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615-Pharm Exam 3 Review Questions And

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1. Mr. Holloway presents to your clinic with a significantly swollen, painful big toe and you diagnose him with gout. Of the following options which would be the best treatment for Mr. Holloway? a. Acetaminophen with codeine b. Low-dose colchicine c. High-dose colchicine d. High-dose aspirin Low-dose colchicine. Low-dose colchicine is 1.2 mg followed by 0.6 mg one hour later or 1.8 mg total. High-dose colchicine is 1.2 mg followed by 0.6 mg Q4 to Q6 hours or 4. mg total. The difference between the two is low-dose is as effective as high-dose with a lower side effect profile.
2. Patient education when prescribing colchicine includes? a. Moderate amounts of alcohol are safe with colchicine b. Colchicine may be constipating c. Colchicine always causes some degree of diarrhea d. Mild muscle weakness is normal Colchicine always causes some degree of diarrhea
3. You have a patient who is taking allopurinol to prevent gout. What labs will you monitor for this patient on allopurinol? a. Blood glucose b. Complete blood count c. BUN, creatinine, and creatinine clearance d. C-reactive protein BUN, creatinine, and creatinine clearance
4. Mr. Thompson has just started taking febuxostat (Uloric) to treat his gout and he needs to be educated on what to expect. a. Feuxostat may cause severe diarrhea b. He will need frequent CBC monitoring c. He should consume a high-calcium diet d. Gout may worsen with therapy Gout may worsen with therapy
5. Ms. Jensen has been on prednisone for 6 months. Patients who have been on prednisone for some time should be assessed for what? a. Iron deficiency anemia b. Renal dysfunction c. Osteoporosis d. Gout Osteoporosis. Prednisone can also worsen diabetic control and you must educate your

patients to report any tarry black stools or abdominal pain.

6. When you place a patient on prednisone and the total dose exceeds 1 gram, what additional drug should you prescribe? a. Naproxen, an NSAID for joint pain b. Omeprazole, a proton-pump inhibitor to prevent PUD c. Metformin, a biguanide to prevent diabetes d. Furosemide, a diuretic to treat fluid retention Omeprazole
7. Janet has fractured her ankle and you give her a prescription for Vicodin (acetaminophen +hydrocodone). What education should you provide before they leave your clinic? a. Okay to double dose if the pain is severe b. Patient should not take any other medications that contain acetaminophen c. Vicodin is not habit forming d. Vicodin may cause loose stools and therefore increase fiber intake Patient should not take any other medications that contain acetaminophen. When you do have a patient who has pain, always start with NSAIDs if they are not contraindicated in your patient. That way if their pain is not controlled you can prescribe a medication that is stronger. My pain is a 3 on the pain scale, can I get a prescription for Dilaudid? Umm, NO!
8. Margaret has been on 60 mg of prednisone for 10 days for her severe asthma exacerbation. Since she is breathing much better it is time to discontinue the medication. What should you know when discontinuing this drug? a. Prednisone can be abruptly discontinued with no adverse effects b. Substitute the prednisone with another anti-inflammatory such as ibuprofen c. Develop a tapering schedule to slowly wean Margaret off the prednisone d. Transition patient onto an inhaled corticosteroid Develop a tapering schedule because tapering helps to avoid both recurrent activity of the underlying disease process and possible cortisol deficiency resulting from the hypothalamic-pituitary-adrenal axis (HPA) suppression during the period of steroid therapy.
9. Patients who are currently on or will start chronic corticosteroid therapy should be monitored for what? a. Stool culture b. Vitamin B c. Serum glucose d. Folate levels Serum glucose. FYI: remember steroid therapy will raise glucose levels even in your nondiabetic patients.
10. Patients with rheumatoid arthritis who are on a chronic low-dose prednisone will need co-treatment with which medications to prevent further adverse effects? a. Vitamin D b. Calcium supplementation c. A bisphosphonate d. All of the above All of the above. FYI: long term steroid therapy can contribute to weakened bones.

11. What is the FDA Black Box Warning for ALL nonsteroidal anti-inflammatory drugs (NSAIDS)? a. Increased risk of developing systemic arthritis with prolonged use

b. Risk of life-threatening rashes, including Stevens-Johnson c. Potential for causing life-threatening gastrointestinal bleeds d. Potential for transient changes in serum glucose levels Potential for causing life-threatening gastrointestinal bleeds (and ulceration and perforation of the stomach or intestines). NSAIDs can also increase the risk of cardiovascular thrombotic events, MI, and stroke, especially with extended use. Elderly patients are at greater risk and can happen without any warning symptoms. So EDUCATE, EDUCATE, EDUCATE!

12. If you are getting ready to prescribe an NSAID, a complete drug history should be conducted as NSAIDs interact with which drug? a. Diphenhydramine (an antihistamine) b. Combined oral contraceptives c. Warfarin (anticoagulant) d. Omeprazole (proton-pump inhibitor) Warfarin. NSAIDs work by inhibiting the cox enzymes. Strathman says to get familiar with the “cox pathway” and how blocking one part of the cox pathway can lead to build up of other different products. NSAIDs stimulate platelet aggregation by the formation of thromboxane-A2 leading to the formation of blood clots. See attachment.
13. Gabriella is a 3-year old diagnosed with otitis media and an upper respiratory infection. You prescribe her an antibiotic (probably amoxicillin) and ibuprofen. What education should the parents receive? a. The ibuprofen dose can be doubled if the pain is severe b. Need to keep Gabriella well hydrated while she is taking ibuprofen c. Ibuprofen is complete safe in children with no known adverse effects as the elderly are more prone to GI events d. The parents can cut the Ibuprofen in half to give to Gabriella Gabriella needs to stay well hydrated while taking ibuprofen. NSAIDs are excreted by the kidneys so it is a good idea to keep them flushed.
14. William is a 78-year old who takes two aspirin every morning while he reads his newspaper to treat arthritis pain in his back. He states the aspirin helps him to “get moving” each day. Lately he has had some heartburn from the aspirin. After you rule out an acute GI bleed, what would be an appropriate course of treatment for William? a. Discontinue the aspirin and switch him to hydrocodone for pain b. Decrease the aspirin dose to one tablet daily c. Add an H2 blocker such as ranitidine to his therapy d. Have William take an antacid 15 minutes before taking the aspirin each day Add an H2 blocker such as ranitidine.
15. Patients prescribed aspirin therapy require education regarding the signs of aspirin toxicity. An early sign of aspirin toxicity is? a. Vomiting b. Tremors c. Black tarry stools d. Tinnitus

Tinnitus.

