Download NR508 Final Exam Questions with Answers With Assured Success On A+ GRADE 2023/2024 Updates and more Exams Nursing in PDF only on Docsity! NR508 Final Exam Questions with Answers With Assured Success On A+ GRADE 2023/2024 Updates Chapter 1. The Role of the Nurse Practitioner Multiple Choice Identify the choice that best completes the statement or answers the question. 1. Nurse practitioner prescriptive authority is regulated by: 1. The National Council of State Boards of Nursing 2. The U.S. Drug Enforcement Administration 3. The State Board of Nursing for each state 4. The State Board of Pharmacy 2. The benefits to the patient of having an Advanced Practice Registered Nurse (APRN) prescriber include: 1. Nurses know more about Pharmacology than other prescribers because they take it both in their basic nursing program and in their APRN program. 2. Nurses care for the patient from a holistic approach and include the patient in decision making regarding their care. 3. APRNs are less likely to prescribe narcotics and other controlled substances. 4. APRNs are able to prescribe independently in all states, whereas a physician’s assistant needs to have a physician supervising their practice. 3. Clinical judgment in prescribing includes: 1. Factoring in the cost to the patient of the medication prescribed 2. Always prescribing the newest medication available for the disease process 3. Handing out drug samples to poor patients 4. Prescribing all generic medications to cut costs 4. Criteria for choosing an effective drug for a disorder include: 1. Asking the patient what drug they think would work best for them 2. Consulting nationally recognized guidelines for disease management 3. Prescribing medications that are available as samples before writing a prescription 4. Following U.S. Drug Enforcement Administration guidelines for prescribing 5. Nurse practitioner practice may thrive under health-care reform because of: 1. The demonstrated ability of nurse practitioners to control costs and improve patient outcomes 2. The fact that nurse practitioners will be able to practice independently 3. The fact that nurse practitioners will have full reimbursement under health-care reform 4. The ability to shift accountability for Medicaid to the state level Chapter 2. Review of Basic Principles of Pharmacology Multiple Choice Identify the choice that best completes the statement or answers the question. 1. A patient’s nutritional intake and laboratory results reflect hypoalbuminemia. This is critical to prescribing because: 1. Distribution of drugs to target tissue may be affected. 2. The solubility of the drug will not match the site of absorption. 3. There will be less free drug available to generate an effect. 4. Drugs bound to albumin are readily excreted by the kidneys. 2. Drugs that have a significant first-pass effect: 1. Must be given by the enteral (oral) route only 2. Bypass the hepatic circulation 3. Are rapidly metabolized by the liver and may have little if any desired action 4. Are converted by the liver to more active and fat-soluble forms 3. The route of excretion of a volatile drug will likely be the: 1. Kidneys 2. Lungs 3. Bile and feces 4. Skin 4. Medroxyprogesterone (Depo Provera) is prescribed intramuscularly (IM) to create a storage reservoir of the drug. Storage reservoirs: 1. Assure that the drug will reach its intended target tissue 2. Are the reason for giving loading doses 3. Increase the length of time a drug is available and active 4. Are most common in collagen tissues 5. The NP chooses to give cephalexin every 8 hours based on knowledge of the drug’s: 1. Propensity to go to the target receptor 2. Biological half-life 3. Pharmacodynamics 4. Safety and side effects 6. Azithromycin dosing requires that the first day’s dosage be twice those of the other 4 days of the prescription. This is considered a loading dose. A loading dose: 1. Rapidly achieves drug levels in the therapeutic range 2. Requires four- to five-half-lives to attain 3. Is influenced by renal function 4. Is directly related to the drug circulating to the target tissues 7. The point in time on the drug concentration curve that indicates the first sign of 20. Steady state is: 1. The point on the drug concentration curve when absorption exceeds excretion 2. When the amount of drug in the body remains constant 3. When the amount of drug in the body stays below the minimum toxic concentration 4. All of the above 21. Two different pain medications are given together for pain relief. The drug— drug interaction is: 1. Synergistic 2. Antagonistic 3. Potentiative 4. Additive 22. Actions taken to reduce drug—drug interaction problems include all of the following EXCEPT: 1. Reducing the dosage of one of the drugs 2. Scheduling their administration at different times 3. Prescribing a third drug to counteract the adverse reaction of the combination 4. Reducing the dosage of both drugs 23. Phase I oxidative-reductive processes of drug metabolism require certain nutritional elements. Which of the following would reduce or inhibit this process? 1. Protein malnutrition 2. Iron-deficiency anemia 3. Both 1 and 2 4. Neither 1 nor 2 24. The time required for the amount of drug in the body to decrease by 50% is called: 1. Steady state 2. Half-life 3. Phase II metabolism 4. Reduced bioavailability time 25. An agonist activates a receptor and stimulates a response. When given frequently over time, the body may: 1. Upregulate the total number of receptors 2. Block the receptor with a partial agonist 3. Alter the drug’s metabolism 4. Downregulate the numbers of that specific receptor 26. Drug antagonism is best defined as an effect of a drug that: 1. Leads to major physiological and psychological dependence 2. Is modified by the concurrent administration of another drug 3. Cannot be metabolized before another dose is administered 4. Leads to a decreased physiological response when combined with another drug 27. Instructions to a client regarding self-administration of oral enteric-coated tablets should include which of the following statements? 1. “Avoid any other oral medicines while taking this drug.” 2. “If swallowing this tablet is difficult, dissolve it in 3 ounces of orange juice.” 3. “The tablet may be crushed if you have any difficulty taking it.” 4. “To achieve best effect, take the tablet with at least 8 ounces of fluid.” 28. The major reason for not crushing a sustained-release capsule is that, if crushed, the coated beads of the drugs could possibly result in: 1. Disintegration 2. Toxicity 3. Malabsorption 4. Deterioration 29. Which of the following substances is the most likely to be absorbed in the intestines rather than in the stomach? 1. Sodium bicarbonate 2. Ascorbic acid 3. Salicylic acid 4. Glucose 30. Which of the following variables is a factor in drug absorption? 1. The smaller the surface area for absorption, the more rapidly the drug is absorbed. 2. A rich blood supply to the area of absorption leads to better absorption. 3. The less soluble the drug, the more easily it is absorbed. 4. Ionized drugs are easily absorbed across the cell membrane. 31. An advantage of prescribing a sublingual medication is that the medication is: 1. Absorbed rapidly 2. Excreted rapidly 3. Metabolized minimally 4. Distributed equally 32. Drugs that use CYP 3A4 isoenzymes for metabolism may: 1. Induce the metabolism of another drug 2. Inhibit the metabolism of another drug 3. Both 1 and 2 4. Neither 1 nor 2 33. Therapeutic drug levels are drawn when a drug reaches steady state. Drugs reach steady state: 1. After the second dose 2. After four to five half-lives 3. When the patient feels the full effect of the drug 4. One hour after IV administration 34. Upregulation or hypersensitization may lead to: 1. Increased response to a drug 2. Decreased response to a drug 3. An exaggerated response if the drug is withdrawn 4. Refractoriness or complete lack of response Chapter 3. Rational Drug Selection Multiple Choice Identify the choice that best completes the statement or answers the question. 1. An NP would prescribe the liquid form of ibuprofen for a 6-year-old child because: 1. Drugs given in liquid form are less irritating to the stomach. 2. A 6-year-old child may have problems swallowing a pill. 3. Liquid forms of medication eliminate the concern for first-pass effect. 4. Liquid ibuprofen does not have to be dosed as often as the tablet form. 2. In deciding which of multiple drugs used to use to treat a condition, the NP chooses Drug A because it: 1. Has serious side effects and it is not being used for a life-threatening condition 2. Will be taken twice daily and will be taken at home 3. Is expensive, but covered by health insurance 4. None of these are important in choosing a drug 3. A client asks the NP about the differences in drug effects between men and women. What is known about the differences between the pharmacokinetics of men and women? 1. Body temperature varies between men and women. 2. Muscle mass is greater in women. 3. Percentage of fat differs between genders. 4. Proven subjective factors exist between the genders. 4. The first step in the prescribing process according to the World Health Organization is: 1. Choosing the treatment 2. Postmarketing research 3. Human safety and efficacy studies 4. The last stage of animal trials before the human trials begin 5. Off-label prescribing is: 1. Regulated by the U.S. Food and Drug Administration 2. Illegal by NPs in all states (provinces) 3. Legal if there is scientific evidence for the use 4. Regulated by the Drug Enforcement Administration 6. The U.S. Drug Enforcement Administration: 1. Registers manufacturers and prescribers of controlled substances 2. Regulates NP prescribing at the state level 3. Sanctions providers who prescribe drugs off-label 4. Provides prescribers with a number they can use for insurance billing 7. Drugs that are designated Schedule II by the U.S. Drug Enforcement Administration: 1. Are known teratogens during pregnancy 2. May not be refilled; a new prescription must be written 3. Have a low abuse potential 4. May be dispensed without a prescription unless regulated by the state 8. Precautions that should be taken when prescribing controlled substances include: 1. Faxing the prescription for a Schedule II drug directly to the pharmacy 2. Using tamper-proof paper for all prescriptions written for controlled drugs 3. Keeping any pre-signed prescription pads in a locked drawer in the clinic 4. Using only numbers to indicate the amount of drug to be prescribed 9. Strategies prescribers can use to prevent misuse of controlled prescription drugs include: 1. Use of chemical dependency screening tools 2. Firm limit-setting regarding prescribing controlled substances 3. Practicing “just say no” to deal with patients who are pushing the provider to prescribe controlled substances 4. All of the above 10. Behaviors predictive of addiction to controlled substances include: 1. Stealing or borrowing another patient’s drugs 2. Requiring increasing doses of opiates for pain associated with malignancy 3. Receiving refills of a Schedule II prescription on a regular basis 4. Requesting that only their own primary care provider prescribe for them 11. Medication agreements or “Pain Medication Contracts” are recommended to be used: 1. Universally for all prescribing for chronic pain 2. For patients who have repeated requests for pain medication 3. When you suspect a patient is exhibiting drug-seeking behavior 4. For patients with pain associated with malignancy 12. A prescription needs to be written for: 1. Legend drugs 2. Most controlled drugs 3. Medical devices 4. All of the above Chapter 5. Adverse Drug Reactions Multiple Choice Identify the choice that best completes the statement or answers the question. 1. Which of the following patients would be at higher risk of experiencing adverse drug reactions (ADRs): 1. A 32-year-old male 2. A 22-year-old female 3. A 3-month-old female 4. A 48-year-old male 2. Infants and young children are at higher risk of ADRs due to: 1. Immature renal function in school-age children 2. Lack of safety and efficacy studies in the pediatric population 3. Children’s skin being thicker than adults, requiring higher dosages of topical medication 4. Infant boys having a higher proportion of muscle mass, leading to a higher volume of distribution 3. The elderly are at high risk of ADRs due to: 1. Having greater muscle mass than younger adults, leading to higher volume of distribution 2. The extensive studies that have been conducted on drug safety in this age group 3. The blood-brain barrier being less permeable, requiring higher doses to achieve therapeutic effect 4. Age-related decrease in renal function 4. The type of adverse drug reaction that is idiosyncratic when a drug given in the usual therapeutic doses is type: 1. A 2. B 3. C 4. D 5. Digoxin may cause a type A adverse drug reaction due to: 1. Idiosyncratic effects 2. Its narrow therapeutic index 3. Being a teratogen 4. Being a carcinogen 6. Sarah developed a rash after using a topical medication. This is a type allergic drug reaction. 1. I 2. II 3. III 4. IV 7. A patient may develop neutropenia from using topical Silvadene for burns. Neutropenia is a(n): 1. Cytotoxic hypersensitivity reaction 2. Immune complex hypersensitivity 3. Immediate hypersensitivity reaction 4. Delayed hypersensitivity reaction 8. Anaphylactic shock is a: 1. Type I reaction, called immediate hypersensitivity reaction 2. Type II reaction, called cytotoxic hypersensitivity reaction 3. Type III allergic reaction, called immune complex hypersensitivity 4. Type IV allergic reaction, called delayed hypersensitivity reaction 9. James has hypothalamic-pituitary-adrenal axis suppression from chronic prednisone (a corticosteroid) use. He is at risk for what type of adverse drug reaction? 