2022/2023 NURS 508 EXAM QUESTIONS WITH ANSWERS GRADED A+, Exams of Nursing

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ANSWERS GRADED A+

Chapter 1 1.Clinical judgment in prescribing includes: (^1) Factoring in the cost to the patient of the medication prescribed (^2) Always prescribing the newest medication available for the disease process (^3) Handing out drug samples to poor patients (^4) Prescribing all generic medications to cut costs 2.The benefits to the patient of having an Advanced Practice Registered Nurse (APRN) prescriber include:

1. (^) Nurses know more about Pharmacology than other prescribers because they take it both in their basic nursing program and in their APRN program. 2. Nurses care for the patient from a holistic approach and include the patient in decision making regarding their care.
2. (^) APRNs are less likely to prescribe narcotics and other controlled substances.
3. (^) APRNs are able to prescribe independently in all states, whereas a physician’s assistant needs to have a physician supervising their practice. 3.Criteria for choosing an effective drug for a disorder include:
4. (^) Asking the patient what drug they think would work best for them 2. (^) Consulting nationally recognized guidelines for disease management
5. (^) Prescribing medications that are available as samples before writing a prescription
6. (^) Following U.S. Drug Enforcement Administration guidelines for prescribing 4.Nurse practitioner prescriptive authority is regulated by:
7. (^) The National Council of State Boards of Nursing .
8. (^) The U.S. Drug Enforcement Administration . 3. (^) The State Board of Nursing for each state . 5.The State Board of Pharmacy
9. (^) Nurse practitioner practice may thrive under health-care reform because of: 1. (^) The demonstrated ability of nurse practitioners to control costs and improve patient outcomes
10. (^) The fact that nurse practitioners will be able to practice independently
11. (^) The fact that nurse practitioners will have full reimbursement under health- care reform
12. (^) The ability to shift accountability for Medicaid to the state level

Chapter 2. Review of Basic Principles of Pharmacology

1.A patient’s nutritional intake and laboratory results reflect hypoalbuminemia. This is critical to prescribing because:

1. Distribution of drugs to target tissue may be affected. 2. (^) The solubility of the drug will not match the site of absorption. 3. (^) There will be less free drug available to generate an effect.

ANSWERS GRADED A+

4. (^) Drugs bound to albumin are readily excreted by the kidneys.

2. Drugs that have a significant first-pass effect:
3. (^) Must be given by the enteral (oral) route only
4. (^) Bypass the hepatic circulation 3. Are rapidly metabolized by the liver and may have little if any desired action
5. (^) Are converted by the liver to more active and fat-soluble forms 3.The route of excretion of a volatile drug will likely be the:
6. (^) Kidneys
7. (^) Lungs 3. Bile and feces
8. (^) Skin 4.Medroxyprogesterone (Depo Provera) is prescribed intramuscularly (IM) to create a storage reservoir of the drug. Storage reservoirs:
9. (^) Assure that the drug will reach its intended target tissue
10. (^) Are the reason for giving loading doses 3. Increase the length of time a drug is available and active
11. (^) Are most common in collagen tissues 5.The NP chooses to give cephalexin every 8 hours based on knowledge of the drug’s:
12. (^) Propensity to go to the target receptor 2. Biological half-life
13. (^) Pharmacodynamics
14. (^) Safety and side effects 6.Azithromycin dosing requires that the first day’s dosage be twice those of the other 4 days of the prescription. This is considered a loading dose. A loading dose: 1. Rapidly achieves drug levels in the therapeutic range
15. (^) Requires four- to five-half-lives to attain
16. (^) Is influenced by renal function
17. (^) Is directly related to the drug circulating to the target tissues 7.The point in time on the drug concentration curve that indicates the first sign of a therapeutic effect is the:
18. (^) Minimum adverse effect level
19. (^) Peak of action 3. Onset of action
20. (^) Therapeutic range 8.Phenytoin requires that a trough level be drawn. Peak and trough levels are done:
21. (^) When the drug has a wide therapeutic range
22. (^) When the drug will be administered for a short time only
23. (^) When there is a high correlation between the dose and saturation of receptor sites 4. To determine if a drug is in the therapeutic range 9.A laboratory result indicates that the peak level for a drug is above the minimum toxic concentration. This means that the:
24. (^) Concentration will produce therapeutic effects

ANSWERS GRADED A+

2. Concentration will produce an adverse response

3. (^) Time between doses must be shortened
4. (^) Duration of action of the drug is too long
5. Drugs that are receptor agonists may demonstrate what property?
6. (^) Irreversible binding to the drug receptor site
7. (^) Upregulation with chronic use 3. Desensitization or downregulation with continuous use
8. (^) Inverse relationship between drug concentration and drug action 11.Drugs that are receptor antagonists, such as beta blockers, may cause:
9. (^) Downregulation of the drug receptor 2. An exaggerated response if abruptly discontinued
10. (^) Partial blockade of the effects of agonist drugs
11. (^) An exaggerated response to competitive drug agonists
12. Factors that affect gastric drug absorption include:
13. (^) Liver enzyme activity
14. (^) Protein-binding properties of the drug molecule 3. Lipid solubility of the drug
15. (^) Ability to chew and swallow
16. Drugs administered via IV:
17. (^) Need to be lipid soluble in order to be easily absorbed 2. Begin distribution into the body immediately
18. (^) Are easily absorbed if they are nonionized
19. (^) May use pinocytosis to be absorbed
20. When a medication is added to a regimen for a synergistic effect, the combined effect of the drugs is:
21. (^) The sum of the effects of each drug individually 2. Greater than the sum of the effects of each drug individually
22. (^) Less than the effect of each drug individually
23. (^) Not predictable, as it varies with each individual
24. Which of the following statements about bioavailability is true? 1. Bioavailability issues are especially important for drugs with narrow therapeutic ranges or sustained-release mechanisms.
25. (^) All brands of a drug have the same bioavailability.
26. (^) Drugs that are administered more than once a day have greater bioavailability than drugs given once daily.
27. (^) Combining an active drug with an inert substance does not affect bioavailability.
28. Which of the following statements about the major distribution barriers (blood-brain or fetal-placental) is true?
29. (^) Water soluble and ionized drugs cross these barriers rapidly. 2. The blood-brain barrier slows the entry of many drugs into and from brain cells.
30. (^) The fetal-placental barrier protects the fetus from drugs taken by the mother.
31. (^) Lipid-soluble drugs do not pass these barriers and are safe for pregnant women.