16. You have a patient that is on long-tern aspirin therapy and what lab should be conducted annually? a. Amylase b. Complete blood count c. Salicylate level d. Urine analysis Complete blood count
17. Monitoring a patient on a high-dose aspirin level includes: a. Salicylate level b. Complete blood count c. Urine pH d. All of the above All of the above
18. Hypoglycemia can result from the action of either insulin or an oral hypoglycemic. Signs and symptoms of hypoglycemia include: a. Diarrhea, abdominal pain, weight loss, and hypertension b. Dizziness, confusion, diaphoresis, and tachycardia c. “fruity” breath odor and rapid respiration d. Easy bruising, palpitations, cardiac dysrhythmias, and coma Dizziness, confusion, diaphoresis, and tachycardia. Hyperglycemia has S/S of polyuria, polydipsia, and weight loss. DKA is “fruity” breath odor, and rapid respirations and include neurologic symptoms of lethargy, focal sign, and obtundation that can progress to coma in later stages.
19. Nonselective beta-blockers and consuming alcohol can create serious drug interactions with insulin because they do what? a. Interfere with the ability of the body to metabolize glucose b. Mask the signs and symptoms of altered glucose levels c. Increase blood glucose levels d. Produce unexplained diaphoresis Mask the S/S of altered glucose levels.
20. Lispro is an insulin analogue produced by recombinant DNA technology. Based on the statements below which is NOT TRUE? a. Duration of action is increased when the dose in increased b. Optimal time of preprandial injection is 15 minutes c. It has no pronounced peak d. It is compatible with neutral protamine Hagedorn insulin Duration of action is increased when the dose is increased is an UNTRUE statement.
21. Metformin is a primary choice of drug to treat hyperglycemia in type 2 diabetes because it: a. Decreases peripheral glucose utilization b. Increases the release of insulin from beta cells c. Decreases glycogenolysis by the liver d. Substitutes for insulin usually secreted by the pancreas

Decreases glycogneolysis by the liver. Metformin’s major effect is to decrease hepatic glucose output by inhibiting gluconeogenesis. It also increases insulin mediated glucose utilization in peripheral tissues such as the muscle and liver (mostly after meals) and has antilopolytic effects that lower serum phreatic concentrations. Which leads to reduced substrate availability for gluconeogenesis. Metformin is also used to decrease cholesterol and triglyceride levels, so it is a very useful drug!

22. When blood glucose levels are difficult to control in type 2 diabetes some form of insulin may be added to the treatment regimen to control blood glucose and limit complication risks. Which of the following statements is accurate based on research? a. Newer premixed insulins are better at lowering HbA1C and postprandial glucose levels than long-acting insulins. b. Premixed insulin analogues are better at lowering HbA1C and have less risk for hypoglycemia. c. Patients who are not controlled on oral agents and have postprandial hyperglycemia can have neutral protamine Hagedorn insulin added at bedtime. d. Premixed insulin analogues and the newer premixed insulins are associated with more weight gain than the oral antidiabetic agents. The answer is: newer premixed insulins are better at lowering HbA1C and postprandial glucose levels than long-acting insulins.
23. The decision may be made to switch from twice daily neutral protamine Hagedorn (NPH) insulin to insulin glargine to improve glycemic control throughout the day. If this is done: a. The initial dose of glargine is 2 to 10 units per day b. Obese patients may require more than 100 units per day c. The initial dose of glargine is reduced by 20% to avoid hypoglycemia d. Patients who have been on high doses of NPH will need tests for insulin antibodies. The initial dose of glargine is reduced by 20% to avoid hypoglycemia
24. Prior to prescribing metformin, you as the provider should: a. Try the patient on insulin b. Tell the patient to increase iodine intake c. Draw a serum creatinine to assess renal function d. Have the patient stop taking any sulfonylurea to avoid dangerous drug interactions. Draw a serum creatinine to assess renal function. FYI: metformin is NOT metabolized and is cleared from the body via tubular secretion and excreted in the urine unchanged.
25. Type 2 diabetes is a complex disorder involving: a. A suboptimal response of insulin-sensitive tissues in the liver b. Absence of insulin production by the beta cells c. Increased levels of glucagon-like peptide in the postprandial period d. Too much fat uptake in the intestine A suboptimal response of insulin-sensitive tissues in the liver.
26. Routine screening of asymptomatic adults for diabetes is appropriate for: a. Individuals who are older than 45 and have a BMI of less than 25 kg/m b. Persons with HDL cholesterol greater than 100 mg/dl

c. Native Americas, African Americans, and Hispanics d. Persons with prediabetes confirmed on at least two occasions Native Americans, African Americans, and Hispanics.

