborative and supervisorial relationships with physicians who will oversee prescribing practices. d. develop relationships with pharmaceutical representatives to learn about new medications as they are developed. ANS: B As nonphysicians develop the roles associated with prescriptive authority, it will be important to learn from the past experiences of physicians and to develop prescribing practices based on evidence-based medicine. It is hoped that all prescribers, including physicians and nurse practitioners, will strive to do better than in the past. NPs should work toward prescriptive authority and for practice that is not supervised by another professional. Pharmaceutical representatives provide information that carries some bias. Academic sources are better. DIF: Cognitive Level: Applying (Application) REF: 4 Chapter 02: Historical Review of Prescriptive Authority: The Role of Nurses (NPs, CNMs, CRNAs, and CNSs) and Physician Assistants Test Bank MULTIPLE CHOICE 1. A primary care NP will begin practicing in a state in which the governor has opted out of the federal facility reimbursement requirement. The NP should be aware that this defines how NPs may write prescriptions: a. without physician supervision in private practice. b. as CRNAs without physician supervision in a hospital setting. c. in any situation but will not be reimbursed for this by government insurers. d. only with physician supervision in both private practice and a hospital setting. ANS: B In 2001, the Centers for Medicare and Medicaid Services changed the federal physician supervision rule for CRNAs to allow state governors to opt out, allowing CRNAs to write prescriptions and dispense drugs without physician supervision. DIF: Cognitive Level: Understanding (Comprehension) REF: 9 2. CRNAs in most states: a. must have a Drug Enforcement Administration (DEA) number to practice. b. must have prescriptive authority to practice. c. order and administer controlled substances but do not have full prescriptive authority. d. administer medications, including controlled substances, under direct physician supervision. ANS: C Only five states grant independent prescriptive authority to CRNAs. CRNAs do not require prescriptive authority because they dispense a drug immediately to a patient and do not prescribe. Without prescriptive authority, they do not need a DEA number. DIF: Cognitive Level: Understanding (Comprehension) REF: 9 3. A CNM: a. may treat only women. b. has prescriptive authority in all 50 states. c. may administer only drugs used during labor and delivery. d. may practice only in birthing centers and home birth settings. ANS: B CNMs have prescriptive authority in all 50 states. They may treat partners of women for sexually transmitted diseases. They have full prescriptive authority and are not limited to drugs used during childbirth. They practice in many other types of settings. DIF: Cognitive Level: Remembering (Knowledge) REF: 9 4. In every state, prescriptive authority for NPs includes the ability to write prescriptions: a. for controlled substances. b. for specified classifications of medications. c. without physician-mandated involvement. d. with full, independent prescriptive authority. ANS: B All states now have some degree of prescriptive authority granted to NPs, but not all states allow authority to prescribe controlled substances. Many states still require some degree of physician involvement with certain types of drugs. DIF: Cognitive Level: Understanding (Comprehension) REF: 12 5. The current trend toward transitioning NP programs to the doctoral level will mean that: a. NPs licensed in one state may practice in other states. b. full prescriptive authority will be granted to all NPs with doctoral degrees. c. NPs will be better prepared to meet emerging health care needs of patients. d. requirements for physician supervision of NPs will be removed in all states. ANS: C The American Association of Colleges of Nursing has recommended transitioning graduate level NP programs to the doctoral level as a response to changes in health care delivery and emerging health care needs. NPs with doctoral degrees will not necessarily have full prescriptive authority or be freed from requirements about physician supervision because those are subject to individual state laws. NPs will still be required to meet licensure requirements of each state. DIF: Cognitive Level: Understanding (Comprehension) REF: 12 6. An important difference between physician assistants (PAs) and NPs is PAs: a. always work under physician supervision. b. are not required to follow drug treatment protocols. c. may write for all drug categories with physician co-signatures. d. have both inpatient and outpatient independent prescriptive authority. ANS: A PAs commonly have co-signature requirements and work under physician supervision. DIF: Cognitive Level: Understanding (Comprehension) REF: 17 Chapter 03: General Pharmacokinetic and Pharmacodynamic Principles Test Bank MULTIPLE CHOICE 1. A primary care nurse practitioner (NP) prescribes a drug to an 80-year-old AfricanAmerican woman. When selecting a drug and determining the correct dose, the NP should understand that the knowledge of how age, race, and gender may affect drug excretion is based on an understanding of: a. bioavailability. b. pharmacokinetics. c. pharmacodynamics. d. anatomy and physiology. ANS: B Pharmacokinetics is the study of the action of drugs in the body and may be thought of as what the body does to the drug. Factors such as age, race, and gender may change the way the body acts to metabolize and excrete a drug. Bioavailability refers to the amount of drug available at the site of action. Pharmacodynamics is the study of the effects of drugs on the body. Anatomy and physiology is a basic understanding of how the body functions. DIF: Cognitive Level: Understanding (Comprehension) REF: 21 2. A patient asks the primary care NP which medication to use for mild to moderate pain. The NP should recommend: a. APAP. b. Tylenol. c. acetaminophen. d. any over-the-counter pain product. ANS: C Providers should use generic drug names when prescribing drugs or recommending them to patients, unless a particular brand is essential for some reason. Because acetaminophen can have many trade names, it is important for patients to understand that the drug is the same for all to avoid overdosing on acetaminophen. APAP is a commonly used abbreviation but should not be used when recommending the drug to patients. DIF: Cognitive Level: Applying (Application) REF: 21 3. A patient wants to know why a cheaper version of a drug cannot be used when the primary care NP writes a prescription for a specific brand name of the drug and writes, “Dispense as Written.” The NP should explain that a different brand of this drug: a. may cause different adverse effects. b. does not necessarily have the same therapeutic effect. c. is likely to be less safe than the brand specified in the prescription. d. may vary in the amount of drug that reaches the site of action in the body. ANS: D Different formulations of the same drug may have varying degrees of bioavailability, and it may be important to stick to a particular brand for drugs with narrow therapeutic ranges. All drugs with similar active ingredients should have the same therapeutic actions and side effects and should be equally safe. DIF: Cognitive Level: Applying (Application) REF: 22 4. A primary care NP wishes to order a drug that will be effective immediately after administration of the drug. Which route should the NP choose? a. Rectal b. Topical c. Sublingual d. Intramuscular ANS: C The sublingual route is preferred for quick action because the drug is directly absorbed into the bloodstream and avoids the pass through of the liver, where much of an oral drug is metabolized. Rectal