NR 508 MIDTERM EXAM – QUESTION AND ANSWERS SET 1 (VERIFIED SOLUTION)

NR 508 MIDTERM EXAM – QUESTION AND ANSWERS SET 1 A patient who has primary hyperlipidemia and who takes atorvastatin (Lipitor) continues to have LDL cholesterol of 140 mg/dL after 3 months of therapy. The primary ca ...

NR 508 MIDTERM EXAM – QUESTION AND ANSWERS SET 1 A patient who has primary hyperlipidemia and who takes atorvastatin (Lipitor) continues to have LDL cholesterol of 140 mg/dL after 3 months of therapy. The primary care NP increases the dose from 10 mg daily to 20 mg daily. The patient reports headache and dizziness a few weeks after the dose increase. The NP should: change the atorvastatin dose to 15 mg twice daily. change the patient’s medication to cholestyramine (Questran). Correct! add ezetimibe (Zetia) and lower the atorvastatin to 10 mg daily. recommend supplements of omega-3 along with the atorvastatin. When used in combination with a low-dose statin, ezetimibe has been noted to produce an additional 18% reduction in LDL. Because this patient continues to have elevated LDL along with side effects of the statin, the NP should resume the lower dose of the statin and add ezetimibe. Atorvastatin is given once daily. Cholestyramine and omega-3 supplements are not indicated. Question 2 2 / 2 pts A patient who has hyperlipidemia has been taking atorvastatin (Lipitor) 60 mg daily for 6 months. The patient’s initial lipid profile showed LDL of 180 mg/dL, HDL of 45 mg/dL, and triglycerides of 160 mg/dL. The primary care NP orders a lipid profile today that shows LDL of 105 mg/dL, HDL of 50 mg/dL, and triglycerides of 120 mg/dL. The patient reports muscle pain and weakness. The NP should: order liver function tests (LFTs). Correct! order a creatine kinase-MM (CK-MM) level. change atorvastatin to twice-daily dosing. add gemfibrozil (Lopid) to the patient’s medication regimen. Hepatotoxicity and muscle toxicity are the two primary adverse effects of greatest concern with statin use. Patients who report muscle discomfort or weakness should have a CK-MM level drawn. LFTs are indicated with signs of hepatotoxicity. It is not correct to change the dosing schedule. Gemfibrozil is not indicated. Question 3 2 / 2 pts A patient comes to the clinic with a 4-day history of 10 to 12 liquid stools each day. The patient reports seeing blood and mucus in the stools. The patient has had nausea but no vomiting. The primary care NP notes a temperature of 37.9° C, a heart rate of 96 beats per minute, and a blood pressure of 90/60 mm Hg. A physical examination reveals dry oral mucous membranes and capillary refill of 4 seconds. The NP’s priority should be to: obtain stool cultures. Correct! begin rehydration therapy. consider prescribing metronidazole. administer opioid antidiarrheal medications. Acute diarrhea is usually mild and self-limited. Nonpharmacologic measures, especially bowel rest and adequate hydration, are helpful and should be a priority. Stool cultures may be ordered after hydration therapy is begun. Metronidazole is indicated if C. difficile is present. Opioid antidiarrheals may prolong symptoms. Question 4 2 / 2 pts A perimenopausal woman tells the primary care NP that she is having hot flashes and increasingly severe mood swings. The woman has had a hysterectomy. The NP should prescribe: Correct! estrogen-only HT. low-dose oral contraceptive therapy. selective serotonin reuptake inhibitor therapy until menopause begins. estrogen-progesterone HT. Estrogen-only regimens are used in women without a uterus and may be initiated to treat perimenopause symptoms if needed. Low-dose oral contraceptive pills are used to treat irregular menstrual bleeding in perimenopausal women. Question 5 2 / 2 pts A primary care NP prescribes a nitroglycerin transdermal patch, 0.4 mg/hour release, for a patient with chronic stable angina. The NP should teach the patient to: change the patch four times daily. use the patch as needed for angina pain. use two patches daily and change them every 12 hours. Correct! apply one patch daily in the morning and remove in 12 hours. To avoid tolerance, the patient should remove the patch after 12 hours. The transdermal patch is not changed four times daily or used on a prn basis. The patch is applied once daily. Question 6 2 / 2 pts 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: order a prescription antitussive medication for the child. Correct! ask the parent to identify all of the ingredients listed on the medication label. calculate the dose for the active ingredient in the over-the-counter preparation. tell the parent to approximate the dose at about one third to one half the adult dose. 