Nursing MSN 571 Pharm Midterm and Final Exam, featuring questions and answers for the 2023 - 2024 academic year. These exams have already been graded A, providing you with the ultimate resource for achieving excellence in your studies. What intervention does the provider take to decrease risk to the patient when prescribing drugs with a narrow therapeutic index? - ANS -- drugs with narrow therapeutic range are more dangerous, provider who is aware of this fact can focus additional attention on monitoring these patients for signs and symptoms of toxicity definition of onset of action - ANS -- Onset of Action: the time it takes a drug to reach the minimum effective concentration after a drug is administered. definition of bioavailability - ANS -- Bioavailability: the amount of an active drug that reaches the systemic circulation from its site of administration. Disintegration time, extended release, capsule coatings, can all effect this. Greatest concern is with drugs that have a narrow therapeutic index. IV administration results in the highest bioavailability. definition of protein binding - ANS -- Plasma protein binding refers to the degree to which medications attach to proteins within the blood. A drug's efficiency may be affected by the degree to which it binds. The less bound a drug is, the more efficiently it can traverse cell membranes or diffuse. definition of loading dose - ANS -- Loading dose: a large initial dose of the drug is given to achieve a rapid minimum effect concentration in the plasma. how to write out a prescription - ANS -- Good to know brand name and generic name (generic is most important), route, dose, frequency. If it is an as needed drug, what is it being prescribed for? A patient is prescribed digoxin. Which screening will the provider order to monitor for potential adverse effects from this drug? - ANS -- digoxin: treats HF and supraventricular dysrhythmias. Heart rate and rhythm should be monitored with periodic ECGs to assess desired effects and signs of toxicity. Baseline and periodic serum creatinine. Periodically monitor electrolytes (potassium, magnesium, calcium) especiall y if on diuretics. Because this drug has a narrow therapeutic range (0.5 - 0.8). Monitor plasma drug levels in patients with unchanged symptoms of heart failure after initiation or patient with signs of toxicity - altered heart rate or rhythm, visual or GI disturbances). Patient should be taught to monitor their pulse and know signs of toxicity. What is pharmacodynamic tolerance? - ANS -- Pharmacodynamic tolerance: a state in which a particular dose elicits a smaller response than it did with initial use, results from regular drug use. - intrinsic responsivity of the receptor system diminishes over time What is a side effect of a nonselective b agonist medication? - ANS -- Bet a 1: tachycardia, dysrhythmias, angina Beta 2: hyperglycemia, tremor Which assessment finding would be of greatest concern for a provider who is attempting to determine the appropriateness of prescribing the patient a nonselective b agonist? - ANS -- Cardiac disease - any dysrhythmias or previous MI, angina, tachycardia. Because it can cause dysrhythmias and tachycardia . For what purpose will a provi der prescribe pilocarpine? - ANS -- Pilocarpine: Muscarinic agonist used mainly for the topical treatment of glaucoma because it reduces intraocular pressure. Second - line drug for open angle glaucoma. Can also treat dry mouth from Sjogren's syndrome. What condition would be contraindicated in using Bethanechol? - ANS -- Bethanechol is a direct acting muscarinic agonist that is used to cause bradycardia, and increases secretions, in GI tract and lungs it causes constriction. Treats non obstructive urinary retention. Contraindications: ASTHMA, because of activation of muscarinic receptors in the lungs cause bronchoconstriction. Also, bowel obstruction. The prescriber has ordered neostigmine for a patient with myasthenia gravis. What physiological process would be assessed to best assure patient safety and the long - term effectiveness of the medication therapy? - ANS -- ANSWER: the patient's current swallowing ability. Many patients hospitalized for myasthenia gravis do not have the musc le strength to swallow well and need a parenteral form of the medication, assessing swallowing ability is an important initial safety measure . When prescribing an anticholinergic drug, what would be a concerning preexisting conditions demonstrates the provider's understanding of possible contraindications to this therapy? And what education would you want to give the patient? - ANS -- Anticholinergic drugs are the same thing as muscarinic antagonists!! These drugs increase heart rate, decrease secretions, relax the bronchi, bladder, and GI tract. Ex. Atropine, oxybutynin, ipratropium. Anticholinergic toxicity - hot as a hare, dry as a bone, red as a beet, blind as a bat, mad as a hatter. Contraindications: glaucoma, intestinal atony, urinary tract obstruction, and tachycardia. Use with caution in patients with