Advanced Pharmacology Midterm Exam: Questions and Answers, Exams of Nursing

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NR565 Advanced Pharmacology Midterm

Exam 2024- 2025

What schedule drugs can APRNs prescribe? - ANSWER>>It depends on the governing body in each state. In AZ there are no restrictions on APRN prescribing by schedule. Who determines and regulates prescriptive authority? - ANSWER>>AZ - State Board of Nursing How does limited prescriptive authority impact patients within the healthcare system? - ANSWER>>Creates numerous barriers to quality affordable and acessible patient care. What are the key responsibilities of prescribing? - ANSWER>>1. Be prudent and deliberate in your decision-making process

2. Have a documented provider-patient relationship with the person for whom you are prescribing
3. Do not prescribe medications for family or friends or for yourself
4. Document a thorough history and physical examination in your records 5.Include any discussions you have with the patient regarding risk factors, side effects, or therapy options
5. Have a documented plan regarding drug monitoring or titration, if applicable. What should be used to make prescribing decisions? - ANSWER>>Cost, availability, current practice guidelines, medication interactions with food side effects need for monitoring how drug is metabolized. special populations. ask if prescriptions are cost prohibitive. Be familiar with pharmacokinetic and pharmacodynamic changes of older adults and how that would translate to baseline information needed to prescribe. - ANSWER>>Older adults often metabolize drugs more slowly. Dosages may need to be adjusted to accommodate age related changes in GI system, liver function, kidney function, etc. What is the BEERS criteria? - ANSWER>>lists potentially inappropriate drugs that lead to adverse effects in the elderly

why is the BEERS criteria important? - ANSWER>>It provides a list of medications that are potentially harmful in elderly. List that identifies drugs with a high likelihood of causing adverse effects in older adults. Beers Criteria are recommendations; ultimately prescribers must determine whether a medication is appropriate for use or not. These guidelines are not intended to limit the use of medications or apply to all older adults. Safe and judicious prescribing is crucial in the older adult to optimize pharmacotherapy. Impacts/outcomes of polypharmacy - ANSWER>>- drug interactions with mild side effects to life-threatening consequences CYP450 inhibitors - ANSWER>>inhibit metabolism, increase blood levels of medications CYP450 inhibitors mnemonic ^ drug levels - ANSWER>>CRACK AMIGOS Cimetidine Ritonavir Amiodarone Ciprofloxacin Ketoconazole Acute Alcohol Use Macrolides Isoniazid Grapefruit Juice Omeprazole Sulfonamides CYP450 inducers mnemonic - ANSWER>>Bull Shit CRAP GPS induces my rage. Barbiturates St. John's wort Carbamzapine Rifampin Alcohol (Chronic use) Phenytoin Griseofulvin Phenobarbital

Sulfonylureas CYP450 inducers - ANSWER>>increase rate of metabolism breaking down more drug. Subsequently reducing the therapeutic concentration of the drug. What happens when someone has a poor metabolism phenotype? - ANSWER>>medications metabolized slower, medication might not work or put them at risk for side-effects What does the US food and drug administration regulate when it comes to medications? - ANSWER>>Whether the drug is safe, effective, and benefits of a drug outweigh the risks reasons for medication non-adherence - ANSWER>>forgetfulness, lack of planning, cost, dissatisfaction, altered dosing black box warning - ANSWER>>A type of warning that appears in a drug's prescribing information and is required by the U.S. Food and Drug Administration (FDA) to alert prescribers of serious adverse events that have occurred with the given drug. Neonate and infant drug absorption Be familiar with general development and when absorption would reach adult levels - ANSWER>>Drug absorption is different up to 2 years of age and is affected by the maturation process of various organs. Common fears with genetic testing - ANSWER>>Lack of education - many health care providers do not possess the knowledge or comfort to interpret the results financial cost - many insurance plans do not cover this. cost can be from $100-2000. discrimination from employers, insurance companies or providers Guiding principles for prescribers for Opioids - ANSWER>>CDC Clinical Practice Guideline for Prescribing Opioids for Pain — United States, 2022 Examples of pure opioid agonists - ANSWER>>Morphine (strong or moderate-strong) Codeine (moderate-strong)

