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D116 Comprehensive assessment with
explanations
1. Which factors could be attributed to limited prescriptive authority for
APRNs?Select all that apply.: Inaccessibility of patient care Feedback: Limiting prescriptive authority for APRNs can create barriers to quality, attordable, and accessible patient care. It may also lead to poor collaboration among providers and higher health care costs. It would not directly impact patient's health literacy. Higher health care costs Feedback: Limiting prescriptive authority for APRNs can create barriers to quality, attordable, and accessible patient care. It may also lead to poor collaboration among providers and higher health care costs. It would not directly impact patient's health literacy.
2. A patient reports that a medication prescribed for recurrent migraine headaches
is not working. Which action should be taken first?: Ask the patient about the number and frequency of tablets taken Feedback: using the drug as ordered. Asking the patient to tell the nurse how many tablets are taken and how often helps the nurse determine compliance. Assessing current pain does not yield information about how well the medication is working unless the patient is currently taking it. The nurse should gather as much information about compliance, symptoms, and drug attentiveness as possible before contacting the prescriber. Biofeedback may be an ettective adjunct to treatment, but it should not be recommended without complete information about drug attentiveness
3. A patient is receiving intravenous gentamicin. A serum drug test reveals tox-ic
2 / 23 levels. The dosing is correct, and this medication has been tolerated bythis patient inthe past. Which could be a probable cause of the test result?: The patient is taking another medication that binds to serum albumin Feedback: Gentamicin binds to albumin, but only weakly, and in the presence of another drug that binds to albumin, it can rise to toxic levels in blood serum. A loading dose increases the initial amount ofa drug and is used to bring drug levels to the desired plateau more quickly. A drug that is not completely dissolved carries a risk of causing embolism. A drug given at a frequency longer than the drug half-life will likely be at subtherapeutic levels and not at toxic levels
4. The nurse is administering morning medications. The nurse gives a patient
multiple medications, two of which compete for plasma albumin receptor sites. As a result of this concurrent administration, the nurse can anticipate that what might occur? Select all that apply: Binding of one or both agents will be reduced Plasma levels of free drug will rise The increase in free drug will intensify ettects Feedback: When two drugs bind to the same site on plasma albumin, coadministration of those drugs produces competition for binding. As a result, binding of one or both agents is reduced, causing plasma levels of free drug to rise. The increase in free drug can intensify the ettect, but it usually undergoes rapid elimination. The increase in plasma levels of free drug is rarely sustained.
5. Which patients are at increased risk for adverse drug events? Select all that apply:
A 2-month-old infant taking a medication for gastroesophageal reflux disease A 40-year-old male who is intubated in the intensive care unit and taking antibiotics and cardiac medications A 7-year-old female receiving insulin for diabetes
4 / 23 therapeutic ettect and adverse ettects asthat given by other routes, except that localized skin reactions may occur and are common with clonidine patches. The patch should be applied to intact, hairless skin on the upper arm or torso
9. A psychiatric nurse is teaching a patient about an antidepressant medica-tion.
The nurse tells the patient that therapeutic effects may not occur for several weeks. The nurse understands that this is likely the result of:: changes in the brain as a result of prolonged drug exposure Feedback: It is thought that beneficial responses to central nervous system (CNS) drugs are delayed because they result from adaptive changes as the CNS modifies itself in response to prolonged drug exposure, and that the responses are not the result of the direct ettects of the drugs on synaptic functions. The blood-brain barrier prevents protein-bound and highly ionized drugs from crossing into the CNS, but it does not slow the ettects of drugs that can cross the barrier. Tolerance is a decreased response to a drug after prolonged use
10. A 25-year-old patient has been newly diagnosed with Parkinson disease, and
the prescriber is considering using pramipexole [Mirapex]. Before begin-ning therapy with this drug, the nurse will ask the patient about:: any history of alcohol abuse or compulsive behaviors Feedback: Pramipexole has been associated with impulse control disorders, and this risk increases in patients with a history of alcohol abuse or compulsive behaviors. Pramipexole increases the risk of hypotension and sleep attacks, so a history of hypertension or insomnia would not be cautionary. Unlike with levodopa, the risk of psychoses is not increased.
