Acute & Critical Care
A pharmacist is checking the ICU drips before her shift ends so she can let the midnight pharmacist know what drips will need to be made overnight. A 210 pound patient is receiving Precedex (200 mcg/50 mL NS) at 0.2 mcg/kg/hr. There is 25 mL remaining in the bag. Assuming a constant rate of infusion, how many more hours will the bag last? (Answer must be numeric; no units or commas; round the final answer to the nearest WHOLE number.)
Correct answer: 5
To provide the correct weight-based dose, the drip should be running at ~4.77 mL/hr. At this rate, the remaining 25 ml will last a little over 5 hours. In reality, a critical drip like this would be made well before it is allowed to run out (as stability allows). Refer to Flow Rates - Calculations IV for additional examples.
An elderly gentleman has been taking tramadol 50 mg 5-8 times daily for 12 months for back and joint pain. The patient also used lorazepam 1 mg 4-5 times daily over the same time period. If the patient attempts to stop either of these medications, he will experience shakiness, agitation and tachycardia due to which of the following?
A. Opioid hyperalgesia
B. Pseudo-addiction
C. Tolerance
D. Addiction
E. Physiological adaptation
E. Physiological adaptation
All patients using enough opioids (or benzodiazepines or barbiturates) will develop physical dependence if used chronically at regular dosing intervals. Physical withdrawal symptoms (e.g., shakiness, tachycardia and agitation) can develop when the opioid or benzodiazepine is abruptly stopped. Addiction implies a psychological need to use the drug, such as getting a "high" from the drug.
Refer to the sections) beginning on pg. 766 of 2022 RxPrep
What is the mechanism of action of misoprostol?
A. Proton pump inhibitor
B. Prostaglandin analog
C. Histamine-2 receptor antagonist
D. Coats the stomach with a protective lining
E. Prokinetic agent
B. Prostaglandin analog
Misoprostol (Cytotec) is a prostaglandin analog. It provides gut protection by replacing the Gl-protective prostaglandins depleted by chronic NSAID therapy. Both misoprostol and sucralfate are no longer used commonly, primarily due to the advent of the proton pump inhibitors.
A patient with end-stage alcoholic cirrhosis is admitted to the medical floor. His serum sodium level is 122 mEq/L. On physical exam, he has ascites and peripheral edema, but only mild shortness of breath. What is the preferred treatment for this patient's hyponatremia?
A. Desmopressin - start when serum sodium drops below 115 mEq/L.
B. Diuresis and fluid restriction - start now.
C. Lactated Ringer's - start now.
D. 0.9% NaCl - start when serum sodium level drops below 120 mEq/L.
E. Sodium chloride tablets by mouth - start now.
B. Diuresis and fluid restriction - start now.
Hypervolemic hyponatremia is common in patients with cirrhosis, heart failure and renal failure. The total body sodium is diluted in an increased volume.
Administering fluids to these patients will often worsen the hyponatremia.
Which of the following is an H2RA that is available in an IV formulation?
A. Famotidine
B. Metoclopramide
C. Nizatidine
D. Cimetidine
E. Misoprostol
A. Famotidine
An H2RA that comes in an IV formulation (for injection) is famotidine.
Which of the following agents are used as ICU sedatives? (Select ALL that apply.)
A. Ativan
B. Midazolam
C. Precedex
D. Diprivan
E. Levophed
A. Ativan
B. Midazolam
C. Precedex
D. Diprivan
Norepinephrine (Levophed) is used as a vasopressor in shock. Though midazolam is no longer branded, many in clinical practice still refer to it by the brand name Versed.
A patient has chronic back pain and requires both analgesic and anti-inflammatory effects. Previously, the patient had a GI bleed from chronic use of ibuprofen that he was purchasing over-the-counter. The physician will begin celecoxib therapy. The patient has the following medication history: hypertension, elevated triglycerides, myocardial infarction (twice), heart failure and alcoholism. Choose the correct statement regarding celecoxib use in this patient.
A. Celecoxib use must be limited to less than 5 days in this patient.
B. Celecoxib is not an appropriate choice for this patient.
C. A more appropriate option is Kadian.
D. A more appropriate option is Nucynta ER.
E. A more appropriate option is the Lidoderm patch.
B. Celecoxib is not an appropriate choice for this patient.
The patient has a high cardiovascular risk and should not use celecoxib. Nucynta ER and Kadian are long-acting formulations of morphine that cannot be used with alcohol; alcohol increases the absorption and could cause the patient to receive a dangerous or even fatal dose. The lidocaine patch would provide analgesia but no anti-inflammatory effects.