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. Question 7 2 / 2 pts A patient who has disabling intermittent claudication is not a candidate for surgery. Which of the following medications should the primary care NP prescribe to treat this patient? Correct! Cilostazol (Pletal) Warfarin (Coumadin) Pentoxifylline (Trental) Low-dose, short-term aspirin Patients with disabling intermittent claudication who are not candidates for surgery or catheter-based intervention should be treated with cilostazol rather than pentoxifylline. Warfarin is not indicated. Patients with chronic limb ischemia are treated with lifelong aspirin therapy. Question 8 2 / 2 pts The primary care NP prescribes an extended-cycle monophasic pill regimen for a young woman who reports having multiple partners. Which statement by the patient indicates she understands the regimen? “I have to take a pill only every 3 months.” Correct! “I should expect to have only four periods each year.” “I will need to use condoms for only 7 more days.” “This type of pill has fewer side effects than other types.” The extended-cycle pills have fewer pill-free intervals, so women have only four periods a year. Patients take pills every day. Because this patient has multiple partners, she should continue to use condoms. This type of pill has the same side effects as other types. Question 9 2 / 2 pts 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: provide pharmaceutical company samples of the medication for the patient. inform the patient that the drug must be paid for out of pocket because it is not covered. Correct! order the closest formulary-approved approximation of the drug and monitor effectiveness. write a letter of medical necessity to the insurer to explain the need for this particular medication. 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. Question 10 2 / 2 pts A primary care NP prescribes levothyroxine for a patient to treat thyroid deficiency. When teaching this patient about the medication, the NP should: counsel the patient to take the medication with food. Correct! tell the patient that changing brands of the medication should be avoided. instruct the patient to stop taking the medication if signs of thyrotoxicosis occur. tell the patient that the drug may be stopped when thyroid function tests stabilize. Patients should be told not to change brands of the medication; there is potential variability in the bioequivalence between manufacturers. The medication should be taken at approximately the same time each day before breakfast or on an empty stomach. Patients should be instructed to contact the provider if signs of thyrotoxicosis are present. Thyroid replacement medications are usually given for life. Question 11 2 / 2 pts A patient who has had four to five liquid stools per day for 4 days is seen by the primary care NP. The patient asks about medications to stop the diarrhea. The NP tells the patient that antidiarrheal medications are: Correct! not curative and may prolong the illness. useful in cases of acute infection with elevated temperature. most beneficial when symptoms persist longer than 2 weeks. useful when other symptoms, such as hematochezia, develop. Treatment of patients with acute diarrhea with antidiarrheals can prolong infection and should be avoided if possible. Antidiarrheals are best used in patients with mild to moderate diarrhea and are used for comfort and not cure. They should not be used for patients with bloody diarrhea or high fever because they can worsen the disease. Prolonged diarrhea can indicate a more serious cause, and antidiarrheals should not be used in those cases. Question 12 2 / 2 pts The primary care NP sees a patient covered by Medicaid, writes a prescription for a medication, and is informed by the pharmacist that the medication is “off-formulary.” The NP should: inform the patient that an out-of-pocket expense will be necessary. Correct! write the prescription for a generic drug if it meets the patient’s needs. call the patient’s insurance provider to advocate for this particular drug. contact the pharmaceutical company to see if medication samples are available. Medicaid often stipulates which medications are or are not covered. Unless the particular drug is absolutely necessary, the NP should substitute with an acceptable generic drug. Insisting that the patient pay out of pocket may mean that the prescription is not filled. If the drug is necessary, the NP may advocate for its use by contacting the third-party payer. Asking for drug samples is not a long-term solution for the problem. Question 13 2 / 2 pts A patient who has type 2 diabetes mellitus takes metformin (Glucophage). The patient tells the primary care NP that he will have surgery in a few weeks. The NP should recommend: taking the metformin dose as usual the morning of surgery. Correct! using insulin during the perioperative and postoperative periods. that the patient stop taking metformin several days before surgery. adding a sulfonylurea medication until recovery from surgery is complete. Insulin should be considered for patients with diabetes during times of physical stress, such as illness or surgery. Question 14 2 / 2 pts A thin 52-year-old woman who has recently had a hysterectomy tells the primary care NP she is having frequent hot flashes and vaginal dryness. A recent bone density study shows early osteopenia. The woman’s mother had CHD. She has no family history of breast cancer. The NP should prescribe: Correct! estrogen-only HT now. estrogen-only HT in 5 years. estrogen-progesterone HT now. estrogen-progesterone HT in 5 years. HT relieves symptoms of menopause and prevents osteoporosis. When started soon after menopause, HT can reduce CHD risk. Breast cancer risk may be decreased if HT is begun 5 years after onset of menopause. This woman has a higher risk of CHD and osteoporosis, so initiating therapy now is a good option. Because she has had a hysterectomy, estrogen-only therapy is indicated. Question 15 2 / 2 pts A patient who has diabetic gastroparesis sees a gastroenterology specialist who orders metoclopramide (Reglan). Within 24 hours, the patient describes having extrapyramidal symptoms (EPS) to the primary care NP. The NP will contact the gastroenterologist and should expect to prescribe: Correct! benztropine (Cogentin). cimetidine. an SSRI antidepressant. a TCA. Cogentin is indicated to treat EPS side effects of medications such as metoclopramide. The patient should be monitored during the first 24 to 48 hours for any adverse reactions. Should EPS occur, treat with intramuscular diphenhydramine (Benadryl) 50 mg or benztropine (Cogentin) 1 to 2 mg Question 16 2 / 2 pts The primary care NP is preparing to prescribe isosorbide dinitrate sustained release (Dilatrate SR) for a patient who has chronic, stable angina. The NP should recommend initial dosing of: 60 mg four times daily at 6-hour intervals. Correct! 