Chapter 8: Safe Medication Use My Nursing Test Banks

Chapter 8: Safe Medication Use

Test Bank

MULTIPLE CHOICE

1. Which pharmacokinetic parameter is affected most by decreased intestinal motility related to the aging process?

a.

Absorption

c.

Metabolism

b.

Distribution

d.

Excretion

ANS: A

Decreased intestinal motility increases the amount of time a substance remains in contact with the intestinal mucosa of the small intestine, where most absorption takes place. With increased exposure, absorption can be increased and the drug effect enhanced. Many medications taken by older adults can also decrease intestinal motility, thereby complicating the titration of medications or introducing new adverse effects through drug-to-drug interactions. Decreased body water leads to higher serum concentrations of water-soluble drugs, increased body fat increases the longevity of fat-soluble drugs, and decreased serum albumin increases the serum concentration of serum proteinbound drugs. Reduced liver mass and hepatic dysfunction can impair oxidative metabolism, which can lead to an accumulation of toxic levels of a drug. Impaired renal function can impair the excretion of drugs through the kidneys.

PTS: 1 DIF: Understand REF: 4-5 TOP: Nursing Process: Evaluation

MSC: Safe, Effective Care Environment

2. Which process is increased in the early morning?

a.

Fibrinolytic activity

c.

Asthma symptoms

b.

Blood plasma

d.

Rheumatoid arthritis pain

ANS: A

Fibrinolytic activity is increased in the early morning. Blood plasma volume falls at night, thus hematocrit increases. Asthma symptoms peak at approximately 4 to 5 AM. Pain from rheumatoid arthritis is more severe in the late afternoon.

PTS:1DIF:RememberREF:44 Table 8-4

TOP: Nursing Process: Assessment MSC: Physiological Integrity

3. Which interaction between each prescription and food or nutritional supplement is favorable?

a.

Warfarin (Coumadin) and ginkgo biloba

b.

Terazosin (Hytrin) and increased fluids

c.

Lithium (Eskalith) and low-sodium diet

d.

Warfarin (Coumadin) and leafy, green vegetables

ANS: B

Increased fluids can combat the hypotensive effects of alpha-adrenergic blockers such as terazosin. Ginkgo biloba can amplify the anticoagulant effect of warfarin, leading to an increased risk of bleeding. Reduced sodium intake contributes to the toxicity of lithium. Leafy, green vegetables can diminish the anticoagulant effect of warfarin (Coumadin).

PTS:1DIF:RememberREF:8-9

TOP: Nursing Process: Assessment MSC: Safe, Effective Care Environment

4. Which medication is correctly matched to the condition given of an older adult patient according to current medical knowledge?

a.

Methylphenidate (Ritalin) for depression at bedtime

b.

Buspirone (BuSpar) for chronic anxiety states

c.

Amitriptyline (Elavil) for depression in the morning

d.

Haloperidol (Haldol) long-term for psychotic behavior

ANS: B

Buspirone (BuSpar) is safer for older adults with anxiety than benzodiazepines. Because it can take up to 5 to 7 days for the therapeutic benefit to be realized, it should be used only for chronic anxiety. Stimulants such as methylphenidate (Ritalin) should be administered in low doses in patients with chronic depression. To prevent insomnia, extended-release forms should be administered early in the morning and short-acting forms at the latest in the early afternoon. Tricyclic antidepressants such as amitriptyline (Elavil) are contraindicated for use with older adults because of the risk for anticholinergic and sedative effects. Tricyclic antidepressants have been replaced with selective serotonin reuptake inhibitors (SSRIs), which are more effective at lower doses with fewer side effects. Antipsychotic agents such as haloperidol (Haldol) can cause extrapyramidal effects, especially in older adults. For long-term administration, they should be used only after a thorough psychiatric evaluation.

PTS: 1 DIF: Understand REF: 26-27 TOP: Nursing Process: Evaluation

MSC: Safe, Effective Care Environment

5. In questioning an older adult, which question is likely to elicit the most accurate information about the individuals adherence to the medication plan?

a.

You take digoxin (Lanoxin) at the correct time, dont you?

b.

Why didnt you take all of your digoxin (Lanoxin) last month?

c.

How many doses of digoxin (Lanoxin) do you think you missed?

d.

You have never missed a dose of digoxin (Lanoxin), have you?

ANS: C

How many doses of digoxin (Lanoxin) do you think you missed? is a question that is worded to put the client at ease and to elicit information in a matter-of-fact way. You take digoxin (Lanoxin) at the correct time, dont you? sounds like a challenge to the patients personal qualities. In addition, the nurse is leading the patient to the answer. The patient is likely to respond simply, Oh, yes. Although the question, Why didnt you take all of your digoxin (Lanoxin) last month? is meant to elicit the reason for nonadherence, it has an accusatory tone that is likely to make the patient defensive. You have never missed a dose of digoxin (Lanoxin), have you? is a question that can be interpreted as judgmental.

