Understanding Pharmacology Essentials For Medication Safety By M. Linda Workman – Test Bank

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Understanding Pharmacology Essentials For Medication Safety By M. Linda Workman – Test Bank

Chapter 02: Safely Preparing and Giving Drugs

Workman & LaCharity: Understanding Pharmacology: Essentials for Medication Safety, 2nd Edition

 

MULTIPLE CHOICE

 

BASIC CONCEPTS

 

  1. How soon should a drug ordered as “STAT” be administered?
a. Immediately
b. With the next meal
c. At the same time every day
d. Only when the stomach is completely empty

 

 

ANS:  A

A STAT order is written by a prescriber for a drug to be administered once and immediately.

 

DIF:    Cognitive Level: Remembering      REF:   p. 29

 

  1. When do most drug errors occur in a hospital setting?
a. When a patient is in the emergency department
b. When a patient is scheduled for a procedure
c. When drugs are being administered to patients
d. When two patients have the same last name

 

 

ANS:  C

Most drug errors are made while giving drugs. Common errors include giving the wrong drug or giving the wrong dose. Follow the “eight rights” to prevent drug errors.

 

DIF:    Cognitive Level: Remembering      REF:   p. 30

 

  1. Which type of drug must always be swallowed without chewing?
a. Liquid drugs
b. Time-release drugs
c. Drugs that taste bad
d. Drugs that act on the intestinal tract

 

 

ANS:  B

Some pills and capsules are prepared for slow absorption. These drugs are often labeled enteric-coated, time release, or slow release. If chewed, crushed, or opened, these drugs may be absorbed too rapidly. This can irritate the gastrointestinal (GI) system or cause symptoms of overdose.

 

DIF:    Cognitive Level: Remembering      REF:   p. 31

 

  1. Which abbreviation means that a drug is to be given orally?
a. PRN
b. NPO
c. PO
d. PPD

 

 

ANS:  C

PO means per os or administration of drugs by the mouth.

 

DIF:    Cognitive Level: Remembering      REF:   p. 32

 

  1. Which needle position is best for an intradermal injection?
a. Bevel side to the right
b. Bevel side to the left
c. Bevel side down
d. Bevel side up

 

 

ANS:  D

When giving an intradermal injection, insert the needle at a 10- to 15-degree angle with the bevel facing up. Do not pull back (aspirate) on the plunger of the syringe. Inject the drug so a little bump forms and remove the needle.

 

DIF:    Cognitive Level: Remembering      REF:   p. 35

 

  1. For which patient condition or problem are rectal drugs avoided?
a. Fever
b. Vomiting
c. Diarrhea
d. Pregnancy

 

 

ANS:  C

The patient with diarrhea cannot hold rectal drugs long enough for absorption to take place.

 

DIF:    Cognitive Level: Remembering      REF:   p. 34

 

  1. Which injection site is located on the front of the thigh?
a. Deltoid
b. Dorsogluteal
c. Ventrogluteal
d. Vastus lateralis

 

 

ANS:  D

The vastus lateralis is located in the muscles on the front of the thigh.

 

DIF:    Cognitive Level: Remembering      REF:   p. 36

 

  1. What is the purpose of using the “Z-track” method of intramuscular injection?
a. Preventing accidental intravenous injection
b. Preventing oozing of drug back through the needle path
c. Reducing the chances of hitting bone or nerve with the needle
d. Allowing larger amounts (volumes) of drugs to be administered into smaller muscles

 

 

ANS:  B

Use the Z-track method of IM injection for drugs that are irritating to subcutaneous tissue or that may permanently stain the tissues. After drawing the drug into the syringe, draw in 0.1 to 0.2 mL of air. The air follows the drug into the muscle and stops it from oozing through the path of the needle. After you select and cleanse the site, pull the tissue laterally and hold it. Insert the needle into the muscle; inject the drug and release the tissue as you remove the needle. Releasing the tissue allows the skin to slide over the injection and seal the drug in the muscle.

 

DIF:    Cognitive Level: Remembering      REF:   p. 37

 

  1. A patient needs a dose of oral potassium for a low serum potassium level (3.4 mEq/dL). Which type of order should the prescriber write?
a. Standing order
b. Single order
c. PRN order
d. STAT order

 

 

ANS:  B

A single-dose order is an order to give a drug once only. This patient’s serum potassium level is close to normal. You should expect that the patient’s potassium level would be checked again and another order written by the prescriber if the level was not within the normal range.

 

DIF:    Cognitive Level: Remembering      REF:   p. 29

 

  1. What temperature should ear drops be when applying them?
a. Just above freezing -33 °F
b. Warmed to 104 °F
c. Refrigerated to 40 °F
d. Room temperature

 

 

ANS:  D

Ear drops are drugs given to treat local infection or inflammation and should be kept at room temperature. This helps to prevent dizziness or nausea when the drops are administered.

 

DIF:    Cognitive Level: Remembering      REF:   p. 40

 

  1. What is the correct position for a sublingual tablet?
a. As far back on the top of the tongue as possible without swallowing it
b. Between the cheek and the gum of the upper teeth
c. Between the cheek and the gum of the lower teeth
d. Under the front of the tongue

 

 

ANS:  D

A drug given by the sublingual route, such as nitroglycerin, is placed under the tongue. The blood supply is very good in the mouth; therefore, these drugs dissolve and are absorbed quickly.

 

DIF:    Cognitive Level: Remembering      REF:   pp. 39-40

 

  1. When is it acceptable to take a verbal order from the prescriber before giving a drug to a patient?
a. During the nightshift when the prescriber is not at the hospital
b. In an emergency situation such as a cardiac arrest
c. When a patient is experiencing severe pain
d. At any time it is convenient

 

 

ANS:  B

Verbal orders should be accepted only in emergency situations. As soon as the emergency has been resolved, verbal orders must be written and signed.

 

DIF:    Cognitive Level: Remembering      REF:   p. 28

 

  1. What is the most important role of the health care worker in preventing drug errors?
a. Always checking the patient’s diagnosis before giving a drug
b. Always following the “eight rights” of drug administration
c. Being the one defense for detecting and preventing drug errors
d. Being most likely to detect a drug error that has occurred

 

 

ANS:  B

When administering drugs, always follow the “eight rights.” Many drug errors occur because one or more of the “rights” is not followed.

 

DIF:    Cognitive Level: Remembering      REF:   p. 27

 

  1. Which statement accurately describes the correct technique for giving subcutaneous drugs?
a. Use a 3/4-inch, 25-gauge needle and a 15-degree angle for injection.
b. Use a 3/8-inch, 25-gauge needle and a 45-degree angle for injection.
c. Use a 1-inch, 22-gauge needle and a 90-degree angle for injection.
d. Use a 2 inch, 25-gauge needle and a 45-degree angle for injection.

 

 

ANS:  B

For subcutaneous drug administration, small, short needles are used ({3/8} inch, 25 to 27 gauge). Insert the needle at a 45-degree angle for most patients. If the patient is obese, you may need to use a 90-degree angle. If the patient is thin, you may need an angle that is less than 45 degrees.

 

DIF:    Cognitive Level: Remembering      REF:   p. 35

 

  1. What administration technique should you use when giving a 2-year-old child ear drops?
a. Pull the earlobe down and back.
b. Pull the earlobe up and out.
c. Keep the earlobe straight.
d. Hang the patient’s head over the side of the bed.

 

 

ANS:  A

For children younger than 3 years, pull the earlobe (pinna) down and back. This straightens the ear canal. This helps to ensure that the ear drops are placed where they are needed to be effective.

 

DIF:    Cognitive Level: Remembering      REF:   p. 40

 

  1. What must you have a patient do after a vaginal drug is administered?
a. Replace the drug in the refrigerator when not in use.
b. Give the drug while the patient is sitting on the toilet.
c. Have the patient empty her bladder after receiving this drug.
d. Keep the patient lying down for 10 to 15 minutes after receiving the drug.

 

 

ANS:  D

Be sure to have the patient lie down for 10 to 15 minutes after receiving vaginal drugs to ensure that the drugs are fully absorbed.

 

DIF:    Cognitive Level: Remembering      REF:   p. 40

 

  1. When giving a drug to a patient who is awake but confused, what is the best way to identify that it is the right patient?
a. Check the room and bed number that the patient occupies.
b. Ask the patient to state his or her name and birth date.
c. Check the name on the patient’s wristband.
d. Ask the patient if he or she is Mr. or Ms. [name].

 

 

ANS:  C

When a patient is confused, he or she may not reply with his or her own name and birth date. Beds can be moved and rooms can be changed. In addition, sometimes patients are placed or get into the wrong bed. In this case, the patient’s wristband provides the most reliable identification information.

 

DIF:    Cognitive Level: Remembering      REF:   p. 27

 

  1. What is the best way to make sure that the right patient is receiving a prescribed drug when the patient is alert and oriented?
a. Ask the patient to state his or her social security number.
b. Check the patient’s wrist band.
c. Look at the patient’s chart.
d. Have the patient state his or her name and birth date.

 

 

ANS:  D

To make sure that the right patient receives any drug that has been prescribed, The Joint Commission (TJC) recommends checking two unique patient identifiers (name and birth date) before medication administration. An alert and oriented patient can be asked directly.

 

DIF:    Cognitive Level: Remembering      REF:   p. 27

 

  1. Why are nose drops or sprays most often given?
a. To treat dryness that may lead to nose bleeds.
b. For allergies to pets, pollen, and molds.
c. To treat congestion and infection.
d. For cold and flu symptoms.

