NURS 104 PHAMACOLOGY FINAL EXAM LATEST UPDDATE 2022/2023 QUESTION AND ANSWERS Essentials, Exams of Pharmacology

Download NURS 104 PHAMACOLOGY FINAL EXAM LATEST UPDDATE 2022/2023 QUESTION AND ANSWERS Essentials and more Exams Pharmacology in PDF only on Docsity! NURS 104 PHAMACOLOGY FINAL EXAM LATEST UPDDATE 2022/2023 QUESTION AND ANSWERS Essentials for Medication Safety, 2nd Edition Chapter 01: Drug Regulation, Actions, and Responses Workman & LaCharity: Understanding Pharmacology: Essentials for Medication Safety, 2nd Edition MULTIPLE CHOICE BASIC CONCEPTS 1. Which health care professional has the major responsibility for dispensing prescribed drugs under the direction of a pharmacist? a. Physician b . Nurse practitioner c. Licensed nurse d . Pharmacy technician ANS: D The physician and nurse practitioner have the major responsibility for prescribing drugs, not dispensing them. The licensed nurse has the primary responsibility for administering drugs, although under some circumstances a licensed nurse may dispense prescribed drugs but this is not his or her major responsibility in drug therapy. The pharmacy technician has the major responsibility of dispensing prescribed drugs under the direction of a licensed pharmacist. DIF: Cognitive Level: Remembering REF: p. 3 2. Which term describes the effect of a drug that improves body function? a. Side effect b . Intended action c. Adverse reaction d . Idiosyncratic response ANS: B The purpose of drug therapy is to take a drug to prevent, reduce, or correct a health problem. This response is any drug’s intended action also known as a therapeutic response. DIF: Cognitive Level: Remembering REF: p. 3 3. Which type of drug name is “owned” by the company that manufactures it? a. Generic name b Chemical name . c. Category name d . Trade name ANS: D The chemical name is a drug’s exact chemical composition. The generic name is the name assigned to the drug by the U.S. Adopted Names Council and is not owned by anyone. The category name refers to the type of drug (what it does or what it is used for) and is not an actual drug name. The trade name (brand name) is the name provided and owned by a specific drug’s manufacturer. DIF: Cognitive Level: Remembering REF: p. 4 4. Which drug or drug class is a “high alert” drug? a. Penicillin b . Insulin c. NSAIDs d . Calcium ANS: B A high alert drug is one in which harm is likely to result if given at the wrong dose, to the wrong patient, or not given to the correct patient. Drugs classified as high alert drugs include potassium, narcotics (opioids), insulin, cancer chemotherapy drugs, and heparin (or any drug that strongly affects blood clotting). Penicillin, NSAIDs, and calcium are not considered high alert drugs. DIF: Cognitive Level: Remembering REF: p. 4 5. What is the term for a drug that has the same action as a naturally occurring body hormone or enzyme? a. Agonist b . Blocking agent c. Chemical d . Duplicator ANS: A A drug agonist is an extrinsic drug that activates the receptor sites of a cell and mimics the actions of naturally occurring body substances (intrinsic drugs). A blocking agent is a drug 11. How are the terms drug and medication different in the health care environment? a. Medications must be prescribed, whereas drugs are available over-the-counter. b . Medications are used to treat health problems, whereas drugs can be misused. c. Drugs are always illegal, whereas medications are legal. d . There is no difference between these two terms. ANS: D Although the lay public may think there is a distinction between these two terms, in health care they mean the same thing. Both are used to treat health problems and both can be misused. DIF: Cognitive Level: Understanding REF: p. 2 12. The prescriber tells a patient with allergies to use oral diphenhydramine (Benadryl) over- the-counter (OTC) to help manage her symptoms. She tells you that she would rather have a prescription for the “real” Benadryl because she knows it is stronger and will work better than the nonprescription form. What is your best response? a. “If you receive a prescription for this drug your name will be added to a controlled substances list.” b . “It is better to use the OTC Benadryl rather than the prescribed form because it has fewer side effects.” c. “The OTC form of Benadryl is the same strength as the one that was available by prescription only.” d . “You are correct. I will ask the health care provider to write a prescription so that you can get the most effective drug.” ANS: C Diphenhydramine (Benadryl) is no longer available by prescription only. The OTC form has the same strength, action, and side effects that the prescription only drug had. DIF: Cognitive Level: Applying or Higher REF: p. 4 13. Why is it important to always ask a patient about his or her use of any herbal supplements or botanicals? a. Many states do not have regulations about herbal supplements or botanicals. b . These substances are illegal and their use by patients must be reported. c. Patients who use botanicals seldom take their prescribed drugs. d . These substances can interact with a prescribed drug. ANS: D Many herbal supplements and botanicals have effects on cell activity. Sometimes these agents can make drug side effects worse or can reduce the effectiveness of a prescribed drug. Others can actually cause health problems. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 5 14. How are the effects of naturally occurring testosterone changed when a patient is taking a drug that is a testosterone agonist? a. Effects are increased. b . Effects are decreased. c. Effects are eliminated. d . Effects are unchanged. ANS: A An agonist drug has the same effects of the naturally occurring drug. So, taking a testosterone agonist adds to the effects of the patient’s naturally occurring testosterone. DIF: Cognitive Level: Understanding REF: pp. 6-7 15. Which feature of a drug agonist increases its potency? a. It is water soluble. b . It binds tighter and longer to its receptors than do other drugs. c. It is excreted through the intestinal tract rather than through the kidneys. d . It is administered intramuscularly rather than by the intravenous route. ANS: B A drug agonist binds to its receptors to cause a change in the cells and tissues. The longer a drug remains bound to its receptors and the more tightly it binds increases its duration of response, making it more potent than a drug that binds with its receptors for a shorter time. DIF: Cognitive Level: Understanding REF: p. 7 16. Which statement about agonist and antagonist drugs is true? a. The target tissues for these types of drugs are invading bacteria and viruses. b . Both agonist and antagonist drugs must interact with receptors to produce their intended responses. c. Antagonist drugs produce only intended responses and agonist drugs produce both intended responses and side effects. d These types of drugs are less likely to cause allergic responses than drugs that are neither . agonists nor antagonists. ANS: B Agonist drugs excite a receptor to produce their intended responses on a cell or tissue in the same way that a naturally occurring substance does. Antagonist drugs produce their intended responses by binding to and blocking receptors. DIF: Cognitive Level: Understanding REF: pp. 6-7 17. A patient asks why he must take a “loading dose” for the first dose of his prescribed drug and then take lower doses after that. What is your best response? a. “The loading dose allows the first dose of this drug to get into your bloodstream faster and because it stays in the bloodstream a long time, you can take lower doses after that.” b . “The first dose of a drug has to be higher to reach the bloodstream because the liver destroys it before it has a chance to start its action and work for you.” c. “By taking the highest dose first and just once, you are reducing the likelihood of having a bad reaction or other side effects to this drug.” d . “This schedule helps by ensuring that the drug is having an effect even if you forget to take the rest of the doses.” ANS: A A loading dose is most often used with drugs that have a long half-life. Giving a higher dose for the first dose allows it to reach the bloodstream rapidly and stay there. Smaller doses follow it to keep the blood drug level at a steady state without increasing the risk for a drug over dose. DIF: Cognitive Level: Applying or Higher REF: p. 16 18. Which action could make a drug more potent? a. Slow drug absorption b . Slow drug elimination c. Normal drug elimination d . Fast drug elimination ANS: B Any condition that keeps a drug active inside the body longer can increase its potency. Slow drug elimination allows a drug to remain longer in the body. Normal or fast elimination does not. Slow drug absorption does not contribute to potency. DIF: Cognitive Level: Understanding REF: p. 15 b . Hydromorphone remains bound to opioid receptors longer than morphine does. c. Morphine is metabolized and eliminated at a faster rate than hydromorphone. d . Hydromorphone is metabolized and eliminated at a faster rate than morphine. ANS: B The length of time and intensity of an agonist drug’s response is related to how tightly and how long it remains bound to its receptors. More potent agonist drugs stay bound longer than do weaker agonist drugs. DIF: Cognitive Level: Understanding REF: pp. 6-7 25. Which drug administration route is the least predictable? a. Enteral b . Intravenous c. Transdermal d . Subcutaneous ANS: A Many issues within an individual patient’s gastrointestinal system can affect drug absorption and, to some extent, drug metabolism. In addition, any food or beverages taken at the same time as an oral drug also affect drug absorption. DIF: Cognitive Level: Understanding REF: p. 13 26. Why is the intravenous route of drug administration route the most dangerous? a. If the needle clogs, the patient does not receive the drug. b . The intestinal tract does not detoxify these drugs. c. Drugs are immediately bioavailable. d . Drugs have extensive “first pass” loss. ANS: C Drugs administered intravenously are immediately available in the bloodstream. If the dosage is wrong or if it is the wrong drug, there is no simple way to stop the drug’s action. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 13 27. The likelihood that a drug will sequester (be trapped) in fat cells and remain in the body longer is increased by which drug characteristic? a. Dissolves easily in water b . Dissolves easily in lipids c. Physical small size d . Physical large size ANS: B Drugs that are lipid soluble (dissolve easily in lipids) enter the plasma membranes of all cells more easily than water-soluble drugs. When a lipid-soluble drug enters a lipid environment (e.g., inside a fat cell), it is often sequestered there and takes a much longer time to be eliminated. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 12 28. A patient has a deficiency of an enzyme that prepares a specific drug for elimination. For which response or issue should you remain alert? a. Toxic blood levels of the drug are more likely to occur. b . Higher drug dosages will be needed for the intended action to occur. c. The drug will be eliminated more rapidly in the feces rather than in the urine. d . Delivery of this drug by the parenteral route is more effective than by the enteral route. ANS: A When a patient has a deficiency of the enzyme needed for drug elimination, the drug remains in the body much longer. The risk for even “normal” dosages to cause serious side effects is higher, and toxic drug blood levels can occur quickly. If such a drug is prescribed for this patient, the dosage is lowered and the drug is administered less often. DIF: Cognitive Level: Applying or Higher REF: p. 15 29. A patient has all of the following health problems. Which problem increases his or her risk for drug side effects? a. Asthma b . Kidney disease c. GI ulcers d . Chronic high blood pressure ANS: B The liver and kidneys are the organs that are most important for drug metabolism and elimination. A problem that decreases the function of either organ increases active blood drug levels and the length of time a single drug dose remains in the body. Both conditions lead to an increased risk for drug side effects. DIF: Cognitive Level: Applying or Higher REF: p. 15 30. When a patient takes 400 mg of an oral drug that has a half-life of 2 hours at noon, at which time will the patient’s blood drug level first be less than 40 mg? a. 2:00 p.m. b . 