Unit 01: Introduction
Rosenthal: Lehne's Pharmacotherapeutics for Advanced Practice Nurses and Physician Assistants, 2nd Edition

MULTIPLE CHOICE

	1.	A patient diagnosed with chronic pain calls to request an oxycodone (Oxycontin) refill. Which action should the prescriber take initially?
a.	Fax the renewal order to the pharmacy.	
b.	Arrange to schedule an appointment with the patient.	
c.	Verify the patient’s adherence to the prescribed drug regimen.	
d.	Determine the patient’s current medication dosage and pain level.	

ANS:	B
Schedule II medications are not eligible for refills, and prescriptions must be handwritten. It is important to verify the patient’s adherence to the drug regimen and determine the current dosage of medication and pain level; however, this can be accomplished by scheduling an appointment and evaluating the patient in person.

	2.	A metered-dose albuterol inhaler is prescribed for asthma management. The patient reports feeling jittery sometimes when taking the medication, and does not feel that the medication is always effective. Which action will the provider take to best minimize patient risks and maximize medication effectiveness?
a.	Ask the patient to demonstrate use of the inhaler and assess effectiveness.	
b.	Assess the patient’s exposure to first- and second-hand tobacco smoke.	
c.	Auscultate the patient's lung sounds and obtain other relevant vital signs.	
d.	Decrease the dosage to reduce side effects.	

ANS:	C
Assessing and evaluating lung sounds as well as other vital signs helps determine the patient's physical response to the medication and allows comparison to the patient's baseline vital signs. Asking the patient to demonstrate inhaler use helps to evaluate the patient’s ability to administer the medication properly and is part of an effective evaluation, but is not a priority intervention based on the patient’s current report. Assessing tobacco smoke exposure helps determine whether nondrug therapies, such as smoke avoidance, can be used as an adjunct to drug therapy, but does not relate to the patient’s current problem. Rewriting the prescription to decrease the dosage may address the degree of jitteriness experienced, but does not address the patient’s concern that the drug is not always effective.

	3.	A patient is prescribed metronidazole for bacterial vaginosis. Which patient history finding would be most concerning to the provider?
a.	The patient had a recent yeast infection.	
b.	There is a family history of cervical cancer.	
c.	The patient drinks two glasses of wine every night.	
d.	The patient is unemployed.	

ANS:	C
Patients taking metronidazole should be educated not to drink alcohol to prevent a disulfiram-like reaction. It would be concerning that the patient drinks wine daily. History of a yeast infection may indicate increased risk for recurrence with administration of an antimicrobial. A family history of cervical cancer is not related to administration of metronidazole. Unemployment can indicate lack of insurance coverage, which may limit the patient’s ability to purchase medications; however, generic metronidazole is one of the less expensive medications.

	4.	The provider prepares a patient with newly diagnosed type 1 diabetes for hospital discharge. Which action by the provider will best support the patient’s ability to effectively manage medication therapy?
a.	Asking the patient to demonstrate how to measure and administer insulin	
b.	Discussing methods of storing insulin and discarding syringes	
c.	Giving information about how diet and exercise affect insulin requirements	
d.	Teaching the patient about the long-term consequences of poor diabetes control	

ANS:	A
Because insulin must be given correctly to control symptoms and prevent an overdose, it is most important for the patient to know how to measure and administer it. Asking for a demonstration of technique is the best way to determine whether the patient has understood the teaching. The other teaching points are important as well, but they are not as critical.

	5.	A patient reports that a medication prescribed for recurrent migraine headaches is not working. Which action is the prescriber’s priority when addressing the patient's concern?
a.	Ask the patient about the number and frequency of tablets taken.	
b.	Assess the patient’s headache pain on a scale from 1 to 10.	
c.	Prescribe a new medication for migraine management.	
d.	Suggest biofeedback as an adjunct to drug therapy.	

