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NR 565 MIDTERM EXAM 2024 | ADVANCED
PHARMACOLOGY | ALL QUESTIONS AND
CORRECT ANSWERS | LATEST EDITION |
ALREADY GRADED A+
·· Which schedule drugs can APRNs prescribe? ------CORRECT ANSWER----------------- Schedule II-V · Who determines and regulates prescriptive authority? ------CORRECT ANSWER-------- ---------Nurse practitioner scope of practice is determined by state practice and licensure laws. · How does limited prescriptive authority impact patients within the healthcare system? - -----CORRECT ANSWER-----------------limited authority creates problems for the patient. The patient is not able to get the care they need · What are the key responsibilities of prescribing? ------CORRECT ANSWER--------------- --1. Be prudent and deliberate in your decision-making process
- Have a documented provider-patient relationship with the person for whom you are prescribing
- Do not prescribe medications for family or friends or for yourself
- Document a thorough history and physical examination in your records 5.Include any discussions you have with the patient regarding risk factors, side effects,
or therapy options
- Have a documented plan regarding drug monitoring or titration, if applicable Pharmakinetiscs and Pharmodynamics of older adults ------CORRECT ANSWER--------- --------drug accumulation secondary to reduced renal function polypharmacy (the use of five or more medications daily) greater severity of illness presence of comorbidities use of drugs that have a low therapeutic index (e.g., digoxin) increased individual variation secondary to altered pharmacokinetics inadequate supervision of long-term therapy During what trimester is a pregnant woman most at risk for adverse drug reactions with potential long term consequences? 1st trimester (fetus most at risk d/t rapid growth) What is BEERS criteria? Recommendations of medications inappropriate for elderly (65 and older), prescriber ultimately decides What is the CYP450 (cytochrome P450) liver enzyme system where medications are metabolized, can either be inducers or inhibitors and create drug-drug interactions CYP450 inducers
Antiepileptic drugs, antimicrobials such as tetracyclines and fluoroquinolones, vitamin A in large doses, some anticoagulants, and hormonal medications such as diethylstilbestrol (DES). How is absorption of intramuscular medications different in neonates? slow and erratic due to low blood flow in muscles first few days of life Why is absorption of medication in the stomach increased in infancy? delayed gastric emptying Some medications that should be avoided in the pediatric patient? glucocorticoids, discoloration of developing teeth with tetracyclines, and kernicterus with sulfonamides, levofloxacin (antibiotics) aspirin (Severe intoxication from acute overdose) what should be included in medication administration patient education? dosage size and timing route and technique of administration duration of treatment drug storage nature and time course of desired responses nature and time course of adverse responses finish taking antibiotic What are some things that put the elderly patient at higher risk for adverse drug reactions? reduced renal function polypharmacy (the use of five or more medications daily) greater severity of illness presence of comorbidities use of drugs that have a low therapeutic index (e.g., digoxin)
increased individual variation secondary to altered pharmacokinetics inadequate supervision of long-term therapy poor patient adherence How can healthcare providers decrease likelihood of an elderly patient experiencing an adverse drug reaction? obtaining a thorough drug history that includes over-the-counter medications considering pharmacokinetic and pharmacodynamics changes due to age monitoring the patient's clinical response and plasma drug levels using the simplest regimen possible monitoring for drug-drug interactions and iatrogenic illness periodically reviewing the need for continued drug therapy encouraging the patient to dispose of old medications taking steps to promote adherence and to avoid drugs on the Beers list How can we promote medication adherence with elderly patients? simplifying drug regimens providing clear and concise verbal and written instructions using an appropriate dosage form clearly labeling and dispensing easy-to-open containers developing daily reminders monitoring frequently affordability of drugs support systems Why do nitrates need to be taken no later than 4 PM? Need nitrate free interval so tolerance doesn't develop Nine factors that impact outcome of medication?