11. A nurse is preparing to administer memantine [Nemanda] to a patient and
notes a slight elevation in the patient's creatinine clearance level. What will the nurse expect the provider to order for this patient?: Continuing the memantine as ordered
5 / 23 Feedback: Patients with severe renal impairment may require a dosage reduction. Adding sodium bicarbonate would alkalinize the urine and increase memantine levels, causing toxicity. It is not necessary to discontinue or decrease the dose of the memantine with mild or moderate renal impairment.
12. A nurse is teaching a group of nursing students about the use of meman-
tine [Namenda] for Alzheimer disease. Which statement by a student indicates understanding of the teaching?: "Memantine modulates the ettects of glutamate to alter calcium influx into neurons." Feedback: Memantine modulates the ettects of glutamate, which is involved in calcium influx into neuronal cells. Memantine is used for patients with moderate to severe AD. Memantine does not prevent calcium from leaving cells; it only attects the influx of calcium. In studies, although the ettects of memantine and donepezil appear to be synergistic or may confer independent benefits, they only demonstrate improvement in cognitive function and not a stop in disease progression
13. A patient will begin taking a cholinesterase inhibitor for early Alzheimer
disease. The nurse is teaching the patient's spouse about the medication. Which statement by the spouse indicates a need for further teaching?: "This drug significantly slows the progression of the disease." Feedback: Cholinesterase inhibitors produce modest improvements in cognition, behavior, and function and may slightly delay disease progression; they do not have a major impact on delaying progression of the disease. Gastrointestinal symptoms are common side ettects. Drugs that block cholinergic receptors, including antihistamines, can reduce therapeutic ettects and should be avoided. Cholinesterase inhibitors do not attect neurons already damaged, but they do improve function in those not yet attected
7 / 23 lower than with ACE inhibitors. They do not promote the accumulation of bradykinin in the lungs and produce a lower incidence of cough. An increased risk of cancer may be a concern with ARBs but is not a concern with ACE inhibitors. As with ACE inhibitors, renal failure can occur in patients with bilateral renal artery stenosis or stenosis in the artery to a single remaining kidney Hyperkalemia Feedback: ARBs do not produce clinically significant hyperkalemia. Angioedema may occur with ARBs, but the incidence is lower than with ACE inhibitors. They do not promote the accumulation of bradykinin in the lungs and produce a lower incidence of cough. An increased risk of cancer may be a concern with ARBs but is not a concern with ACE inhibitors. As with ACE inhibitors, renal failure can occur in patients with bilateral renal artery stenosis or stenosis in the artery to a single remaining kidney
17. A nurse administers an ACE inhibitor to a patient who is taking the drug
for the first time. What will the nurse do?: Instruct the patient not to get up without assistance. Feedback: Severe hypotension can result with the first dose of an ACE inhibitor. The patient should be discouraged from getting up without assistance. Potassium supplements are contraindicated. A dry cough is an expected side ettect that eventually may cause a patient to discontinue the drug; however, it is not a contraindication to treatment. Diuretics can exacerbate hypotension and should be discontinued temporarily when a patient starts an ACE inhibitor.
18. A female patient taking an ACE inhibitor learns that she is pregnant. What
will the nurse tell this patient?: The patient should stop taking the medication and contact her provider immediately Feedback: ACE inhibitors are known to cause serious fetal injury during the second and third trimesters of pregnancy. Whether injury occurs earlier in pregnancy is unknown, and the incidence probably is low. However, women should be counseled to stop taking the drug if they become pregnant, and they should not take it if they are contemplating becoming pregnant. Women who
8 / 23 take ACE inhibitors in the first trimester should be counseled that the risk to the fetus is probably low. Women should stop taking the drug when pregnant. ARBs carry the same risk as ACE inhibitors.
19. Apatient has begun taking anHMG-COA reductase inhibitor. Which state-
ment about this class of drugs made by the nurse during patient education would be inappropriate?: "You should come into the clinic for liver enzymes in 1 month." Feedback: Baseline liver enzyme tests should be done before a patient starts taking an HMG-COA reductase inhibitor. They should be measured again in 6 to 12 months unless the patient has poor liver function, in which case the tests
10 / 23 hypertension. Thiazide diuretics promote hyperglycemia.