Refer to the sections) beginning on pg. 763 of 2022 RPrep Course Book.
GG is a 70-year-old patient who has had reflux symptoms for years but was using chewable calcium tablets when he felt discomfort. His healthcare provider wants to put him on a proton pump inhibitor, but since GG does not swallow well, he would like to prescribe one that comes as an orally disintegrating tablet (ODT). Which proton pump inhibitor is available as an ODT?
A. Rabeprazole
B. Dexlansoprazole
C. Pantoprazole
D. Esomeprazole
E. Lansoprazole
E. Lansoprazole
Lansoprazole is available in the Prevacid SoluTab formulation, which is an orally disintegrating tablet (ODT).
A patient in the ICU is receiving a dopamine drip at 44 mL/hr. The patient weighs 200 lbs and is receiving the hospital's standard dopamine drip (400 mg/250 mL).
What receptor effect should be expected from this dose?
A. Beta-i receptor agonism
B. Beta-1 receptor antagonism
C. Dopamine-1 receptor agonism
D. Alpha-1 receptor agonism
E. Alpha-1 receptor antagonism
D. Alpha-1 receptor agonism
The dose must be calculated first.
(400 mg / 250 mL) x (44 mL / 1hr) x (1 hr / 60 min) x (1000 mcg / 1 mg) = 1173.3333 mcg/min
200 lb / 2.2 = 90.9 kg
1173.3333 mcg/min / 90.9 kg = 12.9 mcg/kg/min
Alpha-1 agonism is expected at this dopamine drip rate of approximately 13 mcg/kg/min. Dopamine doses > 10 mcg/kg/min are considered high dose.
All of the following proton pump inhibitors come in capsules that can opened and mixed in applesauce EXCEPT:
A. Esomeprazole
B. Lansoprazole
C. Omeprazole
D. Pantoprazole
E. Dexlansoprazole
D. Pantoprazole
The PPis dexlansoprazole, esomeprazole, lansoprazole, omeprazole and rabeprazole have capsules that can be opened and sprinkled in applesauce.
A pharmacist is checking several ICU drips that were made by a technician. The first is a demedetomidine drip labeled with a final concentration of 2 mcg/mL. In reviewing the technician's notes and IV room waste, the technician used 2 mL from a dexmedetomidine vial (100 mcg/mL) and added this to 48 mL of NS to prepare a final volume of 50 mL. What is the correct final concentration of this drip in mcg/ml? (Answer must be numeric; no units or commas.)
Correct answer: 4
2 mL x 100 mcg/mL = 200 mcg. The prepared concentration is 200 mcg/50 ml or 4 mcg/mL. Refer to Calculations IV - Flow Rates for additional examples, though this is a simple concentration problem.
JS has been hospitalized for many months receiving chemotherapy. He is stabilized, and his pain is manageable on Dilaudid 2 mg IV Q3H. In anticipation of discharge, the medical team would like to convert him to an oral pain medication regimen. The palliative care physician wants to switch to MS Contin Q12H. How many milligrams of MS Contin PO Q12H is equivalent to JS's current Dilaudid regimen? (Answer must be numeric; no units or commas; round the final answer to the nearest WHOLE number.)
Correct answer: 160
Hydromorphone (Dilaudid) 1.5 mg IV is equivalent to morphine (MS Contin) 30 mg PO.
16 mg hydromorphone IV / X mg morphine PO = 1.5 mg hydromorphone IV / 30 mg morphine PO
x = 320 mg morphine PO daily (or MS Contin 160 mg PO Q12H)
Refer to the section(s) beginning on pg. 770 of 2022 RPrep Course Book.
An elderly female has hypertension, renal insufficiency (CrCl = 32 mL/min), mild memory loss, Parkinson disease and frequent episodes of GERD. She presents at the
pharmacy with a prescription for metoclopramide 10 mg QID. Which of the following statements is/are correct? (Select ALL that apply.)