routes have unpredictable absorption rates. Topical routes are the slowest. Intramuscular routes are slow. DIF: Cognitive Level: Remembering (Knowledge) REF: 22 5. A patient receives an inhaled corticosteroid to treat asthma. The patient asks the primary care NP why the drug is given by this route instead of orally. The NP should explain that the inhaled form: a. is absorbed less quickly. b. has reduced bioavailability. c. has fewer systemic side effects. d. provides dosing that is easier to regulate. ANS: C An inhaled corticosteroid goes directly to the site of action and does not have to pass through gastrointestinal tract absorption or the liver to get to the lungs. It is generally well absorbed at this site, although dosing is not necessarily easier to regulate because it is not always clear how much of an inhaled drug gets into the lungs. DIF: Cognitive Level: Applying (Application) REF: 21 6. A patient takes an oral medication that causes gastrointestinal upset. The patient asks the primary care NP why the drug information insert cautions against using antacids while taking the drug. The NP should explain that the antacid may: a. alter drug absorption. b. alter drug distribution. c. lead to drug toxicity. d. increase stomach upset. ANS: A Changing the pH of the gastric mucosa can alter the absorption of the drug. Drug distribution is not affected. It may indirectly cause drug toxicity if a significant amount more of the drug is absorbed. It would decrease stomach upset. DIF: Cognitive Level: Applying (Application) REF: 22 7. A patient will begin taking two drugs that are both protein-bound. The primary care NP should: a. prescribe increased doses of both drugs. b. monitor drug levels, actions, and side effects. c. teach the patient to increase intake of protein. d. stagger the doses of drugs to be given 1 hour apart. ANS: B Protein-bound drugs bind to albumin, and serum albumin levels may affect how drugs are distributed. The provider should monitor drug levels, actions, and side effects and change dosing accordingly. Increasing the dose of both drugs is not recommended unless monitoring indicates. Increasing dietary protein does not affect this. Staggering the drugs will not affect this. DIF: Cognitive Level: Applying (Application) REF: 25 8. A patient is taking drug A and drug B. The primary care NP notes increased effects of drug B. The NP should suspect that in this case drug A is a cytochrome P450 (CYP450) enzyme: a. inhibitor. b. substrate. c. inducer. d. metabolizer. ANS: A If drug A is a CYP450 enzyme inhibitor, it decreases the capacity of the enzyme to metabolize drug B, causing more of drug B to be available. A substrate is a drug acted on by the enzyme. If drug B is an enzyme inducer, it would cause increased metabolism of drug A. DIF: Cognitive Level: Applying (Application) REF: 26 - 27 9. The primary care NP should understand that a drug is at a therapeutic level when it is: a. at peak plasma level. b. past 4 or 5 half-lives. c. at its steady plasma state. d. between minimal effective concentration and toxic levels. ANS: D The therapeutic range of a drug is the area between the minimal effective concentration and the toxic concentration. Peak plasma level is the highest level the drug reaches and may be well into the toxic range. Steady state occurs when there is a stable concentration of the drug and generally occurs after 4 or 5 half-lives. DIF: Cognitive Level: Applying (Application) REF: 31 10. A primary care NP is preparing to prescribe a drug and notes that the drug has nonlinear kinetics. The NP should: a. monitor frequently for desired and adverse effects. b. administer a much higher initial dose as a loading dose. c. monitor creatinine clearance at baseline and periodically. d. administer the drug via a route that avoids the first-pass effect. ANS: A Drugs with nonlinear kinetics are not eliminated based on dose or concentration of the drug, and these drugs have a narrow therapeutic window and must be monitored closely for desired effects and toxicity. DIF: Cognitive Level: Applying (Application) REF: 32 11. A primary care NP is prescribing a drug for a patient who does not take any other medications. The NP should realize that: a. CYP450 enzyme reactions will not interfere with this drug’s metabolism. b. substrates such as alcohol cannot interfere with the drug when the patient is abstaining. c. food-drug interactions are limited to those where food enhances or inhibits drug absorption. d. a thorough history of diet, alcohol use, smoking, and over-the-counter and herbal products is required. ANS: D Drugs are not the only substances that interfere with drug kinetics and dynamics. The primary care NP should conduct a thorough history of food and alcohol intake, smoking, and over-the-counter and herbal supplements to identify things that might interfere with a drug. All of these may interfere with CYP enzymes. Alcohol intake can influence this even when the patient is abstaining because of long-term effects on the liver. DIF: Cognitive Level: Understanding (Comprehension) REF: 38-39 Chapter 04: Special Populations: Geriatrics Test Bank MULTIPLE CHOICE 1. A nurse practitioner (NP) is considering a possible drug regimen for an 80-year-old patient who reports being forgetful. To promote adherence to the regimen, the NP should: a. select drugs that can be given once or twice daily. b. provide detailed written instructions for each medication. c. order medications that can be given on an empty stomach. d. instruct the patient to take a lower dose if side effects occur. ANS: A To promote adherence in elderly patients, selecting the smallest number of medications with the simplest dose regimens is recommended, with once-daily dosing preferred. Instructions should be simplified. Drug dosing should be timed with mealtimes to help patients remember to take them. Lower dosing may be necessary with some drugs, but patients should not do this without consulting their provider. DIF: Cognitive Level: Applying (Application) REF: 57 - 58 2. A 75-year-old patient who lives alone will begin taking a narcotic analgesic for pain. To help ensure patient safety, the NP prescribing this medication should: a. assess this patient’s usual sleeping patterns. b. ask the patient about problems with constipation. c. obtain a baseline creatinine clearance test before the first dose. d. perform a thorough evaluation of cognitive and motor abilities. ANS: D The body system most significantly affected by increased receptor sensitivity in elderly patients is the central nervous system, making this population sensitive to numerous drugs. It is important to evaluate motor and cognitive function before beginning drugs that affect the central nervous system to minimize the risk of falls. Assessment of sleeping patterns is important, but not in relation to patient safety. It is not necessary to evaluate stool patterns or renal function. DIF: Cognitive Level: Applying (Application) REF: 50| 55 3. A thin 90-year-old patient who will begin taking warfarin has experienced a recent weight loss of 15 pounds. The NP caring for this patient should: a. obtain a baseline liver function test (LFT) before starting the drug. b. write the initial prescription at the lowest possible dose. c. encourage the patient to consume a diet high in fat and protein. d. counsel the patient to take the drug with food to enhance absorption. ANS: B A common age change that affects the distribution of drugs in older adults is a decrease in serum albumin. Significant changes that may affect drug therapy may be seen in malnourished elderly patients. Warfarin has a high binding affinity with albumin. Significant decreases in albumin may result in a greater free concentration of highly protein-bound drugs. It is important to order the lowest possible dose and titrate