Comprehensive Nursing Pharmacology NCLEX Test Bank Quiz #1 | 50 Questions 1. Question 1 of 50 1. Question A 2-year-old child is receiving temporary total p... arenteral nutrition (TPN) through a central venous line. This is the first day of TPN therapy. Although all of the following nursing actions must be included in the plan of care of this child, which one would be a priority at this time? ◦ A. Use aseptic technique during dressing changes. ◦ B. Maintain central line catheter integrity. ◦ C. Monitor serum glucose levels. ◦ D. Check results of liver function tests. Correct Answer: C. Monitor serum glucose levels Monitor serum glucose levels. Hyperglycemia may occur during the first day or 2 as the child adapts to the high-glucose load of the TPN solution. Thus, a chief nursing responsibility is blood glucose testing. Total parenteral nutrition (TPN), also known as parenteral nutrition (PN) is a form of nutritional support given completely via the bloodstream, intravenously with an IV pump. TPN administers proteins, carbohydrates, fats, vitamins, and minerals. It aims to prevent and restore nutritional deficits, allowing bowel rest while supplying adequate caloric intake and essential nutrients, and removing antigenic mucosal stimuli (Perry et al., 2014). ◦ Option A: With proper care, a central catheter can be maintained for several days or even weeks for the delivery of TPN. Apply strict aseptic technique during insertion, care, and maintenance. Frequently assess the CVC site for redness, tenderness, or drainage. Notify the health care provider of any signs and symptoms of infection. ◦ Option B: Strict asepsis is to be observed during the placement of the catheter. A chest radiograph should be taken prior to the commencement of feeding to confirm the position of the catheter-tip and to exclude traumatic pneumothorax, the commonest complication related to catheter placement. ◦ Option D: Review lab values for increases and decreases out of the normal range. Lab values include CBC, electrolytes, calcium, magnesium, phosphorus, potassium, glucose, albumin, BUN (blood urea nitrogen), creatinine, triglycerides, and transferrin. 1. Question 2 of 50 2. Question Nurse Jamie is administering the initial total parenteral nutrition solution to a client. Which of the following assessments requires the nurse’s immediate attention? ◦ A. Temperature of 37.5 degrees Celsius. ◦ B. Urine output of 300 cc in 4 hours. ◦ C. Poor skin turgor. ◦ D. Blood glucose of 350 mg/dl. Correct Answer: D. Blood glucose of 350 mg/dl. Total parenteral nutrition formulas contain dextrose in concentrations of 10% or greater to supply 20% to 50% of the total calories. Blood glucose levels should be checked every 4 to 6 hours. A sliding scale dose of insulin may be ordered to maintain the blood glucose level below 200mg/dl. ◦ Option A: Catheter-related bloodstream infection or CR-BSI, which starts at the hub connection, is the spread of bacteria through the bloodstream. There’s an increased risk of CR-BSI with TPN, due to the high dextrose concentration of TPN. Symptoms include tachycardia, hypotension, elevated or decreased temperature, increased breathing, decreased urine output, and disorientation. Strict adherence to aseptic technique with insertion, care, and maintenance; avoid hyperglycemia to prevent infection complications; closely monitor vital signs and temperature. IV antibiotic therapy is required. Monitor white blood cell count and patient for the malaise. Replace IV tubing frequently as per agency policy (usually every 24 hours). ◦ Option B: Monitor and record every eight hours or as per agency policy. Monitor for signs and symptoms of fluid overload (excessive weight gain) by completing a cardiovascular and respiratory assessment. Assess intakes such as IV (intravenous fluids), PO (oral intake), NG (nasogastric tube feeds). Assess outputs: NG (removed gastric content through the nasogastric tube), fistula drainage, BM (liquid bowel movements), colostomy/ileostomy drainage, closed suction drainage devices (Penrose or Jackson-Pratt drainage), and chest tube drainage. ◦ Option C: Related to a sudden increase in glucose after a recent malnourished state. After starvation, glucose intake suppresses gluconeogenesis by leading to the release of insulin and the suppression of glycogen. Excessive glucose may lead to hyperglycemia, with osmotic diuresis, dehydration, metabolic acidosis, and ketoacidosis. Excess glucose also leads to lipogenesis (again caused by insulin stimulation). This may cause fatty liver, increased CO2 production, hypercapnia, and respiratory failure. 1. Question 3 of 50 3. Question Nurse Susan administered intravenous gamma globulin to an 18 month-old child with AIDS. The parent asks why this medication is being given. What is the nurse’s best response? ◦ A. “It will slow down the replication of the virus.” ◦ B. “This medication will improve your child’s overall health status.” ◦ C. “This medication is used to prevent bacterial infections.” ◦ D. “It will increase the effectiveness of the other medications your child receives.” Correct Answer: C. “This medication is used to prevent bacterial infections.” Intravenous gamma globulin is given to help prevent as well as to fight bacterial infections in young children with AIDS. Gamma globulin injections seem to lower the number of certain infections among children with AIDS but do not cure the lethal ailment. ◦ Option A: The main immunological abnormality in human immunodeficiency virus (HIV)-infected patients, and particularly those with the acquired immune deficiency syndrome (AIDS), is a deficiency in cellular immunity. However, symptomatic HIV-infected children also have evidence of deficiency of specific antibody synthesis, and intravenous immune globulin (IVIG) preparations in doses of 0.2-0.4 g/kg every 2-4 weeks have been shown to reduce the incidence of respiratory infections. ◦ Option B: IVIG therapy may also reduce the mortality and incidence of bacterial infections in adults but further studies are required. In addition, high-dose IVIG therapy (1-2 g/kg over 2-5 days) produces increased platelet counts in patients with idiopathic thrombocytopenic purpura (ITP) associated with HIV infection. Finally, IVIG therapy may have a role in HIV-infected patients suffering from severe parvovirus B19 or measles infection, or in patients suffering from autoimmune disorders where high-dose IVIG therapy has been shown to be efficacious. ◦ Option C: Doctors said that although the gamma globulin treatment did not cure AIDS it seemed to ”enhance the quality” the lives of the children in the study group because it freed them from the constant infections that added to their suffering. Such episodes of sepsis are often a result of bacterial infection. The gamma globulin contains antibodies to many common bacteria, including ones that often kill children whose immune systems have been paralyzed by the AIDS virus. 4. Question When caring for a client with total parenteral nutrition (TPN), what is the most important action on the part of the nurse? • A. Record the number of stools per day. • B. Maintain strict intake and output records. • C. Sterile technique for dressing change at IV site. • D. Monitor for cardiac arrhythmias. Correct Answer: C. Sterile technique for dressing change at IV site. Clients receiving TPN are very susceptible to infection. The concentrated glucose solutions are a good medium for bacterial growth. Strict sterile technique is crucial in preventing infection at IV infusion sites. Catheter-related sepsis rates have decreased since the introduction of guidelines that emphasize sterile techniques for catheter insertion and skin care around the insertion site. The increasing use of dedicated teams of physicians and nurses who specialize in various procedures including catheter insertion also has accounted for a decrease in catheter-related infection rates. • Option A: Progress of patients with a TPN line should be followed on a flowchart. An interdisciplinary nutrition team, if available, should monitor patients. Weight, complete blood count, electrolytes, and blood urea nitrogen should be monitored often (eg, daily for inpatients). Plasma glucose should be monitored every 6 hours until patients and glucose levels become stable. Fluid intake and output should be monitored continuously. When patients become stable, blood tests can be done much less often. • Option B: Volume overload (suggested by > 1 kg/day weight gain) may occur when patients have high daily energy requirements and thus require large fluid volumes. • Option D: Forty?one percent of procedures resulted in atrial arrhythmias and 25% produced some degree of ventricular ectopy, 30% of these were ventricular couplets or greater. Ventricular ectopy was significantly more common in shorter patients and when the catheter was inserted from the right subclavian position (43% ventricular ectopy vs 10% at the other sites). Other variables such as age, cardiac history, serum potassium, type of procedure, and catheter brand were not significant. 5. Question The nurse is administering an intravenous vesicant chemotherapeutic agent to a client. Which assessment would require the nurse’s immediate action? • A. Stomatitis lesion in the mouth. • B. Severe nausea and vomiting. • C. Complaints of pain at the site of infusion. • D. A rash on the client’s extremities. Correct Answer: C. Complaints of pain at the site of infusion. A vesicant is a chemotherapeutic agent capable of causing blistering of tissues and possible tissue necrosis if there is extravasation. These agents are irritants that cause pain along the vein wall, with or without inflammation. • Option A: Platinum compounds have been classified as irritants. Oxaliplatin has been recently reported to have vesicant properties. Extravasation usually begins with a palpable swelling and discomfort upon palpation. Lesions usually progress to erythematous painful lesions and resemble erysipelas. • Option B: Nausea and vomiting can start within the first few hours after chemotherapy drugs are given and usually last about 24 hours. However, nausea and vomiting may start more than 24 hours after treatment and last several days (called delayed nausea and vomiting). Some people may have anticipatory nausea after having a few treatments, where they feel nauseated even before treatment is given because they expect to be sick. • Option D: Taxanes, including docetaxel and paclitaxel, are most often classified by literature as vesicants although there is no clear delineation. Most reactions following the extravasation of taxanes consist of erythema, tenderness, and swelling. 