ANSWERS GRADED A+

17. Drugs are metabolized mainly by the liver via phase I or phase II reactions. The purpose of both of these types of reactions is to:
    1. (^) Inactivate prodrugs before they can be activated by target tissues
    2. (^) Change the drugs so they can cross plasma membranes 3. Change drug molecules to a form that an excretory organ can excrete
    3. (^) Make these drugs more ionized and polar to facilitate excretion
18. Once they have been metabolized by the liver, the metabolites may be:
    1. (^) More active than the parent drug
    2. (^) Less active than the parent drug
    3. (^) Totally “deactivated” so they are excreted without any effect 4. All of the above
19. All drugs continue to act in the body until they are changed or excreted. The ability of the body to excrete drugs via the renal system would be increased by:
    1. (^) Reduced circulation and perfusion of the kidney
    2. (^) Chronic renal disease
    3. (^) Competition for a transport site by another drug 4. Unbinding a nonvolatile drug from plasma proteins
20. Steady state is:
    1. (^) The point on the drug concentration curve when absorption exceeds excretion 2. When the amount of drug in the body remains constant
    2. (^) When the amount of drug in the body stays below the minimum toxic concentration
    3. (^) All of the above
21. Two different pain medications are given together for pain relief. The drug—drug interaction is:
    1. (^) Synergistic
    2. (^) Antagonistic
    3. (^) Potentiative 4. Additive
22. Actions taken to reduce drug—drug interaction problems include all of the following EXCEPT:
    1. (^) Reducing the dosage of one of the drugs
    2. (^) Scheduling their administration at different times 3. Prescribing a third drug to counteract the adverse reaction of the combination
    3. (^) Reducing the dosage of both drugs
23. Phase I oxidative-reductive processes of drug metabolism require certain nutritional elements. Which of the following would reduce or inhibit this process?
    1. (^) Protein malnutrition
    2. (^) Iron-deficiency anemia
    3. (^) Both 1 and 2 4. Neither 1 nor 2
24. The time required for the amount of drug in the body to decrease by 50% is called:
    1. (^) Steady state

ANSWERS GRADED A+

2. Half-life

3. (^) Phase II metabolism
4. (^) Reduced bioavailability time
5. An agonist activates a receptor and stimulates a response. When given frequently over time, the body may:
6. (^) Upregulate the total number of receptors
7. (^) Block the receptor with a partial agonist
8. (^) Alter the drug’s metabolism 4. Downregulate the numbers of that specific receptor
9. Drug antagonism is best defined as an effect of a drug that:
10. (^) Leads to major physiological and psychological dependence 2. Is modified by the concurrent administration of another drug
11. (^) Cannot be metabolized before another dose is administered
12. (^) Leads to a decreased physiological response when combined with another drug
13. Instructions to a client regarding self-administration of oral enteric-coated tablets should include which of the following statements?
14. (^) “Avoid any other oral medicines while taking this drug.”
15. (^) “If swallowing this tablet is difficult, dissolve it in 3 ounces of orange juice.”
16. (^) “The tablet may be crushed if you have any difficulty taking it.” 4. “To achieve best effect, take the tablet with at least 8 ounces of fluid.”
17. The major reason for not crushing a sustained-release capsule is that, if crushed, the coated beads of the drugs could possibly result in:
18. (^) Disintegration 2. Toxicity
19. (^) Malabsorption
20. (^) Deterioration
21. Which of the following substances is the most likely to be absorbed in the intestines rather than in the stomach? 1. Sodium bicarbonate
22. (^) Ascorbic acid
23. (^) Salicylic acid
24. (^) Glucose
25. Which of the following variables is a factor in drug absorption?
26. (^) The smaller the surface area for absorption, the more rapidly the drug is absorbed. 2. A rich blood supply to the area of absorption leads to better absorption.
27. (^) The less soluble the drug, the more easily it is absorbed.
28. (^) Ionized drugs are easily absorbed across the cell membrane.
29. An advantage of prescribing a sublingual medication is that the medication is: 1. Absorbed rapidly
30. (^) Excreted rapidly
31. (^) Metabolized minimally
32. (^) Distributed equally

ANSWERS GRADED A+

32. Drugs that use CYP 3A4 isoenzymes for metabolism may:
    1. (^) Induce the metabolism of another drug
    2. (^) Inhibit the metabolism of another drug 3. Both 1 and 2
    3. (^) Neither 1 nor 2
33. Therapeutic drug levels are drawn when a drug reaches steady state. Drugs reach steady state:
    1. (^) After the second dose 2. After four to five half-lives
    2. (^) When the patient feels the full effect of the drug
    3. (^) One hour after IV administration
34. Upregulation or hypersensitization may lead to:
    1. (^) Increased response to a drug
    2. (^) Decreased response to a drug 3. An exaggerated response if the drug is withdrawn
    3. (^) Refractoriness or complete lack of response

Chapter 3. Rational Drug Selection

1.An NP would prescribe the liquid form of ibuprofen for a 6-year-old child because:

1. (^) Drugs given in liquid form are less irritating to the stomach. 2. A 6-year-old child may have problems swallowing a pill.
2. (^) Liquid forms of medication eliminate the concern for first-pass effect.
3. (^) Liquid ibuprofen does not have to be dosed as often as the tablet form. 2.In deciding which of multiple drugs used to use to treat a condition, the NP chooses Drug A because it:
4. (^) Has serious side effects and it is not being used for a life-threatening condition 2. Will be taken twice daily and will be taken at home
5. (^) Is expensive, but covered by health insurance
6. (^) None of these are important in choosing a drug 3.A client asks the NP about the differences in drug effects between men and women. What is known about the differences between the pharmacokinetics of men and women?
7. (^) Body temperature varies between men and women.
8. (^) Muscle mass is greater in women. 3. Percentage of fat differs between genders.
9. (^) Proven subjective factors exist between the genders. 4.The first step in the prescribing process according to the World Health Organization is:
10. (^) Choosing the treatment
11. (^) Educating the patient about the medication 3. Diagnosing the patient’s problem
12. (^) Starting the treatment 5.Treatment goals in prescribing should:
13. (^) Always be curative