27. The action of “gliptins” is different from other antidiabetic agents because they: a. Are not associated with weight gain b. Act on the incretin system to indirectly increase insulin production c. Have a low risk for hypoglycemia d. Close ATP-dependent potassium channels in the beta cell Act on the incretin system to indirectly increase insulin production (Inhibitors Dipeptidyl peptidase-4 (DPP4)). The mechanism of action of the dpp-4 inhibitors is to increase incretin levels which inhibit glucagon release which in turn increases insulin secretion, decreases gastric emptying, and decreases blood glucose levels.
28. GLP-1 agonists: a. Have been approved for monotherapy b. Directly bind to a receptor in the pancreatic beta cell c. Speed gastric emptying to decrease appetite d. Can be given orally once daily Directly bind to a receptor in the pancreatic beta cell. Glucagon-like peptide- receptor agonist also known as GLP-1 receptor agonist or incretin mimetics are agonists of the GLP-1 receptor. They bind to glucagon-like peptide-1 receptors and cause slowing of gastric emptying and increase insulin secretion by the beta cells of the pancreas. FYI: GLP-1 is normally secreted by L cells of the gastro intestinal mucosa in response to meals.
29. Avoid concurrent administration of exenatide with which of the following drugs? a. Digoxin b. Lovastatin c. Warfarin d. All of the above All of the above. Exenatide is a synthetic version of exendin-4 hormone found in the saliva of the Gila monster and it displays biological properties similar to human glucagon-like peptide or GLP-1, which is a regulator of glucose metabolism and insulin secretion. Basically exenatide enhances glucose-dependent insulin secretion by the pancreatic beta-cell, suppresses inappropriately elevated glucagon secretion and slows gastric emptying.
30. Administration of exenatide is by subcutaneous injection: a. 30 minutes prior to morning meal b. 15 minutes after the evening meal c. 60 minutes prior to the morning and evening meal d. 60 minutes before each meal daily 60 minutes prior to the morning and evening meal
31. Potentially fatal granulocytopenia has been associated with treatment of hyperthyroidism with propylthiouracil (PTU). Patients should be taught to report: a. Tinnitus and decreased salivation b. Hypocalcemia and osteoporosis

c. Laryngeal edema and difficult swallowing d. Fever and sore throat Fever and sore throat. As a provider, you should monitor for vasculitis, a temporary alopecia, rash, aplastic anemia, and acute renal failure. PTU inhibits the enzyme thyroperoxidase, which normally acts in thyroid hormone synthesis by oxidizing the anion iodide (I-) to iodine (I0), facilitating iodine’s addition to tyrosine residues on the hormone precursor thyroglobulin. This is one of the essential steps in the formation of thyroxine (T4).

32. Elderly patients who are started on levothyroxine for thyroid replacement should be monitored for: a. Tachycardia and angina b. Weight gain c. Cold intolerance d. Excessive sedation Tachycardia and angina. Also monitor for insomnia and nervousness. Levothyroxine is a synthetic thyroid hormone that is chemically identical to levothyroxine T4, which is naturally secreted by the follicular cells of the thyroid gland.
33. What should you teach your patients when they are prescribed levothyroxine? Take medication on an empty stomach preferably 30 minutes before breakfast.
34. When methimazole is started for hyperthyroidism it may take to see a total reversal of hyperthyroid symptoms. a. 2 to 4 weeks b. 1 to 2 months c. 3 to 4 months d. 6 to 12 months 6 to 12 months to reverse hyperthyroid symptoms.
35. In addition to methimazole, a symptomatic patient with hyperthyroidism may need a prescription for: a. A calcium channel blocker b. A beta blocker c. Liothyronine d. An alpha blocker A beta-blocker
36. When starting a patient on levothyroxine for hypothyroidism the patient will need follow-up measurement of thyroid function in: a. 2 weeks b. 4 weeks c. 2 months d. 6 months 4 weeks
37. In hyperthyroid states, what organ system other than CV must be evaluated to establish potential adverse issues? a. The liver b. The nails and skin

c. The eye d. The ear The eyes

38. Treatment of a patient with hypothyroidism and cardiovascular disease consists of: a. Levothyroxine b. Liothyronine c. Liotrix d. Methimazole Levothyroxine
39. A woman who is pregnant and has hyperthyroidism is best managed by a specialty team who will most likely treat her with: a. Methimazole b. Propylthiouracil (PTU) c. Radioactive iodine d. Nothing, treatment is best delayed until after her pregnancy ends Propylthiouracil (PTU)
40. Once a patient who is being treated for hypothyroidism returns to euthyroid with normal TSH levels, he or she should be monitored with TSH and free T4 levels every: a. 2 weeks b. 4 weeks c. 2 months d. 6 months 6 months
41. What lab values will you as a provider monitor in your patient on levothyroxine? Blood free thyroxine and TSH levels. This is done 4-8 weeks after the start of treatment or a change in dose. You want to make sure the level is adequate. Once the adequate replacement dose has been established the test can be repeated after six and then 12 months unless there is a change in symptoms.
42. Goals when treating hypothyroidism with thyroid replacement include: a. Normal TSH and free T4 levels b. Resolution of fatigue c. Weight loss to baseline d. All of the above All of the above
43. Insulin is used to treat both types of diabetes. It acts by: a. Increasing beta cell response to low blood glucose levels b. Stimulating hepatic glucose production c. Increasing peripheral glucose uptake by skeletal muscle and fat d. Improving the circulation of free fatty acids Increasing peripheral glucose uptake by skeletal muscle and fat.
44. Sulfonylureas may be added to a treatment regimen for type 2 diabetics when lifestyle modifications and metformin are insufficient to achieve target glucose levels. Sulfonylureas have been moved to Step 2 therapy because they: a. Increase endogenous insulin secretion

b. Have a significant risk for hypoglycemia c. Address the insulin resistance found in type 2 diabetic d. Improve insulin binding to receptors Have a significant risk for hypoglycemia. Refer to the pharm presentations by your classmates.

45. Dipeptidyl peptidase-4 inhibitors (gliptins) act on the incretin system to improve glycemic control. Advantages of these drugs include: a. Better reduction in glucose levels than other classes b. Less weight gain than sulfonylureas c. Low risk for hypoglycemia d. Can be given twice daily Low risk of hypoglycemia. Refer to the pharm presentations by your classmates.
46. What contraindications for therapy with alpha-glucosidase inhibitors? Patients with irritable or inflammatory bowel syndrome because of the flatulence that this drug will produce.
47. What is the dosage schedule for alpha-glucosidase inhibitors? Alpha-glucosidase inhibitors (acarbose) is available in 50 and 100 mg tablets and should be taken with the first bite of each meal. Few people can tolerate more than 300 mg daily.
48. Ethnic groups differ in their risk for and presentation of diabetes. Hispanics: a. Have a high incidence of obesity, elevated triglycerides, and hypertension b. Do best with drugs that foster weight loss, such as metformin c. Both 1 and 2 d. Neither 1 nor 2 Both 1 and 2
49. The drugs recommended for older adults with type 2 diabetes include: a. Second-generation sulfonylureas b. Metformin c. Pioglitazone d. Third-generation sulfonylureas Third-generation sulfonylureas
50. Treatment with insulin for type 1 diabetics: a. Starts with a total daily dose of 0.2 to 0.4 units per kg of body weight b. Divides the total doses into three injections based on meal size c. Uses a total daily dose of insulin glargine given once daily with no other insulin required d. Is based on the level of blood glucose Starts with a total daily dose of 0.2 to 0.4 units per kg of body weight
51. Insulin preparations are divided into categories based on onset, duration, and intensity of action following subcutaneous injection. Which of the following insulin preparations has the shortest onset and duration of action? a. Lispro b. Glulisine c. Glargine