23. A patient has been taking digoxin [Lanoxin] 0.25 mg, and furosemide [Lasix] 40
mg, daily. Upon routine assessment bythe nurse, the patient states, "I see yellow halos around the lights." The nurse should perform which action based on this assessment?: Check the patient for other symptoms of digitalis toxicity. Feedback: Yellow halos around lights indicate digoxin toxicity. The use of furosemide increases the risk of hypokalemia, which in turn potentiates digoxin toxicity. The patient should also be assessed for headache, nausea, and vomiting, and blood should be drawn for measurement of the serum digoxin level. The nurse should not withhold the dose of furosemide until further assessment is done, including measurement of a serum digoxin level. No evidence indicates that the patient is in worsening heart failure. Documentation of findings is secondary to further assessment and prevention of digoxin toxicity.
24. A patient tells a nurse that she is thinking about getting pregnant and asks
about nutritional supplements. What will the nurse recommend?: 400 to 800 mg of folic acid per day Feedback: The current recommendation is that all women of childbearing age receive folic acid supplementation to prevent the development of neural tube defects that can occur early in pregnancy. Dietary folic acid is not suflcient to provide this amount. Iron supplements are given when pregnancy occurs and are not necessary before becoming pregnant. Vitamin B12 supplements are not recommended
25. Which finding would indicate that terazosin has been effective for a patient
with BPH?: Improved urinary hesitation Feedback: Terazosin is an alpha1-adrenergic antagonist. These medications relax the smooth muscles of the bladder neck to improve urinary symptoms experienced with BPH. They do not decrease the size of the prostate. Increased urinary frequency
11 / 23 is a sign of worsening BPH, not improvement.
26. A patient with stable COPD is prescribed a bronchodilator medication.
Which type of bronchodilator is preferred for this patient?: A long-acting inhaled beta agonist Feedback: LABAs are preferred over SABAs for COPD. Oral beta2 agonists are not first-line therapy. Although theo-phylline, a methylxanthine, was once standard therapy in COPD, it is no longer recommended. It is used only if beta2 agonists are not available
27. A patient with asthma comes to a clinic for treatment of an asthma ex-
acerbation. The patient's medication history lists an inhaled glucocorticoid, montelukast [Singulair], and a SABA as needed via MDI. The NP assesses the patient and notes a respiratory rate of 18 breaths/minute, a heart rate of 96 beats/minute, and an oxygen saturation of 95%. The nurse Practitioneraus-cultates mild expiratory wheezes and equal breath sounds bilaterally. What will the nurse do?: Question the patient about how much albuterol has been used Feedback: To determine the next course of action, it is important to assess the drugs given before these symptoms were observed. Patients who continue to wheeze after using a SABA need systemic glucocorticoids and nebulized albuterol. If a SABA has not been used, that will be the first intervention. LABAs are not used for exacerbations. If a patient reports using a SABA without good results, evaluating the MDI technique may be warranted
28. Which medication should be used for asthma patients as part of step 1
management?: Short-acting beta2 agonists Feedback: Patients needing step 1 management have intermittent, mild symptoms and can be managed with a
13 / 23 face. The patient is irritable, anxious, and has difficulty sleeping. The patient complains of soreness of the tongue and mouth. Whenteaching this patient about vitamin therapy for this disorder, the nurse will tell the patient to report which side effects?: Flushing, dizziness, and nausea Feedback: This patient shows signs of niacin deficiency. Side ettects of niacin deficiency include flushing, dizziness, and nausea secondary to vasodilation. Abdominal cramps, diarrhea, migraines, and numbness of extremities are not side ettects of niacin deficiency
33. A patient with hyperlipidemia has been told by the NP to take extra niacin.
The NP will tell the patient to:: take nicotinic acid supplements Feedback: Nicotinic acid is given in high doses to treat hyperlipidemia. Increasing dietary niacin is not suflcient to treat hyperlipidemia. Nicotinamide does not attect plasma lipoproteins. Dietary tryptophan is converted by the body into nicotinic acid, but not in suflcient amounts to treat hyperlipidemia.
