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.
... [Show More] The 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]