upward as needed. A baseline LFT is not indicated. A diet high in fat and protein is not indicated. DIF: Cognitive Level: Applying (Application) REF: 50 - 51 4. An 86-year-old patient is seen in clinic for a scheduled follow-up after starting a new oral medication 1 month prior. The patient reports no change in symptoms, and a laboratory test reveals a subtherapeutic serum drug level. The NP caring for this patient should: a. consider ordering more frequent dosing of the drug. b. titrate the patient’s dose upward and recheck in 1 month. c. ask the patient about any increased frequency of bowel movements. d. determine the number of pills left in the patient’s prescription bottle. ANS: D Because of cost concerns, poor understanding of a drug’s actions, or confusion about how to take a medication, many elderly patients do not comply with drug regimens and may not take drugs as prescribed. Before increasing the frequency or amount of a drug, it is important to assess first whether or not the patient has been taking the drug as ordered. Counting the number of pills in the bottle will help the provider assess whether the patient is taking the drug as ordered. Changes in gastric motility do not generally have major effects on the effectiveness or serum drug levels of medications. DIF: Cognitive Level: Applying (Application) REF: 57 - 58 5. An NP learns that a 90-year-old patient is chronically constipated and has frequent problems with acid reflux. The NP notes a weight loss of 20 pounds in this patient in the previous 6 months. Which of the following drugs that this patient is taking is cause for concern? a. Quinidine b. Naproxen c. Calcium citrate d. Calcium channel blocker ANS: B Naproxen has a high binding affinity for protein, and these drugs can become toxic in patients who may have low serum albumin because of the amount of free drug in serum. Constipation and acid reflux may cause problems with absorption for some drugs, but not the drugs listed. DIF: Cognitive Level: Analyzing (Analysis) REF: 50 - 52 6. An NP is caring for a 70-year-old patient who reports having seasonal allergies with severe rhinorrhea. Using the Beers criteria, which of the following medications should the NP recommend for this patient? a. Loratadine (Claritin) b. Hydroxyzine (Vistaril) c. Diphenhydramine (Benadryl) d. Chlorpheniramine maleate (Chlorphen 12) ANS: A Loratadine is the only nonsedating antihistamine on this list. Older patients are especially susceptible to sedation side effects and should not use these medications if possible. DIF: Cognitive Level: Applying (Application) REF: 57 7. An NP orders an inhaled corticosteroid 2 puffs twice daily and an albuterol metered-dose inhaler 2 puffs every 4 hours as needed for cough or wheezing for a 65-year-old patient with recent onset of reactive airways disease who reports symptoms occurring every 1 or 2 weeks. At a follow-up appointment several months later, the patient reports no change in frequency of symptoms. The NP’s initial action should be to: a. order spirometry to evaluate pulmonary function. b. prescribe a systemic corticosteroid to help with symptoms. c. ask the patient to describe how the medications are taken each day. d. give the patient detailed information about the use of metered-dose inhalers. ANS: C It is essential to explore with the older patient what he or she is actually doing with regard to daily medication use and compare this against the “prescribed” medication regimen before ordering further tests, prescribing any increase in medications, or providing further education. DIF: Cognitive Level: Applying (Application) REF: 57 - 58 Chapter 05: Special Populations: Pediatrics Test Bank MULTIPLE CHOICE 1. A nurse practitioner (NP) is preparing to prescribe a medication for a 5-year-old child. To determine the correct dose for this child, the NP should: a. calculate the dose at one third of the recommended adult dose. b. estimate the child’s body surface area (BSA) to calculate the medication dose. c. divide the recommended adult dose by the child’s weight in kilograms (kg). d. follow the drug manufacturer’s recommendations for medication dosing. ANS: D The package insert provided by the manufacturer is the best source for pediatric dose recommendations. Approximated reduction in the adult dose is not a safe or effective way of calculating pediatric doses of medications, so using a third of the adult dose may not be safe. Errors inherent in determining BSA make this method less reliable than dose based on accurate weights. Dividing the adult dose by the child’s weight is incorrect. DIF: Cognitive Level: Understanding (Comprehension) REF: 64 - 65 2. An NP is prescribing a drug that is known to be safe in children but is unable to find recommendations about drug dosing. The recommended adult dose is 100 mg per dose. The child weighs 14 kg. Using Clark’s rule, the NP should order _____ mg per dose. a. 20 b. 10 c. 14 d. 9.3 ANS: A Clark’s rule suggests dividing the weight of the child in kg by the weight of an adult in kg and multiplying the result by the adult dose to get an approximation of the child’s dose. The average adult weighs 150 lb, or 70 kg. The equation is: 14 kg/70 kg = 0.2. 0.2 100 = 20 mg [Show Less]
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nr-508-pharmacology-mid-term-
A patient has three consecutive blood pressure readings of 140/95 mm Hg. The patient’s body mass index is 24. A fasting plasma glucose is 100 mg/dL. Cr... [Show More] eatinine clearance and cholesterol tests are normal. The primary care NP should order: a β-blocker. an angiotensin-converting enzyme inhibitor. Correct! a thiazide diuretic. dietary and lifestyle changes. The patient has stage I hypertension. Because there are no compelling indications for other treatment, a thiazide diuretic should be used initially to treat the hypertension. Dietary and lifestyle changes should also be recommended but are not sufficient for patients with stage I hypertension. Other drugs may be added later if thiazide diuretic therapy fails. Question 2 2 / 2 pts An African-American patient is taking captopril (Capoten) 25 mg twice daily. When performing a physical examination, the primary care nurse practitioner (NP) learns that the patient continues to have blood pressure readings of 135/90 mm Hg. The NP should: increase the captopril dose to 50 mg twice daily. Correct! add a thiazide diuretic to this patient’s regimen. change the drug to losartan (Cozaar) 50 mg once daily. recommend a low-sodium diet in addition to the medication. Some African-American patients do not appear to respond as well as whites in terms of blood pressure reduction. The addition of a low-dose thiazide diuretic often allows for efficacy in blood pressure lowering that is comparable with that seen in white patients. Increasing the captopril dose is not indicated. Losartan is an angiotensin receptor blocker (ARB) and is not indicated in this case. Question 3 2 / 2 pts A 50-year-old woman reports severe, frequent hot flashes and vaginal dryness. She is having irregular periods. She has no family history of CHD or breast cancer and has no personal risk factors. The primary care NP should recommend: estrogen-only HT. Correct! low-dose oral contraceptive therapy. selective serotonin reuptake inhibitor therapy until menopause begins. estrogen-progesterone HT. Oral contraceptive pills are not approved by the U.S. Food and Drug Administration for management of perimenopausal symptoms except to treat irregular menstrual bleeding. This patient has a low risk for CHD and breast cancer, so oral contraceptive pills are relatively safe. She is also at risk for pregnancy, so oral contraceptive pills can help to prevent that. Question 4 2 / 2 pts The primary care NP is prescribing a medication for an off-label use. To help prevent a medication