Nurse practitioners have the autonomy to evaluate patients, diagnose, order and interpret tests, initiate and manage treatments and prescribe medications, including controlled substances without physician oversight. What is reduced practice authority? Nurse practitioners are limited in at least one element of practice. The state requires a formal collaborative agreement with an outside health discipline for the nurse practitioner to provide patient care. ex/ physician involvement for 5 yrs than independent What is restricted practice authority? Nurse practitioners are limited in at least one element of practice by requiring supervision, delegation, or team management by an outside health discipline for the nurse practitioner to provide patient care.- typically doctor on site What are components of Rx? Prescriber Contact info Prescribers name NPI DEA Patient name DOB Date Allergies Medication name Strength Quantity Indication for use Direction for use Refills
Signature What are some potential problems that arise with written prescriptions? Must contain all elements May have pre-populated information Write legibly Avoid error prone abbreviations Tamper resistant scripts are often required Reasons for monitoring drug therapy determining therapeutic dosage evaluating medication adequacy identifying adverse effects serious or life-threatening risks. Which schedules of drugs can APRNs prescribe? depends on state - most II-V How does limited prescriptive authority impact patients within the healthcare system? longer wait times to sign a prescription limits practitioners that are needed in rural areas unequal relationships between providers. Ex. one has more power high need for providers due to lack of providers and high amounts of patients. Independent practitioners= more patients being seen= lessens the patient/provider load Provider key responsibilities when prescribing? safe and competent practice understanding of the drugs, reactions, and pharmacology Be aware of the age group you are prescribing to
Which statements are possible reasons for medication non-adherence? "I tried to take for weeks and it just wasn't working" "It was so expensive I only took it once a day instead of twice" "I dropped the whole medication bottle on the floor" "I was traveling and busy" "I lost the medication level" "I ran out" "I couldn't remember if I took it this morning and sometimes I just forget" What are black box warnings? Is the strongest safety warning a drug can carry and still remain on the market. Usually presented on the label with a heavy black border. Why are black box warnings issued? Issued by the FDA due to having serious or life-threatening risks What is neonate and infant drug dosing based on? weight or body surface area (BSA) After age one what happens to pharmacokinetic parameters, including drug sensitivity? mirror adult parameters Children under two have fast metabolism true How is absorption of transdermal medications different in neonates? more rapid and complete in infants than in older children and adults. the skin is very thin and blood flow is great in infants
How is absorption of oral medications different in neonates? absorption may be enhanced or impeded depending on the properties of the drug. gastric emptying is irregular, drugs absrobed in the intestine are absorbed slower. Common fears with genetic testing Lack of education - many health care providers do not possess the knowledge or comfort to interpret the tesgin financial cost - many insurance plans do not cover this. cost can be from $100-2000. discrimination from employers, insurance companies or providers 12 CDC guidelines for prescribing opioids Opioids are not first line therapy establish goals for pain and function Discuss risks and benefits Use immediate release opioids when starting Use the lowest effective dose Prescribe short durations for acute pain Evaluate benefits and harms frequently Use strategies to migrate risk Review PDMP data Use urine drug testing Avoid concurrent opioid and benzo prescribing Offer treatment for opioid use disorder Pure opioid agonist activate opioid receptors in brain resulting in opioid effect examples of pure opioid agonist
What is used to calculate pt's overdose risk? total morphine milligram equivalent (MME) per day to help assess the patient's overdose risk. If it is high (≥50 MME/day and especially ≥90 MME/day) Calculate total daily dose: 1. daily amount of each opioid that patient takes 2. convert to MME, multiply dose for each opioid by conversion factor 3. add them together What is MME and when to use? morphine milligram equivalent, represents the potency of an opioid in comparison to morphine, used to identify opioid prescription burden of a person What is the prescription drug monitoring program? electronic databases enable providers to access information regarding a patient's prescription history of controlled substances. Nearly all states have implemented PDMPs, and some states require providers to check the PDMP before prescribing controlled substances. When should PDMP be used? anytime a controlled substance is prescribed, refilled, or filled Why is PDMP important? identify those at risk for overdose Assess someone for possible drug diversion? Urine test at least yearly PDMP routinely How does renal and hepatic function impact medication levels in body?