PTS: 1 DIF: Understand REF: 17-21 TOP: Nursing Process: Evaluation

MSC: Safe, Effective Care Environment

6. Which of the following is on the list of drugs considered suitable for the older adult?

a.

Indomethacin (Indocin)

c.

Chlorpheniramine (Chlor-Trimeton)

b.

Reserpine (Reserpine)

d.

Bupropion (Wellbutrin)

ANS: D

Bupropion is a safe antidepressant for an older adult that is also less likely to cause sexual dysfunction than other nonsteroidal SSRIs. Indomethacin is unsuitable for an older adult because it produces the most central nervous system effects of all nonsteroidal antiinflammatory agents. Reserpine is unsuitable for an older adult because it poses a risk of depression, sedation, and orthostatic hypotension. Chlorpheniramine and similar antihistamines are unsuitable for an older adult because of their anticholinergic properties.

PTS:1DIF:RememberREF:25-27

TOP: Nursing Process: Assessment MSC: Safe, Effective Care Environment

7. A patient receives heparin daily. The nurse should assess for which clinical response that indicates the need to discontinue heparin therapy?

a.

International normalized ratio (INR) of 2.5

b.

Platelet count of 150,000/mm3

c.

Reflux

d.

Hematuria

ANS: D

Hematuria is a serious side effect and requires temporary discontinuation of heparin therapy. A low platelet count can occur in a small percentage of patients who are receiving heparin therapy, which often resolves without intervention. The INR value is obtained to assess the effectiveness of warfarin therapy, not heparin. Heparin is administered parenterally, not by mouth, thus decreasing the risk for irritation.

PTS:1DIF:AnalyzeREF:12-14

TOP: Nursing Process: Assessment MSC: Safe, Effective Care Environment

8. A geriatric nurse practitioner prescribes an antidepressant for a patient. The patient asks, How long will I have to be on this medication before I feel like my old self? The nurse recalls that a therapeutic response to an antidepressant medication most often takes which one of the following?

a.

24 hours

c.

2 weeks

b.

2 days

d.

2 months

ANS: D

One to 2 months may be necessary to achieve a maximal response to therapy. Both 24 hours and 2 days are too short of timeframes to have a response to therapy. Patients often have an initial response to therapy 1 to 3 weeks after starting the medication.

PTS: 1 DIF: Apply REF: 26-27 TOP: Nursing Process: Planning

MSCharmacological and Parenteral Therapies

9. The nurse prepares to administer vancomycin (Vancocin) to an older adult. Which laboratory test should the nurse review before administering this medication?

a.

Stool culture

c.

Creatinine clearance

b.

Serum potassium

d.

Alkaline phosphatase

ANS: C

Antibiotics, as a group of drugs, are hard on the kidneys; thus the nurse should check the creatinine clearance of this individual. Although approximately 30% of absorbed vancomycin is protein bound, it is cleared by the kidneys, and creatinine clearance is the best index available of renal function. Because approximately 70% of vancomycin circulates in the bloodstream in the active form, the dose must be reduced or the dosing intervals increased to maintain the desired drug level and to prevent toxicity in the older adult who has renal dysfunction. The pathogen is already identified; however, some value can be obtained from subsequent stool cultures to determine whether the infection is eradicated. Serum potassium is a reasonable parameter to check in an older adult; however, if used as a measure of renal function, then the creatinine clearance is a better choice. Alkaline phosphatase is a measure of hepatic function and a reasonable parameter to check when administering medications; hepatic clearance is important in the metabolism of many medications.

PTS: 1 DIF: Apply REF: 8| 33 TOP: Nursing Process: Planning

MSC: Safe, Effective Care Environment

10. The nurse prepares to administer diltiazem (Cardizem LA) to an older adult with ischemic heart disease. When is the optimal time to administer this medication to help prevent complications of heart disease associated with rhythmical variations?

a.

Midday

c.

At breakfast

b.

At bedtime

d.

Every 4 hours

ANS: B

Diltiazem is a calcium-channel blocker used for hypertension, heart rate control, and angina from ischemic heart disease. To take advantage of rhythmical variations in heart disease, the best time to administer long-acting diltiazem (Cardizem LA) is at bedtime; the medication will then be active in the early morning hours when a cardiovascular event is most likely to take place. Midday administration is a less advantageous time for the medication administration because the main period of drug activity will occur in the evening. Morning administration is too late for administration because morning administration misses the critical period around 4 and 5 AM. Administering Cardizem LA every 4 hours is contraindicated because it is a long-acting formulation meant to be administered once daily.