asthma. Patient education: void before taking the medication, you can wear sunglasses outdoors for the photosensitivity and avoid hazardous activities if vision is impaired, consume lots of fiber to prevent constipation, avoid exercise in the heat, suck on candy for the dry mouth, stay hydrated. Dopamine is administered to a patient who has hypotension. Other than an increase in blood pressure, which indicator would the provider use to evaluate a successful response? - ANS -- Dopamine is an adrenergic agonist, that mainly effects beta - 1 and also alpha - 1 at high doses. A successful response would cause an increase in cardiac outpu t, improving tissue perfusion, and an increased heart rate. Dopamine receptors in the kidneys are activated which dilates blood vessels and improves renal perfusion. The provider is discussing home management with a patient who will begin taking an a - adrenergic antagonist for hypertension, how will you educate the patient on this medication? - ANS -- These drugs usually end in - osin, also treat hypertension and BPH. Patient education: forewarn patients about the first - dose hypotension. Advise them t o sit or lie down if they feel dizzy. Move slowly when changing position. Avoid driving or other hazardous activities for 12 - 24 hours after first dose. Take the initial dose at bedtime to minimize this effect. Teach them how to monitor HR and BP. What are negative side effects to a patient who takes a b blocker? And how would you educate your patient on these side effects? - ANS -- Adverse effects involve beta - 1 and beta - 2. Most therapeutic response is from beta 1. Adverse effects: bradycardia (can treat with isoproterenol or atropine - muscarinic antagonist), reduced cardiac output, precipitation of heart failure (SOB, night coughs, swelling of extremities), AV heart block, rebound cardiac excitation (minimize this r isk by discontinuing slowly), bronchoconstriction, hypoglycemia. Patient education: it can mask early s/s of hypoglycemia by preventing tachycardia, tremors, and perspiration. Advise patients to not rely on these s/s as indicators to hypoglycemia. Use other signs like hunger, fatigue poor concentration. Warns pts about s/s of heart failure which are SOB, night cough, swelling of extremities, notify provider if these occur. Warn that abrupt discontinuation can cause tachycardia and dysrhythmias. When traveling, carry an adequate supply. How would you educate your patient who you prescribed methyldopa for hypertension? - ANS -- Methyldopa is an oral antihypertensive lowers BP by acting t sites in CNS. It is an indirect - acting antiadrenergic agent aka adrenergic antagonist. Patient Education: Patients need a Coombs test, CBC, and liver enzyme labs drawn before treatment, 6 - 12 weeks into treatment, then periodically. Positive Coombs can cause hemolytic anemia (withdraw immediately) and it is hepatotoxic. Can cause CNS effects like nightmares, depression. CNS depression can increase risk of accidents - fall precautions. A patient reports that the clonidine recently prescribed for hypertension is causing drowsiness. Which response by the provider to this concern is appropriate? - ANS -- Clonidine adverse effects: CNS depression is common, 35% of patients experience drowsiness. It will become less intense with continued use of the drug. In early weeks, pts should be advised to avoid hazardous activities if alertness is impaired . When would a provider prescribe clonidine ER (Kapvay ER)? - ANS -- Kapvay ER is used to tre at ADHD in children A patient who takes levodopa/carbidopa for Parkinson disease reports periods of lost drug effect lasting from minutes to several hours with no relationship to the timing of drug administration. What course of action will the provider take? - ANS - - Abrupt loss of effect: can occur at any time in the dosing interval and lasts minutes to hours. Treated with entacapone or another COMT inhibitor. Avoiding high - protein meals may also help. Before beginning therapy with pramipexole for your Parkison's patient, the provider will ask the patient which assessment question in order to minimize risk for injury? - ANS -- " Do you have a history of alcohol abuse or impulsive behaviors?" - pramipexole is associated with impulse control disorders, and this risk increases in patients with a history of alcohol abuse or impulsive behaviors. This is a dopamine agonist. Used alone in early - stage PD and can be combined with levodopa for advanced stage PD. Blood - brain barrier - ANS -- · protective functional separation of the circulating blood from the extracellular fluid of the central nervous system. It limits the penetration of substances, including drugs. In order for drugs to enter the central nervous system, drugs must either be highly hydrophobic (lipid soluble) or engage in a specific transport mechanism. First - pass effect - ANS -- rapid hepatic inactivation of certain oral drugs. Some drugs go directly to liver before they enter the bloodstream, so when they actually hit the bloodstream, they may