error, the NP should: Correct! write “off-label use” on the prescription and provide a rationale. call the pharmacist to explain why the instructions deviate from common use. write the alternative drug regimen on the prescription and send it to the pharmacy. tell the patient to ignore the label directions and follow the verbal instructions given in the clinic. When prescribing a drug for an off-label use, the provider should specify this on the written prescription and should provide a rationale so that the pharmacist understands why the prescription is different from the normal use. Calling the pharmacist would not provide written documentation. Merely writing the different instructions can lead to errors if the pharmacist changes the label to conform to usual standards. The patient may forget verbal instructions and follow the usual regimen instead. Question 5 2 / 2 pts The primary care nurse practitioner (NP) sees a patient in the clinic who has a blood pressure of 130/85 mm Hg. The patient’s laboratory tests reveal high-density lipoprotein, 35 mg/dL; triglycerides, 120 mg/dL; and fasting plasma glucose, 100 mg/dL. The NP calculates a body mass index of 29. The patient has a positive family history for cardiovascular disease. The NP should: prescribe a thiazide diuretic. consider treatment with an angiotensin-converting enzyme inhibitor. reassure the patient that these findings are normal. Correct! counsel the patient about dietary and lifestyle changes. The patient’s blood pressure indicates prehypertension, but the patient does not have cardiovascular risk factors such as hyperlipidemia or hyperinsulinemia. The body mass index indicates that the patient is overweight but not obese. Pharmacologic treatment is not recommended for prehypertension unless compelling reasons are present. The findings are not normal, so it is appropriate to counsel the patient about diet and exercise. Question 6 2 / 2 pts A patient who has had a new onset of AF the day prior will undergo cardioversion that day. The primary care NP will expect the cardiologist to: give clopidogrel after administering cardioversion. Correct! administer cardioversion without using anticoagulants. give warfarin and aspirin before attempting cardioversion. give low-dose aspirin before administering cardioversion. If the onset of AF has occurred within 48 hours, cardioversion can be done without anticoagulation. Clopidogrel is used in other cases for patients who cannot take aspirin. For patients with rheumatic mitral valve disease and AF or a history of systemic embolism, cardioversion plus aspirin is used. Warfarin is used in patients with one or more risk factors for stroke. Question 7 2 / 2 pts A patient in the clinic reports frequent episodes of bloating, abdominal pain, and loose stools to the primary care nurse practitioner (NP). An important question the NP should ask about the abdominal pain is: Correct! the relation of the pain to stools. what time of day the pain occurs. whether the pain is sharp or diffuse. the age of the patient when the pain began. The new Rome II guidelines maintain that irritable bowel syndrome (IBS) of any subtype is characterized by a strong relationship between abdominal pain and defecation because of visceral hypersensitivity to gut-related events. The other characteristics of pain may be assessed to help guide management of IBS, but the first is necessary for a correct diagnosis. Question 8 2 / 2 pts A 55-year-old woman has a history of myocardial infarction (MI). A lipid profile reveals LDL of 130 mg/dL, HDL of 35 mg/dL, and triglycerides 150 mg/dL. The woman is sedentary with a body mass index of 26. The woman asks the primary care NP about using a statin medication. The NP should: recommend dietary and lifestyle changes first. Correct! begin therapy with atorvastatin 10 mg per day. discuss quality-of-life issues as part of the decision to begin medication. tell her there is no clinical evidence of efficacy of statin medication in her case. This woman would be using a statin medication for secondary prevention because she already has a history of MI, so a statin should be prescribed. Dietary and lifestyle changes should be a part of therapy, but not the only therapy. She is relatively young, and quality-of-life issues are not a concern. There is no clinical evidence to support use of statins as primary prevention in women. Question 9 2 / 2 pts A 2-year-old child has chronic “toddler’s” diarrhea, which has an unknown but benign etiology. The child’s parent asks the primary care NP if a medication can be used to treat the child’s symptoms. The NP should recommend giving: diphenoxylate (Lomotil). attapulgite (Kaopectate). Correct! an electrolyte solution (Pedialyte). bismuth subsalicylate (Pepto-Bismol). Antidiarrheals are not recommended in children. Opioids are contraindicated in children younger than 2 years. Bismuth and attapulgite are not recommended in children younger than 3 years of age. Oral rehydration with electrolyte solution is safe for young children. Question 10 2 / 2 pts A patient who has hyperlipidemia has been taking atorvastatin (Lipitor) 60 mg daily for 6 months. The patient’s initial lipid profile showed LDL of 180 mg/dL, HDL of 45 mg/dL, and triglycerides of 160 mg/dL. The primary care NP orders a lipid profile today that shows LDL of 105 mg/dL, HDL of 50 mg/dL, and triglycerides of 120 mg/dL. The patient reports muscle pain and weakness. The NP should: order liver function tests (LFTs). Correct! order a creatine kinase-MM (CK-MM) level. change atorvastatin to twice-daily dosing. add gemfibrozil (Lopid) to the patient’s medication regimen. Hepatotoxicity and muscle toxicity are the two primary adverse effects of greatest concern with statin use. Patients who report muscle discomfort or weakness should have a CK-MM level drawn. LFTs are indicated with signs of hepatotoxicity. It is not correct to change the dosing schedule. Gemfibrozil is not indicated. Question 11 2 / 2 pts A patient brings written information about a medication to a primary care NP about a new drug called Prism and wants to know if the NP will prescribe it. The NP notes that the information is from an internet site called “Prism.com.” The NP should tell this patient that: Correct! this information is probably from a drug advertisement website. this is factual, evidence-based material with accurate information. the information is from a nonprofit group that will not profit from drug sales. internet information is unreliable because anyone can post information there. Commercial internet sites are identifiable by “com” at the end of their web address. Many provide reliable information, but others may be more interested in selling something. Nonprofit groups use “org” at the end of their web addresses. Internet information is reliable as long as the internet user is aware of how things are posted and by whom. Question 12 2 / 2 pts A patient who is taking an ACE inhibitor sees the primary care NP for a follow-up visit. The patient reports having a persistent cough. The NP should: Correct! consider changing the medication to an ARB. order a bronchodilator to counter the bronchospasm caused by this drug. ask whether the patient has had any associated facial swelling with this cough. reassure the patient that tolerance to this adverse effect will develop over time. A persistent cough may occur with ACE inhibitors and may warrant discontinuation of the drug. An ARB would be the next drug of choice because it does not have this side effect. The cough is not related to bronchospasm. Angioedema is not related to ACE inhibitor–induced cough. Patients do not develop tolerance to this side effect. Question 13 2 / 2 pts A primary care NP is prescribing a drug for a patient who does not take any other medications. The NP should realize that: CYP450 