ANSWERS GRADED A+

2. Be patient-centered

3. (^) Be convenient for the provider
4. (^) Focus on the cost of therapy 6.The therapeutic goals when prescribing include(s):
5. (^) Curative
6. (^) Palliative
7. (^) Preventive 4. All of the above 7.When determining drug treatment the NP prescriber should:
8. (^) Always use evidence-based guidelines 2. Individualize the drug choice for the specific patient
9. (^) Rely on his or her experience when prescribing for complex patients
10. (^) Use the newest drug on the market for the condition being treated 8.Patient education regarding prescribed medication includes:
11. (^) Instructions written at the high school reading level 2. Discussion of expected adverse drug reactions
12. (^) How to store leftover medication such as antibiotics
13. (^) Verbal instructions always in English 9.Passive monitoring of drug effectiveness includes:
14. (^) Therapeutic drug levels
15. (^) Adding or subtracting medications from the treatment regimen
16. (^) Ongoing provider visits 4. Instructing the patient to report if the drug is not effective
17. Pharmacokinetic factors that affect prescribing include:
18. (^) Therapeutic index
19. (^) Minimum effective concentration 3. Bioavailability
20. (^) Ease of titration 11.Pharmaceutical promotion may affect prescribing. To address the impact of pharmaceutical promotion, the following recommendations have been made by the Institute of Medicine: 1. Conflicts of interest and financial relationships should be disclosed by those providing education.
21. (^) Providers should ban all pharmaceutical representatives from their office setting.
22. (^) Drug samples should be used for patients who have the insurance to pay for them, to ensure the patient can afford the medication.
23. (^) Providers should only accept low-value gifts, such as pens and pads of paper, from the pharmaceutical representative.
24. Under new U.S. Food and Drug Administration labeling, Pregnancy Categories will be:
25. (^) Strengthened with a new coding such as C+ or C- to discern when a drug is more or less toxic to the fetus 2. Changed to incorporate a pregnancy risk summary and clinical considerations on the drug label

ANSWERS GRADED A+

3. (^) Eliminated, and replaced with a link to the National Library of Medicine TOXNET Web site for in-depth information regarding pregnancy concerns
4. (^) Clarified to include information such as safe dosages in each trimester of pregnancy

Chapter 4. Legal and Professional Issues in Prescribing

1.The U.S. Food and Drug Administration regulates:

1. (^) Prescribing of drugs by MDs and NPs 2. The official labeling for all prescription and over-the-counter drugs
2. (^) Off-label recommendations for prescribing
3. (^) Pharmaceutical educational offerings 2.The U.S. Food and Drug Administration approval is required for: 1. Medical devices, including artificial joints
4. (^) Over-the-counter vitamins
5. (^) Herbal products, such as St John’s wort
6. (^) Dietary supplements, such as Ensure 3.An Investigational New Drug is filed with the U.S. Food and Drug Administration:
7. (^) When the manufacturer has completed phase III trials
8. (^) When a new drug is discovered
9. (^) Prior to animal testing of any new drug entity 4. Prior to human testing of any new drug entity 4.Phase IV clinical trials in the United States are also known as:
10. (^) Human bioavailability trials 2. Postmarketing research
11. (^) Human safety and efficacy studies
12. (^) The last stage of animal trials before the human trials begin 5.Off-label prescribing is: 1. (^) Regulated by the U.S. Food and Drug Administration 2. (^) Illegal by NPs in all states (provinces) 3. Legal if there is scientific evidence for the use 4. (^) Regulated by the Drug Enforcement Administration 6.The U.S. Drug Enforcement Administration: 1. Registers manufacturers and prescribers of controlled substances 2. (^) Regulates NP prescribing at the state level 3. (^) Sanctions providers who prescribe drugs off-label 4. (^) Provides prescribers with a number they can use for insurance billing 7.Drugs that are designated Schedule II by the U.S. Drug Enforcement Administration: 1. (^) Are known teratogens during pregnancy 2. May not be refilled; a new prescription must be written 3. (^) Have a low abuse potential 4. (^) May be dispensed without a prescription unless regulated by the state 8.Precautions that should be taken when prescribing controlled substances include:

ANSWERS GRADED A+

1. (^) Faxing the prescription for a Schedule II drug directly to the pharmacy 2. Using tamper-proof paper for all prescriptions written for controlled drugs 3. (^) Keeping any pre-signed prescription pads in a locked drawer in the clinic 4. (^) Using only numbers to indicate the amount of drug to be prescribed 9.Strategies prescribers can use to prevent misuse of controlled prescription drugs include: 1. (^) Use of chemical dependency screening tools 2. (^) Firm limit-setting regarding prescribing controlled substances 3. (^) Practicing “just say no” to deal with patients who are pushing the provider to prescribe controlled substances 4. All of the above

10. Behaviors predictive of addiction to controlled substances include: 1. Stealing or borrowing another patient’s drugs 2. (^) Requiring increasing doses of opiates for pain associated with malignancy 3. (^) Receiving refills of a Schedule II prescription on a regular basis 4. (^) Requesting that only their own primary care provider prescribe for them 11.Medication agreements or “Pain Medication Contracts” are recommended to be used: 1. Universally for all prescribing for chronic pain 2. (^) For patients who have repeated requests for pain medication 3. (^) When you suspect a patient is exhibiting drug-seeking behavior 4. (^) For patients with pain associated with malignancy 12.A prescription needs to be written for:
11. (^) Legend drugs
12. (^) Most controlled drugs
13. (^) Medical devices 4. (^) All of the above

Chapter 5. Adverse Drug Reactions

1.Which of the following patients would be at higher risk of experiencing adverse drug reactions (ADRs):