6. Question Nurse Celine is caring for a client with clinical depression who is receiving an MAO inhibitor. When providing instructions about precautions with this medication, the nurse should instruct the client to: • A. Avoid chocolate and cheese. • B. Take frequent naps. • C. Take the medication with milk. • D. Avoid walking without assistance. Correct Answer: A. Avoid chocolate and cheese. Foods high in tryptophan, tyramine, and caffeine, such as chocolate and cheese may precipitate hypertensive crises. Tyramine is an amino acid that helps regulate blood pressure. It occurs naturally in the body, and it’s found in certain foods. Medications called monoamine oxidase inhibitors (MAOIs) block monoamine oxidase, which is an enzyme that breaks down excess tyramine in the body. Blocking this enzyme helps relieve depression. • Option B: Naps do not have an effect on MAO inhibitors. MAOIs, although effective, generally have been replaced by newer antidepressants that are safer and cause fewer side effects. Still, an MAOI is a good option for some people. In certain cases, an MAOI relieves depression when other treatments have failed. • Option C: Aged, mature, or hard cheeses (aged cheddar, Swiss, Parmesan, blue cheese, Camembert) and milk should be avoided. Beverages with caffeine also may contain tyramine, so your doctor may recommend limits. • Option D: Perform a thorough physical assessment to establish baseline data before drug therapy begins, to determine the effectiveness of therapy, and to evaluate for the occurrence of any adverse effects associated with drug therapy. Question 7 While providing home care to a client with congestive heart failure, the nurse is asked how long diuretics must be taken. The best response to this client should be: • A. “As you urinate more, you will need less medication to control fluid.” • B. “You will have to take this medication for about a year.” • C. “The medication must be continued so the fluid problem is controlled.” • D. “Please talk to your physician about medications and treatments.” Correct Answer: C. “The medication must be continued so the fluid problem is controlled.” This is the most therapeutic response and gives the client accurate information. Diuretics are used to achieve and maintain euvolemia (the patient’s ‘dry weight’) with the lowest possible dose. This means that the dose must be adjusted, particularly after the restoration of the dry body weight, to avoid the risk of dehydration, which leads to hypotension and renal dysfunction. • Option A: In general, due to their greater effectiveness, loop diuretics, such as furosemide, are the mainstay of diuretic therapy in HF. Indeed loop diuretics produce more intense and shorter diuresis than thiazides, which results in more gentle and prolonged diuresis. • Option B: Diuretic efficacy may be limited by adverse neurohormonal activation and by ‘congestion-like’ symptoms. Diuretics are an extremely useful and varied class of agents for the management of hypovolemic states. • Option D: Furosemide is by far the most common oral loop diuretic, but patients with resistance to oral furosemide therapy may benefit from trials with second-generation oral loop diuretics (bumetanide and torasemide). These may be more efficacious, due to their increased oral bioavailability and potency. 8. Question George, age 8, is admitted with rheumatic fever. Which clinical finding indicates to the nurse that George needs to continue taking the salicylates he had received at home? • A. Chorea • B. Polyarthritis • C. Subcutaneous nodules • D. Erythema marginatum Correct Answer: B. Polyarthritis Polyarthritis is characterized by swollen, painful, hot joints that respond to salicylates. Polyarthritis refers to a joint disease that involves at least five joints. One or more signs of inflammation, including pain, movement restriction, swelling, warmth, and redness, are seen in the joints involved. • Option A: Chorea is the restless and sudden aimless and irregular movements of the extremities suddenly seen in persons with rheumatic fever, especially girls. Chorea may be viewed as resulting from increased dopaminergic activity in the projections from the substantia nigra to the striatum, resulting in decreased GABAergic projection from the striatum to the globus pallidus. • Option C: Subcutaneous nodules are non tender swellings over bony prominences sometimes seen in persons with rheumatic fever. Subcutaneous nodules are deep-seated lesions in the skin, located in the deep dermis and subcutis, often with minimal changes appreciated on the surface of the skin. They are often easier to feel than see. • Option D: Erythema marginatum is a skin condition characterized by nonpruritic rash, affecting the trunk and proximal extremities, seen in persons with rheumatic fever. The pathogenesis for the occurrence of these lesions in cases of hereditary angioedema is proposed to be bradykinin mediated. This was evidenced by the presence of dense stromal and endothelial deposits of bradykinin in skin biopsy specimens taken from lesions of erythema marginatum in patients with hereditary angioedema. 9. Question An order is written to start an IV on a 74-year-old client who is getting ready to go to the operating room for a total hip replacement. What gauge of catheter would best meet the needs of this client? • A. 18 • B. 20 • C. 21 butterfly • D. 25 Correct Answer: A. 18 Clients going to the operating room ideally should have an 18- gauge catheter. This is large enough to handle blood products safely and to allow rapid administration of large amounts of fluid if indicated during the perioperative period. An 18-gauge catheter is recommended. • Option B: A 20-gauge catheter is a second choice. One may be able to push blood* through this size if an 18 gauge can’t be used, but always check the employer’s protocol. This size is better for patients with smaller veins. • Option C: A 21-gauge needle is too small and a butterfly too unstable for a client going to surgery. Mostly used for transfusions in pediatric, neonate, and older adult patients. • Option D: A 25-gauge needle is too small. It is most commonly used for neonatal and pediatric patients. ◦ 10. Question A client with an acute exacerbation of rheumatoid arthritis is admitted to the hospital for treatment. Which drug, used to treat clients with rheumatoid arthritis, has both an anti-inflammatory and immunosuppressive effect? ◦ A. Gold sodium thiomalate (Myochrysine) ◦ B. Azathioprine (Imuran) ◦ C. Prednisone (Deltasone) ◦ D. Naproxen (Naprosyn) Correct Answer: C. Prednisone (Deltasone) Prednisone is used to treat persons with acute exacerbations of rheumatoid arthritis. This medication is given for its anti-inflammatory and immunosuppressive effects. Prednisone is in a class of medications called corticosteroids. It works to treat patients with low levels of corticosteroids by replacing steroids that are normally produced naturally by the body. It works to treat other conditions by reducing swelling and redness and by changing the way the immune system works. ◦ Option A: Gold sodium thiomalate is usually used in combination with aspirin and nonsteroidal anti-inflammatory drugs to relieve pain. Gold has an immunosuppressive effect. Gold sodium thiomalate is a form of gold that affects the process of inflammation in the body. Gold sodium thiomalate is used to treat rheumatoid arthritis in adults and children. ◦ Option B: Azathioprine is used for clients with life-threatening rheumatoid arthritis for its immunosuppressive effects. Azathioprine is in a class of medications called immunosuppressants. It works by decreasing the activity of the body’s immune system so it will not attack the transplanted organ or the joints. ◦ Option D: Naproxen is a nonsteroidal anti-inflammatory drug. Immunosuppression does not occur. Naproxen is a nonsteroidal anti-inflammatory drug (NSAID). It works by reducing hormones that cause inflammation and pain in the body. Naproxen is used to treat pain or inflammation caused by conditions such as arthritis, ankylosing spondylitis, tendinitis, bursitis, gout, or menstrual cramps. It can also be used to treat acute pain caused by other conditions not listed in this medication guide. 1. Question 11 of 50 11. Question Which of the following is least likely to influence the potential for a client to comply with lithium therapy after discharge? ◦ A. The impact of lithium on the client’s energy level and lifestyle. ◦ B. The need for consistent blood level monitoring. ◦ C. The potential side effects of lithium. ◦ D. What the client’s friends think of his need to take medication. Correct Answer: D. What the client’s friends think of his need to take medication. While the client’s social network can influence the client in terms of compliance, the influence is typically secondary to that of the other factors listed. Lithium acts on a person’s central nervous system (brain and spinal cord). Doctors don’t know exactly how lithium works to stabilize a person’s mood, but it is thought to help strengthen nerve cell connections in brain regions that are involved in regulating mood, thinking, and behavior. ◦ Option A: The impact of lithium on the client’s energy level and lifestyle are great determinants to compliance. as your body gets used to lithium, these side effects should wear off. If these symptoms do not get better within a week or two, your doctor may either reduce your dose or increase it more slowly. If that does not work you may need to switch to a different medicine. ◦ Option B: The frequent blood level monitoring required is difficult for clients to follow for a long period of time. Check with the doctor right away if there is anxiety, restlessness, a fast heartbeat, fever, sweating, muscle spasms, twitching, nausea, vomiting, diarrhea, or see or hear things that are not there. These may be symptoms of a serious condition called serotonin syndrome. The risk may be higher if one also takes certain other medicines that affect serotonin levels in the body. ◦ Option C: Potential side effects such as fine tremor, drowsiness, diarrhea, polyuria, thirst, weight gain, and fatigue can be disturbing to the client. Some side effects may occur that usually do not need medical attention. These side effects may go away during treatment as the body adjusts to the medicine. Also, the health care professional may be able to tell about ways to prevent or reduce some of these side effects. 1. Question 12 of 50 12. Question A male patient is to receive a percutaneously inserted central catheter (PICC). He asks the nurse whether the insertion will hurt. How will the nurse reply? ◦ A. “You will have general anesthesia so you won’t feel anything.” ◦ B. “It will be inserted rapidly, and any discomfort is fleeting.” ◦ C. “The insertion site will be anesthetized. Threading the catheter through the vein is not painful.” ◦ D. “You will receive sedation prior to the procedure.” Correct Answer: C. “The insertion site will be anesthetized. Threading the catheter through the vein is not painful.” Pain related to PICC insertion occurs with the puncture of the skin. When inserting PICC lines, the insertion site is anesthetized so no pain is felt. Unnecessary pain should be prevented. Peripherally inserted central catheters (PICCs) are a subset of central venous catheters. They are 50 cm to 60 cm long single, double or triple lumen catheters that are placed in a peripheral arm vein and terminate in the thorax. They can be used for medium-term venous access, which is defined as anywhere between several weeks to 6 months. ◦ Option A: The patient will not receive general anesthesia or sedation. After placement and functionality have been confirmed, appropriate maintenance, which includes the use of stabilization devices, frequent flushing of line with saline and heparin-containing solutions, and sterile dressings replaced at regular intervals, should be employed to minimize complications. ◦ Option B: This statement is not correct. If not treated, pain can compromise the resolution of processes underlying disease, delay surgical recovery, and increase the costs of healthcare. In addition, multiple painful and stressful events experienced by clients induce acute physiological changes, as well as permanent structural and functional changes in the central nervous system. This can have long-term consequences, including chronic pain and altered neurobehavioral responses to pain. Appropriate use of environmental, behavioral, and pharmacological interventions may prevent, reduce, or eliminate the pain associated with procedures in clients. ◦ Option D: An exploratory descriptive study, that evaluated 43 neonates in the neonatal unit of a hospital in the city of São Paulo, indicated that 86.1% of PICC insertions were not accompanied by analgesia, and in 13.9% of cases, sedatives were used. Nonpharmacologic methods of pain relief and stress were not used. Therefore, a high frequency of sedatives was noted during PICC insertion in neonates. Midazolam is a benzodiazepine with a short and limited analgesic effect, commonly used in the NICU to produce sedation and muscle relaxation. Chloral hydrate is used for sedation, particularly when numbness is necessary without analgesia. An increased incidence of apnea and oxygen desaturation in term neonates less than one month of age and preterm infants less than 60 weeks of postnatal age, who received this barbiturate to perform magnetic resonance imaging, was identified. 