NRNP 6566 Midterm Exam Review Questions With Answers Latest (Graded A+)

NRNP 6566 Midterm Exam Review Questions With Answers Latest (Graded A+) . Describe ways to lessen the hepatic first pass effect Some drugs, such as propranolol or enalapril, undergo significant metabolism during a single passage through the liver. This is called the first-pass effect. When drugs are highly susceptible to the first-pass effect, the oral dose needed to cause a response will be significantly higher than the intravenous dose used to cause the same response. Alternative routes of administration, such as suppository, intravenous, intramuscular, inhalational aerosol, transdermal, or sublingual, avoid the first-pass effect because they allow drugs to be absorbed directly into the systemic circulation. 4. Be able to calculate creatinine clearance using the Cockgraft Gault equation The Cockcroft-Gault formula for estimating creatinine clearance (CrCl) should be used routinely as a simple means to provide a reliable approximation of residual renal function in all patients with CKD. The formulas are as follows: - CrCl (male) = ([140-age] × weight in kg)/(serum creatinine × 72) - CrCl (female) = CrCl (male) × 0.85 5. Describe what determines the frequency of drug administration Plasma concentration data collected from this type of study is plotted against time and analyzed in order to understand the behavior of a specific drug in the body. This type of pharmacokinetic data, collected from average adults, is the basis for determining dose, dosing intervals, and limitations on the safe use of a drug. Absorption, distribution, metabolism, and elimination or ADME. 6. Be familiar with the Beers criteria and how to use it The 2019 update uses the five criteria outlined in 2015; these include medications that should typically be avoided in most older patients, medications that should be avoided in older patients with certain conditions, medications that should be used with caution because of benefits that may offset risks, medication interactions, and changes in dosing based on kidney function. In addition to these criteria, decisions about medications should take into account a variety of factors, including stopping medications when they are no longer beneficial. 7. Describe factors that affect absorption, distribution, metabolism and excretion The rate and extent of absorption depends on the route of administration, the formulation and chemical properties of the drug, and physiologic factors that can impact the site of absorption. The acid environment or presence of food in the stomach, the solubility and other chemical properties of the drug, and the effect of the initial exposure to metabolic processes in the liver may all reduce the amount of drug that reaches the systemic circulation after oral administration, thereby reducing the bioavailability of the drug. Patient variables that can affect distribution include body composition, cardiac decompensation (heart failure), age of the patient, and albumin levels. Factors affecting metabolism include genetics, age, and drug/drug reactions. 8. Define narrow therapeutic index How would you monitor a patient with a narrow therapeutic index? Narrow therapeutic index (NTI) drugs are defined as those drugs where small differences in dose or blood concentration may lead to dose and blood concentration dependent, serious therapeutic failures or adverse drug reactions. We defined the following drugs to be NTIdrugs: aminoglycosides, ciclosporin, carbamazepine, digoxin, digitoxin, flecainide, lithium, phenytoin, phenobarbital, rifampicin, theophylline and warfarin. Frequent lab monitoring would be needed to maintain the narrow index. 9. Describe how aging affect absorption, distribution, metabolism, and excretion With age, body fat generally increases and total body water decreases. Increased fat increases the volume of distribution for highly lipophilic drugs and may increase their elimination half-lives. Aging results in a number of significant changes in the human liver including reductions in liver blood flow, size, drug-metabolizing enzyme content, and pseudocapillarization. Drug metabolism is also influenced by comorbid disease, frailty, concomitant medicines, and genetics. Organ function gradually declines with age and the elderly may poorly tolerate drugs that require metabolism. Usually, age does not greatly affect clearance of drugs that are metabolized by conjugation and glucuronidation (phase II reactions). First-pass metabolism (metabolism, typically hepatic, that occurs before a drug reaches systemic circulation) is also affected by aging, decreasing by about 1%/yr after age 40. Week 2 and 3 1. Identify and describe 12 lead EKGs that demonstrate: a. 1 st, 2nd, and 3rd degree AV blocks b. STEMI in any lead (know what area of the heart is affected based on lead location) c. Atrial fibrillation and flutter d. Ventricular fibrillation and tachycardia e. Asystole EKG strips page 351. 