What is used to calculate a patients overdose risk? - ANSWER>>Calculate morphine milligram equivalent how would you know when to refer someone to a pain specialist for pain management? - ANSWER>> CYP450 inducers - ANSWER>>Increase the hepatic metabolism rate, decreasing the therapeutic drug levels in the body. CYP450 inducers mnemonic (decrease drug levels) - ANSWER>>CRAP GPS Carbamazepine Rifampicin Alcohol Phenytoin Griseofulvin Phenobarbitone Sulphonylureas What happens when someone has a poor metabolism phenotype? - ANSWER>>A poor metabolism phenotype means that drug metabolism is decreased leading to improper or unexpected drug response. What does the FDA regulate when it comes to medications? - ANSWER>>the safety and effectiveness of drugs sold in the United States reasons for medication non-adherence - ANSWER>>1. patient feels not needed

2. affordability
3. side effects
4. forgetfulness
5. lack of info
6. lack of disease concern
7. poor social support
8. low reaction satisfaction
9. poor physician relationship black box warning - ANSWER>>A type of warning that appears in a drug's prescribing information and is required by the U.S. Food and Drug

Administration (FDA) to alert prescribers of serious adverse events that have occurred with the given drug. neonate drug absorption - ANSWER>>Slow and erratic due to low blood flow in muscles in the first few days of life infant medication absorption - ANSWER>>Increased absorption due to delayed gastric emptying medications avoided in pediatric patients - ANSWER>>Glucocorticoids, tetracyclines, sulfonamides, levofloxacin, and aspirin common fears from genetic testing - ANSWER>>discrimination guiding principles for prescribing opioids - ANSWER>>CDC clinical practice guidelines Opioids are not first-line therapy Establish goals for pain and function Discuss risks and benefits Use immediate-release opioids when starting Use the lowest effective dose Prescribe short durations for acute pain Evaluate benefits and harms frequently Use strategies to migrate risk Review PDMP data Use urine drug testing Avoid concurrent opioid and benzo prescribing Offer treatment for opioid use disorder Pure opioid agonists - ANSWER>>morphine methadone fentanyl heroin oxycodone hydrocodone opium What is used to calculate a patient's overdose risk? - ANSWER>>total morphine milligram equivalent (MME) example:

50 MME/day:50 mg of hydrocodone (10 tablets of hydrocodone/ acetaminophen 5/300) 33 mg of oxycodone (~2 tablets of oxycodone sustained-release 15 mg) 12 mg of methadone ( <3 tablets of methadone 5 mg) greater than or equal to 50 is reason for considering a taper. greater than or equal to 90 is reason for intervention. How would you know when to refer a patient to a pain specialist for pain management? - ANSWER>>If the cause of the pain is known (or unknown), serious disease is excluded, no curative treatment is readily available, current treatment is not helping, or the pain interferes with daily function, referral to a pain specialist should be considered. Prescription Drug Monitoring Program (PMDP) - ANSWER>>Electronic database that tracks controlled substance prescriptions. How hepatic function affects medication levels in the body - ANSWER>>The liver's metabolism of drugs depends on hepatic blood flow and liver enzyme levels. How renal function affects medication levels in the body - ANSWER>>The kidneys filter both prescription and non-prescription medications. If kidneys do not have proper blood flow or are damaged medication levels can build up in the body. How to assess someone for a possible drug diversion - ANSWER>>Drug diversion is the transfer of a prescription drug from a lawful to an unlawful channel of distribution or use. I: Identify where diversion occurs in the healthcare environment II: Identify workers at risk for drug diversion III: Define a comprehensive drug diversion program IV: Engage leadership V: Tap into technology VI: Incorporate approach into culture and training When should naloxone be prescribed for a patient? - ANSWER>>- Providers should consider offering naloxone to patients when the following factors that increase risk of an opioid overdose are present