6:00 p.m. c. 8:00 p.m. d . Midnight ANS: C With a half-life of 2 hours, the amount of drug remaining in the blood decreases by 50% every 2 hours. So, when 400 mg are given at noon, by 2:00 p.m., 200 mg remain; by 4:00 p.m., 100 mg remain; by 6:00 p.m., 50 mg remain; by 8:00 p.m., 25 mg remain; by 10:00 p.m., 12.5 mg remain, and by midnight, 6.25 mg remain. DIF: Cognitive Level: Understanding REF: p. 16 31. When an oral drug that is not absorbed systemically is prescribed to a woman who is breastfeeding, what is the risk for harm to the infant? a. Not predicted to increase risk b . Low likelihood of increasing the risk c. Moderate likelihood of increasing the risk d . High likelihood of increasing the risk ANS: A If a drug is not absorbed systemically, it does not enter breast milk and is not predicted to increase the infant’s risk for harm. DIF: Cognitive Level: Understanding REF: p. 21 32. A patient is prescribed a drug that has an extremely short half-life for chest pain (angina). Which modification in drug dosage or scheduling should you expect? a. Once-daily dosing b . More frequent dosing for a sexually active woman of childbearing age, two different types of reliable birth control methods are recommended. DIF: Cognitive Level: Applying or Higher REF: p. 21 37. Which precaution is most important to teach parents about giving an over-the- counter (OTC) drug to a child? a. “OTC drugs are only for adults, not children.” b . “Be sure to crush the tablets or capsules to prevent choking.” c. “Check with your pediatrician or pharmacist for the proper dosage.” d . “Only use the liquid form of the drug to make it easier to swallow.” ANS: C Some OTC drugs can be given to children; however, the dosage must be carefully calculated and is not the same as dosages for adults. Most dosages are either age based or weight based. The pediatrician and the pharmacist are the most knowledgeable about the correct dosage of an OTC drug for a child. DIF: Cognitive Level: Applying or Higher REF: p. 17 MULTIPLE RESPONSE 1. Which body tissues or fluids are routes of drug elimination? (select all that apply) a. Bone marrow b . Heart c. Liver d . Lungs e. Ovary f. Saliva g . Tears ANS: C, D, F, G The liver and kidneys are the main sites of drug metabolism and drug elimination. The lungs are able to eliminate drugs that are easily turned into gases (vaporized). Although only a small amount of any drug can be expected to be in the saliva or tears, they are an excretion and elimination route. The bone marrow, heart, and ovaries are not true excretory organs. DIF: Cognitive Level: Remembering REF: p. 15 COMPLETION BASIC CONCEPTS 1. What is the weight in pounds for an individual who weighs 70 kg? lb ANS: 154 1 kg = 2.2 lb; 70 2.2 = 154 lb. DIF: Cognitive Level: Understanding REF: p. 17 ADVANCED CONCEPTS 2. An adult patient weighing 180 lb is prescribed a drug dose of 2 mg/kg. What actual dose should you prepare for this patient? mg ANS: 164 1 kg = 2.2 lb. To obtain the kilogram weight for this patient: 180/2.2 = 81.8 kg (rounded up to 82 kg). The correct dose is 2 mg 82 kg = 164 mg. DIF: Cognitive Level: Applying or Higher REF: p. 17 Chapter 02: Safely Preparing and Giving Drugs Workman & LaCharity: Understanding Pharmacology: Essentials for Medication Safety, 2nd Edition MULTIPLE CHOICE BASIC CONCEPTS 1. How soon should a drug ordered as “STAT” be administered? a. Immediately b . With the next meal c. At the same time every day d . Only when the stomach is completely empty ANS: A A STAT order is written by a prescriber for a drug to be administered once and immediately. DIF: Cognitive Level: Remembering REF: p. 29 2. When do most drug errors occur in a hospital setting? a. When a patient is in the emergency department b . When a patient is scheduled for a procedure c. When drugs are being administered to patients d . When two patients have the same last name ANS: C Most drug errors are made while giving drugs. Common errors include giving the wrong drug or giving the wrong dose. Follow the “eight rights” to prevent drug errors. DIF: Cognitive Level: Remembering REF: p. 30 3. Which type of drug must always be swallowed without chewing? a. Liquid drugs b . Time-release drugs c. Drugs that taste bad d . Drugs that act on the intestinal tract ANS: B Some pills and capsules are prepared for slow absorption. These drugs are often labeled enteric- coated, time release, or slow release. If chewed, crushed, or opened, these drugs may be absorbed too rapidly. This can irritate the gastrointestinal (GI) system or cause symptoms of overdose. DIF: Cognitive Level: Remembering REF: p. 31 4. Which abbreviation means that a drug is to be given orally? a. PRN b . NPO c. PO d . PPD ANS: C ANS: D Ear drops are drugs given to treat local infection or inflammation and should be kept at room temperature. This helps to prevent dizziness or nausea when the drops are administered. DIF: Cognitive Level: Remembering REF: p. 40 11. What is the correct position for a sublingual tablet? a. As far back on the top of the tongue as possible without swallowing it b . Between the cheek and the gum of the upper teeth c. Between the cheek and the gum of the lower teeth d . Under the front of the tongue ANS: D A drug given by the sublingual route, such as nitroglycerin, is placed under the tongue. The blood supply is very good in the mouth; therefore, these drugs dissolve and are absorbed quickly. DIF: Cognitive Level: Remembering REF: pp. 39-40 12. When is it acceptable to take a verbal order from the prescriber before giving a drug to a patient? a. During the nightshift when the prescriber is not at the hospital b . In an emergency situation such as a cardiac arrest c. When a patient is experiencing severe pain d . At any time it is convenient ANS: B Verbal orders should be accepted only in emergency situations. As soon as the emergency has been resolved, verbal orders must be written and signed. DIF: Cognitive Level: Remembering REF: p. 28 13. What is the most important role of the health care worker in preventing drug errors? a. Always checking the patient’s diagnosis before giving a drug b . Always following the “eight rights” of drug administration c. Being the one defense for detecting and preventing drug errors d . Being most likely to detect a drug error that has occurred ANS: B When administering drugs, always follow the “eight rights.” Many drug errors occur because one or more of the “rights” is not followed. DIF: Cognitive Level: Remembering REF: p. 27 14. Which statement accurately describes the correct technique for giving subcutaneous drugs? a. Use a 3/4-inch, 25-gauge needle and a 15-degree angle for injection. b . Use a 3/8-inch, 25-gauge needle and a 45-degree angle for injection. c. Use a 1-inch, 22-gauge needle and a 90-degree angle for injection. d . Use a 2 inch, 25-gauge needle and a 45-degree angle for injection. ANS: B For subcutaneous drug administration, small, short needles are used ({3/8} inch, 25 to 27 gauge). Insert the needle at a 45-degree angle for most patients. If the patient is obese, you may need to use a 90-degree angle. If the patient is thin, you may need an angle that is less than 45 degrees. DIF: Cognitive Level: Remembering REF: p. 35 15. What administration technique should you use when giving a 2-year-old child ear drops? a. Pull the earlobe down and back. b . Pull the earlobe up and out. c. Keep the earlobe straight. d . Hang the patient’s head over the side of the bed. ANS: A For children younger than 3 years, pull the earlobe (pinna) down and back. This straightens the ear canal. This helps to ensure that the ear drops are placed where they are needed to be effective. DIF: Cognitive Level: Remembering REF: p. 40 16. What must you have a patient do after a vaginal drug is administered? a. Replace the drug in the refrigerator when not in use. b . Give the drug while the patient is sitting on the toilet. c. Have the patient empty her bladder after receiving this drug. d . Keep the patient lying down for 10 to 15 minutes after receiving the drug. ANS: D Be sure to have the patient lie down for 10 to 15 minutes after receiving vaginal drugs to ensure that the drugs are fully absorbed. DIF: Cognitive Level: Remembering REF: p. 40 17. When giving a drug to a patient who is awake but confused, what is the best way to identify that it is the right patient? a. Check the room and bed number that the patient occupies. b . Ask the patient to state his or her name and birth date. c. Check the name on the patient’s wristband. d . Ask the patient if he or she is Mr. or Ms. [name]. ANS: C When a patient is confused, he or she may not reply with his or her own name and birth date. Beds can be moved and rooms can be changed. In addition, sometimes patients are placed or get into the wrong bed. In this case, the patient’s wristband provides the most reliable identification information. DIF: Cognitive Level: Remembering REF: p. 27 18. What is the best way to make sure that the right patient is receiving a prescribed drug when the patient is alert and oriented? a. Ask the patient to state his or her social security number. b . Check the patient’s wrist band. c. Look at the patient’s chart. d . Have the patient state his or her name and birth date. ANS: D To make sure that the right patient receives any drug that has been prescribed, The Joint Commission (TJC) recommends checking two unique patient identifiers (name and birth date) before medication administration. An alert and oriented patient can be asked directly. DIF: Cognitive Level: Remembering REF: p. 27 19. Why are nose drops or sprays most often given? a. To treat dryness that may lead to nose bleeds. b For allergies to pets, pollen, and molds. . ANS: A Prescribers often include limitations about when a drug should or should not be given. You should first check the order for any limitations. Because a heart rate of 60 beats/min is borderline low, and unless there are no limitations, you should notify the prescriber and ask if the drug should be given to this patient. DIF: Cognitive Level: Applying or Higher REF: p. 31 25. A patient is prescribed omeprazole (Prilosec) 60 mg once a day orally. The patient is having difficulty with swallowing and has a feeding tube in place. What is your best action? a. Open the capsule and mix the contents with water, then give the drug through the feeding tube. b . Raise the head of the bed 90 degrees and mix the capsule in applesauce for easier swallowing. c. Contact the prescriber and pharmacist about using another drug or another form of the drug. d . Hold the tube feeding for at least 30 minutes before giving the drug. ANS: C Omeprazole comes in time-released capsules, which should not be opened to prevent rapid absorption of the drug and consequent side effects or adverse effects. Mixing the drug with applesauce and asking the patient to swallow it when the patient has difficulty swallowing puts the patient at high risk for aspiration. DIF: Cognitive Level: Applying or Higher REF: p. 32 26. A patient with severe postoperative pain is ordered to receive morphine 2 mg intravenously. The patient asks if the drug could be taken by mouth instead. What is your best response? a. “Giving the drug intravenously will give you faster pain relief.” b . “I will call your prescriber and ask if the order can be changed.” c. “Your surgeon wants you to receive the drug intravenously.” d . “We can substitute the intravenous drug with an oral drug.” ANS: A The intravenous route is used when a drug needs to enter the bloodstream rapidly or a large dose of a drug must be given. The rates of absorption and action are very rapid with this route and this route is best for a patient with severe postoperative pain. DIF: Cognitive Level: Applying or Higher REF: p. 38 27. The prescriber orders a new drug over the telephone for a nursing home patient who has symptoms of a urinary tract infection. The order is for Gantanol, 2 g now and then 1 g every 12 hours for the next 10 days. What further information is most important for you to obtain from the prescriber? a. “How many refills are needed?” b . “Do you want the drug given orally or intravenously?” c. “Which brand of drug should be given, or is this a generic drug?” d . “Does this drug need to be given with a meal or on an empty stomach?” ANS: B The prescriber must indicate the route of administration for the drug prescribed. Although this drug is available only as an oral drug, the actual drug order needs to include this information. Because this prescription is for an inpatient (nursing home resident) not for a patient taking the drug at home, the refill information is not important at this time. Whether or not the drug should be taken with food or on an empty stomach might be a special instruction, but is not as critical as the correct route. DIF: Cognitive Level: Applying or Higher REF: p. 28 28. The prescriber orders all of the following drugs for a patient who had surgery 2 days ago. Which drug order should you administer first? a. Alphamine (cyanocobalamin) 100 mcg intramuscularly once b . Benadryl (diphenhydramine) 25 mg orally every 8 hours c. Compazine (prochlorperazine) 10 mg orally STAT d . Dalmane (flurazepam) 30 mg orally at night PRN ANS: C STAT drugs are prescribed to correct or help an immediate problem; they are given as soon as they are available. If the drug