1. (^) A 32-year-old male
2. (^) A 22-year-old female 3. A 3-month-old female
3. (^) A 48-year-old male 2.Infants and young children are at higher risk of ADRs due to:
4. (^) Immature renal function in school-age children 2. Lack of safety and efficacy studies in the pediatric population
5. (^) Children’s skin being thicker than adults, requiring higher dosages of topical medication
6. (^) Infant boys having a higher proportion of muscle mass, leading to a higher volume of distribution 3.The elderly are at high risk of ADRs due to:
7. (^) Having greater muscle mass than younger adults, leading to higher volume of distribution
8. (^) The extensive studies that have been conducted on drug safety in this age group

ANSWERS GRADED A+

3. (^) The blood-brain barrier being less permeable, requiring higher doses to achieve therapeutic effect 4. Age-related decrease in renal function 4.The type of adverse drug reaction that is idiosyncratic when a drug given in the usual therapeutic doses is type:
4. (^) A
5. B
6. (^) C
7. (^) D 5.Digoxin may cause a type A adverse drug reaction due to:
8. Idiosyncratic effects 2. Its narrow therapeutic index
9. Being a teratogen
10. Being a carcinogen 6.Sarah developed a rash after using a topical medication. This is a type allergic drug reaction.
11. (^) I
12. II
13. III 4. (^) IV 7.A patient may develop neutropenia from using topical Silvadene for burns. Neutropenia is a(n): 1. Cytotoxic hypersensitivity reaction
14. (^) Immune complex hypersensitivity
15. (^) Immediate hypersensitivity reaction
16. (^) Delayed hypersensitivity reaction 8.Anaphylactic shock is a: 1. Type I reaction, called immediate hypersensitivity reaction
17. (^) Type II reaction, called cytotoxic hypersensitivity reaction
18. (^) Type III allergic reaction, called immune complex hypersensitivity
19. (^) Type IV allergic reaction, called delayed hypersensitivity reaction 9.James has hypothalamic-pituitary-adrenal axis suppression from chronic prednisone (a corticosteroid) use. He is at risk for what type of adverse drug reaction? 1. Type B
20. (^) Type C
21. (^) Type E
22. (^) Type F
23. Immunomodulators such as azathioprine may cause a delayed adverse drug reaction known as a type D reaction because they are known:
24. (^) Teratogens 2. Carcinogens
25. (^) To cause hypersensitivity reactions
26. (^) Hypothalamus-pituitary-adrenal axis suppressants

ANSWERS GRADED A+

11. A 24-year-old male received multiple fractures in a motor vehicle accident that required significant amounts of opioid medication to treat his pain. He is at risk for a adverse drug reaction when he no longer requires the opioids.
    1. (^) Rapid
    2. (^) First-dose 3. Late
    3. (^) Delayed
12. An example of a first-dose reaction that may occur includes: 1. Orthostatic hypotension that does not occur with repeated doses
    2. (^) Purple glove syndrome with phenytoin use
    3. (^) Hemolytic anemia from ceftriaxone use
    4. (^) Contact dermatitis from neomycin use
13. Drugs that are prone to cause adverse drug effects include:
    1. (^) Diuretics
    2. (^) Inhaled anticholinergics 3. Insulins
    3. (^) Stimulants
14. The U.S. Food and Drug Administration MedWatch system is activated when:
    1. (^) There is an adverse event to a vaccine.
    2. (^) The patient has a severe reaction that is noted in the “Severe Reaction” section in the medication label.
    3. (^) A lactating woman takes a medication that is potentially toxic to the breastfeeding infant. 4. An adverse event or serious problem occurs with a medication that is not already identified on the label.
15. The Vaccine Adverse Events Reporting System is:
    1. (^) A mandatory reporting system for all health-care providers when they encounter an adverse vaccine event 2. A voluntary reporting system that health-care providers or consumers may use to report vaccine adverse events
    2. (^) Utilized to send out safety alerts regarding emerging vaccine safety issues
    3. (^) Activated when a vaccine has been proven to cause significant adverse effects

Chapter 6. Factors That Foster Positive Outcomes

1.A comprehensive assessment of a patient should be holistic when trying to determine competence in drug administration. Which of the following factors would the NP omit from this type of assessment?

1. (^) Financial status
2. (^) Mobility
3. (^) Social support 4. Sexual practices 2.Elena Vasquez’s primary language is Spanish, and she speaks very limited English. Which technique would be appropriate to use in teaching her about a new drug you have just prescribed?

ANSWERS GRADED A+

1. (^) Use correct medical terminology because Spanish has a Latin base.

ANSWERS GRADED A+

2. (^) Use a family member who speaks more English to act as an interpreter. 3. Use a professional interpreter or a reliable staff member who can act as an interpreter.
3. (^) Use careful, detailed explanations. 3.Rod, age 68, has hearing difficulty. Which of the following would NOT be helpful in assuring that he understands teaching about his drug?
4. (^) Stand facing him and speak slowly and clearly.
5. (^) Speak in low tones or find a provider who has a lower voice.
6. (^) Write down the instructions as well as speaking them. 4. If he reads lips, exaggerate lips movements when pronouncing the vowel sounds. 4.Which of the following factors may adversely affect a patient’s adherence to a therapeutic drug regimen?
7. (^) Complexity of the drug regimen
8. (^) Patient perception of the potential adverse effects of the drugs 3. Both 1 and 2
9. (^) Neither 1 nor 2 5.The health-care delivery system itself can create barriers to adherence to a treatment regimen. Which of the following system variables creates such a barrier? 1. Increasing copayments for care
10. (^) Unrestricted formularies for drugs, including brand names
11. (^) Increasing the number of people who have access to care
12. (^) Treating a wider range of disorders 6.Ralph’s blood pressure remains elevated despite increased doses of his drug. The NP is concerned that he might not be adhering to his treatment regimen. Which of the following events would suggest that he might not be adherent? 1. Ralph states that he always takes the drug “when I feel my pressure is going up.”
13. (^) Ralph contacts his NP to discuss the need to increase the dosage.
14. (^) Ralph consistently keeps his follow-up appointments to check his blood pressure.
15. (^) All of the above show that he is adherent to the drug regimen. 7.Nonadherence is especially common in drugs that treat asymptomatic conditions, such as hypertension. One way to reduce the likelihood of nonadherence to these drugs is to prescribe a drug that:
16. (^) Has a short half-life so that missing one dose has limited effect
17. (^) Requires several dosage titrations so that missed doses can be replaced with lower doses to keep costs down 3. Has a tolerability profile with fewer of the adverse effects that are considered “irritating,” such as nausea and dizziness
18. (^) Must be taken no more than twice a day 8.Factors in chronic conditions that contribute to nonadherence include:
19. (^) The complexity of the treatment regimen
20. (^) The length of time over which it must be taken
21. (^) Breaks in the usual daily routine, such as vacations and weekends 4. All of the above