ANS:	A
When evaluating the effectiveness of a drug, it is important to determine how often the patient is using the drug. Asking the patient to identify how many tablets are taken and how often helps the provider determine effective dosages and adherence to the medication regimen. The patient has already stated that the medication is not working; the actual level of pain may determine the degree to which it is not working, but it does not help the provider to determine why it is not working. The assessment process should gather as much information about compliance, symptoms, and drug effectiveness as possible before enacting a change in treatment. Biofeedback may be an effective adjunct to treatment, but it should not be recommended without complete information about drug effectiveness.

	6.	The drug manual states that older adult patients are at increased risk for hepatotoxicity. Which action is most important when prescribing this medication to an 80-year-old patient?
a.	Obtaining baseline liver function studies	
b.	Ensuring that the drug is taken in the correct dose at the correct time	
c.	Discontinuing the order; the drug is contraindicated for this patient	
d.	Giving the medication intravenously to avoid first pass metabolism	

ANS:	A
The drug manual indicates that this drug increases risk of hepatotoxicity for elderly patients. Getting information about liver function before giving the drug establishes baseline data that can be compared with posttreatment data to determine whether the drug is affecting the liver. Taking the correct dose at the correct interval may minimize risk, but without baseline information, the effects cannot be determined. Drugs are not routinely contraindicated for an increased risk of adverse effects.

	7.	A patient with bipolar disorder is prescribed daily lithium. Which action is most important for the provider to take in order to determine if the therapeutic level is maintained?
a.	Evaluate preadministration blood work.	
b.	Prescribe the lithium to be taken at regular intervals.	
c.	Order periodic laboratory testing.	
d.	Assess the patient for signs and symptoms of lithium toxicity.	

ANS:	C
Therapeutic serum levels are determined through periodic laboratory testing. Preadministration blood work may be necessary to obtain baseline status prior to initiating treatment, but it will not determine therapeutic levels. Scheduling medication administration at regular intervals will help to ensure medication is absorbed and metabolized predictably, but it will not determine therapeutic blood levels. Assessing the patient for signs and symptoms of toxicity will help to determine if the therapeutic level has been exceeded, not maintained.

	8.	Which factor best supports an increase for full prescriptive authority for both advanced practice registered nurses (APRNs) and physician assistants (PAs)?
a.	More patients will have access to health care.	
b.	Enrollment in medical schools is predicted to decrease.	
c.	Enrollment in both APRN and PA programs has increased.	
d.	Physician practices have become so large, quality care is in jeopardy.	

ANS:	A
Implementation of the Affordable Care Act has increased the number of individuals with health care coverage, and thus the number who have access to health care services. The increase in the number of patients creates the need for more providers with prescriptive authority. APRNs and physical assistants can fill this practice gap. Enrollment in medical school has increased in recent years and shows no indication of decline. While some medical practices have increased in patient volume, there is no reason to believe care has suffered. While enrollment for both APRN and PA education has increased, that is not the primary factor associated with the need for increased prescriptive authority for these providers.

	9.	A pediatric patient prescribed ampicillin for streptococcal pharyngitis reports new onset of a pruritic, dull red, maculopapular rash on the chest and neck. Which action is most important for the provider to take to minimize this patient’s risk for injury?
a.	Prescribe azithromycin to replace the ampicillin.	
b.	Discontinue the ampicillin.	
c.	Prescribe an antihistamine for the itching.	
d.	Flag all medical records with an “Allergic to Penicillin” notice.	

ANS:	B
The priority action is to discontinue the medication to prevent a potential worsening of the patient’s symptoms. A different prescription may be indicated depending on the length of treatment. An antihistamine may be administered for pruritis. Rashes are a common side effect of ampicillin. Pruritic maculopapular rashes such as the one described occur in 5% to 10% of children taking ampicillin, especially in the presence of viral infections. They do not contraindicate future administration of penicillin antibiotics.