 

 

ANS:  C

Nose drops or sprays are most often used to treat congestion or infection.

 

DIF:    Cognitive Level: Remembering      REF:   p. 40

 

ADVANCED CONCEPTS

 

  1. Which technique is used with some intramuscular drug injections but not with subcutaneous or intradermal drug injections?
a. Ensuring the site selected is appropriate for injection
b. Cleansing the selected site before inserting the needle
c. Aspirating the syringe before injecting the drug solution
d. Checking for allergic or sensitivity reactions to the injection

 

 

ANS:  C

Aspiration is not recommended for IM injection of vaccines or immunizations. For drugs such as penicillin, aspiration may be indicated. When indicated, aspirate the syringe (pull back on the plunger) to make sure that the needle is not in a vein. If the needle is in a vein, blood will appear in the syringe. Remove the needle and discard the drug if this happens. Get a new dose of the drug and a sterile needle and syringe and give the injection in another site.

 

DIF:    Cognitive Level: Understanding     REF:   p. 36

 

  1. What is the proper way to prepare skin for a transdermal patch?
a. Shave the skin that will be underneath the patch.
b. Leave the old patch on and apply the new one next to it.
c. Clean and dry the skin where the patch will be applied.
d. Remove the old patch and apply the new one to the exact same spot.

 

 

ANS:  C

When administering a transdermal patch, first wash your hands and put on gloves. Clean the area of skin where the drug will be applied. Apply topical drugs in a smooth, thin layer, and cover the area. When administering transdermal drugs, remove old patches or doses of the drug. Be sure to remove all traces of the drug from the previous dosage site, and rotate sites to avoid skin irritation or breakdown.

 

DIF:    Cognitive Level: Understanding     REF:   p. 39

 

  1. A patient is to receive nitroglycerin ointment, 1 inch STAT, for elevated blood pressure. What must be done before giving this drug?
a. Shave the hair off the patient’s chest.
b. Place the patient on a heart monitor.
c. Put on a pair of disposable gloves.
d. Measure the dose directly on the patient’s skin.

 

 

ANS:  C

Wash your hands and put on gloves. Without gloves, if you come into contact with the ointment you may experience the same side effects as a patient (e.g., headache, drop in blood pressure).

 

DIF:    Cognitive Level: Applying or Higher                                         REF:    p. 39

 

  1. To prevent a drug overdose from receiving two doses too close together, what should you do immediately after giving a PRN pain drug?
a. Ask if the patient’s pain has been relieved.
b. Check the patient’s vital signs.
c. Notify the prescriber.
d. Document the action.

 

 

ANS:  D

It is important to document giving PRN (as needed) drugs as soon as possible before another health care worker gives a second dose in response to a patient’s statements about pain.

 

DIF:    Cognitive Level: Applying or Higher                                         REF:    p. 28

 

  1. The prescriber orders atenolol (Tenormin) 25 mg to be given orally once a day to control a patient’s high blood pressure. You check the patient’s vital signs and find that the blood pressure is 128/80 mm Hg and the heart rate is 60 beats/min. What should you do first before giving this drug?
a. Check the order for prescriber limitations on when the drug should be given.
b. Notify the prescriber and ask if the drug should be given.
c. Reassess the blood pressure and heart rate in 30 minutes.
d. Give the drug exactly as prescribed.

 

 

ANS:  A

Prescribers often include limitations about when a drug should or should not be given. You should first check the order for any limitations. Because a heart rate of 60 beats/min is borderline low, and unless there are no limitations, you should notify the prescriber and ask if the drug should be given to this patient.

 

DIF:    Cognitive Level: Applying or Higher                                         REF:    p. 31

 

  1. A patient is prescribed omeprazole (Prilosec) 60 mg once a day orally. The patient is having difficulty with swallowing and has a feeding tube in place. What is your best action?
a. Open the capsule and mix the contents with water, then give the drug through the feeding tube.
b. Raise the head of the bed 90 degrees and mix the capsule in applesauce for easier swallowing.
c. Contact the prescriber and pharmacist about using another drug or another form of the drug.
d. Hold the tube feeding for at least 30 minutes before giving the drug.

 

 

ANS:  C

Omeprazole comes in time-released capsules, which should not be opened to prevent rapid absorption of the drug and consequent side effects or adverse effects. Mixing the drug with applesauce and asking the patient to swallow it when the patient has difficulty swallowing puts the patient at high risk for aspiration.

 

DIF:    Cognitive Level: Applying or Higher                                         REF:    p. 32

 

  1. A patient with severe postoperative pain is ordered to receive morphine 2 mg intravenously. The patient asks if the drug could be taken by mouth instead. What is your best response?
a. “Giving the drug intravenously will give you faster pain relief.”
b. “I will call your prescriber and ask if the order can be changed.”
c. “Your surgeon wants you to receive the drug intravenously.”
d. “We can substitute the intravenous drug with an oral drug.”

 

 

ANS:  A

The intravenous route is used when a drug needs to enter the bloodstream rapidly or a large dose of a drug must be given. The rates of absorption and action are very rapid with this route and this route is best for a patient with severe postoperative pain.

 

DIF:    Cognitive Level: Applying or Higher                                         REF:    p. 38

 

  1. The prescriber orders a new drug over the telephone for a nursing home patient who has symptoms of a urinary tract infection. The order is for Gantanol, 2 g now and then 1 g every 12 hours for the next 10 days. What further information is most important for you to obtain from the prescriber?
a. “How many refills are needed?”
b. “Do you want the drug given orally or intravenously?”
c. “Which brand of drug should be given, or is this a generic drug?”
d. “Does this drug need to be given with a meal or on an empty stomach?”

 

 

ANS:  B

The prescriber must indicate the route of administration for the drug prescribed. Although this drug is available only as an oral drug, the actual drug order needs to include this information. Because this prescription is for an inpatient (nursing home resident) not for a patient taking the drug at home, the refill information is not important at this time. Whether or not the drug should be taken with food or on an empty stomach might be a special instruction, but is not as critical as the correct route.

 

DIF:    Cognitive Level: Applying or Higher                                         REF:    p. 28

 

  1. The prescriber orders all of the following drugs for a patient who had surgery 2 days ago. Which drug order should you administer first?
a. Alphamine (cyanocobalamin) 100 mcg intramuscularly once
b. Benadryl (diphenhydramine) 25 mg orally every 8 hours
c. Compazine (prochlorperazine) 10 mg orally STAT
d. Dalmane (flurazepam) 30 mg orally at night PRN

 

 

ANS:  C

STAT drugs are prescribed to correct or help an immediate problem; they are given as soon as they are available. If the drug is not available on the unit, you must call the pharmacy for an immediate drug dose. PRN drugs may be important but are given at the patient’s indication for a need of the drug. The Benadryl order is written as a standing order and does not indicate an immediate need. Although Alphamine is written as a single-dose drug order, there is no indication for immediate administration.

 

DIF:    Cognitive Level: Applying or Higher                                         REF:    p. 29

 

  1. You ask the patient to state his name and birth date, and the patient responds correctly. Then you give the patient the prescribed drug tablet. The patient says “I haven’t ever taken a green pill before.” What is your best response?
a. “Go ahead and take the drug. The same medications from different drug companies may have a different color.”
b. “Go ahead and take the drug. It is likely that your health care provider has prescribed a new drug for you.”
c. “Don’t take this drug right now. It is probably not the one prescribed for you.”
d. “Don’t take this drug right now. Let me recheck everything to be sure.”

 

 

ANS:  D

When a patient does not recognize a drug that is being given, it is a “red flag” for a possible error. Even though the drug may be newly ordered or may be made by a different manufacturer than what the patient has had in the past, it is always best to recheck the order, the drug, and the patient before proceeding. Although withholding the drug entirely is not completely wrong, there may be no drug error and this response may frighten the patient unnecessarily.

 

DIF:    Cognitive Level: Applying or Higher                                         REF:    p. 31

 

  1. Which question is most important for you to ask a patient before administering a new drug?
a. “Are you allergic to any drugs?”
b. “Do you know what this drug is for?”
c. “When was the last time you ate or drank?”
d. “What other drugs have you taken in the last 24 hours?”

 

 

ANS:  A

All of these questions are important to know when giving a new drug. The information that is most critical, however, is whether the patient has an allergy to this drug or any other drug. A drug allergy can result in life-threatening effects.

 

DIF:    Cognitive Level: Applying or Higher                                         REF:    p. 31

 

  1. When you bring in the next dose of a drug that a patient first received 6 hours ago, the patient reports a “pounding” heart rate ever since taking the last dose. What is your best first action?
a. Document the report as the only action.
b. Check the patient’s vital signs for changes.
c. Hold the dose and notify the prescriber immediately.
d. Reassure the patient that this is an expected response to the drug.

 

 

ANS:  B

Any side effect or response a patient has after starting a new drug should be investigated, even when it is an expected side effect of the drug. Some drugs may increase the strength of the heartbeat and heart rate either as the intended action or as a side effect. However, any drug that affects heart response can also cause adverse heart problems. Before giving the drug or notifying the prescriber, you should check the patient’s vital signs, especially heart rate and quality, heart rhythm, and blood pressure. These changes are important to know for you and the prescriber.

