NR 508 pharmacology assorted questions from different Chapters with correct answers and Rationale latest edition

NR 508 pharmacology assorted questions from different Chapters with correct answers and Rationale latest edition Chapter 01: Prescriptive Authority and Role Implementation: Tradition vs. Change Test Bank MULTIPLE CHOICE 1. Which of the following has influenced an emphasis on primary care education in medical schools? a. Changes in Medicare reimbursement methods recommended in 1992 b. Competition from nonphysicians desiring to meet primary care shortages c. The need for monopolistic control in the marketplace of primary outpatient care d. The recognition that nonphysicians have variable success providing primary care ANS: A The Physician Payment Review Commission in 1992 directly increased financial reimbursement to clinicians who provide primary care. Coupled with a shortage of primary care providers, this incentive led medical schools to place greater emphasis on preparing primary care physicians. Competition from Nonphysicians increased coincidentally as professionals from other disciplines stepped up to meet the needs. Nonphysicians have had increasing success at providing primary care and have been shown to be safe and effective. DIF: Cognitive Level: Remembering (Knowledge) REF: 2 2. Which of the following statements is true about the prescribing practices of physicians? a. Older physicians tend to prescribe more appropriate medications than younger physicians. b. Antibiotic medications remain in the top five classifications of medications prescribed. c. Most physicians rely on a ―therapeutic armamentarium‖ that consists of less than 100 drug preparations per physician. d. The dominant form of drug informationused by primary care physicians continues to be that provided by pharmaceutical companies. ANS: D Even though most physicians claim to place little weight on drug advertisements, pharmaceutical representatives, and patient preference and state that they rely on academic sources for drug information, a study showed that commercial rather than scientific sources of drug information dominated their drug information materials. Younger physicians tend to prescribe fewer and more appropriate drugs. Antibiotics have dropped out of the top five classifications of drugs prescribed. Most physicians have a therapeutic armamentarium of about 144 drugs. DIF: Cognitive Level: Remembering (Knowledge) REF: 3 3. As primary care nurse practitioners (NPs) continue to develop their role as prescribers of medications, it will be important to: a. attain the same level of expertise as physicians who currently prescribe medications. b. learn from the experiences of physicians and develop expertise based on evidencebased practice. c. maintain collaborative and supervisorial relationships with physicians who will oversee prescribing practices. d. develop relationships with pharmaceutical representatives to learn about new medications as they are developed. ANS: B As nonphysicians develop the roles associated with prescriptive authority, it will be important to learn from the past experiences of physicians and to develop prescribing practices based on evidence-based medicine. It is hoped that all prescribers, including physicians and nurse practitioners, will strive to do better than in the past. NPs should work toward prescriptive authority and for practice that is not supervised by another professional. Pharmaceutical representatives provide information that carries some bias. Academic sources are better. DIF: Cognitive Level: Applying (Application) REF: 4 Chapter 02: Historical Review of Prescriptive Authority: The Role of Nurses (NPs, CNMs, CRNAs, and CNSs) and Physician Assistants Test Bank MULTIPLE CHOICE1. A primary care NP will begin practicing in a state in which the governor has opted out of the federal facility reimbursement requirement. The NP should be aware that this defines how NPs may write prescriptions: a. without physician supervision in private practice. b. as CRNAs without physician supervision in a hospital setting. c. in any situation but will not be reimbursed for this by government insurers. d. only with physician supervision in both private practice and a hospital setting. ANS: B In 2001, the Centers for Medicare and Medicaid Services changed the federal physician supervision rule for CRNAs to allow state governors to opt out, allowing CRNAs to write prescriptions and dispense drugs without physician supervision. DIF: Cognitive Level: Understanding (Comprehension) REF: 9 2. CRNAs in most states: a. must have a Drug Enforcement Administration (DEA) number to practice. b. must have prescriptive authority to practice. c. order and administer controlled substances but do not have full prescriptive authority. d. administer medications, including controlled substances, under direct physician supervision. ANS: C Only five states grant independent prescriptive authority to CRNAs. CRNAs do not require prescriptive authority because they dispense a drug immediately to a patient and do not prescribe. Without prescriptive authority, they do not need a DEA number. DIF: Cognitive Level: Understanding (Comprehension) REF: 9 3. A CNM: a. may treat only women. b. has prescriptive authority in all 50 states. c. may administer only drugs used during labor and delivery. d. may practice only in birthing centers and home birth settings. ANS: BCNMs have prescriptive authority in all 50 states. They may treat partners of women for sexually transmitted diseases. They have full prescriptive authority and are not limited to drugs used during childbirth. They practice in many other types of settings. DIF: Cognitive Level: Remembering (Knowledge) REF: 9 4. In every state, prescriptive authority for NPs includes the ability to write prescriptions: a. for controlled substances. b. for specified classifications of medications. c. without physician-mandated involvement. d. with full, independent prescriptive authority. ANS: B All states now have some degree of prescriptive authority granted to NPs, but not all states allow authority to prescribe controlled substances. Many states still require some degree of physician involvement with certain types of drugs. DIF: Cognitive Level: Understanding (Comprehension) REF: 12 5. The current trend toward transitioning NP programs to the doctoral level will mean that: a. NPs licensed in one state may practice in other states. b. full prescriptive authority will be granted to all NPs with doctoral degrees. c. NPs will be better prepared to meet emerging health care needs of patients. d. requirements for physician supervision of NPs will be removed in all states. ANS: C The American Association of Colleges of Nursing has recommended transitioning graduate level NP programs to the doctoral level as a response to changes in health care delivery and emerging health care needs. NPs with doctoral degrees will not necessarily have full prescriptive authority or be freed from requirements about physician supervision because those are subject to individual state laws. NPs will still be required to meet licensure requirements of each state. DIF: Cognitive Level: Understanding (Comprehension) REF: 12 6. An important difference between physician assistants (PAs) and NPs is PAs: a. always work under physician supervision. b. are not required to follow drug treatment protocols. c. may write for all drug categories with physician co-signatures.d. have both inpatient and outpatient independent prescriptive authority. ANS: A PAs commonly have co-signature requirements and work under physician supervision. DIF: Cognitive Level: Understanding (Comprehension) REF: 17 Chapter 03: General Pharmacokinetic and Pharmacodynamic Principl es Test Bank MULTIPLE CHOICE 1. A primary care nurse practitioner (NP) prescribes a drug to an 80-year-old AfricanAmerican woman. When selecting a drug and determining the correct dose, the NP should understand that the knowledge of how age, race, and