enzyme reactions will not interfere with this drug’s metabolism. substrates such as alcohol cannot interfere with the drug when the patient is abstaining. food-drug interactions are limited to those where food enhances or inhibits drug absorption. Correct! a thorough history of diet, alcohol use, smoking, and over-the-counter and herbal products is required. Drugs are not the only substances that interfere with drug kinetics and dynamics. The primary care NP should conduct a thorough history of food and alcohol intake, smoking, and over-the-counter and herbal supplements to identify things that might interfere with a drug. All of these may interfere with CYP enzymes. Alcohol intake can influence this even when the patient is abstaining because of long-term effects on the liver. Question 14 2 / 2 pts A male patient tells the primary care NP he is experiencing decreased libido, lack of energy, and poor concentration. The NP performs an examination and notes increased body fat and gynecomastia. A serum testosterone level is 225 ng/dL. The NP’s next action should be to: order LH and FSH levels. order a serum prolactin level. prescribe testosterone replacement. Correct! obtain a morning serum testosterone level. To diagnose hypogonadism, two serum testosterone levels must be drawn, with serum collected in the morning. LH, FSH, and prolactin levels may be drawn as well. Testosterone replacement should not be prescribed until the diagnosis is definitive. Question 15 2 / 2 pts In every state, prescriptive authority for NPs includes the ability to write prescri [Show Less]
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nr-508-nr508-advanced-pharm-midterm-questions-and-answers-exam-
A patient who has primary hyperlipidemia and who takes atorvastatin (Lipitor) continues to have LDL cholesterol of 140 mg/dL after 3 months of therapy. Th... [Show More] e primary care NP increases the dose from 10 mg daily to 20 mg daily. The patient reports headache and dizziness a few weeks after the dose increase. The NP should: change the atorvastatin dose to 15 mg twice daily. change the patient’s medication to cholestyramine (Questran). Correct! add ezetimibe (Zetia) and lower the atorvastatin to 10 mg daily. recommend supplements of omega-3 along with the atorvastatin. When used in combination with a low-dose statin, ezetimibe has been noted to produce an additional 18% reduction in LDL. Because this patient continues to have elevated LDL along with side effects of the statin, the NP should resume the lower dose of the statin and add ezetimibe. Atorvastatin is given once daily. Cholestyramine and omega- 3 supplements are not indicated. Question 2 2 / 2 pts A patient who has hyperlipidemia has been taking atorvastatin (Lipitor) 60 mg daily for 6 months. The patient’s initial lipid profile showed LDL of 180 mg/dL, HDL of 45 mg/dL, and triglycerides of 160 mg/dL. The primary care NP orders a lipid profile today that shows LDL of 105 mg/dL, HDL of 50 mg/dL, and triglycerides of 120 mg/dL. The patient reports muscle pain and weakness. The NP should: order liver function tests (LFTs). Correct! order a creatine kinase-MM (CK-MM) level. change atorvastatin to twice-daily dosing. add gemfibrozil (Lopid) to the patient’s medication regimen. Hepatotoxicity and muscle toxicity are the two primary adverse effects of greatest concern with statin use. Patients who report muscle discomfort or weakness should have a CK-MM level drawn. LFTs are indicated with signs of hepatotoxicity. It is not correct to change the dosing schedule. Gemfibrozil is not indicated. Question 3 2 / 2 pts A patient comes to the clinic with a 4-day history of 10 to 12 liquid stools each day. The patient reports seeing blood and mucus in the stools. The patient has had nausea but no vomiting. The primary care NP notes a temperature of 37.9° C, a heart rate of 96 beats per minute, and a blood pressure of 90/60 mm Hg. A physical examination reveals dry oral mucous membranes and capillary refill of 4 seconds. The NP’s priority should be to: obtain stool cultures. Correct! begin rehydration therapy. consider prescribing metronidazole. administer opioid antidiarrheal medications. Acute diarrhea is usually mild and self-limited. Nonpharmacologic measures, especially bowel rest and adequate hydration, are helpful and should be a priority. Stool cultures may be ordered after hydration therapy is begun. Metronidazole is indicated if C. difficile is present. Opioid antidiarrheals may prolong symptoms. Question 4 2 / 2 pts A perimenopausal woman tells the primary care NP that she is having hot flashes and increasingly severe mood swings. The woman has had a hysterectomy. The NP should prescribe: Correct! estrogen-only HT. low-dose oral contraceptive therapy. selective serotonin reuptake inhibitor therapy until menopause begins. estrogen-progesterone HT. Estrogen-only regimens are used in women without a uterus and may be initiated to treat perimenopause symptoms if needed. Low-dose oral contraceptive pills are used to treat irregular menstrual bleeding in perimenopausal women. Question 5 2 / 2 pts A primary care NP prescribes a nitroglycerin transdermal patch, 0.4 mg/hour release, for a patient with chronic stable angina. The NP should teach the patient to: change the patch four times daily. use the patch as needed for angina pain. use two patches daily and change them every 12 hours. Correct! apply one patch daily in the morning and remove in 12 hours. To avoid tolerance, the patient should remove the patch after 12 hours. The transdermal patch is not changed four times daily or used on a prn basis. The patch is applied once daily. Question 6 2 / 2 pts A parent calls a clinic for advice about giving an over-the-counter cough medicine to a 6-year-old child. The parent tells the NP that the medication label does not give instructions about how much to give a child. The NP should: order a prescription antitussive medication for the child. Correct! ask the parent to identify all of the ingredients listed on the medication label. calculate the dose for the active ingredient in the over-the-counter preparation. tell the parent to approximate the dose at about one third to one half the adult dose. Over-the-counter cough medications often contain dextromethorphan, which can be toxic to young children. It is important to identify ingredients of an over-the-counter medication before deciding if it is safe for children. A prescription antitussive is probably not warranted until the cough is evaluated to determine the cause. Until the ingredients are known, it is not safe to approximate the child’s dose based on only the active ingredient. Question 7 2 / 2 pts A patient who has disabling intermittent claudication is not a candidate for surgery. Which of the following medications should the primary care NP prescribe to treat this patient? Correct! Cilostazol (Pletal) Warfarin (Coumadin) Pentoxifylline (Trental) Low-dose, short-term aspirin Patients with disabling intermittent claudication who are not candidates for surgery or catheter-based intervention should be treated with cilostazol rather than pentoxifylline. Warfarin is not indicated. Patients with chronic limb ischemia are treated with lifelong aspirin therapy. Question 8 2 / 2 pts The primary care NP prescribes an extended-cycle monophasic pill regimen for a young woman who reports having multiple partners. Which statement by the patient indicates she understands the regimen? “I have to take a pill only every 3 months.” Correct! “I should expect to have only four periods each year.” “I will need to use condoms for only 7 more days.” “This type of pill has fewer side effects than other types.” The extended-cycle pills have fewer pill-free intervals, so women have only four periods a year. Patients take pills every day. Because this patient has