 

DIF:    Cognitive Level: Applying or Higher                                         REF:    p. 31

 

  1. A 1-year-old child is prescribed a transdermal drug patch for pain control. To which site should you apply the patch?
a. On the lower arm where changing the patch is easier
b. On the back between the shoulders so the child cannot reach it
c. On the upper chest so that any skin irritation can be seen quickly
d. On the leg between the knee and the thigh for fastest drug absorption

 

 

ANS:  B

When a transdermal patch is placed in an area visible to a small child, he or she usually picks at it and may remove it. Placing it between the shoulders on the back removes it from the child’s sight and attention. On a small child, circulation is not usually a problem and the drug would be as well absorbed from the back as from anywhere else.

 

DIF:    Cognitive Level: Applying or Higher                                         REF:    p. 33

 

  1. Which action is most important when you prepare to administer an oral drug to a patient of any age?
a. Asking the patient whether he or she prefers a tablet or a capsule
b. Determining when the patient last ate or drank
c. Assessing whether the patient has nausea
d. Checking the patient’s ability to swallow

 

 

ANS:  D

A patient who cannot swallow should not take any drug, drink, or food by the oral route. The risk for aspiration is very high and can lead to many serious complications, even death.

 

DIF:    Cognitive Level: Applying or Higher                                         REF:    p. 32

 

  1. Which condition requires that you withhold a drug dose for a patient with a feeding tube?
a. The drug is in the form of a tablet.
b. The drug volume is greater than 20 mL.
c. Carbon dioxide is detected from the feeding tube.
d. The patient is unconscious and unable to swallow.

 

 

ANS:  C

When carbon dioxide comes from the feeding tube, the tube is in the trachea rather than the stomach. Using this compromised feeding tube for drug administration would result in drug placement into the lungs instead of the stomach, which can cause serious complications.

 

DIF:    Cognitive Level: Applying or Higher                                         REF:    p. 33

 

  1. You prepare to administer an intravenous (IV) push drug, but the skin around the patient’s IV site is swollen and red. The patient states that the area hurts, and no blood return is obtained when you aspirate the IV setup. What is your best action?
a. Continue IV administration of the drug.
b. Discontinue IV administration and notify the prescriber.
c. Dilute the drug more before injecting it into the current IV site.
d. Reassure the patient that this is an expected reaction and offer the prescribed pain medication.

 

 

ANS:  B

These symptoms indicate there has been IV infiltration and the needle is no longer in the vein. No further drugs can be delivered through this IV setup, even if they are well diluted. IV administration of the drug must be discontinued. The prescriber should be notified before restarting IV administration of the drug. The prescriber may change the drug to a different form or prescribe a different drug.

 

DIF:    Cognitive Level: Applying or Higher                                         REF:    p. 38

 

  1. You are receiving a telephone order from a health care provider. After receiving all the information, what is the most important next action to perform?
a. Notify the supervisor about the verbal order.
b. Administer the drug as soon as it is available.
c. Read the order back to the prescriber and ask whether it is correct.
d. Inform the patient and family that a new drug has been prescribed by the health care provider.

 

 

ANS:  C

For safety, when you contact the prescriber by telephone or follow a verbal order, be sure to write the order, read it back, and ask for confirmation that what you wrote is correct before administering any drug. Be sure to document that you read back the order to the prescriber.

 

DIF:    Cognitive Level: Applying or Higher                                         REF:    p. 28

 

  1. What is the most important action to take after giving a patient a newly prescribed drug for hypertension?
a. Teach the patient to measure his or her pulse.
b. Check the patient’s blood pressure an hour later.
c. Ask the patient whether any other family members also have hypertension.
d. Ask the patient whether he or she has ever taken a drug for hypertension in the past.

 

 

ANS:  B

You must be familiar with the patient’s medical diagnosis and the purpose of the drug. Assessing for drug effectiveness is important. After you give a drug, check the patient to make sure that the drug has the desired effect. For example, check the blood pressure for improvement after giving an antihypertensive drug. Be sure to document what you monitored and any other appropriate interventions.

 

DIF:    Cognitive Level: Applying or Higher                                         REF:    p. 28

 

  1. When you bring a sedative for sleep in to the patient, he asks you to leave the drug on his table and he will take it when his television show is over. What should you do?
a. Insist that he take the drug right now.
b. Leave it at his bedside as he requests.
c. Tell him you will bring it back later, after the show.
d. Document that he refused to take his prescribed drug.

 

 

ANS:  C

You are responsible for documenting that drugs have been taken and must witness that this has occurred. Most drugs, including sedatives, should never be left at the bedside. You have no idea whether it was actually taken by the patient or by someone else. It is possible for a patient to collect drugs left at the bedside and take them all at once.

 

DIF:    Cognitive Level: Applying or Higher                                         REF:    p. 32

 

MULTIPLE RESPONSE

 

ADVANCED CONCEPTS

 

  1. Before administering any drug, what should you do? (select all that apply)
a. Check the order.
b. Wash your hands.
c. Instruct the patient that he or she must take the drug.
d. Find out the patient’s family history.
e. Check the patient’s identification band.
f. Keep drug in container until at the bedside.

 

 

ANS:  A, B, E, F

Before giving any drug, always follow the “eight rights.” Always check the written order. Check the patient’s identification wristband and ask the patient’s name and birth date. Limit interruptions and distractions. Wash your hands and wear clean gloves when needed (e.g., parenteral, rectal routes). Keep drugs in their containers or wrappers until at the patient’s bedside. Avoid touching pills or capsules. Never give drugs prepared by someone else. Follow sterile technique when handling syringes and needles. Remain alert to drug names that sound or look alike. Giving the wrong drug can have serious adverse effects.

 

DIF:    Cognitive Level: Applying or Higher                                         REF:    p. 27

 

  1. The patient with an NG tube has orders for several enteral drugs (e.g., capsules, tablets, and liquids). What should you do before giving these drugs? (select all that apply)
a. Check with the pharmacist about crushing the tablets.
b. Follow the procedures of the “eight rights.”
c. Aspirate to check for stomach contents.
d. Open the extended-release capsules.
e. Inject 150 mL of water to check tube patency.
f. Place the patient in a supine position.

 

 

ANS:  A, B, C

As with all oral drugs, check the drug orders, which may be written as PO or by feeding tube. Check your drug book or with the pharmacist before crushing tablets or opening capsules. Wash your hands and place the patient upright. Check to make sure that the tube is located in the stomach by withdrawing (aspirating) stomach contents with a syringe, or you can attach an end-tidal carbon dioxide (CO2) detector to the feeding tube. The presence of carbon dioxide indicates that the tube is in the trachea rather than the stomach. Additionally, if the patient is receiving a tube feeding, check the amount of tube feeding remaining in the stomach (residual). Some drugs are not well absorbed when food is in the stomach (e.g., phenytoin [Dilantin]), and the tube feeding must be stopped for a period before and after administration. Liquid drugs should be diluted and flushed through the tube. Crushed tablets and the contents of opened capsules are first dissolved in water before being given through the tube. To give the drugs, attach a large syringe to the tube, pour the liquid or dissolved drug into the syringe, and let it run in by gravity.

 

DIF:    Cognitive Level: Applying or Higher                                         REF:    pp. 32-34

 

  1. You are teaching a patient about a prescribed sublingual drug. What will you be sure to tell the patient? (select all that apply)
a. “Keep the drug sterile to avoid infection.”
b. “Do not drink anything until the drug is completely dissolved.”
c. “Place this drug between your jaw and your molar teeth.”
d. “Notify your prescriber if you experience side effects.”
e. “Place the drug beside or below the tongue.”
f. “Don’t swallow this drug.”

 

 

ANS:  B, D, E, F

A drug given by the sublingual route, such as nitroglycerin, is placed under the tongue. The blood supply is very good in the mouth; therefore, these drugs dissolve and are absorbed quickly. The patient should not eat or drink until the drug is completely dissolved. Teach the patient not to swallow or chew while the drug is in the mouth because these drugs are not effective if absorbed through the GI tract. A patient should be taught to notify the prescriber for any side effects.

 

DIF:    Cognitive Level: Applying or Higher                                         REF:    pp. 39-40

 

  1. You are giving morning medications to a patient who refuses to take an oral dose of docusate (Colace). What is your best response?
a. “Your prescriber ordered that you must take this drug twice a day.”
b. “Docusate will soften your bowel movements so that you do not strain.”
c. “This drug will help prevent constipation while you are on bed rest.”
d. “Can you tell me why you do not want to take the docusate?”

 

 

ANS:  D

The patient may have a good reason for refusing to take this drug. For example, he or she may be experiencing diarrhea. Understanding the patient’s reason for refusal helps you to understand how to intervene for him or her. A patient has the right to refuse any drug. Be sure that he or she understands why the drug has been prescribed and the consequences of refusing to take it. When a patient refuses to take a drug, document the refusal, including the fact that the patient understands what may happen if the drug is not taken.

 

DIF:    Cognitive Level: Applying or Higher                                         REF:    p. 28

 

  1. Safe drug administration requires that the individual giving a drug be knowledgeable about which drug features? (select all that apply)
a. Purpose
b. Actions
c. Brand name
d. Side effects
e. Abnormal reactions
f. Follow-up care

 

 

ANS:  A, B, D, E, F

You are responsible for providing competent, safe patient care, including giving drugs. To give drugs safely, you should be knowledgeable about the purpose of the drug, its actions, side effects, abnormal reactions, delivery methods, and any necessary follow-up.

 

DIF:    Cognitive Level: Applying or Higher                                         REF:    p. 27

 

  1. A patient is to receive an acetaminophen (Tylenol) suppository for an elevated temperature of 102.8° F. What actions must the nurse take? (select all that apply)
a. Ask if the patient is having any diarrhea.
b. Lubricate the blunt end of the suppository.
c. Put on a pair of sterile gloves.
d. Place the patient in the Sims’ position.
e. Ask the patient to take a deep breath and bear down.
f. Push the suppository into the rectum about 1 inch.