40 mg twice daily 30 minutes before meals. 60 mg on awakening and 40 mg 7 hours later. 80 mg three times daily at 8:00 AM, 1:00 PM, and 6:00 PM. Long-acting nitrates should be considered to treat chronic, stable angina. The main limitation is tolerance, which can be limited by providing a nitrate-free period of 6 to 10 hours each day. The medication should be taken on an empty stomach, 30 to 60 minutes before a meal. An appropriate initial dose of isosorbide dinitrate is 40 mg every 12 hours. This dose can be increased as needed. Isosorbide mononitrate is given on awakening and again 7 hours later. The medication is not given four times daily. Dosing may be increased to 80 mg tid, and the dosing schedule of 8:00 AM, 1:00 PM, and 6:00 PM. would be appropriate at that point. Question 17 2 / 2 pts A patient who has hypothyroidism has been taking levothyroxine 50 mcg daily for 2 weeks. The patient reports continued fatigue. The primary care NP should: order a T4 level today. increase the dose to 100 mcg. Correct! check the TSH level in 1 week. reassure the patient that this will improve in several weeks. Full therapeutic effectiveness may not be achieved for 3 to 6 weeks. Measuring the TSH level is indicated to evaluate drug effectiveness. The dose should not be increased without first evaluating the patient’s TSH level. Question 18 2 / 2 pts 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: compromise with the parents and order a nasogastric tube for feedings. Correct! initiate a discussion with the parents about the potential outcomes of each possible action. refer the family to a case manager who can help guide the parents to the best decision. understand that the child’s parents have a right to make choices that override those of the medical team. 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. Question 19 2 / 2 pts A female patient who is underweight tells the primary care NP that she has been using bisacodyl (Dulcolax) daily for several years. The NP should: Correct! prescribe docusate sodium (Colace) and decrease bisacodyl gradually. suggest she use polyethylene glycol (MiraLAX) on a daily basis instead. tell her that long-term use of suppositories is safer than long-term laxative use. counsel the patient to discontinue the laxative and increase fluid and fiber intake. Patients who abuse laxatives are at risk for cathartic colon and for electrolyte imbalances. These patients should be weaned from their stimulant laxative and placed on safer long-term laxatives, such as a bulk laxative or stool softener. Polyethylene glycol is a stimulant. Long-term use of suppositories causes rectal irritation. Discontinuing the laxative without a long-term laxative will lead to rebound constipation. Question 20 2 / 2 pts 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: Correct! contact the insurance provider to explain why this particular formulation is necessary. change the patient’s medication to a different drug class that doesn’t have these bioavailability variations. accept the situation and monitor the patient closely for drug effects with each prescription refill. ask the pharmaceutical company that makes the drug for samples so that the patient does not incur out-of-pocket expense. 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. Question 21 2 / 2 pts A patient is in the clinic for a follow-up examination after a myocardial infarction (MI). The patient has a history of left ventricular systolic dysfunction. The primary care NP should expect this patient to be taking: nadolol (Corgard). Correct! carvedilol (Coreg). timolol (Blocadren). propranolol (Inderal). The 2012 guides for prevention of cardiovascular disease recommend that β-blocker therapy should be used in all patients with left ventricular systolic dysfunction with heart failure or prior MI. Use should be limited to carvedilol, metoprolol succinate, or bisoprolol. Question 22 2 / 2 pts A male patient tells the primary care NP he is experiencing decreased libido, lack of energy, and poor concentration. The NP performs an examination and notes increased body fat and gynecomastia. A serum testosterone level is 225 ng/dL. The NP’s next action should be to: order LH and FSH levels. order a serum prolactin level. prescribe testosterone replacement. Correct! obtain a morning serum testosterone level. To diagnose hypogonadism, two serum testosterone levels must be drawn, with serum collected in the morning. LH, FSH, and prolactin levels may be drawn as well. Testosterone replacement should not be prescribed until the diagnosis is definitive. Question 23 2 / 2 pts An African-American patient is taking captopril (Capoten) 