multiple partners, she should continue to use condoms. This type of pill has the same side effects as other types. Question 9 2 / 2 pts The primary care NP prescribes an inhaled corticosteroid for a patient who has asthma. The third-party payer for this patient denies coverage for the brand that comes in the specific strength the NP prescribes. The NP should: provide pharmaceutical company samples of the medication for the patient. inform the patient that the drug must be paid for out of pocket because it is not covered. Correct! order the closest formulary-approved approximation of the drug and monitor effectiveness. write a letter of medical necessity to the insurer to explain the need for this particular medication. The second step of medical decision making takes into account benefits versus costs along with an understanding that it is impossible to do everything because of limited resources. The NP should prescribe what is covered and evaluate its effectiveness; if it does not work, the third-party payer may be approached about the need for the other medication. Providing samples is not always possible, and this practice is being discouraged, so it is not a viable solution. Asking patients to pay out of pocket ultimately may be necessary but carries risks that the patient will not obtain the medication. Writing a letter of medical necessity may be indicated if the available drugs are not effective but is not the initial step. Question 10 2 / 2 pts A primary care NP prescribes levothyroxine for a patient to treat thyroid deficiency. When teaching this patient about the medication, the NP should: counsel the patient to take the medication with food. Correct! tell the patient that changing brands of the medication should be avoided. instruct the patient to stop taking the medication if signs of thyrotoxicosis occur. tell the patient that the drug may be stopped when thyroid function tests stabilize. Patients should be told not to change brands of the medication; there is potential variability in the bioequivalence between manufacturers. The medication should be taken at approximately the same time each day before breakfast or on an empty stomach. Patients should be instructed to contact the provider if signs of thyrotoxicosis are present. Thyroid replacement medications are usually given for life. Question 11 2 / 2 pts A patient who has had four to five liquid stools per day for 4 days is seen by the primary care NP. The patient asks about medications to stop the diarrhea. The NP tells the patient that antidiarrheal medications are: Correct! not curative and may prolong the illness. useful in cases of acute infection with elevated temperature. most beneficial when symptoms persist longer than 2 weeks. useful when other symptoms, such as hematochezia, develop. Treatment of patients with acute diarrhea with antidiarrheals can prolong infection and should be avoided if possible. Antidiarrheals are best used in patients with mild to moderate diarrhea and are used for comfort and not cure. They should not be used for patients with bloody diarrhea or high fever because they can worsen the disease. Prolonged diarrhea can indicate a more serious cause, and antidiarrheals should not be used in those cases. Question 12 2 / 2 pts The primary care NP sees a patient covered by Medicaid, writes a prescription for a medication, and is informed by the pharmacist that the medication is “off-formulary.” The NP should: inform the patient that an out-of-pocket expense will be necessary. Correct! write the prescription for a generic drug if it meets the patient’s needs. call the patient’s insurance provider to advocate for this particular drug. contact the pharmaceutical company to see if medication samples are available. Medicaid often stipulates which medications are or are not covered. Unless the particular drug is absolutely necessary, the NP should substitute with an acceptable generic drug. Insisting that the patient pay out of pocket may mean that the prescription is not filled. If the drug is necessary, the NP may advocate for its use by contacting the third-party payer. Asking for drug samples is not a long-term solution for the problem. Question 13 2 / 2 pts A patient who has type 2 diabetes mellitus takes metformin (Glucophage). The patient tells the primary care NP that he will have surgery in a few weeks. The NP should recommend: taking the metformin dose as usual the morning of surgery. Correct! using insulin during the perioperative and postoperative periods. that the patient stop taking metformin several days before surgery. adding a sulfonylurea medication until recovery from surgery is complete. Insulin should be considered for patients with diabetes during times of physical stress, such as illness or surgery. Question 14 2 / 2 pts A thin 52-year-old woman who has recently had a hysterectomy tells the primary care NP she is having frequent hot flashes and vaginal dryness. A recent bone density study shows early osteopenia. The woman’s mother had CHD. She has no family history of breast cancer. The NP should prescribe: Correct! estrogen-only HT now. estrogen-only HT in 5 years. estrogen-progesterone HT now. estrogen-progesterone HT in 5 years. HT relieves symptoms of menopause and prevents osteoporosis. When started soon after menopause, HT can reduce CHD risk. Breast cancer risk may be decreased if HT is begun 5 years after onset of menopause. This woman has a higher risk of CHD and osteoporosis, so initiating therapy now is a good option. Because she has had a hysterectomy, estrogen-only therapy is indicated. Question 15 2 / 2 pts A patient who has diabetic gastroparesis sees a gastroenterology specialist who orders metoclopramide (Reglan). Within 24 hours, the patient describes having extrapyramidal symptoms (EPS) to the primary care NP. The NP will contact the gastroenterologist and should expect to prescribe: Correct! benztropine (Cogentin). cimetidine. an SSRI antidepressant. a TCA. Cogentin is indicated to treat EPS side effects of medications such as metoclopramide. The patient should be monitored during the first 24 to 48 hours for any adverse reactions. Should EPS occur, treat with intramuscular diphenhydramine (Benadryl) 50 mg or benztropine (Cogentin) 1 to 2 mg Question 16 2 / 2 pts The primary care NP is preparing to prescribe isosorbide dinitrate sustained release (Dilatrate SR) for a patient who has chronic, stable angina. The NP should recommend initial dosing of: 60 mg four times daily at 6-hour intervals. Correct! 40 mg twice daily 30 minutes before meals. 60 mg on awakening and 40 mg 7 hours later. 80 mg three times daily at 8:00 AM, 1:00 PM, and 6:00 PM. Long-acting nitrates should be considered to treat chronic, stable angina. The main limitation is tolerance, which can be limited by providing a nitrate-free period of 6 to 10 hours each day. The medication should be taken on an empty stomach, 30 to 60 minutes before a meal. An appropriate initial dose of isosorbide dinitrate is 40 mg every 12 hours. This dose can be increased as needed. Isosorbide mononitrate is given on awakening and again 7 hours later. The medication is not given four times daily. Dosing may be increased to 80 mg tid, and the dosing schedule of 8:00 AM, 1:00 PM, and 6:00 PM. would be appropriate at that point. Question 17 2 / 2 pts A patient who has hypothyroidism has been taking levothyroxine 50 mcg daily for 2 weeks. The patient reports continued fatigue. The primary care NP should: order a T4 level today. increase the dose to 100 mcg. Correct! check the TSH level in 1 week. reassure the patient that this will improve in several weeks. Full therapeutic effectiveness may not be achieved for 3 to 6 weeks. Measuring the TSH level is indicated to evaluate drug effectiveness. The dose should not be increased without first evaluating the