is not available on the unit, you must call the pharmacy for an immediate drug dose. PRN drugs may be important but are given at the patient’s indication for a need of the drug. The Benadryl order is written as a standing order and does not indicate an immediate need. Although Alphamine is written as a single-dose drug order, there is no indication for immediate administration. DIF: Cognitive Level: Applying or Higher REF: p. 29 29. You ask the patient to state his name and birth date, and the patient responds correctly. Then you give the patient the prescribed drug tablet. The patient says “I haven’t ever taken a green pill before.” What is your best response? a. “Go ahead and take the drug. The same medications from different drug companies may have a different color.” b . “Go ahead and take the drug. It is likely that your health care provider has prescribed a new drug for you.” c. “Don’t take this drug right now. It is probably not the one prescribed for you.” d . “Don’t take this drug right now. Let me recheck everything to be sure.” ANS: D When a patient does not recognize a drug that is being given, it is a “red flag” for a possible error. Even though the drug may be newly ordered or may be made by a different manufacturer than what the patient has had in the past, it is always best to recheck the order, the drug, and the patient before proceeding. Although withholding the drug entirely is not completely wrong, there may be no drug error and this response may frighten the patient unnecessarily. DIF: Cognitive Level: Applying or Higher REF: p. 31 30. Which question is most important for you to ask a patient before administering a new drug? a. “Are you allergic to any drugs?” b . “Do you know what this drug is for?” c. “When was the last time you ate or drank?” d . “What other drugs have you taken in the last 24 hours?” ANS: A All of these questions are important to know when giving a new drug. The information that is most critical, however, is whether the patient has an allergy to this drug or any other drug. A drug allergy can result in life-threatening effects. DIF: Cognitive Level: Applying or Higher REF: p. 31 31. When you bring in the next dose of a drug that a patient first received 6 hours ago, the patient reports a “pounding” heart rate ever since taking the last dose. What is your best first action? a. Document the report as the only action. b . Check the patient’s vital signs for changes. c. Hold the dose and notify the prescriber immediately. d Reassure the patient that this is an expected response to the drug. ANS: C For safety, when you contact the prescriber by telephone or follow a verbal order, be sure to write the order, read it back, and ask for confirmation that what you wrote is correct before administering any drug. Be sure to document that you read back the order to the prescriber. DIF: Cognitive Level: Applying or Higher REF: p. 28 37. What is the most important action to take after giving a patient a newly prescribed drug for hypertension? a. Teach the patient to measure his or her pulse. b . Check the patient’s blood pressure an hour later. c. Ask the patient whether any other family members also have hypertension. d . Ask the patient whether he or she has ever taken a drug for hypertension in the past. ANS: B You must be familiar with the patient’s medical diagnosis and the purpose of the drug. Assessing for drug effectiveness is important. After you give a drug, check the patient to make sure that the drug has the desired effect. For example, check the blood pressure for improvement after giving an antihypertensive drug. Be sure to document what you monitored and any other appropriate interventions. DIF: Cognitive Level: Applying or Higher REF: p. 28 38. When you bring a sedative for sleep in to the patient, he asks you to leave the drug on his table and he will take it when his television show is over. What should you do? a. Insist that he take the drug right now. b . Leave it at his bedside as he requests. c. Tell him you will bring it back later, after the show. d . Document that he refused to take his prescribed drug. ANS: C You are responsible for documenting that drugs have been taken and must witness that this has occurred. Most drugs, including sedatives, should never be left at the bedside. You have no idea whether it was actually taken by the patient or by someone else. It is possible for a patient to collect drugs left at the bedside and take them all at once. DIF: Cognitive Level: Applying or Higher REF: p. 32 MULTIPLE RESPONSE ADVANCED CONCEPTS 1. Before administering any drug, what should you do? (select all that apply) a. Check the order. b . Wash your hands. c. Instruct the patient that he or she must take the drug. d . Find out the patient’s family history. e. Check the patient’s identification band. f. Keep drug in container until at the bedside. ANS: A, B, E, F Before giving any drug, always follow the “eight rights.” Always check the written order. Check the patient’s identification wristband and ask the patient’s name and birth date. Limit interruptions and distractions. Wash your hands and wear clean gloves when needed (e.g., parenteral, rectal routes). Keep drugs in their containers or wrappers until at the patient’s bedside. Avoid touching pills or capsules. Never give drugs prepared by someone else. Follow sterile technique when handling syringes and needles. Remain alert to drug names that sound or look alike. Giving the wrong drug can have serious adverse effects. DIF: Cognitive Level: Applying or Higher REF: p. 27 2. The patient with an NG tube has orders for several enteral drugs (e.g., capsules, tablets, and liquids). What should you do before giving these drugs? (select all that apply) a. Check with the pharmacist about crushing the tablets. b . Follow the procedures of the “eight rights.” c. Aspirate to check for stomach contents. d . Open the extended-release capsules. e. Inject 150 mL of water to check tube patency. f. Place the patient in a supine position. ANS: A, B, C As with all oral drugs, check the drug orders, which may be written as PO or by feeding tube. Check your drug book or with the pharmacist before crushing tablets or opening capsules. Wash your hands and place the patient upright. Check to make sure that the tube is located in the stomach by withdrawing (aspirating) stomach contents with a syringe, or you can attach an end- tidal carbon dioxide (CO2) detector to the feeding tube. The presence of carbon dioxide indicates that the tube is in the trachea rather than the stomach. Additionally, if the patient is receiving a tube feeding, check the amount of tube feeding remaining in the stomach (residual). Some drugs are not well absorbed when food is in the stomach (e.g., phenytoin [Dilantin]), and the tube feeding must be stopped for a period before and after administration. Liquid drugs should be diluted and flushed through the tube. Crushed tablets and the contents of opened capsules are first dissolved in water before being given through the tube. To give the drugs, attach a large syringe to the tube, pour the liquid or dissolved drug into the syringe, and let it run in by gravity. DIF: Cognitive Level: Applying or Higher REF: pp. 32-34 3. You are teaching a patient about a prescribed sublingual drug. What will you be sure to tell the patient? (select all that apply) a. “Keep the drug sterile to avoid infection.” b . “Do not drink anything until the drug is completely dissolved.” c. “Place this drug between your jaw and your molar teeth.” d . “Notify your prescriber if you experience side effects.” e. “Place the drug beside or below the tongue.” f. “Don’t swallow this drug.” ANS: B, D, E, F A drug given by the sublingual route, such as nitroglycerin, is placed under the tongue. The blood supply is very good in the mouth; therefore, these drugs dissolve and are absorbed quickly. The patient should not eat or drink until the drug is completely dissolved. Teach the patient not to swallow or chew while the drug is in the mouth because these drugs are not effective if absorbed through the GI tract. A patient should be taught to notify the prescriber for any side effects. DIF: Cognitive Level: Applying or Higher REF: pp. 39-40 4. You are giving morning medications to a patient who refuses to take an oral dose of docusate (Colace). What is your best response? a. “Your prescriber ordered that you must take this drug twice a day.” b . “Docusate will soften your bowel movements so that you do not strain.” c. “This drug will help prevent constipation while you are on bed rest.” d . “Can you tell me why you do not want to take the docusate?” ANS: D The patient may have a good reason for refusing to take this drug. For example, he or she may be experiencing diarrhea. Understanding the patient’s reason for refusal helps you to understand how to intervene for him or her. A patient has the right to refuse any drug. Be sure that he or she understands why the drug has been prescribed and the consequences of refusing to take it. When a patient refuses to take a drug, document the refusal, including the fact that the patient understands what may happen if the drug is not taken. a. When a patient is in the emergency department b . When a patient is scheduled for a procedure c. When drugs are being administered to patients d . When two patients have the same last name ANS: C Most drug errors are made while giving drugs. Common errors include giving the wrong drug or giving the wrong dose. Follow the “eight rights” to prevent drug errors. DIF: Cognitive Level: Remembering REF: p. 30 3. Which type of drug must always be swallowed without chewing? a. Liquid drugs b . Time-release drugs c. Drugs that taste bad d . Drugs that act on the intestinal tract ANS: B Some pills and capsules are prepared for slow absorption. These drugs are often labeled enteric- coated, time release, or slow release. If chewed, crushed, or opened, these drugs may be absorbed too rapidly. This can irritate the gastrointestinal (GI) system or cause symptoms of overdose. DIF: Cognitive Level: Remembering REF: p. 31 4. Which abbreviation means that a drug is to be given orally? a. PRN b . NPO c. PO d . PPD ANS: C PO means per os or administration of drugs by the mouth. DIF: Cognitive Level: Remembering REF: p. 32 5. Which needle position is best for an intradermal injection? a. Bevel side to the right b . Bevel side to the left c. Bevel side down d . Bevel side up ANS: D When giving an intradermal injection, insert the needle at a 10- to 15-degree angle with the bevel facing up. Do not pull back (aspirate) on the plunger of the syringe. Inject the drug so a little bump forms and remove the needle. DIF: Cognitive Level: Remembering REF: p. 35 6. For which patient condition or problem are rectal drugs avoided? a. Fever b . Vomiting c. Diarrhea d . Pregnancy ANS: C The patient with diarrhea cannot hold rectal drugs long enough for absorption to take place. DIF: Cognitive Level: Remembering REF: p. 34 7. Which injection site is located on the front of the thigh? a. Deltoid b . Dorsogluteal c. Ventrogluteal d . Vastus lateralis ANS: D The vastus lateralis is located in the muscles on the front of the thigh. DIF: Cognitive Level: Remembering REF: p. 36 8. What is the purpose of using the “Z-track” method of intramuscular injection? a. Preventing accidental intravenous injection b . Preventing oozing of drug back through the needle path c. Reducing the chances of hitting bone or nerve with the needle d . Allowing larger amounts (volumes) of drugs to be administered into smaller muscles ANS: B Use the Z-track method of IM injection for drugs that are irritating to subcutaneous tissue or that may permanently stain the tissues. After drawing the drug into the syringe, draw in 0.1 to 0.2 mL of air. The air follows the drug into the muscle and stops it from oozing through the path of the needle. After you select and cleanse the site, pull the tissue laterally and hold it. Insert the needle into the muscle; inject the drug and release the tissue as you remove the needle. Releasing the tissue allows the skin to slide over the injection and seal the drug in the muscle. DIF: Cognitive Level: Remembering REF: p. 37 9. A patient needs a dose of oral potassium for a low serum potassium level (3.4 mEq/dL). Which type of order should the prescriber write? a. Standing order b . Single order c. PRN order d . STAT order ANS: B A single-dose order is an order to give a drug once only. This patient’s serum potassium level is close to normal. You should expect that the patient’s potassium level would be checked again and another order written by the prescriber if the level was not within the normal range. DIF: Cognitive Level: Remembering REF: p. 29 10. What temperature should ear drops be when applying them? a. Just above freezing −33 F b . Warmed to 104 F c. Refrigerated to 40 F d . Room temperature ANS: D Ear drops are drugs given to