ANSWERS GRADED A+

9.While patient education about their drugs is important, information alone does not necessarily lead to adherence to a drug regimen. Patients report greater adherence when:

1. (^) The provider spent a lot of time discussing the drugs with them 2. Their concerns and specific area of knowledge deficit were addressed
2. (^) They were given written material, such as pamphlets, about the drugs
3. (^) The provider used appropriate medical and pharmacological terms
4. Patients with psychiatric illnesses have adherence rates to their drug regimen between 35% and 60%. To improve adherence in this population, prescribe drugs: 1. With a longer half-life so that missed doses produce a longer taper on the drug curve
5. (^) In oral formulations that are more easily taken
6. (^) That do not require frequent monitoring
7. (^) Combined with patient education about the need to adhere even when symptoms are absent 11.Many disorders require multiple drugs to treat them. The more complex the drug regimen, the less likely the patient will adhere to it. Which of the following interventions will NOT improve adherence?
8. (^) Have the patient purchase a pill container with compartments for daily or multiple times-per-day dosing.
9. (^) Match the clinic appointment to the next time the drug is to be refilled.
10. (^) Write prescriptions for new drugs with shorter times between refills. 4. Give the patient a clear drug schedule that the provider devises to fit the characteristic of the drug.
11. Pharmacologic interventions are costly. Patients for whom the cost/benefit variable is especially important include: 1. Older adults and those on fixed incomes
12. (^) Patients with chronic illnesses
13. (^) Patients with copayments for drugs on their insurance
14. (^) Patients on public assistance
15. Providers have a responsibility for determining the best plan of care, but patients also have responsibilities. Patients the provider can be assured will carry through on these responsibilities include those who:
16. (^) Are well-educated and affluent
17. (^) Have chronic conditions
18. (^) Self-monitor drug effects on their symptoms 4. None of the above guarantee adherence
19. Monitoring adherence can take several forms, including:
20. (^) Patient reports from data in a drug diary
21. (^) Pill counts
22. (^) Laboratory reports and other diagnostic markers 4. All of the above
23. Factors that explain and predict medication adherence include:
24. (^) Social

ANSWERS GRADED A+

2. (^) Financial
3. (^) Health system 4. (^) All of the above

Chapter 9. Nutrition and Nutraceuticals

1.The most frequent type of drug-food interaction is food:

1. (^) Causing increased therapeutic drug levels
2. (^) Affecting the metabolism of the drug
3. (^) Altering the volume of distribution of drugs 4. Affecting the gastrointestinal absorption of drugs 2.Food in the gastrointestinal tract affects drug absorption by:
4. (^) Altering the pH of the colon, which decreases absorption
5. (^) Competing with the drug for plasma proteins 3. Altering gastric emptying time
6. (^) Altering the pH of urine 3.Food can alter the pH of the stomach, leading to:
7. (^) Enhanced drug metabolism
8. (^) Altered vitamin K absorption
9. (^) Increased vitamin D absorption 4. Altered drug bioavailability 4.Fasting for an extended period can:
10. (^) Increase drug absorption due to lack of competition between food and the drug
11. (^) Alter the pH of the gastrointestinal tract, affecting absorption 3. Cause vasoconstriction, leading to decreased drug absorption
12. (^) Shrink the stomach, causing decreased surface area for drug absorption 5.Tetracycline needs to be given on an empty stomach because it chelates with:
13. (^) Calcium
14. (^) Magnesium
15. (^) Iron 4. All of the above 6.A low-carbohydrate, high-protein diet may: 1. Increase drug-metabolizing enzymes
16. (^) Decrease drug absorption from the GI tract
17. (^) Alter drug binding to plasma proteins
18. (^) Enhance drug elimination 7.Grapefruit juice contains furanocoumarins that have been found to:
19. (^) Alter absorption of drugs through competition for binding sites 2. Inhibit CYP 3A4, leading to decreased first-pass metabolism of drugs
20. (^) Alter vitamin K metabolism, leading to prolonged bleeding
21. (^) Enhance absorption of calcium and vitamin D 8.Cruciferous vegetables may alter drug pharmacokinetics by:
22. (^) Enhancing absorption of weakly acidic drugs
23. (^) Altering CYP 3A4 activity, leading to elevated levels of drugs, such as the statins

ANSWERS GRADED A+

3. Inducing CYP 1A2, possibly leading to therapeutic failure of drugs metabolized by CYP 1A

4. (^) Decreasing first-pass metabolism of drugs 9.Milk and other foods that alkalinize the urine may: 1. Result in basic drugs being reabsorbed in the renal tubule
5. (^) Increase the elimination of basic drugs in the urine
6. (^) Decrease the elimination of acidic drugs
7. (^) Not alter drug elimination due to the minimal change in urine pH
8. Antacids such as calcium carbonate (Tums) can reduce the absorption of which of the following nutrients?
9. (^) Protein
10. (^) Calcium 3. Iron
11. (^) Vitamin K 11.Phenytoin decreases folic acid absorption by:
12. (^) Altering the pH of the stomach
13. (^) Increasing gastric emptying time 3. Inhibiting intestinal enzymes required for folic acid absorption
14. (^) Chelation of the folic acid into inactive ingredients
15. Patients taking warfarin need to be educated about the vitamin K content of foods to avoid therapeutic failure. Foods high in vitamin K that should be limited to no more than one serving per day include: 1. Spinach
16. (^) Milk
17. (^) Romaine lettuce
18. (^) Cauliflower
19. The American Dietetic Association has recommended the use of specific nutritional supplements in the following population(s): 1. 400 IU per day of vitamin D in all infants and children
20. (^) 1,000 IU per day of vitamin D for all pregnant women
21. (^60) mg per day of iron for all adults over age 50 years
22. (^) All of the above
23. The American Dietetic Association recommends pregnant women take a supplement including:
24. (^) 1,000 IU daily of vitamin D
25. (^) 2.4 mcg/day of vitamin B 12 3. 600 mcg/day of folic acid
26. (^8) mg/day of iron
27. The American Heart Association and the American Dietetic Association recommend a minimum daily fiber intake of for cardiovascular health:
28. (^) 10 mg/day
29. (^) 15 mg/day
30. (^) 20 mg/day