PTS: 1 DIF: Apply REF: 8-9 | 40 Box 8-1| 41 Box 8-2

TOP:Nursing Process: Planning | Nursing Process: Diagnosis

MSC: Safe, Effective Care Environment

11. A health care provider has ordered alendronate (Fosamax) for an older adult who has been admitted for a hip fracture. Which is the best response from the nurse when educating the patient on the new medication?

a.

You will need to have your calcium checked monthly while on this medication.

b.

If you miss a dose, you will need to take the medication as soon as you remember.

c.

Take on an empty stomach.

d.

Do not take with alcohol.

ANS: C

Drug-food interactions may either decrease or increase the amount absorbed. For example, when a bisphosphonate such as Fosamax is taken with food of any kind, the absorption is reduced to only a few milligrams; therefore the drug has no effect on the target organthe bones. If a patient misses a dose, then he or she should not take it as soon as remembered; it should be taken at its next scheduled dose. No current recommendations suggest that calcium levels are to be checked monthly.

PTS: 1 DIF: Analyze REF: 4-5 TOP: Nursing Process: Planning

MSCharmacological and Parenteral Therapies

12. When completing medication reconciliation for an older woman, the nurse notes that the patient is being discharged home on anticoagulant therapy. The nurse also notes that at admission, the patient reported that she uses herbal supplements at home. Which instruction should the nurse include during discharge teaching?

a.

You may need to supplement with only ginkgo while on anticoagulant therapy.

b.

You may need to increase the use of garlic supplements while on anticoagulant therapy.

c.

Avoid using Hawthorn supplements while taking an anticoagulant medication.

d.

Avoid using chamomile supplements while on anticoagulant therapy.

ANS: D

The nurses priority is to stop this older adults intake of chamomile supplements at home; they will increase the effectiveness of anticoagulation. The nurse instructs this individual to avoid chamomile while she is taking an anticoagulant because the womans blood will be much less able to clot, exposing her to a very high risk of a catastrophic injury in the event of a fall or trauma. The patient does not need to supplement with only ginkgo; the patient should cease taking ginkgo while on anticoagulant therapy, as well as the use of garlic supplements. Both increase the effectiveness of anticoagulation. The use of Hawthorn supplements has not been shown to affect the use of anticoagulant medications.

PTS: 1 DIF: Analyze REF: 42 Table 8-3 TOP: Nursing Process: Planning

MSCharmacological and Parenteral Therapies

13. The nurse provides instruction about medication safety to older adults. Which instruction should the nurse provide?

a.

Nausea and vomiting are common, harmless drug side effects.

b.

Keep a supply of medications at the bedside for convenience.

c.

Ask the health care provider to describe the purpose of therapy.

d.

Take your daily medications on an empty stomach with water.

ANS: C

Older adults should ask the health care provider for the purpose of each drug and record the information. Although nausea and vomiting are among the most common adverse effects of pharmacotherapy, they can indicate medication toxicity and should be reported to the health care provider. Keeping a medication at the bedside is dangerous for anyone and can be especially dangerous for older adults who are taking antianxiety agents, hypnotic agents, and opioid analgesics; these and other medications can cause respiratory depression with and without excessive dosing. If sleepy or lethargic, then the older adult can inadvertently take more than the correct dose and suffer serious consequences as a result. Taking a medication on an empty stomach with water is a suitable instruction for many medications; however, many medications that are likely to cause nausea are taken with food. The nurse should instruct older adults to keep a record of the recommended method of administration.

PTS: 1 DIF: Understand REF: 51 Box 8-6 TOP: Teaching/Learning

MSC: Safe, Effective Care Environment

14. An older man is taking aripiprazole (Abilify) for agitation. Which patient assessment is the nurses priority to prevent catastrophic effects of the medication?

a.

Oral and facial dyskinesia

c.

Muscle spasms of the face

b.

Mask facies, shuffling gait

d.

Repetitive aimless walking

ANS: A

This individual is taking an atypical antipsychotic agent to control manic episodes of dementia. Although these agents are less likely to cause tardive dyskinesia (TD), the nurse monitors for the associated abnormal movements of TD including oral and facial dyskinesia, which is an impairment in the ability to execute voluntary facial movement. The nurse immediately reports this effect to stop therapy and to prevent an irreversible condition. Mask facies, having a masklike appearance, and shuffling gait are parkinsonian side effects of antipsychotic agents and can be improved with antiparkinsonian agents. Muscle spasms of the face, tongue, neck, and back are adverse effects of antipsychotic agents usually observed within the first 5 days of therapy. They are potential indicators of acute dystonia and can be improved with antiparkinsonian agents. Motor restlessness is an adverse effect of antipsychotic agents and is characteristic of akathisia.