1. Question 13 of 50 13. Question The nurse is caring for an elderly client who has been diagnosed as having sundown syndrome. He is alert and oriented during the day but becomes disoriented and disruptive around dinnertime. He is hospitalized for evaluation. The nurse asks the client and his family to list all of the medications, prescription and nonprescription, he is currently taking. What is the primary reason for this action? ◦ A. Multiple medications can lead to dementia. ◦ B. The medications can provide clues regarding his medical background. ◦ C. Ability to recall medications is a good assessment of the client’s level of orientation. ◦ D. Medications taken by a client are part of every nursing assessment. Correct Answer: A. Multiple medications can lead to dementia. Drugs commonly used by elderly people, especially in combination, can lead to dementia. In general, sundown syndrome is characterized by the emergence or increment of neuropsychiatric symptoms such as agitation, confusion, anxiety, and aggressiveness in the late afternoon, in the evening, or at night. Sundowning is highly prevalent among individuals with dementia. It is thought to be associated with impaired circadian rhythmicity, environmental and social factors, and impaired cognition. ◦ Option B: Assessment of the medication taken may or may not provide information on the client’s medical background. However, this is not the primary reason for assessing medications in a client who is exhibiting sundown syndrome. Neurophysiologically, it appears to be mediated by degeneration of the suprachiasmatic nucleus of the hypothalamus and decreased production of melatonin. A variety of treatment options have been found to be helpful to ameliorate the neuropsychiatric symptoms associated with this phenomenon: bright light therapy, melatonin, acetylcholinesterase inhibitors, N-methyl-d-aspartate receptor antagonists, antipsychotics, and behavioral modifications. ◦ Option C: Ability to recall medications may indicate short-term memory and recall. However, that is not the primary reason for assessing medications in a client with sundown syndrome. Prinz and Raskind6 defined sundowning as a marked increase in confusion, disorientation, and possibly agitation in an elderly or severely cognitively impaired subject at sunset or when daylight is reduced. Other clinical manifestations associated with sundowning are screaming, delusional thinking, moaning, and wandering. ◦ Option D: Medication history should be a part of the nursing assessment. In this client, there is an even more important reason for evaluating the medications taken. It is a well-known fact that virtually, any pharmacological agent and combination of different medications may induce cognitive, affective, and behavioral changes in patients with dementia. Moreover, medications that are used to treat above mentioned changes may worsen previously existing pathology. Hypnotics, benzodiazepines, and low-potency antipsychotics are among conventional therapy that used to manage evening agitation and behavioral disruptions associated with sundowning. 1. Question 14 of 50 14. Question A 25-year-old woman is in her fifth month of pregnancy. She has been taking 20 units of NPH insulin for diabetes mellitus daily for six years. Her diabetes has been well controlled with this dosage. She has been coming for routine prenatal visits, during which diabetic teaching has been implemented. Which of the following statements indicates that the woman understands the teaching regarding her insulin needs during her pregnancy? ◦ A. “Are you sure all this insulin won’t hurt my baby?” ◦ B. “I’ll probably need my daily insulin dose raised.” ◦ C. “I will continue to take my regular dose of insulin.” ◦ D. “These finger sticks make my hand sore. Can I do them less frequently?” Correct Answer: B. “I’ll probably need my daily insulin dose raised.” The client starts to need increased insulin in the second trimester. As a result of placental maturation and placental production of lactogen, insulin requirements begin increasing in the second trimester and may double or quadruple by the end of pregnancy. Insulin doses depend on blood glucose levels. Extra testing can be an extreme burden on patients but may be necessary for a short time for aggressive insulin treatment to achieve glycemic goals in a timely manner. Regardless of the method of initiating or adjusting insulin, aggressive management is necessary to attain quick glucose control. Maintaining tight control throughout pregnancy will require close and frequent monitoring to prescribe appropriate doses. ◦ Option A: This statement indicates a lack of understanding. Insulin has long been considered the standard of care to attain optimal glucose control in pregnancy, although multiple methods are available to initiate insulin. Weight-based dosing, weight plus gestational age–based dosing, and even a “one-dose-for-all” type of dosing have been used. ◦ Option C: Insulin isophane (NPH) is a U-100, intermediate-acting insulin. It is produced in E. coli. It is identical to human insulin and is in a suspension. Its onset of action is 1–2 hours, with an average peak of 4 hours (range: 4–8 hours). Duration of action is 10–20 hours. Vials are good for 31 days at room temperature, and pens are good for 14 days. ◦ Option D: Finger sticks for glucose levels must be continued. Accurate and timely adjustments depend on accurate blood glucose testing, type of insulin used, and consistent carbohydrate levels for meals. Fasting, preprandial, 1-hour postprandial, and bedtime blood glucose levels are all important to monitor all types of diabetes during pregnancy. 1. Question 15 of 50 15. Question Mrs. Johanson’s physician has prescribed tetracycline 500 mg po q6h. While assessing Mrs. Johanson’s nursing history for allergies, the nurse notes that Mrs. Johanson’s is also taking oral contraceptives. What is the most appropriate initial nursing intervention? ◦ A. Administer the dose of tetracycline. ◦ B. Notify the physician that Mrs. Johanson is taking oral contraceptives. ◦ C. Tell Mrs. Johanson, she should stop taking oral contraceptives since they are inactivated by tetracycline. ◦ D. Tell Mrs. Johanson, to use another form of birth control for at least two months. Correct Answer: B. Notify the physician that Mrs. Johanson is taking oral contraceptives. The nurse should be aware that tetracyclines decrease the effectiveness of oral contraceptives. The physician should be notified. Note on the client’s chart that the physician was notified. The two groups of antibiotics most commonly involved in contraceptive failures are tetracyclines and penicillins, namely ampicillin. Both ampicillin and tetracycline have been shown to affect plasma and urinary concentrations of estrogen in both pregnant and nonpregnant women, while progesterone levels remain constant. ◦ Option A: Tetracycline decreases the effectiveness of oral contraceptives. There may be an equally effective antibiotic available that can be prescribed. Broad spectrum antibiotics can lead to lower levels of circulating oral contraceptive hormone levels and have, thus, been implicated in causing failures in women taking oral contraceptives. Failure of oral contraceptive steroids can lead to several outcomes, including breakthrough bleeding, pregnancy and menstrual abnormalities such as amenorrhea and spotting ◦ Option C: The nurse should not tell the client to stop taking oral contraceptives unless the physician orders this. Oral contraceptives (birth control pills) containing estrogen may not work properly if taken while the woman is taking tetracyclines. Unplanned pregnancies may occur. ◦ Option D: If the physician chooses to keep the client on tetracycline, the client should be encouraged to use another form of birth control. Antibiotics are suspected to diminish oral contraceptive efficacy by two main mechanisms: induction of the cytochrome P450 group of hepatic microsomal enzymes and interference with enterohepatic cycling of ethinylestradiol. 1. Question 16 of 50 16. Question An adult client’s insulin dosage is 10 units of regular insulin and 15 units of NPH insulin in the morning. The client should be taught to expect the first insulin peak: ◦ A. As soon as food is ingested. ◦ B. In two to four hours. ◦ C. In six hours. ◦ D. In ten to twelve hours. Correct Answer: B. In two to four hours. The first insulin peak will occur two to four hours after administration of regular insulin. Regular insulin is classified as rapid-acting and will peak two to four hours after administration. The second peak will be eight to twelve hours after the administration of NPH insulin. This is why a snack must be eaten mid-morning and also three to four hours after the evening meal. ◦ Option A: Rapid Acting Insulin Analogs (Insulin Aspart, Insulin Lyspro, Insulin Glulisine) has an onset of action of 5 to 15 minutes, peak effect in 1 to 2 hours, and duration of action that lasts 4-6 hours. With all doses, large and small, the onset of action and the time to peak effect is similar, The duration of insulin action is, however, affected by the dose – so a few units may last 4 hours or less, while 25 or 30 units may last 5 to 6 hours. As a general rule, assume that these insulins have a duration of action of 4 hours. ◦ Option C: Regular Human Insulin has an onset of action of 1/2 hour to 1 hour, peak effect in 2 to 4 hours, and duration of action of 6 to 8 hours. The larger the dose of regular the faster the onset of action, but the longer the time to peak effect and the longer the duration of the effect. ◦ Option D: Long-acting insulin analogs (Insulin Glargine, Insulin Detemir) have an onset of insulin effect in 1 1/2-2 hours. The insulin effect plateaus over the next few hours and is followed by a relatively flat duration of action that lasts 12-24 hours for insulin detemir and 24 hours for insulin glargine. 1. Question 17 of 50 17. Question An adult is hospitalized for treatment of deep electrical burns. Burn wound sepsis develops and mafenide acetate 10% (Sulfamylon) is ordered BID. While applying the Sulfamylon to the wound, it is important for the nurse to prepare the client for expected responses to the topical application, which include: ◦ A. Severe burning pain for a few minutes following application. ◦ B. Possible severe metabolic alkalosis with continued use. ◦ C. Black discoloration of everything that comes in contact with this drug. ◦ D. Chilling due to evaporation of solution from the moistened dressings. Correct Answer: A. Severe burning pain for a few minutes following application. Mafenide acetate 10% (Sulfamylon) does cause burning on application. An analgesic may be required before the ointment is applied. Sulfamylon (mafenide acetate) is a topical (for the skin) antibiotic used to prevent infection in severe burn wounds. Common side effects of Sulfamylon include skin rash, redness, or itching, or pain, burning, or redness of the treated skin areas. ◦ Option B: Mafenide acetate 10% (Sulfamylon) is a strong carbonic anhydrase inhibitor that affects the renal tubular buffering system, resulting in metabolic acidosis. ◦ Option C: Mafenide acetate 10% (Sulfamylon) does not cause discoloration. Silver nitrate solution, another topical antibiotic used to treat burn sepsis, has the disadvantage of turning everything it touches black. ◦ Option D: Mafenide acetate 10% (Sulfamylon) is an ointment that is applied directly to the wound. It has the ability to diffuse rapidly through the eschar. The wound may be left open or dry dressing may be applied. Silver nitrate solution is applied by soaking the wound dressings and keeping them constantly wet, which may cause chilling and hypotension. 