ANSWERS GRADED A+

4. 25 mg/day

16. Which of the following vitamin or mineral supplements may by teratogenic if a pregnant woman takes more than the recommended amount?
17. (^) Iron 2. Vitamin A
18. (^) Vitamin B 6
19. (^) Vitamin C
20. Vitamin B 2 (riboflavin) may be prescribed to:
21. (^) Decrease the incidence of beriberi 2. Reduce headaches and migraines
22. (^) Prevent pernicious anemia
23. (^) Treat hyperlipidemia
24. Isoniazid (INH) may induce a deficiency of which vitamin? 1. B 6
25. (^) C
26. (^) D
27. (^) E
28. Pregnant patients who are taking isoniazid (INH) should take 25 mg/day of vitamin B 6 (pyridoxine) to prevent:
29. (^) Beriberi 2. Peripheral neuropathy
30. (^) Rickets
31. (^) Megaloblastic anemia
32. Vitamin B 12 deficiency may lead to:
33. (^) Hair loss
34. (^) Insomnia
35. (^) Dry scales on the scalp 4. Numbness and tingling of the hands
36. Smokers are at risk for vitamin C deficiency. It is recommended that smokers take vitamin C supplement.
37. (^) 100 mg/day
38. (^) 500 mg/day
39. (^) 1,000 mg/day 4. (^35) mg/day more than nonsmokers
40. There is strong evidence to support that adequate vitamin C intake prevents:
41. (^) The common cold
42. (^) Breast cancer 3. Scurvy
43. (^) All of the above
44. Adequate vitamin D is needed for:
45. (^) Absorption of calcium from the gastrointestinal tract

ANSWERS GRADED A+

2. (^) Regulation of serum calcium levels
3. (^) Regulation of serum phosphate levels 4. All of the above
4. Newborns are at risk for early vitamin K deficiency bleeding and the American Academy of Pediatrics recommends that all newborns receive: 1. IM vitamin K (phytonadione) within 24 hours of birth
5. (^) Oral vitamin K supplementation in the first 3 weeks of life
6. (^) Formula containing vitamin K or breast milk
7. (^) Oral vitamin K in the first 24 hours after birth
8. Symptoms of folate deficiency include:
9. (^) Thinning of the hair
10. (^) Bruising easily 3. Glossitis
11. (^) Numbness and tingling of the hands and feet
12. A patient with a new onset of systolic ejection murmur should be assessed for which nutritional deficiency? 1. (^) Vitamin B 12 2. (^) Vitamin C 3. Folate 4. (^) Niacine
13. According to the 2003-2006 National Health and Nutrition Examination Survey study of dietary intake, the group at highest risk for inadequate calcium intake was: 1. (^) The elderly (over age 60 years) 2. Teenage females 3. (^) Teenage males 4. (^) Preschoolers
14. Patients with iron deficiency will develop: 1. (^) Hemolytic anemia 2. (^) Megaloblastic anemia 3. (^) Macrocytic-hypochromic anemia 4. Microcytic-hypochromic anemia
15. There is evidence that dietary supplementation or adequate intake of fish oils and omega-3 fatty acids have well-documented: 1. (^) Concern for developing cardiac dysrhythmias 2. Anti-inflammatory effects 3. (^) Total cholesterol-lowering effects 4. (^) Effects on fasting blood sugar
16. There is enough preliminary evidence to recommend that children with autism receive which supplemental nutrient? 1. (^) Vitamin B 1 (thiamine) 2. (^) Vitamin B 2 (riboflavin) 3. (^) Calcium

ANSWERS GRADED A+

4. Omega-3 fatty acids

31. There is sufficient evidence to support the use of omega-3 fatty acids to treat the following disease(s): 1. (^) Asthma 2. Autism 3. (^) Arthritis 4. (^) All of the above
32. It is reasonable to recommend supplementation with in the treatment of hyperlipidemia. 1. (^) Omega-3 fatty acids 2. (^) Probiotics 3. Plant sterols 4. (^) Calcium
33. Probiotics are recommended to be co-administered when are prescribed: 1. (^) Antacids 2. (^) Antihypertensives 3. (^) Antidiarrheals 4. Antibiotics
34. It is reasonable to add to a Helicobacter pylori treatment regimen to improve eradication rates of H. pylori. 1. Probiotics 2. (^) Omega-3 fatty acids 3. (^) Plant sterols 4. (^) Fiber

Chapter 13. Over-the-Counter Medications

1.Michael asks you about why some drugs are over-the-counter and some are prescription. You explain that in order for a drug to be approved for over-the-counter use the drug must:

1. (^) Be safe and labeled for appropriate use
2. (^) Have a low potential for abuse or misuse
3. (^) Be taken for a condition the patient can reliably self-diagnose 4. All of the above 2.In the United States, over-the-counter drugs are regulated by:
4. (^) No one. There is no oversight for over-the-counter medications. 2. The U.S. Food and Drug Administration Center for Drug Evaluation and Research
5. (^) The U.S. Drug Enforcement Administration
6. (^) MedWatch 3.As drugs near the end of their patent, pharmaceutical companies may apply for the drug to change to over- the-counter status in order to:
7. (^) Get a new patent for the over-the-counter form of the drug
8. (^) Lower the costs because most prescription benefit plans do not cover generics
9. (^) Market the drug to a whole new population, as they are able to market to patients instead of just providers

ANSWERS GRADED A+

4. Continue to make large profits from their blockbuster brand-name drug 4.New over-the-counter drug ingredients must undergo the U.S. Food and Drug Administration New Drug Application process, just as prescription drugs do. 1. True