A. She could experience more fatigue and sleepiness.
B. Her Parkinson disease symptoms will worsen.
C. Metoclopramide is a dopamine antagonist.
D. Metoclopramide is safe to use at the current dose prescribed.
E. Metoclopramide is a preferred treatment for GERD.
Metoclopramide (Reglan) is a dopamine-blocking agent and should be avoided, at any dose, in patients with Parkinson disease. It can worsen symptoms of Parkinson disease and has side effects of drowsiness and fatigue. It is not a preferred guideline-recommended treatment for GERD. If metoclopramide is used in someone with a CrCl ‹ 40 mL/min, the dose should be decreased by 50% to reduce the risk of CNS side effects or
Which of the following agents is a depolarizing neuromuscular blocking agent?
A. Succinylcholine
B. Pancuronium
C. Atracurium
D. Vecuronium
E. Cisatracurium
A. Succinylcholine
Succinylcholine is the only available depolarizing neuromuscular blocking agent. It is not used long-term in the ICU but is generally reserved for intubations.
A middle-aged gentleman has reflux symptoms. He has been diagnosed with GERD and told to purchase Prilosec OTC. The patient reports that he will use the medication whenever he gets symptoms, which occur 3-4 times per week. Choose the correct counseling statement.
A. This medication should be taken before bedtime.
B. This medication is best taken daily, before the morning meal.
C. This medication works best when taken as needed.
D. This medication should be started twice daily.
E. This medication should be taken immediately after eating,
B. This medication is best taken daily, before the morning meal.
Counseling points for PPIs: take before meals, consistently (they are not as effective when used as needed). For most Pls, if using once daily it should be taken before breakfast; if using twice daily, it should be taken before breakfast and dinner.
An ICU patient is receiving demedetomidine for sedation. Which of the following statements regarding demedetomidine is correct?
A. This agent has higher risk of causing respiratory depression compared to other sedatives.
B. The duration of the infusion should not exceed 72 hours.
C. Dexmedetomidine is an alpha-2 adrenergic antagonist.
D. Patients receiving demedetomidine must be intubated.
E. Patients are arousable and alert upon stimulation when using this agent.
E. Patients are arousable and alert upon stimulation when using this agent.
The duration of infusion should not exceed 24 hours. There is a lower risk of respiratory depression with demedetomidine than other sedatives, but the incidence (approximately 37%) is not low. Importantly, dexmedetomidine is an alpha-2 adrenergic agonist (same MOA as clonidine).
What is the lowest available strength for the fentanyl patch?
A. 50 mcg/hour
B. 100 mcg/hour
C. 25 mcg/hour
D. 12.5 mcg/hour
E. 5 mcg/hour
D. 12.5 mcg/hour
When approved, the FDA wanted to avoid dosing errors (12.5 mcg/hr vs. 125 mcg/hr). Thus, the 12 mcg/hour patch delivers 12.5 mcg/hour. The highest patch strength is 100 mcg/hour.
Metoclopramide is most commonly used for which condition?
A. H. pylori induced ulcers
B. Gastroesophageal reflux disease
C. Gastroparesis
D. Diarrhea
E. Peptic ulcer disease
C. Gastroparesis
Metoclopramide accelerates gastric emptying (increases peristalsis); it should not be used routinely for GERD. Use is typically reserved for patients with gastroparesis. It is dosed before meals and at bedtime.
Refer to the section(s) beginning on pg. 916 of 2022 RxPrep Course Book.
A patient picks up a prescription for an EpiPen for her son. Which of the following ratio strengths is used for epinephrine given by intramuscular administration?
A. 1:1,000
B. 1:500
C. 1:1,000,000
D. 1:10,000
E. 1:100,000
A. 1:1,000
Epinephrine |1:1,000] is used in epinephrine products designed for intramuscular or subcutaneous administration. The Institute for Safe Medication Practices (ISMP) has advocated for changes to epinephrine labeling due to frequent errors associated with confusion between the available strengths (1:1,000 vs. 1:10,000).
A pregnant female is asking the pharmacist for a recommendation for heartburn symptoms. The symptoms began during the third month of the pregnancy (she is currently 14 weeks pregnant). She states that whenever she eats anything, she has heartburn. She takes a daily prenatal vitamin. She gets adequate calcium from the vitamin and a cheese stick she eats with lunch. Choose the most appropriate recommendation.
A. Tagamet
B. Protonix|
C. Tums
D. Misoprostol
E. Metoclopramide
C. Tums
Calcium antacids are considered first-line in pregnancy.