d. Detemir Glulisine

52. The American Heart Association states that people with diabetes have a 2- to 4-fold increase in the risk of dying from cardiovascular disease. Treatments and targets that do not appear to decrease risk for micro- and macro-vascular complications include: a. Glycemic targets between 7% and 7.5% b. Use of insulin in type 2 diabetics c. Control of hypertension and hyperlipidemia d. Stopping smoking Glycemic targets between 7% and 7.5%
53. All diabetic patients with known cardiovascular disease should be treated with: a. Beta blockers to prevent MIs b. Angiotensin-converting enzyme inhibitors and aspirin to reduce risk of cardiovascular events c. Sulfonylureas to decrease cardiovascular mortality d. Pioglitazone to decrease atherosclerotic plaque buildup Angiotensin-converting enzyme inhibitors and aspirin to reduce risk of cardiovascular events.
54. Both angiotensin converting enzyme inhibitors and some angiotensin II receptor blockers have been approved in treating: a. Hypertension in diabetic patients b. Diabetic nephropathy c. Both 1 and 2 d. Neither 1 nor 2 Diabetic nephropathy
55. Protein restriction helps slow the progression of albuminuria, glomerular filtration rate, decline, and end stage renal disease in some patients with diabetes. It is useful for patients who: a. Cannot tolerate angiotensin converting enzyme inhibitors or angiotensin receptor blockers b. Have uncontrolled hypertension c. Have HbA1C levels above 7% d. Show progression of diabetic nephropathy despite optimal glucose and blood pressure control Show progression of diabetic nephropathy despite optimal glucose and blood pressure control.
56. What is the Black Box Warning issued by the FDA regarding the administration of thiazolidinediones (TZDs)? Side effects of TZDs include water retention leading to edema and can potentially be a serious issue in those with unrecognized heart failure. Also, patients taking this medication for more than 1 year are at risk for bladder cancer. You MUST educate your patient to monitor their weight closely, daily would be a good idea to be honest. FYI: Actos is a TZD.
57. What is the onset of action, peak of action, and duration of each insulin preparation?

Rapid-acting insulins like Lispro, Aspart, and Glulisine. The onset is about five minutes and a peek at one hour, duration of about four or five hours. Short acting or regular insulin is sometimes used around mealtime, taken about 30 to 45 minutes before eating. It peeks in three to four hours, and duration is four to 10 hours. Intermediate acting like NPH is mixed with protamine delaying absorption. Insulin looks cloudy and has to be mixed before injected. Its onset is 1 to 1-1/2 and hours; peak of 4 to 10 hours, and duration of 12 to 24 hours. Long acting like Glargine or Levemir(detemir) insulins onset 2 to 4 hours; duration 24 hours with little or no peak. Table 21-8 in our Pharm book page 559

58. When changing from NPH to Glargine insulin, how will you adjust the patient's dose? The initial dose of glargine is reduced by 20% to avoid hypoglycemia. It consists of microcrystals it slowly releases insulin giving a long duration of action of 18 to 26 hours with a peak-less profile. FYI: Pharmacokinetic it resembles basal insulin secretion of a non- diabetic pancreatic beta cells.
59. What are the side effects of insulin therapy? a. Loss of brain cells b. Anxiety and depression c. Hypoglycemia and hypokalemia d. Improved social life Hypoglycemia and hypokalemia
60. Bridgette is a 19-year-old college student with type 1 diabetes. She is on NPH twice daily and Novolog before meals. She usually walks for 40 minutes each evening as part of her exercise regimen. She is beginning a 30-minute swimming class three times a week at 1 p.m. What is important for her to do with this change in routine? a. Delay eating the midday meal until after the swimming class. b. Increase the morning dose of NPH insulin on days of the swimming class. c. Adjust the morning insulin injection so that the peak occurs while swimming. d. Check glucose level before, during, and after swimming. Check glucose level before, during, and after swimming. BG must be checked more often in T1 especially when adding more exercise, which can lower the BG levels. The other answers would cause hypoglycemia either during or after exercise.
61. Bridgette is a 19-year-old college student with type 1 diabetes. Bridgette’s pre-meal BG at 11:30 a.m. is 130. She eats an apple and has a sugar-free soft drink. At 1 p.m. before swimming her BG is 80. What should she do? a. Proceed with the swimming class. b. Recheck her BG immediately. c. Eat a granola bar or other snack with CHO. d. Take an additional dose of insulin. Eat a granola bar or other snack with carbs. Although her BG is normal, it will more than likely drop during exercise so she should eat a CHO source before exercising. A and D

would likely increase her likelihood of hypoglycemia. B would not be helpful in this situation.

