NR 508 Midterm Exam 2 – Questions, Answers & Explanations
Chamberlain College of Nursing NR 508 Midterm Exam 2 – Questions, Answers & Explanations
... [Show More] (Graded A)
1. A primary care NP prescribes levothyroxine for a patient to treat thyroid deficiency. When teaching this patient about the medication, the NP should:
Answer: Tell the patient that changing brands of the medication should be avoided.
Explanation: 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.
2. 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:
Answer: Add a thiazide diuretic to this patient's regimen
Explanation: 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.
3. A primary care NP sees a patient who is about to take a cruise and reports having had motion sickness with nausea on a previous cruise. The NP prescribes the scopolamine transdermal patch and should instruct the patient to apply the patch:
Answer: Every 3 days.
Explanation: The transdermal system allows steady-state plasma levels of scopolamine to be reached rapidly and maintained for 3 days. The onset of action is approximately 4 hours. The patch should be changed every 3 days and left on at all times, not as needed
4. A 12-year-old patient who is obese develops type 2 diabetes mellitus. The primary care NP should order
Answer: Metformin (Glucophage).
Explanation: Metformin is the only drug listed that is recommended for children
5. 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:
Answer: not curative and may prolong the illness
Explanation: 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.
6. In every state, prescriptive authority for NPs includes the ability to write prescriptions
Answer: for specified classifications of medications.
Explanation: 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.
7. 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:
Answer: begin therapy with atorvastatin 10 mg per day
Explanation: 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.
8. A patient develops hypertension. The primary care nurse practitioner (NP) plans to begin diuretic therapy for this patient. The NP notes clear breath sounds, no organomegaly, and no peripheral edema. The patient's serum electrolytes are normal. The NP should prescribe:
Answer: hydrochlorothiazide (HydroDIURIL)
Explanation: Thiazide diuretics are first-line drugs for treating hypertension. The other three drugs are not thiazide diuretics
9. The primary care nurse practitioner (NP) is using critical thinking skills when
Answer: analyzing current research and synthesizing new approaches to patient care.
Explanation: Practitioners use critical thinking skills by reviewing and analyzing current knowledge and synthesizing approaches to apply to unique patient situations. Using standardized protocols, adhering to scientific principles, and following practices of seasoned mentors may be useful, but these do not encompass the concept of critical thinking, which requires the practitioner to use what is known in new situations.
10. A patient comes to the clinic and asks the primary care NP about using a newly developed formulation of the drug the patient has been taking for a year. When deciding whether or not to prescribe this formulation, the NP should:
Answer: tell the patient that when post-marketing data is available, it will be considered.
Explanation: About 6 to 12 months of post-marketing experience can yield information about drug efficacy and side effects, so patients should be cautioned to wait for these data. Drug company promotional materials have biased information. Most new drugs are more expensive, and costs alone should not determine drug choice. Extended-release forms are often more expensive.
11. 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:
Answer: contact the insurance provider to explain why this particular formulation is necessary.
Explanation: 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.
12. 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.
Answer: bismuth subsalicylate (Pepto-Bismol)
Explanation: Bismuth reduces symptoms through antidiarrheal and antibacterial properties and can decrease nausea and vomiting. Opioid antidiarrheals should be given after the cause of infectious diarrhea is treated; these can actually prolong symptoms because they slow transit of the causative organisms through the gut. Attapulgite can be used because it binds bacteria and toxins in the gastrointestinal tract, but bismuth is a better choice in this case because it helps to treat nausea. The patient is drinking Gatorade and is getting electrolyte replacement.
13. To increase the likelihood of successful pharmacotherapy, when teaching a patient about using a medication, the primary care nurse practitioner (NP) should:
Answer: encourage the patient to participate in the choice of the medication.
Explanation: It is important that the patient "owns the problem" and has a part in the solution. Providing education about the medication, stressing the importance of following medication instructions, and distributing package inserts may be useful, but it is essential that patients take an active role in their care.
14. A patient in the clinic develops sudden shortness of breath and tachycardia. The primary care NP notes thready pulses, poor peripheral perfusion, and a decreased level of consciousness. The NP activates the emergency medical system and should anticipate that this patient will receive:
Answer: unfractionated heparin (UFH) and warfarin
OR
Alteplase
Explanation: This patient has unstable pulmonary embolism (PE) and should receive thrombolytic therapy. Intravenous alteplase is the preferred agent. UFH and warfarin are recommended for stable PE. LMWH is beneficial in submassive PE and deep vein thrombosis (DVT) but is controversial for treatment of massive PE.
15. A primary care nurse practitioner (NP) prescribes a drug to an 80-year-old African-American 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:
Answer: pharmacokinetics
Explanation: 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.
16. An 80-year-old female patient with a history of angina has increased TSH and decreased T4. The primary care NP should prescribe _____ mcg of _____.
Answer: 25; levothyroxine
Explanation: Elderly individuals may experience exacerbation of cardiovascular disease and angina with thyroid hormone replacement. It is advisable to start low at 25 mcg and work up as tolerated. Liothyronine is a synthetic T3.