treat local infection or inflammation and should be kept at room temperature. This helps to prevent dizziness or nausea when the drops are administered. Be sure to have the patient lie down for 10 to 15 minutes after receiving vaginal drugs to ensure that the drugs are fully absorbed. DIF: Cognitive Level: Remembering REF: p. 40 17. When giving a drug to a patient who is awake but confused, what is the best way to identify that it is the right patient? a. Check the room and bed number that the patient occupies. b . Ask the patient to state his or her name and birth date. c. Check the name on the patient’s wristband. d . Ask the patient if he or she is Mr. or Ms. [name]. ANS: C When a patient is confused, he or she may not reply with his or her own name and birth date. Beds can be moved and rooms can be changed. In addition, sometimes patients are placed or get into the wrong bed. In this case, the patient’s wristband provides the most reliable identification information. DIF: Cognitive Level: Remembering REF: p. 27 18. What is the best way to make sure that the right patient is receiving a prescribed drug when the patient is alert and oriented? a. Ask the patient to state his or her social security number. b . Check the patient’s wrist band. c. Look at the patient’s chart. d . Have the patient state his or her name and birth date. ANS: D To make sure that the right patient receives any drug that has been prescribed, The Joint Commission (TJC) recommends checking two unique patient identifiers (name and birth date) before medication administration. An alert and oriented patient can be asked directly. DIF: Cognitive Level: Remembering REF: p. 27 19. Why are nose drops or sprays most often given? a. To treat dryness that may lead to nose bleeds. b . For allergies to pets, pollen, and molds. c. To treat congestion and infection. d For cold and flu symptoms. . ANS: C Nose drops or sprays are most often used to treat congestion or infection. DIF: Cognitive Level: Remembering REF: p. 40 ADVANCED CONCEPTS 20. Which technique is used with some intramuscular drug injections but not with subcutaneous or intradermal drug injections? a. Ensuring the site selected is appropriate for injection b . Cleansing the selected site before inserting the needle c. Aspirating the syringe before injecting the drug solution d . Checking for allergic or sensitivity reactions to the injection ANS: C Aspiration is not recommended for IM injection of vaccines or immunizations. For drugs such as penicillin, aspiration may be indicated. When indicated, aspirate the syringe (pull back on the plunger) to make sure that the needle is not in a vein. If the needle is in a vein, blood will appear in the syringe. Remove the needle and discard the drug if this happens. Get a new dose of the drug and a sterile needle and syringe and give the injection in another site. DIF: Cognitive Level: Understanding REF: p. 36 21. What is the proper way to prepare skin for a transdermal patch? a. Shave the skin that will be underneath the patch. b . Leave the old patch on and apply the new one next to it. c. Clean and dry the skin where the patch will be applied. d . Remove the old patch and apply the new one to the exact same spot. ANS: C When administering a transdermal patch, first wash your hands and put on gloves. Clean the area of skin where the drug will be applied. Apply topical drugs in a smooth, thin layer, and cover the area. When administering transdermal drugs, remove old patches or doses of the drug. Be sure to remove all traces of the drug from the previous dosage site, and rotate sites to avoid skin irritation or breakdown. DIF: Cognitive Level: Understanding REF: p. 39 22. A patient is to receive nitroglycerin ointment, 1 inch STAT, for elevated blood pressure. What must be done before giving this drug? a. Shave the hair off the patient’s chest. b . Place the patient on a heart monitor. c. Put on a pair of disposable gloves. d . Measure the dose directly on the patient’s skin. ANS: C Wash your hands and put on gloves. Without gloves, if you come into contact with the ointment you may experience the same side effects as a patient (e.g., headache, drop in blood pressure). DIF: Cognitive Level: Applying or Higher REF: p. 39 23. To prevent a drug overdose from receiving two doses too close together, what should you do immediately after giving a PRN pain drug? a. Ask if the patient’s pain has been relieved. b . Check the patient’s vital signs. c. Notify the prescriber. d . Document the action. ANS: D It is important to document giving PRN (as needed) drugs as soon as possible before another health care worker gives a second dose in response to a patient’s statements about pain. DIF: Cognitive Level: Applying or Higher REF: p. 28 24. The prescriber orders atenolol (Tenormin) 25 mg to be given orally once a day to control a patient’s high blood pressure. You check the patient’s vital signs and find that the blood pressure is 128/80 mm Hg and the heart rate is 60 beats/min. What should you do first before giving this drug? a. Check the order for prescriber limitations on when the drug should be given. b . Notify the prescriber and ask if the drug should be given. c. Reassess the blood pressure and heart rate in 30 minutes. d . Give the drug exactly as prescribed. ANS: A . drug for you.” c. “Don’t take this drug right now. It is probably not the one prescribed for you.” d . “Don’t take this drug right now. Let me recheck everything to be sure.” ANS: D When a patient does not recognize a drug that is being given, it is a “red flag” for a possible error. Even though the drug may be newly ordered or may be made by a different manufacturer than what the patient has had in the past, it is always best to recheck the order, the drug, and the patient before proceeding. Although withholding the drug entirely is not completely wrong, there may be no drug error and this response may frighten the patient unnecessarily. DIF: Cognitive Level: Applying or Higher REF: p. 31 30. Which question is most important for you to ask a patient before administering a new drug? a. “Are you allergic to any drugs?” b . “Do you know what this drug is for?” c. “When was the last time you ate or drank?” d . “What other drugs have you taken in the last 24 hours?” ANS: A All of these questions are important to know when giving a new drug. The information that is most critical, however, is whether the patient has an allergy to this drug or any other drug. A drug allergy can result in life-threatening effects. DIF: Cognitive Level: Applying or Higher REF: p. 31 31. When you bring in the next dose of a drug that a patient first received 6 hours ago, the patient reports a “pounding” heart rate ever since taking the last dose. What is your best first action? a. Document the report as the only action. b . Check the patient’s vital signs for changes. c. Hold the dose and notify the prescriber immediately. d . Reassure the patient that this is an expected response to the drug. ANS: B Any side effect or response a patient has after starting a new drug should be investigated, even when it is an expected side effect of the drug. Some drugs may increase the strength of the heartbeat and heart rate either as the intended action or as a side effect. However, any drug that affects heart response can also cause adverse heart problems. Before giving the drug or notifying the prescriber, you should check the patient’s vital signs, especially heart rate and quality, heart rhythm, and blood pressure. These changes are important to know for you and the prescriber. DIF: Cognitive Level: Applying or Higher REF: p. 31 32. A 1-year-old child is prescribed a transdermal drug patch for pain control. To which site should you apply the patch? a. On the lower arm where changing the patch is easier b . On the back between the shoulders so the child cannot reach it c. On the upper chest so that any skin irritation can be seen quickly d . On the leg between the knee and the thigh for fastest drug absorption ANS: B When a transdermal patch is placed in an area visible to a small child, he or she usually picks at it and may remove it. Placing it between the shoulders on the back removes it from the child’s sight and attention. On a small child, circulation is not usually a problem and the drug would be as well absorbed from the back as from anywhere else. DIF: Cognitive Level: Applying or Higher REF: p. 33 33. Which action is most important when you prepare to administer an oral drug to a patient of any age? a. Asking the patient whether he or she prefers a tablet or a capsule b . Determining when the patient last ate or drank c. Assessing whether the patient has nausea d . Checking the patient’s ability to swallow ANS: D A patient who cannot swallow should not take any drug, drink, or food by the oral route. The risk for aspiration is very high and can lead to many serious complications, even death. DIF: Cognitive Level: Applying or Higher REF: p. 32 34. Which condition requires that you withhold a drug dose for a patient with a feeding tube? a. The drug is in the form of a tablet. b . The drug volume is greater than 20 mL. c. Carbon dioxide is detected from the feeding tube. d . The patient is unconscious and unable to swallow. ANS: C When carbon dioxide comes from the feeding tube, the tube is in the trachea rather than the stomach. Using this compromised feeding tube for drug administration would result in drug placement into the lungs instead of the stomach, which can cause serious complications. DIF: Cognitive Level: Applying or Higher REF: p. 33 35. You prepare to administer an intravenous (IV) push drug, but the skin around the patient’s IV site is swollen and red. The patient states that the area hurts, and no blood return is obtained when you aspirate the IV setup. What is your best action? a. Continue IV administration of the drug. b . Discontinue IV administration and notify the prescriber. c. Dilute the drug more before injecting it into the current IV site. d . Reassure the patient that this is an expected reaction and offer the prescribed pain medication. ANS: B These symptoms indicate there has been IV infiltration and the needle is no longer in the vein. No further drugs can be delivered through this IV setup, even if they are well diluted. IV administration of the drug must be discontinued. The prescriber should be notified before restarting IV administration of the drug. The prescriber may change the drug to a different form or prescribe a different drug. DIF: Cognitive Level: Applying or Higher REF: p. 38 36. You are receiving a telephone order from a health care provider. After receiving all the information, what is the most important next action to perform? a. Notify the supervisor about the verbal order. b . Administer the drug as soon as it is available. c. Read the order back to the prescriber and ask whether it is correct. d . Inform the patient and family that a new drug has been prescribed by the health care provider. ANS: C For safety, when you contact the prescriber by telephone or follow a verbal order, be sure to write the order, read it back, and ask for confirmation that what you wrote is correct before administering any drug. Be sure to document that you read back the order to the prescriber. 