have no therapeutic effect. Gastrointestinal absorption - ANS -- if oral - absorbed from stomach and intestine to portal circulation. Renal filtration - ANS -- 3 main processes. Glomerular filtration, passive tubular reabsorption, active tubular secretion. Factors that impact this are pH - dependent ioniza tion, competition for active tubular transport, patient age. What are withdrawal side effects of Baclofen? - ANS -- Abrupt discontinuation of baclofen is associated with visual hallucinations, paranoid ideation, and seizures. Adverse effects (not withdrawal) include weakness, dizziness, fatigue, and drowsiness. Respiratory depression is a result of an overdose. How would you educate your patient when prescribing Cyclobenzaprine (Flexeril)? - ANS -- Used for relief of muscle spasm and associated pain. It has significant anticholinergic effects and patients should be warned about dry mouth, blurred vision, and consti pation. Can also cause CNS effects such as drowsiness and dizziness which are most intense in early therapy and diminish with continued use. A patient who takes phenytoin for seizures asks the provider for a prescription for oral contraceptives. What reco mmendation will the provider make to help assure the effectiveness of the contraception method? - ANS -- This patient should consider a different form of birth control while taking phenytoin. Phenytoin can reduce the effects of oral contraceptives pills and because avoiding pregnancy is desirable while taking phenytoin patients should be advised to increase the dose of the oral contraceptives or consider another form of birth control. Increasing the dose of phenytoin is not necessary; OCP's do not affect phenytoin levels. Phenytoin is linked to birth defects. The spouse of a patient with Alzheimer disease asks the provi der for more information about the rivastigmine transdermal patch that is being used, how would you educate this patient and spouse? - ANS -- Doses are lower but more steady with a transdermal patch, reduced side effects occur with the transdermal patch, you should remove the patch before applying a new one, the patch should be changed every 24 hours. Most common side effects include nausea, vomiting, diarrhea, abdominal pain, tremors, and anorexia. What is donepezil 10 mg and how do you increase its dose? - ANS -- The dose can be increased only when the patient has been taking th e medication for at least 3 months. During initiation of the drug, it can cause bradycardia, fainting, falls, and fall - related fractures. To minimize side effects, patients are stabilized on an initial dosage for 1 to 3 months before an increase. A 10mg dose is for severe Alzheimer's disease, it causes reversible inhibition of AChE. Must be on 10mg for 3 months then you can increase dose to 23mg daily. When prescribing Sumatriptan, what disease process is contraindicated? - ANS -- This is the first line drug for terminating a migraine attack. It is contraindicated in patients with risk factors for coronary artery disease (postmenopausal women, over 40 years, smokers, hypertension, hypercholesteremia, diabetes, family history of CAD) until CAD has been ruled out. Contraindicated in patients with ischemic heart disease, MI, uncontrolled hypertension, or other heart disease. Remember "heavy arms" or "ch est pressure" is a normal side effect and not concerning. Ergotamine withdrawal - ANS -- this is the second line drug to stop an ongoing attack. It should not be used daily and can lead to physical dependence. Withdrawal is characterized by headache, nausea, vomiting, and restlessness. Ergotism - ANS -- Overdose of ergotamine - cold pale extremities, muscle pain, paresthesia. Risk is higher in patient's peripheral vascular disease, renal or hepatic impairment. Sumatriptan side effects - ANS -- bad taste in the mouth, heavy arms/chest pressure (this is ok, reassure patient it is a transient, reversible side effect), coronary vasospasm (biggest concern!), teratogenesis. DO NOT give within 24 hours of a ergot. How will you educate y our patient who takes aspirin daily to minimize the risk of bleeding during their surgery in 1 week? - ANS -- High - dose aspirin should be discontinued at least one week before surgery or childbirth to minimize blood loss. In most cases low dose to protect ag ainst thrombosis should not be interrupted for elective surgery. An adolescent is brought to the emergency department after consuming a bottle of extended - release acetaminophen tablets between 8 and 10 hours ago. Which intervention will the provider order? - ANS -- Overdose can cause severe liver damage, early symptoms include nausea, vomiting, abdominal pain, sweating, diarrhea. Hepatic injury appear s 48 to 72 hours after ingestion. The antidote is acetylcysteine. Most effective if given 8 - 10 hours after the overdose but still ok to give as much as 24 hours after the poisoning. Who is aspirin contraindicated in? - ANS -- Aspirin is contraindicated in patients with peptic ulcer disease, bleeding disorders (hemophilia, vitamin K