62. Mrs. Johnson is on metformin and glipizide arrives at her 11:30 a.m. clinic appointment diaphoretic and dizzy. She reports taking her medication this morning and ate a bagel and coffee for breakfast. BP is 110/70 and random finger-stick glucose is 64. How should this Mrs. Johnson be treated? a. 12 oz apple juice with 1 tsp sugar b. 10 oz diet soda c. 8 oz milk or 4 oz orange juice d. 4 cookies and 8 oz chocolate milk 8 oz milk or 4 oz orange juice. Approximately 15 grams of fast-acting CHO is the treatment of choice. Diet soda would not treat hypoglycemia. The other choices would over treat and cause rebound hyperglycemia.
63. Max is a patient is a 67-year-old male with T2 DM. He is on glipizide and metformin. He presents to the clinic with confusion, sluggishness, and extreme thirst. His wife tells you Max does not follow his meal plan or exercise regularly, and hasn’t checked his BG for 1 week. A random glucose is drawn and it is 500. What is a likely diagnosis based on preliminary assessment? a. Diabetic keto acidosis (DKA) b. Hyperglycemic hyperosmolar syndrome (HHS) c. Infection d. Hypoglycemia HHS is the most likely diagnosis based on diagnosis, age, and signs and symptoms. DKA may occur in T2 diabetes, but initially HHS would be suspect.
64. What would one expected assessment finding be for hyperglycemic hyperosmolar syndrome? a. Low hemoglobin b. Ketones in the urine c. Deep, labored breathing d. pH of 7. Ketones in the urine. Normal pH of 7.35. C and B are indicative of DKA. Hgb may be low, normal or high in HHNKS.
65. What assessment should be made before prescribing any antihypertensive agent? a. Mental health b. Liver and renal function c. Potassium level d. Edema Liver and renal function. The renal function especially for ACE inhibitors and ACE receptor blockers which work primarily in the kidneys.
66. Why are ACE inhibitors the drug of choice for diabetic patients with hypertension? a. Allow the patient to lose weight faster b. Reduce the adverse effects of diabetes on the kidneys c. Dry hacking cough is minimized d. ACE works on some beta cells in the pancreas

They reduce the adverse effects of diabetes on the kidneys. ACE inhibitors slow the onset of diabetic nephropathy in patients with microalbuminuria and type 1 diabetes.

67. What's the most common adverse effect of ACE inhibitors? a. Water retention b. Tachycardia c. Hyponatremia d. Dry hacking cough A dry, hacking cough. That's the most common reason to change treatment from an ACE inhibitor to an ACE receptor blocker otherwise known as ARBs.
68. Which of the following disease processes could be made worse by taking a nonselective beta blocker? a. Asthma b. Diabetes c. Both might worsen d. Beta blockade does not affect these disorders Both asthma and diabetes may worsen.
69. Angiotensin-converting enzyme (ACE) inhibitors treat hypertension because they: a. Reduce sodium and water retention b. Decrease vasoconstriction c. Increase vasodilation d. All of the above All of the above. The renin-angiotensin system is systemically and locally driven. The systemic process is triggered by the kidneys’ response to decreased effective blood volume and begins with the secretion of insulin from the renal cortex. Once released, renin cleaves angiotensinogen to form angiotensin-I. This product in turn is catalyzed by angiotensin converting enzyme or ACE, formed primarily in the pulmonary vasculature and angiotensin-II. This potent vasoconstrictor effects tissues and systems throughout the body, research shows that these vasoconstrictor effects are attenuated by ACE inhibition. Be sure to understand the RAAS system! Refer to the PDF announcements if there is one.
70. Direct renin inhibitors have the following properties. They: a. Are primarily generic drugs b. Are a renin-angiotensin-aldosterone system (RAAS) medication that is safe during pregnancy c. Can be used with an angiotensin-converting enzyme and angiotensin II receptor blocker medications for stronger impact d. “Shut down” the entire RAAS cycle Shut down the entire RAAS cycle
71. When comparing angiotensin-converting enzyme (ACE) and angiotensin II receptor blocker (ARB) medications, which of the following holds true? a. Both have major issues with a dry, irritating cough b. Both contribute to some retention of potassium c. ARBs have a stronger impact on hypertension control than ACE medications

d. ARBs have stronger diabetes mellitus renal protection properties than ACE medications. Both contribute to some retention of potassium

72. An ACE inhibitor and what other class of drug may reduce proteinuria in patients with diabetes better than either drug alone? a. Beta blockers b. Diuretics c. Non-dihydropyridine calcium channel blockers d. Angiotensin II receptor blockers Non-dihydropyridine calcium channel blockers
73. What is a common side effect concern with hypertensive medications and all individuals, but especially the elderly? a. Risk of falls b. Triggering of a hypertensive crisis c. Erectile priapism d. Risk for bladder cancer development Risk of falls. You must educate your patients to sit on the edge of the bed before standing up so they don’t have a hypotensive event.
74. Beta blockers treat hypertension because they: a. Reduce peripheral resistance b. Vaso-constrict coronary arteries c. Reduce norepinephrine d. Reduce angiotensin II production Reduce peripheral resistance
75. What is the mechanism of action of calcium channel blockers? a. Prevent or reduce the opening of calcium channels b. Allow extra potassium into cardiac cells c. Make cells more excitable d. Allows the body to produce more calcium CCB prevent or reduce the opening of calcium channels. In the body's tissues the concentration of calcium ions outside the cells is normally about ten thousand-fold higher than the concentration inside the cells. Embedded in the membrane of some cells are calcium channels and these cells receive a certain signal the channels open letting calcium rush into the cell. The resulting increase in intracellular calcium has different effects on different types of cells. Calcium channel blockers prevent or reduce the opening of these channels and thereby reduce the effects. Voltage-dependent calcium channels are responsible for excitation, contraction, coupling of skeletal smooth and cardiac muscle, and for regulating aldosterone in cortisol secretion in the end of them cells of the adrenal cortex. In the heart, they are also involved in conduction of pacemaker signals.
76. Calcium channel blockers are used as medications and primarily have four effects: a. by acting on vascular smooth muscle they reduce contraction in arteries and causes an increase in arterial diameter a phenomenon called vasodilatations. Calcium channel blockers do not work on venous smooth muscle.

b. by acting on cardiac muscles or the myocardium they reduce the force of the contraction of the heart. c. by slowing down the conduction of electrical activity within the heart they slow down the heart rate. d. by blocking calcium signal on adrenal cortex cells, they reduce aldosterone production which collaborates to lower blood pressure. All of the above.

