Mnemonic PIRATES for Afib
P = pulmonary disease (COPD PE)
I = Ischemia (CAD)
R = Rheumatic heart disease (mitral stenosis)
A = Anemia (high out failure/tachycardia) atrial myxoma
T = thyrotoxicosis (tachycardia), Tox (cocaine)
E = Ethanol/endocarditis
S = Sepsis/sick sinus syndrom
1. A patient asks a primary care NP whether over-the-counter drugs are safer than prescription drugs. The NP should explain that over-the-counter drugs are:
A. generally safe when label information is understood and followed.
B. safer because over-the-cou
A. generally safe when label information is understood and followed
. A woman who is being treated with radiotherapy for breast cancer asks her primary care nurse practitioner (NP) about using dietary supplements to improve her chance of recovery. The NP should tell her that:
A. vitamin E is not harmful but has not been s
D. Vitamin C, taken atleast 6 days per week may lower her risk of cancer recurrence
Question 3.3. A patient with type 2 diabetes mellitus takes metformin (Glucophage) 1000 mg twice daily and glyburide (Micronase) 12 mg daily. At an annual physical examination, the BMI is 29 and hemoglobin A1c is 7.3%. The NP should:
A. begin insulin ther
A. Begin insulin therapy
2 common meds for first line treatment of HF
Diuretic and ACEI
Classes of Heart failure
I. w/ dz but without limitation in physical activity
II. w/dz resulting in slight limitation in physical activity, comfortable at rest
III. w/ dz and marked limitation of physical activity, comfortable at rest, less than ordinary activity causes fatigue
I
A patient comes to the clinic to discuss weight loss. The primary care NP notes a BMI of 32 and performs a health risk assessment that reveals no obesity-related risk factors. The NP should recommend:
A. orlistat (Xenical).
B. surgical intervention.
C. ch
D. Changes in diet and exercise along w/ short-term phentermine
Digoxin
inotropic, caused by enhancement of excitation-coupline triggered by membrane depolarization (acts as cellular membrane by inhibiting sodium-potassium pump, causing increase in intracellular Na
digoxin
increases Na/Ca exchange - ca accumulationin sacroplasmic reticulum
cardiac contractile protiens activated, actin and myosin-increased force of contraction of cardiac muscle
Increases CO and produces mild diuresis
As needed for systolic HF
Should not be g
digitalization can be achieved when?
w/in one week w/ small maint doses
Half life of digoxin
36 hours takes 5-6 days for steady state
Generic digoxin
may not be equivalent to branded digoxin (Lanoxin)
Digoxin dosing
Capsules: 0.4mg-0.6mg po, then 0.1-.03mg po q 6-8 hr (total of 0.6-1mg in 24 hrs)
Tabs: 0.5-0.75mg po , then 0.125-0.375mg po q 6-8hr (total of 0.75-1.25mg in 24 hrs)
Type of dosing to start with for digoxin
start w/ low dose and increase in 2-4 weeks if therapuetic not achieved
Maintenance dosing for digoxin
capsules 0.1-0.4mg po daily
tabs 0.125-0.5mg po daily
Maintenance dosing for digoxin w/ renal insufficiency
CrCl 10-50ml: 25-75% of dose
CrCl<10 10-25% of dose or regular dose Q 48 hr
Which of the following statements is true about the prescribing practices of physicians?
A. Older physicians tend to prescribe more
appropriate medications than younger
physicians.
B. Antibiotic medications remain in the top five
classifications of medica
D. the dominant form of drug information used by primary care physicians continues to be that provided by pharmaceutical companies
Monitoring requirements for digoxin
Monitor digoxin levels because it can be therapeutic w/ subtherapeutic drug level (0.5-0.8ng/ml)
Toxicity level of digoxin
level >2 (some become toxic at lower doses)
Levels drawn at least 6-8 hrs after last dose and ideally before next dose
Early signs of digoxin toxicity
increased fatigue, visual disturbances, brady, anorexia, weakness, nausea (will have nonspecific ST segment depression or T wave flattening
Treatment of digoxin toxicity
tx arrhythmias, digitalis-immune fragments of antibodies (FAB) is treatment digoxin intoxication (IV binds free dig. S/S w/in half hour)
A primary care NP is aware that many patients in the community use herbal remedies to treat various conditions. The NP understands the importance of:
A. learning about the actions, uses, doses, and
toxicities of these agents.