deficiency, hypoprothrombinemia), or hypersensitivity to aspirin or other NSAID's, children and adolescent s (risk for Reye's syndrome). Use with extreme caution in pregnant women (avoid use) - contraindicated especially in the third trimester because it causes premature closure of the ductus arteriosus. How will you treat a patient who was prescribed too much Warfarin? - ANS -- Signs that a patient has overdosed warfarin included bleeding, hematomas or petechiae. If vitals are stable, provider will initially order a PT and INR (2 - 3 is good). If lab values indicate overdose, then give vitamin K (1). Small doses of 2.5mg PO are preferred, large doses (10mg) can hamper restoration of anticoagulation after bleeding is under control. A patient who has taken warfarin for a year has now been prescribed carbamazepine. What additional action will the provider take to assure the patient's safety? - ANS -- Increase the dose of warfarin. Carbamazepine can accelerate how quickly a person goes th rough warfarin (degradation). Decreasing the dose of carbamazepine is not indicated. Extra monitoring is not needed. What labs are you concerned with when your patient is taking iron supplements? - ANS -- Hemoglobin and hematocrit. Black stools are an expe cted side effect. If patient has blood loss that is causing hypotension give an isotonic fluid bolus and PRBC's A patient is admitted to the hospital with a diagnosis of vitamin B12 deficiency, hypoxia and anemia. How would you treat this patient? - ANS -- In addition to oxygen therapy this patient should receive IM cyanocobalamin and folic acid (should be given parenterally, oral is not recommended). How would you treat Otitis externa? - ANS -- Otitis externa aka swimmers ear present with rapid onset ear pain with pruritus, a sensation of ear fullness, tenderness on manipulation of the external ear, edema or erythema of the external auditory canal (EAC). - one or more of these sym ptoms This is managed with application of acidifying drops or acidifying drops with alcohol (2% acetic acid solution applied 3 - 4 times a day for 7 days). Should clear in 10 days, symptoms resolve in 3. If not cleared by this, next you can try a fluoroquinolone (cipro) with a glucocorticoid. Keep ear clean and dry - don't remove earwax or use earplugs, don't put anything in ear. Tilt head to drain water after swimming. H ow would you treat Otitis Media? - ANS -- Symptoms: ear pain (tugging at ear), fever, nausea, sleeplessness, irritability, anorexia. Diagnosis by acute onset of symptoms, middle ear effusion (MEE), or TM is ruptured, purulent drainage, middle ear inflammation. - treatment can start with observation and symptomatic relief for 38 - 72 hours if follow up can be ensured, greater than 2 years old, no severe symptoms - first line treatment is high - dose amoxicillin for 5 - 10 days. - treat pain with ibuprofen or Tylenol, can use lidocaine drops. How would you treat a patient using topical Benzoyl Peroxide who is having an adverse reaction? Not an allergic reaction. - ANS -- Benzoyl peroxide is the first line for mild to moderate acne. It can cause drying and burning of the skin, advise the patient to reduce the frequency of application. What education would you want to inclu de with an adolescent patient with moderate acne has begun a regimen consisting of combination clindamycin/benzoyl peroxide and tretinoin? - ANS -- Tretinoin increases sensitivity to the sun so they should wear sunscreen every day. Avoid irritant soaps and scrubs, wash and dry skin before applying medication and wash hands after, keep away from eyes, mouth, and mucus membranes, women who may become pregnant should adhere strictly to birth control. A patient will begin initial treatment for severe acne. Which regimen will the provider order? - ANS -- Doxycycline and tretinoin. Oral antibiotics are used for moderate to severe acne and are usually combined with a topical retinoid. A patient with open - angle glaucoma has a history of chronic obstructive pulmonary disease. Which ophthalmic b blocker will the provider prescribe? - ANS -- Betaxolol is the only ophthalmic b blocker that is b1 selective, meaning that it has less chance of causing bronchial constriction. It is preferred for patients with asthma and COPD. The other agents are not b1 selective. What education would you want to include for the patient with glaucoma that has begun using brimonidine for long - term reduction of increased ocular pressure? - ANS -- Patients using this drug should wait 15 minutes before putting in contacts, because soft contacts can absorb the drug. Even though the medication is topical, it can be absorbed systemically, causing systemic side effects such as drowsiness or lowered blood pressure. Itching and hyperemia may occur and do not indicate allergy. What is a common side effect of latanoprost ophthalmic drops? - ANS -- Latanoprost can cause a harmless, heightened brown pigment of the iris that stops when the medication is discontinued but does not regress or reverse. It is not a sign of a toxic