Pharmacology Practice Test #11: Respiratory and GI Medications

Answer: C. "These changes can be a serious side effect of montelukast. I need to let the provider know right away, and the child should be evaluated today. If the child talks about self-harm, stay with them and call 988 or 911."

Rationale: Montelukast, a leukotriene receptor antagonist, carries an FDA boxed warning for serious neuropsychiatric events, including nightmares and sleep problems, agitation, aggression, depression, and suicidal thoughts or behavior. These effects can occur in children and adults, during treatment or after it stops. A statement about not wanting to be here is a safety concern that needs same-day evaluation, and the provider must be told so the medication can be reviewed. Option A is wrong because it dismisses a known, serious adverse effect. Option B is wrong because changing the time of day does not address mood changes or suicidal statements. Option D is wrong because the rescue inhaler and other asthma medicines must not be stopped without the provider; only the provider decides how to change the asthma plan.

Answer: A. "I will use it once a day, every day, even when I am breathing well. It is not the inhaler for a sudden breathing attack."

Rationale: Tiotropium is a long-acting muscarinic antagonist (LAMA) used for daily maintenance bronchodilation in COPD. It has a slow onset and long duration, so it is taken on a regular schedule, usually once daily, whether or not the client has symptoms. A short-acting bronchodilator such as albuterol is the rescue inhaler for sudden symptoms. Option B is wrong because tiotropium is not a rescue medication. Option C is wrong because extra doses do not give fast relief and increase anticholinergic effects such as dry mouth, urinary retention and blurred vision; worsening breathing should be treated with the rescue inhaler and reported. Option D is wrong because some tiotropium products use a capsule that is placed in an inhaler device and inhaled; the capsule is never swallowed.

Answer: D. "When I start wheezing, I take a few extra puffs of my fluticasone-salmeterol to stop the attack."

Rationale: Salmeterol is a long-acting beta2 agonist (LABA) with a slow onset, and fluticasone is an inhaled corticosteroid that reduces airway inflammation over time. Neither is meant to relieve an acute attack, and taking extra doses raises the risk of LABA adverse effects such as tachycardia, tremor and palpitations without giving quick relief. Acute wheezing is treated with the short-acting rescue inhaler (albuterol), and frequent need for the rescue inhaler should be reported to the provider. Option A is correct teaching: rinsing and spitting after an inhaled corticosteroid lowers the risk of oral candidiasis (thrush) and hoarseness. Option B is correct: controller medications are used on schedule even without symptoms. Option C is correct: the rescue inhaler should always be available.

Answer: B. Instruct the client to hold the next theophylline dose and notify the provider, anticipating a serum theophylline level.

Rationale: Theophylline has a narrow therapeutic range. Tobacco smoke speeds up the liver enzymes (mainly CYP1A2) that break theophylline down, so smokers often need a higher dose. When a client stops smoking, theophylline clearance falls over the following weeks and the blood level can climb into the toxic range on an unchanged dose. Nausea, vomiting, tachycardia, restlessness and insomnia are early signs of toxicity; severe toxicity can cause dysrhythmias and seizures. The nurse should have the client hold the next dose and contact the provider, who will likely order a serum level and adjust the dose. Option A is wrong because assuming withdrawal could miss dangerous toxicity. Option C is wrong because caffeine is a methylxanthine like theophylline and adds to the stimulant effects. Option D is wrong because increasing the dose would worsen toxicity.

Answer: A. "I will swallow each capsule whole, and I will keep the bottle locked up and out of reach of my grandchildren."

Rationale: Benzonatate is a non-opioid antitussive that numbs stretch receptors in the airways. If the capsule is chewed, sucked, broken or dissolved in the mouth, it can cause rapid numbness of the mouth and throat, which can lead to choking, and severe reactions such as bronchospasm or laryngospasm have been reported. The FDA has warned that accidental ingestion by young children can cause serious harm and death, and the drug is not approved for children younger than 10 years. Clients should swallow capsules whole and store them securely away from children. Options B and D are wrong because chewing, dissolving or opening the capsule releases the drug in the mouth and throat. Option C is wrong because the medication is prescribed for this client only and is dangerous for a young child.

Answer: C. "Take it 30 to 60 minutes before breakfast, unless your provider tells you a different time."