B. prescribing these agents w
A. learning about the actions, uses, doses, and toxicities of these agents
Pregnancy category of digoxin
Category C
Digoxin teaching
how to take pulse and not take w/o provider if heart rate<60; dont take otc meds (antacids, cough, cold or allergy meds)
Contraindications of digoxin
Vfib, vtach, dig tox, hypersensitivity, diastolic HF
Caution in:
SA and AV blocks (can prolong PR)
acute MI and other pulmonary dx may predispose to dig tox
can worsen brady w/ Sick sinus
cardiomyopathies will not respond to it
renal function impairment delays excrement
hypothyroid pts require less because of decreased
A patient who is at risk for DVT tells the primary care NP she has just learned she is pregnant. The NP should expect that this patient will use which of the following anticoagulant medications?
A. Aspirin
B. Heparin
C. Dabigatran
D. Warfarin
B. Heparin
Pharmcokinetics of digoxin
unless meal very high in fiber, food does not affect absorption. Widely distributed in tissues crosses blood brain barrier and placenta. Mostly not metabolized. 50-75% excreted unchanged from kidneys
As primary care nurse practitioners (NPs) continue to develop their role as prescribers of medications, it will be important to:
A. attain the same level of expertise as physicians
who currently prescribe medications.
B. learn from the experiences of phys
B. learn from the experiences of physicians and develop expertise based on evidenced-based practice
Adverse effects of digoxin
GI: most common; anorexia, NVD, abdominal pain, not feeling well
CNS: HA, weakness, apathy, drowsy, visual distrubances, yellow or green vision, depression, seizures, hallucinations, neuralgia, psychosis
Cardiac arrhythmias : (vtach and unifocal or multif
Drugs that increase dig levels
amiodarone, alprazolam, diazepam, bepridil, cyclosporine, diphenoxylate, indomethacin, clairthromycin, erythromycin, propafenone, propantheline, quinidine, spironlactone, tetracycline verapamil
decrease dig levels
amioglycosides, antacids, antineoplastics, charcoal, cholesytramine, colestiopol, kaolin, metoclorpramide, neomycin, penicillamine, rifampin, St Johns wort, sulfaslazine
Cardiac glyosides
increases force of myocardial contraction
depress SA node by stimulating vagal activity
prolong conduction to AV node via vagal stimulation
increase the refractory period of AV node
increase peripheral resitant
HR slowed
To improve HR symptoms
ACEIs, Arbs, bblockers, hydralazine/nitrates (African americans) aldosterone antagonists
A patient with a previous history of myocardial infarction (MI) who takes nitroglycerin for angina develops hypertension. The primary care NP is considering ordering an ACE inhibitor. Preliminary laboratory tests reveal decreased renal function. The NP sh
D. order a renal perfusion study before starting treatment
Loop diuretics in patients with fluid retention
furosemide over thiazide diuretic (start at 40mg po daily or 20mg for small, elderly patient, doseage gradually increased until relieved)
A 40-year-old woman tells the primary care nurse practitioner (NP) that she does not want more children and would like a contraceptive. She does not smoke and has no personal or family history of cardiovascular disease. She has frequent tension headaches.
D. low-estrogen COCP
Question 11.11. A postmenopausal woman develops NSID-induced ulcer. The primary care NP should prescribe:
A. ranitidine (Zantac).
B. omeprazole (Prilosec).
C. esomeprazole (Nexium).
D. pantoprazole (Protonix).
A. ranitidine (zantac)
A 52-year-old woman reports having hot flashes and intense mood swings. After a year of having irregular menstrual periods, she has not had a period for 6 months. The primary care NP should diagnose:
A. menopause.
B. dysmenorrhea.
C. perimenopause.
D. pos
C. Perimenopause
Question 14.14. An 80-year-old patient has begun taking propranolol (Inderal) and reports feeling tired all of the time. The primary care NP should: (Points : 2)
A. tell the patient to stop taking the medication immediately.
B. recommend that the patient
D. contact the patient's cardiologist to discuss decreasing the dose of propranolol
The primary care NP is preparing to prescribe a diuretic for a patient who has heart failure. The patient reports having had an allergic reaction to sulfamethoxazole-trimethoprim (Bactrim) previously. The NP should prescribe:
A. ethacrynic acid.
B. furose
A. ethacrynic acid ( a different kind of loop diuretic)
A patient who has diabetes mellitus and congestive heart failure takes insulin and warfarin. The patient will begin taking exogenous testosterone to treat secondary hypogonadism. The primary care NP should recommend:
A. increasing the dose of warfarin.
B.