 

 

ANS:  A, D, E, F

Diarrhea may make the rectal route of drug administration undesirable because the patient may be unable to hold the drug in the rectum long enough to be absorbed. Disposable gloves should be used, but they do not need to be sterile. The suppository is inserted pointed end first, not blunt end. The Sims’ position (with the patient turned to the side and one leg bent over the other) is the best position for giving a rectal suppository. The suppository should be pushed into the rectum about 1 inch for better absorption. Be sure to instruct the patient about how long the suppository should be held in the rectum.

 

DIF:    Cognitive Level: Applying or Higher                                         REF:    p. 34

 

  1. A patient with several chronic illnesses is being cared for in a hospital acute care setting. For which events should you expect to apply the principles of the process of medication reconciliation? (select all that apply)
a. The patient is transferred from the ICU to a medical care unit.
b. The patient is transported to radiology for a CT scan.
c. The patient’s care is transferred from the evening to the night nurse.
d. The patient is moved from an acute care to a long-term care facility.
e. The patient is relocated to a private room on the same medical care unit.
f. The patient is sent to a different hospital for specialized surgery.

 

 

ANS:  A, D, F

When a patient visits a health care provider, is admitted to the hospital, or is transferred from unit to unit in the hospital, it is common to receive new prescriptions or to have changes made in currently prescribed drugs. The process of medication reconciliation is used during these transitions of patient care to avoid drug errors such as omissions, duplications, dosing errors, and drug interactions.

 

DIF:    Cognitive Level: Applying or Higher                                         REF:    p. 30

 

Chapter 16: Drug Therapy for Hypertension

Workman & LaCharity: Understanding Pharmacology: Essentials for Medication Safety, 2nd Edition

 

MULTIPLE CHOICE

 

BASIC CONCEPTS

 

  1. Which term means high blood pressure from no known cause?
a. Orthostatic hypertension
b. Orthostatic hypotension
c. Primary hypertension
d. Secondary hypertension

 

 

ANS:  C

Primary hypertension is defined as hypertension for which there is no known cause but is associated with risk factors; 85% to 90% of cases of hypertension are of this type.

 

DIF:    Cognitive Level: Remembering      REF:   p. 254

 

  1. What condition is a major cause of long-term high blood pressure?
a. Atherosclerosis
b. Bleeding disorders
c. Chronic liver disease
d. Diabetes insipidus

 

 

ANS:  A

High blood pressure causes arterial walls to thicken and harden. With atherosclerosis plaques are formed inside the walls of arteries. As arterial walls harden and thicken, the arteries become narrow resulting in increased blood pressure over time.

 

DIF:    Cognitive Level: Remembering      REF:   p. 254

 

  1. What types of over-the-counter drugs can worsen high blood pressure?
a. Drugs for asthma
b. Laxatives
c. Cortisone creams
d. Aspirin

 

 

ANS:  A

Patients with hypertension should not take over-the-counter drugs (such as drugs for appetite control, asthma, colds, and hay fever) without asking their prescriber. These drugs can cause worsening of high blood pressure because they all constrict blood vessels.

 

DIF:    Cognitive Level: Remembering      REF:   p. 251

 

  1. How do most diuretics lower blood pressure?
a. Preventing clots from forming
b. Promoting water and sodium loss
c. Constricting blood vessel muscles
d. Reversing atherosclerosis

 

 

ANS:  B

Diuretics are drugs that decrease blood pressure by eliminating excess water and salt from the body.

 

DIF:    Cognitive Level: Remembering      REF:   p. 256

 

  1. How do angiotensin-converting enzyme (ACE) inhibitors lower blood pressure?
a. Preventing clots from forming
b. Promoting water and potassium retention
c. Relaxing blood vessel muscles
d. Reversing atherosclerosis

 

 

ANS:  C

ACE inhibitors block production of substances that constrict (narrow) blood vessels. They also help decrease the buildup of water and salt in the blood and body tissues. The exact way that these drugs work is not known but they block an enzyme in the body that is necessary for production of angiotensin II (a substance that causes blood vessels to tighten or constrict). The result is that blood vessels relax and blood pressure is decreased.

 

DIF:    Cognitive Level: Remembering      REF:   p. 257

 

  1. Which side effect of ACE inhibitors is very common?
a. Hypertension
b. Difficulty sleeping
c. Constipation
d. Dry, hacking cough

 

 

ANS:  D

The more common side effects of ACE inhibitors include hypotension; protein in the urine; taste disturbances; increased blood potassium level (hyperkalemia); headache; and persistent, dry cough. If one ACE inhibitor causes a cough, it is likely that others will also, and the patient will need to be prescribed another type of antihypertensive drug.

 

DIF:    Cognitive Level: Remembering      REF:   p. 257

 

  1. What is a possible life-threatening adverse effect that can occur when a person is taking an ACE inhibitor?
a. Angioedema
b. Rebound hypertension
c. Loss of taste sensation
d. Rapid development of glaucoma

 

 

ANS:  A

Angioedema is a diffuse swelling of the eyes, lips, and tongue. It may occur with allergic reactions to ACE inhibitors and may be life threatening. Swelling of the trachea (windpipe/airway) can interfere with breathing, a life-threatening event. Angioedema can occur months or even years after ACE inhibitor therapy is started.

 

DIF:    Cognitive Level: Remembering      REF:   p. 258

 

  1. What substance should patients taking ACE inhibitors avoid?
a. Alcoholic beverages
b. Salt substitutes
c. Citrus fruits
d. Aspirin

 

 

ANS:  B

Teach patients to avoid salt substitutes. Salt substitutes contain potassium, and a side effect of ACE inhibitors is increased blood potassium level (hyperkalemia). Salt substitutes and ACE inhibitors together can significantly increase potassium levels.

 

DIF:    Cognitive Level: Remembering      REF:   p. 258

 

  1. Which drug is an angiotensin II receptor blocker (ARB)?
a. Lisinopril
b. Bumetanide
c. Ramipril
d. Losartan

 

 

ANS:  D

ARBs block the effects of angiotensin II (vasoconstriction, sodium, and water retention) by directly blocking the binding of angiotensin II to angiotensin II type 1 receptors. The generic names for ARBs end in “-sartan” (e.g., valsartan, losartan, candesartan).

 

DIF:    Cognitive Level: Remembering      REF:   p. 259

 

  1. Which condition can be a severe adverse reaction to angiotensin II receptor blockers?
a. Asthma
b. Heart failure
c. Kidney failure
d. Seizure activity

 

 

ANS:  C

Adverse effects of ARBs are rare but include kidney failure and life-threatening angioedema.

 

DIF:    Cognitive Level: Remembering      REF:   p. 259

 

  1. How do calcium channel blockers help to lower blood pressure?
a. Relaxing arteries and slowing heart contractions
b. Increasing constriction of muscles in veins
c. Inducing weight loss and reducing obesity
d. Increasing water and sodium loss

 

 

ANS:  A

Calcium channel blockers block calcium from entering the muscle cells of the heart and arteries. Blocking calcium causes a decrease in the contraction of the heart and also dilates (widens) the arteries. Widening the arteries causes a decrease in blood pressure and reduces the workload of the heart.

 

DIF:    Cognitive Level: Remembering      REF:   p. 260

 

  1. What side effect is common to calcium channel blockers?
a. Diarrhea
b. Leg and ankle swelling
c. Worsening of glaucoma
d. Dry, hacking cough

 

 

ANS:  B

The most common side effects of calcium channel blockers are constipation, nausea, headache, flushing, rash, edema (legs, ankles), hypotension, drowsiness, and dizziness.

 

DIF:    Cognitive Level: Remembering      REF:   p. 261

 

  1. Which drug for high blood pressure is a beta blocker?
a. Verapamil
b. Telmisartan
c. Captopril
d. Propranolol

 

 

ANS:  D

Beta blockers block the effects of epinephrine (adrenaline) on the heart. They decrease the heart rate and force of heart contractions, which leads to decreased blood pressure. As a result the heart does not work as hard and requires less oxygen. The generic names of beta blockers end with “-olol” (e.g., metoprolol, atenolol, propranolol).

 

DIF:    Cognitive Level: Remembering      REF:   p. 263

 

  1. Which condition is a possible severe adverse effect of beta blockers?
a. Difficulty breathing
b. Blood clots
c. Kidney failure
d. Worsening glaucoma

 

 

ANS:  A

Signs of beta blocker overdose include very slow heart rate, chest pain, severe dizziness or fainting, fast or irregular heart rate, difficulty breathing, bluish-colored fingernails and palms, and seizures. Report these signs and symptoms to the prescriber at once.

 

DIF:    Cognitive Level: Remembering      REF:   p. 263

 

  1. How do alpha blockers work to lower blood pressure?
a. Preventing clots from forming
b. Promoting water and potassium loss
c. Relaxing blood vessel muscles
d. Reversing atherosclerosis

 

 

ANS:  C

Alpha blockers block receptors in arteries and smooth muscle. This relaxes the blood vessels and leads to an increase in blood flow and a lower blood pressure.

 

DIF:    Cognitive Level: Remembering      REF:   p. 264

 

  1. What are the most common side effects of alpha blockers?
a. Shakiness and tremors
b. Leg and ankle swelling
c. Constipation and nausea
d. Dizziness and drowsiness

 

 

ANS:  D

The most common side effects of alpha blockers are dizziness, drowsiness, fatigue, headache, nervousness, irritability, stuffy or runny nose, nausea, pain in the arms and legs, hypotension, and weakness.