gender may affect drug excretion is based on an understanding of: a. bioavailability. b. pharmacokinetics. c. pharmacodynamics. d. anatomy and physiology. ANS: B Pharmacokinetics is the study of the action of drugs in the body and may be thought of as what the body does to the drug. Factors such as age, race, and gender may change the way the body acts to metabolize and excrete a drug. Bioavailability refers to the amount of drug available at the site of action. Pharmacodynamics is the study of the effects of drugs on the body. Anatomy and physiology is a basic understanding of how the body functions. DIF: Cognitive Level: Understanding (Comprehension) REF: 21 2. A patient asks the primary care NP which medication to use for mild to moderate pain. The NP should recommend: a. APAP. b. Tylenol. c. acetaminophen. d. any over-the-counter pain product. ANS: C Providers should use generic drug names when prescribing drugs or recommending them to patients, unless a particular brand is essential for some reason. Because acetaminophen can have many trade names, it is important for patients to understand that the drug is the same for all to avoid overdosing on acetaminophen. APAP is a commonly used abbreviation but should not be used when recommending the drug to patients. DIF: Cognitive Level: Applying (Application) REF: 213. A patient wants to know why a cheaper version of a drug cannot be used when the primary care NP writes a prescription for a specific brand name of the drug and writes, ―Dispense as Written.‖ The NP should explain that a different brand of this drug: a. may cause different adverse effects. b. does not necessarily have the same therapeutic effect. c. is likely to be less safe than the brand specified in the prescription. d. may vary in the amount of drug that reaches the site of action in the body. ANS: D Different formulations of the same drug may have varying degrees of bioavailability, and it may be important to stick to a particular brand for drugs with narrow therapeutic ranges. All drugs with similar active ingredients should have the same therapeutic actions and side effects and should be equally safe. DIF: Cognitive Level: Applying (Application) REF: 22 4. A primary care NP wishes to order a drug that will be effective immediately after administration of the drug. Which route should the NP choose? a. Rectal b. Topical c. Sublingual d. Intramuscular ANS: C The sublingual route is preferred for quick action because the drug is directly absorbed into the bloodstream and avoids the pass through of the liver, where much of an oral drug is metabolized. Rectal routes have unpredictable absorption rates. Topical routes are the slowest. Intramuscular routes are slow. DIF: Cognitive Level: Remembering (Knowledge) REF: 22 5. A patient receives an inhaled corticosteroid to treat asthma. The patient asks the primary care NP why the drug is given by this route instead of orally. The NP should explain that the inhaled form: a. is absorbed less quickly. b. has reduced bioavailability. c. has fewer systemic side effects. d. provides dosing that is easier to regulate. ANS: C An inhaled corticosteroid goes directly to the site of action and does not have to pass through gastrointestinal tract absorption or the liver to get to the lungs. It is generally well absorbed at this site, although dosing is not necessarily easier to regulate because it is notalways clear how much of an inhaled drug gets into the lungs. DIF: Cognitive Level: Applying (Application) REF: 21 6. A patient takes an oral medication that causes gastrointestinal upset. The patient asks the primary care NP why the drug information insert cautions against using antacids while taking the drug. The NP should explain that the antacid may: a. alter drug absorption. b. alter drug distribution. c. lead to drug toxicity. d. increase stomach upset. ANS: A Changing the pH of the gastric mucosa can alter the absorption of the drug. Drug distribution is not affected. It may indirectly cause drug toxicity if a significant amount more of the drug is absorbed. It would decrease stomach upset. DIF: Cognitive Level: Applying (Application) REF: 22 7. A patient will begin taking two drugs that are both protein-bound. The primary care NP should: a. prescribe increased doses of both drugs. b. monitor drug levels, actions, and side effects. c. teach the patient to increase intake of protein. d. stagger the doses of drugs to be given 1 hour apart. ANS: B Protein-bound drugs bind to albumin, and serum albumin levels may affect how drugs are distributed. The provider should monitor drug levels, actions, and side effects and change dosing accordingly. Increasing the dose of both drugs is not recommended unless monitoring indicates. Increasing dietary protein does not affect this. Staggering the drugs will not affect this. DIF: Cognitive Level: Applying (Application) REF: 25 8. A patient is taking drug A and drug B. The primary care NP notes increased effects of drug B. The NP should suspect that in this case drug A is a cytochrome P450 (CYP450) enzyme: a. inhibitor. b. substrate. c. inducer. d. metabolizer. ANS: A If drug A is a CYP450 enzyme inhibitor, it decreases the capacity of the enzyme tometabolize drug B, causing more of drug B to be available. A substrate is a drug acted on by the enzyme. If drug B is an enzyme inducer, it would cause increased metabolism of drug A. DIF: Cognitive Level: Applying (Application) REF: 26 - 27 9. The primary care NP should understand that a drug is at a therapeutic level when it is: a. at peak plasma level. b. past 4 or 5 half-lives. c. at its steady plasma state. d. between minimal effective concentration and toxic levels. ANS: D The therapeutic range of a drug is the area between the minimal effective concentration and the toxic concentration. Peak plasma level is the highest level the drug reaches and may be well into the toxic range. Steady state occurs when there is a stable concentration of the drug and generally occurs after 4 or 5 half-lives. DIF: Cognitive Level: Applying (Application) REF: 31 10. A primary care NP is preparing to prescribe a drug and notes that the drug has nonlinear kinetics. The NP should: a. monitor frequently for desired and adverse effects. b. administer a much higher initial dose as a loading dose. c. monitor creatinine clearance at baseline and periodically. d. administer the drug via a route that avoids the first-pass effect. ANS: A Drugs with nonlinear kinetics are not eliminated based on dose or concentration of the drug, and these drugs have a narrow therapeutic window and must be monitored closely for desired effects and toxicity. DIF: Cognitive Level: Applying (Application) REF: 32 11. A primary care NP is prescribing a drug for a patient who does not take any other medications. The NP should realize that: a. CYP450 enzyme reactions will not interfere with this drug’s metabolism. b. substrates such as alcohol cannot interfere with the drug when the patient is abstaining. c. food-drug interactions are limited to thosewhere food enhances or inhibits drug absorption. d. a thorough history of diet, alcohol use, smoking, and over-the-counter and herbal products is required. ANS: D Drugs are not the only substances that interfere with drug kinetics and dynamics. The primary care NP should conduct a thorough history of food and alcohol intake, smoking, and over-the-counter and herbal supplements to identify things that might interfere with a drug. All of these may interfere with CYP enzymes. Alcohol intake can influence this even when the patient is abstaining because of long-term effects on the liver. DIF: Cognitive Level: Understanding (Comprehension) REF: 38-39 Chapter 04: Special Populations: Geriatrics Test Bank MULTIPLE CHOICE 1. A nurse practitioner (NP) is considering a possible drug regimen for an 80-year-old patient who reports being forgetful. To promote adherence to the regimen, the NP should: a. select drugs that can be given once or twice daily. b. provide