1. Question 18 of 50 18. Question Ms.Clark has hyperthyroidism and is scheduled for a thyroidectomy. The physician has ordered Lugol’s solution for the client. The nurse understands that the primary reason for giving Lugol’s solution preoperatively is to: ◦ A. Decrease the risk of agranulocytosis postoperatively. ◦ B. Prevent tetany while the client is under general anesthesia. ◦ C. Reduce the size and vascularity of the thyroid and prevent hemorrhage. ◦ D. Potentiate the effect of the other preoperative medication so less medicine can be given while the client is under anesthesia. Correct Answer: C. Reduce the size and vascularity of the thyroid and prevent hemorrhage. The client may receive an iodine solution (Lugol’s solution) for 10 to 14 days before surgery to decrease vascularity of the thyroid and thus prevent excess bleeding. Plummer observed a 75% decrease in mortality associated with thyroidectomy when Lugol’s solution was introduced. At that time metabolic rate decreased as well as symptoms. ◦ Option A: Doses of over 30 mg/day may increase the risk of agranulocytosis. In a recent randomized control trial in patients receiving Lugol’s solution median blood losses (50 vs. 140?mL), and operative times (138 vs. 150?min), were also significantly less compared to controls. The reduced blood loss is associated with both a 60% reduction in systemic angiogenic factor (VEGF) and with 50% of interleukin-16. If other angiogenic mediators also are involved is unknown. ◦ Option B: Lugol’s solution does not act to prevent tetany. Calcium is used to treat tetany. Lugol’s solution is used both in combination with antithyroid drugs preoperatively in planned thyroidectomies in certain centers routinely, and alone as rescue therapy if severe side effects to antithyroid drugs have occurred. ◦ Option D: Lugol’s solution does not potentiate any other preoperative medication. Lugol’s solution and other iodide preparations seem to have a low frequency of adverse effects. In doses of 1000 times the normal nutritional need, side effects may include acne, loss of appetite, or upset stomach. More severe side effects are fever, weakness, unusual tiredness, swelling in the neck or throat, mouth sores, skin rash, nausea, vomiting, stomach pains, irregular heartbeat, numbness or tingling of the hands or feet, or a metallic taste in the mouth. 1. Question 19 of 50 19. Question A two-year-old child with congestive heart failure has been receiving digoxin for one week. The nurse needs to recognize that an early sign of digitalis toxicity is: ◦ A. Bradypnea ◦ B. Failure to thrive ◦ C. Tachycardia ◦ D. Vomiting Correct Answer: D. Vomiting The earliest sign of digitalis toxicity is vomiting, although one episode does not warrant discontinuing the medication. Digitalis is a plant-derived cardiac glycoside commonly used in the treatment of chronic heart failure (CHF), atrial fibrillation, and reentrant supraventricular tachycardia. Digoxin is the only available preparation of digitalis in the United States. ◦ Option A: Bradypnea (slow breathing) is not associated with digitalis toxicity. Bradycardia is associated with digitalis toxicity. The respiratory rate is sometimes increased. Basal crepitations are associated with CHF. Although GI symptoms are common, the abdominal examination is usually nonspecific. An enlarged liver secondary to CHF (ie, hepatic congestion) may be palpated. Hepatojugular reflux is present. Pedal edema is noted if the patient has renal failure or decompensated CHF. ◦ Option B: Although children with congestive heart failure often have a related condition of failure to thrive, it is not directly related to digitalis administration. It is more related to chronic hypoxia. The therapeutic daily dose of digoxin ranges from 5-15 mcg/kg. The absorption of digoxin tablets is 70-80%; its bioavailability is 95%. The kidney excretes 60-80% of the digoxin dose unchanged. ◦ Option C: Tachycardia is not a sign of digitalis toxicity. Bradycardia is a sign of digitalis toxicity. Digoxin and other cardiac glycosides cause direct vasoconstriction in the arterial and venous system in vascular smooth muscle. Bidirectional ventricular tachycardia is particularly characteristic of severe digitalis toxicity and results from alterations in intraventricular conduction, junctional tachycardia with aberrant intraventricular conduction, or, on rare occasions, alternating ventricular pacemakers. 1. Question 20 of 50 20. Question Mr. Bates is admitted to the surgical ICU following left adrenalectomy. He is sleepy but easily aroused. An IV containing hydrocortisone is running. The nurse planning care for Mr. Bates knows it is essential to include which of the following nursing interventions at this time? ◦ A. Monitor blood glucose levels every shift to detect the development of hypo- or hyperglycemia. ◦ B. Keep flat on back with minimal movement to reduce the risk of hemorrhage following surgery. ◦ C. Administer hydrocortisone until vital signs stabilize, then discontinue the IV. ◦ D. Teach Mr. Bates how to care for his wound since he is at high risk for developing postoperative infection. Correct Answer: A. Monitor blood glucose levels every shift to detect development of hypo- or hyperglycemia. Hydrocortisone promotes gluconeogenesis and elevates blood glucose levels. Following adrenalectomy, the normal supply of hydrocortisone is interrupted and must be replaced to maintain the blood glucose at normal levels. Care for the client following adrenalectomy is similar to that for any abdominal operation. ◦ Option B: The client is encouraged to change position, cough, and deep breathe to prevent postoperative complications such as pneumonia or thrombophlebitis. Most patients will be able to eat, drink, and walk around normally the day after surgery. If the client has open adrenalectomy, they might have to wait longer to resume eating, drinking, and moving around normally. To prevent blood clots from forming, they’ll be encouraged to walk around as soon as it is safe to do so. ◦ Option C: Maintenance doses of hydrocortisone will be administered IV until the client is able to take it by mouth and will be necessary for six months to two years or until the remaining gland recovers. The patients who have undergone unilateral adrenalectomy become steroid-dependent. Therefore, sufficient replacement of glucocorticoid is needed during the postoperative period. ◦ Option D: The client undergoing adrenalectomy is at increased risk for infection and delayed wound healing and will need to learn about wound care, but not at this time while he is in the ICU. A clinical practice guideline stated that glucocorticoid replacement after surgery is required until the HPA axis recovers and the mean period of replacement is eighteen months after unilateral adrenalectomy. 1. Question 21 of 50 21. Question Corinne is experiencing diarrhea after consuming her prescribed antibiotics for the whole week. This is because: ◦ A. The drugs render food indigestible. ◦ B. Gastric flora is disturbed. ◦ C. Fluid is added into the intestine. ◦ D. Normal intestinal bacteria are destroyed. Correct Answer: D. Normal intestinal bacteria are destroyed. The destruction of normal intestinal flora causes diarrhea. Bacteria in the gut, for example, help break down food. Antibiotics kill these “good” microbes along with bacteria that are causing an infection. This upsets the balance of the normal flora in the intestines. The result is often loose, watery stools known as antibiotic-associated diarrhea. ◦ Option A: A drug that rendered food indigestible could not be given because it would cause severe malnutrition. Thousands of species of bacteria, yeast, and other microorganisms live on our skin, in our intestines, and on other body surfaces. They’re known as our “normal flora.” When it is in balance, these microbes stay put and many of them contribute to good health. Bacteria in the gut, for example, help break down food. ◦ Option B: This is incorrect because there is no gastric flora. About one in three people who take antibiotics develop diarrhea. The symptoms usually start on the last day or two of antibiotic therapy, or a day or so after it has ended. The diarrhea is usually mild, with two to four loose stools lasting for a couple days. In most cases, it gets better quickly without treatment. That said, antibiotic-associated diarrhea makes some people very sick. The most severe form, called C. difficile colitis, can be life-threatening. ◦ Option C: There is no way to add fluid into the intestine. Almost all antibiotics, particularly those that act on anaerobes, can cause diarrhea, but the risk is higher with aminopenicillins, a combination of aminopenicillins and clavulanate, cephalosporins, and clindamycin.1,4,5 Host factors for antibiotic-associated diarrhea include age over 65, immunosuppression, being in an intensive care unit, and prolonged hospitalization. 1. Question 22 of 50 22. Question When a client with chronic obstructive pulmonary disease is taking theophylline also receives ciprofloxacin (Cipro), which of the following interactions would occur? ◦ A. Cipro Toxicity ◦ B. Ineffectiveness of ciprofloxacin ◦ C. Theophylline toxicity ◦ D. Ineffective theophylline Correct Answer: C. Theophylline toxicity Theophylline toxicity may occur because the action of theophylline is increased when given with Ciprofloxacin. Theophylline has an extremely narrow therapeutic window. Theophylline toxicity occurs when serum theophylline levels surpass the levels in the therapeutic range. This can occur by intentional overdose or unintentionally when metabolism and/or clearance of theophylline is altered due to certain physiological stressors. ◦ Option A: There is no such thing as Cipro toxicity. Toxic doses of theophylline can be as low as 7.5 mg/kg. When taken orally, 80% to 100% of theophylline is absorbed in the gastrointestinal tract. Peak serum levels can occur from 30 to 120 minutes for immediate release formulations. Sustained-release formulations have peak levels between 6 and 10 hours. ◦ Option B: One mechanism is that theophylline blocks adenosine receptors, which has both therapeutic and toxic effects such as bronchodilation, tachycardia, cardiac arrhythmias, seizures, and cerebral vasoconstriction. At larger doses, theophylline inhibits phosphodiesterase causing increased cyclic adenosine monophosphate resulting in increased levels of adrenergic activation and catecholamine release. ◦ Option D: In theophylline toxicity, epinephrine levels can be 4- to 8-times higher than normal, and norepinephrine concentrations can be 4- to 10-times higher than normal. Increased catecholamine concentrations have a variety of adverse effects such as cardiac arrhythmias, metabolic acidosis, hyperglycemia, and hypokalemia. Chronic theophylline toxicity can occur when there is an accumulation of the drug due to metabolism being overwhelmed or inhibited. It can also occur when clearance is decreased. 1. Question 23 of 50 23. Question The client at highest risk for nephrotoxicity with aminoglycoside use is a: ◦ A. Male with a creatinine of 1.7 and BUN of 52 on a 10-day regimen. ◦ B. Female with BUN of 12 and creatinine of 0.8. ◦ C. Female with past history of cystitis on 5 days of therapy. ◦ D. Male with history of kidney stones on 8 days of therapy. Correct Answer: A. Male with a creatinine of 1.7 and BUN of 52 on a 10-day regimen Aminoglycosides preferentially affect the proximal tubular cells. These agents are freely filtered by the glomeruli and quickly taken up by the proximal tubular epithelial cells, where they are incorporated into lysosomes after first interacting with phospholipids on the brush border membranes. They exert their main toxic effect within the tubular cell by altering phospholipid metabolism. In addition to their direct effect on cells, aminoglycosides cause renal vasoconstriction. ◦ Option B: A 24-year-old woman with a normal BUN and creatinine would not be at higher risk than others when given aminoglycosides. ◦ Option C: Recurrent cystitis on limited-time therapy does not present a high risk for nephrotoxicity. ◦ Option D: A history of kidney stones on limited-time therapy does not present a high risk for nephrotoxicity. 