PTS:1DIF:AnalyzeREF:27-31

TOP: Nursing Process: Assessment MSC: Health Promotion and Maintenance

15. An older man is taking chlorpromazine (Thorazine), and the nurse helps him choose menu items. To prevent an exacerbation of potential adverse effects of therapy, which menu item does the nurse instruct the man to avoid?

a.

Biscuits and gravy

c.

Whole grain bread

b.

Coffee with cream

d.

Mixed green salad

ANS: B

Because antipsychotic medications potentially impair the bodys thermoregulatory ability, the nurse instructs an older adult who takes an antipsychotic agent such as chlorpromazine to avoid caffeinated beverages because they contribute to dehydration. This man is at high risk for organ damage as a result of hyperthermia from mild elevations in the environmental temperature; therefore he must avoid dehydration, stay in cool temperatures, keep out of direct sunlight, and alert people around him and caregivers to monitor his temperature carefully and to be prepared to provide cooling sponge baths, cool liquids, and other measures to reduce his temperature quickly. The nurse instructs all older adults to avoid eating biscuits and gravy because these items have an excessively high fat content. Whole grain bread is a healthy food item to choose. Mixed green salad is a healthy food item to choose.

PTS:1DIF:ApplyREF:13| 28-29

TOP: Nursing Process: Implementation MSC: Safe, Effective Care Environment

MULTIPLE RESPONSE

1. An older woman who takes escitalopram (Lexapro) 10 mg by mouth daily states she does not feel better after 1 week of treatment. Rank the interventions in order, starting with the first intervention the nurse should implement to facilitate patient compliance with therapy.

a.

Tell her that the beneficial effects can take 4 to 6 weeks to appear.

b.

Instruct her to take the medication as prescribed without stopping.

c.

Suggest hard candy, ice chips, and sips of water for a dry mouth.

d.

Collaborate with the health care provider to provide an increased dose.

ANS: A, B, C, D

Usually, older adults are sensitive to the effects of medications, but under normal circumstances, the therapeutic effect of escitalopram and other SSRI antidepressant medications can take up to 4 to 6 weeks to appear. Conversely, if an individual who is taking an antidepressant experiences adverse effects of the medication, then the individual should be instructed to take the medication continually as prescribed for 1 to 2 months before abandoning the therapy; the untoward effects usually diminish or disappear with time. To bolster the initial intervention, the nurse instructs the older adult to continue therapy without stopping because consistent, daily administration is the best method of achieving the full beneficial effects of an antidepressant. A common, early adverse effect of antidepressant therapy is dry mouth; therefore the nurse supplies the individual with strategies for effectively counteracting the anticholinergic effects of this medication. The nurse assists the older adult with strategies to manage antidepressant therapy before asking for an increased dose. Titration of an antidepressant medication for an older adult is a slow process because of increased sensitivity to the effects of the medication. In addition, dosing trial and error is a common strategy for determining an individuals optimal dose.

PTS: 1 DIF: Analyze REF: 26-27 TOP: Nursing Process: Planning

MSC: Safe, Effective Care Environment

2. Which herbal supplement(s) when taken with an anticoagulant increases the effectiveness of the medication and should be avoided during anticoagulant therapy? (Select all that apply.)

a.

Chamomile

b.

Garlic

c.

Ginkgo

d.

Hawthorn

e.

Ginseng

f.

Green tea

ANS: A, B, C, E, F

The intake of chamomile, garlic, ginkgo, ginseng, and green tea supplements at home should be avoided because each increases the effectiveness of anticoagulation. Individuals should avoid these herbal supplements while taking an anticoagulant because the patients blood will be significantly less able to clot, exposing him or her to the risk of a catastrophic injury in the event of a fall or trauma. The use of Hawthorn supplements has not been shown to affect the use of anticoagulants.

PTS: 1 DIF: Remember REF: 42 Table 8-3 TOP: Nursing Process: Planning

MSCharmacological and Parenteral Therapies

3. Through which pathway(s) are drugs and their metabolites eliminated? (Select all that apply.)

a.

Sweat

c.

Kidneys

b.

Saliva

d.

Spleen

ANS: A, B, C

Drugs and their metabolites are excreted in sweat, saliva, and other secretions but primarily through the kidneys. Metabolites are not eliminated through the spleen.

PTS: 1 DIF: Remember REF: 8-9 TOP: Nursing Process: Planning

MSCharmacological and Parenteral Therapies

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