77. Hypertensive African Americans are typically listed as not being as responsive to which drug groups? a. ACE inhibitors b. Calcium channel blockers c. Diuretics d. Bidil (hydralazine family of medications) ACE inhibitors
78. What are the adverse effects of dihydropyridine-type calcium channel blockers (nifedipine and nicardipine) which work on the vasculature and do not work on the heart? a. Reflex tachycardia b. Worsen proteinuria in patients with neuropathy c. Edema of the hands and feet d. All of the above All of the above
79. What are the adverse effects of statins? a. Rhabdomyolysis b. Increased risk of diabetes c. Increased liver enzymes d. Cognitive loss, neuropathy, pancreatic/hepatic/sexual dysfunction e. All of the above All of the above. Oh boy, sign me up!!!
80. Annamarie has type 2 diabetes and a high triglyceride level. She has gemfibrozil prescribed to treat her hypertriglyceridemia. A history of which of the following might contraindicate the use of this drug? a. Reactive airway disease/asthma b. Inflammatory bowel disease c. Allergy to aspirin d. Gallbladder disease Gallbladder disease
81. When considering which cholesterol-lowering drug to prescribe, which factor determines the type and intensity of treatment? a. Total LDL b. Fasting HDL c. Coronary artery disease risk level d. Fasting total cholesterol Coronary artery disease risk level.

82. First-line therapy for hyperlipidemia is: a. Statins b. Niacin c. Lifestyle changes d. Bile acid-binding resins Lifestyle changes. Based on question 79 I would definitely push for lifestyle changes!
83. What lipid disorders do fibric acids derivatives treat? They mainly treat elevated triglycerides. Fibrates are used as an accessory therapy in many forms of hypercholesterolemia usually in combination with statins. Fibrates reduce the number of nonfatal heart attacks but do not improve all-cause mortality and therefore are indicated in those not tolerant to statins. Although less effective in lowering LDL and triglycerides levels the ability of fibrates to increase HDL and lower triglyceride levels seems to reduce insulin resistance when the dyslipidemia is associated with other features of a metabolic syndrome like hypertension and diabetes type II. They are therefore used in many hyperlipidemias. Fibrates are not suitable for patients with low HDL levels.
84. Jacob is a 49-year-old patient with an LDL level of 120 and normal triglycerides. Appropriate first-line therapy for Jacob may include diet counseling, increased physical activity, and: a. A statin b. Niacin c. Sterols d. A fibric-acid derivative Sterols
85. Mary is a 60-year-old patient with an LDL of 132 and a family history of coronary artery disease. She has already tried diet changes (increased fiber and plant sterols) to lower her LDL and after 6 months her LDL is slightly higher. The next step in her treatment would be: a. A statin b. Niacin c. Sterols d. A fibric-acid derivative A statin
86. Many patients with hyperlipidemia are treated with more than one drug. Combining a fibric acid derivative such as gemfibrozil with which of the following is not recommended? The drug and the reason must both be correct for the answer to be correct. a. Reductase inhibitors, due to an increased risk for rhabdomyolysis b. Bile-acid sequestering resins, due to interference with folic acid absorption c. Grapefruit juice, due to interference with metabolism d. Niacin, due to decreased gemfibrozil activity Reductase inhibitors, due to an increased risk for rhabdo

87. Cynthia is a 65-year-old patient who has been on a lipid-lowering diet and using plant sterol margarine daily for the past 3 months. Her LDL is 135 mg/dL. An appropriate treatment for her would be: a. A statin b. Niacin c. A fibric-acid derivative d. Determined by her risk factors Determined by her risk factors
88. Randy is a 54-year-old male with multiple risk factors who has been on a high-dose statin for 3 months to treat his high LDL level. His LDL is 135 mg/dL and his triglycerides are elevated. A reasonable change in therapy would be to: a. Discontinue the statin and change to a fibric-acid derivative. b. Discontinue the statin and change to ezetimibe. c. Continue the statin and add in ezetimibe. d. Refer him to a specialist in managing patients with recalcitrant hyperlipidemia. Continue the statin and add in ezetimibe
89. Before starting therapy with a statin, the following baseline laboratory values should be evaluated: a. Complete blood count b. Liver function (ALT/AST) and creatinine kinase c. C-reactive protein d. All of the above Liver function (ALT/AST) and creatinine kinase
90. Monitoring of a patient who is on a lipid-lowering drug includes: a. Fasting total cholesterol every 6 months b. Lipid profile with attention to serum LDL 6 to 8 weeks after starting therapy, then again in 6 weeks c. Complete blood count, C-reactive protein, and erythrocyte sedimentation rate after 6 weeks of therapy d. All of the above Lipid profile with attention to serum LDL 6-8 weeks after starting therapy, then again in 6 weeks.
91. When starting a patient on a statin, education would include: a. If they stop the medication their lipid levels will return to pretreatment levels. b. Medication is a supplement to diet therapy and exercise. c. If they have any muscle aches or pain, they should contact their provider. d. All of the above All of the above
92. Niaspan is less likely to cause which side effect that is common to niacin? a. Gastrointestinal irritation b. Cutaneous flushing c. Dehydration d. Headaches Cutaneous flushing