detailed written instructions for each medication. c. order medications that can be given on an empty stomach. d. instruct the patient to take a lower dose if side effects occur. ANS: A To promote adherence in elderly patients, selecting the smallest number of medications with the simplest dose regimens is recommended, with once-daily dosing preferred. Instructions should be simplified. Drug dosing should be timed with mealtimes to help patients remember to take them. Lower dosing may be necessary with some drugs, but patients should not do this without consulting their provider. DIF: Cognitive Level: Applying (Application) REF: 57 - 58 2. A 75-year-old patient who lives alone will begin taking a narcotic analgesic for pain. To help ensure patient safety, the NP prescribing this medication should: a. assess this patient’s usual sleeping patterns. b. ask the patient about problems with constipation.c. obtain a baseline creatinine clearance test before the first dose. d. perform a thorough evaluation of cognitive and motor abilities. ANS: D The body system most significantly affected by increased receptor sensitivity in elderly patients is the central nervous system, making this population sensitive to numerous drugs. It is important to evaluate motor and cognitive function before beginning drugs that affect the central nervous system to minimize the risk of falls. Assessment of sleeping patterns is important, but not in relation to patient safety. It is not necessary to evaluate stool patterns or renal function. DIF: Cognitive Level: Applying (Application) REF: 50| 55 3. A thin 90-year-old patient who will begin taking warfarin has experienced a recent weight loss of 15 pounds. The NP caring for this patient should: a. obtain a baseline liver function test (LFT) before starting the drug. b. write the initial prescription at the lowest possible dose. c. encourage the patient to consume a diet high in fat and protein. d. counsel the patient to take the drug with food to enhance absorption. ANS: B A common age change that affects the distribution of drugs in older adults is a decrease in serum albumin. Significant changes that may affect drug therapy may be seen in malnourished elderly patients. Warfarin has a high binding affinity with albumin. Significant decreases in albumin may result in a greater free concentration of highly protein-bound drugs. It is important to order the lowest possible dose and titrate upward as needed. A baseline LFT is not indicated. A diet high in fat and protein is not indicated. DIF: Cognitive Level: Applying (Application) REF: 50 - 51 4. An 86-year-old patient is seen in clinic for a scheduled follow-up after starting a new oral medication 1 month prior. The patient reports no change in symptoms, and a laboratory test reveals a subtherapeutic serum drug level. The NP caring for this patient should: a. consider ordering more frequent dosing of the drug. b. titrate the patient’s dose upward and recheck in 1 month. c. ask the patient about any increased frequency of bowel movements. d. determine the number of pills left in the patient’s prescription bottle.ANS: D Because of cost concerns, poor understanding of a drug’s actions, or confusion about how to take a medication, many elderly patients do not comply with drug regimens and may not take drugs as prescribed. Before increasing the frequency or amount of a drug, it is important to assess first whether or not the patient has been taking the drug as ordered. Counting the number of pills in the bottle will help the provider assess whether the patient is taking the drug as ordered. Changes in gastric motility do not generally have major effects on the effectiveness or serum drug levels of medications. DIF: Cognitive Level: Applying (Application) REF: 57 - 58 5. An NP learns that a 90-year-old patient is chronically constipated and has frequent problems with acid reflux. The NP notes a weight loss of 20 pounds in this patient in the previous 6 months. Which of the following drugs that this patient is taking is cause for concern? a. Quinidine b. Naproxen c. Calcium citrate d. Calcium channel blocker ANS: B Naproxen has a high binding affinity for protein, and these drugs can become toxic in patients who may have low serum albumin because of the amount of free drug in serum. Constipation and acid reflux may cause problems with absorption for some drugs, but not the drugs listed. DIF: Cognitive Level: Analyzing (Analysis) REF: 50 - 52 6. An NP is caring for a 70-year-old patient who reports having seasonal allergies with severe rhinorrhea. Using the Beers criteria, which of the following medications should the NP recommend for this patient? a. Loratadine (Claritin) b. Hydroxyzine (Vistaril) c. Diphenhydramine (Benadryl) d. Chlorpheniramine maleate (Chlorphen 12) ANS: A Loratadine is the only nonsedating antihistamine on this list. Older patients are especially susceptible to sedation side effects and should not use these medications if possible. DIF: Cognitive Level: Applying (Application) REF: 57 7. An NP orders an inhaled corticosteroid 2 puffs twice daily and an albuterol metered-dose inhaler 2 puffs every 4 hours as needed for cough or wheezing for a 65-year-old patient with recent onset of reactive airways disease who reports symptoms occurring every 1 or 2 weeks. At a follow-up appointment several months later, the patient reports no change in frequency of symptoms. The NP’s initial action should be to:a. order spirometry to evaluate pulmonary function. b. prescribe a systemic corticosteroid to help with symptoms. c. ask the patient to describe how the medications are taken each day. d. give the patient detailed information about the use of metered-dose inhalers. ANS: C It is essential to explore with the older patient what he or she is actually doing with regard to daily medication use and compare this against the ―prescribed‖ medication regimen before ordering further tests, prescribing any increase in medications, or providing further education. DIF: Cognitive Level: Applying (Application) REF: 57 – 58 Chapter 05: Special Populations: Pediatrics Test Bank MULTIPLE CHOICE 1. A nurse practitioner (NP) is preparing to prescribe a medication for a 5-year-old child. To determine the correct dose for this child, the NP should: a. calculate the dose at one third of the recommended adult dose. b. estimate the child’s body surface area (BSA) to calculate the medication dose. c. divide the recommended adult dose by the child’s weight in kilograms (kg). d. follow the drug manufacturer’s recommendations for medication dosing. ANS: D The package insert provided by the manufacturer is the best source for pediatric dose recommendations. Approximated reduction in the adult dose is not a safe or effective way of calculating pediatric doses of medications, so using a third of the adult dose may not be safe. Errors inherent in determining BSA make this method less reliable than dose based on accurate weights. Dividing the adult dose by the child’s weight is incorrect. DIF: Cognitive Level: Understanding (Comprehension) REF: 64 - 65 2. An NP is prescribing a drug that is known to be safe in children but is unable to find recommendations about drug dosing. The recommended adult dose is 100 mg per dose. The child weighs 14 kg. Using Clark’s rule, the NP should order _____ mg per dose. a. 20 b. 10c. 14 d. 9.3 ANS: A Clark’s rule suggests dividing the weight of the child in kg by the weight of an adult in kg and multiplying the result by the adult dose to get an approximation of the child’s dose. The average adult weighs 150 lb, or 70 kg. The equation is: 14 kg/70 kg = 0.2. 