17. A patient who has a history of chronic constipation uses a bulk laxative to prevent episodes of acute constipation. The patient reports having an increased frequency of episodes. The primary care NP should recommend:
Answer: adding docusate sodium (Colace).
Explanation: Patients treated for long-term constipation should begin with a bulk laxative. If that is not effective, the addition of a second laxative may be necessary. Using two laxatives from the same category is not recommended. A stool softener, such as docusate sodium, is appropriate. Bisacodyl is not a second-line treatment. Lactulose and polyethylene glycol are from the same category.
18. A patient comes to the clinic to discuss weight loss. The primary care NP notes a BMI of 32 and performs a health risk assessment that reveals no obesity-related risk factors. The NP should recommend:
Answer: changes in diet and exercise along with short-term phentermine.
Explanation: This patient is grade 2 overweight (obese), so a short-term course of phentermine is useful, especially as there are no cardiovascular risk factors. Orlistat is a second-line drug. Surgical intervention is indicated when other therapies fail. Changes in diet and physical activity alone do not bring immediate results, and patients often get discouraged.
19. A primary care NP sees a 3-year-old patient who has been vomiting for several days. The child has had fewer episodes of vomiting the past day and is now able to take sips of fluids without vomiting. The child has dry oral mucous membranes, 2-second capillary refill, and pale but warm skin. The child's blood pressure is 88/46 mm Hg, the heart rate is 110 beats per minute, and the temperature is 37.2° C. The NP should:
Answer: begin oral rehydration therapy
Explanation: The use of antiemetics in children is discouraged for cases of uncomplicated vomiting. The child has compensated, mild dehydration and is now able to tolerate fluids, so oral rehydration is indicated.
20. A primary care NP sees a 5-year-old child who is morbidly obese. The child has an elevated hemoglobin A1c and increased lipid levels. Both of the child's parents are overweight but not obese, and they tell the NP that they see nothing wrong with their child. They both state that it is difficult to refuse their child's requests for soda or ice cream. The NP should:
Answer: initiate a dialogue with the parents about the implications of the child's laboratory values.
Explanation: In this case, the child is at risk if the parents do not intervene. The NP should help the parents to see the potential adverse effects so that they can understand the need for treatment. The other answers are examples of the NP creating solutions. Unless the parents see the problem, they are not likely to engage in the treatment regimen.
21. The primary care NP refers a patient to a cardiologist who diagnoses long QT syndrome. The cardiologist has prescribed propranolol (Inderal). The patient exercises regularly and is not obese. The patient asks the NP what else can be done to minimize risk of sudden cardiac arrest. The NP should counsel the patient to:
Answer: drink extra fluids when exercising.
Explanation: Patients with long QT syndrome should avoid situations in which they might overheat or get dehydrated. This patient should be encouraged to drink plenty of fluids while exercising and should avoid activities such as yoga and hot baths. Implantable cardioverter-defibrillators are used for high-risk patients. Procainamide can cause long QT syndrome.
22. A 55-year-old patient with no prior history of hypertension has a blood pressure greater than 140/90 on three separate occasions. The patient does not smoke, has a body mass index of 24, and exercises regularly. The patient has no known risk factors for cardiovascular disease. The primary care NP should:
Answer: perform a careful cardiovascular physical assessment.
Explanation: If the patient is younger than 20 or older than 50 years old at the onset of elevated blood pressure, the NP should look for causes of secondary hypertension. The physical examination should include a careful cardiovascular assessment. This patient will need pharmacologic treatment, but not until the underlying cause of hypertension is determined.
23. The primary care NP sees a patient who has a history of hypertension and alcoholism. The patient is not taking any medications. The NP auscultates crackles in both lungs and palpates the liver 2 cm below the costal margin. Laboratory tests show an elevated creatinine level. The NP will refer this patient to a cardiologist and should prescribe:
Answer: furosemide (Lasix).
Explanation: In the treatment of heart failure, loop diuretics relieve the congestive symptoms of pulmonary and congestive edema. Loop diuretics are also useful to treat states of volume excess in cirrhosis and renal insufficiency. Because this patient has a history of alcoholism and has an enlarged liver on examination, furosemide is a good first choice to relieve this patient's congestive symptoms. Spironolactone and chlorthalidone are not loop diuretics. Albuterol might be used for symptomatic treatment only.
24. An 80-year-old patient has begun taking propranolol (Inderal) and reports feeling tired all of the time. The primary care NP should:
Answer: contact the patient's cardiologist to discuss decreasing the dose of propranolol.
Explanation: Elderly patients have described sedation and sleep disturbances with β-blockers. Elderly patients often need lower doses of these drugs. Patients should not be advised to discontinue the medication abruptly.
25. A patient reports having occasional acute constipation with large, hard stools and pain and asks the primary care NP about medication to treat this condition. The NP learns that the patient drinks 1500 mL of water daily; eats fruits, vegetables, and bran; and exercises regularly. The NP should recommend:
Answer: a saline laxative as needed.