1. Question 24 of 50 24. Question When assessing clients for evidence of a penicillin allergy, which of the following symptoms may not be considered to be a true hypersensitivity reaction? ◦ A. Wheezing ◦ B. Nausea ◦ C. Urticaria ◦ D. Angioneurotic edema Correct Answer: B. Nausea GI disturbances such as nausea are usually caused by direct irritation or overgrowth of gram-positive bacteria or yeasts and are not indicative of a true penicillin allergy. Anaphylaxis, characterized by symptomatic hypotension with associated dyspnoea, urticaria, and possibly gastrointestinal (GI) symptoms, is the most severe manifestation of IgE-mediated drug allergy. It is most common after parenteral drug administration and is rare with oral or cutaneous exposure. ◦ Option A: Anaphylaxis results when antigen-specific IgE is present on mast cells and systemic exposure to antigen occurs, cross-linking the IgE. This results in the simultaneous degranulation of large numbers of mast cells. ◦ Option C: Mast cells contain histamine and other vasoactive mediators. Their sudden release, due to either an IgE-mediated anaphylactic reaction or a similar non-IgE-mediated reaction (referred to as an “anaphylactic” reaction), results in a sudden drop in blood pressure and blood volume, flushing, itching, and potentially respiratory compromise, bowel edema, and potential death ◦ Option D: If a patient has exhibited signs of a true allergic reaction, re-exposure to penicillin or related antibiotics can trigger life-threatening anaphylaxis. It has been estimated that up to 60% of penicillin-allergic patients will experience another allergic event if given the drug again. However, new data suggest that this rate is less than 2%. 1. Question 25 of 50 25. Question All of the following symptoms are evidence of a superinfection except: ◦ A. White oral plaques ◦ B. Creamy vaginal discharge ◦ C. Skin rash ◦ D. Darkened tongue Correct Answer: C. Skin rash Skin rashes are indicative of hypersensitivity reactions in clients on penicillin therapy. True penicillin allergy is rare with the estimated frequency of anaphylaxis at 1-5 per 10 000 cases of penicillin therapy. Hypersensitivity is, however, its most important adverse reaction resulting in nausea, vomiting, pruritus, urticaria, wheezing, laryngeal edema, and ultimately, cardiovascular collapse. ◦ Option A: The antibiotic most frequently related to superinfection was ciprofloxacin (38.1%), followed by cefotaxime (23.3%), imipenem (12%), meropenem (10.2%), and cefepime (6.1%). The lowest percentage of superinfection was observed with the use of piperacillin-tazobactam (5.4%). ◦ Option B: A superinfection develops when the antibacterial intended for the preexisting infection kills the protective microbiota, allowing another pathogen resistant to the antibacterial to proliferate and cause a secondary infection ◦ Option D: Peri-implant superinfections are a major risk associated with broad-spectrum antibiotics in immunocompetent individuals. Lack of follow-up and antibiotic susceptibility testing and indiscriminate empiric treatment regimens may lead to ongoing microbial challenge that exacerbates and maintains the disease progression. 1. Question 26 of 50 26. Question Which of the following statements is true when educating clients about penicillin therapy? ◦ A. The client must take the medication at evenly spaced intervals. ◦ B. The client may save leftover medication for a future illness. ◦ C. If signs of an allergic reaction, continue the medication and notify the physician. ◦ D. Clients taking oral contraceptives must be cautioned to use an alternate form of birth control while being treated with penicillin. Correct Answer: D. Clients taking oral contraceptives must be cautioned to use an alternate form of birth control while being treated with penicillin. Penicillin will reduce the effectiveness of birth control pills. Numerous antibiotics have been implicated in causing oral contraceptive failure by means of interfering with the enterohepatic recirculation of ethinylestradiol. The two groups of antibiotics most commonly involved in contraceptive failures are tetracyclines and penicillins, namely ampicillin. ◦ Option A: The safety of penicillin and penicillin derivatives when administered either intramuscularly, intravenously, or orally for extended periods of time (beyond the usual duration of use) can be extrapolated from multiple published studies. A review of the medical literature reveals studies in which such drugs have been used therapeutically for extended treatment durations. This includes studies of the treatment of recurrent acute otitis media, endocarditis, salmonella infections, prophylaxis of at-risk populations (asplenic children, young children with sickle cell disease, patients with prior rheumatic fever), and the long term treatment of certain types of Lyme disease. ◦ Option B: 159 patients were treated with 200,000 units orally BID, 143 were treated with 200,000 units orally BID-TID, and 9 patients were treated with an unspecified dose. In these studies, the safety and tolerability of the regimen is summarized by such descriptions as the treatment was “generally well tolerated.” There were no reports in any of these studies of adverse events including serious adverse events or adverse events requiring treatment. ◦ Option C: Although there are no specific studies that directly assess the safety of these antibiotics when given over an extended period of time, there is a significant amount of information that supports the safety of such therapy. Despite very wide usage for many years, no reports were found in the literature which described specific adverse events related to long term use of penicillin or amoxicillin. 1. Question 27 of 50 27. Question Antonietta is taking antitubercular, the most common adverse effect she may be experiencing is: ◦ A. Red-orange discoloration of urine ◦ B. Hypersensitivity ◦ C. Hepatotoxicity ◦ D. CHF Incorrect Correct Answer: C. Hepatotoxicity Hepatotoxicity is the most common side effect associated with antitubercular agents. All first-line antitubercular medications, rifampin, isoniazid, pyrazinamide, and ethambutol can exert hepatotoxic effects. A continual rise in liver functions test should prompt discontinuation of treatment. Liver function tests should be monitored routinely as rifampin, isoniazid, pyrazinamide, and ethambutol all may exert hepatotoxic effects. ◦ Option A: Orange discoloration is a side effect of rifampin but not with antitubercular in general. Distribution of the drug is high throughout the body, and reaches effective concentrations in many organs and body fluids, including the cerebrospinal fluid. Since the substance itself is red, this high distribution is the reason for the orange-red color of the saliva, tears, sweat, urine, and feces. ◦ Option B: Adverse drug reaction to tuberculous chemotherapy is not an uncommon problem. Usually, it occurs with single drugs and can be treated easily with minimal intervention. Immediate-type allergic reactions from antituberculosis drugs are not rare and not related to disease or treatment characteristics. ◦ Option D: Aminoglycoside induced nephrotoxicity is reversible when stopping the medication. Renal toxicity depends on the patient if any underlying renal disease is present, and on the dose of the medication being administered. Renal insufficiency is avoidable in most patients. 1. Question 28 of 50 28. Question In treatment of tuberculosis, the therapeutic rationale for combination drug therapy is to: ◦ A. Decrease cost and improve compliance. ◦ B. Reduce the incidence of cumulative effects. ◦ C. Increase blood dyscrasias. ◦ D. Decrease emergence of drug-resistance strains. Correct Answer: D. Decrease emergence of drug-resistance restraints. Combination therapy helps decrease the emergence of drug-resistant strains. One major benefit of combination therapies is that they reduce the development of drug resistance since a pathogen or tumor is less likely to have resistance to multiple drugs simultaneously. ◦ Option A: Multiple drugs usually increase cost and reduce compliance. Combination therapy may seem costlier than monotherapy in the short term, but when it is used appropriately, it causes significant savings: lower treatment failure rate, lower case-fatality ratios, fewer side-effects than monotherapy, slower development of resistance, and thus less money needed for the development of new drugs. ◦ Option B: Multiple drugs increase cumulative effects. In the case of a drug that is effective against actively multiplying mycobacteria, this would be advantageous because the drug would continually be available for prolonged periods at the site in the event the organism underwent any multiplication cycle. Microsphere technology has the capability of accomplishing these goals by achieving intracellular delivery of antimycobacterial drugs and allowing programmed controlled release over a prolonged period ◦ Option C: Blood dyscrasias would be an untoward effect not the desired effect. Nausea, diarrhea, and loss of appetite are very common adverse effects, they usually pass after a few weeks as TB medication is continued. Strong and continuous nausea can be treated with medicines. 1. Question 29 of 50 29. Question Changes in visual acuity and color perception are associated with treatment by which of the following agents? ◦ A. INH (isoniazid) ◦ B. PZA (pyrazinamide) ◦ C. ETH (ethambutol) ◦ D. SM (streptomycin) Correct Answer: C. ETH (ethambutol) Ethambutol will cause changes in visual acuity and color perception. Remember “E” for ethambutol and eyes. However, there are reports of cases of irreversible blindness. Due to the adverse effect of ethambutol associated optic neuropathy, visual acuity testings such as a baseline visual acuity, color vision, and a Humphrey visual field (HVF), should be performed when administering EMB treatment and periodically during the regimen. ◦ Option A: Peripheral neuropathy is a side effect associated with INH. Peripheral neuropathy is also a commonly-associated adverse event of isoniazid therapy, although its incidence is less than 0.2%. In all adults preparing to begin isoniazid treatment, the clinician should order baseline measurements of aspartate aminotransferase (AST), alanine aminotransferase (ALT), bilirubin, alkaline phosphatase, serum creatinine, and platelet count. ◦ Option B: Gout is a side effect associated with pyrazinamide. Pyrazinamide can increase uric acid concentrations and precipitate acute gout flare-ups in predisposed individuals. The recommendation is to monitor uric acid concentrations routinely for patients managed with pyrazinamide. ◦ Option D: Ototoxicity may occur with streptomycin. Monitoring is based on the limited therapeutic index of aminoglycosides and known toxicities, particularly nephrotoxicity and ototoxicity. In general, clinicians should avoid concomitant use of additional medications with possible ototoxic or nephrotoxic effects. Ototoxicity and vestibular impairment are often thought to be the hallmark of streptomycin toxicity. In extreme cases, deafness may occur due to ototoxicity, thus caution must be exercised when combining streptomycin with other potentially ototoxic drugs. Vestibular impairment usually manifests during the course of treatment and is typically permanent. 