1. Type B 2. Type C 3. Type E 4. Type F 10. Immunomodulators such as azathioprine may cause a delayed adverse drug reaction known as a type D reaction because they are known: 1. Teratogens 2. Carcinogens 3. To cause hypersensitivity reactions 4. Hypothalamus-pituitary-adrenal axis suppressants 7. Nonadherence is especially common in drugs that treat asymptomatic conditions, such as hypertension. One way to reduce the likelihood of nonadherence to these drugs is to prescribe a drug that: 1. Has a short half-life so that missing one dose has limited effect 2. Requires several dosage titrations so that missed doses can be replaced with lower doses to keep costs down 3. Has a tolerability profile with fewer of the adverse effects that are considered “irritating,” such as nausea and dizziness 4. Must be taken no more than twice a day 8. Factors in chronic conditions that contribute to nonadherence include: 1. The complexity of the treatment regimen 2. The length of time over which it must be taken 3. Breaks in the usual daily routine, such as vacations and weekends 4. All of the above 9. While patient education about their drugs is important, information alone does not necessarily lead to adherence to a drug regimen. Patients report greater adherence when: 1. The provider spent a lot of time discussing the drugs with them 2. Their concerns and specific area of knowledge deficit were addressed 3. They were given written material, such as pamphlets, about the drugs 4. The provider used appropriate medical and pharmacological terms 10. Patients with psychiatric illnesses have adherence rates to their drug regimen between 35% and 60%. To improve adherence in this population, prescribe drugs: 1. With a longer half-life so that missed doses produce a longer taper on the drug curve 2. In oral formulations that are more easily taken 3. That do not require frequent monitoring 4. Combined with patient education about the need to adhere even when symptoms are absent 11. Many disorders require multiple drugs to treat them. The more complex the drug regimen, the less likely the patient will adhere to it. Which of the following interventions will NOT improve adherence? 1. Have the patient purchase a pill container with compartments for daily or multiple times-per- day dosing. 2. Match the clinic appointment to the next time the drug is to be refilled. 3. Write prescriptions for new drugs with shorter times between refills. 4. Give the patient a clear drug schedule that the provider devises to fit the characteristic of the drug. 12. Pharmacologic interventions are costly. Patients for whom the cost/benefit variable is especially important include: 1. Older adults and those on fixed incomes 2. Patients with chronic illnesses 3. Patients with copayments for drugs on their insurance 4. Patients on public assistance 13. Providers have a responsibility for determining the best plan of care, but patients also have responsibilities. Patients the provider can be assured will carry through on these responsibilities include those who: 1. Are well-educated and affluent 2. Have chronic conditions 3. Self-monitor drug effects on their symptoms 4. None of the above guarantee adherence 14. Monitoring adherence can take several forms, including: 1. Patient reports from data in a drug diary 2. Pill counts 3. Laboratory reports and other diagnostic markers 4. All of the above 15. Factors that explain and predict medication adherence include: 1. Social 2. Financial 3. Health system 4. All of the above Chapter 9. Nutrition and Nutraceuticals Multiple Choice Identify the choice that best completes the statement or answers the question. 1. The most frequent type of drug-food interaction is food: 1. Causing increased therapeutic drug levels 2. Affecting the metabolism of the drug 3. Altering the volume of distribution of drugs 4. Affecting the gastrointestinal absorption of drugs 2. Food in the gastrointestinal tract affects drug absorption by: 1. Altering the pH of the colon, which decreases absorption 2. Competing with the drug for plasma proteins 3. Altering gastric emptying time 4. Altering the pH of urine 3. Food can alter the pH of the stomach, leading to: 1. Enhanced drug metabolism 2. Altered vitamin K absorption 3. Increased vitamin D absorption 4. Altered drug bioavailability 4. Fasting for an extended period can: 1. Increase drug absorption due to lack of competition between food and the drug 2. Alter the pH of the gastrointestinal tract, affecting absorption 3. Cause vasoconstriction, leading to decreased drug absorption 4. Shrink the stomach, causing decreased surface area for drug absorption 5. Tetracycline needs to be given on an empty stomach because it chelates with: 1. Calcium 2. Magnesium 3. Iron 4. All of the above 6. A low-carbohydrate, high-protein diet may: 1. Increase drug-metabolizing enzymes 2. Decrease drug absorption from the GI tract 3. Alter drug binding to plasma proteins 4. Enhance drug elimination 7. Grapefruit juice contains furanocoumarins that have been found to: 1. Alter absorption of drugs through competition for binding sites 2. Inhibit CYP 3A4, leading to decreased first-pass metabolism of drugs 3. Alter vitamin K metabolism, leading to prolonged bleeding 4. Enhance absorption of calcium and vitamin D 8. Cruciferous vegetables may alter drug pharmacokinetics by: 1. Enhancing absorption of weakly acidic drugs 2. Altering CYP 3A4 activity, leading to elevated levels of drugs, such as the statins 3. Inducing CYP 1A2, possibly leading to therapeutic failure of drugs metabolized by CYP 1A2 4. Decreasing first-pass metabolism of drugs 9. Milk and other foods that alkalinize the urine may: 1. Result in basic drugs being reabsorbed in the renal tubule 2. Increase the elimination of basic drugs in the urine 22. There is strong evidence to support that adequate vitamin C intake prevents: 1. The common cold 2. Breast cancer 3. Scurvy 4. All of the above 23. Adequate vitamin D is needed for: 1. Absorption of calcium from the gastrointestinal tract 2. Regulation of serum calcium levels 3. Regulation of serum phosphate levels 4. All of the above 24. Newborns are at risk for early vitamin K deficiency bleeding and the American Academy of Pediatrics recommends that all newborns receive: 1. IM vitamin K (phytonadione) within 24 hours of birth 2. Oral vitamin K supplementation in the first 3 weeks of life 3. Formula containing vitamin K or breast milk 4. Oral vitamin K in the first 24 hours after birth 25. Symptoms of folate deficiency include: 1. Thinning of the hair 2. Bruising easily 3. Glossitis 4. Numbness and tingling of the hands and feet 26. A patient with a new onset of systolic ejection murmur should be assessed for which nutritional deficiency? 1. Vitamin B12 2. Vitamin C 3. Folate 4. Niacine 27. According to the 2003-2006 National Health and Nutrition Examination Survey study of dietary intake, the group at highest risk for inadequate calcium intake was: 1. The elderly (over age 60 years) 2. Teenage females 3. Teenage males 4. Preschoolers 28. Patients with iron deficiency will develop: 1. Hemolytic anemia 2. Megaloblastic anemia 3. Macrocytic-hypochromic anemia 4. Microcytic-hypochromic anemia 29. There is evidence that dietary supplementation or adequate intake of fish oils and omega-3 fatty acids have well-documented: 1. Concern for developing cardiac dysrhythmias 2. Anti-inflammatory effects 3. Total cholesterol-lowering effects 4. Effects on fasting blood sugar 30. There is enough preliminary evidence to recommend that children with autism receive which supplemental nutrient? 1. Vitamin B1 (thiamine) 2. Vitamin B2 (riboflavin) 3. Calcium 4. Omega-3 fatty acids 31. There is sufficient evidence to support the use of omega-3 fatty acids to treat the following disease(s): 1. Asthma 2. Autism 3. Arthritis 4. All of the above 32. It is reasonable to recommend supplementation with in the treatment of hyperlipidemia. 1. Omega-3 fatty acids 2. Probiotics 3. Plant sterols 4. Calcium 33. Probiotics are recommended to be co-administered when are prescribed: 1. Antacids 2. Antihypertensives 3. Antidiarrheals 4. Antibiotics 34. It is reasonable to add to a Helicobacter pylori treatment regimen to improve eradication rates of H. pylori. 1. Probiotics 2. Omega-3 fatty acids 3. Plant sterols 4. Fiber Chapter 12. Pharmacoeconomics Multiple Choice Identify the choice that best completes the statement or answers the question. 1. Pharmacoeconomics is: 1. The study of the part of the U.S. economy devoted to drug use 2. The study of the impact of prescription drug costs on the overall economy 3. The analysis of the costs and consequences of any health-care-related treatment or service 4. The analysis of the clinical efficacy of the drug 2. The direct costs of drug therapy include: 1. The actual cost of acquiring the medication 2. The loss of income due to illness 3. Pain and suffering due to inadequate drug therapy 4. The cost of a funeral associated with premature death 3. Indirect costs associated with drug therapy include: 1. The cost of diagnostic tests to monitor therapeutic levels 2. Health-care provider time to prescribe and educate the patient 3. Child-care expenses incurred while receiving therapy 4. Loss of wages while undergoing drug therapy 4. The intangible costs of drug therapy include: 1. Loss of wages while undergoing therapy 2. Inconvenience, pain, and suffering incurred with therapy 3. Cost of medical equipment in the laboratory used to monitor therapeutic drug levels 4. Cost of prescription drug coverage, such as Medicare Part D 5. When a pharmacoeconomic analysis looks at two or more treatment alternatives that are considered equal in efficacy and compares the costs of each it is referred to as: 1. Cost-minimization analysis 2. Cost-of-illness analysis 3. Cost-effectiveness analysis 4. Cost-benefit analysis 6. Cost-effectiveness analysis compares two or more treatments or programs that are: 1. Not necessarily therapeutically equivalent 6. Common over-the-counter pain relievers such as acetaminophen or ibuprofen: 1. Are always safer for the patient than prescription pain medication 2. Are harmful if taken in higher than recommended amounts 3. Have minimal interaction with prescription medications 4. Should never be given to children unless recommended by their provider 7. When obtaining a drug history from Harold, he gives you a complete list of his prescription medications. He denies taking any other drugs, but you find that he occasionally takes aspirin for his arthritis flare ups. This is an example of: 1. His appropriately only telling you about his regularly prescribed medications 2. His hiding information regarding his inappropriate use of aspirin from you 3. A common misconception that intermittently taken over-the counter medications are not an important part of his drug history 4. A common misuse of over-the-counter aspirin 8. The Combat Methamphetamine Epidemic Act, which is part of the 2006 U.S. Patriot Act: 1. Requires all providers to screen their patients for methamphetamine use 2. Restricts the prescribing of amphetamines to U.S. citizens 3. Requires a prescription be written for all methamphetamine precursors in all states 4. Restricts the sales of drugs that contain methamphetamine precursors, including a daily and 30- day limit on sales 9. When prescribing a tetracycline or quinolone antibiotic it is critical to instruct the patient: 1. Not to take their regularly prescribed medications while on these antibiotics 2. Regarding the need for lots of acidic foods and juices, such as orange juice, to enhance absorption 3. Not to take antacids while on these medications, as the antacid decreases absorption 4. That there are no drug interactions with these antibiotics Chapter 14. Drugs Affecting the Autonomic Nervous System Multiple Choice Identify the choice that best completes the statement or answers the question. 1. Charlie is a 65-year-old male who has been diagnosed with hypertension and benign prostatic hyperplasia. Doxazosin has been chosen to treat his hypertension because it: 1. Increases peripheral vasoconstriction 2. Decreases detrusor muscle contractility 3. Lowers supine blood pressure more than standing pressure 4. Relaxes smooth muscle in the bladder neck 2. To reduce potential adverse effects, patients taking a peripherally acting alpha1 antagonist should do all of the following EXCEPT: 1. Take the dose at bedtime 2. Sit up slowly and dangle their feet before standing 3. Monitor their blood pressure and skip a dose if the pressure is less than 120/80 4. Weigh daily and report weight gain of greater than 2 pounds in one day 3. John has clonidine, a centrally acting adrenergic blocker, prescribed for his hypertension. He should: 1. Not miss a dose or stop taking the drug because of potential rebound hypertension 2. Increase fiber in the diet to treat any diarrhea that may occur 3. Reduce fluid intake to less than 2 liters per day to prevent fluid retention 4. Avoid sitting for long periods, as this can lead to deep vein thrombosis 4. Clonidine has several off-label uses, including: 1. Alcohol and nicotine withdrawal 2. Post-herpetic neuralgia 3. Both 1 and 2 4. Neither 1 nor 2 5. Jim is being treated for hypertension. Because he has a history of heart attack, the drug chosen is atenolol. Beta blockers treat hypertension by: 1. Increasing heart rate to improve cardiac output 2. Reducing vascular smooth muscle tone 3. Increasing aldosterone-mediated volume activity 4. Reducing aqueous humor production 6. Which of the following adverse effects are less likely in a beta1-selective blocker? 