B. more frequent blood glucose monitoring
A patient who has insulin-dependent type 2 diabetes reports having difficulty keeping blood glucose within normal limits and has had multiple episodes of both hypoglycemia and hyperglycemia. As adjunct therapy to manage this problem, the primary care NP s
A. pramlintide (Symlin)
A patient who has IBS experiences diarrhea, bloating, and pain but does not want to take medication. The primary care NP should recommend:
A. 25 g of fiber each day.
B. avoiding gluten and lactose in the diet.
C. increasing water intake to eight to ten gl
A. 25g of fiber each day
A patient takes an antispasmodic and an occasional antidiarrheal medication to treat IBS. The patient comes to the clinic and reports having dry mouth, difficulty urinating, and more frequent constipation. The primary care NP notes a heart rate of 92 beat
D. lower the dose of the antispasmodic
A patient comes to the clinic with a 4-day history of 10 to 12 liquid stools each day. The patient reports seeing blood and mucus in the stools. The patient has had nausea but no vomiting. The primary care NP notes a temperature of 37.9� C, a heart rate o
B. begin rehydration therapy
A woman who uses a transdermal contraceptive calls the primary care NP to report that while dressing that morning she discovered that the patch had come off and she was unable to find the patch. The NP should tell her to apply a new patch and:
A. take one
C. use condoms for the next 7 days
A patient who has migraine headaches has begun taking timolol and 2 months after beginning this therapy reports no change in frequency of migraines. The patient's current dose is 30 mg once daily. The primary care NP should:
A. change the medication to pr
D. tell the patient to continue taking the timolol and return in 1 month
ACEIs or ARBs in all patients unless contraindicated
Used in stage 1 before structural abnormalities
do not start if dehydrated- can cause renal failure
limiting factor : hypotension
cough from ACEI - change to ARB
start low dose and titrate up (every 1-2 weeks)
ACEIS: cause regression of L vent hypertrophy
A patient with CHF will begin therapy w a diuretic medication. The primary care NP orders lab tests, which reveal a GFR of 25ml/min. The initial drug the NP should prescribe is:
A. metolazone
B. furosemide (Lasix)
C. spironolactonce (Aldactone)
D. hydroch
A. metolazone
A patient who has a hx of angina has SL ntg to use prn. The primary care NP reviews this med with the patient at the patient's annual physical exam. Which statement by the patient indicates understanding of the medication?