Patients with renal or hepatic insufficiency can experience greater peak effect and longer duration of action for medications, thereby reducing the dose at which respiratory depression and overdose may occur. Similarly, for patients ages 65 years and older, reduced renal function and medication clearance due to age can result in a smaller therapeutic window between safe dosages and dosages associated with respiratory depression and overdose. How do elderly metabolize differently than younger people? Older adults metabolize opioids slowly and therefore require lower doses than younger adults. When should naloxone be prescribed? with every opioid prescription What is the typical dose of naloxone and how is it administered? 4 mg, nasal spray- one spray to one nostril If no response, additional doses can be given every 2 to 3 minutes until emergency services arrive In regards to dosage, why do we need to be cautious when giving naloxone? Dosage must be titrated carefully bc if too much is given the patient will swing from a state of intoxication to withdrawal What is the half-life of naloxone? Short- naloxone must be administered every few hours until opioid concentrations have dropped to nontoxic levels US Drug Enforcement Administration description of the scheduled drugs The DEA enacted the Controlled Substances Act (CSA) in 1970 to regulate drugs and other substances based on their potential for abuse and dependency. Five schedules of controlled substances were created that are updated annually. Classes of scheduled substances include narcotics, depressants,
substances, or chemicals are defined as drugs with a low potential for abuse and low risk of dependence example schedule IV Xanax, Soma, Darvon, Valium, Ativan, Talwin, Ambien, Tramadol Schedule V substances or chemicals are defined as drugs with lower potential for abuse than schedule IV and consist of preparations containing limited quantities of certain narcotics. Are generally used for antidiarrheal, antitussive, and analgesic purposes example schedule V drugs Cough preparations with less than 200 milligrams of Codeine or per 100 milliliters (Robitussin AC), Lomotil, Motofen, Lyrica, Parepectolin What type of analgesic for mild to moderate pain? tylenol, NSAID (Advil/motrin), COX2 inhibitors (like NSAIDS) What type of analgesic for moderate to severe pain? opioids When to start using short acting opioids? Should be used exclusively for acute pain in opioid naïve (never had before) patients as opposed to opioid tolerant patients Adverse effects of opioids constipation urinary retention orthostatic hypotension emesis
neurotoxicity (delirium, agitation) tolerance and physical dependence respiratory depression What are strong opioids analgesics usually reserved for? moderate to severe pain, postoperative pain, labor and delivery, cancer, chronic pain, hospice/palliative care, end of life, acute traumatic events, burns Use of opioids and these other medications should be avoided and why? respiratory depression with other drugs with CNS depressant action CNS depressants barbiturates benzo alcohol general aesthetics anti-histamines phenothiazine anticholinergic drugs atropine tricyclic antidepressants (constipation and urinary retention) what is the classic triad of symptoms for an opioid overdose? MAOI (hyperpyrexia coma) coma, resp depression, pinpoint pupuls How does strength of fentanyl compare to morphine high milligram potency (about 100 times that of morphine) through what system is fentanyl metabolized?
moderate to moderately severe What schedule is tramadol classified as? schedule IV What population should tramadol be AVOIDED in? pt's with epilepsy, neurologic disorders, elderly What drugs should be avoided for patients taking tramadol? CNS depressants (benzo, alcohol), MAOI, SSRI, serotonin and norepinephrine reuptake inhibitors, tricyclic antidepressants, triptans What government branch declared the opioid crisis a public health emergency? Health and Human Services (HHS) what are the top 5 priorities of HHS? Improving access to treatment and recovery services Promoting use of overdose-reversing drugs Strengthening our understanding of the epidemic through better public health surveillance Providing support for cutting edge research on pain and addiction Advancing better practices for pain management What were provisions made to the guidelines for prescribing opioids to non-cancer patients? Using opioids only after non-opioid analgesics or more conservative methods have failed Discussing the benefits and risks for long term opioids with patient When possible, one prescriber, one pharmacy Ensuring comprehensive follow up to assess efficacy and side effects of treatment and monitor for signs of opioid abuse Stopping opioids after an attempt at opioid rotation had produced inadequate benefits
Fully documenting the entire process When prescribing opioids should patient be initially started on IR or ER? IR- lowest dose for shortest amount of time How are patients initially exposed to opioids? either recreationally (illicitly) or in context of pain management in medical setting Which group of professionals are at greater risk for abusing? health care providers, nurses, pharmacists What are some effects of opioid use that DON'T change with long term use and tolerance? constipation and miosis (pupil constriction) tolerance does develop? euphoria, respiratory depression, and nausea Is opioid withdrawal life threatening? unpleasant but rarely dangerous Methadone can be used for which two therapies? maintenance- transferring addict from abuse opioid to oral methadone suppressive- prevent the reinforcing effects of opioid induced euphoria Methadone half life? long, prescribed only by providers with special training in pain management Does methadone or buprenorphine have a ceiling (drugs that impact on body plateus) to respiratory depression?