25 mg twice daily. When performing a physical examination, the primary care nurse practitioner (NP) learns that the patient continues to have blood pressure readings of 135/90 mm Hg. The NP should: increase the captopril dose to 50 mg twice daily. Correct! add a thiazide diuretic to this patient’s regimen. change the drug to losartan (Cozaar) 50 mg once daily. recommend a low-sodium diet in addition to the medication. Some African-American patients do not appear to respond as well as whites in terms of blood pressure reduction. The addition of a low-dose thiazide diuretic often allows for efficacy in blood pressure lowering that is comparable with that seen in white patients. Increasing the captopril dose is not indicated. Losartan is an angiotensin receptor blocker (ARB) and is not indicated in this case. Question 24 2 / 2 pts A 50-year-old woman who is postmenopausal is taking an aromatase inhibitor as part of a breast cancer treatment regimen. She calls her primary care NP to report that she has had hot flashes and increased vaginal discharge but no bleeding. The NP should: Correct! schedule her for a gynecologic examination. recommend that she use a barrier method of contraception. tell her to stop taking the medication and call her oncologist. reassure her that these are normal side effects of the medication. Any abnormal vaginal discharge should be reported immediately and should be evaluated with a gynecologic examination to rule out carcinoma. She is not showing signs of ovulation, so contraception is not necessary. She should not stop taking the medication unless the gynecologic examination is positive. These are common side effects but are not always normal. Question 25 2 / 2 pts A 40-year-old patient is in the clinic for a routine physical examination. The patient has a body mass index (BMI) of 26. The patient is active and walks a dog daily. A lipid profile reveals low-density lipoprotein (LDL) of 100 mg/dL, high-density lipoprotein (HDL) of 30 mg/dL, and triglycerides of 250 mg/dL. The primary care nurse practitioner (NP) should: Correct! order a fasting plasma glucose level. consider prescribing metformin (Glucophage). suggest dietary changes and increased exercise. obtain serum insulin and hemoglobin A1c levels. Testing for type 2 diabetes should be considered in all adults with a BMI greater than 25 who have risk factors such as HDL less than 35 mg/dL or triglycerides greater than 250 mg/dL. A fasting plasma glucose level greater than 126 mg/dL indicates diabetes. Metformin is not indicated unless testing is positive. Lifestyle changes may be part of the treatment plan. Serum insulin level is not indicated. Question 26 2 / 2 pts The primary care NP is seeing a patient for a hospital follow-up after the patient has had a first myocardial infarction. The patient has a list of the prescribed medications and tells the NP that “no one explained anything about them.” The NP’s initial response should be to: ask the patient to describe the medication regimen. ask the patient to make a list of questions about the medications. Correct! determine what the patient understands about coronary artery disease. give the patient information about drug effects and any adverse reactions. When a patient is first diagnosed with a medical problem, education must start with explaining the pathophysiology in terms the patient will understand. When patients understand what has happened to them, they can move on to consider what to do about it. The other responses are part of an education plan but are not the initial response. Question 27 2 / 2 pts A man with a BMI of 38 and a waist size of 48 inches is seen in the clinic for an annual well check-up. The primary care NP orders laboratory tests and notes a fasting plasma glucose of 110 mg/dL, triglyceride level of 220 mg/dL, and high-density lipoprotein level of 40 mg/dL. The man’s blood pressure is 160/110 mm Hg. The man has a history of cardiovascular disease and tells the NP he has tried to lose weight numerous times. The NP should consider: Correct! orlistat (Xenical). phentermine (Adipex-P). an oral antidiabetic agent. a strict low-fat, low-sodium diet. This man’s BMI and waist circumference indicate that he is obese, and he has more than three indicators of metabolic syndrome. Because of his history of cardiovascular disease, his past failed attempts to lose weight, and his elevated blood pressure, treatment is indicated. Phentermine would be a good initial choice but carries significant risks in patients with cardiovascular disease and high blood pressure. Orlistat is a safer choice for pharmacologic therapy. An oral antidiabetic agent would be used if insulin resistance were present, but his fasting plasma glucose is normal. A strict change in diet is warranted but in this case should be combined with pharmacologic treatment. Question 28 2 / 2 pts A primary care NP orders thyroid function tests. The patient’s TSH is 1.2 microunits/mL, and T4 is 1.7 ng/mL. The NP should: assess the patient for symptoms of hyperthyroidism. ask the patient about the use of medications such as lithium. Correct! tell the patient that the results most likely indicate hypothyroidism. ask an endocrinologist to evaluate for possible Hashimoto’s thyroiditis. Primary hypothyroidism is the most common form of hypothyroidism. Use of certain drugs, such as lithium, and diseases such as Hashimoto’s thyroiditis