93. When are statins traditionally ordered to be taken? a. At bedtime b. At noon c. At breakfast d. With the evening meal With the evening meal because of the pattern of cholesterol synthesis.
94. Janice has elevated LDL, VLDL, and triglyceride levels. Niaspan, an extended-release form of niacin, is chosen to treat her hyperlipidemia. Due to its metabolism and excretion, which of the following laboratory results should be monitored? a. Serum alanine aminotransferase b. Serum amylase c. Serum creatinine d. Phenylketonuria Serum creatinine
95. Felicity has been prescribed colestipol to treat her hyperlipidemia. Unlike other anti- lipidemics, this drug: a. Blocks synthesis of cholesterol in the liver b. Exchanges chloride ions for negatively charged acids in the bowel c. Increases HDL levels the most among the classes d. Blocks the lipoprotein lipase pathway Exchanges chloride ions for negatively charged acids in the bowel.
96. Which the following persons should not have a statin medication ordered? a. Someone with 3 first- or second-degree family members with history of muscle issues when started on statins b. Someone with high lipids, but low BMI c. Premenopausal woman with recent history of hysterectomy d. Pre-diabetic male with known metabolic syndrome Some with three 1 st^ & 2 nd^ degree family members w/history of muscle issues when started on statins.
97. Ian has been diagnosed with hyperlipidemia. Based on his lipid profile, atorvastatin is prescribed. Rhabdomyolysis is a rare but serious adverse response to this drug. Ian should be told to: a. Become a vegetarian because this disorder is associated with eating red meat. b. Stop taking the drug if abdominal cramps and diarrhea develop. c. Report muscle weakness or tenderness and dark urine to his provider immediately. d. Expect “hot flash” sensations during the first 2 weeks of therapy. Report muscle weakness or tenderness and dark urine to his provider immediately.
98. What lipid disorders do bile acid sequestrants treat (cholestyramine, Cholybar, Oletyr) since they bind bile in the GI tract to prevent its reabsorption? BAS’s are used to reduce low density lipoprotein (LDL) cholesterol levels. Cholestyramine removes bile acids from the body by forming insoluble complexes with bile acids in the intestine which are then excreted in the feces. As a result of this loss of

bile acids or plasma cholesterol is converted to bile acids in the liver to normalize levels. This conversion of cholesterol in a bile acid lowers plasma cholesterol levels.

99. What would you recommend to a patient who is experiencing flushing with niacin therapy? a. Stop activity and rest for 15 minutes b. Take 300 mg of aspirin 30 minutes before taking niacin c. Call 911, it’s an emergency d. Stop drop and roll, you are on fire! Take 300 mg of ASA 30 minutes before taking niacin. The main side effect is flushing which usually last for 15 to 30 minutes, although it can sometimes last up to two hours. It's sometimes accompanied by prickling or itching sensation in particular in areas covered by clothing. So that flushing can be blocked by taking 300 milligrams of aspirin a half an hour before taking niacin.
100. What is considered the order of statin strength from lowest effect to highest? a. Lovastatin, Simvastatin, Rosuvastatin b. Rosuvastatin, Lovastatin, Atorvastatin c. Atorvastatin, Rosuvastatin, Simvastatin d. Simvastatin, Atorvastatin, Lovastatin Lovastatin, Simvastatin, Rosuvastatin
101. How is amlodipine metabolized? It is metabolized in the liver to inactive metabolites via CYP3A
102. Patient teaching related to amlodipine includes: a. Increase calcium intake to prevent osteoporosis from a calcium blockade. b. Do not crush the tablet; it must be given in liquid form if the patient has trouble swallowing it. c. Avoid grapefruit juice as it affects the metabolism of this drug. d. Rise slowly from a supine position to reduce orthostatic hypotension. Avoid grapefruit juice as it affects the metabolism of this drug.
103. What are the side effects of amlodipine while treating HTN and to prevent chest pain and or heart failure? a. common and dose-related can see peripheral edema, dizziness and palpitations, and flushing. b. common not dose-related: include fatigue, nausea, abdominal pain, and somnolence. c. rare side effects include: blood disorders, impotence, depression, insomnia, tachycardia, gingival enlargement, hepatitis, and jaundice. d. All of the above All of the above
104. The NP orders a thyroid panel for a patient on amiodarone. The patient tells the NP that he does not have thyroid disease and wants to know why the test is ordered. Which is a correct response? a. Amiodarone inhibits an enzyme that is important in making thyroid hormone and can cause hypothyroidism.

b. Amiodarone damages the thyroid gland and can result in inflammation of that gland, causing hyperthyroidism. c. Amiodarone is a broad-spectrum drug with many adverse effects. Many different tests need to be done before it is given. d. Amiodarone can cause corneal deposits in up to 25% of patients. Amiodarone inhibits an enzyme that is important in making thyroid hormone and can cause hypothyroidism. Amiodarone is structurally similar to thyroxine which contributes to the effects of amiodarone on thyroid function. Both under and over activity of the thyroid may occur on amiodarone treatment. Treatment of free thyroxine alone may be unreliable in detecting these problems and thyroid stimulating hormone should therefore be checked every six months or TSH should be checked every six months.

105. What dermatological issue is linked to Amiodarone use? a. Increased risk of basal cell carcinoma b. Flare up of any prior psoriasis problems c. Development of plantar warts d. Progressive change of skin tone toward a blue spectrum Progressive change of skin tone toward a blue spectrum, aka Smurf!
106. Commercials on TV for erectile dysfunction (ED) medications warn about mixing them with nitrates. Why? a. Increased risk of priapism b. Profound hypotension c. Development of blue discoloration to the visual field d. Inactivation of the ED medication effect Profound hypotension
107. What patient teaching will you provide when prescribing amiodarone? a. Eyes: side effects include corneal micro deposits and optic neuropathy can occur. So any visual problems using amiodarone definitely see the doctor or provider right away. b. Skin: you can see a bluish-gray discoloration of the skin and photosensitivity so make sure that your patients use sunscreen. c. Lung: you can see some interstitial lung disease. d. You can see both hypo and hyperthyroidism and they should monitor their blood pressure daily! All of the above
108. What are the drug interactions with digoxin since it is a purified cardio- glycoside similar to digitoxin extracted from the foxglove plant digitalas lanata? The most common indication for digoxin are a fib and a flutter with that rapid ventricular response although beta blockers and calcium channel blockers are a better first choice. By slowing down the conduction of the AV node and increasing its refractory period digoxin can reduce the ventricular rate. The arrhythmia insult was not affected but the pumping function of the heart improves owing to improve filling. Digoxin has potentially serious interactions with verapamil, amiodarone, erythromycin, and epinephrine as would be injected by a local with a local in the anesthetic. The

digoxin level should be monitored while taking albuterol; need to monitor renal functions as it's excreted in the kidneys.