Rationale: Proton pump inhibitors such as omeprazole block the proton pumps in the parietal cells, and they work best on pumps that are active. Pumps are activated by a meal, so taking the PPI 30 to 60 minutes before the first meal of the day lets the drug reach the cells as acid secretion starts. Some clients are prescribed twice-daily dosing or a different schedule, so the client should follow the provider's directions. Option A is wrong because PPIs do not work by coating the stomach, and taking them with a bedtime snack is not the usual timing. Option B is wrong because a PPI prescribed daily works by steady acid suppression and is not an as-needed medication like an antacid. Option D is wrong because taking it with a meal, rather than before, reduces its effect. Clients on long-term PPI therapy should also have the need reviewed regularly, because long-term use has been linked to low magnesium, low vitamin B12 and fractures.

Answer: D. "Take the ciprofloxacin at least 2 hours before your sucralfate dose. The pharmacist can help you set a schedule."

Rationale: Sucralfate forms a protective barrier over the ulcer base. It works best on an empty stomach, usually 1 hour before meals and at bedtime. Because it contains aluminum and binds other drugs in the GI tract, it can greatly reduce the absorption of medications such as ciprofloxacin and other fluoroquinolones, levothyroxine, digoxin, phenytoin and warfarin. Ciprofloxacin labeling advises giving it at least 2 hours before (or 6 hours after) sucralfate. The pharmacist can build a schedule around all the client's medications. Option A is wrong because taking them together would lower the antibiotic level and could lead to treatment failure. Option B is wrong because sucralfate is taken before meals, not with them. Option C is wrong because antacids should be separated from sucralfate (commonly by about 30 minutes), and the tablet is not mixed with them.

Answer: B. Instruct the client to hold the next metoclopramide dose and notify the provider promptly about the involuntary movements.

Rationale: Metoclopramide is a dopamine antagonist used to speed gastric emptying and treat nausea. It carries an FDA boxed warning for tardive dyskinesia, a movement disorder with involuntary movements of the face, lips, tongue and limbs that can become permanent. Risk rises with longer treatment and higher total dose, and older adults, especially women, are at higher risk. Treatment longer than 12 weeks is generally avoided unless the benefit clearly outweighs the risk. New involuntary movements should lead to holding the drug and prompt notification of the provider, who will usually discontinue it. Option A is wrong because these movements are not normal aging. Option C is wrong because a higher dose increases the risk. Option D is wrong because delay allows continued exposure and makes a permanent movement disorder more likely.

Answer: C. Review the client's most recent ECG for the QTc interval and report the low potassium and the methadone to the provider before giving the dose.

Rationale: Ondansetron, a serotonin 5-HT3 receptor antagonist, can prolong the QT interval, which raises the risk of torsades de pointes. The risk is higher when the client has low potassium or magnesium, heart failure, bradycardia, congenital long QT syndrome, or takes other QT-prolonging drugs such as methadone. Electrolyte problems should be corrected before or during therapy, and ECG monitoring is recommended for clients at risk. The nurse should check the QTc and inform the provider so they can decide whether to replace electrolytes, adjust the plan or choose another antiemetic. Option A is wrong because rapid IV administration is not recommended and does not address the cardiac risk. Option B is wrong because it ignores a correctable risk factor. Option D is wrong because the nurse cannot decide on permanent restrictions; the provider may still use ondansetron with monitoring or order a different antiemetic.

Answer: A. "Use a reliable form of birth control while taking misoprostol, and stop it and call your provider right away if you think you could be pregnant."

Rationale: Misoprostol is a prostaglandin E1 analog that protects the stomach lining in clients taking NSAIDs. It also stimulates uterine contractions and carries an FDA boxed warning: taken during pregnancy it can cause miscarriage, birth defects and uterine rupture. For people who could become pregnant, prescribers typically require a negative pregnancy test before starting and use of effective contraception during treatment, and the client must stop the drug and contact the provider immediately if pregnancy is possible. Option B is wrong because misoprostol is taken on schedule to prevent ulcers, not as needed for pain. Option C is wrong because diarrhea and abdominal cramping, not constipation, are the most common side effects. Option D is wrong because misoprostol is dangerous in pregnancy.