can cause hypothyroidism but are less likely. The patient does not have signs of hyperthyroidism. Question 29 2 / 2 pts A postmenopausal woman develops NSAID-induced ulcer. The primary care NP should prescribe: Correct! ranitidine (Zantac). omeprazole (Prilosec). esomeprazole (Nexium). pantoprazole (Protonix). PPIs carry a possible increased risk of fractures in postmenopausal women. The NP should begin therapy with a histamine-2 blocker, such as ranitidine. Question 30 2 / 2 pts A patient who is newly diagnosed with type 2 diabetes mellitus has not responded to changes in diet or exercise. The patient is mildly obese and has a fasting blood glucose of 130 mg/dL. The patient has normal renal function tests. The primary care NP plans to prescribe a combination product. Which of the following is indicated for this patient? Correct! Metformin/glyburide (Glucovance) Insulin and metformin (Glucophage) Saxagliptin/metformin (Kombiglyze) Metformin/pioglitazone (ACTOplus met) Obese patients with normal renal function and elevated fasting plasma glucose may be started on a combination of metformin and a second-generation sulfonylurea. Question 31 2 / 2 pts A patient comes to the clinic to discuss weight loss. The primary care NP notes a BMI of 32 and performs a health risk assessment that reveals no obesity-related risk factors. The NP should recommend: orlistat (Xenical). surgical intervention. changes in diet and exercise. Correct! changes in diet and exercise along with short-term phentermine. This patient is grade 2 overweight (obese), so a short-term course of phentermine is useful, especially as there are no cardiovascular risk factors. Orlistat is a second-line drug. Surgical intervention is indicated when other therapies fail. Changes in diet and physical activity alone do not bring immediate results, and patients often get discouraged. Question 32 2 / 2 pts 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: tell the patient to stop taking the supplement immediately. Correct! inform the patient of the risks of toxic side effects with this supplement. refer the patient to a CAM provider who can manage this patient’s therapy. prescribe another herbal drug that has fewer adverse effects than the one the patient is taking. 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. Question 33 2 / 2 pts A patient who has insulin-dependent type 2 diabetes reports having difficulty keeping blood glucose within normal limits and has had multiple episodes of both hypoglycemia and hyperglycemia. As adjunct therapy to manage this problem, the primary care NP should prescribe: Correct! pramlintide (Symlin). repaglinide (Prandin). glyburide (Micronase). metformin (Glucophage). Pramlintide is indicated in patients with type 1 diabetes and insulin-dependent type 2 diabetes and is helpful for patients with wide glycemic swings. Repaglinide requires a functioning pancreas to be effective. Glyburide and metformin are first-line oral agents and are not indicated. Question 34 2 / 2 pts A patient who takes spironolactone for heart failure has begun taking digoxin (Lanoxin) for atrial fibrillation. The primary care NP provides teaching for this patient and asks the patient to repeat back what has been learned. Which statement by the patient indicates understanding of the teaching? Correct! “I should avoid high-sodium foods.” “I should eat foods high in potassium.” “I need to take a calcium supplement every day.” “I should use a salt substitute while taking these medications.” Patients should be taught to reduce their overall sodium intake by avoiding salty foods and not adding salt while cooking. Spironolactone is a potassium-sparing diuretic and carries a risk of hyperkalemia, which can make the myocardium more sensitive to the effects of digoxin. Hypercalcemia can predispose the patient to digoxin toxicity. Salt substitutes are high in potassium. Question 35 2 / 2 pts A patient who is taking nifedipine develops mild edema of both feet. The primary care NP should contact the patient’s cardiologist to discuss: Correct! changing to amlodipine. ordering renal function tests. increasing the dose of nifedipine. evaluation of left ventricular function. Mild to moderate peripheral edema occurs in the lower extremities in about 10% of patients; this is caused by arterial dilation, not by left ventricular dysfunction. Amlodipine is less likely to have this effect. Renal function tests are not indicated. Increasing the nifedipine dose would worsen the symptoms. Question 36 2 / 2 pts A patient who has atrial fibrillation (AF) has been taking warfarin (Coumadin). The primary care nurse practitioner (NP) plans to change the patient’s medication to dabigatran (Pradaxa). To do this safely, the NP should: Correct! initiate dabigatran when the patient’s international normalized ratio (INR) is less than 2. start dabigatran 7 to 14 days after discontinuing warfarin. begin giving dabigatran 1 week before discontinuing warfarin. order frequent monitoring of the patient’s INR after dabigatran therapy begins. There are no requirements for monitoring the INR or other measures for patients taking dabigatran. When changing from warfarin, it is recommended that dabigatran be initiated when the INR is less than 2. Question 37 2 / 2 pts A patient who takes an ACE inhibitor and a thiazide diuretic for hypertension will begin taking spironolactone. The primary care NP should counsel