1. Question 30 of 50 30. Question Which of the following groups of antitubercular agents includes first-line agents? ◦ A. INH, PZA, RIF ◦ B. SM, PAS, INH ◦ C. EMB, PAS, INH ◦ D. INH, cycloserine, RIF Correct Answer: A. INH, PZA, RIF INH, PZA, and RIF are used as combination first-line agents. Antitubercular medications: rifampin, isoniazid, pyrazinamide, and ethambutol are FDA approved for the treatment of Mycobacterium tuberculosis infections. The combination and duration on which medications to use for therapy rely on whether the patient has an active or latent disease. ◦ Option B: Rifampin exerts its effects by reversibly inhibiting DNA-dependent RNA polymerase, which further inhibits bacterial protein synthesis and transcription. Isoniazid is a pro-drug that is converted to its active form metabolite by catalase-peroxidase and exerts its action by further inhibiting the biosynthesis of mycolic acid. Pyrazinamide’s mechanism of action remains unknown and not fully understood. Pyrazinamide is converted to its active form pyrazinoic acid and exerts its effect by inhibiting trans-translation and possibly coenzyme A synthesis needed for the bacteria to survive. ◦ Option C: Ethambutol inhibits the enzyme arabinosyl transferases and prevents the biosynthesis of the mycobacterial cell wall. Aminoglycosides exert their action by binding to the 30S subunit of ribosomes and inhibiting the protein synthesis of the mycobacteria. Fluoroquinolones exert their effects by inhibiting DNA gyrase and topoisomerase IV, further inhibiting DNA synthesis within the bacteria. ◦ Option D: During active disease, there are two phases for treatment: the initiation phase and the continuation phase. The initiation phase consists of two months of rifampin, isoniazid, pyrazinamide, and ethambutol therapy. This regimen is administered orally daily for eight weeks for a total of 56 doses. Once completed, isoniazid and rifampin are continued for an additional four-month for the continuation phase. This regimen is administered orally daily for 18 weeks for a total of 126 doses. For patients that cannot tolerate ethambutol, streptomycin can be substituted. 1. Question 31 of 50 31. Question Antitubercular therapy may be determined ineffective when: ◦ A. Sputums are negative ◦ B. Symptoms resolve ◦ C. Hepatitis results ◦ D. Drug-resistant bacteria emerge Correct Answer: D. Drug-resistant bacteria emerge. The emergence of drug-resistant bacteria indicates that antitubercular therapy is ineffective because the drug(s) are no longer ending bacterial multiplication. A feared complication of tuberculosis therapy is multi-drug-resistant tuberculosis(MDR-TB). MDR-TB is distinguished from its resistance to first-line medications isoniazid and rifampin. Therapy for MDR-TB is steadily advancing, and suggestions are continually changing. ◦ Option A: A negative sputum is the desired effect. Second-line drugs that are in common use for MDR-TB are kanamycin, capreomycin, and amikacin via injections. Fluoroquinolones such as levofloxacin, moxifloxacin, and gatifloxacin and are also amongst the common second-line agents used when drug resistance develops to the first-line agents. ◦ Option B: Resolved symptoms is the desired effect of the therapy. Drugs that have recently received FDA approval for the multi-drug resistant TB are pretomanid, used in sequence with bedaquiline, and linezolid. ◦ Option C: Liver function tests should be monitored routinely as rifampin, isoniazid, pyrazinamide, and ethambutol all may exert hepatotoxic effects. All first-line antitubercular medications, rifampin, isoniazid, pyrazinamide, and ethambutol can exert hepatotoxic effects. A continual rise in liver functions test should prompt discontinuation of treatment. 1. Question 32 of 50 32. Question Fluconazole (Diflucan) can be administered to a client with: ◦ A. Pneumococcal meningitis ◦ B. Oral thrush ◦ C. Cryptococcal meningitis ◦ D. Pneumococcal pneumonia Correct Answer: C. Cryptococcal meningitis Fluconazole (Diflucan) is a drug given for the treatment of cryptococcal meningitis. The combination of amphotericin B and flucytosine has proved the most effective measure to clear the infection, and it showed a greater survival benefit over amphotericin alone. However, due to its cost, flucytosine is often unavailable in poor-resource settings where the disease burden is significant. A and D are incorrect because pneumococcal meningitis and pneumonia are not caused by fungal infections. ◦ Option A: Antibiotics and supportive care are critical in all cases of bacterial meningitis. The type of antibiotic is based on the presumed organism causing the infection. The clinician must take into account patient demographics and past medical history in order to provide the best antimicrobial coverage. ◦ Option B: Oral thrush is treated with a more mild antifungal, such as nystatin. Oral candidiasis or thrush is an infection of the oral cavity by Candida albicans. It was first described in 1838 by pediatrician Francois Veilleux. Oral candidiasis is generally obtained secondary to immune suppression, whether a patient’s oral cavity has decreased immune function or if it is systemic. ◦ Option D: Antibiotic treatment for invasive pneumococcal infections typically includes ‘broad-spectrum’ antibiotics until results of antibiotic sensitivity testing are available. Broad-spectrum antibiotics work against a wide range of bacteria. Once the sensitivity of the bacteria is known, a more targeted (or ‘narrow-spectrum’) antibiotic may be selected. 1. Question 33 of 50 33. Question When administering amphotericin B, which of the following must be used? Correct Answer: B. A diluent of 5% dextrose with no preservatives Amphotericin B must be mixed with a solution with no preservatives. Amphotericin B is amphoteric (can act as both an acid and a base) and virtually water-insoluble. It is not absorbable via oral or intramuscular administration. ◦ Option A: The solution is sensitive to light but does not require the infusion to be covered. Amphotericin B acts by binding to ergosterol in the cell membrane of most fungi. After binding with ergosterol, it causes the formation of ion channels leading to loss of protons and monovalent cations, which results in depolarization and concentration-dependent cell killing. ◦ Option C: Amphotericin B, which is more commonly administered in a liposomal formulation and exhibits increased tolerability and a reduced toxicity profile. These lipid formulations permit a higher daily dose, provide better delivery to organs within the reticuloendothelial system such as the lungs, liver, and spleen, have similar efficacy when compared to conventional amphotericin B, and are less nephrotoxic. ◦ Option D: A micron filter should not be used; if unavoidable, it must be less than 1 ?. Additionally, amphotericin B also produces oxidative damage to the cells with the formation of free radicals and subsequently increased membrane permeability. Additionally, amphotericin B has a stimulatory effect on phagocytic cells, which assists in fungal infection clearance. 1. Question 34 of 50 34. Question Which of the following nursing diagnoses might occur when administering large parenteral doses of amphotericin B with vancomycin (Vancocin)? ◦ A. Decreased cardiac output ◦ B. Ineffective airway clearance ◦ C. Ineffective breathing pattern ◦ D. Fluid volume excess Correct Answer: D. Fluid volume excess These two drugs are both nephrotoxic, so this nursing diagnosis may result from renal problems. Renal toxicity correlates with conventional amphotericin B use and can lead to renal failure and requirement for dialysis. But the azotemia often stabilizes with therapy and renal damage is reversible after discontinuation of amphotericin B. Avoiding concomitant use of other nephrotoxic agents, and appropriate hydration with normal saline may significantly decrease the likelihood and severity of azotemia associated with amphotericin B. ◦ Option A: Amphotericin exhibits infusion-related toxicity, which accounts for its extended administration times. Infuse slowly over 3 hours; rapid infusion can cause cardiotoxicity. Other potential uncommon side effects include demyelinating encephalopathy in patients with bone marrow transplants with total body irradiation or who are receiving cyclosporine. ◦ Option B: Monitoring is a recommendation to evaluate for the presence of side effects. Initially, a daily electrolyte panel, including potassium and magnesium concentrations until the dose increases to its therapeutic level, and after that, weekly electrolyte concentrations are sufficient. ◦ Option C: The monitoring of amphotericin B concentrations in the serum or CSF is of little value because the relationships between plasma and tissue concentrations and clinical efficacy or toxicity have not had adequate research performed. 1. Question 35 of 50 35. Question Arvic, a 16-year-old student, has acquired systemic fungal infection, he should be treated with: ◦ A. Amphotericin B (Fungizone) ◦ B. Miconazole (Monistat IV) ◦ C. Ketoconazole (Nizoral) ◦ D. Griseofulvin (Fulvicin) Correct Answer: A. Amphotericin B (Fungizone) Serious life-threatening fungal infections are treated with amphotericin B. Amphotericin B deoxycholate belongs to the polyene class of antifungals. It is also known by the name conventional amphotericin B and has been in use for the treatment of invasive fungal infections for more than 50 years. It was first isolated as a natural product of a soil actinomycete. ◦ Option B: Topical miconazole is approved to treat cutaneous and mucocutaneous mycoses, particularly vulvovaginal candidiasis. Oral formulations of miconazole are indicated for oropharyngeal candidiasis. ◦ Option C: Ketoconazole, when applied topically, has been approved for treating tinea corporis, tinea cruris, tinea pedis, tinea versicolor, cutaneous candidiasis, and seborrheic dermatitis. Off-label, topical ketoconazole is used to treat several oral candidal pathologies, including chronic mucocutaneous candidiasis and oral thrush. ◦ Option D: Griseofulvin is only approved as a systemic (oral) agent and is indicated for the treatment of dermatophytoses of the skin, hair, and nails, which is severe or refractory to topical therapy. Specifically, this drug treats tinea (corporis, pedis, cruris, barbae, capitis, and unguium). 1. Question 36 of 50 36. Question Which of the following must always be present before beginning antifungal therapy? ◦ A. Coagulation profile ◦ B. Confirmed diagnosis ◦ C. Biopsy of the infected site ◦ D. Urinalysis Correct Answer: B. Confirmed diagnosis The diagnosis of fungal infection, as opposed to infection caused by virus or bacteria, is necessary before beginning therapy with antifungal agents. Clinically, fungal infections are best categorized first according to the site and extent of the infection, then the route of acquisition, and finally, the virulence of the causative organism. These classifications are essential when determining the most effective treatment regimen for a particular mycosis. ◦ Option A: Mycoses classify as local (superficial, cutaneous, subcutaneous) or systemic (deep, bloodborne). The acquisition of the fungal infection is either an exogenous (airborne/inhalation, cutaneous exposure, percutaneous inoculation) or endogenous process (normal flora or reactivated infection). ◦ Option C: The virulence of the organism classified as either a primary infection (disease arising in a healthy host), or opportunistic infection (disease arising in human hosts that have a compromised immune system, or other defenses). ◦ Option D: Polyene antifungals (e.g., amphotericin B) bind to ergosterol, a steroid-alcohol unique to Fungi. The polyene-ergosterol complex creates pores in the fungal cell membrane, ultimately leading to electrolyte leakage, cell lysis, and cell death. 