0.2  100 = 20 mg. DIF: Cognitive Level: Understanding (Comprehension) REF: 65 3. A child who weighs 22 lb, 2 oz needs a medication. The NP learns that the recommended dosing for this drug is 25 to 30 mg per kg per day in three divided doses. The NP should order: a. 100 mg daily. b. 100 mg tid. c. 300 mg daily. d. 300 mg tid. ANS: B The NP should first convert the child’s weight to kg, which is about 10 kg. The dose is then calculated to be 250 to 300 mg per day in three divided doses, which is 83 to 100 mg per dose given tid. DIF: Cognitive Level: Applying (Application) REF: 65 4. The mother of a 3-year-old child who weighs 15 kg tells the NP that she has liquid acetaminophen at home but does not know what dose to give her child. The NP should tell the mother: a. to give 1 teaspoon every 4 to 6 hours as needed. b. to throw away the old medication and get a new bottle. c. that she may give 5 to 7.5 mL per dose every 4 to 6 hours. d. to find out whether she has a preparation made for infants or children. ANS: D Acetaminophen drops for infants are three times as concentrated as the oral liquid for children. The drops have been pulled from the market, but many parents may still have old preparations on hand. The NP should first determine which preparation this mother has before giving dosage recommendations. If the mother has the oral liquid for children, answers A and C would both be acceptable because the concentration is 160 mg per 5 mL. The mother should not be counseled to throw away the medication until the NP has more information. DIF: Cognitive Level: Applying (Application) REF: 655. The parent of a toddler asks the NP about using a topical antihistamine to treat the child’s atopic dermatitis symptoms. The NP should tell the parent that: a. topical medications have fewer side effects in children. b. medications given by this route are not absorbed well in young children. c. topical application of an antihistamine may result in drug toxicity in children. d. it is important to apply topical medications liberally over a large surface area. ANS: C Children have the potential for increased absorption through the skin because their skin is thinner and more sensitive, increasing their risk for drug toxicity. Topical medications have enhanced side effects in children. Topical medications are readily absorbed by children. Applying topical medications liberally over a large surface area would increase the risk of toxicity. DIF: Cognitive Level: Understanding (Comprehension) REF: 67 - 68 6. An NP is prescribing a medication for a 6-month-old infant. The medication comes in the following formulations. Which one should the NP select to improve absorption and distribution of the medication? a. Oral elixir b. Rectal suppository c. Lipid soluble compound d. Sustained-release capsule ANS: A An elixir is a solution in which the drug molecules are dissolved and evenly distributed. Most oral drugs in soluble solutions are readily absorbed from the gastrointestinal tract, and the fact that the drug is evenly distributed helps to ensure that each dose will have equal amounts of the drug. Rectal suppositories generally should be avoided for drug administration, primarily because children may not retain the dosage form long enough to receive the entire dose. Drugs that are lipid soluble may not distribute well in infants. Drugs may pass quickly through the gastrointestinal tract in infants, making sustainedrelease preparations less well absorbed. DIF: Cognitive Level: Understanding (Comprehension) REF: 60| 61| 66 7. An NP prescribes an oral elixir medication for a child who is to take 1 tsp PO bid. When counseling the child’s parents about administering this drug, the NP should tell them to: a. shake the medication well before giving each dose. b. mix the medication with cereal orapplesauce to improve its taste. c. administer the medication on an empty stomach to enhance absorption. d. use a syringe purchased at the pharmacy to measure the medication accurately. ANS: D Because the measured volume of ―teaspoons‖ ranges from 2.5 to 7.8 mL, parents should obtain a calibrated medicine spoon or syringe from the pharmacy for dosing small children. Elixirs are solutions in which the drug molecules are dissolved and evenly distributed, so there is no need to shake the drug before each dose. Mixing a drug with food can be problematic if the child does not eat all of the food. An elixir does not need to be administered on an empty stomach. DIF: Cognitive Level: Understanding (Comprehension) REF: 66 - 67| 69 8. A 4-month-old infant has a viral illness with high fever and cough. The infant’s parent asks the NP about what to give the infant to help with symptoms. The NP should prescribe which of the following? a. Aspirin to treat the fever b. Acetaminophen as needed c. Dextromethorphan for coughing d. An antibiotic to prevent increased infection ANS: B Infants should not be given aspirin, which carries a risk of Reye’s syndrome, or dextromethorphan, which has an increased risk of respiratory depression in infants. An antibiotic is not indicated unless there is a known bacterial infection. Acetaminophen is safe for infants. DIF: Cognitive Level: Applying (Application) REF: 64 9. A parent brings a 5-year-old child to a clinic for a hospital follow-up appointment. The child is taking a medication at a dose equal to an adult dose. The parent reports that the medication is not producing the desired effects. The NP should: a. order renal function tests. b. prescribe another medication to treat this child’s symptoms. c. discontinue the drug and observe the child for toxic side effects. d. obtain a serum drug level and consider increasing the drug dose. ANS: D By a child’s first birthday, the liver’s metabolic capabilities are not only mature but also more vigorous than the adult liver, meaning that certain drugs may need to be given inhigher doses or more often. It is prudent to obtain a serum drug level and then consider increasing the dose to achieve the desired effect. Renal function tests are not indicated. Unless the child is experiencing toxic effects, the drug does not need to be discontinued. DIF: Cognitive Level: Applying (Application) REF: 62| 66 - 67 10. An NP is prescribing an antibiotic for a child who will need to take a total of 750 mg per day. Which dosing regimen should the NP prescribe to promote compliance? a. 250 mg/5 mL—375 mg PO bid b. 250 mg/5 mL—250 mg PO tid c. 500 mg/5 mL—375 mg PO bid d. 500 mg/5 mL—250 mg PO tid ANS: C To improve compliance with a drug regimen, convenient dosage forms and dosing schedules should be chosen when possible. A 500 mg/5 mL preparation means that a smaller volume can be given to achieve the desired dose. A bid dosing schedule is more likely to be followed than one that is tid. DIF: Cognitive Level: Applying (Application) REF: 69 11. An NP sees a preschooler in clinic for the first time. When obtaining a medication history, the NP notes that the child is taking a medication for which safety and effectiveness in children has not been established in drug information literature. The NP should: a. discontinue the medication. b. order serum drug levels to evaluate toxicity. c. report the prescribing provider to the Food and Drug Administration (FDA). d. ask the parent about the drug’s use and side effects. ANS: D Many of the drugs and biologic products most widely used in pediatric patients carry disclaimers stating that safety and effectiveness in pediatric patients have not been established. The NP should find out why the drug was prescribed and whether there are any significant side effects. The medication should not be discontinued unless there are known toxic effects. Serum drug levels may be warranted if side effects are reported. The NP would not report the prescribing provider to the FDA unless there are clear, evidencebased contraindications to prescribing a drug to children. DIF: Cognitive Level: Applying (Application) REF: 67 – 69 Chapter 06: Special Populations: Pregnant and Nursing Women Test BankMULTIPLE CHOICE 1. A woman is in the 36th week of pregnancy. The nurse practitioner (NP) providing prenatal care learns that the woman has a history of two previous urinary tract infections during this pregnancy. A dipstick urinalysis in the office today is negative for leukocyte esterase and nitrites. The NP should: a. prescribe a low-dose sulfonamide antibiotic for urinary tract infection prophylaxis. b. order nitrofurantoin daily to minimize the patient’s risk of urinary tract infection late in her pregnancy. c. encourage the patient to increase daily water intake and to wear only cotton underwear. d. order a voiding cystourethrogram to rule out structural anomalies that may cause urinary tract infection. ANS: C For women at risk for recurrent urinary tract infection while pregnant, prevention and treatment begin with nonpharmacologic therapy: forcing fluids and wearing cotton underpants. Sulfonamide antibiotics and nitrofurantoin are used for documented urinary tract infection during pregnancy, but not after the 36th week of gestation. A voiding cystourethrogram is not indicated and would expose the fetus to radiation. DIF: Cognitive Level: Applying (Application) REF: 77 - 78 2. A woman tells a primary care NP that she is considering getting pregnant. During a health history, the NP learns that the patient has seasonal allergies, asthma, and epilepsy, all of which are well controlled with a second-generation antihistamine daily, an inhaled steroid daily with albuterol as needed, and an antiepileptic medication daily. The NP should counsel this patient to: a. take her asthma medications only when she is having an acute exacerbation. b. avoid using antihistamine medications during her first trimester of pregnancy. c. discontinue her seizure medications at least 6 months before becoming pregnant. d. use only oral corticosteroids and not inhaled steroids while pregnant for improved asthma control. ANS: B Optimal treatment of asthma during pregnancy includes treatment of comorbid allergic rhinitis, which can trigger symptoms. Antihistamines are recommended after the first trimester, if possible. Asthma medications should be continued during pregnancy becausepoorly controlled asthma can be detrimental to the fetus; she should continue using her daily inhaled corticosteroid. Although discontinuing seizure medications is optimal, this must be done in conjunction with this woman’s neurologist because management of epilepsy during pregnancy is beyond the scope of the primary care provider. Oral corticosteroids have greater systemic side effects and greater effects on the fetus and should be used only as necessary. DIF: Cognitive Level: Applying (Application) REF: 78 - 79 3. A woman has just learned she is pregnant and is in her 10th gestational week. The woman reports that she takes valproic sodium (Depakote) for a seizure disorder and has been seizure-free for several years. The NP should: a. prescribe folic acid supplements. b. change her antiepileptic drug to lamotrigine (Lamictal). c. order prophylactic vitamin K to be given in the second trimester. d. recommend that she discontinue taking the valproic sodium by 12 weeks. ANS: A Maternal folic acid deficiency is induced by anticonvulsants, especially valproic acid, so folic acid supplements must be given. Although antiepileptic drugs can have consequences for the developing fetus, once a woman is pregnant, the benefit-risk ratio favors continued use of the woman’s current antiepileptic medication, so she should not discontinue the medication or change to lamotrigine. Vitamin K is recommended beginning at 36 weeks of gestation and for the newborn at birth to counter the possibility of hemorrhagic disease of the newborn. DIF: Cognitive Level: Applying (Application) REF: 79 4. A woman who is pregnant develops gestational diabetes. The NP’s initial action is to: a. prescribe an oral antidiabetic agent. b. give her information about diet and exercise. c. begin treating her with daily insulin injections. d. reassure her that her glucose levels will return to normal after pregnancy. ANS: B Patients with gestational diabetes should be treated with diet and exercise, with insulin added as needed for poor control. There is insufficient evidence to support the use of oral antidiabetic agents during pregnancy, and some of these are pregnancy category D. Insulin injections may be used but are not the initial intervention. Although glucose levels will return to prepregnancy values in the postpartum period, the NP must initiate therapy.DIF: Cognitive Level: Applying (Application) REF: 79 - 80 5. A woman who takes an angiotensin converting enzyme inhibitor for hypertension tells her primary care NP that she is trying to get pregnant. The NP should: a. consider replacing her angiotensin converting enzyme inhibitor with methyldopa. b. lower her angiotensin converting enzyme inhibitor dose during the first trimester. c. counsel her to increase her antihypertensive medications during pregnancy. d. add an angiotensin receptor blocker (ARB) during the first trimester of her pregnancy. ANS: A Angiotensin converting enzyme inhibitors, ARBs, and statins are contraindicated during the first trimester of pregnancy and should be discontinued before conception and replaced by safer alternatives, such as methyldopa. The use of antihypertensives during pregnancy remains controversial; increasing the dose is not indicated. DIF: Cognitive Level: Applying (Application) REF: 80 6. A woman who is pregnant tells an NP that she has been taking sertraline for depression for several years but is worried about the effects of this drug on her fetus. The NP will consult with this patient’s psychiatrist and will recommend that she: a. stop taking the sertraline now. b. continue taking the antidepressant. c. change to a monoamine oxidase inhibitor (MAOI). d. discontinue the sertraline a week before delivery. ANS: B Many women are taking medication for depression before becoming pregnant. Abrupt discontinuation is not recommended, and many clinicians suggest that women at high risk for serious depression during pregnancy might best be served by continuing medication throughout pregnancy. MAOIs may limit fetal growth and are generally discouraged during pregnancy. It is not necessary to discontinue the sertraline just before delivery. DIF: Cognitive Level: Applying (Application) REF: 80 7. A woman is 4 weeks pregnant. The primary care NP sees her for her first prenatal visit and obtains a rubella titer, which is negative. The woman tells the NP that she drinks 2 cups of coffee and smokes 3 to 5 cigarettes each day. She denies alcohol use. The NP should:a. administer rubella vaccine. b. provide smoking cessation information. c. counsel her to avoid caffeine while pregnant. d. reassure her that her habits are not likely to cause harm. ANS: B Each cigarette smoked decreases maternal blood pressure for up to 15 minutes and decreases uteroplacental perfusion. The NP should encourage the woman to quit smoking. Rubella vaccine should be given after the baby is delivered because rubella vaccine is a live virus, with severe teratogenic effects. There is no conclusive evidence that women who are pregnant should avoid caffeine completely. Her habits, although not severe, are not harmless. DIF: Cognitive Level: Applying (Application) REF: 82 - 83 8. A woman who is breastfeeding her infant asks the primary care NP what she can use for headaches while she is nursing. The NP tells her: a. most medications enter breast milk and are not safe. b. most over-the-counter medications are safe for the breastfed infant. c. she may need to interrupt breastfeeding when taking headache medications. d. she should consider weaning her infant to formula if her headaches are frequent. ANS: B Most over-the-counter medications are considered safe for the breastfed infant and do not necessitate a disruption of breastfeeding, even though most medications cross easily into breast milk. Any interruption of breastfeeding carries a risk of premature weaning and so is indicated only when the mother must take medications known to cause serious harm to the baby. It is not recommended that she wean her infant to formula when she needs medications for her headaches. DIF: Cognitive Level: Applying (Application) REF: 85 Chapter 07: Over-the-Counter Medications Test Bank MULTIPLE CHOICE 1. A patient asks a primary care nurse practitioner (NP) about using over-the-counter medications to treat an upper respiratory infection with symptoms of cough, fever, and nasal congestion. The NP should: a. recommend a cough preparation that alsocontains acetaminophen. b. suggest using single-ingredient products to treat each symptom separately. c. recommend a product containing antitussive, antipyretic, and decongestant ingredients. d. tell the patient that over-the-counter medications are usually not effective in manufacturer-recommended doses. ANS: B A basic principle guiding over-the-counter use is to look at specific symptoms and treat each separately because some products contain therapeutic doses of one ingredient and subtherapeutic doses of others. Cough preparations containing acetaminophen often do not contain therapeutic doses, and patients often overdose when they supplement with acetaminophen. Over-the-counter medications are effective at recommended doses. Patients should follow dosing recommendations on the package. DIF: Cognitive Level: Understanding (Comprehension) REF: 89| 90 2. A patient asks a primary care NP whether over-the-counter drugs are safer than prescription drugs. The NP should explain that over-the-counter drugs are: a. generally safe when label information is understood and followed. b. safer because over-the-counter doses are lower than prescription doses of the same drug. c. less safe because they are not well regulated by the Food and Drug Administration (FDA). d. not extensively tested, so claims made by manufacturers cannot be substantiated. ANS: A Over-the-counter products have a wider margin of safety because most of these drugs have undergone rigorous testing before marketing and further refinement through years of over-the-counter use by consumers. When labels are understood and followed, overthe-counter medications are safe. Over-the-counter medications are regulated by the FDA. DIF: Cognitive Level: Understanding (Comprehension) REF: 88 3. A parent calls a clinic for advice about giving an over-the-counter cough medicine to a 6- year-old child. The parent tells the NP that the medication label does not give instructions about how much to give a child. The NP should: a. order a prescription antitussive medication for the child.b. ask the parent to identify all of the ingredients listed on the medication label. c. calculate the dose for the active ingredient in the over-the-counter preparation. d. tell the parent to approximate the dose at about one third to one half the adult dose. ANS: B Over-the-counter cough medications often contain dextromethorphan, which can be toxic to young children. It is important to identify ingredients of an over-the-counter medication before deciding if it is safe for children. A prescription antitussive is probably not warranted until the cough is evaluated to determine the cause. Until the ingredients are known, it is not safe to approximate the child’s dose based on only the active ingredient. DIF: Cognitive Level: Applying (Application) REF: 89 4. A primary care NP recommends an over-the-counter medication for a patient who has acid reflux. When teaching the patient about this drug, the NP should tell the patient: a. to take the dose recommended by the manufacturer. b. not to worry about taking this drug with any other medications. c. to avoid taking other drugs that cause sedation while taking this drug. d. that over-the-counter acid reflux medications are generally safe to take with other medications. ANS: A Because patients often increase over-the-counter drug doses themselves, it is important to reinforce the need to follow the manufacturer’s recommendations for dosing. As with any drug, interactions may occur with other medications. Antacids do not cause sedation, so patients need not be cautioned to avoid other sedating medications. DIF: Cognitive Level: Applying (Application) REF: 89 5. A primary care NP is performing a previsit health history on a new patient. The patient reports taking vitamins every day. The NP should: a. ask the patient to bring all vitamin bottles to the clinic appointment. b. recommend natural vitamin products over synthetic vitamin products. c. reassure the patient that vitamins that are high in folic acid are safe to take. d. tell the patient that some vitamins, such as vitamin C, are safe in large doses.ANS: A It is important to determine exactly what the patient is taking, so asking patients to bring vitamin bottles to the clinic is appropriate. There is no evidence that natural products are better than synthetic products. High doses of folic acid may mask signs of vitamin B12 deficiency. Vitamin C in high doses can cause dependency. DIF: Cognitive Level: Applying (Application) REF: 89 6. A patient reports taking antioxidant supplements to help prevent cancer. The primary care NP should: a. review healthy dietary practices with this patient. b. make sure that the supplements contain large doses of vitamin A. c. tell the patient that antioxidants are especially important for patients who smoke. d. tell the patient that evidence shows antioxidants to be effective in preventing cancer. ANS: A Epidemiologic evidence indicates that people who eat fruits and vegetables regularly have a decreased risk of cancer. Although retrospective studies have suggested major benefits from antioxidants, no intervention studies have determined conclusively that antioxidants prevent cancer. Large doses of vitamin A can produce a yellow hue to the skin. Antioxidants can be beneficial, but in certain populations, such as smokers, they may be harmful. DIF: Cognitive Level: Understanding (Comprehension) REF: 89 7. A patient who has an upper respiratory infection reports using over-the-counter cold preparations. The primary care NP should counsel this patient to use caution when taking additional over-the-counter medications such as: a. antipyretics. b. calcium supplements. c. acid reflux medications. d. antioxidant supplements. ANS: A Cold preparations often contain antipyretics such as acetaminophen or aspirin. Patients should be cautioned about taking additional antipyretics to avoid overdose. DIF: Cognitive Level: Applying (Application) REF: 89 Chapter 08: Complementary and Alternative Therapies Test BankMULTIPLE CHOICE 1. A patient with chronic back pain that is unrelieved by prescription analgesic medications asks a primary care nurse practitioner (NP) about acupuncture treatments. The NP should tell this patient: a. biofield therapy has been shown to be more effective than acupuncture. b. creatine has been shown to be an effective herbal choice to treat back pain. c. there is no valid research documenting the efficacy of this treatment for pain. d. most studies that show benefits of alternative therapies are based on observation. ANS: D Current literature does not allow definitive conclusions to be drawn regarding the use of complementary and alternative medicine (CAM) because much of what appears in the literature continues to be based on observational reports and small studies. Biofield therapy has not been shown to be more effective than acupuncture. Creatine is used to increase muscle mass. DIF: Cognitive Level: Applying (Application) REF: 93 2. A primary care NP is aware that many patients in the community use herbal remedies to treat various conditions. The NP understands the importance of: a. learning about the actions, uses, doses, and toxicities of these agents. b. prescribing these agents when possible to ensure safe dosing. c. counseling patients to stop using herbal products to avoid toxic side effects. d. teaching patients that these products are unregulated and unsafe to use. ANS: A It is important for primary care providers to be familiar with these products and their ingredients so that they can help patients choose the safest product for their ailments. Because there are few evidence-based recommendations for the use of these