this patient to: Correct! avoid foods that are high in potassium. use a salt substitute when seasoning foods. discuss changing the ACE inhibitor to an ARB with the cardiologist. avoid taking antacids containing magnesium while taking these drugs. Use of potassium-sparing diuretics or salt substitutes can induce hyperkalemia when taking ACE inhibitors, so this patient should be counseled to restrict potassium. Salt substitutes are high in potassium and are contraindicated. It is not necessary to change to an ARB. Antacids are not contraindicated. Question 38 2 / 2 pts A patient has been taking furosemide 80 mg once daily for 4 weeks and returns for a follow-up visit. The primary care NP notes a blood pressure of 100/60 mm Hg. The patient’s lungs are clear, and there is no peripheral edema. The patient’s serum potassium is 3.4 mEq/L. The NP should: continue furosemide at the current dose. Correct! decrease furosemide to 60 mg once daily. increase furosemide to 80 mg twice daily. change furosemide dose the 40 mg twice daily. The major toxicities related to loop diuretics result from fluid and electrolyte imbalances. This patient has a low potassium level just under the lower limit, so a reduction in dose is indicated. Question 39 2 / 2 pts The primary care NP is reviewing evidence-based recommendations about the off-label use of a particular drug. Which recommendation should influence the NP’s decision about prescribing the medication? Correct! Data from randomized, experimental studies Patient reports about effectiveness of the drug for this purpose Pharmaceutical company reports using anecdotal evidence Endorsement of this use by a leading practitioner in the field Randomized, experimental studies yield the best data about use of medications. Patient reports carry the least weight because bias can occur and other factors can influence outcomes. Pharmaceutical company reports are biased. Question 40 2 / 2 pts A patient who has a history of chronic constipation uses a bulk laxative to prevent episodes of acute constipation. The patient reports having an increased frequency of episodes. The primary care NP should recommend: Correct! adding docusate sodium (Colace). polyethylene glycol (MiraLAX) and bisacodyl (Dulcolax). lactulose (Chronulac) and polyethylene glycol (MiraLAX). adding nonpharmacologic measures such as biofeedback. Patients treated for long-term constipation should begin with a bulk laxative. If that is not effective, the addition of a second laxative may be necessary. Using two laxatives from the same category is not recommended. A stool softener, such as docusate sodium, is appropriate. Bisacodyl is not a second-line treatment. Lactulose and polyethylene glycol are from the same category. Question 41 2 / 2 pts 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: suggest that they give the child diet soda and low-fat frozen yogurt. understand and respect the parents’ beliefs about their child’s self-image. Correct! initiate a dialogue with the parents about the implications of the child’s laboratory values. suggest family counseling to explore ways to improve parenting skills and limits. 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. Question 42 2 / 2 pts A 55-year-old patient with no prior history of hypertension has a blood pressure greater than 140/90 on three separate occasions. The patient does not smoke, has a body mass index of 24, and exercises regularly. The patient has no known risk factors for cardiovascular disease. The primary care NP should: prescribe a thiazide diuretic and an angiotensin-converting enzyme inhibitor. Correct! perform a careful cardiovascular physical assessment. counsel the patient about dietary and lifestyle changes. order a urinalysis and creatinine clearance and begin therapy with a β-blocker. If the patient is younger than 20 or older than 50 years old at the onset of elevated blood pressure, the NP should look for causes of secondary hypertension. The physical examination should include a careful cardiovascular assessment. This patient will need pharmacologic treatment, but not until the underlying cause of hypertension is determined. Question 43 2 / 2 pts A patient who has diabetes mellitus and congestive heart failure takes insulin and warfarin. The patient will begin taking exogenous testosterone to treat secondary hypogonadism. The primary care NP should recommend: increasing the dose of warfarin. Correct! more frequent blood glucose monitoring. a higher than usual dose of testosterone. increasing insulin doses to prevent hypoglycemia. Patients with diabetes may require a decrease in insulin dose because of the metabolic effects of androgens. More frequent blood glucose monitoring should be performed. Warfarin doses may need to be decreased because androgens increase sensitivity to anticoagulants. Question 44 2 / 2 pts A primary care NP sees a patient who reports having decreased frequency of stools over the past few months. In the clinic today, the patient has severe abdominal cramping and an abdominal radiograph shows an increased stool load in the sigmoid colon and rectum. The NP should: give magnesium hydroxide (Milk of Magnesia). start daily methylcellulose (Citrucel) and increased fluids. Correct! order a sodium phosphate enema and psyllium (Metamucil). recommend polyethylene glycol (MiraLAX) and 2000 mL of fluid daily. If a patient is severely constipated, an enema is indicated. When there is underlying chronic constipation, long-term management may be necessary. Bulk laxatives, such as psyllium, are first-line treatments for long-term constipation. Question 45 2 / 2 pts A primary care NP writes a prescription for an off-label use for a drug. To help ensure compliance, the NP should: Correct! include information about the off-label use on the E-script. provide the patient with written instructions about how to use the medication. tell the patient to let the pharmacist know that the drug is being used for an off-label use. follow up by phone in several days to see if the patient is using the drug appropriately. 