109. Which of the following create a higher risk for digoxin toxicity? Both the cause and the reason for it must be correct. a. Older adults because of reduced renal function b. Administration of aldosterone antagonist diuretics because of decreased potassium levels c. Taking an antacid for gastroesophageal reflux disease because it increases the absorption of digoxin d. Doses between 0.25 and 0.5 mg/day Older adults because of reduced renal function.
110. Serum digoxin levels are monitored for potential toxicity. Monitoring should occur: a. Within 6 hours of the last dose b. Because a reference point is needed in adjusting a dose c. After three half-lives from the starting of the drug d. When a patient has stable renal function Because a reference point is needed in adjusting a dose.
111. Isosorbide dinitrate is prescribed for a patient with chronic stable angina. This drug is administered twice daily, but the schedule is 7 a.m. and 2 p.m. because: a. It is a long-acting drug with potential for toxicity. b. Nitrate tolerance can develop. c. Orthostatic hypotension is a common adverse effect. d. It must be taken with milk or food. Nitrate tolerance can develop. Tolerance, is the attenuation or loss of one or several the effects of organic nitrates after long-term administration. Nitroglycerin is used for the treatment of angina, acute myocardial infarction, severe hypertension, and coronary artery spasms. FYI: All organic nitrate regimens using frequent dosing of long acting nitrates (which is about three or more times daily) continuous delivery symptoms transdermal nitroglycerin patches, or continuous IV infusions of nitroglycerin or long- acting preparations, will result in partial or complete nitrate tolerance.
112. Marty is a 55-year-old smoker who has been diagnosed with angina and placed on nitrates. He complains of headaches after using his nitrate. An appropriate reply might be: a. This is a parasympathetic response to the vasodilating effects of the drug. b. Headaches are common side effects with these drugs. How severe are they? c. This is associated with your smoking. Let’s work on having you stop smoking. d. This is not related to your medication. Are you under a lot of stress? Headaches are common side effects with these drugs. In the short run, Glyceryl Trinitrate can cause severe headaches necessitating analgesic administration for relief of pain; severe hypotension; and in certain cases bradycardia. This makes some providers nervous and should prompt caution when starting nitrate administration.
113. To avoid tolerance to long-term nitrate therapy regimens should be: Tailored to provide a 10 to 12-hour nitrate-free interval level when possible.

114. Jose has been prescribed procainamide after a myocardial infarction. He is monitored for dyspnea, jugular venous distention, and peripheral edema because they may indicate: a. Widening of the area of infarction b. Onset of congestive heart failure c. An electrolyte imbalance involving potassium d. Renal dysfunction Onset of congestive heart failure
115. Which of the following is true about procainamide and its dosing schedule? a. It produces bradycardia and should be used cautiously in patients with cardiac conditions that a slower heart rate might worsen. b. Gastrointestinal adverse effects are common so the drug should be taken with food. c. Adherence can be improved by using a sustained release formulation that can be given once daily. d. Doses of this drug should be taken evenly spaced around the clock to keep an even blood level. Doses of this drug should be taken evenly spaced around the clock to keep an even blood level.
116. What are the contraindications to Coumadin while preventing thrombosis and thromboembolisms? Warfarin is contraindicated in pregnancy as it passes through the placental barrier and may cause bleeding in the fetus. Warfarin use during pregnancy is commonly associated with spontaneous abortion, stillbirth, neonatal death, and preterm birth. There are also known teratogens in the incidence of birth defects of infants exposed to Warfarin in- utero (to be around five percent although higher figures up to thirty percent have been reported in some studies) depending on when exposure occurs during pregnancy, two distinct combinations of congenital abnormalities can arise. Warfarin and related 4-hydroxycoumarin containing molecules decreased blood coagulation by inhibiting vitamin K epoxide reductase enzyme that recycles oxidized vitamin K to its reduced form after it has participated in the carboxylation of several blood clot blood coagulation proteins. Mainly prothrombin and factor VII. Despite being labeled a vitamin K antagonist, Warfarin is not antagonize the action vitamin K or rather antagonizes vitamin K recycling depleting active vitamin K. Thus, the pharmacologic action may always be reversed with fresh vitamin K. So, educate your patients to avoid foods with vitamin K such as kale and spinach.
117. What classes of medications are used in the treatment of congestive heart failure? First-line therapy for people with heart failure due to reduced systolic function should include angiotensin converting ACE inhibitors or ACE receptor blockers.

Beta blockers also form part of the first line treatment adding to the improvement in symptoms of mortality provided by ACE inhibitors and ACE receptor blockers. In people who are intolerant of ACE inhibitors or ARBs or who have significant kidney dysfunction the use of combined hydralazine and a long-acting nitrate such isosorbide nitrate is an effective alternative strategy. This regimen has been shown to reduce mortality and people with moderate heart failure it's especially beneficial in African Americans. In African Americans were symptomatic hydralazine and isosorbide nitrate can be added to an ACE inhibitor or ARB. In people with markedly reduced ejection fraction the use of an aldosterone antagonist in addition to beta blockers and ACE inhibitors can improve symptoms and reduce mortality. Second line drugs for congestive heart failure do not conform mortality benefit. Digitalis is one such drug—its narrow therapeutic window; high degree of toxicity, and the failure in multiple trials to show a mortality benefit has reduced its role included our clinical practice. It is now only used in small number of people with poor refractory symptoms or are in a-fib or have chronic low blood pressure. Diuretics have been a mainstay of treatment for the treatment of fluid accumulation and includes diuretics classes such as loop diuretics, thiazide-like diuretics, and potassium-sparing diuretics although widely used evidence of their efficacy is safety limited with the effect exception of spironolactone antagonists.

118. Furosemide is added to a treatment regimen for heart failure that includes digoxin. Monitoring for this combination includes: a. Hemoglobin b. Serum potassium c. Blood urea nitrogen d. Serum glucose Serum potassium. Remember furosemide (Lasix) will waste potassium.
119. Because primary hypertension has no identifiable cause, treatment is based on interfering with the physiological mechanisms that regulate blood pressure. Thiazide diuretics treat hypertension because they: a. Increase renin secretion b. Decrease the production of aldosterone c. Deplete body sodium and reduce fluid volume d. Decrease blood viscosity Deplete body sodium and reduce fluid volume That’s a wrap! Good luck everyone on Pharm Exam 3