	10.	Which prescriber action will have the greatest impact on the patient’s commitment to adherence to any type of medication therapy?
a.	Prescribing the medication in oral form whenever possible	
b.	Scheduling once a day administration	
c.	Providing medication education that the patient can easily understand	
d.	Assuring that the medication prescription will be covered by the patient’s insurance	

ANS:	C
No other provider action assures the patient’s commitment to adhere to a medication plan more than effective medication education provided in a concise, understandable form. It is not always possible or appropriate to prescribe an oral form. While medication costs can present a barrier to compliance, insurance coverage is but one factor affecting costs.

	11.	Which patient statement suggests to the provider that the patient’s nonadherence with their medication plan is related to dissatisfaction with the therapy?
a.	“This medication is too expensive; I can’t afford it any longer.”	
b.	“I’ve been taking this medication for well over a week and I lost only a half a pound.”	
c.	“It’s too hard to remember to take the pill every other day; so, I’ve missed several doses.”	
d.	“I have a very intense, fast paced job; it’s hard to make time to take the medication like I should.”	

ANS:	B
Dissatisfaction with drug therapy can take the form of a patient’s unrealistic expectation of desired results such as in the case of significant weight loss in a relatively short period of time. Medication costs, forgetfulness, and lack of planning are suggested by the other options.

MULTIPLE RESPONSE

	1.	How can the prescriber’s regular collaboration with a pharmacist improve positive outcomes for patients? (Select all that apply.)
a.	Pharmacists can suggest foods that will help with the medications' absorption.	
b.	Pharmacists have additional information on drug interactions.	
c.	The pharmacist can suggest adequate medication dosing.	
d.	Pharmacists have firsthand knowledge of the facility formulary.	
e.	Pharmacy can alter prescriptions when necessary to prevent patient harm.	

ANS:	B, C, D
Providers should collaborate with pharmacists because they will likely have additional information on formulary, drug interactions, and suggestions for adequate medication dosing. Dietitians can make food recommendations to treat the patient’s condition. The pharmacist can contact the prescriber about questionable prescriptions, but cannot alter the prescription without notification of and approval by the provider.

	2.	Which statements made by the prescriber demonstrate an understanding of effective medication education? (Select all that apply.)
a.	“This medication needs to be stored in the refrigerator.”	
b.	“Take 3 tablets daily: 1 with breakfast, 1 with lunch, and one with dinner.”	
c.	“You need to take the medication as we discussed until all the tablets are gone.”	
d.	“Call the office immediately if you begin experiencing any itching, headache, or difficulty breathing.”	
e.	“When you call about a medication refill, be sure to let the pharmacist know you are talking about your heart pill.”	

ANS:	A, B, C, D
There are basic components that should be included when teaching about any new medication. They are (1) medication name, (2) purpose, (3) dosing regimen, (4) administration, (5) adverse effects, (6) any special storage needs, (7) associated laboratory testing, (8) food or drug interactions, and (9) duration of therapy. The statement suggesting referring to the medication as “your heart pill” is inappropriate since being familiar with the drug’s name is important in avoiding medication errors.

	3.	The patient who has been prescribed lithium for a diagnosis of bipolar disorder asks why blood tests are required on a regular basis. Which provider responses demonstrate an understanding of why the patient requires a variety of laboratory tests? (Select all that apply.)
a.	“We need to monitor how your thyroid is functioning.”	
b.	“We need to monitor kidney function while you are on this drug.”	
c.	This medication can cause you to lose sodium, so we need to measure sodium levels.”	
d.	“Your liver can be damaged by lithium; regular testing helps us monitor for that.”	
e.	“Lithium can cause you to lose potassium; so, we regularly monitor your blood potassium level.”	

ANS:	A, B, C
Lithium therapy can affect thyroid and renal function as well as deplete sodium levels. Regular laboratory testing is needed to monitor sodium levels and thyroid and renal function and so allows for modification of the lithium dose as needed. Lithium is not associated with altered liver function or potassium depletion.