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. Question 46 2 / 2 pts 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: may cause different adverse effects. does not necessarily have the same therapeutic effect. is likely to be less safe than the brand specified in the prescription. Correct! may vary in the amount of drug that reaches the site of action in the body. 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. Question 47 2 / 2 pts A 2-year-old child has chronic “toddler’s” diarrhea, which has an unknown but benign etiology. The child’s parent asks the primary care NP if a medication can be used to treat the child’s symptoms. The NP should recommend giving: diphenoxylate (Lomotil). attapulgite (Kaopectate). Correct! an electrolyte solution (Pedialyte). bismuth subsalicylate (Pepto-Bismol). Antidiarrheals are not recommended in children. Opioids are contraindicated in children younger than 2 years. Bismuth and attapulgite are not recommended in children younger than 3 years of age. Oral rehydration with electrolyte solution is safe for young children. Question 48 2 / 2 pts A primary care NP has prescribed phentermine for a patient who is obese. The patient loses 10 lb in the first month but reports that the drug does not seem to be suppressing appetite as much as before. The NP should: Correct! discontinue the phentermine. increase the dose of phentermine. continue the phentermine at the same dose. change to a combination of phentermine and topiramate. Tolerance to the effects of phentermine usually develops within a few weeks of starting therapy. When this occurs, the drug should be discontinued, not increased. Phentermine use is not recommended longer than a few weeks. Question 49 2 / 2 pts A patient is newly diagnosed with type 2 diabetes mellitus. The primary care NP reviews this patient’s laboratory tests and notes normal renal function, increased triglycerides, and deceased HDL levels. The NP should prescribe: nateglinide (Starlix). glyburide (Micronase). colesevelam (Welchol). Correct! metformin (Glucophage). Metformin is recommended as initial pharmacologic treatment for type 2 diabetes. It has been shown to decrease triglycerides and LDLs. Question 50 2 / 2 pts A 50-year-old woman with a family history of CHD is experiencing occasional hot flashes and is having periods every 3 to 4 months. She asks the primary care NP about HT to relieve her symptoms. The NP should: prescribe estrogen-only therapy. initiate oral contraceptive pills now. discuss using bioidentical HT. Correct! plan to use estrogen-progesterone therapy when menopause begins. The timing hypothesis suggests that initiating HT at or very near to the time of menopause, which begins when a woman has not had a period for 12 months, reduces CHD in postmenopausal women. Estrogen-only therapy is indicated only for women who do not have a uterus. Oral contraceptive pills increase the risk of CHD. Bioidentical HT is not indicated. Question 51 2 / 2 pts A primary care NP prescribes a COCP for a woman who is taking them for the first time. After teaching, the woman should correctly state the need for using a backup form of contraception if she: Correct! is having vomiting or diarrhea. delays taking a pill by 5 or 6 hours. takes nonsteroidal antiinflammatory drugs several days in a row. has recurrent headaches or insomnia. Vomiting and diarrhea may cause oral contraceptive failure, so women should be advised to use backup contraception if they experience these. The other conditions do not lead to oral contraceptive failure. Question 52 2 / 2 pts A patient who is taking an oral anticoagulant is in the clinic in the late afternoon and reports having missed the morning dose of the medication because the prescription was not refilled. The primary care NP should counsel this patient to: avoid foods that are high in vitamin K for several days. take a double dose of the medication the next morning. refill the prescription and take today’s dose immediately. Correct! skip today’s dose and resume a regular dosing schedule in the morning. Consistency is the key to successful warfarin treatment, and the patient should take the medication at the same time every day. For missed doses, the patient should take the medication as soon as possible after the missed dose or not at all that day. Because it is late afternoon, the patient should skip the dose and resume normal scheduling the next day. It is not necessary to avoid foods high in vitamin K. Patients should not double up the next day. Question 53 2 / 2 pts A patient comes to the clinic with a 2-day history of cough and wheezing. The patient has no previous history of asthma. The patient reports having heartburn for several months, which has worsened considerably. The