3. You are teaching a patient about a prescribed sublingual drug. What will you be sure to tell the patient? (select all that apply) a. “Keep the drug sterile to avoid infection.” b . “Do not drink anything until the drug is completely dissolved.” c. “Place this drug between your jaw and your molar teeth.” d . “Notify your prescriber if you experience side effects.” e. “Place the drug beside or below the tongue.” f. “Don’t swallow this drug.” ANS: B, D, E, F A drug given by the sublingual route, such as nitroglycerin, is placed under the tongue. The blood supply is very good in the mouth; therefore, these drugs dissolve and are absorbed quickly. The patient should not eat or drink until the drug is completely dissolved. Teach the patient not to swallow or chew while the drug is in the mouth because these drugs are not effective if absorbed through the GI tract. A patient should be taught to notify the prescriber for any side effects. DIF: Cognitive Level: Applying or Higher REF: pp. 39-40 4. You are giving morning medications to a patient who refuses to take an oral dose of docusate (Colace). What is your best response? a. “Your prescriber ordered that you must take this drug twice a day.” b . “Docusate will soften your bowel movements so that you do not strain.” c. “This drug will help prevent constipation while you are on bed rest.” d . “Can you tell me why you do not want to take the docusate?” ANS: D The patient may have a good reason for refusing to take this drug. For example, he or she may be experiencing diarrhea. Understanding the patient’s reason for refusal helps you to understand how to intervene for him or her. A patient has the right to refuse any drug. Be sure that he or she understands why the drug has been prescribed and the consequences of refusing to take it. When a patient refuses to take a drug, document the refusal, including the fact that the patient understands what may happen if the drug is not taken. DIF: Cognitive Level: Applying or Higher REF: p. 28 5. Safe drug administration requires that the individual giving a drug be knowledgeable about which drug features? (select all that apply) a. Purpose b Actions . c. Brand name d . Side effects e. Abnormal reactions f. Follow-up care ANS: A, B, D, E, F You are responsible for providing competent, safe patient care, including giving drugs. To give drugs safely, you should be knowledgeable about the purpose of the drug, its actions, side effects, abnormal reactions, delivery methods, and any necessary follow-up. DIF: Cognitive Level: Applying or Higher REF: p. 27 6. A patient is to receive an acetaminophen (Tylenol) suppository for an elevated temperature of 102.8° F. What actions must the nurse take? (select all that apply) a. Ask if the patient is having any diarrhea. b . Lubricate the blunt end of the suppository. c. Put on a pair of sterile gloves. d . Place the patient in the Sims’ position. e. Ask the patient to take a deep breath and bear down. f. Push the suppository into the rectum about 1 inch. ANS: A, D, E, F Diarrhea may make the rectal route of drug administration undesirable because the patient may be unable to hold the drug in the rectum long enough to be absorbed. Disposable gloves should be used, but they do not need to be sterile. The suppository is inserted pointed end first, not blunt end. The Sims’ position (with the patient turned to the side and one leg bent over the other) is the best position for giving a rectal suppository. The suppository should be pushed into the rectum about 1 inch for better absorption. Be sure to instruct the patient about how long the suppository should be held in the rectum. DIF: Cognitive Level: Applying or Higher REF: p. 34 7. A patient with several chronic illnesses is being cared for in a hospital acute care setting. For which events should you expect to apply the principles of the process of medication reconciliation? (select all that apply) a. The patient is transferred from the ICU to a medical care unit. b . The patient is transported to radiology for a CT scan. c. The patient’s care is transferred from the evening to the night nurse. d . The patient is moved from an acute care to a long-term care facility. e. The patient is relocated to a private room on the same medical care unit. f. The patient is sent to a different hospital for specialized surgery. ANS: A, D, F When a patient visits a health care provider, is admitted to the hospital, or is transferred from unit to unit in the hospital, it is common to receive new prescriptions or to have changes made in currently prescribed drugs. The process of medication reconciliation is used during these transitions of patient care to avoid drug errors such as omissions, duplications, dosing errors, and drug interactions. DIF: Cognitive Level: Applying or Higher REF: p. 30 Chapter 05: Dosage Calculation of Intravenous Solutions and Drugs Workman & LaCharity: Understanding Pharmacology: Essentials for Medication Safety, 2nd Edition MULTIPLE CHOICE 1. What does the term infiltration mean? a. Leakage of intravenous fluid into the surrounding tissue b . Infusion of intravenous fluids at a faster rate than was prescribed c. Plugging up or clotting off the needle during intravenous infusion d . Infusion of intravenous fluids without the use of a pump or controller ANS: A The definition of infiltration is a condition in which an IV needle or catheter pulls from the vein and leaks IV fluids into the surrounding tissue, resulting in tissue swelling. An infusion of IV fluids faster than prescribed is a “runaway” IV. Plugging or clotting of a needle has no specific name. Infusion of fluids without a pump or controller is a manually controlled infusion. DIF: Cognitive Level: Remembering REF: p. 79 2. How many drops per milliliter (mL) does a microdrip chamber and tubing provide? a. 15 b . 20 c. 60 d . 100 . ANS: B Drugs administered by IV infusion are immediately in the bloodstream and reach their target tissues fastest. This means that both the drug benefits (intended actions) and any adverse actions can happen more quickly. IV drugs tend to cost more than oral drugs. Although the patient does not have to be alert to receive IV drugs, it is not their main advantage. Administering IV drugs can only be performed by a skilled health care provider. DIF: Cognitive Level: Understanding REF: p. 76 9. How does the “drop factor” affect IV infusions? a. Fluid with a larger drop factor infuses more slowly than fluid with a smaller drop factor. b . Smaller drop factors occur with smaller needles (or cannulas) and larger drop factors occur with larger needles. c. The smaller the drop factor, the fewer the number of drops needed to administer 1 mL of infusion fluid. d . The larger the drop factor, the fewer the number of drops needed to administer 1 mL of infusion fluid. ANS: D The drop factor is the number of drops (gtt) needed to make 1 mL of IV fluid. The larger the drop, the fewer drops needed to make 1 mL. DIF: Cognitive Level: Understanding REF: p. 77 10. A patient is to receive 1000 mL intravenously of dextrose 5% in lactated Ringer’s solution in 8 hours. When you check the intravenous (IV) bag after 2 hours, 700 mL remain in the bag. How many milliliters have already infused? a. 100 b . 300 c. 700 d . 1000 ANS: B The amount infused is equal to the starting amount (1000 mL) minus the amount remaining in the IV bag or other container (700 mL). 1000 – 700 = 300 mL have infused. DIF: Cognitive Level: Understanding REF: p. 80 11. How is extravasation different from infiltration? a. Infiltration occurs in the hand, whereas extravasation occurs in the arm. b . Both conditions lead to swelling, but extravasation causes tissue damage. c. Infiltration is swelling accompanied by pain, whereas extravasation is not painful. d . Extravasation causes phlebitis along with tissue swelling, whereas infiltration causes fluid overload along with swelling. ANS: B Both conditions result from leakage of fluid out of the vein and into surrounding tissues. Infiltration, although uncomfortable, does not result in tissue damage. Extravasation results directly or indirectly in tissue damage. If the damage is severe enough, tissue can become necrotic and slough. DIF: Cognitive Level: Understanding REF: p. 79 12. An IV infusion order for a patient reads “1000 mL dextrose 5% in normal saline intravenously, immediately.” What additional information does the prescriber need to provide for it to be a valid order? a. Drip rate b . Drop factor c. Duration d . Start time ANS: C A valid intravenous (IV) therapy order must include the duration of infusion. The word “immediately” in this prescription refers to when the IV infusion is to start, not its duration. DIF: Cognitive Level: Understanding REF: p. 77 13. Which problem is a major disadvantage of an intravenous (IV) pump? a. The alarms are so sensitive that nurses tend to ignore them when they sound frequently. b . Patients and families can override the automatic features and reset the infusion rate. c. It can “run away” and cause a patient to experience fluid overload. d . It can continue to push fluid into the tissue when infiltration occurs. ANS: D IV pumps push fluid into the patient at a rate greater than gravity and can continue to push even when resistance is increased. Infiltration or extravasation may not be detected by the machine until the situation is serious. DIF: Cognitive Level: Understanding REF: p. 79 14. Which drop factor allows the greatest volume of intravenous fluid to be delivered per hour at a drip rate of 50 gtt per minute? a. 10 b . 15 c. 20 d . 60 ANS: A A drop factor of 10 means that 10 gtt equal 1 mL. At a drip rate of 50 gtt/min, a drop factor of 10 delivers 5 mL/min or 300 mL/h. At a drip rate of 50 gtt/min, a drop factor of 15 delivers 3.3 mL/min or 188 mL/h. At a drip rate of 50 gtt/min, a drop factor of 20 delivers 2.5 mL/min or 150 mL/h. At a drip rate of 50 gtt/min, a drop factor of 60 delivers 0.8 mL/min or 50 mL/h. DIF: Cognitive Level: Understanding REF: p. 77 |p. 80 15. What will the drip rate of an intravenous infusion with a drop factor of 20 need to be in order to deliver 1000 mL in 8 hours? a. 13 gtt/min b . 31 gtt/min c. 42 gtt/min d . 60 gtt/min ANS: C To deliver 1000 mL over 8 hours, 125 mL must be delivered per hour or 2.08 mL/min. 2.08 mL/min times 20 gtt/mL equals 41.6 gtt/min, round up to 42. DIF: Cognitive Level: Understanding REF: p. 80 16. Which precaution is most important to teach a patient who is receiving intravenous (IV) drug therapy? a. “Turn on your call light if the IV machine starts to beep for any reason.” b . “Do not use the arm that has the IV running in it for any reason whatsoever.” c. “Call me immediately if you start to feel any pain or burning in the arm with the IV.” d . “If you think the IV is running too slowly, just push the up-arrow button on the machine once or twice.” The flow rate is incorrect. With 8 gtt in 15 seconds, the drops per minute are only 32. The drip rate must be increased to 10 gtt in 15 seconds to achieve a drip rate of 42 gtt/min. At 15 gtt/15 seconds, the drip rate would be 60 gtt/min. At 6 gtt/15 seconds, the drip rate would be 24 gtt/min. DIF: Cognitive Level: Applying or Higher REF: pp. 80-81 COMPLETION 1. What is the hourly flow rate for 250 mL of normal saline to be administered over 2 hours? mL/h ANS: 125 The patient should receive 125 mL/h (250 mL/2 hours = 125 mL). DIF: Cognitive Level: Understanding REF: p. 80 2. A patient is to receive 1000 mL of D5W intravenously over 6 hours. The tubing set has a drop factor of 15 gtt/mL. How many drops per minute are needed to infuse this fluid in the prescribed time? gtt per minute ANS: 42 1000 mL in 6 hours = 167 mL/h (1000/6 = 166.6 mL, round up to 167). 2.8 mL/min (167 mL/60 minutes = 2.78 mL, round up to 2.8 mL/min); 42 gtt/min (2.8 mL  drop factor of 15 = 42 gtt/min). DIF: Cognitive Level: Applying or Higher REF: p. 80 3. A patient is to receive 100 mL of normal saline over the next 5 hours with microdrip tubing. How many drops per minute are required to infuse this fluid in the prescribed time? gtt per minute ANS: 20 The flow rate for 100 mL over 5 hours is 20 mL/h (100 mL/5 hours). With microdrip tubing, the drop factor of 60 gtt/mL is the same as the number of minutes in 1 hour (60). The two sets of 60 cancel each other out, and the flow rate for microdrip tubing always equals the drop rate. So, 20 mL/h by microdrip tubing = 20 gtt/min. DIF: Cognitive Level: Applying or Higher REF: p. 80 Chapter 06: Anti-Inflammatory Drugs Workman & LaCharity: Understanding Pharmacology: Essentials for Medication Safety, 2nd Edition MULTIPLE CHOICE BASIC CONCEPTS 1. Which stage of the inflammatory response involves capillary leak syndrome? a. Stage I b . Stage II c. Stage III d . Stage IV ANS: A The first stage of the inflammatory response involves white blood cells releasing chemical substances that act on blood vessels, making the pores larger so that fluid leaks out of the blood vessels into the damaged tissue. DIF: Cognitive Level: Remembering REF: p. 84 2. Which corticosteroid is applied topically to the skin? a. Betamethasone (Celestone) b . Triamcinolone (Kenalog) c. Dexamethosone (Decadron) d . Methylprednisolone (Solu-Medrol) ANS: B Betemethasone and dexamethosone are oral drugs. Methylprednisolone is a parenteral drug. Of the drugs on this list, only triamcinolone is applied as a topical drug. DIF: Cognitive Level: Remembering REF: p. 86 3. Which problem is a common side effect of long-term corticosteroid use? a. Acne b . Weight loss c. Redness and pain d . Low blood pressure ANS: A Corticosteroid use has many side effects including weight gain (not loss), retention of sodium and water leading to high blood pressure (not low blood pressure), and a lot of skin changes, including acne. Corticosteroids are used to reduce inflammation, so they eliminate redness and pain, they do not cause these side effects. DIF: Cognitive Level: Remembering REF: p. 87 4. Which side effect of corticosteroid therapy is permanent even after the drug is stopped? a. Difficulty sleeping b . Stretch marks c. Weight gain d . Moon face ANS: B After corticosteroid therapy is stopped, many side effects resolve although this can take months to years. The sleep disturbance, weight gain, and moon-shaped face do go away over time. The stretch marks are permanent although they usually change from reddish-purple to silver over time so that they are less noticeable. DIF: Cognitive Level: Remembering REF: p. 87 5. Which anti-inflammatory drug is classified as a “COX-1” inhibitor? a. Hydrocortisone (Lanacort) b. Celecoxib (Celebrex) c. Zyleuton (Zyflo) d . Naproxen (Aleve) ANS: D Naproxen is the only COX-1 class anti-inflammatory drug on this list. Hydrocortisone is a corticosteroid. Celecoxib is a COX-2 inhibitor, not COX-1. Zyleuton is a leukotriene inhibitor. DIF: Cognitive Level: Remembering REF: p. 90 6. Which NSAID is a COX-2 inhibitor? a. Celecoxib (Celebrex) Most DMARDs are antibodies to the substance tumor necrosis factor (TNF), which is produced by the body as part of the inflammatory response and can attack and destroy normal body tissues. DIF: Cognitive Level: Remembering REF: p. 96 12. Why is inflammation considered a nonspecific body response? a. Inflammation is the basis for almost every type of chronic disease. b . Infection by bacteria or viruses is always a part of inflammation. c. The same tissue responses occur regardless of the type of triggering event. d . The discomfort associated with inflammation can be reduced by over-the-counter drugs. ANS: C Inflammation is a syndrome of normal tissue responses that always occur in the same way with any type of injury or invasion, regardless of the location on the body or what caused the response to start. DIF: Cognitive Level: Understanding REF: p. 83 13. When is an inflammatory response a health problem rather than a helpful protection? a. When a patient’s immune system is suppressed b . When infection accompanies inflammation c. When inflammation is prolonged d . When pain is experienced ANS: C Inflammation starts tissue actions that cause visible and uncomfortable symptoms that are important in ridding the body of harmful organisms and helping repair damaged tissue. However, if the inflammatory response is prolonged or excessive, tissue damage may result. DIF: Cognitive Level: Understanding REF: p. 85 14. A patient is prescribed an oral corticosteroid for a chronic inflammatory health problem. Which precaution is most important to teach? a. “Never stop taking this drug without consulting your prescriber.” b . “Avoid crowds and people who are ill.” c. “Be sure to take this drug with food.” d . “Reduce your salt intake.” ANS: A All of the choices are precautions that the nurse should teach the patient taking an oral corticosteroid for the long term. However, the most critical precaution is to not stop taking the drug because long-term corticosteroid use causes atrophy of the adrenal glands. With adrenal gland atrophy, the individual no longer makes his or her own normal levels of corticosteroids, which are essential for life. Long-term steroid use is never suddenly stopped. DIF: Cognitive Level: Applying or Higher REF: p. 88 15. Why are corticosteroid drugs usually prescribed for a short period of time? a. The inflammatory process cannot be controlled with less powerful drugs. b . Inhalation of corticosteroid drugs causes irreversible damage to the lungs. c. These drugs work less effectively when given over an extended period. d . Corticosteroids have many adverse effects and side effects. ANS: D When taken orally or parenterally, corticosteroids are usually given for a short period of time because they have many adverse effects and side effects. These drugs can be given over longer periods with the goal that the patient takes the lowest dose that will control inflammation, so that side effects and adverse effects can be minimized. DIF: Cognitive Level: Understanding REF: p. 86 16. A patient who has been taking 30 mg of prednisone daily for the last 10 days reports crying more often and then suddenly getting angry at small issues. What is your best action? a. Document the patient’s response as the only action. b . Hold the next dose and notify the prescriber immediately. c. Reassure the patient that this is an expected drug response. d . Suggest that the patient see a counselor or attend an anger management class. ANS: C Prednisone, a type of corticosteroid, increases a patient’s emotional responses (emotional lability). It is an uncomfortable but expected side effect that will stop after the drug has been discontinued. Usually, this side effect is not a reason to stop drug therapy and counseling or anger management will not stop the responses. It is helpful for the patient to know this and to be able to tell family members that they are not responsible for the changes in the patient’s emotional state. DIF: Cognitive Level: Applying or Higher REF: p. 87 17. A patient who has been prescribed long-term low-dose prednisone to control inflammation reports concern about the changes in her appearance caused by the drug. What is your best response? a. “This often happens when an individual takes this drug. You now have Cushing’s disease.” b . “When you stop taking this drug, the changes will disappear, but it may take a while.” c. “You can make use of different styles of clothes to minimize changes in appearance.” d . “Changes in your diet and an exercise program will eliminate these changes while you are on this drug.” ANS: B Changes in appearance are a side effect of corticosteroids. The patient develops a Cushingoid appearance. When a patient stops taking these drugs, the side effects and changes in body appearance disappear, but it may take a year or more for this to occur. DIF: Cognitive Level: Applying or Higher REF: p. 87 18. A patient is prescribed topical hydrocortisone 0.1% for skin inflammation. What action is most important to teach the patient for applying this drug? a. “Use a thick layer of drug just to the area that needs treatment.” b . “Apply a thin layer to the affected area and to the skin near the area.” c. “Apply a thick layer over and 1 inch around the affected area.” d . “Use as thin a layer as possible just to the area that needs treatment.” ANS: D Topical corticosteroids are absorbed through the skin and can have some systemic effects. Thus patients should use only the minimum amount needed to control the skin problem. Teach the patient to apply only a thin layer just to the areas of skin that need treatment. DIF: Cognitive Level: Applying or Higher REF: p. 89 19. Which assessment is most important to perform when providing care to an older adult patient who has been prescribed a topical corticosteroid? a. Skin assessment b . Intake and output c. Cognition or mental status d . Urinary tract infection Corticosteroids are prescribed for children who have severe or chronic inflammatory problems. Children are at risk for the same corticosteroid side effects as adults, including stomach ulcers. DIF: Cognitive Level: Understanding REF: p. 89 25. Which statement made by the patient newly prescribed to take a nonsteroidal anti- inflammatory drug (NSAID) indicates that more teaching is needed? a. “I should avoid taking acetaminophen (Tylenol) any time I am also taking an over-the- counter NSAID.” b . “Because aspirin causes me to have asthma, I should never take another NSAID like ibuprofen (Advil).” c. “I should try to avoid taking any NSAID, even over-the-counter NSAIDs, for more than a few days or a week.” d . “Because Celebrex (celecoxib) has so few side effects, I don’t have to worry about how often I take it.” ANS: D Because celecoxib mostly suppresses the COX-2 pathway, allowing the normal housekeeping functions of the COX-1 pathway to continue, it has fewer side effects than COX-1 NSAIDs. However, if a patient takes more than the prescribed dose, the side effects are the same as for the COX-1 NSAIDs. This drug does not affect platelet action and blood clotting. So, bruising and gum bleeding are not expected side effects. DIF: Cognitive Level: Applying or Higher REF: p. 91 26. A patient is prescribed ibuprofen (Advil) 200 mg four times a day as needed for inflammation and pain related to arthritis. The patient is scheduled for oral surgery. What priority teaching is appropriate for this patient? a. “The Advil will help relieve your pain after surgery.” b . “Report any bruising to your prescriber immediately.” c. “Ask about having the injectable form of this drug after surgery.” d . “Stop taking this drug at least 36 hours before your scheduled surgery.” ANS: D Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID). These drugs reversibly inhibit the action of the COX enzyme. Reduced activity of COX-1 decreases platelet clumping and can reduce blood clotting for 1 to 2 days. Any patient taking a COX-1 NSAID is at increased risk for bleeding and should stop taking the drug 1 to 2 days before surgery. There is no injectable form of ibuprofen. DIF: Cognitive Level: Applying or Higher REF: p. 91 27. A patient taking a nonsteroidal anti-inflammatory drug (NSAID) tells you that the drug causes an upset stomach. What is your best response? a. “Always take this drug with food or with milk.” b . “Stop taking the drug and notify your prescriber.” c. “Try chewing the drug instead of swallowing it whole.” d . “Take the drug on an empty stomach to avoid vomiting.” ANS: A Upset stomach is a common side effect for NSAIDs. Most of the time, this side effect can be reduced or avoided by ensuring that the drug is taken on a full stomach, with food or with milk. DIF: Cognitive Level: Applying or Higher REF: p. 91 28. For which drug should you ask a patient about an allergy to “sulfa” drugs before administering it? a. Aspirin (Bufferin) b . Ketorolac (Toradol) c. Celecoxib (Celebrex) d . Oxaprozin (Daypro) ANS: C Celecoxib (Celebrex) is made from a chemical similar to the “sulfa drug” type of antibiotic. A patient who is allergic to sulfa drugs is likely to also be allergic to celecoxib. DIF: Cognitive Level: Applying or Higher REF: p. 91 29. Which new symptom in a patient taking celecoxib (Celebrex) requires immediate medical attention? a. Headache b . Ankle swelling c. Chest pain d . Itchy nose ANS: C Celecoxib is a COX-2 inhibitor. Other drugs from this class have caused an increased incidence of strokes and heart attacks by promoting inappropriate blood clot formation in small blood vessels. Although the incidence of this problem is lower with celecoxib, any patient with new onset chest pain should be seen immediately. DIF: Cognitive Level: Applying or Higher REF: p. 92 30. An older adult is prescribed naproxen (Naprosyn) 250 mg orally twice daily for management of arthritis pain. Which precaution is most important to teach the patient? a. “Weigh yourself daily every morning, and if you gain more than 3 to 4 lb in a week, report it to your prescriber.” b . “Avoid taking blood pressure medicine at the same time as this drug because Naprosyn inactivates these drugs.” c. “Go to the emergency department for an injection of Naprosyn if you are vomiting and cannot keep the drug down.” d . “Drink a full glass of water every time you take a dose of Naprosyn.” ANS: A Naproxen and other NSAIDs cause salt and water retention that can lead to fluid overload and high blood pressure, increasing the risk for heart attack or heart failure. Teach older adult patients taking NSAIDs to check their weight daily and to report any weight gain of more than 3 to 4 lb to the prescriber. This amount of weight gain is associated with fluid retention rather than increased body fat. NSAIDs reduce the effectiveness of some blood pressure drugs because of the fluid retention, not because they inactivate the drug. DIF: Cognitive Level: Applying or Higher REF: p. 93 31. A patient is prescribed 20 mg of ketorolac (Toradol) intramuscularly. How many milliliters should you draw up from a vial of ketorolac containing 30 mg/mL? a. 0.5 b . 0.7 c. 1 d . 