1. Dysrhythmias 2. Impaired insulin release 3. Reflex orthostatic changes 4. Decreased triglycerides and cholesterol 7. Richard is 70 years old and has a history of cardiac dysrhythmias. He has been prescribed nadolol. You do his annual laboratory work and find a CrCl of 25 ml/min. What action should you take related to his nadolol? 1. Extend the dosage interval. 2. Decrease the dose by 75%. 3. Take no action because this value is expected in the older adult. 4. Schedule a serum creatinine level to validate the CrCl value. 8. Beta blockers are the drugs of choice for exertional angina because they: 1. Improve myocardial oxygen supply by vasodilating the coronary arteries 2. Decrease myocardial oxygen demand by decreasing heart rate and vascular resistance 3. Both 1 and 2 4. Neither 1 nor 2 9. Adherence to beta blocker therapy may be affected by their: 1. Short half-lives requiring twice daily dosing 2. Tendency to elevate lipid levels 3. Effects on the male genitalia, which may produce impotence 4. None of the above 10. Beta blockers have favorable effects on survival and disease progression in heart failure. Treatment should be initiated when the: 1. Symptoms are severe 2. Patient has not responded to other therapies 3. Patient has concurrent hypertension 4. Left ventricular dysfunction is diagnosed 11. Abrupt withdrawal of beta blockers can be life threatening. Patients at highest risk for serious consequences of rapid withdrawal are those with: 1. Angina 2. Coronary artery disease 3. Both 1 and 2 4. Neither 1 nor 2 12. To prevent life-threatening events from rapid withdrawal of a beta blocker: 1. The dosage interval should be increased by 1 hour each day. 2. An alpha blocker should be added to the treatment regimen before withdrawal. 3. The dosage should be tapered over a period of weeks. 4. The dosage should be decreased by one-half every 4 days. 13. Beta blockers are prescribed for diabetics with caution because of their ability to produce hypoglycemia and block the common symptoms of it. Which of the following symptoms of hypoglycemia is not blocked by these drugs and so can be used to warn diabetics of possible decreased blood glucose? 1. Dizziness 2. Increased heart rate 3. Nervousness and shakiness 4. Diaphoresis 3. Release of dopamine at the pleasure center 4. Stimulation of the locus coeruleus 27. Nicotine gum products are: 1. Chewed to release the nicotine and then swallowed for a systemic effect 2. “Parked” in the buccal area of the mouth to produce a constant amount of nicotine release 3. Bound to exchange resins so the nicotine is only released during chewing 4. Approximately the same in nicotine content as smoking two cigarettes 28. Nicotine replacement therapy (NRT): 1. Is widely distributed in the body only when the gum products are used 2. Does not cross the placenta and so is safe for pregnant women 3. Delays healing of esophagitis and peptic ulcers 4. Has no drug interactions when a transdermal patch is used 29. Success rates for smoking cessation using NRT: 1. Are about the same regardless of the method chosen 2. Vary from 40% to 50% at 12 months 3. Both 1 and 2 4. Neither 1 nor 2 30. Cholinergic blockers are used to: 1. Counteract the extrapyramidal symptoms (EPS) effects of phenothiazines 2. Control tremors and relax smooth muscle in Parkinson’s disease 3. Inhibit the muscarinic action of ACh on bladder muscle 4. All of the above 31. Several classes of drugs have interactions with cholinergic blockers. Which of the following is true about these interactions? 1. Drugs with a narrow therapeutic range given orally may not stay in the GI tract long enough to produce an action. 2. Additive antimuscarinic effects may occur with antihistamines. 3. Cholinergic blockers may decrease the sedative effects of hypnotics. 4. Cholinergic blockers are contraindicated with antipsychotics. 32. Scopolamine can be used to prevent the nausea and vomiting associated with motion sickness. The patient is taught to: 1. Apply the transdermal disk at least 4 hours before the antiemetic effect is desired. 2. Swallow the tablet 1 hour before traveling where motion sickness is possible. 3. Place the tablet under the tongue and allow it to dissolve. 4. Change the transdermal disk daily for maximal effect. 33. You are managing the care of a patient recently diagnosed with benign prostatic hyperplasia (BPH). He is taking tamsulosin but reports dizziness when standing abruptly. The best option for this patient is: 1. Continue the tamsulosin because the side effect will resolve with continued treatment. 2. Discontinue the tamsulosin and start doxazosin. 3. Have him double his fluid intake and stand more slowly. 4. Prescribe meclizine as needed for the dizziness. 34. You are treating a patient with a diagnosis of Alzheimer’s disease. The patient’s wife mentions difficulty with transportation to the clinic. Which medication is the best choice? 1. Donepezil 2. Tacrine 3. Doxazosin 4. Verapamil 35. A patient presents with a complaint of dark stools and epigastric pain described as gnawing and burning. Which of the medications is the most likely cause? 1. Acetaminophen 2. Estradiol 3. Donepezil 4. Bethanechol 36. Your patient calls for an appointment before going on vacation. Which medication should you ensure he has an adequate supply of before leaving to avoid life-threatening complications? 1. Carvedilol 2. Donepezil 3. Bethanechol 4. Tacrine 37. Activation of central alpha2 receptors results in inhibition of cardioacceleration and centers in the brain. 1. Vasodilation 2. Vasoconstriction 3. Cardiovascular 4. Respiratory Chapter 15. Drugs Affecting the Central Nervous System Multiple Choice Identify the choice that best completes the statement or answers the question. 1. Sarah, a 42-year-old female, requests a prescription for an anorexiant to treat her obesity. A trial of phentermine is prescribed. Prescribing precautions include: 1. Understanding that obesity is a contraindication to prescribing phentermine 2. Anorexiants may cause tolerance and should only be prescribed for 6 months 3. Patients should be monitored for postural hypotension 4. Renal function should be monitored closely while on anorexiants 2. Before prescribing phentermine to Sarah, a thorough drug history should be taken including assessing for the use of serotonergic agents such as selective serotonin reuptake inhibitors (SSRIs) and St John’s wort due to: 1. Additive respiratory depression risk 2. Additive effects affecting liver function 3. The risk of serotonin syndrome 4. The risk of altered cognitive functioning 3. Antonia is a 3-year-old child who has a history of status epilepticus. Along with her routine antiseizure medication, she should also have a home prescription for to be used for an episode of status epilepticus. 1. IV phenobarbital 2. Rectal diazepam (Diastat) 3. IV phenytoin (Dilantin) 4. Oral carbamazepine (Tegretol) 4. Rabi is being prescribed phenytoin for seizures. Monitoring includes assessing: 1. For phenytoin hypersensitivity syndrome 3 to 8 weeks after starting treatment 2. For pedal edema throughout therapy 3. Heart rate at each visit and consider altering therapy if heart rate is less than 60 bpm 4. For vision changes, such as red-green blindness, at least annually 5. Dwayne has recently started on carbamazepine to treat seizures. He comes to see you and you note that while his carbamazepine levels had been in the therapeutic range, they are now low. The possible cause for the low carbamazepine levels include: 1. Dwayne hasn’t been taking his carbamazepine because it causes insomnia. 2. Carbamazepine auto-induces metabolism, leading to lower levels in spite of good compliance. 3. Dwayne was not originally prescribed the correct amount of carbamazepine. 4. Carbamazepine is probably not the right antiseizure medication for Dwayne. 6. Carbamazepine has a Black Box Warning due to life-threatening: 1. Renal toxicity, leading to renal failure 2. Hepatotoxicity, leading to liver failure 3. Dermatologic reaction, including Steven’s Johnson and toxic epidermal necrolysis 4. Cardiac effects, including supraventricular tachycardia 19. Taylor is a 10-year-old child diagnosed with major depression. The appropriate first- line antidepressant for children is: 1. Fluoxetine 2. Fluvoxamine 3. Sertraline 4. Escitalopram 20. Suzanne is started on paroxetine (Paxil), a selective serotonin reuptake inhibitor (SSRI), for depression. Education regarding her antidepressant includes: 1. SSRIs may take 2 to 6 weeks before she will have maximum drug effects. 2. Red-green color blindness may occur and should be reported. 3. If she experiences dry mouth or heart rates greater than 80, she should stop taking the drug immediately. 4. She should eat lots of food high in fiber to prevent constipation. 21. Cecilia presents with depression associated with complaints of fatigue, sleeping all the time, and lack of motivation. An appropriate initial antidepressant for her would be: 1. Fluoxetine (Prozac) 2. Paroxetine (Paxil) 3. Amitriptyline (Elavil) 4. Duloxetine (Cymbalta) 22. Jake, a 45-year-old patient with schizophrenia, was recently hospitalized for acute psychosis due to medication noncompliance. He was treated with IM long-acting haloperidol. Besides monitoring his schizophrenia symptoms, the patient should be assessed by his primary care provider: 1. For excessive weight loss 2. With the Abnormal Involuntary Movement Scale (AIMS) for extrapyramidal symptoms (EPS) 3. Monthly for tolerance to the haloperidol 4. Only by the mental health provider, as most NPs in primary care do not care for mentally ill patients 23. Anticholinergic agents, such as benztropine (Cogentin), may be given with a phenothiazine to: 1. Reduce the chance of tardive dyskinesia 2. Potentiate the effects of the drug 3. Reduce the tolerance that tends to occur 4. Increase central nervous system (CNS) depression 24. Patients who are prescribed olanzapine (Zyprexa) should be monitored for: 1. Insomnia 2. Weight gain 3. Hypertension 4. Galactorrhea 25. A 19-year-old male was started on risperidone. Monitoring for risperidone includes observing for common side effects, including: 1. Bradykinesia, akathisia, and agitation 2. Excessive weight gain 3. Hypertension 4. Potentially fatal agranulocytosis 26. In choosing a benzodiazepam to treat anxiety the prescriber needs to be aware of the possibility of dependence. The benzodiazepam with the greatest likelihood of rapidly developing dependence is: 1. Chlordiazepoxide (Librium) 2. Clonazepam (Klonopin) 3. Alprazolam (Xanax) 4. Oxazepam (Serax) 27. A patient with anxiety and depression may respond to: 1. Duloxetine (Cymbalta) 2. Fluoxetine (Prozac) 3. Oxazepam (Serax) 4. Buspirone (Buspar) and an SSRI combined 28. When prescribing temazepam (Restoril) for insomnia, patient education includes: 1. Take temazepam nightly approximately 15 minutes before bedtime. 2. Temazepam should not be used more than three times a week for less than 3 months. 3. Drinking 1 ounce of alcohol will cause additive effects and the patient will sleep better. 4. Exercise for at least 30 minutes within 2 hours of bedtime to enhance the effects of temazepam. 29. Patients should be instructed regarding the rapid onset of zolpidem (Ambien) because: 1. Zolpidem should be taken just before going to bed. 2. Zolpidem may cause dry mouth and constipation. 3. Patients may need to double the dose for effectiveness. 4. They should stop drinking alcohol at least 30 minutes before taking zolpidem. 30. One major drug used to treat bipolar disease is lithium. Because lithium has a narrow therapeutic range, it is important to recognize symptoms of toxicity, such as: 1. Orthostatic hypotension 2. Agitation and irritability 3. Drowsiness and nausea 4. Painful urination and abdominal distention 31. Tom is taking lithium for bipolar disorder. He should be taught to: 1. Take his lithium with food 2. Eat a diet with consistent levels of salt (sodium) 3. Drink at least 2 quarts of water if he is in a hot environment 4. Monitor blood glucose levels 32. Cynthia is taking valproate (Depakote) for seizures and would like to get pregnant. What advice would you give her? 1. Valproate is safe during all trimesters of pregnancy. 2. She can get pregnant while taking valproate, but she should take adequate folic acid. 3. Valproate is not safe at any time during pregnancy. 4. Valproate is a known teratogen, but may be taken after the first trimester if necessary. 33. When prescribing an opioid analgesic such as acetaminophen and codeine (Tylenol #3), instructions to the patient should include: 1. The medication may cause sedation and they should not drive. 2. Constipation is a common side effect and they should increase fluids and fiber. 3. Patients should not take any other acetaminophen-containing medications at the same time. 4. All of the above 34. Kirk sprained his ankle and is asking for pain medication for his mild-to-moderate pain. The appropriate first-line medication would be: 1. Ibuprofen (Advil) 2. Acetaminophen with hydrocodone (Vicodin) 3. Oxycodone (Oxycontin) 4. Oral morphine (Roxanol) 35. Kasey fractured his ankle in two places and is asking for medication for his pain. The appropriate first-line medication would be: 1. Ibuprofen (Advil) 2. Acetaminophen with hydrocodone (Vicodin) 3. Oxycodone (Oxycontin) 4. Oral morphine (Roxanol) 36. Jack, age 8, has attention deficit disorder (ADD) and is prescribed methylphenidate (Ritalin). He and his parents should be educated about the side effects of methylphenidate, which are: 1. Slurred speech and insomnia 2. Bradycardia and confusion 3. Dizziness and orthostatic hypotension 4. Insomnia and decreased appetite 10. Rapid-acting nitrates are important for all angina patients. Which of the following are true statements about their use? 1. These drugs are useful for immediate symptom relief when the patient is certain it is angina. 