34. A patient reports taking an oral bisacodyl laxative [Dulcolax] for several
years. The FNPhas suggested discontinuing the laxative, but the patient is unsure how to do this. The FNP will tell the patient to:: stop taking the laxative immediately and expect no stool for several days. Feedback: The first step in breaking the laxative habit is abrupt cessation of laxative use. Bowel movements will be absent for several days after laxative withdrawal. Using a suppository, a bulk-forming laxative, or tapering the laxative only prolongs the habit and prevents normal function from returning
35. The FNP has recommended a bulk-forming laxative for occasional constipa-
tion.Which statement by the patient indicates understanding of the teaching about this
14 / 23 agent?: "I should take each dose with a full glass of water." Feedback: Bulk-forming laxatives provide insoluble substances that swell in water to both soften and increase the size of the fecal mass. Patients should be taught to take the dose with a full glass of water. Laxatives in general are not recommended for long- term use. Bulk-forming laxatives are safe for patients with diverticulitis. They are often used to treat diarrhea, because they help form the fecal mass
36. A patient is taking bismuth subsalicylate [Pepto-Bismol] to prevent diar-
rhea. The nurse Practitionerperforming an assessment notes that the pa-tient's tongue is black. What will the NP do?: Reassure the patient that this is an expected side ettect of this drug. Feedback: Bismuth subsalicylate can cause blackening of the tongue and stools, an expected side ettect. This finding does not indicate GI bleeding, hepatotoxicity, or drug overdose
37. The nurse is providing education to a patient who has been prescribed both
an antacid and cimetidine [Tagamet]. Which instruction should the nurse give the patient about taking the medications?: Take the antacid 1 hour after the ranitidine." Feedback: Because antacids raise the gastric pH, they can attect the dissolution and absorption of ranitidine; therefore, 1 hour should separate administration of antacids and ranitidine. Antacids and ranitidine should not be taken at the same time, because dissolution and absorption of ranitidine will be reduced. One hour should separate administration of antacids and ranitidine; intervals of 15 minutes and 30 minutes are not long enough
38. A patient is diagnosed with peptic ulcer disease. The patient is
otherwise healthy. The nurse Practitionerlearns that the patient does not smoke and that he drinks 1 or 2 glasses of wine with meals each week. The nurse Practitioner will
16 / 23 when treatment is begun; colchicine is given to prevent a gouty episode. Colchicine does not enhance the ettects of allopurinol.
41. A patient who has type 2 diabetes will begin taking glipizide [Glucotrol].
Which statement by the patient is concerning to the nurse Practitioner?: "I may continue to have a glass of wine with dinner." Feedback: Glipizide is a sulfonylurea antidiabetic agent and can cause a disulfiram-like reaction when combined with alcohol. Patients should be taught to avoid alcohol while taking this medication. The initial dosing is once daily with breakfast. There is no drug interaction with grapefruit juice. Patients will need to monitor their blood glucose
42. Insulin glargine is prescribed for a patient who has diabetes. When will the
patient administer this drug?: Once daily at bedtime Feedback: Glargine insulin is indicated for once-daily subcutaneous administration to treat adults and children with type 1 diabetes and adults with type 2 diabetes. According to the package labeling, the once-daily injection should be given at bedtime. Glargine insulin should not be given more than once a day, although some patients require bid dosing to achieve a full 24 hours of basal coverage.