primary care NP makes a diagnosis of asthma and orders oral steroids and inhaled albuterol. The patient’s condition worsens, and a chest radiograph obtained 2 days later shows bilateral infiltrates. The NP has failed to: Correct! confirm the diagnosis. determine the aggressiveness of therapy. prescribe an adequate dose of medications. allow the drugs an adequate amount of time to work. This patient had symptoms that could occur with both asthma and aspiration pneumonia. The NP failed to confirm the diagnosis and prescribed the wrong treatment, leading to worsening of symptoms. Question 54 2 / 2 pts A 5-year-old child has chronic constipation. The primary care NP plans to prescribe a laxative for long-term management. In addition to pharmacologic therapy, the NP should also recommend _____ g of fiber per day. Correct! 10 15 20 25 Each day a child should receive 1 g of fiber per year of age plus 5 g after 2 years of age. Question 55 2 / 2 pts A patient in the clinic reports heartburn 30 minutes after meals, a feeling of fullness, frequent belching, and a constant sour taste. The patient has a normal weight and reports having a high-stress job. The primary care NP should recommend: antacid therapy as needed. changes in diet to avoid acidic foods. Correct! daily treatment with a PPI. consultation with a gastroenterologist for endoscopy. This patient has symptoms of GERD. PPIs are first-line medications for treating GERD and may be started empirically. Antacids are not first-line medications. Changes in diet are not recommended as treatment but may help with symptoms. Patients with symptoms unrelieved by PPIs should be referred for possible endoscopy. Question 56 2 / 2 pts A patient who has angina is taking nitroglycerin and long-acting nifedipine. The primary care NP notes a persistent blood pressure of 90/60 mm Hg at several follow-up visits. The patient reports lightheadedness associated with standing up. The NP should consult with the patient’s cardiologist about changing the medication to: amlodipine (Norvasc). isradipine (DynaCirc). Correct! verapamil HCl (Calan). short-acting nifedipine (Procardia). Verapamil and diltiazem are less likely to cause hypotension than nifedipine and related drugs, such as isradipine and amlodipine. Question 57 2 / 2 pts A 40-year-old woman tells the primary care nurse practitioner (NP) that she does not want more children and would like a contraceptive. She does not smoke and has no personal or family history of cardiovascular disease. She has frequent tension headaches. For this patient, the NP should prescribe: condoms. tubal ligation. monophasic combined oral contraceptive pill (COCP). Correct! low-estrogen COCP. Low-estrogen COCPs are recommended for women older than 40 with or without cardiovascular risk. Monophasic COCPs are recommended for women with migraine headaches. Condoms are more useful for preventing sexually transmitted diseases and not as reliable as contraception. Tubal ligation has surgical risks. Question 58 2 / 2 pts A woman who has been taking a COCP tells the primary care NP that, because of frequent changes in her work schedule, she has difficulty remembering to take her pills. The woman and the NP decide to change to a vaginal ring. The NP will instruct her to insert the ring: Correct! within 7 days after her last active pill. and use a backup contraceptive for 7 days. and continue the COCP for one more cycle. on the same day she stops taking her COCP. Patients should be switched from a COCP to a vaginal ring by insertion within 7 days after the last active pill. No backup method is needed. Patients do not need to continue one more cycle of COCPs. Women taking progestin-only pills insert the ring on the last day of the pill pack. Question 59 2 / 2 pts A patient who has severe arthritis and who takes nonsteroidal antiinflammatory drugs (NSAIDs) daily develops a duodenal ulcer. The patient has tried a cyclooxygenase-2 selective NSAID in the past and states that it is not as effective as the current NSAID. The primary care nurse practitioner (NP) should: prescribe cimetidine (Tagamet). Correct! prescribe omeprazole (Prilosec). teach the patient about a bland diet. change the NSAID to a corticosteroid. Patients with NSAID-induced ulcer should discontinue the NSAID if possible and use an acid suppressant. This patient has severe arthritis and so cannot discontinue the NSAID. In a situation such as this, a PPI is indicated. Cimetidine is a histamine-2 blocker, which would be a second-line choice, but cimetidine has many serious side effects. Bland diets are not effective in treating ulcers. Corticosteroids are not indicated. Question 60 0 / 2 pts A patient in the clinic develops sudden shortness of breath and tachycardia. The primary care NP notes thready pulses, poor peripheral perfusion, and a decreased level of consciousness. The NP activates the emergency medical system and should anticipate that this patient will receive: You Answered intravenous alteplase. low-dose aspirin and warfarin. low-molecular-weight heparin (LMWH). Correct Answer unfractionated heparin (UFH) and warfarin. This patient has unstable pulmonary embolism (PE) and should receive thrombolytic therapy. Intravenous alteplase is the preferred agent. UFH and warfarin are recommended for stable PE. LMWH is beneficial in submassive PE and deep vein thrombosis (DVT) but is controversial for treatment of massive PE.