2. The dose is one sublingual tablet or spray every 5 minutes until the chest pain goes away. 3. Take one nitroglycerine tablet or spray at the first sign of angina; repeat every 5 minutes for no more than two doses. If chest pain is still not relieved, call 911. 4. All of the above 11. Isosorbide dinitrate is a long-acting nitrate given twice daily. The schedule for administration is 7 a.m. and 2 p.m. because: 1. Long-acting forms have a higher risk for toxicity. 2. Orthostatic hypotension is a common adverse effect. 3. It must be taken with milk or food. 4. Nitrate tolerance can develop. 12. Combinations of a long-acting nitrate and a beta blocker are especially effective in treating angina because: 1. Nitrates increase MOS and beta blockers increase MOD. 2. Their additive effects permit lower doses of both drugs and their adverse reactions cancel each other out. 3. They address the pathology of patients with exertional angina who have fixed atherosclerotic coronary heart disease. 4. All of the above 13. Drug choices to treat angina in older adults differ from those of younger adults only in: 1. Consideration of risk factors for diseases associated with and increased in aging 2. The placement of drug therapy as a treatment choice before lifestyle changes are tried 3. The need for at least three drugs in the treatment regimen because of the complexity of angina in the older adult 4. Those with higher risk for silent myocardial infarction 14. Which of the following drugs has been associated with increased risk for myocardial infarction in women? 1. Aspirin 2. Beta blockers 3. Estrogen replacement 4. Lipid-lowering agents 15. Cost of antianginal drug therapy should be considered in drug selection because of all of the following EXCEPT: 1. Patients often require multiple drugs 2. A large number of angina patients are older adults on fixed incomes 3. Generic formulations may be cheaper but are rarely bioequivalent 4. Lack of drug selectivity may result in increased adverse reactions 16. Situations that suggest referral to a specialist is appropriate include: 1. When chronic stable angina becomes unpredictable in its characteristics and precipitating factors 2. When a post-myocardial infarction patient develops new-onset angina 3. When standard therapy is not successful in improving exercise tolerance or reducing the incidence of angina 4. All of the above 17. The rationale for prescribing calcium blockers for angina can be based on the need for: 1. Increased inotropic effect in the heart 2. Increasing peripheral perfusion 3. Keeping heart rates high enough to ensure perfusion of coronary arteries 4. Help with rate control 18. Medications are typically started for angina patients when: 1. The first permanent EKG changes occur 2. The start of class I or II symptoms 3. The events trigger a trip to the emergency department 4. When troponin levels become altered 19. The most common cause of angina is: 1. Vasospasm of the coronary arteries 2. Atherosclerosis 3. Platelet aggregation 4. Low systemic oxygen 20. Ranolazine is used in angina patients to: 1. Dilate plaque-filled arteries 2. Inhibit platelet aggregation 3. Restrict late sodium flow in the myocytes 4. Induce vasoconstriction in the periphery to open coronary vessels 21. When is aspirin (ASA) used in angina patients? 1. All angina patients should be taking ASA unless it is contraindicated for allergy or other medical reasons. 2. ASA should only be used in men. 3. ASA has no role in angina, but is useful in MI prevention. 4. The impact of ASA is best at the time of an angina attack. Chapter 36. Heart Failure Multiple Choice Identify the choice that best completes the statement or answers the question. 1. Angiotensin-converting-enzyme (ACE) inhibitors are a central part of the treatment of heart failure because they have more than one action to address the pathological changes in this disorder. Which of the following pathological changes in heart failure is NOT addressed by ACE inhibitors? 1. Changes in the structure of the left ventricle so that it dilates, hypertrophies, and uses energy less efficiently. 2. Reduced formation of cross-bridges so that contractile force decreases. 3. Activation of the sympathetic nervous system that increases heart rate and preload. 4. Decreased renal blood flow that decreases oxygen supply to the kidneys. 2. One of the three types of heart failure involves systolic dysfunction. Potential causes of this most common form of heart failure include: 1. Myocardial ischemia and injury secondary to myocardial infarction 2. Inadequate relaxation and loss of muscle fiber secondary to valvular dysfunction 3. Increased demands of the heart beyond its ability to adapt secondary to anemia 4. Slower filling rate and elevated systolic pressures secondary to uncontrolled hypertension 3. The American Heart Association and the American College of Cardiology have devised a classification system for heart failure that can be used to direct treatment. Patients with symptoms and underlying disease are classified as stage: 1. A 2. B 3. C 4. D 4. Diagnosis of heart failure cannot be made by symptoms alone because many disorders share the same symptoms. The most specific and sensitive diagnostic test for heart failure is: 1. Chest x-rays that show cephalization and measure heart size 2. Two-dimensional echocardiograms that identify structural anomalies and cardiac dysfunction 3. Complete blood count, blood urea nitrogen, and serum electrolytes that facilitate staging for end-organ damage 4. Measurement of brain natriuretic peptide to distinguish between systolic and diastolic dysfunction 5. Treatments for heart failure, including drug therapy, are based on the stages developed by the ACC/AHA. Stage A patients are treated with: 1. Drugs for hypertension and hyperlipidemia, if they exist 2. Lifestyle management including diet, exercise, and smoking cessation only 3. Angiotensin-converting enzyme (ACE) inhibitors to directly affect the heart failure only 4. No drugs are used in this early stage 4. When stage IV is determined 18. HF patients frequently take more than one drug. When are anticoagulants typically used? 1. When the patient enters stage III 2. Only in cases of diastolic failure 3. When there is concurrent A Fib 4. In all cases 19. What can chest x-rays contribute to the diagnosis and management of HF? 1. They have no role. 2. They can give very precise pictures of pulmonary fluid status. 3. They provide an idea of general cardiac size and pulmonary great vessel distribution. 4. They can confirm the diagnosis. Chapter 40. Hypertension Multiple Choice Identify the choice that best completes the statement or answers the question. 1. 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: 1. Increase renin secretion 2. Decrease the production of aldosterone 3. Deplete body sodium and reduce fluid volume 4. Decrease blood viscosity 2. Because of its action on various body systems, the patient taking a thiazide or loop diuretic may also need to receive the following supplement: 1. Potassium 2. Calcium 3. Magnesium 4. Phosphates 3. All patients with hypertension benefit from diuretic therapy, but those who benefit the most are: 1. Those with orthostatic hypertension 2. African Americans 3. Those with stable angina 4. Diabetics 4. Beta blockers treat hypertension because they: 1. Reduce peripheral resistance 2. Vasoconstrict coronary arteries 3. Reduce norepinephrine 4. Reduce angiotensin II production 5. Which of the following disease processes could be made worse by taking a nonselective beta blocker? 1. Asthma 2. Diabetes 3. Both might worsen 4. Beta blockade does not affect these disorders 6. Disease states in addition to hypertension in which beta blockade is a compelling indication for the use of beta blockers include: 1. Heart failure 2. Angina 3. Myocardial infarction 4. Dyslipidemia 7. Angiotensin-converting enzyme (ACE) inhibitors treat hypertension because they: 1. Reduce sodium and water retention 2. Decrease vasoconstriction 3. Increase vasodilation 4. All of the above 8. Compelling indications for an ACE inhibitor as treatment for hypertension based on clinical trials includes: 1. Pregnancy 2. Renal parenchymal disease 3. Stable angina 4. Dyslipidemia 9. An ACE inhibitor and what other class of drug may reduce proteinuria in patients with diabetes better than either drug alone? 1. Beta blockers 2. Diuretics 3. Nondihydropyridine calcium channel blockers 4. Angiotensin II receptor blockers 10. If not chosen as the first drug in hypertension treatment, which drug class should be added as a second step because it will enhance the effects of most other agents? 1. ACE inhibitors 2. Beta blockers 3. Calcium channel blockers 4. Diuretics 11. Treatment costs are important for patients with hypertension. Which of the following statements about cost is NOT true? 1. Hypertension is a chronic disease where patients may be taking drugs for a long time. 2. Most patients will require more than one drug to treat the hypertension. 3. The cost includes the price of any routine or special laboratory tests that a specific drug may require. 4. Few antihypertensive drugs come in generic formulations. 12. Caffeine, exercise, and smoking should be avoided for at least how many minutes before blood pressure measurement? 1. 15 2. 30 3. 60 4. 90 13. Blood pressure checks in children: 1. Should occur with their annual physical examinations after 6 years of age 2. Require a blood pressure cuff that is one-third the diameter of the child’s arm 3. Should be done during every health-care visit after 3 years of age 4. Require additional laboratory tests such as serum creatinine 14. Lack of adherence to blood pressure management is very common. Reasons for this lack of adherence include: 1. Lifestyle changes are difficult to achieve and maintain. 2. Adverse drug reactions are common and often fall into the categories more associated with nonadherence. 3. Costs of drugs and monitoring with laboratory tests can be expensive. 4. All of the above 15. Lifestyle modifications for patients with prehypertension or hypertension include: 1. Diet and increase exercise to achieve a BMI greater than 25. 2. Drink 4 ounces of red wine at least once per week. 3. Adopt the dietary approaches to stop hypertension (DASH) diet. 4. Increase potassium intake. 1. Venlafaxine (Effexor) 2. Escitalopram (Lexapro) 3. Buspirone (Buspar) 4. Amitriptyline (Elavil) 9. The laboratory monitoring required when a patient is on a selective serotonin reuptake inhibitor is: 1. Complete blood count every 3 to 4 months 2. Therapeutic blood levels every 6 months after a steady state is achieved 3. Blood glucose every 3 to 4 months 4. There is no laboratory monitoring required 10. Jaycee has been on escitalopram (Lexapro) for a year and is willing to try tapering off of the selective serotonin reuptake inhibitor. What is the initial dosage adjustment when starting a taper off antidepressants? 1. Change dose to every other day dosing for a week 2. Reduce dose by 50% for 3 to 4 days 3. Reduce dose by 50% every other day 4. Escitalopram (Lexapro) can be stopped abruptly due to its long half-life 11. The longer-term Xanax patient comes in and states they need a higher dose of the medication. They deny any additional, new, or accelerating triggers of their anxiety. What is the probable reason? 1. They have become tolerant of the medication, which is characterized by the need for higher and higher doses. 2. They are a drug seeker. 3. They are suicidal. 4. They only need additional counseling on lifestyle modification. 12. What “onset of action” symptoms should be reviewed with patients who have been newly prescribed a selective serotonin reuptake inhibitor? 1. They will have insomnia for a week. 2. They can feel a bit of nausea, but this resolves in a week. 3. They will have an “onset seizure” but this is considered normal. 4. They will no longer dream. 13. Which of the following should not be taken with a selective serotonin reuptake inhibitor? 1. Aged blue cheese 2. Grapefruit 3. Alcohol 4. Green leafy vegetables 14. Why is the consistency of taking paroxetine (Paxil) and never running out of medication more important than with most other selective serotonin reuptake inhibitors (SSRIs)? 1. It has a shorter half-life and withdrawal syndrome has a faster onset without taper. 2. It has the longest half-life and the withdrawal syndrome has a faster onset. 3. It is quasi-addictive in the dopaminergic reward system. 4. It is the most activating of SSRI medications and will cause the person to have sudden deep sadness. 15. The patient shares with the provider that he is taking his Prozac at night before going to bed. What is the best response? 1. This is a good idea because this class of medications generally makes people sleepy. 2. Have you noticed that you are having more sleep issues since you started that? 3. This a good way to remember to take your daily medications because it is near your toothbrush. 4. This is a good plan because you can eat grapefruit if there is 8–12 hours difference in the time each are ingested. Chapter 43. Smoking Cessation Multiple Choice Identify the choice that best completes the statement or answers the question. 