 

DIF:    Cognitive Level: Remembering      REF:   p. 265

 

  1. Which drug acts directly on the peripheral arteries, causing them to dilate and leading to decreased blood pressure?
a. Minoxidil (Loniten)
b. Propranolol (Inderal)
c. Captopril (Capoten)
d. Diltiazem (Cardizem)

 

 

ANS:  A

Minoxidil is a direct vasodilator that acts on peripheral arteries, causing them to dilate (widen) and leading to decreased blood pressure. Propranolol is a beta blocker, captopril is an angiotensin-converting enzyme inhibitor, and diltiazem is a calcium channel blocker.

 

DIF:    Cognitive Level: Remembering      REF:   p. 268

 

  1. Which class of antihypertensive drugs has a higher incidence of side effects?
a. Angiotensin-converting enzyme (ACE) inhibitors
b. Calcium channel blockers
c. Alpha-beta blockers
d. Direct vasodilators

 

 

ANS:  D

Direct vasodilators and centrally acting drugs have a higher incidence of side effects.

 

DIF:    Cognitive Level: Remembering      REF:   p. 269

 

ADVANCED CONCEPTS

 

  1. A patient’s blood pressure is consistently around 138/88 mm Hg. What does this reading represent?
a. Normal blood pressure
b. Prehypertension
c. Stage 1 hypertension
d. Stage 2 hypertension

 

 

ANS:  B

There are five classifications of hypertension (see Table 16-1 in the text). This patient’s blood pressure is consistently within the range for prehypertension.

 

DIF:    Cognitive Level: Understanding     REF:   p. 253

 

  1. What is the difference between primary hypertension and secondary hypertension?
a. Secondary hypertension is not as severe as primary hypertension.
b. Primary hypertension usually occurs at an earlier age than secondary hypertension.
c. Secondary hypertension is caused by another health problem, whereas primary hypertension does not have a known cause.
d. Primary hypertension can be treated with antihypertensive drugs, whereas secondary hypertension does not respond to drug therapy.

 

 

ANS:  C

Although there are many factors that contribute to the development of primary hypertension (e.g., obesity, smoking, stress, unhealthy diet), it has no single cause. (Many people with hypertension risk factors do not always develop hypertension.) On the other hand, secondary hypertension results from either another health problem or from the drug treatment of another health problem.

 

DIF:    Cognitive Level: Understanding     REF:   p. 254

 

  1. You are teaching a patient about antihypertensive therapy. Which statement by the patient indicates the need for more teaching?
a. “Now that my blood pressure is normal, I won’t need to take my medication anymore.”
b. “When I take my blood pressure at home, I always try to take it at just about the same time every day.”
c. “I check the labels on cans and other food packages to be sure they do not have too much sodium.”
d. “I hope that by continuing to lose weight, I might not have to take medications to manage my high blood pressure.”

 

 

ANS:  A

Antihypertensive drugs do not cure high blood pressure, they only control it. The patient must continue to take the drug to keep blood pressure at target levels unless the factors that are increasing the blood pressure are changed or eliminated. For example, sometimes blood pressure becomes normal again when the person is no longer overweight. In addition, if another drug is causing the hypertension, like corticosteroids, and the patient no longer needs to take that drug, blood pressure can become normal again.

 

DIF:    Cognitive Level: Applying or Higher                                         REF:    p. 255

 

  1. Which drug action is most likely to lower blood pressure?
a. Increasing the effectiveness of heart pumping
b. Relaxing (dilating) blood vessel smooth muscle
c. Increasing the concentration of urine
d. Retaining the body’s concentration of potassium

 

 

ANS:  B

The most common physiologic change that increases blood pressure is narrowing or constricting of the small arteries. Drugs that cause blood vessels to relax or dilate are most effective at lowering blood pressure.

 

DIF:    Cognitive Level: Understanding     REF:   p. 256

 

  1. Which action or precaution is most important for before giving any type of drug for hypertension?
a. Check the patient’s blood pressure.
b. Ensure that the patient is in a sitting position.
c. Check the patient’s pulse for regularity.
d. Have the patient drink a full glass of water.

 

 

ANS:  A

Drugs that lower blood pressure can make a normal pressure too low and can make a low blood pressure worse. Checking the patient’s blood pressure before giving a drug ensures that the patient is not hypotensive at the time he or she receives the drug. Some drugs can change the body’s electrolyte concentration so much that an irregular heart rate can occur; however, all antihypertensive drugs can lower blood pressure.

 

DIF:    Cognitive Level: Applying or Higher                                         REF:    p. 255

 

  1. You are checking a patient’s blood pressure before administering an antihypertensive. The reading of 88/52 mm Hg. What is your best action?
a. Give the patient a cup of coffee and retake the blood pressure in 30 minutes.
b. Document the finding as the only action and administer the drug as usual.
c. Raise the side rails and apply oxygen by mask or nasal cannula.
d. Hold the dose and notify the prescriber.

 

 

ANS:  D

This patient’s blood pressure is quite low. If the patient is receiving this drug because he or she has hypertension, another dose of the drug right now could make the patient’s blood pressure dangerously low. Sometimes a patient may be prescribed an antihypertensive drug for another reason. You must check with the prescriber before administering this antihypertensive drug dose.

 

DIF:    Cognitive Level: Applying or Higher                                         REF:    p. 255

 

  1. You give the first dose of an antihypertensive drug to a hospitalized patient. Which instruction should you give to the patient next?
a. “Stay in bed and call for help if you need to get up for any reason.”
b. “Urinate in a container so that we can keep track of your urine output.”
c. “If you develop a headache, we can give you some acetaminophen (Tylenol).”
d. “You may get up but only if you need to use the bathroom.”

 

 

ANS:  A

After taking the first dose of an antihypertensive drug, a patient may develop dizziness, light-headedness, or orthostatic hypotension. The patient should be given the call light and instructed to call for help getting up out of bed. The patient should also be instructed to change positions slowly.

 

DIF:    Cognitive Level: Applying or Higher                                         REF:    p. 265

 

  1. A patient prescribed a thiazide diuretic for hypertension reports having cramps and feeling like the heart is skipping beats. What side effect of this drug do you suspect?
a. Muscle breakdown
b. Orthostatic hypotension
c. Hypokalemia
d. Dysrhythmia

 

 

ANS:  C

A side effect of both thiazide and loop diuretics is loss of potassium resulting in hypokalemia (low blood potassium). Signs of hypokalemia include cramps, sudden decrease in urination, and irregular heartbeats.

 

DIF:    Cognitive Level: Applying (Application) or Higher         REF:   p. 257

 

  1. A patient taking a thiazide diuretic has the following blood laboratory values for kidney function. Which value will you report to the prescriber immediately?
a. Sodium 124 mEq/L
b. Potassium 3.6 mEq/L
c. Creatinine 0.9 mg/dL
d. Blood urea nitrogen 16 mg/dL

 

 

ANS:  A

Normal blood levels of sodium range between 135 and 145 mEq/L. The value listed here, 124 mEq/L, is low (hyponatremia) and can weaken the skeletal muscles, increasing the risk for falls. Most likely, the diuretic therapy caused the kidneys to excrete too much sodium.

 

DIF:    Cognitive Level: Applying or Higher                                         REF:    p. 257

 

  1. A patient asks you how atenolol (Tenormin) will help reduce hypertension. What is your best response?
a. “It will help your body rid itself of excess fluids and decrease the work your heart must do to pump blood.”
b. “It will help decrease built-up water and salt in your blood and tissues.”
c. “It will block vasoconstriction as well as salt and water retention.”
d. “It will decrease your heart rate and how hard your heart pumps.”

 

 

ANS:  D

Atenolol is a beta blocker that blocks the action of epinephrine on the heart. This results in a decreased heart rate and force of contraction, which leads to decreased blood pressure. As a result the heart does not work as hard and requires less oxygen.

 

DIF:    Cognitive Level: Applying or Higher                                         REF:    p. 262

 

  1. A patient taking metoprolol (Lopressor) for hypertension reports all of the following side effects. For which side effect will you notify the prescriber?
a. Increased urination during the daytime
b. Heart rate of 68 per minute
c. Chest pain during exercise
d. Decreased sexual ability

 

 

ANS:  C

Chest pain is never considered normal. Chest pain should be reported to the prescriber any time a patient experiences it because this is one symptom of many serious cardiac problems such as angina or heart attack.

 

DIF:    Cognitive Level: Applying (Application) or Higher         REF:   p. 264

 

  1. Which precaution is most important for you to teach a patient who has been prescribed a beta blocker drug for hypertension?
a. “Avoid alcoholic beverages while taking this drug.”
b. “Weigh yourself daily at the same time every morning.”
c. “Wear gloves and other warm clothing during cold weather.”
d. “Do not suddenly stop taking this drug without notifying your prescriber.”

 

 

ANS:  D

Beta blocker therapy increases the number of beta-adrenergic receptors in the heart and blood vessels. If these drugs are suddenly stopped, there are more beta receptors present and the patient’s own adrenaline (epinephrine and norepinephrine) can bind to these receptors and cause dangerously high blood pressure.

 

DIF:    Cognitive Level: Applying (Application) or Higher         REF:   p. 264

 

  1. A 38-year-old patient has been prescribed nadolol (Corgard) 80 mg daily for hypertension. The patient tells you that he has stopped taking the drug. What is your best first action at this time?
a. Instruct the patient to begin taking the drug immediately.
b. Ask the patient if he is experiencing side effects of the drug.
c. Document this finding in detail.
d. Immediately notify the prescriber.