• history of nonfatal OD
• hx of substance abuse disorder
• higher opioid dosages (>50 MME/day)
• Concurrent benzo use
• high risk of returning to a dose to which tolerance is no longer expected, such as when a pt is released from jail What behaviors predict a controlled substance addiction? - ANSWER>>risk-taking neglecting responsibility legal trouble physical signs of drug abuse bloodshot eyes with abnormal pupil dilation appetite changes changes in sleep patterns appearing fearful or anxious for no apparent reason other behaviors may be present Schedule II drugs - ANSWER>>have a high potential for abuse but have an accepted medical use examples: hydromorphone, oxycodone, and fentanyl US drug enforcement administration (DEA) description of scheduled drugs
• ANSWER>>Drugs, substances, and certain chemicals used to make drugs are classified into five (5) distinct categories or schedules depending upon the drug's acceptable medical use and the drug's abuse or dependency potential. The abuse rate is a determinate factor in the scheduling of the drug; for example, Schedule I drugs have a high potential for abuse and the potential to create severe psychological and/or physical dependence. As the drug schedule changes-- Schedule II, Schedule III, etc., so does the abuse potential-- Schedule V drugs represent the least potential for abuse. Schedule I has no accepted medical use. treatment of chronic pain
• how should osteoarthritis be treated? - ANSWER>>topical NSAIDs NSAIDs injections of corticosteroid hyaluronic acid injections PRP/stem cell injections

Methadone (Dolophine) - ANSWER>>Abstinence maintenance med. Binds with opiate receptors in CNS to produce analgesic and euphoric effects. Prevents withdrawal symptoms in clients who were addicted to opiate drugs. Precautions/interactions: do not use in clients who have severe asthma, chronic respiratory disease, or a history of head injury. Side/adverse effects: sedation, respiratory depression, paradoxical CNS excitation. black box warning: respiratory depression buprenorphine/naloxone - ANSWER>>Because of buprenorphine's opioid effects, it can be misused, particularly by people who do not have an opioid dependency. Naloxone is added to buprenorphine to decrease the likelihood of diversion and misuse of the combination drug product. pregablin instead of opioid for chronic pain - ANSWER>>nerve pain how to treat hypertension - ANSWER>>thiazide diuretics ACE-I ARBs CCB BB which antihypertensive is best for diabetics? - ANSWER>>ACE-I or ARB What is the best approach at treating someone who is pregnant or who may become pregnant for hypertension? - ANSWER>>labetalol methyldopa MOA of antihypertensive drugs - ANSWER>>Thiazide diuretics MOA blockade of sodium and chloride reabsorption. increases renal excretion of sodium, chloride, potassium, and water (hyponatremia, hypochloremia, hypokalemia) ACE inhibitors MOA Angiotensin Converting Enzyme Inhibitors (ACE-I) prevent the conversion of angiotensin I to angiotensin II, which disrupts the renin-angiotensin- aldosterone system (RAAS). Reduce levels of angiotensin II (through

inhibition of ACE)2. increasing levels of bradykinin (through inhibition of kinase 11) End in - pril ARBS MOA Block angiotensin II receptors on blood vessels in the heart and adrenals. Increases renal excretion of sodium and water. Cause dilation of arterioles and veins. End in - sartan CCB MOA They work by preventing calcium from entering the cells of the heart and arteries. Calcium causes the heart and arteries to squeeze (contract) more strongly. By blocking calcium, calcium channel blockers allow blood vessels to relax and open. blockade of peripheral arterioles causes dilation and reduces arterial pressure, arterioles of the heart increase coronary perfusion, blockade of the SA node reduces heart rate, decreases AV node conduction, myocardium decreases the force of contraction Ethnic considerations for antihypertensive medications - ANSWER>>For African Americans which class of HTN medications is appropriate? thiazide, CCB, BBS avoid the use of ACE-I and ARBs in African American population Prescribing considerations when carbamazepine is prescribed with warfarin. - ANSWER>>Carbemazepine is an inducer. When prescribing warfarin with carbamazepine, the warfarin is less effective. Close monitoring of PT and INR to make adjustments in warfarin dosing is necessary. Beta Blockers - ANSWER>>-Beta Blockers suppress nitroglycerin-induced tachycardia. They do so by preventing sympathetic activation of beta- 1 adrenergic receptors in the heart.