1. Nicotine withdrawal symptoms include: 1. Nervousness 2. Increased appetite 3. Difficulty concentrating 4. All of the above 2. If a patient wants to quit smoking, nicotine replacement therapy is recommended if the patient: 1. Smokes more than 10 cigarettes a day 2. Smokes within 30 minutes of awakening in the morning 3. Smokes when drinking alcohol 4. All of the above 3. Instructions for a patient who is starting nicotine replacement therapy include: 1. Smoke less than 10 cigarettes a day when starting nicotine replacement. 2. Nicotine replacement will help with the withdrawal cravings associated with quitting tobacco. 3. Nicotine replacement can be used indefinitely. 4. Nicotine replacement therapy is generally safe for all patients. 4. Nicotine replacement therapy should not be used in which patients? 1. Pregnant women 2. Patients with worsening angina pectoris 3. Patients who have just suffered an acute myocardial infarction 4. All of the above 5. Instructions for the use of nicotine gum include: 1. Chew the gum quickly to get a peak effect. 2. The gum should be “parked” in the buccal space between chewing. 3. Acidic drinks such as coffee help with the absorption of the nicotine. 4. The highest abstinence rates occur if the patient chews the gum when he or she is having cravings. 6. Patients who choose the nicotine lozenge to assist in quitting tobacco should be instructed: 1. Chew the lozenge well. 2. Drink at least 8 ounces of water after the lozenge dissolves. 3. Use one lozenge every 1 to 2 hours (at least nine per day with a maximum of 20 per day). 4. A tingling sensation in the mouth should be reported to the provider. 7. Transdermal nicotine replacement (the patch) is an effective choice in tobacco cessation because: 1. The patch provides a steady level of nicotine without reinforcing oral aspects of smoking. 2. There is the ability to “fine tune” the amount of nicotine that is delivered to the patient at any one time. 3. There is less of a problem with nicotine toxicity than other forms of nicotine replacement. 4. Transdermal nicotine is safer in pregnancy. 8. The most common adverse effect of the transdermal nicotine replacement patch is: 1. Nicotine toxicity 2. Tingling at the site of patch application 3. Skin irritation under the patch site 4. Life-threatening dysrhythmias 9. If a patient is exhibiting signs of nicotine toxicity when using transdermal nicotine, they should remove the patch and: 1. Wash the area thoroughly with soap and water. 2. Flush the area with clear water. 3. Reapply a new patch in 8 hours. 4. Take acetaminophen for the headache associated with toxicity. 10. When a patient is prescribed nicotine nasal spray for tobacco cessation, instructions include: 1. Inhale deeply with each dose to ensure deposition in the lungs. 9. Lispro is an insulin analogue produced by recombinant DNA technology. Which of the following statements about this form of insulin is NOT true? 1. Optimal time of preprandial injection is 15 minutes. 2. Duration of action is increased when the dose is increased. 3. It is compatible with neutral protamine Hagedorn insulin. 4. It has no pronounced peak. 10. The decision may be made to switch from twice daily neutral protamine Hagedorn (NPH) insulin to insulin glargine to improve glycemia control throughout the day. If this is done: 1. The initial dose of glargine is reduced by 20% to avoid hypoglycemia. 2. The initial dose of glargine is 2 to 10 units per day. 3. Patients who have been on high doses of NPH will need tests for insulin antibodies. 4. Obese patients may require more than 100 units per day. 11. 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? 1. Premixed insulin analogues are better at lowering HbA1C and have less risk for hypoglycemia. 2. Premixed insulin analogues and the newer premixed insulins are associated with more weight gain than the oral antidiabetic agents. 3. Newer premixed insulins are better at lowering HbA1C and postprandial glucose levels than long-acting insulins. 4. Patients who are not controlled on oral agents and have postprandial hyperglycemia can have neutral protamine Hagedorn insulin added at bedtime. 12. Metformin is a primary choice of drug to treat hyperglycemia in type 2 diabetes because it: 1. Substitutes for insulin usually secreted by the pancreas 2. Decreases glycogenolysis by the liver 3. Increases the release of insulin from beta cells 4. Decreases peripheral glucose utilization 13. Prior to prescribing metformin, the provider should: 1. Draw a serum creatinine to assess renal function 2. Try the patient on insulin 3. Tell the patient to increase iodine intake 4. Have the patient stop taking any sulfonylurea to avoid dangerous drug interactions 14. The action of “gliptins” is different from other antidiabetic agents because they: 1. Have a low risk for hypoglycemia 2. Are not associated with weight gain 3. Close ATP-dependent potassium channels in the beta cell 4. Act on the incretin system to indirectly increase insulin production 15. Sitagliptin has been approved for: 1. Monotherapy in once-daily doses 2. Combination therapy with metformin 3. Both 1 and 2 4. Neither 1 nor 2 16. GLP-1 agonists: 1. Directly bind to a receptor in the pancreatic beta cell 2. Have been approved for monotherapy 3. Speed gastric emptying to decrease appetite 4. Can be given orally once daily 17. Avoid concurrent administration of exenatide with which of the following drugs? 1. Digoxin 2. Warfarin 3. Lovastatin 4. All of the above 18. Administration of exenatide is by subcutaneous injection: 1. 30 minutes prior to the morning meal 2. 60 minutes prior to the morning and evening meal 3. 15 minutes after the evening meal 4. 60 minutes before each meal daily 19. Potentially fatal granulocytopenia has been associated with treatment of hyperthyroidism with propylthiouracil. Patients should be taught to report: 1. Tinnitus and decreased salivation 2. Fever and sore throat 3. Hypocalcemia and osteoporosis 4. Laryngeal edema and difficulty swallowing 20. Elderly patients who are started on levothyroxine for thyroid replacement should be monitored for: 1. Excessive sedation 2. Tachycardia and angina 3. Weight gain 4. Cold intolerance 21. Which of the following is not an indication that growth hormone supplements should be discontinued? 1. Imaging indication of epiphyseal closure 2. Growth curve increases have plateaued 3. Complaints of mild bone pain 4. Achievement of anticipated height goals 22. Besides osteoporosis, IV bisphosphonates are also indicated for: 1. Paget’s Disease 2. Early osteopenia 3. Renal cancer 4. Early closure of cranial sutures 23. What is the role of calcium supplements when patients take bisphosphonates? 1. They must be restricted to allow the medication to work. 2. They must be taken in sufficient amounts to provide foundational elements for bone growth. 3. They must be taken at the same time as the bisphosphonates. 4. They only work with bisphosphonates if daily intake is restricted. 24. Which of the following statements about pancreatic enzymes is true? 1. Dosing may be titrated according to the decrease of steatorrhea. 2. The amount of carbohydrates in the meal drives the amount of enzyme used. 3. The amount of medication used is increased with a cystic fibrosis pulmonary flare. 4. The FDA and Internet-available formulations are bioequivalent. 25. Besides cystic fibrosis, which other medical state may trigger the need for pancreatic enzymes? 1. Paget’s disease 2. Pulmonary cancers 3. Gallbladder surgery 4. Some bariatric surgeries Chapter 33. Diabetes Mellitus Multiple Choice Identify the choice that best completes the statement or answers the question. 1. Type 1 diabetes results from autoimmune destruction of the beta cells. Eighty-five to 90% of type 1 diabetics have: 1. Autoantibodies to two tyrosine phosphatases 2. Mutation of the hepatic transcription factor on chromosome 12 3. A defective glucokinase molecule due to a defective gene on chromosome 7p 4. Mutation of the insulin promoter factor 14. Establishing glycemic targets is the first step in treatment of both types of diabetes. For type 1 diabetes: 1. Tight control/intensive therapy can be given to adults who are willing to test their blood glucose at least twice daily. 2. Tight control is acceptable for older adults if they are without complications. 3. Plasma glucose levels are the same for children as adults. 4. Conventional therapy has a fasting plasma glucose target between 120 and 150 mg/dl. 15. Treatment with insulin for type 1 diabetics: 1. Starts with a total daily dose of 0.2 to 0.4 units per kg of body weight 2. Divides the total doses into three injections based on meal size 3. Uses a total daily dose of insulin glargine given once daily with no other insulin required 4. Is based on the level of blood glucose 16. When the total daily insulin dose is split and given twice daily, which of the following rules may be followed? 1. Give two-thirds of the total dose in the morning and one-third in the evening. 2. Give 0.3 units per kg of premixed 70/30 insulin with one-third in the morning and two-thirds in the evening. 3. Give 50% of an insulin glargine dose in the morning and 50% in the evening. 4. Give long-acting insulin in the morning and short-acting insulin at bedtime. 17. Studies have shown that control targets that reduce the HbA1C to less than 7% are associated with fewer long-term complications of diabetes. Patients who should have such a target include: 1. Those with long-standing diabetes 2. Older adults 3. Those with no significant cardiovascular disease 4. Young children who are early in their disease 18. Prevention of conversion from prediabetes to diabetes in young children must take highest priority and should focus on: 1. Aggressive dietary manipulation to prevent obesity 2. Fostering LDL levels less than 100 mg/dl and total cholesterol less than 170 mg/dl to prevent cardiovascular disease 3. Maintaining a blood pressure that is less than 80% based on weight and height to prevent hypertension 4. All of the above 19. The drugs recommended by the American Academy of Pediatrics for use in children with diabetes (depending upon type of diabetes) are: 1. Metformin and insulin 2. Sulfonylureas and insulin glargine 3. Split-mixed dose insulin and GPL-1 agonists 4. Biguanides and insulin lispro 20. Unlike most type 2 diabetics where obesity is a major issue, older adults with low body weight have higher risks for morbidity and mortality. The most reliable indicator of poor nutritional status in older adults is: 1. Weight loss in previously overweight persons 2. Involuntary loss of 10% of body weight in less than 6 months 3. Decline in lean body mass over a 12-month period 4. Increase in central versus peripheral body adiposity 21. The drugs recommended for older adults with type 2 diabetes include: 1. Second-generation sulfonylureas 2. Metformin 3. Pioglitazone 4. Third-generation sulfonylureas 22. Ethnic groups differ in their risk for and presentation of diabetes. Hispanics: 1. Have a high incidence of obesity, elevated triglycerides, and hypertension 2. Do best with drugs that foster weight loss, such as metformin 3. Both 1 and 2 4. Neither 1 nor 2 23. 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: 1. Glycemic targets between 7% and 7.5% 2. Use of insulin in type 2 diabetics 3. Control of hypertension and hyperlipidemia 4. Stopping smoking 24. All diabetic patients with known cardiovascular disease should be treated with: 1. Beta blockers to prevent MIs 2. Angiotensin-converting enzyme inhibitors and aspirin to reduce risk of cardiovascular events 3. Sulfonylureas to decrease cardiovascular mortality 4. Pioglitazone to decrease atherosclerotic plaque buildup 25. All diabetic patients with hyperlipidemia should be treated with: 1. HMG-CoA reductase inhibitors 2. Fibric acid derivatives 3. Nicotinic acid 4. Colestipol 26. Both angiotensin converting enzyme inhibitors and some angiotensin II receptor blockers have been approved in treating: 1. Hypertension in diabetic patients 2. Diabetic nephropathy 3. Both 1 and 2 4. Neither 1 nor 2 27. 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: 1. Cannot tolerate angiotensin converting enzyme inhibitors or angiotensin receptor blockers 2. Have uncontrolled hypertension 3. Have HbA1C levels above 7% 4. Show progression of diabetic nephropathy despite optimal glucose and blood pressure control 28. Diabetic autonomic neuropathy (DAN) is the earliest and most common complication of diabetes. Symptoms associated with DAN include: 1. Resting tachycardia, exercise intolerance, and orthostatic hypotension 2. Gastroparesis, cold intolerance, and moist skin 3. Hyperglycemia, erectile dysfunction, and deficiency of free fatty acids 4. Pain, loss of sensation, and muscle weakness 29. Drugs used to treat diabetic peripheral neuropathy include: 1. Metoclopramide 2. Cholinergic agonists 3. Cardioselective beta blockers 4. Gabapentin 30. The American Diabetic Association has recommended which of the following tests for ongoing management of diabetes? 1. Fasting blood glucose 2. HbA1C 3. Thyroid function tests 4. Electrocardiograms 31. Allison is an 18-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? 1. Delay eating the midday meal until after the swimming class. 2. Increase the morning dose of NPH insulin on days of the swimming class. 3. Adjust the morning insulin injection so that the peak occurs while swimming. 4. 