products, NPs should not prescribe them. Counseling patients to stop using the products would probably not be effective; it is more important to know about the products to assist patients in decision making. Although it is true that the products are not directly regulated by the Food and Drug Administration (FDA), there are agencies that maintain safety of the products. DIF: Cognitive Level: Applying (Application) REF: 943. A patient has been using an herbal supplement for 2 years that the primary care NP knows may have toxic side effects. The NP should: a. tell the patient to stop taking the supplement immediately. b. inform the patient of the risks of toxic side effects with this supplement. c. refer the patient to a CAM provider who can manage this patient’s therapy. d. prescribe another herbal drug that has fewer adverse effects than the one the patient is taking. ANS: B It is important for primary care NPs to inform patients of any known risks associated with herbal supplements. Asking the patient to stop an herbal remedy immediately when the patient has been using it for 2 years would probably be met with resistance. The NP should realize that referral to a CAM provider can incur legal liabilities if the CAM provider does not have proper competencies and licensure. Likewise, unless there is evidence-based documentation about the safety and efficacy of a product, the NP should not prescribe these therapies. DIF: Cognitive Level: Applying (Application) REF: 94 4. A patient asks a primary care NP why herbal supplements are not regulated by the FDA. The nurse practitioner should tell the patient these products are not regulated by the FDA because they are: a. natural, plant-based products and not man-made. b. not marketed as products that can treat or cure disease. c. regulated by the Dietary Supplement Health and Education Act. d. covered by the Hatch-Richardson Bill of 1992, which allows them to make health claims without FDA approval. ANS: B A manufacturer must comply with the rigorous standards of safety and efficacy set forth by the FDA only when the claim is made that a product can be used to treat or cure an illness or disease. The Hatch-Richardson Bill of 1992 defines herbal supplements as different from a food additive or drug. The Dietary Supplement Health and Education Act allows claims to be made as long as they are substantiated with evidence. DIF: Cognitive Level: Understanding (Comprehension) REF: 95 5. A patient is diagnosed with lupus and reports occasional use of herbal supplements. Theprimary care NP should caution this patient to avoid: a. ginseng. b. echinacea. c. ginkgo biloba. d. St. John’s wort. ANS: B Patients with lupus who take echinacea may experience an increase in symptoms, even if the patient is taking immunosuppressants. DIF: Cognitive Level: Understanding (Comprehension) REF: 98 6. A patient who takes warfarin (Coumadin) experiences excessive bleeding, even though serum drug levels are normal. The primary care NP should question this patient about the use of: a. feverfew. b. echinacea. c. green tea. d. ginkgo biloba. ANS: D Ginkgo biloba decreases blood viscosity and can enhance the effects of warfarin. Feverfew, echinacea, and green tea do not have this effect. DIF: Cognitive Level: Applying (Application) REF: 99 7. A patient develops hepatotoxicity from chronic acetaminophen use. The primary care NP may recommend: a. milk thistle. b. chondroitin. c. coenzyme Q. d. glucosamine. ANS: A Milk thistle has been shown to protect the liver after exposure to hepatotoxins such as acetaminophen, ethanol, and halothane. The other supplements listed do not have this effect. DIF: Cognitive Level: Understanding (Comprehension) REF: 100 Chapter 09: Establishing the Therapeutic Relationship Test Bank MULTIPLE CHOICE 1. To increase the likelihood of successful pharmacotherapy, when teaching a patient about using a medication, the primary care nurse practitioner (NP) should:a. encourage the patient to participate in the choice of the medication. b. provide education about the medication actions and adverse effects. c. stress the importance of taking the medication exactly as it is prescribed. d. give the patient copies of medication package inserts describing the drug use. ANS: A It is important that the patient ―owns the problem‖ and has a part in the solution. Providing education about the medication, stressing the importance of following medication instructions, and distributing package inserts may be useful, but it is essential that patients take an active role in their care. DIF: Cognitive Level: Applying (Application) REF: 104 2. A patient has recurrent symptoms and tells the primary care NP that she can’t remember to take her medication all the time. The NP should: a. give her shortened regimens of the drug to facilitate compliance. b. provide written information about her condition and the medication. c. administer the medication in the clinic to ensure that she takes the drug. d. ask her about her lifestyle, her schedule, and her understanding of her condition. ANS: D If the attitude is that the patient has a problem for the health care provider to solve, then the provider owns the problem and often hastens to solve it. When patients own their problems, they are more likely to engage in their care and treatment. Giving shortened regimens, providing written information, and administrating medication in the clinic are examples of the provider solving the problem for the patient. DIF: Cognitive Level: Applying (Application) REF: 104 3. A primary care NP prepares to teach a patient about the management of a chronic condition. The patient says, ―I don’t want to know all of that. Just tell me what to take and when.‖ The NP should initially: a. give the patient basic written instructions about medications, follow up visits, and symptoms. b. ask the patient to describe the disease process and the medications to evaluate understanding. c. explain to the patient that without mutualcooperation, the treatment regimen will not be effective. d. ask the patient to explore feelings and fears about having a chronic disease and taking medications. ANS: A The patient has stated expectations about care and treatment for the condition. The NP should begin by respecting that and providing the amount of information the patient wants. As the therapeutic relationship grows, the NP may elicit more active participation and understanding. DIF: Cognitive Level: Applying (Application) REF: 104 4. A parent brings a child who has moderate-persistent asthma to the clinic and tells the primary care NP that none of the child’s medications are working. The parent says, ―Everybody tells me something different. I don’t know what to do.‖ The NP suspects that the parent is not administering the medications appropriately. The NP should initially: a. perform a careful history of the child’s symptoms and the medications that are given. b. provide a written asthma action plan and encourage the parent to call when symptoms are worse. c. review what other providers have prescribed in the past and explain these interventions to the parent. d. explain the different purposes of maintenance and rescue medications and give the parent a schedule for medication administration. ANS: A Clinical providers must refine listening and questioning skills and focus on the patient and the environment. It is important to begin with a thorough history and to elicit the patient’s understanding of a disease or a medication to identify potential problems. Providing written action plans, reviewing past providers’ prescriptions, and explaining medications are useful only after the NP determines what the problem is. DIF: Cognitive Level: Applying (Application) REF: 104 5. A primary care NP sees a 5-year-old child who is morbidly obese. The child has an elevated hemoglobin A1c and increased lipid levels. Both of the child’s parents are overweight but not obese, and they tell the NP that they see nothing wrong with their child. They