2. Identify and describe the medications to treat each one of the EKGS listed in #1 1 st degree – Rarely needs treatment, Pacemaker if symptomatic. 2 nd degree – Rarely needs treatment, Evaluate meds, electrolytes, and thyroid function. Echo to R/O heart disease. 3 rd degree – IV atropine can be given for S/S of poor perfusion, immediate EP consult for pacemaker placement STEMI – MONA Afib/flutter – AV node blockers, beta blockers, antiarrhythmics. Cardioversion. Rate vs Rhythm V-fib – D-fib first followed by 1 mg Epinephrine, Amiodarone 300 mg, Mg 2 g. V-tach – Amiodarone, Mexiletine, Sotalol 3. Distinguish between dihydropyridine and non-dihydropyridine calcium channel blocker. Know what conditions each class would be used to treat. Dihydropyridines are more selective to smooth muscle. Because they reduce systemic vascular resistance and arterial pressure, dihydropyridines are used to treat hypertension. Two examples of medications in this class are amlodipine and nifedipine. Non-dihydropyridines are more selective to the myocardium. Verapamil has a very important role in treating angina (by reducing myocardial oxygen demand and reversing coronary vasospasm) and arrhythmias. Diltiazem is intermediate between verapamil and dihydropyridines because it is selective for vascular calcium channels. By having both cardiac depressant and vasodilator actions, diltiazem is able to reduce arterial pressure with a lower degree of reflex cardiac stimulation caused by dihydropyridines. Dihydropyridine causes peripheral vasodilation, while non-dihydropyridine calcium channel blockers directly relax the heart. Non-dihydropyridine calcium channel blockers should not be used on patients with heart failure or patients taking beta-blockers, diltiazem, or verapamil. Dihydropyridine can be used for patients with heart failure and patients on beta-blockers but can be associated with pedal edema. Dihydropyridine and non-dihydropyridine calcium channel blockers are used for hypertension, hypertensive crisis, angina, sinus tachycardia, PACs, atrial tachycardia, AVNRT, and AVRT. 4. Describe the medications to treat atrial fibrillation (rate, rhythm, and embolus prevention). Know the side effects, needed monitoring, and interaction for each of these medications for rate control. Beta blockers such as metoprolol, Inderal, or esmolol or Non-dihydropyridine calcium channel blockers, such as diltiazem or verapamil for rate control. Antiarrhythmics such as amiodarone for rhythm control. Anticoagulants such as ASA, coumadin, NOACs, or DOACs for embolus. A-fib treatment - Page 333. Monitor renal function & chest x-ray for pulmonary fibrosis. 5. Calculate a CHADS2 score and describe treatment based on the score 6. Calculate a HASBLED score and describe treatment based on the score 7. Describe the symptoms of hyperthyroidism, lab values that are altered, and medications to treat the disease and symptoms. Symptoms include: Hypermetabolism, heat intolerance, fatigue, anxiety, nervousness, manic behavior, confusion/restlessness, emotional lability, fine tremors, diaphoresis, hyperreflexia of DTRs, resting tachycardia. Exertional dyspnea, low-grade fever, weight loss, frequent bowel movements, fine/thin hair, smooth velvet skin, exophthalmos, eyelid lag, infrequent blinking, or irregular menstruation. Labs: TSH is low, while T3 and T4 are elevated. Elevated ESR and ANA. Hypercalcemia and anemia cause decreased granulocytes. High iodine uptake. Meds: Propranolol or metoprolol if resting HR 90. Tapazole 30-60 mg daily divided in 3 doses. 5-15 mg daily for maintenance. Propylthiouracil 300-600 mg daily in 4 doses, 100-150 mg daily for maintenance. Radioactive iodine or thyroid removal. 8. Identify when cardioversion is indicated and relevant testing that should occur prior to it. Afib or A-flutter, WPW, VT, V-fib without a pulse, and SVT and all rhythms that can indicate cardioversion. A TEE or anticoagulation for at least 3 weeks.