6 months 8. Treatment of a patient with hypothyroidism and cardiovascular disease consists of: 1. Levothyroxine 2. Liothyronine 3. Liotrix 4. Methimazole 9. Infants with congenital hypothyroidism are treated with: 1. Levothyroxine 2. Liothyronine 3. Liotrix 4. Methimazole 10. When starting a patient with hypothyroidism on thyroid replacement hormones patient education would include: 1. They should feel symptomatic improvement in 1 to 2 weeks. 2. Drug adverse effects such as lethargy and dry skin may occur. 3. It may take 4 to 8 weeks to get to euthyroid symptomatically and by laboratory testing. 4. Because of its short half-life, levothyroxine doses should not be missed. 11. In hyperthyroid states, what organ system other than CV must be evaluated to establish potential adverse issues? 1. The liver 2. The nails and skin 3. The eye 4. The ear 12. Why are “natural” thyroid products not readily prescribed for most patients? 1. There is no reliability for the amount of hormone per dose. 2. There is higher incidence of allergic reactions. 3. There is a more reliable dose of T3 to T4 per batch. 4. All of the above 13. What is the desired mixed of T3 to T4 drug levels in newly diagnosed endocrine patients? 1. 99% of T3 and the rest is T4 to get rapid resolution. 2. Most needs to be T4 to mimic natural ratios of hormone. 3. The ratio is unimportant. 4. The mix needs to be 50-50 at first. 14. Laboratory values are actually different for TSH when screening for thyroid issues and when used for medication management. Which of the follow holds true? 1. Screening TSH has a wider range of normal values 0.02-5.0; therapeutic levels need to remain above 5.0. 2. Screening values are much narrower than the acceptable range used to keep a person stable on hormone replacement. 3. Therapeutic values are kept between 0.05 and 3.0 ideally. Screening values are considered acceptable up to 10. 4. Screening values are between 5 and 10, and therapeutic values are greater than 10. 15. What happens to the typical hormone replacement dose when a woman becomes pregnant? 1. Most women need less medication. 2. Most women do not require a dose change. 3. The average woman needs more medication during pregnancy. 4. The average woman needs more medication only if carrying multiples. Chapter 25. Drugs Used in Treating Inflammatory Processes Multiple Choice Identify the choice that best completes the statement or answers the question. 1. Henry presents to clinic with a significantly swollen, painful great toe and is diagnosed with gout. Of the following, which would be the best treatment for Henry? 1. High-dose colchicine 2. Low-dose colchicine 3. High-dose aspirin 4. Acetaminophen with codeine 2. Patient education when prescribing colchicine includes: 1. Colchicine may be constipating. 2. Colchicine always causes some degree of diarrhea. 3. Mild muscle weakness is normal. 4. Moderate amounts of alcohol are safe with colchicine. 3. Larry is taking allopurinol to prevent gout. Monitoring of a patient who is taking allopurinol includes: 1. Complete blood count 2. Blood glucose 3. C-reactive protein 4. BUN, creatinine, and creatinine clearance 4. Phil is starting treatment with febuxostat (Uloric). Education of patients starting febuxostat includes: 1. Gout may worsen with therapy. 2. Febuxostat may cause severe diarrhea. 3. He should consume a high-calcium diet. 4. He will need frequent CBC monitoring. 5. Sallie has been taking 10 mg per day of prednisone for the past 6 months. She should be assessed for: 1. Gout 2. Iron deficiency anemia 3. Osteoporosis 4. Renal dysfunction 6. Patients whose total dose of prednisone will exceed 1 gram will most likely need a second prescription for: 1. Metformin, a biguanide to prevent diabetes 2. Omeprazole, a proton pump inhibitor to prevent peptic ulcer disease 3. Naproxen, an NSAID to treat joint pain 4. Furosemide, a diuretic to treat fluid retention 7. Daniel has been on 60 mg of prednisone for 10 days to treat a severe asthma exacerbation. It is time to discontinue the prednisone. How is prednisone discontinued? 1. Patients with asthma are transitioned directly off the prednisone onto inhaled corticosteroids. 2. Prednisone can be abruptly discontinued with no adverse effects. 3. Develop a tapering schedule to slowly wean Daniel off the prednisone. 4. Substitute the prednisone with another anti-inflammatory such as ibuprofen. 8. Patients with rheumatoid arthritis who are on chronic low-dose prednisone will need co- treatment with which medications to prevent further adverse effects? 1. A bisphosphonate 2. Calcium supplementation 3. Vitamin D 4. All of the above 9. Patients who are on or who will be starting chronic corticosteroid therapy need monitoring of: 1. Serum glucose 2. Stool culture 3. Folate levels 4. Vitamin B12 10. Patients who are on chronic long-term corticosteroid therapy need education regarding: 1. Receiving all vaccinations, especially the live flu vaccine 3. Vicky, age 56 years, comes to the clinic requesting a refill of her Fiorinal (aspirin and butalbital) that she takes for migraines. She has been taking this medication for over 2 years for migraines and states one dose usually works to abort her migraine. What is the best care for her? 1. Switch her to sumatriptan (Imitrex) to treat her migraines. 2. Assess how often she is using Fiorinal and refill her medication. 3. Switch her to a beta blocker such as propranolol to prevent her migraine. 4. Request she return to the original prescriber of Fiorinal as you do not prescribe butalbital for migraines. 4. When prescribing ergotamine suppositories (Wigraine) to treat acute migraine, patient education would include: 1. Ergotamine will briefly make the migraine worse before the migraine resolves. 2. The patient may experience bradycardia and dizziness. 3. They may need premedication with an antinausea medication. 4. Ergotamine works best if the patient starts off with a full suppository to get the full effect. 5. Migraines in pregnancy may be safely treated with: 1. Acetaminophen with codeine (Tylenol #3) 2. Sumatriptan (Imitrex) 3. Ergotamine tablets (Ergostat) 4. Dihydroergotamine (DHE) 6. Xi, a 54-year-old female, has a history of migraines that do not respond well to OTC migraine medication. She is asking to try Maxalt (rizatriptan) because it works well for her friend. Appropriate decision making would be: 1. Prescribe the Maxalt, but only give her four tablets with no refills to monitor the use. 2. Prescribe Maxalt and arrange to have her observed in the clinic or urgent care with the first dose. 3. Explain that rizatriptan is not used for postmenopausal migraines and recommend Fiorinal (aspirin and butalbital). 4. Prescribe sumatriptan (Imitrex) with the explanation that it is the most effective triptan. 7. Kelly is a 14-year-old patient who presents to the clinic with a classic migraine. She says she is having a headache two to three times a month. The initial plan would be: 1. Prescribe NSAIDs as abortive therapy and have her keep a headache diary to identify her triggers. 2. Prescribe zolmitriptan (Zomig) as abortive therapy and recommend relaxation therapy to reduce her stress. 3. Prescribe acetaminophen with codeine (Tylenol #3) for her to take at the first onset of her migraine. 4. Prescribe sumatriptan (Imitrex) nasal spray and arrange for her to receive the first dose in the clinic. 8. Jayla is a 9-year-old patient who has been diagnosed with migraines for almost 2 years. She is missing up to a week of school each month. Her headache diary confirms she averages four or five migraines per month. Which of the following would be appropriate? 1. Prescribe amitriptyline (Elavil) daily, start at a low dose and increase dosage slowly every 2 weeks until it’s effective in eliminating migraines. 2. Encourage her mother to give her Excedrin Migraine (aspirin, acetaminophen, and caffeine) at the first sign of a headache to abort the headache. 3. Prescribe propranolol (Inderal) to be taken daily for at least 3 months. 4. Explain that it is rare for a 9-year-old child to get migraines and she needs an MRI to rule out a brain tumor. 9. Amber is a 24-year-old patient who has had migraines for 10 years. She reports a migraine on average of once a month. The migraines are effectively aborted with naratriptan (Amerge). When refilling Amber’s naratriptan, education would include: 1. Naratriptan will interact with antidepressants, including selective serotonin reuptake inhibitors (SSRIs) and St John’s wort, and she should inform any providers she sees that she has migraines. 2. Continue to monitor her headaches, if the migraine is consistently happening around her menses there is preventive therapy available. 3. Pregnancy is contraindicated when taking a triptan. 4. All of the above 10. When prescribing for migraines, patient education includes: 1. Triptans are safe to be used as often as needed as long as the patient is healthy. 2. Use triptan before trying OTC meds such as acetaminophen or naproxen. 3. Stress reduction and regular sleep are integral to migraine treatment. 4. If migraines worsen they are to increase their medication. 11. Juanita presents to the clinic with a complaint of headaches off and on for months. She reports they feel like someone is “squeezing” her head. She occasionally takes Tylenol for the pain, but usually just “toughs it out.” Initial treatment for tension headache includes asking her to keep a headache diary and a prescription for: 1. Sumatriptan (Imitrex) 2. Naproxen (Aleve) 3. Ergotamine (Ergostat) 4. Tylenol with codeine (Tylenol #3) 12. Nonpharmacologic therapy for tension headaches includes: 1. Biofeedback 2. Stress management 3. Massage therapy 4. All of the above 13. James has been diagnosed with cluster headaches. Appropriate acute therapy would be: 1. Butalbital and aspirin (Fiorinal) 2. Meperidine IM (Demerol) 3. Oxygen 100% for 15 to 30 minutes 4. Indomethacin (Indocin) 14. Preventative therapy for cluster headaches includes: 1. Massage or relaxation therapy 2. Ergotamine nightly before bed 3. Intranasal lidocaine four times a day during “clusters” of headaches 4. Propranolol (Inderal) daily 15. When prescribing any headache therapy, appropriate use of medications needs to be discussed to prevent medication-overuse headaches. A clinical characteristic of medication- overuse headaches is that they: 1. Are increasing in frequency 2. Are increasing in intensity 3. Recur when medication wears off 4. Begin to “cluster” into a pattern Chapter 52. Pain Management: Acute and Chronic Pain Multiple Choice Identify the choice that best completes the statement or answers the question. 1. Different areas of the brain are involved in specific aspects of pain. The reticular and limbic systems in the brain influence the: 1. Sensory aspects of pain 2. Discriminative aspects of pain 3. Motivational aspects of pain 4. Cognitive aspects of pain 2. Patients need to be questioned about all pain sites because: 1. Patients tend to report the most severe or important in their perception. 2. Pain tolerance generally decreases with repeated exposure. 3. The reported pain site is usually the most important to treat. 4. Pain may be referred from a different site to the one reported. 3. The chemicals that promote the spread of pain locally include: 1. Serotonin 2. Norepinephrine 15. Chronic pain is a complex problem. Some specific strategies to deal with it include: 1. Telling the patient to “let pain be your guide” to using treatment therapies 2. Prescribing pain medication on a “PRN” basis to keep down the amount used 3. Scheduling return visits on a regular basis rather than waiting for poor pain control to drive the need for an appointment 4. All of the above 16. Chemical dependency assessment is integral to the initial assessment of chronic pain. Which of the following raises a “red flag” about potential chemical dependency? 1. Use of more than one drug to treat the pain 2. Multiple times when prescriptions are lost with requests to refill 3. Preferences for treatments that include alternative medicines 4. Presence of a family member who has abused drugs 17. The Pain Management Contract is appropriate for: 1. Patients with cancer who are taking morphine 2. Patients with chronic pain who will require long-term use of opiates 3. Patients who have a complex drug regimen 4. Patients who see multiple providers for pain control Chapter 17. Drugs Affecting the Respiratory System Multiple Choice Identify the choice that best completes the statement or answers the question. 1. Digoxin levels need to be monitored closely when the following medication is started: 1. Loratadine 2. Diphenhydramine 3. Ipratropium 4. Albuterol 2. Patients with pheochromocytoma should avoid which of the following classes of drugs because of the possibility of developing hypertensive crisis? 1. Expectorants 2. Beta-2-agonists 3. Antitussives 4. Antihistamines 3. Harold, a 42-year-old African American, has moderate persistent asthma. Which of the following asthma medications should be used cautiously, if at all? 1. Betamethasone, an inhaled corticosteroid 2. Salmeterol, an inhaled long-acting beta-agonist 3. Albuterol, a short-acting beta-agonist 4. Montelukast, a leukotriene modifier 4. Long-acting beta-agonists (LTBAs) received a Black Box Warning from the U.S. Food and Drug Administration due to the: 1. Risk of life-threatening dermatological reactions 2. Increased incidence of cardiac events when LTBAs are used 3. Increased risk of asthma-related deaths when LTBAs are used 4. Risk for life-threatening alterations in electrolytes 5. The bronchodilator of choice for patients taking propranolol is: 1. Albuterol 2. Pirbuterol 3. Formoterol 4. Ipratropium 6. James is a 52-year-old overweight smoker taking theophylline for his persistent asthma. He tells his provider he is going to start the Atkin’s diet for weight loss. The appropriate response would be: 1. Congratulate him on making a positive change in his life. 2. Recommend he try stopping smoking instead of the Atkin’s diet. 3. Schedule him for regular testing of serum theophylline levels during his diet due to increased excretion of theophylline. 