2 ANS: B 1 is to 30 as X is to 20, so 1/30 = X/20; 20 1 = 20; 20/30 = 0.67 mL, rounded up to 0.7 mL. DIF: Cognitive Level: Applying or Higher REF: p. 90 32. Why are aspirin and aspirin-containing drugs avoided for use in children? a. Aspirin is associated with the development of Reye’s syndrome. b . Aspirin would drop a child’s body temperature below normal. Diphenhydramine is an H1 receptor blocker commonly used for inflammation triggered by allergic reactions such as hives, watery eyes, and runny nose. Side effects of these drugs include dry mouth and throat as well as drowsiness. Sometimes these drugs are prescribed as a sleep aid. DIF: Cognitive Level: Applying or Higher REF: p. 94 38. Which precaution is important to teach a patient who takes antihistamines at home? a. Avoid drinking coffee and other beverages containing caffeine. b . Avoid drinking alcohol within 4 hours of taking the drug. c. Do not stop taking this drug suddenly. d . Avoid taking aspirin while on this drug. ANS: B Most antihistamines induce some degree of drowsiness or sleepiness. Alcohol potentiates this effect and the patient could fall or have another type of accident. DIF: Cognitive Level: Applying or Higher REF: p. 94 39. A patient prescribed zileutin (Zyflo) has yellowing of the sclera. Which laboratory test result is most important to check? a. Kidney function tests b . Complete blood count c. Liver function tests d . Serum electrolytes ANS: C Zileutin is a leukotriene inhibitor with rare adverse effects that include liver impairment and allergic reactions. DIF: Cognitive Level: Applying or Higher REF: p. 96 40. Which question is most important to ask a patient before giving the first dose of etaneracept (Enbrel)? a. Do you have diabetes? b . Are you pregnant or breastfeeding? c. Do you have psoriasis or another skin disorder? d . Have you ever had tuberculosis or hepatitis B or C? ANS: D Etaneracept is a disease modifying antirheumatic drug (DMARD) that lowers immunity. If the patient has ever had certain viral diseases or tuberculosis, the disease can reappear in an active form when the immune response is suppressed. Previous infection with any of these diseases is a contraindication for this drug. DIF: Cognitive Level: Applying or Higher REF: p. 97 MULTIPLE RESPONSE BASIC CONCEPTS 1. Which symptoms of inflammation are caused by leakage of blood plasma into the tissues at the site of injury or invasion? (select all that apply) a. Increased production and migration of leukocytes b . Phagocytosis and fever c. Warmth and redness d . Swelling and pain ANS: C, D With capillary leak, blood plasma leaks into the tissues causing swelling and pain. The swelling creates a cushion of fluid to prevent more tissue injury. Swelling alone can compress pain receptors (nociceptors) and result in pain perception. DIF: Cognitive Level: Remembering REF: p. 84 2. Which factors determine the size and severity of the inflammatory response? (select all that apply) a. Intensity of the injury b . Type of tissue injured c. Severity of the invasion d . Gender of the patient e. Extent of injury f. Duration of the invasion ANS: A, C, E, F The inflammatory response is nonspecific. The same tissue responses occur with any type of invasion or injury. Size and severity of the inflammatory response depend on intensity, severity, duration, and extent of the injury or invasion. DIF: Cognitive Level: Remembering REF: p. 83 3. Which main signs and symptoms should you teach a patient to recognize as inflammation? (select all that apply) a. Warmth b . Redness c. Headache d . Swelling e. Pain f. Bleeding g . Decreased function ANS: A, B, D, E, G The five main signs and symptoms of inflammation are warmth, redness, swelling, pain, and loss of function. DIF: Cognitive Level: Understanding REF: p. 84 Chapter 07: Drugs for Pain Control Workman & LaCharity: Understanding Pharmacology: Essentials for Medication Safety, 2nd Edition MULTIPLE CHOICE BASIC CONCEPTS 1. What is another name for an opioid drug? a. Nanogram b . Narcoleptic c. Nociceptor d . Narcotic ANS: D Opioid analgesics, also called narcotics, are drugs that contain any ingredient derived from the poppy plant (or a similar synthetic chemical) that change an individual’s perception of pain and have the potential for psychologic or physical dependence. . e. Schedule V ANS: A Heroin has a very high likelihood of abuse and addiction. In addition, it has no accepted medical use in the United States. Therefore it meets the criteria for a controlled substance schedule I drug. DIF: Cognitive Level: Remembering REF: p. 105 8. Which problem is a psychologic response to chronic opioid use? a. Tolerance b . Addiction c. Withdrawal d . Dependence ANS: B The definition for addiction is the psychologic need or craving for the “high” feeling that results from using opioids when pain is not present. DIF: Cognitive Level: Remembering REF: p. 106 9. What is the most common side effect of an opioid used for 5 days? a. Addiction b . Hallucinations c. Constipation d . Excessive thirst ANS: C The most common side effect of opioids is constipation because these drugs slow intestinal movement. Most patients who are on opioids for 2 or more days experience constipation. Ask patients who are prescribed opioids about constipation on a daily basis. Be sure to administer any prescribed stool softeners or laxatives. DIF: Cognitive Level: Remembering REF: p. 108 10. Which is the best clinical definition of pain? a. A state of extreme physical distress or discomfort b . A condition of sensation caused by tissue damage c. A cognitive awareness of a change in comfort d . Whatever the patient says it is ANS: D Pain is a personal experience that includes physical and emotional components. What is painful for one individual may not be painful to another. Because everyone experiences pain in a different way, the most useful clinical definition is that pain is whatever the patient says it is and exists whenever he or she says it does. DIF: Cognitive Level: Remembering REF: p. 101 11. Which statement about pain is true? a. Each patient perceives a painful event differently. b . Patients who cannot describe their pain do not really have pain. c. It is not necessary to assess for pain in patients who are sleeping. d . Infants and young children feel pain less intensely than adults do. ANS: A How we feel and react to pain depends on our emotional makeup along with our previous experiences with pain. Issues like culture, age, gender, and our interactions with society also affect our responses to pain. As a result, no two people perceive pain in exactly the same way. DIF: Cognitive Level: Remembering REF: p. 103 12. A patient who is paralyzed from the waist down as a result of an injury that completely severed the spinal cord has an open wound on the right heel. Why is this patient unaware of any pain caused from this wound? a. The nociceptors in the heel are no longer stimulated when injury occurs. b . The patient has become completely desensitized to this type of chronic pain. c. The severed spinal cord prevents the sensation of pain from reaching the brain. d . The spinal cord injury results in chronic pain that can mask any acute pain sensation. ANS: C Pain is perceived in the brain, not in the area of tissue injury. When the nociceptors are stimulated by tissue damage, the impulse must be transmitted to the brain before it can be “felt” as pain. With a completely severed spinal cord, the pain impulses are not transmitted to the brain. DIF: Cognitive Level: Remembering REF: p. 102 13. A patient with arthritis of the left knee reports pain extending from the knee half- way down the lower leg. What type of pain is this patient perceiving? a. Localized b . Referred c. Radiating d . Phantom ANS: C Radiating pain may be felt all around and extending from the damaged area causing the pain. DIF: Cognitive Level: Remembering REF: p. 104 14. Pain is considered to be the “fifth vital sign.” How does this principle affect patient care? a. It ensures that pain assessment occurs on a regular basis for all patients. b . It helps health care workers understand that experiencing pain can change heart rate and respiratory rate. c. It helps health care workers to ensure that vital organ function is adequate before administering drugs to reduce pain. d . It encourages health care providers to assess two parameters during patient contact to improve time management. ANS: A Pain is common in patients and undertreated pain remains a major yet avoidable health problem. More frequent and more accurate assessment can improve pain management. Making pain assessment the “fifth vital sign” assists health care workers to both recognize the presence of pain and see how the patient responds to drugs and other interventions. These actions increase the likelihood of appropriate pain management. DIF: Cognitive Level: Remembering REF: p. 104 15. Which event or condition is most likely to result in chronic pain? a. Severe headache associated with a spinal tap b . Insertion of a needle for intravenous (IV) therapy c. Hip replacement surgery d Osteoarthritis forever.” d . “I will take enough pain medication to make me comfortable without making me too sleepy.” ANS: B One cause of underreporting pain and undertreating it is that many patients and health care providers believe that pain is a normal part of aging. Pain may occur more frequently among older adults, but is never considered “normal.” Patients of any age with pain for any reason deserve to have their pain reduced to a manageable level. DIF: Cognitive Level: Applying or Higher REF: p. 104 21. What is the best way for you to determine a patient’s need for pain medication on the second day after an abdominal laparotomy? a. Check when the patient last received medication for pain. b . Assess the patient’s facial expression and vital signs. c. Consider the patient’s age and ethnicity. d . Ask the patient to rate his or her pain. ANS: D Pain experience and pain tolerance are very personal. True assessment of a patient’s discomfort cannot be determined by and should not be based on the patient’s behaviors or changes in vital signs. Nor can it be based on how recently the patient received a drug for pain. The only way to know is to ask the patient to rate the pain. DIF: Cognitive Level: Applying or Higher REF: p. 103 22. After surgery, a patient expresses the fear of becoming addicted to the opioid analgesic that has been prescribed for pain. What is your best response? a. “Opioid-based drugs are not addictive.” b . “Have you or anyone in your family ever been addicted to drugs?” c. “When opioid drugs are taken for acute pain, they are rarely addictive.” d . “If you take the medication no more frequently than every 4 hours, it is not possible for you to become addicted.” ANS: C The fear of addiction to opioids is one cause of poorly treated pain. Remind the patient that addiction will not occur if the drugs are taken to relieve pain. Pain after surgery is acute and temporary pain. The use of opioid drugs, when used for relief of acute pain, even in high doses, rarely results in addiction. DIF: Cognitive Level: Applying or Higher REF: p. 106 23. You are assigned to care for a patient with chronic low back pain. What adjustment in pain management do you expect to make? a. Encouraging the patient to hold off taking a pain drug as long as possible to reduce the potential for addiction. b . Relying on patient report of pain rather than on changes in heart rate, blood pressure, and pulse rate. c. Keeping the environment as quiet as possible to avoid distracting or irritating the patient. d . Using nondrug measures in place of analgesics to relieve the patient’s pain. ANS: B Adaptation to the presence of chronic pain is physiologic, not psychologic. Thus the usual alterations in physiologic parameters when acute pain is present do not accompany chronic pain. DIF: Cognitive Level: Applying (Application) or Higher REF: p. 104 24. You check a patient for pain relief 1 hour after administering 15 mg of morphine intramuscularly. The patient is sleeping and has a respiratory rate of 10 breaths/min. What is your best first action? a. Attempt to arouse the patient by calling his or her name and lightly shaking the arm. b . Administer oxygen by mask or nasal cannula and notify the prescriber. c. Check the patient’s oxygen saturation and raise the head of the bed. d . Document the finding as the only action. ANS: A Many patients experience some degree of respiratory depression with opioid analgesics. If the patient can be aroused with minimally intrusive techniques and the respiratory rate increases spontaneously, no further intervention is required. DIF: Cognitive Level: Applying or Higher REF: pp. 108-109 25. You prepare to give a patient the next scheduled dose of an opioid analgesic. The patient arouses easily but the respiratory rate remains at 10 breaths/min. What is your best first action? a. Hold the dose and notify the prescriber. b . Hold the dose and apply oxygen by mask or nasal cannula. c. Check the patient’s oxygen saturation and ask about his or her pain level. d . Call the Rapid Response Team and prepare to administer the prescribed opioid antagonist. ANS: C Many people experience mild respiratory depression with opioid analgesics. If the patient is easily arousable and the oxygen saturation is at normal levels, it is not necessary to apply oxygen, call the Rapid Response Team, or prepare to administer an opioid antagonist. If the patient’s oxygen saturation level is acceptable and he or she is in pain, it is alright to give the next scheduled opioid dose. Checking the patient’s normal respiratory rate is also a good idea. Most people have a usual respiratory rate that is at least 12 breaths/min, but some patients may have a usual rate of only 10 breaths/min. Although this is not a customary response and you should document it in the patient care notes, check other indicators of breathing adequacy before notifying the prescriber. DIF: Cognitive Level: Applying or Higher REF: p. 109 26. A patient taking oxycodone with acetaminophen (Percocet) for pain at home 3 days after fracturing an ankle reports constipation and continuing moderate to severe pain that is relieved by the prescribed drug. What is your best advice? a. “Either increase the time between drug doses or take only half the dose at each scheduled time.” b . “Stop