patient’s TSH level. Question 18 2 / 2 pts The primary care NP has referred a child who has significant gastrointestinal reflux disease to a specialist for consideration for a fundoplication and gastrostomy tube placement. The child’s weight is 80% of what is recommended for age, and a recent swallow study revealed significant risk for aspiration. The child’s parents do not want the procedure. The NP should: compromise with the parents and order a nasogastric tube for feedings. Correct! initiate a discussion with the parents about the potential outcomes of each possible action. refer the family to a case manager who can help guide the parents to the best decision. understand that the child’s parents have a right to make choices that override those of the medical team. In general, the goal of a health care decision maker is to choose an action that is most likely to deliver the outcomes the patient wants. Initiating a discussion about outcomes helps parents decide based on end results. A nasogastric tube is not the best choice for the child, and compromising without first exploring options is incorrect. As part of the therapeutic relationship, the NP should be involved with patients’ decisions. Although patients and families have the right to make decisions, the NP has an obligation to ensure that the decisions are informed decisions. Question 19 2 / 2 pts A female patient who is underweight tells the primary care NP that she has been using bisacodyl (Dulcolax) daily for several years. The NP should: Correct! prescribe docusate sodium (Colace) and decrease bisacodyl gradually. suggest she use polyethylene glycol (MiraLAX) on a daily basis instead. tell her that long-term use of suppositories is safer than long-term laxative use. counsel the patient to discontinue the laxative and increase fluid and fiber intake. Patients who abuse laxatives are at risk for cathartic colon and for electrolyte imbalances. These patients should be weaned from their stimulant laxative and placed on safer long-term laxatives, such as a bulk laxative or stool softener. Polyethylene glycol is a stimulant. Long-term use of suppositories causes rectal irritation. Discontinuing the laxative without a long-term laxative will lead to rebound constipation. Question 20 2 / 2 pts A patient takes a cardiac medication that has a very narrow therapeutic range. The primary care NP learns that the particular brand the patient is taking is no longer covered by the patient’s medical plan. The NP knows that the bioavailability of the drug varies from brand to brand. The NP should: Correct! contact the insurance provider to explain why this particular formulation is necessary. change the patient’s medication to a different drug class that doesn’t have these bioavailability variations. accept the situation and monitor the patient closely for drug effects with each prescription refill. ask the pharmaceutical company that makes the drug for samples so that the patient does not incur out-of-pocket expense. In this case, the NP should advocate for the desired drug because changing the drug can have life-threatening consequences. If this fails, other options may have to be explored. Question 21 2 / 2 pts A patient is in the clinic for a follow-up examination after a myocardial infarction (MI). The patient has a history of left ventricular systolic dysfunction. The primary care NP should expect this patient to be taking: nadolol (Corgard). Correct! carvedilol (Coreg) [Show Less]
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A patient who has diabetes reports intense discomfort when needing to void. A urinalysis is normal. To treat this, the primary care NP should consider ... [Show More] prescribing: flavoxate (Urispas). bethanechol (Urecholine). phenazopyridine (Pyridium). Correct! oxybutynin chloride (Ditropan XL). This patient is describing urge incontinence, or overactive bladder, which occurs when the detrusor muscle is hyperactive, causing an intense urge to void before the bladder is full. Urge incontinence is associated with many conditions, including diabetes. Oxybutynin chloride, which is an anticholinergic, acts to decrease detrusor overactivity and is indicated for treatment of urge incontinence. Flavoxate is used to treat dysuria associated with UTI. Bethanechol is indicated for urinary retention. Phenazopyridine is used to treat dysuria. Question 2 2 / 2 pts A patient reports difficulty returning to sleep after getting up to go to the bathroom every night. A physical examination and a sleep hygiene history are noncontributory. The primary care NP should prescribe: zaleplon. Correct! ZolpiMist. ramelteon. chloral hydrate. ZolpiMist oral spray is useful for patients who have trouble returning to sleep in the middle of the night. Zaleplon and ramelteon are used for insomnia caused by difficulty with sleep onset. Chloral hydrate is not typically used as outpatient therapy. Question 3 2 / 2 pts A 5-year-old child who has no previous history of otitis media is seen in clinic with a temperature of 100° F. The primary care NP visualizes bilateral erythematous, nonbulging, intact tympanic membranes. The child is taking fluids well and is playing with toys in the examination room. The NP should: prescribe azithromycin once daily for 5 days. prescribe amoxicillin twice daily for 10 days. prescribe amoxicillin-clavulanate twice daily for 10 days. Correct! initiate antibiotic therapy if the child’s condition worsens. Signs and symptoms of otitis media that indicate a need for antibiotic treatment include otalgia, fever, otorrhea, or a bulging yellow or red tympanic membrane. This child has a low-grade fever, no history of otitis media, a nonbulging tympanic membrane, and no otorrhea, so watchful waiting is appropriate. When an antibiotic is started, amoxicillin is the drug of choice. Question 4 2 / 2 pts An 80-year-old patient with congestive heart failure has a viral upper respiratory infection. The patient asks the primary care NP about treating the fever, which is 38.5° C. The NP should: Correct! recommend acetaminophen. recommend high-dose acetaminophen. tell the patient that antibiotics are needed with a fever that high. tell the patient a fever less than 40° C does not need to be treated. Patients with congestive heart failure may have tachycardia from fever that aggravates their symptoms, so fever should be treated. High doses should be given with caution in elderly patients because of possible decreased hepatic function. Antibiotics should not be given without evidence of bacterial infection. Question 5 2 / 2 pts A patient who takes levodopa and carbidopa for Parkinson’s disease reports experiencing freezing episodes between doses. The primary care NP should consider using: selegiline. amantadine. Correct! apomorphine. modified-release levodopa. Apomorphine injection is used for acute treatment of immobility known as “freezing.” Question 6 2 / 2 pts A patient is being tapered from long-term therapy with prednisolone and reports weight loss and fatigue. The primary care NP should counsel this patient to: consume foods high in vitamin D and calcium. begin taking dexamethasone because it has longer effects. expect these side effects to occur as the medication is tapered. Correct! increase the dose of prednisolone to the most recent amount taken. Sudden discontinuation or rapid tapering of glucocorticoids in patients who have developed adrenal suppression can precipitate symptoms of adrenal insufficiency, including nausea, weakness, depression, anorexia, myalgia, hypotension, and hypoglycemia. When patients experience these symptoms during a drug taper, the dose should be increased to the last dose. Vitamin D deficiency is common while taking glucocorticoids, but these are not symptoms of vitamin D deficiency. Changing to another glucocorticoid is not