4. Decrease his theophylline dose because a high-protein diet may lead to elevated theophylline levels. 7. Li takes theophylline for his persistent asthma and calls the office with a complaint of nausea, vomiting, and headache. The best advice for him would be to: 1. Reassure him this is probably a viral infection and should be better soon 2. Have him seen the same day for an assessment and theophylline level 3. Schedule him for an appointment in 2 to 3 days, which he can cancel if he is better 4. Order a theophylline level at the laboratory for him 8. Tiotropium bromide (Spiriva) is an inhaled anticholinergic: 1. Used for the treatment of chronic obstructive pulmonary disease (COPD) 2. Used in the treatment of asthma 3. Combined with albuterol for treatment of asthma exacerbations 4. Combined with fluticasone for the treatment of persistent asthma 9. Christy has exercise-induced and mild persistent asthma and is prescribed two puffs of albuterol 15 minutes before exercise and as needed for wheezing. One puff per day of beclomethasone (QVAR) is also prescribed. Teaching regarding her inhalers includes: 1. Use one to two puffs of albuterol per day to prevent an attack with no more than eight puffs per day 2. Beclomethasone needs to be used every day to treat her asthma 3. Report any systemic side effects she is experiencing, such as weight gain 4. Use the albuterol metered-dose inhaler (MDI) immediately after her corticosteroid MDI to facilitate bronchodilation 10. When prescribing montelukast (Singulair) for asthma, patients or parents of patients should be instructed: 1. Montelukast twice a day is started when there is an asthma exacerbation. 2. Patients may experience weight gain on montelukast. 3. Aggression, anxiety, depression, and/or suicidal thoughts may occur when taking montelukast. 4. Lethargy and hypersomnia may occur when taking montelukast. 11. Montelukast (Singulair) may be prescribed for: 1. A 6-year-old child with exercise-induced asthma 2. A 2-year-old child with moderate persistent asthma 3. An 18-month-old child with seasonal allergic rhinitis 4. None of the above; montelukast is not approved for use in children 12. The known drug interactions with the inhaled corticosteroid beclomethasone (QVAR) include: 1. Albuterol 2. MMR vaccine 3. Insulin 4. None of the above 13. When educating patients who are starting on inhaled corticosteroids, the provider should tell them that: 1. They need to get any live vaccines before starting the medication. 2. Inhaled corticosteroids need to be used daily during asthma exacerbations to be effective. 3. Patients should rinse their mouths out after using the inhaled corticosteroid to prevent thrush. 4. They can triple the dose number of inhalations of medication during colds to prevent needing systemic steroids. 14. Patients with allergic rhinitis may benefit from a prescription of: 1. Fluticasone (Flonase) 2. Cetirizine (Zyrtec) 3. OTC cromolyn nasal spray (Nasalcrom) 4. Any of the above 15. Howard is a 72-year-old male who occasionally takes diphenhydramine for his seasonal allergies. Monitoring for this patient taking diphenhydramine would include assessing for: 1. Urinary retention 5. When prescribing griseofulvin (Grifulvin V) to treat tinea capitis it is critical to instruct the patient or parent to: 1. Mix the griseofulvin with ice cream before administering 2. Take the griseofulvin until the tinea clears, in approximately 4 to 5 weeks 3. Shampoo with baby shampoo daily while taking the griseofulvin 4. Griseofulvin is best absorbed if ingested with a high-fat food. 6. First-line therapy for treating topical fungal infections such as tinea corporis (ringworm) or tinea pedis (athlete’s foot) would be: 1. OTC topical azole (clotrimazole, miconazole) 2. Oral terbinafine 3. Oral griseofulvin microsize 4. Nystatin cream or ointment 7. When prescribing topical penciclovir (Denavir) for the treatment of herpes labialis (cold sores) patient education would include: 1. Spread penciclovir liberally all over lips and area surrounding lips. 2. Penciclovir therapy is started at the first sign of a cold sore outbreak. 3. Skin irritation is normal with penciclovir and it should resolve. 4. The penciclovir should be used a minimum of 2 weeks to prevent recurrence. 8. Erika has been prescribed isotretinoin (Accutane) by her dermatologist and is presenting to her primary care provider with symptoms of sadness and depression. A Beck’s Depression Scale indicates she has mild to moderate depression. What would be the best care for her at this point? 1. Prescribe a select serotonin reuptake inhibitor (SSRI) antidepressant 2. Refer her to a mental health therapist 3. Contact her dermatologist about discontinuing the isotretinoin 4. Reassure her that mood swings are normal and schedule follow up in a week 9. Drew is a 17-year-old competitive runner who presents with complaint of pain in his hip that occurred after he fell while running. His only medical problem is severe acne for which he takes isotretinoin (Accutane). With this history what would you be concerned for? 1. He may have pulled a muscle and needs to rest to recover. 2. He is at risk for bone injuries and needs to be evaluated for fracture. 3. Isotretinoin interacts with ibuprofen which is the pain medication of choice. 4. Teen athletes are at risk for repetitive stress injuries. 10. Catherine calls the clinic with concerns that her acne is worse 1 week after starting topical tretinoin. What would be the appropriate care for her? 1. Change her to a different topical acne medication as she is having an adverse reaction to the tretinoin. 2. Switch her to an oral antibiotic to treat her acne. 3. Advise her to apply an oil-based lotion to her face to soothe the redness. 4. Reassure her that the worsening of acne is normal and it should improve with continued use. 11. Li is a 6-month-old infant with severe eczema. She would benefit from topical corticosteroid therapy. Instructions for using topical corticosteroids in children include: 1. Apply liberally to all areas with eczema. 2. Double the frequency of application when the eczema is severe. 3. Apply sparingly to eczema areas. 4. Cover the eczema area with an occlusive dressing after applying a corticosteroid. 12. Jose has had eczema for many years and reports that he thinks his corticosteroid cream is not working as well as it was previously. He may be experiencing tolerance to the corticosteroid. Treatment options include: 1. Increase the potency of the corticosteroid cream. 2. Recommend an interrupted or cyclic schedule of application. 3. Increase the frequency of dosing of the corticosteroid. 4. Discontinue the corticosteroid because it isn’t working any longer . 13. When prescribing tacrolimus (Protopic) to treat atopic dermatitis patients should be informed that: 1. Tacrolimus is the most effective if it is used continuously for 4 to 6 months. 2. Tacrolimus should be spread generously over the affected area. 3. The FDA has issued a Black Box warning about the use of tacrolimus and the development of cancer in animals and humans. 4. The FDA recommends patients be screened for cancer before prescribing tacrolimus. 14. Patients who are treated with greater than 100 grams per week of topical calcipotriene for psoriasis need to be monitored for: 1. High vitamin D levels 2. Hyperkalemia 3. Hypercalcemia 4. Hyperuricemia 15. Jesse is prescribed tazarotene for his psoriasis. Patient education regarding topical tazarotene includes instructing them: 1. That tazarotene is applied in a thin film to the psoriasis plaque lesions 2. To apply it liberally to all psoriatic lesions 3. To apply tazarotene to nonaffected areas to prevent breakout 4. That tazarotene may cause hypercalcemia if it is overused 16. Instructions for the use of selenium sulfide shampoo (Selsun) to treat scalp seborrhea include: 1. Shampoo daily and rinse well. 2. Worsening of seborrhea for the first week is normal. 3. Seborrhea usually clears up after a few weeks of treatment. 4. Shampoo twice a week for 2 weeks, then weekly. 17. Topical diphenhydramine (Benadryl) is available OTC to treat itching. Patients or parents should be instructed regarding the use of topical diphenhydramine that: 1. For maximum effectiveness in treating itching, combine topical with oral diphenhydramine. 2. Topical diphenhydramine is the treatment of choice in treating poison ivy or poison oak. 3. Topical diphenhydramine should not be used in children younger than age 2 years. 4. When applying topical diphenhydramine, apply the cream liberally to all areas that itch. 18. A patient has been prescribed silver sulfadiazine (Silvadene) cream to treat burns on his leg. Normal adverse effects of silver sulfadiazine cream include: 1. Transient leukopenia on days 2 to 4 that should resolve 2. Worsening of burn symptoms briefly before resolution 3. A red, scaly rash that will resolve with continued use 4. Hypercalcemia 19. Instructions for the use of malathion (Ovide) for head lice include: 1. Use a blow dryer to dry the hair after applying. 2. Malathion (Ovide) is used daily for a week until all lice are dead. 3. Rinse the malathion (Ovide) off and shampoo hair after 8 to 12 hours. 4. Use gloves to apply the malathion (Ovide). 20. When writing a prescription of permethrin 5% cream (Elimite) for scabies, patient education would include: 1. All members of the household and personal contacts should also be treated. 2. Infants should have permethrin applied from the neck down. 3. The permethrin is washed off after 10 to 20 minutes. 4. Permethrin is flammable and to avoid open flame while the medication is applied. Chapter 26. Drugs Used in Treating Eye and Ear Disorders Multiple Choice Identify the choice that best completes the statement or answers the question. 1. The Centers for Disease Control recommends all newborn infants receive prophylactic administration of within 1 hour of birth. 1. Gentamicin ophthalmic ointment 2. Ciprofloxacin ophthalmic drops 3. Erythromycin oral suspension 3. One goal of asthma therapy outlined by the NHLBI Expert Panel 3 guidelines is: 1. Ability to use albuterol daily to control symptoms 2. Minimize exacerbations to once a month 3. Keep nighttime symptoms at a maximum of twice a week 4. Require infrequent use of beta 2 agonists (albuterol) for relief of symptoms 4. A stepwise approach to the pharmacologic management of asthma: 1. Begins with determining the severity of asthma and assessing asthma control 2. Is used when asthma is severe and requires daily steroids 3. Allows for each provider to determine their personal approach to the care of asthmatic patients 4. Provides a framework for the management of severe asthmatics, but is not as helpful when patients have intermittent asthma 5. Treatment for mild intermittent asthma is: 1. Daily inhaled medium-dose corticosteroids 2. Short-acting beta-2-agonists (albuterol) as needed 3. Long-acting beta-2-agonists every morning as a preventative 4. Montelukast (Singulair) daily 6. The first-line therapy for mild-persistent asthma is: 1. High-dose montelukast 2. Theophylline 3. Low-dose inhaled corticosteroids 4. Long-acting beta-2-agonists 7. Monitoring a patient with persistent asthma includes: 1. Monitoring how frequently the patient has an upper respiratory infection (URI) during treatment 2. Monthly in-office spirometry testing 3. Determining if the patient has increased use of his or her long-acting beta-2-agonist due to exacerbations 4. Evaluating the patient every 1 to 6 months to determine if the patient needs to step up or down in their therapy 8. Asthma exacerbations at home are managed by the patient by: 1. Increasing frequency of beta-2-agonists and contacting their provider 2. Doubling inhaled corticosteroid doses 3. Increasing frequency of beta-2-agonists 4. Starting montelukast (Singulair) 9. Patients who are at risk of a fatal asthma attack include patients: 1. With moderate persistent asthma 2. With a history of requiring intubation or ICU admission for asthma 3. Who are on daily inhaled corticosteroid therapy 4. Who are pregnant 10. Pregnant patients with asthma may safely use throughout their pregnancy. 1. Oral terbutaline 2. Prednisone 3. Inhaled corticosteroids (budesonide) 4. Montelukast (Singulair) 11. One goal of asthma management in children is: 1. They independently manage their asthma 2. Participation in school and sports activities 3. No exacerbations 4. Minimal use of inhaled corticosteroids 12. Medications used in the management of patients with chronic obstructive pulmonary disease (COPD) include: 1. Inhaled beta-2-agonists 2. Inhaled anticholinergics (ipratropium) 3. Inhaled corticosteroids 4. All of the above 13. Patients with a COPD exacerbation may require: 1. Doubling of inhaled corticosteroid dose 2. Systemic corticosteroid burst 3. Continuous inhaled beta-2-agonists 4. Leukotriene therapy 14. Patients with COPD require monitoring of: 1. Beta-2-agonist use 2. Serum electrolytes 3. Blood pressure 4. Neuropsychiatric effects of montelukast 15. Education of patients with COPD who use inhaled corticosteroids includes: 1. Doubling the dose at the first sign of a URI 2. Using their inhaled corticosteroid first and then their bronchodilator 3. Rinsing their mouth after use 4. Abstaining from smoking for at least 30 minutes after using 16. Education for patients who use an inhaled beta-agonist and an inhaled corticosteroid includes: 1. Use the inhaled corticosteroid first, followed by the inhaled beta-agonists. 