 

 

ANS:  B

It is important to address the reason that the patient has stopped taking the drug at this time. Fairly common side effects of beta blockers include decreased sexual ability, dizziness, drowsiness, trouble sleeping, tiredness, and weakness. All of the other actions are important and appropriate, but do not focus on the patient’s concerns with regard to why he stopped taking the drug.

 

DIF:    Cognitive Level: Applying (Application) or Higher         REF:   p. 264

 

  1. A patient has a dose of labetalol (Normodyne) ordered twice a day and is due to have an exercise stress test this morning. What is your best action at this time?
a. Give the dose as ordered.
b. Hold the dose and notify the prescriber.
c. Give half the dose now and half after the procedure.
d. Ask the patient about chest pain, dizziness, and light-headedness.

 

 

ANS:  B

Labetalol is a beta blocker which decreases heart rate, force of heart contraction, and blood pressure. Its actions can affect the results of the test, causing inaccurate results.

 

DIF:    Cognitive Level: Applying or Higher                                         REF:    p. 266

 

  1. For which patient is labetalol (Normodyne) contraindicated as an antihypertensive drug?
a. 48-year-old woman who is going through menopause
b. 72-year-old man who has an enlarged prostate gland
c. 80-year-old woman with severe glaucoma
d. 60-year-old man with severe asthma

 

 

ANS:  D

Labetalol is a beta blocking agent. Although it relaxes blood vessel smooth muscle to lower blood pressure, it causes constriction of smooth muscles in the airways and can worsen asthma. It should be given to anyone with respiratory problems, especially severe asthma.

 

DIF:    Cognitive Level: Applying or Higher                                         REF:    p. 266

 

  1. A patient who has been prescribed enalapril (Vasotec) has developed a persistent nonproductive cough. What is your best action?
a. Ask the prescriber to order something for the patient’s cough.
b. Suggest that the family bring the patient some cough drops.
c. Offer the patient sips of water and ice chips.
d. Hold the dose and notify the prescriber.

 

 

ANS:  D

Development of a dry, persistent cough is a side effect of angiotensin-converting enzyme inhibitor drugs such as enalapril. The cough indicates that the patient is having a reaction to the drug. The drug needs to be discontinued and the patient should be started on another drug to control hypertension.

 

DIF:    Cognitive Level: Applying or Higher                                         REF:    p. 257

 

  1. A patient who has been taking lisinopril (Zestril) develops swollen lips and reports that the tongue feels thick. What is your best action?
a. Document the report and reassure the patient that this is a common drug side effect.
b. Check the patient’s pulse for rhythm and take the patient’s blood pressure.
c. Ask the patient whether this has ever happened before.
d. Hold the lisinopril dose and notify the prescriber.

 

 

ANS:  D

About 15% of patients taking an angiotensin-converting enzyme (ACE) inhibitor develop allergies to the drug with the first symptom angioedema (swelling) of the face, lips, tongue, and neck. The swelling can become severe enough to block the patient’s airway. Although this reaction is not usually as immediately life threatening as anaphylaxis, another dose of the drug would worsen the problem.

 

DIF:    Cognitive Level: Applying or Higher                                         REF:    p. 257

 

  1. An older patient has been prescribed an angiotensin-converting enzyme (ACE) inhibitor. Which precaution is most important for you to teach the patient about this drug?
a. “Avoid caffeinated drinks that may increase your blood pressure.”
b. “Take this drug at night so that you won’t be aware of nausea.”
c. “Change positions slowly when rising up from a sitting position.”
d. “Weigh yourself daily upon first arising in the morning.”

 

 

ANS:  C

Older adults are at greater risk for postural (orthostatic) hypotension when taking ACE inhibitors because of the cardiovascular changes associated with aging. Quickly changing from lying or sitting position to standing can lower blood pressure so rapidly that the patient can get dizzy or faint, leading to a fall.

 

DIF:    Cognitive Level: Applying or Higher                                         REF:    p. 259

 

  1. You are to give the first dose of enalapril (Vasotec) to a patient whose medication reconciliation indicates he also takes furosemide (Lasix) for hypertension. What action should you take?
a. Administer both drugs as prescribed.
b. Be sure to separate administering the two drugs by at least 6 hours.
c. Notify the prescriber that this patient already takes a drug for hypertension.
d. Suggest to the patient that he take the enalapril in the morning and the furosemide at bedtime.

 

 

ANS:  A

Sometimes hypertension is not well controlled using only one antihypertensive agent. Often two drugs from different classes are prescribed for better control. Enalapril is an angiotensin-converting enzyme inhibitor and furosemide is a “loop” diuretic. They have different mechanisms of action to lower blood pressure and can be taken together.

 

DIF:    Cognitive Level: Applying or Higher                                         REF:    p. 259

 

  1. A patient has been prescribed losartan (Cozaar). Which substance, drug, or activity do you teach the patient to avoid?
a. Oral contraceptives
b. Salt substitutes
c. Caffeine
d. Running

 

 

ANS:  B

Salt substitutes are mostly composed of potassium. Losartan is an angiotensin receptor blocker, and this class of drugs causes the kidneys to retain potassium. Taking in more potassium along with this drug could lead to high blood potassium levels (hyperkalemia), which has severe effects on heart contractility.

 

DIF:    Cognitive Level: Applying or Higher                                         REF:    p. 258

 

  1. How does the drug diltiazem (Cardizem) lower blood pressure?
a. Prevents angiotensin from binding to its receptors.
b. Blocks nerve stimulation of blood vessels.
c. Increases water and sodium loss.
d. Widens small arteries.

 

 

ANS:  D

Constricted blood vessels increase peripheral resistance and raise blood pressure. Calcium channel blockers work in several ways to lower blood pressure. The main way is by preventing calcium from entering smooth muscle cells in blood vessels, especially small arteries. With less calcium entering these smooth muscle cells, they are more relaxed, dilating (widening) the blood vessels.

 

DIF:    Cognitive Level: Understanding     REF:   p. 261

 

  1. An older adult man who takes verapamil (Calan) reports that his breasts have enlarged. What is your best action?
a. Ask the patient whether he has had any difficulty getting or maintaining an erection.
b. Document the response and reassure the patient that this is a common side effect.
c. Instruct the patient to use an elastic wrap to bind his breasts during the day.
d. Hold the drug dose and notify the prescriber.

 

 

ANS:  B

Breast enlargement (gynecomastia) is a common side effect of verapamil in men. The cause of the enlargement is not completely known, but it does not represent cancer or any health problem. Unless the patient is very distressed by the presence of the breast enlargement, it is not necessary to stop the drug.

 

DIF:    Cognitive Level: Applying or Higher                                         REF:    p. 261

 

  1. A patient who is taking nicardipine (Cardene) develops skin lesions, itching, fever, and achy joints. What is your best first action?
a. Hold the drug and notify the prescriber.
b. Document the finding as expected with this drug.
c. Administer a dose of oral diphenhydramine (Benadryl).
d. Apply a thin coat of hydrocortisone ointment to the lesions.

 

 

ANS:  A

An adverse effect of calcium channel blocker drugs is Stevens-Johnson syndrome (erythema multiforme), a skin disorder from an allergic reaction. It causes damage to blood vessels of the skin. Symptoms include many different types of skin lesions, itching, fever, joint aching, and generally feeling ill.

 

DIF:    Cognitive Level: Applying (Application) or Higher         REF:   p. 261

 

  1. You are teaching a patient who has just been prescribed prazosin (Minipress) for hypertension. You immediately notify the prescriber and question the order upon discovering that the patient is also taking which drug?
a. Aspirin
b. Atenolol (Tenormin)
c. Chlorothiazide (Diuril)
d. Sildenafil (Viagra)

 

 

ANS:  D

Sildenafil is a drug for erectile dysfunction and works by dilating blood vessels. When taken with an alpha blocker, sildenafil can cause a very rapid drop in blood pressure to the extent that the patient may fall or pass out.

 

DIF:    Cognitive Level: Applying or Higher                                         REF:    p. 265

 

  1. A patient with hypertension is prescribed terazosin (Hytrin). When should you administer the first dose of this drug to the patient?
a. In the morning to avoid waking the patient at night
b. With meals to avoid GI problems
c. With a full glass of water
d. At bedtime

 

 

ANS:  D

Orthostatic hypotension is a common side effect of the first dose of an alpha blocker drug. You should give the first dose at bedtime and caution the patient not to get up without assistance.

 

DIF:    Cognitive Level: Applying (Application) or Higher         REF:   p. 265

 

  1. A patient with hypertension and type 2 diabetes mellitus is taking carvedilol (Coreg). What special precaution should you teach the patient to take when taking this drug?
a. Check blood pressure in both arms.
b. Keep a strict record of intake and output.
c. Check blood sugar levels regularly.
d. Avoid sugar-containing drinks.

 

 

ANS:  C

Carvedilol is an alpha-beta blocker drug. These drugs can cause elevated blood glucose levels, so you should teach a patient with diabetes to monitor blood glucose levels regularly.

 

DIF:    Cognitive Level: Applying or Higher                                         REF:    p. 266

 

  1. You are teaching a patient how to administer clonidine (Catapres) using the transdermal patch system. How often do you teach the patient to change the patch?
a. Daily
b. Every 3 days
c. Every 7 days
d. Every 14 days

 

 

ANS:  C

The nature of the clonidine patch delivers a low dose of the drug continually from the patch for 7 days. After 7 days, minimal drug is left in the patch and the patient will no longer receive a therapeutic dose. To ensure a continual therapeutic dose, the patch is removed after 7 days and a fresh one applied.