1. Question 37 of 50 37. Question Which choice describes the action of nucleoside analogs? ◦ A. Exert anti-HIV activity at the reverse transcriptase level and cause premature termination of viral DNA chain synthesis. ◦ B. Completely stop the replication of HIV virus. ◦ C. Allow for a patient to become non-contagious after taking for at least 3 days. ◦ D. Are all equally effective and free of side effects. Correct Answer: A. Exert anti-HIV activity at the reverse transcriptase level and cause premature termination of viral DNA chain synthesis This choice correctly describes the action of nucleoside analogs. The nucleoside/nucleotide reverse transcriptase inhibitors (NRTIs) were the first class of antiretroviral drugs to be approved by the FDA. NRTIs are taken as prodrugs and must be taken into the host cell and phosphorylated before they become active. Once inside the host cell, cellular kinases will activate the drug. The drug exerts its effect through its structure. ◦ Option B: NRTIs lack a 3’-hydroxyl group at the 2’-deoxyribosyl moiety and will have either a nucleoside or nucleotide as a base. Due to the missing 3’hydroxyl group, the NRTI prevents the formation of a 3’-5’-phosphodiester bond in growing DNA chains and can thus prevent replication of the virus. ◦ Option C: An interesting feature of these drugs is that their incorporation during RNA-dependent DNA or DNA-dependent DNA synthesis, which inhibits the production of either positive or negative strands of the DNA. ◦ Option D: Currently, research and trials are underway to assess the efficacy in the use of reverse transcriptase inhibitors for pre-exposure prophylaxis. Studies show that there is anywhere from a 67% to 75% reduction in the risk of becoming infected through the use of pre-exposure prophylaxis. 1. Question 38 of 50 38. Question Which of the following is true about protease inhibitors? ◦ A. Work better when used alone. ◦ B. Are the same as nucleoside analogs. ◦ C. Affect replication of HIV at different stages than nucleoside analogs. ◦ D. Have a high level of toxicity. Correct Answer: C. Affect replication of HIV at different stages than nucleoside analogs. Protease inhibitors cleave the viral polyprotein precursors that are essential for the maturation of infectious viruses. IV-1 protease causes cleavage of protein precursors generating new viral particles. Protease inhibitors disrupt this cleavage process, hence interrupting the production of new viral particles. ◦ Option A: Protease inhibitors work best when used in combination with other drugs. Lopinavir/ritonavir, in combination with other standard ARV medications, has provided significant virological suppression and better immune outcomes in both treatment-naive and treatment-experienced patients. ◦ Option B: Nucleosides interfere with the replication of HIV by inhibiting reverse transcriptase. The nucleoside/nucleotide reverse transcriptase inhibitors (NRTIs) were the first class of antiretroviral drugs to be approved by the FDA. NRTIs are taken as prodrugs and must be taken into the host cell and phosphorylated before they become active. Once inside the host cell, cellular kinases will activate the drug. The drug exerts its effect through its structure. ◦ Option D: Because there is a small quantity of ritonavir in combination with lopinavir/ritonavir, there are few reports of ritonavir toxicity. However, there have been a few case reports suggesting retinal toxicity secondary to ritonavir. One such case showed an improvement after discontinuing ritonavir after 2 and 4 weeks. 1. Question 39 of 50 39. Question The human cells specifically affected by HIV are: ◦ A. Gonocytes ◦ B. CD4+ T lymphocytes ◦ C. Islet cells ◦ D. Red blood cells Correct Answer: B. CD4+ T lymphocytes HIV directly infects CD4+ T lymphocytes. HIV is a retrovirus that attacks CD4 T lymphocytes eventually leading to the death of these cells and severe immunodeficiency of the individual who has acquired the infection. Once the CD4 count becomes too low, host immune defenses cannot fend off opportunistic infections and malignancies. ◦ Option A: The presence of a CD4 count of less than 200 or an AIDS-defining illness in a patient with HIV is the criteria for a diagnosis of AIDS. Treatment of AIDS is focused on opportunistic illness or condition and decreasing the HIV viral load and monitoring for an increase in CD4 cells through antiretroviral therapy (ART.) ◦ Option C: HIV is a retrovirus, with two subtypes: HIV-1 and HIV-2. The HIV-1 subtype is the most common and responsible for AIDS throughout most of the world. HIV-2 is found primarily in Western Africa and is much less common. ◦ Option D: The number of CD4 cells within the affected individual will fall by approximately 50-80 cells/uL per year without the initiation of ART, and the decline may be even faster once the count falls below 200 cells/uL. 1. Question 40 of 50 40. Question Which of the following statements is true about monotherapy for treatment of HIV disease? ◦ A. It is the only FDA-approved treatment for HIV disease. ◦ B. It is able to effectively destroy all viral particles of HIV. ◦ C. It interferes with the replication of HIV virus without causing any side effects. ◦ D. It appears to cause rapid resistance. Correct Answer: D. It appears to cause rapid resistance. With monotherapy, resistance can emerge within a few months. Antiretrovirals are drugs used to treat HIV infections/AIDS, and they are used in various combinations, commonly referred to as highly active antiretroviral therapy (HAART). The antiretrovirals agent include nucleoside/nucleotide reverse transcriptase inhibitors (NRTIs), NRTI fixed-dose combinations, integrase inhibitors, non-nucleoside reverse transcriptase inhibitors (NNRTIs), protease inhibitors, and CCR5 inhibitors. ◦ Option A: HIV antiretroviral therapy should always be done with combination regimens. Initial treatment usually consists of two NRTIs (usually abacavir/lamivudine or tenofovir/emtricitabine) in combination with a third antiviral drug from one of the following classes: integrase inhibitor, NNRTI or protease inhibitor plus an enhancer (cobicistat or ritonavir). ◦ Option B: All patients with HIV, regardless of what level of CD4, should be started on HAART, which is a treatment for life. This therapy has been shown to reduce morbidity and mortality and lower the risk of transmitting the infection to others, as long as they have a low or undetectable viral load. ◦ Option C: Based on recent multicenter-multinational randomized controlled trials the latest guidelines indicate that HIV antiretroviral therapy should be initiated early in the disease process regardless of CD4 cell count in all adult and adolescent patients. This strategy has been shown to decrease morbidity and mortality related to HIV infection as well as HIV transmission. 1. Question 41 of 50 41. Question Which of the following statements is true about combination therapy for the treatment of HIV disease? ◦ A. It completely shuts off replication of HIV. ◦ B. Is the only FDA-approved treatment for HIV disease. ◦ C. It appears to cause a sustained benefit achieved by drug no. 1 preventing the emergence of resistance to drug no. 2 despite resistance to drug no. 1. ◦ D. It is only effective if used alternating with periods of monotherapy. Correct Answer: C. It appears to cause a sustained benefit achieved by drug no. 1 preventing the emergence of resistance to drug no. 2 despite resistance to drug no. 1 Combination therapy is superior to monotherapy at this time for reasons described in this choice. This form of therapy is recommended for all patients with HIV by the Department of Health and Human Services (DHHS) and the World Health Organization (WHO). This daily treatment of multiple HIV medications is an HIV regimen. ◦ Option A: A typical initial HIV regimen includes three HIV medications from a minimum of two drug classes. Although this treatment is not curative, it can provide longer lives for patients and reduce HIV transmission. This reduction of transmission has become a popular use of antiretroviral therapy for individuals who are HIV-positive and are with an HIV-negative partner. ◦ Option B: The FDA does not approve of investigational HIV drugs. Investigational drugs include those used to treat or prevent HIV and vaccines to treat or prevent HIV. These drugs are only available in clinical trials. No vaccines exist yet; however, researchers are studying this possibility. ◦ Option D: The successes of antiretroviral therapy have reduced HIV to a chronic condition in many parts of the world as progression to AIDS has become rare. Studies have found that 3-drug therapy has led to a 60% to 80% decline in rates of AIDs, hospitalization, and death. By 2030 the CDC plans to implement a 90-90-90 plan (90% HIV diagnosed, 90% on therapy, and 90% suppressed). 1. Question 42 of 50 42. Question When administering topical ophthalmic preparations, the nurse must assess: ◦ A. Visual acuity ◦ B. Intraocular movements ◦ C. Color of the sclera ◦ D. Blinking reflex Correct Answer: A. Visual acuity The nurse must assess visual acuity, extraocular eye movements, tearing, and discharge when administering topical eye medications. Topical ophthalmic medications are widely prescribed by growing numbers of eye-care professionals. Increasingly, these agents are being prescribed by optometrists and ophthalmic-trained nurses in addition to ophthalmologists and general practitioners. As the number and variety of topical agents on the market rises, and as the number of clinicians involved in prescribing those agents increases; the risk of systemic adverse effects will also increase. ◦ Option B: It is the elderly population who are at the greatest risk of experiencing systemic adverse effects of topical agents. Chronic ophthalmic diseases, and hence long term ophthalmic drop treatments, are more prevalent among older people. Such individuals are also likely to have other medical conditions (e.g. cardiac, respiratory, or neurological disease) that may be induced or exacerbated by topical ophthalmic agents. Moreover, polypharmacy is common in elderly people, and this is associated with an increased risk of drug interactions. ◦ Option C: To apply the eye ointment, wash hands first. To avoid contamination, be careful not to touch the tube tip or let it touch the eye or any other surface. Tilt the head back, look upward, and pull down the lower eyelid to make a pouch. ◦ Option D: If using another kind of eye medication (e.g., drops or ointments), apply the eye drops first and wait at least 5 minutes before applying this eye ointment. Use eye drops before eye ointments to allow the eye drops to enter the eye. If using another type of eye ointment, wait at least 10 minutes after using this medication before applying it. 1. Question 43 of 50 43. Question Which of the following drugs might be given to relieve pain from corneal abrasions? ◦ A. Proparacaine hydrochloride (Alcaine) ◦ B. Timolol maleate (Timoptic) ◦ C. Betaxolol hydrochloride (Betoptic) ◦ D. Levobunolol hydrochloride (Betagan) Correct Answer: A. Proparacaine hydrochloride (Alcaine) This is the only drug listed that is an anesthetic eye preparation. ALCAINE (proparacaine hydrochloride ophthalmic solution) (Proparacaine Hydrochloride) Ophthalmic Solution is indicated for topical anesthesia in ophthalmic practice. Representative ophthalmic procedures in which the preparation provides good local anesthesia include measurement of intraocular pressure (tonometry), removal of foreign bodies and sutures from the cornea, conjunctival scraping in diagnosis and gonioscopic examination; it is also indicated for use as a topical anesthetic prior to surgical operations such as cataract extraction. ◦ Option B: Ophthalmic timolol is used to treat glaucoma, a condition in which increased pressure in the eye can lead to the gradual loss of vision. Timolol is in a class of medications called beta-blockers. It works by decreasing the pressure in the eye. Timolol eye drops and gel-forming solution control glaucoma but do not cure it. Continue to use timolol even if you feel well. Do not stop using the medication without talking to a doctor. ◦ Option C: Ophthalmic betaxolol is used to treat glaucoma, a condition in which increased