both state that it is difficult to refuse their child’s requests for soda or ice cream. The NP should: a. suggest that they give the child diet sodaand low-fat frozen yogurt. b. understand and respect the parents’ beliefs about their child’s self-image. c. initiate a dialogue with the parents about the implications of the child’s laboratory values. d. suggest family counseling to explore ways to improve parenting skills and limits. ANS: C In this case, the child is at risk if the parents do not intervene. The NP should help the parents to see the potential adverse effects so that they can understand the need for treatment. The other answers are examples of the NP creating solutions. Unless the parents see the problem, they are not likely to engage in the treatment regimen. DIF: Cognitive Level: Applying (Application) REF: 108 6. A patient bursts into tears when the primary care NP diagnoses diabetes. The NP should: a. ask the patient about past experiences with anyone who has this diagnosis. b. reassure the patient that the medications and blood tests will become routine. c. call in a social worker to assist the patient to obtain equipment and supplies. d. refer the patient to a diabetes educator to provide teaching about the disease. ANS: A To help patients participate in their disease management, the NP must have an understanding of the patient’s concerns and fears. The first step when the patient is obviously upset is to determine what the patient knows and fears about the disease. DIF: Cognitive Level: Applying (Application) REF: 107 7. A primary care NP writes a prescription for an off-label use for a drug. To help ensure compliance, the NP should: a. include information about the off-label use on the E-script. b. provide the patient with written instructions about how to use the medication. c. tell the patient to let the pharmacist know that the drug is being used for an off-label use. d. follow up by phone in several days to see if the patient is using the drug appropriately.ANS: A Effective communication extends beyond just the patient-provider relationship. It is important to include anyone involved in the patient’s care. The best way in this case is to include the information on the E-script so that there is a record of the off-label use and to help clarify or reinforce the provider’s instructions. DIF: Cognitive Level: Applying (Application) REF: 111 Chapter 11: Evidence-Based Decision Making and Treatment Guidelines Test Bank MULTIPLE CHOICE 1. The primary care nurse practitioner (NP) is using critical thinking skills when: a. using standardized protocols to guide patient care. b. adhering to scientific principles to solve a patient problem. c. following the practices of seasoned mentors when giving care. d. analyzing current research and synthesizing new approaches to patient care. ANS: D Practitioners use critical thinking skills by reviewing and analyzing current knowledge and synthesizing approaches to apply to unique patient situations. Using standardized protocols, adhering to scientific principles, and following practices of seasoned mentors may be useful, but these do not encompass the concept of critical thinking, which requires the practitioner to use what is known in new situations. DIF: Cognitive Level: Understanding (Comprehension) REF: 123 - 124 2. The primary care NP has referred a child who has significant gastrointestinal reflux disease to a specialist for consideration for a fundoplication and gastrostomy tube placement. The child’s weight is 80% of what is recommended for age, and a recent swallow study revealed significant risk for aspiration. The child’s parents do not want the procedure. The NP should: a. compromise with the parents and order a nasogastric tube for feedings. b. initiate a discussion with the parents about the potential outcomes of each possible action. c. refer the family to a case manager who can help guide the parents to the best decision.d. understand that the child’s parents have a right to make choices that override those of the medical team. ANS: B In general, the goal of a health care decision maker is to choose an action that is most likely to deliver the outcomes the patient wants. Initiating a discussion about outcomes helps parents decide based on end results. A nasogastric tube is not the best choice for the child, and compromising without first exploring options is incorrect. As part of the therapeutic relationship, the NP should be involved with patients’ decisions. Although patients and families have the right to make decisions, the NP has an obligation to ensure that the decisions are informed decisions. DIF: Cognitive Level: Applying (Application) REF: 126 3. The primary care NP prescribes an inhaled corticosteroid for a patient who has asthma. The third-party payer for this patient denies coverage for the brand that comes in the specific strength the NP prescribes. The NP should: a. provide pharmaceutical company samples of the medication for the patient. b. inform the patient that the drug must be paid for out of pocket because it is not covered. c. order the closest formulary-approved approximation of the drug and monitor effectiveness. d. write a letter of medical necessity to the insurer to explain the need for this particular medication. ANS: C The second step of medical decision making takes into account benefits versus costs along with an understanding that it is impossible to do everything because of limited resources. The NP should prescribe what is covered and evaluate its effectiveness; if it does not work, the third-party payer may be approached about the need for the other medication. Providing samples is not always possible, and this practice is being discouraged, so it is not a viable solution. Asking patients to pay out of pocket ultimately may be necessary but carries risks that the patient will not obtain the medication. Writing a letter of medical necessity may be indicated if the available drugs are not effective but is not the initial step. DIF: Cognitive Level: Applying (Application) REF: 125 4. A patient takes a cardiac medication that has a very narrow therapeutic range. The primary care NP learns that the particular brand the patient is taking is no longer covered by the patient’s medical plan. The NP knows that the bioavailability of the drug varies from brand to brand. The NP should:a. contact the insurance provider to explain why this particular formulation is necessary. b. change the patient’s medication to a different drug class that doesn’t have these bioavailability variations. c. accept the situation and monitor the patient closely for drug effects with each prescription refill. d. ask the pharmaceutical company that makes the drug for samples so that the patient does not incur out-of-pocket expense. ANS: A In this case, the NP should advocate for the desired drug because changing the drug can have life-threatening consequences. If this fails, other options may have to be explored. DIF: Cognitive Level: Applying (Application) REF: 131 5. A patient comes to the clinic reporting dizziness and fatigue associated with nausea and vomiting. The primary care NP suspects anemia and orders a complete blood count. The patient’s hemoglobin is elevated. The NP correctly concludes that the patient is not anemic. The NP has made an error in: a. context formulation. b. inappropriate knowledge base. c. cost-versus-benefit analysis. d. hypothesis triggering and information processing. ANS: D Faulty hypothesis triggering occurs when the clinician fails to consider appropriate initial hypotheses. The patient had nausea and vomiting, which can cause dehydration, leading to orthostatic hypotension and dizziness. The NP made an assumption that the dizziness was caused by anemia and ordered a complete blood count. Faulty information gathering occurs when clinicians fail to order appropriate tests. An error in context formulation occurs when clinicians and patients have different goals. Errors in know