43. A nurse Practitioner is teaching a patient who will begin taking
methima-zole [Tapazole] for Graves disease about the medication. Which statement by the patient indicates understanding of the teaching?: "I should report a sore throat or fever to my provider if either occurs." Feedback: Agranulocytosis is rare but can occur with methimazole, so patients should report signs of infection, such as a sore throat or fever. Liver toxicity is not a side ettect, so liver function tests are not indicated. Because agranulocytosis often develops rapidly, periodic blood counts do not guarantee early detection. Methimazole is contraindicated in the first trimester of pregnancy
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44. The nurse Practitioner is caring for a pregnant patient recently diagnosed
with hypothyroidism. The patient tells the NP she does not want to take medications while she is pregnant. What will the NPexplain to this patient?: - Neuropsychologic deficits in the fetus can occur if the condition is not treated Feedback: Maternal hypothyroidism can result in permanent neuropsychologic deficits in the child. Hypothyroidism is not a normal ettect of pregnancy and is a serious condition that can attect both mother and fetus. The greatest danger to the fetus occurs in the first trimester, because the thyroid does not fully develop until the second trimester. Early identification is essential. Symptoms often are vague. Treatment should begin as soon as possible, or mental retardation and other developmental problems may occur
45. A patient in her twenties with Graves disease who takes methimazole
[Tapazole] tells a nurse Practitionerthat she is trying to conceive and asks about disease management during pregnancy. What will the NP tell her?: The patient should discuss changing to propylthiouracil from now until her second trimester Feedback: Methimazole is not safe during the first trimester of pregnancy, because it is associated with neonatal hypothyroidism, goiter, and cretinism; however, it is safe in the second and third trimesters. Propylthiouracil is recommended for pregnant patients only in the first trimester and during lactation only if a thionamide is absolutely necessary. Iodine-131 is used in women older than 30 years who have not responded to medication therapy and is contraindicated during pregnancy
46. An 18 month old has developed a rash and urticaria and the NP orders
promethazine (Phenergan). What should be considered before finalizing this prescription?: Reconsider order due potential respiratory depression in children Feedback: Promethazine can cause severe respiratory depression, especially in very young patients; it is contraindi-cated in
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50. A 4½-year-old child who has been receiving high-dose systemic glucocor-
ticoids for several months comes to a clinic for school immunizations, which usually include the DTaP vaccine; varicella virus vaccine [Varivax]; the measles, mumps, and rubella virus (MMR) vaccine; and the inactivated poliovirus vac-cine (IPV). The clinic nurse will expect to administer which vaccines to this child?: DTaP and IPV only Feedback: Children who are immunocompromised should not receive live virus vaccines, including the MMR vaccine and Varivax. Children taking high-dose systemic glucocorticoids are immunocompromised and should not receive the vaccine until therapy is stopped and normal glucocorticoid production returns. The oral polio vaccine (OPV) contains live virus and is contraindicated. Immunoglobulins are not indicated unless children are exposed to the diseases themselves.
51. An NP student asks the instructor what an accurate description of a drug
agonist is. What is the instructors best response?: A drug that interacts directly with receptor sites to cause the same activity that a natural chemical would cause at that site Feedback: Agonists are drugs that produce ettects similar to those produced by naturally occurring neurotransmitters, hormones, or other substances found in the body. Noncompetitive antagonists are drugs that react with some receptor sites preventing the reaction of another chemical with a ditterent receptor site. Drug enzyme interactions interfere with the enzyme systems that stimulate various chemical reactions
52. The Nurse practitioner teaches a patient about bethanechol (Urecholine).
Which statement by the patient requires an intervention by the NP?: "The med-ication should be taken with meals" Feedback: Bethanechol should be taken 1 hour before or 2 hours after meals; nausea and vomiting and gastric upset may occur if bethanechol is taken with meals.
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53. A nurse is discussing early indications of toxicity with a client who has a
new prescription for lithium carbonate for bipolar disorder. The nurse should include which of the following manifestations in the teaching? (Select all that apply.): polyuria muscle weakness Feedback: B. CORRECT: Polyuria is an early indication of lithium toxicity D. CORRECT: Muscle weakness is an early indication of lithium toxicity.
54. A patient test reveals the philadelphia chromosome. What disease is this
chromosome most commonly associated with?: Chronic myelogenous leukemia (CML) Feedback: The truncated chromosome 22 that results from the reciprocal translocation t(9;22)(q34;q11) is known as the Philadelphia chromosome (Ph) and is a hallmark of chronic myeloid leukemia (CML). In leukemia cells, Ph not only impairs the physiological signaling pathways but also disrupts genomic stability.
55. A 55 year old male patient is diagnosed with chronic kidney disease. The
patient's recent GFR was 25 mL/min. What stage of chronic kidney disease is this known as?: Stage 4 Feedback: his is known as Stage 4 of CKD because the GFR (glomerular filtration rate) for this stage is 15-29 mL/min (patient's GFR is 25 mL/min). The other stage's criteria are as follows: Stage 1: Kidney damage with normal renal function GFR > ml/min but with proteinuria (3 months or more); Stage 2: Kidney damage with mild loss of renal function GFR 60-89 ml/min with proteinuria (3 months or more); Stage 3: Mild-to-severe loss of renal function GFR 30-59 mL/min; Stage 4: Severe loss renal function GFR 15-29 mL/min; Stage 5: End stage renal disease GRF less 15 mL/min
56. A patient with myasthenia gravis will be eating lunch at 1200. It is now