pressure in the eye can lead to the gradual loss of vision. Betaxolol is in a class of medications called beta-blockers. It works by decreasing the pressure in the eye. ◦ Option D: Ophthalmic levobunolol is used to treat glaucoma, a condition in which increased pressure in the eye can lead to a gradual loss of vision. Levobunolol is in a class of medications called beta-blockers. It works by decreasing the pressure in the eye. 1. Question 44 of 50 44. Question Drugs that lower intraocular pressure work by increasing: ◦ A. The flow of aqueous humor through the anterior chamber. ◦ B. Fluid volume in the eye's anterior chamber. ◦ C. Pressure in the eye chambers. ◦ D. Diameter of the eye chambers. Correct Answer: A. The flow of aqueous humor through the anterior chamber. Drugs that lower intraocular pressure increases the flow of aqueous humor through the eye’s anterior chamber. The goal of glaucoma treatment is to improve quality of life through the reduction of IOP to preserve visual function. In the process of IOP reduction, an ideal medication should have a schedule that is simple to follow, be least interrupting with a patient’s life, highly tolerable, and affordable. ◦ Option B: The primary mechanism of action of prostaglandins is believed to reduce IOP by increasing uveoscleral outflow. This is in contrast to other classes of antiglaucoma medications, which act by increasing aqueous humor outflow via the trabecular meshwork or by inhibiting aqueous production. ◦ Option C: There is some evidence suggesting that long-term therapy with bimatoprost increases both pressure-dependent trabecular outflow and pressure-independent uveoscleral outflow via remodeling of extracellular matrix in the trabecular meshwork and ciliary muscle, respectively. ◦ Option D: Systemic adverse events reported after treatment with bimatoprost 0.03% have included colds and upper respiratory tract infections occurring in approximately 10% of patients, and headaches, abnormal liver function tests, asthenia, and hirsutism. Bimatoprost 0.03% did not have any clinically significant effect on heart rate or blood pressure in patients with glaucoma or ocular hypertension in clinical trials. 1. Question 45 of 50 45. Question When administering otic preparations, the nurse should observe the tympanic membrane for: ◦ A. Erythema ◦ B. Perforation ◦ C. Fluid ◦ D. All of the above Correct Answer: D. All of the above The nurse should assess all of these parameters when administering otic preparations. When a patient is seen in the clinic setting, the healthcare provider may be responsible for examining the outer structures of the ear (i.e., the earlobe and the skin around the ear) as part of the intake procedure. Be sure to document a description of any drainage or visible wax. Before prescribing an otic preparation, the primary health care provider examines the ear’s external and internal structures. ◦ Option A: Assess the patient’s response to therapy. For example, a decrease in pain or inflammation should occur. Examine and palpate the outer ear and ear canal for any local redness or irritation that may indicate sensitivity to the drug. ◦ Option B: Perforated eardrums may be a contraindication to some of the otic preparations. Check with the primary health care provider before administering an otic preparation to a patient with a perforated eardrum. ◦ Option C: These drugs are contraindicated in patients with a known hypersensitivity to the drugs. The otic drugs are used with caution during pregnancy and lactation. The pregnancy category of most of these drugs is unknown when they are used as otic drugs. Drugs to remove cerumen are not used if ear drainage, discharge, pain, or irritation is present; if the eardrum is perforated; or after ear surgery. 1. Question 46 of 50 46. Question Mara Francesca has been diagnosed with scabies. His physician has ordered crotamiton (Eurax). After 1 week of treatment, the client reports that the pruritus has not stopped. You would advise the client to: ◦ A. Stop applying the medication. ◦ B. Continue treatment because pruritus may persist for 4 to 6 weeks. ◦ C. Call the physician. ◦ D. None of the above. Correct Answer: B. Continue treatment because pruritus may persist for 4 to 6 weeks. Many times pruritus is not relieved for 4 to 6 weeks after therapy has been initiated. Use this medicine only as directed. Do not use it more often than the doctor ordered. To do so may increase the chance of side effects. This medicine usually comes with patient directions. Read them carefully before using. ◦ Option A: It is never appropriate to discontinue medication without a physician’s direction. The dose of this medicine will be different for different patients. Follow the doctor’s orders or the directions on the label. The following information includes only the average doses of this medicine. If the dose is different, do not change it unless the doctor orders. ◦ Option C: Keep crotamiton away from the eyes and other mucous membranes, such as the inside of the nose. It may cause irritation. If one should accidentally get some in the eyes, flush them thoroughly with water at once. ◦ Option D: The amount of medicine that the client takes depends on the strength of the medicine. Also, the number of doses he or she takes each day, the time allowed between doses, and the length of time they take the medicine depend on the medical problem for which they are using the medicine. 1. Question 47 of 50 47. Question Jake has psoriasis of the scalp. The physician has ordered Zetar shampoo. You would advise the client to: ◦ A. Avoid sun exposure to the scalp. ◦ B. Use the shampoo PRN. ◦ C. Report pruritus. ◦ D. None of the above. Correct Answer: A. Avoid sun exposure to the scalp. One of the side effects of Zetar shampoo is photosensitivity. This medication makes a person more sensitive to the sun. Be sure to completely wash off the medication before going out into the sun. Avoid sun exposure, tanning booths, and sunlamps for at least 24 hours after using this medication unless the doctor directs otherwise. Other medications may also increase sun sensitivity. ◦ Option B: Use this product usually twice a week or as directed by the doctor. Dosage is based on the medical condition, the product type/brand, and response to treatment. Do not use large amounts of this medication, use it more often, or use it for a longer period than directed. The condition will not clear faster, but the chance for side effects may be increased. ◦ Option C: Skin/scalp irritation or staining of skin/hair (especially in patients with blonde, bleached, dyed, or gray hair) may occur. If skin irritation develops or worsens, stop using this product and tell the doctor or pharmacist promptly. ◦ Option D: This medication is used on the hair/scalp to treat dandruff and other scaly, itchy skin conditions (psoriasis or seborrheic dermatitis). Coal tar belongs to a class of drugs known as keratoplastics. It works by causing the skin to shed dead cells from its top layer and slow down the growth of skin cells. This effect decreases scaling and dryness. Coal tar can also decrease itchiness from these skin conditions. 1. Question 48 of 50 48. Question Topical antibiotics work by: ◦ A. Inhibiting replication of a virus. ◦ B. Blocking histamine-1 and -2 receptors. ◦ C. Binding to fungal cell membranes. ◦ D. Inhibiting bacterial cell wall synthesis. Correct Answer: D. Inhibiting bacterial cell wall synthesis Topical antibiotics work by inhibiting bacterial cell wall synthesis. The pharmacology behind antibiotics includes destroying the bacterial cell by either preventing cell reproduction or changing a necessary cellular function or process within the cell. ◦ Option A: This describes antiviral actions. It inhibits DNA synthesis and viral replication after it is converted to acyclovir triphosphate by viral and cellular enzymes. Acyclovir is an antiviral agent that incorporates itself into viral DNA preventing further synthesis. ◦ Option B: This describes the action of antipruritics. Antipruritic drugs act centrally by a property related to sedation; H1 receptor antagonists have a peripheral antipruritic action only when the itch is due to histamine release, as in the wealing disorders. ◦ Option C: This describes the action of antifungals. Antifungals can be grouped into three classes based on their site of action: azoles, which inhibit the synthesis of ergosterol (the main fungal sterol); polyenes, which interact with fungal membrane sterols physicochemically; and 5-fluorocytosine, which inhibits macromolecular synthesis. 1. Question 49 of 50 49. Question Pediculicides are used to treat which of the following disorders? ◦ A. Scabies ◦ B. Fungal infections ◦ C. Viral infections ◦ D. Head lice Correct Answer: D. Head lice Pediculicides are an effective treatment for head lice. An anti-parasite medication used to treat head lice, onchocerciasis, strongyloidiasis, ascariasis, trichuriasis, and enterobiasis. ◦ Option A: Scabicides are used to treat scabies. Products used to treat scabies are called scabicides because they kill scabies mites; some also kill mite eggs. Scabicides used to treat human scabies are available only with a doctor’s prescription. No “over-the-counter” (non-prescription) products have been tested and approved to treat scabies. ◦ Option B: Antifungals are used to treat fungal infections. An antifungal medication, also known as an antimycotic medication, is a pharmaceutical fungicide or fungistatic used to treat and prevent mycosis such as athlete’s foot, ringworm, candidiasis (thrush), serious systemic infections such as cryptococcal meningitis, and others. ◦ Option C: Antivirals are used to treat viral infections. Antivirals are medications that reduce the ability of flu viruses to multiply. The CDC considers antiviral drugs as a “second line of defense against the flu.” The first line of defense is getting an annual flu vaccine. When taken at the onset of flu, these drugs help decrease the severity and duration of flu symptoms. 1. Question 50 of 50 50. Question Alice is using antiviral creams for her genital herpes. Which of the following is a potential side effect of the medication? ◦ A. Vulvitis ◦ B. Headache ◦ C. Dizziness ◦ D. Staining of the skin Correct Answer: A. Vulvitis Antiviral creams can cause vulvitis when applied to the genitalia to treat genital herpes. Acyclovir cream is used to treat cold sores (fever blisters; blisters that are caused by a virus called herpes simplex) on the face or lips. Acyclovir ointment is used to treat first outbreaks of genital herpes (a herpes virus infection that causes sores to form around the genitals and rectum from time to time) and to treat certain types of sores caused by the herpes simplex virus in people with weak immune systems. ◦ Option B: Acyclovir is in a class of antiviral medications called synthetic nucleoside analogues. It works by stopping the spread of the herpes virus in the body. Acyclovir does not cure cold sores or genital herpes, does not prevent outbreaks of these conditions, and does not stop the spread of these conditions to other people. ◦ Option C: Topical acyclovir comes as a cream and an ointment to apply to the skin. Acyclovir cream is usually applied five times a day for 4 days. Acyclovir cream may be applied at any time during a cold sore outbreak, but it works best when it is applied at the very beginning of a cold sore outbreak when there is tingling, redness, itching, or a bump but the cold sore has not yet formed. ◦ Option D: Acyclovir ointment is usually applied six times a day (usually 3 hours apart) for 7 days. It is best to begin using acyclovir ointment as soon as possible after the client experiences the first symptoms of infection. Follow the directions on the prescription label carefully, and ask the doctor or pharmacist to explain any part that is not understood. [Show More]
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