2. Use the inhaled beta-agonist first, followed by the inhaled corticosteroid. 3. Increase fluid intake to 3 liters per day. 4. Avoid use of aspirin or ibuprofen while using inhaled medications. Chapter 32. Dermatologic Conditions Multiple Choice Identify the choice that best completes the statement or answers the question. 1. When choosing a topical corticosteroid cream to treat diaper dermatitis, the ideal medication would be: 1. Intermediate potency corticosteroid ointment (Kenalog) 2. A combination of a corticosteroid and an antifungal (Lotrisone) 3. A low-potency corticosteroid cream applied sparingly (hydrocortisone 1%) 4. A high-potency corticosteroid cream (Diprolene AF) 2. Topical immunomodulators such as pimecrolimus (Elidel) or tacrolimus (Protopic) are used for: 1. Short-term or intermittent treatment of atopic dermatitis 2. Topical treatment of fungal infections (Candida) 3. Chronic, inflammatory seborrheic dermatitis 4. Recalcitrant nodular acne 3. Long-term treatment of moderate atopic dermatitis includes: 1. Topical corticosteroids and emollients 2. Topical corticosteroids alone 3. Topical antipruritics 4. Oral corticosteroids for exacerbations of atopic dermatitis 4. Severe contact dermatitis caused by poison ivy or poison oak exposure often requires treatment with: 1. Topical antipruritics 2. Oral corticosteroids for 2 to 3 weeks 3. Thickly applied topical intermediate-dose corticosteroids 4. Isolation of the patient to prevent spread of the dermatitis 5. When a patient has contact dermatitis, wet dressings with Domeboro solution are used for: 1. Cleaning the weeping area of dermatitis 18. Rick has male pattern baldness on the vertex of his head and has been using Rogaine for 2 months. He asks how effective minoxidil (Rogaine) is. Minoxidil: 1. Provides a permanent solution to male pattern baldness if used for at least 4 months 2. Will show results after 4 months of twice-a-day use 3. May not work for Rick’s type of baldness 4. Works better if he also uses hydrocortisone cream daily on his scalp Principles of prescribing for older adults include: 1.Avoiding prescribing any newer high-cost medications 2. Starting at a low dose and increasing the dose slowly 3. Keeping the total dose at a lower therapeutic range 4.All of the above Sadie is a 90-year-old patient who requires a new prescription. What changes in drug distribution with aging would influence prescribing for Sadie? 1. Increased volume of distribution 2. Decreased lipid solubility 3. Decreased plasma proteins 4. Increased muscle-to-fat ratio Glen is an 82-year-old patient who needs to be prescribed a new drug. What changes in elimination should be taken into consideration when prescribing for Glen? 1. Increased glomerular filtration rate (GFR) will require higher doses of some renally excreted drugs. 2. Decreased tubular secretion of medication will require dosage adjustments. 3. Thin skin will cause increased elimination via sweat. 4. Decreased lung capacity will lead to measurable decreases in lung excretion of drugs. A medication review of an elderly person's medications involves: 1.Asking the patient to bring a list of current prescription medications to the visit 2. Having the patient bring all of their prescription, over-the-counter, and herbal medications to the visit 3.Asking what other providers are writing prescriptions for them 4.All of the above Steps to avoid polypharmacy include: 1. Prescribing two or fewer drugs from each drug class 2. Reviewing a complete drug history every 12 to 18 months 3. Encouraging the elderly patient to coordinate their care with all of their providers 4. Evaluating for duplications in drug therapy and discontinuing any duplicationss Robert is a 72-year-old patient who has hypertension and angina. He is at risk for common medication practices seen in the elderly including: 1. Use of another person's medications 2. Hoarding medications 3. Changing his medication regimen without telling his provider 4.All of the above To improve positive outcomes when prescribing for the elderly the nurse practitioner should: 1.Assess cognitive functioning in the elder 2. Encourage the patient to take a weekly "drug holiday" to keep drug costs down 3. Encourage the patient to cut drugs in half with a knife to lower costs 4.All of the above When an elderly diabetic patient is constipated the best treatment, options include: 1. Mineral oil 2. Bulk-forming laxatives such as psyllium 3. Stimulant laxatives such as senna 4. Stool softeners such as docusate Delta is an 88-year-old patient who has mild low-back pain. What guidelines should be followed when prescribing pain management for Delta? 1. Keep the dose of oxycodone low to prevent development of tolerance. 2.Acetaminophen is the first-line drug of choice. 3.Avoid prescribing NSAIDs. 4.Add in a short-acting benzodiazepine for a synergistic effect on pain. Robert is complaining of poor sleep. Medications that may contribute to sleep problems in the elderly include: 1. Diuretics 2. Trazodone 3. Clonazepam 4. Levodopa The GFRs for a 91-year-old woman who weighs 93 pounds and is 5'1" with a serum creatinine of 1.1, and for a 202-pound, 25-year-old male who is 5'9" with the same serum creatinine according to the Cockcroft Gault formula are: 1. 25ml/ min and 133 mL/min respectively 2. 25 mL/min and 103 mL/min respectively 3. 22 ml/min and 133 mL/min respectively 4. 22 ml/min and 103 mL/min respectively In geriatric patients, the percentage of body fat is increased. What are the pharmacologic implications of this physiologic change? 1.A lipid-soluble medication will be eliminated more quickly and not work as well. 2.A lipid-soluble medication will accumulate in fat tissue and its duration of action may be prolonged. 3.Absorption of lipid-soluble drugs is impaired in older adults. 4. The bioavailability of the lipid-soluble drug will be increased in older adults. All of the following statements about the Beer's List are true except: 1. It is a list of medications or medication classes that should generally be avoided in persons 65 years or older because they are either ineffective or they pose unnecessarily high risk for older persons and a safer alternative is available. 2. It is derived from the expert opinion of one geriatrician and is not evidence- based. 3.These criteria have been adopted by the Centers for Medicare and Medicaid Services for regulation of long-term care facilities. 4.These criteria are directed at the general population of patients over 65 years of age and do not take disease states into consideration. You are reviewing the data from several meta-analyses that addressed the most common causes of adverse drug reactions in the older adult. Which of the following would you find to be decreased and the most common cause of these problems in older adults? 1. Body fat content 2. Liver function 3. Renal function/clearance 4. Plasma albumin levels Which of the following is not consistent with the rules for geriatric prescribing: 1. Half-life will be longer in older adults 2. Steady state is reached more quickly in the older adult 3. Reduce the number of drugs in the patient's regimen whenever possible 4.Adverse drug responses present atypically in the older adult The Pediatric Research Equity Acts requires: 1.All children be provided equal access to drug research trials 2. Children to be included in the planning phase of new drug development 3.That pediatric drug trials guarantee children of multiple ethnic groups are included 4.All applications for new active ingredients, new indications, new dosage forms, or new routes of administration require pediatric studies The Best Pharmaceuticals for Children Act: 1. Includes a pediatric exclusivity rule which extends the patent on drugs studied in children 2. Establishes a committee that writes guidelines for pediatric prescribing 3. Provides funding for new drug development aimed at children 4. Encourages manufacturers specifically to develop pediatric formulations The developmental variation in Phase I enzymes has what impact on pediatric prescribing? 1. None, Phase I enzymes are stable throughout childhood. 2. Children should always be prescribed lower than adult doses per weight due to low enzyme activity until puberty. 3. Children should always be prescribed higher than adult doses per weight due to high enzyme activity. 4. Prescribing dosages will vary based on the developmental activity of each 2.Acetaminophen suppository 3. Ibuprofen suppository 4.Alternating acetaminophen and ibuprofen The factor that has the greatest effect on males developing male sexual characteristics is: 1. Cultural beliefs 2. Effective male role models 3.Adequate intake of testosterone in the diet 4.Androgen production When assessing a male for hypogonadism prior to prescribing testosterone replacement, serum testosterone levels are drawn: 1. Without regard to time of day 2. First thing in the morning 3. Late afternoon 4. In the evening Some research supports that testosterone replacement therapy may be indicated in which of the following diagnoses in men? 1.Age-related decrease in cognitive functioning 2. Metabolic syndrome 3. Decreased muscle mass in aging men 4.All of the above The goal of testosterone replacement therapy is: 1.Absence of all hypogonadism symptoms 2.Testosterone levels in the mid-normal range 1 week after an injection 3.Testosterone levels in the mid-normal range just prior to the next injection 4.Avoidance of high serum testosterone levels during therapy While on testosterone replacement, hemoglobin and hematocrit levels should be monitored. Levels suggestive of excessive erythrocytosis or abuse are: 1. Hemoglobin 14 g/dl or hematocrit 39% 2. Hemoglobin 11.5 g/dl or hematocrit 31% 3. Hemoglobin 13 g/dl or hematocrit 38% 4. Hemoglobin 17.5 g/dl or hematocrit 54% Monitoring of an older male patient on testosterone replacement includes: 1. Oxygen saturation levels at every visit 2. Serum cholesterol and lipid profile every 3 to 6 months 3. Digital rectal prostate screening exam at 3 and 6 months after starting therapy 4. Bone mineral density at 3 months and 6 months after starting therapy When prescribing phosphodiesterase type 5 (PDE-5) inhibitors such as sildenafil (Viagra) patients should be screened for use of: 1. Statins 2. Nitrates 3. Insulin 4. Opioids Men who are prescribed phosphodiesterase type 5 (PDE-5) inhibitors for erectile dysfunction should be educated regarding the adverse effects of the drug which include: 1. Hearing loss 2. Hypotension 3. Delayed ejaculation 4. Dizziness Male patients who should not be prescribed phosphodiesterase type 5 (PDE-5) inhibitors include: 1. Diabetics 2. Those who have had an acute myocardial infarction in the past 6 months 3. Patients who are deaf 4. Patients under age 60 years of age Monitoring of male patients who are using phosphodiesterase type 5 (PDE-5) inhibitors includes: 1. Serum fasting glucose levels 2. Cholesterol and lipid levels 3. Blood pressure 4. Complete blood count Pernicious anemia is treated with: 1. Folic acid supplements 2.Thiamine supplements 3. Vitamin B12 4. Iron Premature infants require iron supplementation with: 1. 10 mg/day of iron 2. 2 mg/kg per day until age 12 months 3. 7 mg/day in their diet 4. 1 mg/kg per day until they are receiving adequate intake of iron from foods Breastfed infants should receive iron supplementation of: 1. 3 mg/kg per day 2. 6 mg/kg per day 3. 1 mg/kg per day 4. Breastfed babies do not need iron supplementation Valerie presents to the clinic with menorrhagia. Her hemoglobin is 10.2 and her ferritin is 15 ng/mL. Initial treatment for her anemia would be: 1. 18 mg/day of iron supplementation 2. 6 mg/kg per day of iron supplementation 3. 325 mg ferrous sulfate per day 4. 325 mg ferrous sulfate tid Chee is a 15-month-old male whose screening hemoglobin is 10.4 g/dL. Treatment for his anemia would be: 1. 18 mg/day of iron supplementation 2. 6 mg/kg per day of elemental iron 3. 325 mg ferrous sulfate per day 4. 325 mg ferrous sulfate tid Monitoring for a patient taking iron to treat iron deficiency anemia is: 1. Hemoglobin, hematocrit, and ferritin 4 weeks after treatment is started 2. Complete blood count every 4 weeks throughout treatment 3.Annual complete blood count 4. Reticulocyte count in 4 weeks Valerie has been prescribed iron to treat her anemia. Education of patients prescribed iron would include: 1. Take the iron with milk if it upsets her stomach. 2.Antacids may help with the nausea and GI upset caused by iron. 3. Increase fluids and fiber to treat constipation. 4. Iron is best tolerated if it is taken at the same time as her other medications. Allie has just had her pregnancy confirmed and is asking about how to ensure a healthy baby. What is the folic acid requirement during pregnancy? 1. 40 mcg/day 2. 200 mcg/day 3. 800 mcg/day 4. 2 gm/day Kyle has Crohn's disease and has a documented folate deficiency. Drug therapy for folate deficiency anemia is: 1. Oral folic acid 1 to 2 mg per day 2. Oral folic acid 1 gram per day 3. IM folate weekly for at least 6 months 4. Oral folic acid 400 mcg daily Patients who are being treated for folate deficiency require monitoring of: 1. Complete blood count every 4 weeks 2. Hematocrit and hemoglobin at 1 week and then at 8 weeks 3. Reticulocyte count at 1 week 4. Folate levels every 4 weeks until hemoglobin stabilizes