KC is a 56-year-old male (85 kg) with a past medical history of COPD, hyperlipidemia and hypertension. He presented to the emergency room with shortness of breath, increased purulent sputum and fever of 102.1°F. His blood pressure did not respond to an initial fluid bolus and is now 78/50 mmHg. Broad-spectrum antibiotics are started. The physician decides to start a norepinephrine 4 mg/250 mL infusion to maintain a mean arterial pressure (MAP) above 65 mmHg. The nurse starts the infusion at a rate of 0.1 mcg/kg/minute. After 20 minutes, the patient's blood pressure is 88/56 mmHg. How should the infusion be adjusted based on the patient's target MAP?
A. Increase the infusion rate
B. Maintain the current infusion rate
C. Add on vasopressin
D. Decrease the infusion rate
E. Stop the infusion
B. Maintain the current infusion rate
MAP = (2 x DBP) + SBP|/3|
МАР = [(2 × 56) + 88]/3 = 66.667 mmHg
KC's MAP is at his goal of greater than 65 mmHg; the nurse should maintain the current infusion rate and there is no indication at this time to increase or decrease the rate. Vasopressin would be added if the patient worsens and is unable to achieve MAP goals on norepinephrine alone. We would not stop the infusion since this would cause the patient's pressure to drop. As the patient improves and the cause of hypotension resolves (in this case, a likely bacterial infection), norepinephrine can be slowly weaned off.
Which of the following analgesic agents are considered serotonergic and should be used carefully in combination with other serotonergic drugs? (Select ALL that apply.)
A. Methadone
B. Meperidine
C. Tramadol
D. Sulindac
E. Acetaminophen
A. Methadone
B. Meperidine
C. Tramadol
Alarm symptoms in GERD that may warrant additional testing include:
A. Cough, chest pain, bloody stools
B. Unintentional weight loss, dysphagia, hematemesis
C. Hypersalivation, cough, sore throat
D. Regurgitation, heartburn, choking
E. Cough, hypersalivation, acid taste
B. Unintentional weight loss, dysphagia, hematemesis
Patients with alarm symptoms should be sent immediately for further evaluation.
JH is a 55-year-old male who will be receiving his third IVIG treatment for autoimmune encephalopathy. He reports that he had been receiving steroid therapy for many years, but was changed to IVIG the previous fall when his symptoms worsened. He has presented to the infusion room. The pharmacist cannot locate the referring physician's paperwork and will attempt to conduct a pre-screening before the treatment. Which of the following screening questions should the pharmacist ask? (Select ALL that apply.)
A. Did the patient use any medications prior to the treatment to help lessen the side effects?
B. Is anyone in the house presently immunocompromised (e.g., family members with cancer or HIV)?
C. Are there any small infants in the house?
D. What is the name of the IVIG medication received previously, and is the patient aware of the dose?
E. Did the patient develop any reactions to the medication, either during the infusion, or afterward?
A. Did the patient use any medications prior to the treatment to help lessen the side effects?
D. What is the name of the IVIG medication received previously, and is the patient aware of the dose?
E. Did the patient develop any reactions to the medication, either during the infusion, or afterward?
The two incorrect choices would apply for certain immunizations but are not necessary prior to an IVIG infusion.
Case
History of Present Illness: SD is a 35-year-old male seen by his primary care provider for an annual check-up. SD reports daily stomach pain that is somewhat relieved by food.
Allergies: Penicillin (rash), ciprofloxacin (numbness)
Past Medical History: None
Medications: Has tried self-treating the pain with OTC Prilosec with no improvement
Tests: Urea breath test (negative)
QUESTION:
The provider suspects SD has H. pylori. What is the best indicator that his suspicions are correct based on the information
A. H. pylori occurs more frequently in patients with quinolone allergies
B. The negative urea breath test
C. Eating lessens the pain
D. Eating worsens the pain
E. H. pylori occurs more frequently in patients with penicillin allergies
C. Eating lessens the pain
Usually, with H. pylori infection, the pain will be lessened by eating, especially if the ulcer is in the duodenum. Although SD has a negative urea breath test, he has been using a PPI which can cause a false negative result. PPls, antibiotics and bismuth products must be discontinued 2 weeks prior to testing.
Refer to the sections) beginning on pg. 917 of 2022 RxPrep Course Book.