A. I should call 911 if chest pa
A. I should call 911 if chest pain persists 5 mins after the first dose
The primary care NP sees a patient in the clinic who has a BP of 130/85. The patient's labs reveal high-density lipoprotein, 35mg/dl, triglycerides 120mg/dl, and fasting glucose, 100 mg/dl. The NP calculates a body mass index of 29. The patient has a posi
D. counsel the patient about dietary and lifestyle changes
A patient has been taking levothyroxine 100mcg daily for several months. The patient comes to the clinic w complaints of insomnia and irritability. The primary NP notes a heart rate of 92 beats per min. The NP should:
A. Change to liothyronine 75mcg/day
B
D. order tsh and t4 levels and decrease the dose to 75 mcg/day
The primary care NP is preparing to prescribe a drug and notes that the drug has nonlinear kinetics. The NP should:
A. monitor frequently for desired and adverse effects
B. administer a much higher initial dose as a loading dose
C. monitor creatinine clea
A. monitor frequently for desired and adverse effects
The primary care NP writes a prescription for an antibiotic using an electronic drug prescription system. The pharmacist will fill this prescription when:
A. the electronic prescription is received
B. the patient brings a written copy of the prescription
A. the electronic prescription is received
The primary NP sees a new patient for a routine physical exam. When auscultating the heart, the NP notes a heart rate of 78 bpm w occasional extra beats followed by a pause. Hx reveals no past cardiovascular disease, but the patient reports occasional syn
A. order ECG and refer to a cardiologist
The primary care NP prescribes an extended-cycle monophasic pill regimen for a young woman who reports having multiple partners. Which statement by the patient indicates she understands the regimen:
A. I have to take a pill only every 3 months
B. I should
B. I should expect to have only four periods each year
A patient who is taking trimethoprim-sulfamethoxazole for prophylaxis of urinary tract infections tells the primary care NP that a sibling recently died from a sudden cardiac arrest, determined to be from long QT syndrome. The NP should:
A. order a treadm
B. order genetic testing for this patient
A patient who has IBS has been taking dicyclomine and reports decreased pain and diarrhea but is now having occasional constipation. The primary care NP should recommend:
A. beginning treatment with an SSRI
B. beginning therapy with a TCA
C. OTC laxatives
C. OTC laxatives as needed when constipated
The primary care NP sees a new patient who has diabetes and hypertension and has been taking a thiazide diuretic for 6 months. The patient's bp at the beginning of treatment was 150/95. The BP today is 138/85. The NP should:
A. order a betablocker
B. add
B. add an angiotensin-converting enzyme inhibitor
A female patient who is underweight tells the primary care NP that she has been using bisacodyl (Dulcolax) daily for several years. The NP should:
A. prescribe docusate sodium (Colace) and decrease bisacodyl gradually
B. suggest she use Miralax on a daily
A. prescribe docusate sodium (Colace) and decrease bisacodyl gradually
A parent calls a clinic for advice about giving an otc medicine to a 6 yr old child. The parent tells the NP that the medication label does not give instructions about how much to give a child. The NP should:
A. order prescription antitussive med for the
B. ask the parent to identify all of the ingredients on the medication label.
A patient who has asthma and who is known to the primary care NP calls the NP after hours and asks for refill of an albuterol metered dose inhaler. The patient has not been seen in the clinic for more than a year. The NP should:
A. call the pharmacy to or
D. refill the drug and tell the patient that an office visit is necessary for further refills
A patient takes a cardiac medication that has a very narrow therapeutic range. The primary care NP learns that the particular brand the patient is taking is no longer covered by the patient's medical plan. The NP knows that the bioavailability of the drug
A. contact the insurance provider to explain why this particular formulation is necessary
A 50 yr old woman who is postmenopausal is taking an aromatase inhibitor as part of a breast cancer treatment regimen. She calls her primary care NP to report that she has had hot flashes and increased vaginal discharge but no bleeding. The NP should:
A.
A. schedule her for a gynecologic exam
A patient has NSAID-induced ulcer and has started taking ranitidine. At a follow up apt 3 days later, the patient reports no alleviation of symptoms. The primary care NP should:
A. order cimetidine
B. add metronidazole to the drug regimen
C. change from r
C. change from rantidine to omeprazole
An 80 yr old patient who has persistent AF takes warfarin (Coumadin) for anticoagulation therapy. The patient has an INR of 3.5. The primary care NP should consider:
A. lowering the dose of warfarin
B. rechecking the INR in 1 week
C. omitting a dose and r
B. rechecking the INR in 1 week
A patient undergoes a routine ECG, which reveals occasional premature ventricular contractions that are present when the patient is resting and disappear w/ exercise. The patient has no previous hx of CAD, and the cardiovascular exam in normal. The primar