reaction. Color perception does not occur. A provider considers prescribing timolol for a patient with primary open - angle glaucoma. Which condition could be worsened if this drug is prescribed? - ANS -- Asthma - Timolol is a b blocker and can precipitate bronchoconstriction if absorbed systemically in sufficient amounts. Patients with asthma may develop shortness of breath and wheezing. Systemically absorbed b blockers can have beneficial, not detrimental, effects on hypertension, tachycardia, and migraine headaches. Which drugs will go through a pharmaceutic phase after it is administered? a. Intramuscular cephalosporins b. Intravenous vasopressors c. Oral analgesics d. Subcutaneous antiglycemics – - ANS -- C. Oral analgesics (When drugs are administered parenterally, there is no pharmaceutic phase, which occurs when a drug becomes a solution that can cross the biologic membrane) The nurse is preparing to administer an oral medication and wants to ensure a rapid drug action. Which form of the medication will the nurse administer? a. Capsule b. Enteric - coated pill c. Liquid suspension d. Tablet -- ANS -- C. Liquid suspension (liquid drugs are already in solution, which is the form necessary for absorption in the GI tract. The other forms must disintegrate into small particles and then dissolve before being absorbed) The nurse is teaching a patient who will be discharged home with a prescription for an enteric - coated tablet. Which statement by the patient indi cates understanding of the teaching? a. "I may crush the tablet and put it in applesauce to improve absorption." b. "I should consume acidic foods to enhance absorption of this medication." c. "I should expect a delay in onset of the drug's effects after taking the tablet." d. "I should take this medication with high - fat foods to improve its action." -- ANS - - C. "I should expect a delay in onset of the drug's effects after taking the tablet." A nurse is preparing to administer an oral chug that is best absorbed in an acidic environment. How will the nurse give the drug? a. On an empty stomach b. With a full glass of water c. With food d. With high - fat food -- ANS -- C. With food The nurse is reviewing medication information with a nursing student prior to administering an oral drug and notes that the drug has extensive first - pass effects. Which statement by the student indicates a need for further teaching about this medication? a. ' The first - pass effect means the drug may be absorbed into systemic circulation from the intestinal lumen. ' b. 'The first - pass effect means the drug may be changed to an inactive form and excreted." c. "The first - pass effect means the drug may be changed to a metabolite, which may be more active than the original." d. 'The first - pass effect means the drug may be unchanged as it passes through the liver." -- ANS -- A. "The first - pass effect means the drug may be absorbed into systemic circulation from the intestinal lumen." A patient has been taking warfarin (Coumadin), which is highly protein - bound. The patient will begin taking gemfibrozil, which is also highly protein - bound. The nurse will observe the patient closely for a. decreased effects of warfari n. b. increased effects of warfarin. c. decreased effects of gemfibrozil. d. decreased effects of both drugs. -- ANS -- B. A patient who takes the anticoagulant warfarin will begin taking the anticonvulsant drug carbamazepine. The nurse reviews the drug information for these drugs and learns that carbamazepine is a hepatic enzyme inducer. The nurse anticipates that the provider will make which dosage adjustment? a. Decrease the dose of carbamazepine b. Increa se the dose of carbamazepine c. Decrease the dose of warfarin d. Increase the dose of warfarin -- ANS -- D. The nurse assesses a patient who is receiving morphine sulfate intravenously using a patient - controlled analgesia pump. The nurse notes somnolence and respiratory depression, which are signs of morphine toxicity. The nurse will prepare to administer naloxone (Narcan) because it a. has synergistic effects with morphine. b. is a narcotic agonist. c . is a narcotic antagonist. d. potentiates narcotic effects. -- ANS -- C. The nurse is teaching a patient about a chug that causes photosensitivity. Which statement by the patient indicates a need for further teaching? a. "I should apply sunscreen with a sun protection factor greater than 15." b. "I should avoid sunlight when possible while taking this drug." C. "I will wear protective clothing when I am outdoors.' D. "I will wear sunglasses even while I am indoors." -- ANS -- D. The nurse reviews a patient's database and learns that the patient lives alone, is forgetful, and does not have an established routine. The patient will be sent home with three new medications to be taken at different times of day. The nurse develops a daily medication chart and enlists a family member to put the patient's pills in a pill organizer. This is an example of which phase of the nursing process? a. Assessment b. Evaluation