 

DIF:    Cognitive Level: Understanding     REF:   p. 267

 

  1. Which antihypertensive drug would you teach a patient is considered safe for use during pregnancy or breastfeeding?
a. Clonidine (Catapres)
b. Methyldopa (Aldomet)
c. Labetalol (Normodyne)
d. Carvedilol (Coreg)

 

 

ANS:  B

Many drugs are not considered safe for use during pregnancy or breastfeeding. Methyldopa, a centrally acting adrenergic drug, has been used safely during both pregnancy and breastfeeding to treat hypertension. Hydralazine (Apresoline), a direct vasodilator, has also been used safely during both pregnancy and breastfeeding. However, small amounts of hydralazine pass into breast milk, putting infants at minimal risk for side effects.

 

DIF:    Cognitive Level: Understanding     REF:   p. 268

 

  1. Which statement by a patient prescribed enalapril (Vasotec) indicates the need for additional teaching?
a. “I will use a salt substitute instead of table salt when I eat.”
b. “I will avoid alcohol while I am taking this medication.”
c. “I will wear long sleeves, a hat, and sunscreen when I go outdoors.”
d. “I will call my prescriber immediately if I notice any swelling in my face.”

 

 

ANS:  A

Teach patients to avoid salt substitutes. Salt substitutes contain potassium, and a side effect of ACE inhibitors is increased blood potassium level (hyperkalemia).

 

DIF:    Cognitive Level: Applying or Higher                                         REF:    p. 258

 

  1. A 33-year-old female patient is currently taking captopril (Capoten) and metoprolol (Lopressor) to control her blood pressure. She tells you that she plans to become pregnant. What should you teach the patient about the use of this drug during pregnancy?
a. ACE inhibitors affect women differently than men.
b. ACE inhibitors have fewer side effects than other hypertension drugs.
c. ACE inhibitors should not be prescribed for women who are pregnant.
d. ACE inhibitors are only safe for use during the third trimester of pregnancy.

 

 

ANS:  C

ACE inhibitors should not be prescribed for women who are pregnant. They can cause low blood pressure, severe kidney failure, increased potassium, and even death in a newborn when used after the first trimester of pregnancy.

 

DIF:    Cognitive Level: Applying or Higher                                         REF:    p. 258

 

  1. A hospitalized patient prescribed nifedipine XL (Procardia) 60 mg once a day informs you that at home he was taking nicardipine (Cardene) 20 mg three times a day and thinks this is the wrong drug. What is your best action?
a. Give the dose as ordered after informing the patient that this is a new medication the prescriber wants him or her to take.
b. Hold the drug and contact the prescriber to clarify the order because of the patient’s concern before administering the dose.
c. Contact the pharmacy to ask what the prescriber ordered and if there was a mistake when the prescription was filled.
d. Administer the dose because nifedipine and nicardipine are from the same class of drugs and may be substituted for each other.

 

 

ANS:  B

Because of the patient’s question, it is essential to contact the prescriber to clarify the order. Both nifedipine and nicardipine are calcium channel blockers but may not be substituted for each other. Nifedipine XL is an extended release form of the drug that only needs to be taken once a day.

 

DIF:    Cognitive Level: Applying or Higher                                         REF:    p. 261

 

MULTIPLE RESPONSE

 

ADVANCED CONCEPTS

 

  1. Which statements are true about blood pressure? (select all that apply)
a. Blood pressure decreases when a person is resting.
b. Blood pressure increases when a person is active.
c. Low blood pressure is called hypotension.
d. Systolic blood pressure is the pressure against artery walls when the heart relaxes.
e. As people get older they are more likely to develop high blood pressure.
f. Primary hypertension is caused by another health problem or prescribed drug.

 

 

ANS:  A, B, C, E

Systolic blood pressure is the pressure of blood against the artery walls when the heart contracts. Diastolic blood pressure represents pressure against artery walls when the heart relaxes. The cause of primary hypertension is unknown while secondary hypertension is caused by another health problem or drug.

 

DIF:    Cognitive Level: Understanding     REF:   p. 253

 

  1. Which conditions or drugs can cause secondary hypertension? (select all that apply)
a. Adrenal gland tumors
b. Estrogen in birth control pills
c. Leukemia
d. Cortisol
e. Kidney infection

 

 

ANS:  A, B, D, E

Secondary hypertension is the result of other health problems or drugs. Table 16-2 in the text lists the health problems and drugs that can cause secondary hypertension.

 

DIF:    Cognitive Level: Understanding     REF:   p. 254

 

COMPLETION

 

ADVANCED CONCEPTS

 

  1. A patient who weighs 220 lb is to receive labetalol 0.25 mg/kg intravenously. The solution of labetalol on hand is 100 mg/20 mL. How many milliliters of labetalol will you prepare for a correct dose?

 

ANS:

5

 

1 kg = 2.2 lb. 220 lb/2.2 = 100 kg.

100 kg ´ 0.25 mg = 25 mg

100 mg/20 mL = 5 mg/1 mL

25/5 = 5 mL

 

DIF:    Cognitive Level: Applying or Higher                                         REF:    p. 262

 

  1. An adult patient is prescribed metoprolol (Lopressor) 50 mg orally twice a day. Metoprolol is available in 100 mg tablets. How many tablets will you give for each dose?

 

ANS:

0.5

 

100 mg/1 tablet : 50 mg/X tablet =  tablet (0.5 tablet).

 

DIF:    Cognitive Level: Applying or Higher                                         REF:    p. 262

 

  1. A child who weighs 68 lb and has very high blood pressure as a result of an adrenal gland tumor is prescribed a STAT dose of oral prazosin (Minipress) at 200 mcg/kg. You have on hand prazosin 2 mg/capsule. How many capsules will you administer to this child?

 

ANS:

3

 

1 kg=2.2 lb. 66/2.2 = 30 kg.

30 kg ´ 200 mcg = 6000 mcg (1000 mcg = 1 mg); 6000/1000 = 6 mg.

1 capsule = 2 mg. 6 mg/2 = 3 capsules.

 

DIF:    Cognitive Level: Applying or Higher                                         REF:    p. 264

 

 

Chapter 32: Drug Therapy for Female Reproductive Issues

Workman & LaCharity: Understanding Pharmacology: Essentials for Medication Safety, 2nd Edition

 

MULTIPLE CHOICE

 

BASIC CONCEPTS

 

  1. What is the most serious adverse effect of hormone replacement therapy for menopause?
a. Pregnancy
b. Blood clots
c. Miscarriage
d. Decreased mental concentration

 

 

ANS:  B

Hormone replacement therapy for perimenopausal symptoms uses different types of estrogens and sometimes progesterone. Exogenous use of these drugs increases the risk for forming blood clots where they are not needed, leading to the potential venous thromboembolism complications of deep vein thrombosis, strokes, and heart attacks.

 

DIF:    Cognitive Level: Remembering      REF:   p. 498

 

  1. Which hormone levels in the blood are reduced as a result of taking hormone replacement therapy for menopause?
a. Estrogen and progesterone
b. Estrogen and follicle stimulating hormone
c. Gonadotrophin releasing hormone and progesterone
d. Follicle stimulating hormone and gonadotrophin releasing hormone

 

 

ANS:  D

The blood levels of estrogen are increased during hormone replacement therapy, which reduces the release of gonadotrophin releasing hormone from the brain. With low levels of gonadotrophin releasing hormone, the anterior pituitary gland greatly reduces secretion of follicle stimulating hormone.

 

DIF:    Cognitive Level: Remembering      REF:   p. 494

 

  1. Which side effects are most common among women taking hormone replacement therapy for menopause?
a. Breast tenderness and fluid retention
b. Increased vaginal dryness and constipation
c. Nausea, vomiting, and diarrhea
d. Skin itching and dark-colored urine

 

 

ANS:  A

The most common side effects of hormone replacement therapy for perimenopausal symptoms are breast tenderness, breakthrough bleeding, fluid retention, weight gain, and acne. Vaginal dryness is reduced, not increased. Skin itching is reduced, not increased. Dark urine would be a symptom of the adverse effect of liver toxicity. These drugs are not commonly a cause of any gastrointestinal problems.

 

DIF:    Cognitive Level: Remembering      REF:   p. 496

 

  1. Which brand name oral contraceptive contains drospirenone?
a. Camila
b. Ovral
c. Yasmin
d. Zovia

 

 

ANS:  C

The brand of oral contraceptive known as Yasmin is a combination of drospirenone and ethinyl estradiol.

 

DIF:    Cognitive Level: Remembering      REF:   p. 497, Table 32-1

 

  1. Which female hormone supports pregnancy by directly maintaining the thickened uterine lining?
a. Estrogen
b. Progesterone
c. Luteinizing hormone
d. Follicle stimulating hormone

 

 

ANS:  B

Estrogen increases the thickness of the uterine lining and then progesterone maintains this lining making the uterus ready for implantation. Luteinizing hormone stimulates ovulation and follicle stimulating hormone causes the ovary to produce estrogen.

 

DIF:    Cognitive Level: Remembering      REF:   p. 493

 

  1. Which type of oral contraceptive drug must be taken every day of the month to be effective?
a. An estrogen-progestin combination
b. An estrogen only “mini” pill
c. A progestin-drospirenone combination
d. A progestin only “mini” pill

 

 

ANS:  D

Progestin only mini pills contain very low concentrations of only one hormone. Because the hormone levels are low, they must be taken daily, without any time off, to be effective.