B. tell the patient that treatment is not indicated
A patient who has an upper resp infection reports using otc cold preparations. The primary care NP should counsel this patient to use caution when taking additional otc meds such as:
A. antipyretics
B. calcium supplements
C. acid reflux meds
D. antioxidan
A. antipyretics
The primary care Np sees a new African-American patient who has blood pressure readings of 140/90, 130/85, and 142/80 on three separate occasions. The NP learns that the patient has a family hx of htn. The NP should:
A. initiate monotherapy with a thiazid
A initiate monotherapy with a thiazide diuretic
A patient has been using an herbal supplement for 2 yrs that the primary NP knows may have toxic side effects. The NP should:
A. Tell the patient to stop taking the supplement immediately
B. inform the patient of the risks of toxic side effects with this
B. inform the patient of the risks of toxic side effects with this supplement
A 45 yr old patient who has a positive family hx but no personal hx of CAD is seen by the primary care NP for a physical exam. The patient has a body mass index of 27 and a bp of 130/78. Lab tests reveal low-density lipoprotein 110, HDL 70, and triglyceri
A . 30 mins of aerobic exercise daily
The primary care NP refers a patient to a cardiologist who diagnoses long QT syndrome. The cardiologist has prescribed propranolol (Inderal). The patient exercises regularly and is not obese. the patient asks the NP what else can be done to minimize risk
A drink extra fluids when exercising
A child who has congenital hypothyroidism takes levothyroxine 75mcg/day. The child weighs 15kg. The primary care NP sees the child for a 3yr old check up. The NP should consult w the pediatric endocrinologist to discuss:
A. increasing the dose to 90mcg/da
C. stopping the medication and checking tsh and t4 in 4 weeks
A 5yr old has chronic constipation. The primary care NP plans to prescribe a laxative for long-term management. In addition to pharmacologic therapy, the NP should recommend _______g of fiber per day.
A. 10
B. 15
C. 20
D. 25
A. 10
A patient who has angina is taking ntg and long-acting nifedipine. The primary care NP notes a persistent bp of 90/60 at several follow up visits. The patient reports lightheadedness associated with standing up. The NP should consult with the patient's ca
C. verapamil
A patient reports taking antioxidant supplements to help prevent cancer. The primary care NP should:
A. review healthy diet practices with this patient
B. make sure that the supplements contain large doses of Vitamin A
C. tell the patient that antioxidant
A. review healthy dietary practices with this patient
A primary care NP has prescribed phentermine for a patient who is obese. The patient loses 10lbs in the first month but reports that the drug does not seem to be suppressing appetite as much as before. The NP should:
A. discontinue the phentermine
B. incr
A. discontinue the phentermine
A patient is taking drug A and drug B. The primary care NP notes increased effects of drug B. The NP should suspect that in this case drug A is a cytochrome P450 (CYP450) enzyme:
A. inhibitor
B. substrate
C. inducer
D. metabolizer
A. inhibitor
The primary care NP is prescribing a medication for an off label use. To help prevent a medication error, the NP should:
A. write "off label use" on the prescription and provide a rationale
B. call the pharamacist to explain why the instructions deviate f
A write "off label use" on the prescription and provide a rationale
A patient who takes digoxin reports that taking psyllium (Metamucil) three or four times each month for constipation. The primary care NP should counsel this patient to:
A. decrease fluid intake to avoid cardiac overload
B. change the laxative to docusate
C. take the digoxin 2 hours before taking the psyllium
A primary care NP prescribes a ntg transdermal patch, 0.4mg/hour release for a patient with chronic stable angina. The NP should teach the patient to:
A. change the patch 4 times a day
B. use the patch as needed for angina pain
C. use 2 patches daily and
D. apply one patch daily in the morning and remove in 12 hours
A primary care NP is prescribing a drug for a patient who does not take any other medications. The NP should realize that:
A. CYP450 enzyme reactions will not interfere with this drugs metabolism
B. substrates such as alcohol cannot interfere w the drug w
D. A thorough hx of diet, alcohol use, smoking, and over-the counter and herbal products is required
A patient who takes ntg for stable angina pectoris develops hypertension. The primary care NP should contact the patient's cardiologist to discuss adding:
A. amlodipine
B. dilitazem
C. verapamil
D. nifedipine
D. nifedipine
The primary care NP is seeing a patient for a hospital follow up after the patient has had a first myocardial infarction. The patient has a list of the prescribed medications and tells the NP that "no one explained anything about them". The NP's initial r
C. determine what the patient understands about coronary artery disease
A patient who has angina uses 0.4mg of SL NTG for angina episodes. The patient brings a log of angina episodes to an annual physical examination. The primary care NP notes that the patient has experienced an increase in frequency of episodes in the past m
D. Contact the patient's cardiologist to discuss admission to the hospital