recommended. Patients should be taught to report the side effects so that action can be taken and should not be told that they are to be expected. Question 7 2 / 2 pts The primary care nurse practitioner (NP) sees a 50-year-old woman who reports frequent leakage of urine. The NP learns that this occurs when she laughs or sneezes. She also reports having an increased urge to void even when her bladder is not full. She is not taking any medications. The NP should: Correct! perform a dipstick urinalysis. prescribe desmopressin (DDAVP). prescribe oxybutynin chloride (Ditropan XL). teach exercises to strengthen the pelvic muscles. A focused history with a careful physical examination is essential for determining the cause of incontinence. Urinalysis can rule out urinary tract infection (UTI), which can cause incontinence. Medications are prescribed after determining the cause, if any, and treating underlying conditions. Exercises to strengthen the pelvic muscles are part of treatment. Question 8 2 / 2 pts A 7-year-old patient who has severe asthma takes oral prednisone daily. At a well-child examination, the primary care NP notes a decrease in the child’s linear growth rate. The NP should consult the child’s asthma specialist about: gradually tapering the child off the prednisone. a referral for possible growth hormone therapy. Correct! giving a double dose of prednisone every other day. dividing the prednisone dose into twice-daily dosing. Administration of a double dose of a glucocorticoid every other morning has been found to cause less suppression of the HPA axis and less growth suppression in children. Because the child has severe asthma, an oral steroid is necessary. Growth hormone therapy is not indicated. Twice-daily dosing would not change the HPA axis suppression. Question 9 2 / 2 pts A patient who is taking isoniazid and rifampin for latent TB is seen by the primary care NP for a routine follow-up visit. The patient reports having nausea, vomiting, and a decreased appetite. The NP should: Correct! ask about alcohol intake. suggest taking the medications with food. reassure the patient that these side effects are common. order liver and renal function tests and serum glucose. Concomitant use of alcohol with isoniazid increases the risk of hepatitis. This patient shows signs of hepatitis, so the NP should ask about alcohol consumption. Isoniazid should be taken on an empty stomach. Question 10 2 / 2 pts A primary care NP sees a child with asthma to evaluate the child’s response to the prescribed therapy. The child uses an ICS twice daily and an albuterol metered-dose inhaler as needed. The child’s symptoms are well controlled. The NP notes slowing of the child’s linear growth on a standardized growth chart. The NP should change this child’s medication regimen to a: combination ICS/LABA inhaler twice daily. short-acting β2-agonist (SABA) with oral corticosteroids when symptomatic. combination ipratropium/albuterol inhaler twice daily. Correct! SABA as needed plus a leukotriene modifier once daily. A leukotriene modifier may be used as an alternative to ICS for children who experience systemic side effects of the ICS. This child’s symptoms are well controlled, so there is no need to step up therapy to include a LABA. Oral corticosteroids should be used only for severe exacerbations. Ipratropium and albuterol are used for severe exacerbations. Question 11 2 / 2 pts A patient is newly diagnosed with Alzheimer’s disease stage 6 on the Global Deterioration Scale. The primary care NP should prescribe: donepezil (Aricept). rivastigmine (Exelon). Correct! memantine (Namenda). galantamine (Razadyne). Patients with moderate to severe dementia (stages 5 to 7) may be started on memantine. Question 12 2 / 2 pts The primary care NP sees a 12-month-old infant who needs the MMR, Varivax, influenza, and hepatitis A vaccines. The child’s mother tells the NP that she is pregnant. The NP should: Correct! administer all of these vaccines today. give the hepatitis A and influenza vaccines. give the Varivax, hepatitis A, and influenza vaccines. withhold all of these vaccines until after the baby is born. Although live-virus vaccines should not be administered to mothers during pregnancy, they may be given to children whose mothers are pregnant. Question 13 2 / 2 pts A parent brings a 5-year-old child to a clinic for a hospital follow-up appointment. The child is taking a medication at a dose equal to an adult dose. The parent reports that the medication is not producing the desired effects. The NP should: order renal function tests. prescribe another medication to treat this child’s symptoms. discontinue the drug and observe the child for toxic side effects. Correct! obtain a serum drug level and consider increasing the drug dose. By a child’s first birthday, the liver’s metabolic capabilities are not only mature but also more vigorous than the adult liver, meaning that certain drugs may need to be given in higher doses or more often. It is prudent to obtain a serum drug level and then consider increasing the dose to achieve the desired effect. Renal function tests are not indicated. Unless the child is experiencing toxic effects, the drug does not need to be discontinued. Question 14 2 / 2 pts An NP orders an inhaled corticosteroid 2 puffs twice daily and an albuterol metered-dose inhaler 2 puffs every 4 hours as needed for cough or wheezing for a 65-year-old patient with recent onset of reactive airways disease who reports symptoms occurring every 1 or 2 weeks. At a follow-up appointment several months later, the patient reports no change in frequency of symptoms. The NP’s initial action should be to: order spirometry to evaluate pulmonary function. prescribe a systemic corticosteroid to help with symptoms. Correct! ask the patient to describe how the medications are taken each day. give the patient detailed information about the use of metered-dose inhalers. It is essential to explore with the older patient what he or she is actually doing with regard to daily medication use and compare this against the “prescribed” medication regimen before ordering further tests, prescribing any increase in medications, or providing further education. Question 15 2 / 2 pts A patient is diagnosed with a condition that causes chronic pain. The primary care NP prescribes an opioid analgesic and should instruct the patient to: wait until the pain is at a moderate level before taking the medication. Correct! take the medication at regular intervals and not just when pain is present. start the medication at higher doses initially and taper down gradually. take the minimum amount needed even when pain is severe to avoid dependency. Chronic pain requires routine administration of drugs, and patients should take analgesics routinely without waiting for increased pain. Question 16 2 / 2 pts A patient tells the primary care NP that he has difficulty getting and maintaining an erection. The NP’s initial response should be to: prescribe sildenafil (Viagra). Correct! perform a medication history. evaluate his cardiovascular status. order a papaverine injection test to screen for erectile dysfunction. Because the use of multiple medications is associated with a higher prevalence of erectile dysfunction, a medication history should be performed first to see if any medications have sexual side effects. A cardiovascular evaluation may be assessed next. Papaverine injection tests are useful screening tools after a thorough history has been performed. Medications are prescribed only after a diagnosis is determined and other causes have been ruled out. Question 17 2 / 2 pts A 55-year-old patient develops Parkinson’s disease characterized by unilateral tremors only. The primary care NP will refer the patient [Show Less]
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