2. (^) False 5.The ailment that generates the greatest over-the-counter annual drug sales is:
3. (^) Constipation 2. Cough and colds
4. (^) Heartburn
5. (^) Acute and chronic pain 6.Common over-the-counter pain relievers such as acetaminophen or ibuprofen:
6. (^) Are always safer for the patient than prescription pain medication 2. Are harmful if taken in higher than recommended amounts
7. (^) Have minimal interaction with prescription medications
8. (^) Should never be given to children unless recommended by their provider 7.When obtaining a drug history from Harold, he gives you a complete list of his prescription medications. He denies taking any other drugs, but you find that he occasionally takes aspirin for his arthritis flare ups. This is an example of:
9. (^) His appropriately only telling you about his regularly prescribed medications
10. (^) His hiding information regarding his inappropriate use of aspirin from you 3. A common misconception that intermittently taken over-the counter medications are not an important part of his drug history
11. (^) A common misuse of over-the-counter aspirin 8.The Combat Methamphetamine Epidemic Act, which is part of the 2006 U.S. Patriot Act:
12. (^) Requires all providers to screen their patients for methamphetamine use
13. (^) Restricts the prescribing of amphetamines to U.S. citizens
14. (^) Requires a prescription be written for all methamphetamine precursors in all states 4. Restricts the sales of drugs that contain methamphetamine precursors, including a daily and 30-day limit on sales 9.When prescribing a tetracycline or quinolone antibiotic it is critical to instruct the patient:
15. (^) Not to take their regularly prescribed medications while on these antibiotics
16. (^) Regarding the need for lots of acidic foods and juices, such as orange juice, to enhance absorption 3. Not to take antacids while on these medications, as the antacid decreases absorption
17. (^) That there are no drug interactions with these antibiotics

chapter 14. Drugs Affecting the Autonomic Nervous System

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1.Charlie is a 65-year-old male who has been diagnosed with hypertension and benign prostatic hyperplasia. Doxazosin has been chosen to treat his hypertension because it:

1. (^) Increases peripheral vasoconstriction
2. (^) Decreases detrusor muscle contractility

ANSWERS GRADED A+

3. (^) Lowers supine blood pressure more than standing pressure 4. Relaxes smooth muscle in the bladder neck 2.To reduce potential adverse effects, patients taking a peripherally acting alpha 1 antagonist should do all of the following EXCEPT:
4. (^) Take the dose at bedtime
5. (^) Sit up slowly and dangle their feet before standing 3. Monitor their blood pressure and skip a dose if the pressure is less than 120/80
6. (^) Weigh daily and report weight gain of greater than 2 pounds in one day 3.John has clonidine, a centrally acting adrenergic blocker, prescribed for his hypertension. He should: 1. Not miss a dose or stop taking the drug because of potential rebound hypertension
7. (^) Increase fiber in the diet to treat any diarrhea that may occur
8. (^) Reduce fluid intake to less than 2 liters per day to prevent fluid retention
9. (^) Avoid sitting for long periods, as this can lead to deep vein thrombosis 4.Clonidine has several off-label uses, including:
10. (^) Alcohol and nicotine withdrawal
11. (^) Post-herpetic neuralgia 3. Both 1 and 2
12. (^) Neither 1 nor 2 5.Jim is being treated for hypertension. Because he has a history of heart attack, the drug chosen is atenolol. Beta blockers treat hypertension by: 1. (^) Increasing heart rate to improve cardiac output 2. Reducing vascular smooth muscle tone 3. (^) Increasing aldosterone-mediated volume activity 4. (^) Reducing aqueous humor production 6.Which of the following adverse effects are less likely in a beta 1 -selective blocker? 1. (^) Dysrhythmias 2. Impaired insulin release 3. (^) Reflex orthostatic changes 4. (^) Decreased triglycerides and cholesterol 7.Richard is 70 years old and has a history of cardiac dysrhythmias. He has been prescribed nadolol. You do his annual laboratory work and find a CrCl of 25 ml/min. What action should you take related to his nadolol? 1. Extend the dosage interval. 2. (^) Decrease the dose by 75%. 3. (^) Take no action because this value is expected in the older adult. 4. (^) Schedule a serum creatinine level to validate the CrCl value. 8.Beta blockers are the drugs of choice for exertional angina because they: 1. (^) Improve myocardial oxygen supply by vasodilating the coronary arteries 2. Decrease myocardial oxygen demand by decreasing heart rate and vascular resistance

ANSWERS GRADED A+

3. (^) Both 1 and 2 4. (^) Neither 1 nor 2 9.Adherence to beta blocker therapy may be affected by their: 1. (^) Short half-lives requiring twice daily dosing 2. (^) Tendency to elevate lipid levels 3. Effects on the male genitalia, which may produce impotence 4. (^) None of the above

10. Beta blockers have favorable effects on survival and disease progression in heart failure. Treatment should be initiated when the: 1. (^) Symptoms are severe 2. (^) Patient has not responded to other therapies 3. (^) Patient has concurrent hypertension 4. Left ventricular dysfunction is diagnosed 11.Abrupt withdrawal of beta blockers can be life threatening. Patients at highest risk for serious consequences of rapid withdrawal are those with: 1. (^) Angina 2. (^) Coronary artery disease 3. Both 1 and 2 4. (^) Neither 1 nor 2
11. To prevent life-threatening events from rapid withdrawal of a beta blocker: 1. (^) The dosage interval should be increased by 1 hour each day. 2. (^) An alpha blocker should be added to the treatment regimen before withdrawal. 3. (^) The dosage should be tapered over a period of weeks. 4. The dosage should be decreased by one-half every 4 days.
12. Beta blockers are prescribed for diabetics with caution because of their ability to produce hypoglycemia and block the common symptoms of it. Which of the following symptoms of hypoglycemia is not blocked by these drugs and so can be used to warn diabetics of possible decreased blood glucose? 1. (^) Dizziness 2. (^) Increased heart rate 3. (^) Nervousness and shakiness 4. Diaphoresis
13. Combined alpha-beta antagonists are used to reduce the progression of heart failure because they: 1. Vasodilate the peripheral vasculature 2. (^) Decrease cardiac output 3. (^) Increase renal vascular resistance 4. (^) Reduce atherosclerosis secondary to elevated serum lipoproteins
14. Carvedilol is heavily metabolized by CYP2D6 and 2C9, resulting in drug interactions with which of the following drug classes? 1. (^) Histamine 2 blockers 2. (^) Quinolones 3. (^) Serotonin re-uptake inhibitors