 

DIF:    Cognitive Level: Remembering      REF:   p. 498

 

  1. A woman taking oral contraceptives reports the following changes. Which one is an expected side effect and requires no intervention?
a. Calf swelling
b. Severe constipation
c. Increased breast size
d. Heavier menstrual periods

 

 

ANS:  C

The hormones in oral contraceptives increase the growth of breast ductal tissue, often resulting in an enlargement of the breasts. This change is not pathologic and does not require intervention. Severe constipation is not related to oral contraceptive use. Calf swelling may indicate a blood clot and is a symptom that must be explored further. Most women have lighter menstrual periods.

 

DIF:    Cognitive Level: Remembering      REF:   p. 498

 

ADVANCED CONCEPTS

 

  1. A patient who has just been prescribed estrogen-based hormone replacement therapy (HRT) also has all of the following health problems. For which problem should you check with the prescriber to determine whether the patient should take HRT?
a. Asthma
b. Hypertension
c. Osteoporosis
d. Diabetes mellitus

 

 

ANS:  B

Common side effects of menopausal HRT include breast tenderness, breakthrough bleeding, fluid retention weight gain, and acne. These occur with conjugated estrogen alone and when combined with progesterone. Fluid retention can cause or worsen hypertension. If the patient’s hypertension is not well controlled, she should not be taking HRT.

 

DIF:    Cognitive Level: Applying or Higher                                         REF:    p. 498

 

  1. Which laboratory finding in a perimenopausal woman who takes Premarin should be reported to the prescriber?
a. Random blood glucose 116 mg/dL
b. Potassium 4.8 mEq/L
c. Sodium 146 mEq/L
d. Hematocrit 27%

 

 

ANS:  D

Premarin taken long-term can thicken the uterine lining and lead to severe dysfunctional uterine bleeding. A hematocrit of 27% is way below normal.

 

DIF:    Cognitive Level: Applying or Higher                                         REF:    p. 496

 

  1. A patient calls to report that her health care provider prescribed Premphase daily and her new bottle of pills says Prempro. What is your best advice?
a. Remind her that Prempro is just another brand of Premphase.
b. Instruct her to take the new bottle back to the pharmacy for replacement with Premphase.
c. Ask her whether she has already taken one of the Prempro and if she has to go to the nearest emergency department.
d. Instruct her to call her health care provider and request that the prescription be changed to Prempro 0.3 mg daily.

 

 

ANS:  B

Prempro and Premphase are sound alike drugs both of which are used to treat perimenopausal symptoms. They can be easily confused; however, because the amounts of hormone are different, these drugs cannot be interchanged.

 

DIF:    Cognitive Level: Applying or Higher                                         REF:    p. 494

 

  1. How does estrogen-based hormone replacement therapy (HRT) reduce perimenopausal symptoms?
a. By inhibiting ovulation and implantation.
b. By making periods more regular and predictable.
c. By inhibiting excessive secretion of follicle stimulating hormone.
d. By increasing the rate of normal involution and menopausal cessation.

 

 

ANS:  C

When the glandular cells of the ovary shrink, they no longer produce normal levels of estrogen. The decreased blood levels of estrogen trigger the brain to secrete GnRH, which then triggers the pituitary gland to secrete follicle stimulating hormone (FSH). Before menopause the FSH acts on the ovary and causes ovarian cells to secrete estrogen, which then inhibits the pathway through negative feedback. With nonfunctional ovarian cells unable to respond to FSH by increasing estrogen secretion, this pathway is disrupted for a time. The continued low blood levels of estrogen constantly stimulate the brain to secrete gonadotrophin releasing hormone (GnRH) in large amounts, resulting in the secretion of very large amounts of FSH. This extra FSH is useless because the ovary cannot respond to it and it has effects on other body tissues. The estrogen taken at this time suppressed GnRH and prevents excessive secretion of FSH, thereby reducing unpleasant symptoms.

 

DIF:    Cognitive Level: Understanding     REF:   p. 494

 

  1. A patient prescribed to take the oral contraceptive with the brand name Ortho Tri-Cyclen asks whether she should stop taking the pill for the 10 days that her husband is out of town on business. What is your best advice?
a. No, this drug’s protection against pregnancy requires taking the drug as prescribed.
b. No, the hormonal confusion this would cause could result in an increased risk for blood clots.
c. Yes, if you would normally have your period any time during the 10 days that your husband is away.
d. Yes, it is very important that your body experience drug-free period from time to time to ensure optimal drug effect.

 

 

ANS:  A

Hormonal contraceptives must be taken exactly as prescribed in order to prevent pregnancy. Even a 2 day miss of the drugs increases the risk for pregnancy.

 

DIF:    Cognitive Level: Applying or Higher                                         REF:    p. 498

 

  1. A woman who wants to use the oral contraceptive drospirenone ethinyl estradiol (Yasmin) is prescribed to take these other drug types daily. Which drug makes Yasmin a poor choice for her?
a. A corticosteroid inhaler
b. A nonsteroidal anti-inflammatory drug
c. An angiotensin-converting enzyme inhibitor
d. A combination opioid receptor agonist/antagonist agent

 

 

ANS:  C

Angiotensin-converting enzyme (ACE) inhibitors increase the reabsorption of potassium. Oral contraceptives that contain drospirenone also increase blood potassium levels. These two drugs should not be taken together.

 

DIF:    Cognitive Level: Applying or Higher                                         REF:    p. 498

 

  1. A woman who wants to take hormone replacement therapy (HRT) for perimenopausal discomfort expresses concern because her father died of a heart attack at age 78. What is your best response?
a. “If you have an electrocardiogram (ECG) performed every 6 months while you are on HRT, your risk for a heart attack will be reduced.”
b. “The risk for a heart attack while taking HRT is slightly higher, which is why the therapy is prescribed for as short a time period as possible.”
c. “Because it was your father who had the heart attack rather than your mother, you do not need to worry.”
d. “You are right to be concerned and are not a good candidate for this form of therapy.”

 

 

ANS:  B

Recent studies indicate that women taking estrogen-based HRT have a slightly higher incidence of myocardial infarction (heart attack). For this reason estrogen-based HRT is not recommended for long-term therapy. If she has no other risk factors for a heart attack, she can be considered for HRT. An ECG does not protect against heart attack. The genetic risks for conditions that increase the risk for a heart attack are not gender-based.

 

DIF:    Cognitive Level: Applying or Higher                                         REF:    p. 496

 

MULTIPLE RESPONSE

 

ADVANCED CONCEPTS

 

  1. Which statements about perimenopausal hormone replacement therapy (HRT) are true? (select all that apply)
a. Insomnia is a common side effect.
b. They slightly increase the risk for heart attacks.
c. They increase the chances of becoming pregnant.
d. Women taking them should avoid caffeine.
e. They are prescribed to prevent osteoporosis.
f. Weight may increase during therapy.
g. They should be used only by women who are sexually active.
h. They cannot be used by anyone who took oral contraceptives for more than 5 years.

 

 

ANS:  B, C, F

HRT does slightly increase the risk for heart attacks and increases the risk for clot formation. Although osteoporosis can be delayed by HRT, because of the heart attack and blood clot risk, they are not prescribed to prevent osteoporosis. Insomnia is a menopause problem. The low dose of estrogen helps prevent ovulation and does not increase the chances for becoming pregnant. HRT does cause water and fluid retention, which often causes some degree of weight gain and hypertension. Patients are prescribed HRT to control perimenopausal symptoms regardless of sexual activity. Caffeine restriction is not needed. A woman who took oral contraceptives for more than 5 years and had no clotting problems with them, can take HRT when it is needed.

 

DIF:    Cognitive Level: Understanding     REF:   pp. 494-496

 

  1. Which precautions are important to teach a patient who is taking hormone replacement therapy (HRT) to reduce menopausal discomfort? (select all that apply)
a. Use oral contraceptives.
b. Avoid cigarette smoking.
c. Avoid drinking alcoholic beverages.
d. Obtain a yearly influenza vaccination.
e. Perform monthly breast self-examinations.
f. Go to the hospital immediately if chest pains or symptoms of a stroke occur.

 

 

ANS:  B, E, F

HRT with estrogens increases the risk for clot formation that could cause venous thromboembolism, stroke, and heart attack. The risk is higher if the patient also smokes. Patients taking HRT should avoid cigarette smoking and should seek medical help immediately if chest pain or symptoms of a stroke occur. Hormones like estrogen can make breast cancers grow faster. The patient should perform monthly breast self-examinations to determine the presence of any lumps that could be cancerous. Although a yearly influenza vaccination is a good health promotion practice, HRT does not increase the risk for influenza. Oral contraceptives should not be used with HRT. There is no contraindication for drinking alcohol (in moderation) while taking HRT.

 

DIF:    Cognitive Level: Understanding     REF:   p. 496

 

COMPLETION

 

ADVANCED CONCEPTS

 

  1. A woman who is hospitalized overnight after surgery usually takes Premarin 2.5 mg daily for control of perimenopausal symptoms. Her prescriber orders a one-time dose of Premarin 2.5 mg orally as soon as possible. The drug on hand is Premarin 0.625 mg/tablet. How many tablets should you administer?

 

ANS:

4

 

Want 2.5 mg, Have 0.625 mg/tablet.

2.5 mg/0.625 mg/tablet = 4 tablets.

 

DIF:    Cognitive Level: Applying or Higher                                         REF:    p. 495

 

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