taking the Percocet and switch to acetaminophen alone.” c. “Wrap your foot tightly and walk for at least 30 minutes daily.” d . “Drink at least 3 L of fluid daily and increase fiber intake.” ANS: D This patient still needs the Percocet. Most patients taking opioids for 2 days or longer have constipation. Urge the patient to drink plenty of fluids. Increasing fiber intake, either with food containing fiber or with over-the-counter fiber supplements, can help reduce constipation. Although increasing activity can help reduce constipation, walking for 30 minutes with a fractured ankle is not permitted at this time. DIF: Cognitive Level: Applying or Higher REF: p. 109 27. An older adult is taking an oral opioid drug at home for pain control. Which precaution to prevent injury is important for you to teach this patient? a. “Increase room lighting to reduce the risk for tripping.” b . “Sleep in a sitting position to reduce respiratory problems.” c. “Drink at least 3 L of fluids daily to reduce constipation.” d . “Avoid drinks containing caffeine to prevent inactivating the drug.” 33. A patient tells you that the usual dose of an opioid drug for cancer pain no longer relieves the pain. What is your best response? a. “We have to be careful about increasing opioid drug dosages to prevent drug addiction.” b . “You may be developing dependence on the drug and that is why it no longer relieves your pain.” c. “Your body may be adjusting to the drug, eliminating it more rapidly, and thus you will need a higher dose to achieve pain relief.” d . “The danger of increasing your opioid drug dosage is that you may experience respiratory failure.” ANS: C An issue that can occur with longer-term opioid use is drug tolerance. Tolerance is the adjustment of the body to long-term opioid use that increases the rate of drug elimination and reduces the main effect (pain relief) and side effects of the drug. It occurs with anyone who is taking opioids for a long period of time. More drug is needed to achieve the same degree of pain relief. DIF: Cognitive Level: Applying or Higher REF: p. 106 34. You are administering the first dose of an opioid drug to a patient. Which specific related actions should you take before and after giving the dose? a. Ask if the patient is allergic to sulfa drugs and monitor for a reaction after giving the drug. b . Place the patient on bed rest before giving the drug and keep him or her on bed rest after to avoid accidental falling. c. Check the patient’s respiratory rate and oxygen saturation before and after giving the drug and monitor for respiratory depression. d . Administer a drug such as naloxone (Narcan) both before and after giving the opioid drug to prevent respiratory depression. ANS: C When giving the first dose of an opioid to a patient who has never taken an opioid (is opioid naïve), check the patient’s respiratory rate and oxygen saturation. Opioids can cause some degree of respiratory depression. After giving the drug, be sure to monitor the patient’s respiratory rate and oxygen saturation for indications of respiratory depression. This is especially important when the patient is receiving an opioid for the first time or when the drug dosage has been increased. DIF: Cognitive Level: Applying or Higher REF: p. 108 35. A patient is receiving morphine (MS Contin) for severe cancer pain. His wife states that he has difficulty swallowing and asks if the tablets can be crushed and given with applesauce or pudding. What is your best response? a. “That is an excellent solution and will make it much easier for him to swallow his pain medicine.” b . “It might be best if we talk with the prescriber about having a feeding tube placed for medication administration.” c. “You can dissolve the tablets in water then give the drug to your husband mixed with juice.” d . “I will contact the prescriber about this because your husband may need to be prescribed a different form of morphine for his pain.” ANS: D MS Contin is an extended release tablet so crushing or dissolving it can cause a drug overdose from releasing too much drug at a time. The best action is to contact the prescriber with the information about the patient’s difficulty swallowing because a different form or morphine or a different drug may be needed to control the pain. Teach patients and their families to take an extended release (ER) form of an oral opioid drug by swallowing the capsule or tablet whole because chewing it or opening the capsule allows too much of the drug to be absorbed all at once and an overdose can occur. DIF: Cognitive Level: Applying or Higher REF: p. 109 36. Which key point should you teach a pregnant woman who is prescribed opioids drugs during pregnancy? a. Your child may become addicted to opioids and go through withdrawal after birth. b . These drugs do not cross the placenta so are safe to use during pregnancy. c. Some opioids have been found to cause birth defects in animal studies. d . Opioids are not present in breast milk so it is safe to breastfeed. ANS: A Opioids may be prescribed to women during pregnancy. These drugs do cross the placenta and enter the fetus. The fetus can become addicted to opioids and go through withdrawal after birth. Opioids also cross into breast milk. DIF: Cognitive Level: Applying or Higher REF: p. 110 37. For which opioid pain drug order should you contact and question the prescriber? a. Adult male, hydromorphone (Dilaudid) 4 mg orally every 4 hours b . Older adult, meperidine (Demerol) 50 mg IM every 3 hours c. Child, codeine 0.5 mg/kg orally every 6 hours d . Adult women, hydrocodone with acetaminophen (Vicodin) 5 mg orally every 6 hours ANS: B Opioids, especially meperidine (Demerol), can make the chest muscles of older adults tighter, which makes breathing and coughing more difficult. Thus the risk for pneumonia and hypoxia is greater for them. Check the respiratory rate and depth as well as the oxygen saturation at least every 2 hours. In addition, meperidine causes the buildup of a toxic metabolite in older adults that can result in seizures. Avoid the use of meperidine in older adults. DIF: Cognitive Level: Applying or Higher REF: p. 110 38. After receiving the first dose of an opioid drug, a patient is sleeping and has a respiratory rate of less than 8 per minute. When called by name the patient does not respond. What is your next best action? a. Place an ice cube on his or her forehead. b . Firmly shake his or her leg or arm. c. Apply pressure to his or her nail bed. d . Squeeze his or her trapezius muscle. ANS: B When the patient is receiving an opioid for the first time or when the drug dosage has been increased, if the respiratory rate is 8 or less and the patient is sleeping, try to wake him or her. First call the patient’s name. If there is no response, gently shake his or her arm or leg. Shake more firmly if needed. If the patient does not respond to these actions, use a slightly stronger trigger (without using enough force to cause harm) such as squeezing the trapezius muscle (located at the angle of the shoulder and neck muscle) or applying pressure to the nail bed. DIF: Cognitive Level: Applying or Higher REF: p. 109 39. The patient who received a first dose of an opioid drug is not arousable and has an oxygen saturation of 88% (five percentage points lower than his or her normal saturation) even when fully awake. What is your best next action? a. Wait 2 minutes and recheck respiratory rate and oxygen saturation. b . Shake the patient firmly and keep trying to arouse him or her. c. Notify respiratory therapy to draw an arterial blood gas. d . Call for help and apply supplemental oxygen. ANS: D If the patient cannot be aroused, immediately call for help. If the patient’s oxygen saturation is below 95% or is five percentage points lower than his or her normal saturation, arouse the patient and check the saturation when fully awake. If the saturation does not improve when fully awake, apply supplemental oxygen and notify the charge nurse or prescriber. ANS: C Virulence is a measure of how well or efficiently a microorganism can gain entry into the body, reproduce there, and make the host sick even when the host has a normal immune system. The more virulent a bacterium is, the more dangerous it is and the harder it is to kill or eliminate. DIF: Cognitive Level: Remembering REF: p. 115 3. What is the main feature of an opportunistic infection? a. It usually leads rapidly to sepsis. b . Children are not susceptible to this type of infection. c. It is most often caused by pathogenic microorganisms. d . It is only found in people who are immunosuppressed. ANS: D We have many microorganisms that are on or in our bodies and do not cause an infection because our immune systems are able to keep their numbers low and prevent them from moving beyond their normal body location. For example, we all have E. coli in our intestinal tracts and this does not cause us harm as long as our immune systems are working well. Even if a few E. coli leave the intestinal tract and enter the blood or the urine, they usually do not cause an infection because our immune systems get rid of these organisms when they are located where they do not belong. However, a person with a suppressed or weak immune system may not be able to remove or destroy these organisms when they are located outside of the intestinal tract and an infection develops. This is called an opportunistic infection because the organism is taking advantage of the host’s weakened immune system and using the opportunity to grow elsewhere in the body. DIF: Cognitive Level: Remembering REF: p. 115 4. Which problem is a sign or symptom of an allergic or anaphylactic response to an antibacterial drug? a. Diarrhea b . Hair loss c. High blood pressure d . Swelling of the face or lips ANS: D Most antibacterial drugs induce diarrhea when taken for a week or longer because they kill off so many of the normal bacteria in the intestinal tract. This is not an allergy and the immune system is taking no part in causing the diarrhea. Hair loss is not a common side effect of antibacterial therapy nor is it an allergic reaction. When a true systemic allergic reaction occurs, it is usually accompanied by low blood pressure because of widespread blood vessel dilation. This blood vessel dilation of a true allergic response often causes swelling of the face, lips, and tongue. DIF: Cognitive Level: Remembering REF: p. 117 5. Which drug category includes the penicillins? a. Protein synthesis inhibitors b . Cell wall synthesis inhibitors c. DNA synthesis inhibitors d . Metabolism inhibitors ANS: B The action of penicillin is disruption of the ability of a bacterium to make, repair, or maintain its cell walls. So, penicillins belong to the cell wall synthesis inhibitor class of antibacterial drugs. Penicillins do not interfere with the bacteria’s ability to make proteins, make DNA, or metabolize. DIF: Cognitive Level: Remembering REF: p. 118 6. Which drug is a first-generation cephalosporin? a. Cefepime (Maxipime) b . Cefotaxime (Claforan) c. Cefoxitin (Mefoxin) d . Cefazolin (Kefzol) ANS: D Only cefazolin (Kefzol) is a first-generation cephalosporin. The other drugs are all cephalosporins but cefepime is fourth-generation, cefotaxime is third-generation, and cefoxitin is second-generation. DIF: Cognitive Level: Remembering REF: p. 121 7. Which two drug types have almost identical chemical structures? a. Aminoglycosides and “sulfa drugs” b . Macrolides and fluoroquinolones c. Penicillins and cephalosporins d . Tetracyclines and penicillins ANS: C Both the penicillins and the cephalosporins have a beta lactam ring as part of their chemical structures, making them nearly identical in how they work and the side effects they have. All of the other drugs on this list have unique chemical structures. DIF: Cognitive Level: Remembering REF: p. 121 8. Which drug is most often used to treat ear infections in children? a. Imipenem (Primaxin) b . Amoxicillin (Amoxil) c. Vancomycin (Vancocin) d . Sulfamethoxazole/trimethoprim (Bactrim) ANS: B Most of the bacteria that invade the middle ear of children (and adults) have cell walls and are sensitive to the less potent cell wall synthesis inhibitors, especially amoxicillin. Both imipenem and vancomycin are powerful antibacterial drugs and are only used for severe infections that do not respond to less potent drugs. Sulfamethoxazole/trimethoprim is used mainly for infections of the urinary tract. DIF: Cognitive Level: Remembering REF: p. 123 9. Which protein synthesis inhibitors can raise the pressure inside the brain? a. Aminoglycosides b . Macrolides c. Lincosamides d . Tetracyclines ANS: D Of the drugs on this list, only the tetracyclines have a potential adverse effect of increasing pressure inside the brain. DIF: Cognitive Level: Remembering REF: p. 131 10. Which drug can cause tooth discoloration when given to young children? a. Aminoglycosides b . Macrolides