ANSWERS GRADED A+

4. All of the above

16. Alpha-beta blockers are especially effective to treat hypertension for which ethnic group? 1. (^) White 2. (^) Asian 3. African American 4. (^) Native American
17. Bethanechol: 1. Increases detrusor muscle tone to empty the bladder 2. (^) Decreases gastric acid secretion to treat peptic ulcer disease 3. (^) Stimulates voluntary muscle tone to improve strength 4. (^) Reduces bronchial airway constriction to treat asthma
18. Clinical dosing of Bethanechol: 1. (^) Begins at the highest effective dose to obtain a rapid response 2. Starts at 5 mg to 10 mg PO and is repeated every hour until a satisfactory clinical response is achieved 3. (^) Requires dosing only once daily 4. (^) Is the same for both the oral and parenteral route
19. Patients who need to remain alert are taught to avoid which drug due to its antimuscarinic effects? 1. (^) Levothyroxine 2. (^) Prilosec 3. (^) Dulcolax 4. Diphenhydramine
20. Anticholinesterase inhibitors are used to treat: 1. (^) Peptic ulcer disease 2. Myasthenia gravis 3. (^) Both 1 and 2 4. (^) Neither 1 nor 2
21. Which of the following drugs used to treat Alzheimer’s disease is not an anticholinergic? 1. (^) Donepezil 2. Memantine 3. (^) Rivastigmine 4. (^) Galantamine
22. Taking which drug with food maximizes it bioavailability? 1. (^) Donepezil 2. (^) Galantamine 3. Rivastigmine 4. (^) Memantine
23. Which of the following drugs should be used only when clearly needed in pregnant and breastfeeding women? 1. (^) Memantine 2. Pyridostigmine

ANSWERS GRADED A+

3. (^) Galantamine 4. (^) Rivastigmine

24. There is a narrow margin between first appearance of adverse reaction to AChE inhibitors and serious toxic effects. Adverse reactions that require immediate action include: 1. (^) Dizziness and headache 2. (^) Nausea 3. (^) Decreased salivation 4. Fasciculations of voluntary muscles
25. Adherence is improved when a drug can be given once daily. Which of the following drugs can be given once daily? 1. (^) Tacrine 2. Donepezil 3. (^) Memantine 4. (^) Pyridostigmine
26. Nicotine has a variety of effects on nicotinic receptors throughout the body. Which of the following is NOT an effect of nicotine? 1. Vasodilation and decreased heart rate 2. (^) Increased secretion of gastric acid and motility of the GI smooth muscle 3. (^) Release of dopamine at the pleasure center 4. (^) Stimulation of the locus coeruleus
27. Nicotine gum products are: 1. (^) Chewed to release the nicotine and then swallowed for a systemic effect 2. (^) “Parked” in the buccal area of the mouth to produce a constant amount of nicotine release 3. Bound to exchange resins so the nicotine is only released during chewing 4. (^) Approximately the same in nicotine content as smoking two cigarettes
28. Nicotine replacement therapy (NRT): 1. (^) Is widely distributed in the body only when the gum products are used 2. (^) Does not cross the placenta and so is safe for pregnant women 3. Delays healing of esophagitis and peptic ulcers 4. (^) Has no drug interactions when a transdermal patch is used
29. Success rates for smoking cessation using NRT: 1. (^) Are about the same regardless of the method chosen 2. Vary from 40% to 50% at 12 months 3. (^) Both 1 and 2 4. (^) Neither 1 nor 2
30. Cholinergic blockers are used to: 1. (^) Counteract the extrapyramidal symptoms (EPS) effects of phenothiazines 2. (^) Control tremors and relax smooth muscle in Parkinson’s disease 3. (^) Inhibit the muscarinic action of ACh on bladder muscle 4. All of the above

ANSWERS GRADED A+

31. Several classes of drugs have interactions with cholinergic blockers. Which of the following is true about these interactions? 1. Drugs with a narrow therapeutic range given orally may not stay in the GI tract long enough to produce an action. 2. (^) Additive antimuscarinic effects may occur with antihistamines. 3. (^) Cholinergic blockers may decrease the sedative effects of hypnotics. 4. (^) Cholinergic blockers are contraindicated with antipsychotics.
32. Scopolamine can be used to prevent the nausea and vomiting associated with motion sickness. The patient is taught to: 1. (^) Apply the transdermal disk at least 4 hours before the antiemetic effect is desired. 2. Swallow the tablet 1 hour before traveling where motion sickness is possible. 3. (^) Place the tablet under the tongue and allow it to dissolve. 4. (^) Change the transdermal disk daily for maximal effect.
33. You are managing the care of a patient recently diagnosed with benign prostatic hyperplasia (BPH). He is taking tamsulosin but reports dizziness when standing abruptly. The best option for this patient is: 1. (^) Continue the tamsulosin because the side effect will resolve with continued treatment. 2. Discontinue the tamsulosin and start doxazosin. 3. (^) Have him double his fluid intake and stand more slowly. 4. (^) Prescribe meclizine as needed for the dizziness.
34. You are treating a patient with a diagnosis of Alzheimer’s disease. The patient’s wife mentions difficulty with transportation to the clinic. Which medication is the best choice? 1. Donepezil 2. (^) Tacrine 3. (^) Doxazosin 4. (^) Verapamil
35. A patient presents with a complaint of dark stools and epigastric pain described as gnawing and burning. Which of the medications is the most likely cause?
    1. (^) Acetaminophen
    2. (^) Estradiol
    3. (^) Donepezil 4. Bethanechol
36. Your patient calls for an appointment before going on vacation. Which medication should you ensure he has an adequate supply of before leaving to avoid life-threatening complications? 1. Carvedilol
    2. (^) Donepezil
    3. (^) Bethanechol
    4. (^) Tacrine
37. Activation of central alpha 2 receptors results in inhibition of cardioacceleration and centers in the brain.
    1. (^) Vasodilation 2. Vasoconstriction