• End in - olol
• Stopping abruptly can increase the incidence and intensity of anginal attacks and may even precipitate MI
• May cause bronchospasm Diuretics - ANSWER>>-Sulfa Allergy
• Pts with severe renal impairment and/or cardiovascular issues
• History of gout-diabetes

• hyperlipidemia
• weight
• vitals
• blood glucose
• BUN & creatinine/kidney function
• electrolytes - sodium, potassium, calcium, magnesium heart failure treatment - ANSWER>>diuretics, RAAS inhibitors, beta blockers, digoxin what to prescribe in response to fibrotic changes - ANSWER>>ACE-I since it inhibits cardiac remodeling Entresto (sacubitril/valsartan) angiotensin receptor neprilysin inhibitor (ANRI) effects of cardiac glycosides - ANSWER>>Increased force of myocardial contraction Increased cardiac output and renal perfusion Increased urine output and decreased blood volume Slowed heart rate Decreased conduction velocity through the AV node positive ionotropic effect What happens when quinidine and digoxin are combined? - ANSWER>>Quinidine (antidysrhythmic) can cause plasma levels of digoxin to rise if taken concurrently.
• displaces digoxin from binding sites
• reduces renal excretion of digoxin both these actions increase the chance of digoxin toxicity when the medications are taken together. Atherosclerotic Cardiovascular Disease (ASCVD) risk score - ANSWER>>ASCVD risk assessment is directed at determining the patient's absolute risk of developing the clinical coronary disease over the next 10 years. Defines high risk as 7.5% or greater. A calculation of your 10 - year risk of having a cardiovascular problem, such as a heart attack or stroke.

In children, screening should be done between ages 9 and 11 and then again at ages 19 and 21. For adults every 5 years after the age of 20. Some people are at greater risk like those with diabetes and a risk score greater than 7.5% and should be screened more often. hyperlipidemia - ANSWER>>excessive amounts of lipids in the blood Statin drugs - ANSWER>>avoid use in children under the age of 10 Ezetimibe (Zetia) - ANSWER>>Cholesterol Absorption Inhibitor- lowers cholesterol levels by decreasing the amount of cholesterol that is absorbed from the small intestine so that there is less intestinal cholesterol delivered to the liver. Does not affect triglycerides contraindicated pregnancy/breastfeeding can be used in monotherapy or as adjunct therapy with a statin or a fibrate Pharmacological option to minimize side effects

• In other words, how would you treat high cholesterol if someone was concerned about or experiencing side effects from other medications? Which drug classification would be a good choice? - ANSWER>>If the statins are causing side effects, ezetimibe, bile acid sequestrants, or fibrates can be used to manage cholesterol. Liver issues, gallbladder issues and constipation should be looked at prior to starting any non-statin cholesterol-lowering therapy therapeutic action of organic nitrates - ANSWER>>direct relaxant effect on vascular smooth muscles, and the dilation of coronary vessels improves oxygen supply to the myocardium. The dilation of peripheral veins, and in higher doses peripheral arteries, reduces preload and afterload and thereby lowers myocardial oxygen consumption. promote vasodilation contraindications for ranolazine - ANSWER>>-QT prolongation and drugs that may cause QT prolongation
• Liver impairment
• Renal impairment CYP3A4 inhibitors. can cause torsades

most appropriate treatment for osteoarthritis - ANSWER>>Non Opioid medications - NSAIDs, cox-2 inhibitorsNonpharmacologic tx - heat/cold, yoga, physical therapy, exercise, healthy weight complications of untreated gout - ANSWER>>Erosion and irreversible joint damage, renal damage, tophi (stone deposits in joints and tissues) treating a gout flare-up with colchicine patient education - ANSWER>>-Only when needed to relieve an attack:

• Start taking this medicine at the first sign of the attack for best results.
• Stop taking this medicine as soon as the pain is relieved or at the first sign of nausea, vomiting, stomach pain, or diarrhea.
• the you wait to start with the attack, the less effective it might be Acute attack (Colcrys only): 1.2 mg at first sign of the flare, followed by 0. mg 1 h later (maximum, 1.8 mg/24 h). Prophylaxis (Colcrys, Mitigare): 0.6 mg once or twice daily (maximum, 1. mg/24 h). what condition can long term use of allopurinol cause - ANSWER>>severe cutaneous adverse reaction (SCAR) rash fever eosinophilia liver and kidney dysfunction allopurinol drug interactions - ANSWER>>warfarin, theophylline, ampicillin, mercaptopurine and azathioprine (immunosuppressants) what should be coadministered with febuxostat - ANSWER>>prophylactic NSAIDs or colchicine therapy NSAIDs black box warning - ANSWER>>All NSAIDs (except aspirin) share a black box warning regarding an increased risk of adverse cardiovascular thrombotic events, including fatal MI and stroke. NSAIDs may counteract the cardioprotective effects of aspirin. NSAIDs drug interactions - ANSWER>>other NSAIDs, alcohol, warfarin (blood thinners), ACE inhibitors, and diuretics

NSAID therapeutic actions - ANSWER>>relieve pain/discomfort reduce inflammation reduce fever NSAID MOA - ANSWER>>Inhibit COX and thus decrease production of thromboxanes, prostaglandins and prostacyclins Anti-inflammatory action: inhibits prostaglandins Analgesic action: inhibits PGE2 sensitization of nerve endings Antipyretic action: inhibit PGE2 from effecting anterior hypothalamus What baseline diagnostics are needed for all DMARDs - ANSWER>>CBC w/diff s/s of infection such as Tb/hepatitis screen for skin malignancies r/o pregnancy liver/renal function immunocompetence comprehensive h&p to allow for monitoring changes from baseline therapeutic response for methotrexate - ANSWER>>3-6 weeks for symptom improvement, 12 weeks to feel full effects RA tx during pregnancy - ANSWER>>high risk in pregnancy with RA?- methotrexatele flunomide biologics: anti-TNF agents, rituximab and abatacept (end in - mab) safe for pregnancy with RA ?-NSAIDs, corticosteroids, plus several DMARDs, including sulfasalazine and hydroxychloroquine Osteoporosis Alendronate - Patient education Ibandronate - Which dietary supplement can interfere with absorption? - ANSWER>>Alendronate patient education on the risk of esophagitis by swallowing the pill whole with a full glass of water, then sitting up for at least 30 min, but 60 min preferred. intake of food prevents absorption, take this med 30 min prior to other intakes Which dietary supplement interferes with Ibandronate absorption?

• calcium, magnesium, iron hydrocodone/acetaminophen - ANSWER>>Pain

5mg/325mg- 1 - 2 tabs q4-6h 7.5mg/325mg- 1tab q 4 - 6h 10mg/325mg- 1tab q4-6h Lisinopril (ACE Inhibitor) - ANSWER>>HTN- 10 - 40 mg once/d HF- 20 - 40 mg once/day Acute MI- 10 mg once/day for at least 6 weeks Amlodipine - ANSWER>>Essential HTN & Angina 5 - 10mg/daily Colchicine - ANSWER>>Gout attack start tx at the first sign of attack, and stop use is side effects occur 0.6-1.2mg q12h-daily as recommended