Explanation: Mild short-term constipation may be treated with a saline laxative or a bulk laxative as needed. Daily laxatives are not recommended. Glycerin suppositories can cause irritation of the rectum with long-term use.
26. A 40-year-old patient is in the clinic for a routine physical examination. The patient has a body mass index (BMI) of 26. The patient is active and walks a dog daily. A lipid profile reveals low-density lipoprotein (LDL) of 100 mg/dL, high-density lipoprotein (HDL) of 30 mg/dL, and triglycerides of 250 mg/dL. The primary care nurse practitioner (NP) should:
Answer: order a fasting plasma glucose level.
Explanation: Testing for type 2 diabetes should be considered in all adults with a BMI greater than 25 who have risk factors such as HDL less than 35 mg/dL or triglycerides greater than 250 mg/dL. A fasting plasma glucose level greater than 126 mg/dL indicates diabetes. Metformin is not indicated unless testing is positive. Lifestyle changes may be part of the treatment plan. Serum insulin level is not indicated.
27. An 80-year-old patient asks a primary care NP about OTC antacids for occasional heartburn. The NP notes that the patient has a normal complete blood count and normal electrolytes and a slight elevation in creatinine levels. The NP should recommend:
Answer: calcium carbonate (Tums).
Explanation: Elderly patients with renal failure should not take antacids containing magnesium because of the risk of hypermagnesemia. Sodium-containing antacids may cause fluid retention in elderly patients. Aluminum hydroxide is not as effective as calcium carbonate.
28. A primary care NP sees a 60-year-old woman for a physical examination. The woman tells the NP she is taking tamoxifen for treatment of breast cancer. To monitor her response to this medication, the NP should order:
Answer: liver enzymes and a complete blood count (CBC).
Explanation: Patients taking antiestrogens, such as tamoxifen, should have periodic monitoring of liver enzymes and a CBC. A chest radiograph is not indicated. Bilirubin, creatinine, and bone mineral density testing are part of routine testing for patients taking aromatase inhibitors.
30. The primary care NP sees a patient who has heart failure following an MI 6 months before this visit. The patient has been taking an ACE inhibitor, nitroglycerin, furosemide, and hydrochlorothiazide. The NP auscultates crackles in both lungs and notes pitting edema of both feet. The NP should prescribe:
Answer: spironolactone (Aldactone).
Explanation: Spironolactone has been shown to be of particular benefit in the treatment of severe congestive heart failure when added to an ACE inhibitor and a loop diuretic.
31. A primary care NP prescribes a COCP for a woman who has never taken oral contraceptives before. The woman is in a monogamous relationship, and she and her partner have been using condoms and wish to stop using them. Her last period was 1 week ago. The NP should:
Answer: tell the patient to begin the first pill today and to continue using condoms for 7 days.
Explanation: To start COCPs using the quick start method, the woman takes the first pill on the day of her office visit and uses a barrier method such as condoms for the first 7 days. The patient should be reasonably sure she is not pregnant; she can take a pregnancy test in 2 to 3 weeks if pregnancy is suspected later. If she is pregnant, taking the COCPs would not negatively affect early pregnancy.
32. A woman is in her first trimester of pregnancy. She tells the primary care nurse practitioner (NP) that she continues to have severe morning sickness on a daily basis. The NP notes a weight loss of 1 pound from her previous visit 2 weeks prior. The NP should consult an obstetrician and prescribe:
Answer: ondansetron (Zofran).
Explanation: No antiemetic drugs should be used for nausea and vomiting during pregnancy unless approved by an obstetrician. Ondansetron has been shown to be safe and effective (off-label) for hyperemesis gravidum.
33. 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:
Answer: estrogen-only HT now.
Explanation: 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.
34. Persistent atrial fibrillation (AF) is diagnosed in a patient who has valvular disease, and the cardiologist has prescribed warfarin (Coumadin). The patient is scheduled for electrical cardioversion in 3 weeks. The patient asks the primary care nurse practitioner (NP) why the procedure is necessary. The NP should tell the patient:
Answer: this medication prevents clots but does not alter rhythm.
Explanation: Persistent AF lasts longer than 7 days and episodes fail to terminate on their own, but episodes can be terminated by electrical cardioversion after therapeutic warfarin therapy for 3 weeks. Warfarin does not alter AF. β-Blockers, calcium channel blockers, and digoxin are sometimes given to alter the rate. Verapamil is not an alternative to cardioversion for patients with persistent AF.
35. A patient reports having episodes of dizziness, nausea, and lightheadedness and describes a sensation of the room spinning when these occur. The primary care NP will refer the patient to a specialist who, after diagnostic testing, is likely to prescribe:
Answer: meclizine.
Explanation: Patients with vertigo may experience whirling or a feeling of the room spinning around. In true vertigo, the patient can identify the direction in which the room is spinning. Anticholinergics are the most effective agents in cases of motion sickness or vertigo. Meclizine has a specific indication to treat vertigo.
36. The primary care NP is seeing a patient for a hospital follow-up after the patient has had a first myocardial infarction. The patient has a list of t [Show Less]