Lehne's Pharmacology for Nursing
Care
12th Edition
• Author(s)Jacqueline Rosenjack
Burchum; Laura D. Rosenthal
,TEST BANK
1. Question Number and Type: 1. MCQ
Clinical Scenario:
A 78-year-old patient with heart failure and moderate hepatic
impairment is prescribed a new medication that is highly
protein-bound and extensively metabolized by the liver.
Question Stem:
The nurse anticipates that this patient is at an increased risk for
which medication-related effect?
Answer Options:
A. Increased renal clearance of the drug
B. Decreased therapeutic effect due to first-pass metabolism
C. Increased free drug concentration and risk of toxicity
D. Decreased drug absorption from the gastrointestinal tract
Correct Answer: C
Detailed Rationale:
The correct answer is C. This patient has two significant risk
factors for elevated free drug levels: advanced age (geriatric)
and hepatic impairment. Many drugs are bound to plasma
proteins, primarily albumin. Only the free (unbound) fraction is
pharmacologically active. In conditions like liver disease or in
,older adults with decreased serum albumin, the number of
protein-binding sites is reduced. This leads to a higher
proportion of free drug. Additionally, the drug is metabolized by
the liver; hepatic impairment slows this process, further
increasing the drug's half-life and plasma concentration. The
combination of these factors creates a high risk for drug toxicity,
even at standard doses.
Incorrect Option Analysis:
• Why It Is Incorrect (A): This option is incorrect. Renal
clearance is primarily affected by kidney function, not
hepatic function or protein binding. While changes in
distribution can affect the amount of drug presented to
the kidneys, this is not the primary anticipated effect.
• Common Clinical Misconception: Students may believe
that the liver is responsible for both metabolism and
excretion, confusing the role of the liver (metabolism) with
that of the kidneys (excretion).
• Potential Medication Safety Risk: The risk is failing to
identify a patient at high risk for toxicity, leading to
standard dosing and potential adverse drug events.
• Appropriate Nursing Consideration: Assess baseline liver
function tests (AST, ALT, albumin) and monitor for signs of
drug toxicity.
, • Why It Is Incorrect (B): This option is incorrect. First-pass
metabolism is a phenomenon of oral drugs where they are
extensively metabolized in the liver before reaching
systemic circulation. It describes bioavailability, not
ongoing risk after the drug is in circulation. The scenario
already assumes the drug is being prescribed, meaning it
has survived first-pass metabolism.
• Common Clinical Misconception: Confusing the concept of
first-pass metabolism with the overall metabolism and
clearance of a drug from the body.
• Potential Medication Safety Risk: Underestimating the
impact of hepatic impairment on already prescribed drugs
by focusing on the initial absorption phase.
• Appropriate Nursing Consideration: Monitor for
therapeutic and adverse effects, as the drug’s
concentration will be higher and last longer than expected.
• Why It Is Incorrect (D): This option is incorrect. Absorption
is the process of drug movement from the site of
administration into the bloodstream. It is influenced by
factors like route of administration, gastric pH, and blood
flow to the absorption site, not by the liver’s metabolic
capacity.
• Common Clinical Misconception: Attributing all aspects of
drug processing to a single organ.
Care
12th Edition
• Author(s)Jacqueline Rosenjack
Burchum; Laura D. Rosenthal
,TEST BANK
1. Question Number and Type: 1. MCQ
Clinical Scenario:
A 78-year-old patient with heart failure and moderate hepatic
impairment is prescribed a new medication that is highly
protein-bound and extensively metabolized by the liver.
Question Stem:
The nurse anticipates that this patient is at an increased risk for
which medication-related effect?
Answer Options:
A. Increased renal clearance of the drug
B. Decreased therapeutic effect due to first-pass metabolism
C. Increased free drug concentration and risk of toxicity
D. Decreased drug absorption from the gastrointestinal tract
Correct Answer: C
Detailed Rationale:
The correct answer is C. This patient has two significant risk
factors for elevated free drug levels: advanced age (geriatric)
and hepatic impairment. Many drugs are bound to plasma
proteins, primarily albumin. Only the free (unbound) fraction is
pharmacologically active. In conditions like liver disease or in
,older adults with decreased serum albumin, the number of
protein-binding sites is reduced. This leads to a higher
proportion of free drug. Additionally, the drug is metabolized by
the liver; hepatic impairment slows this process, further
increasing the drug's half-life and plasma concentration. The
combination of these factors creates a high risk for drug toxicity,
even at standard doses.
Incorrect Option Analysis:
• Why It Is Incorrect (A): This option is incorrect. Renal
clearance is primarily affected by kidney function, not
hepatic function or protein binding. While changes in
distribution can affect the amount of drug presented to
the kidneys, this is not the primary anticipated effect.
• Common Clinical Misconception: Students may believe
that the liver is responsible for both metabolism and
excretion, confusing the role of the liver (metabolism) with
that of the kidneys (excretion).
• Potential Medication Safety Risk: The risk is failing to
identify a patient at high risk for toxicity, leading to
standard dosing and potential adverse drug events.
• Appropriate Nursing Consideration: Assess baseline liver
function tests (AST, ALT, albumin) and monitor for signs of
drug toxicity.
, • Why It Is Incorrect (B): This option is incorrect. First-pass
metabolism is a phenomenon of oral drugs where they are
extensively metabolized in the liver before reaching
systemic circulation. It describes bioavailability, not
ongoing risk after the drug is in circulation. The scenario
already assumes the drug is being prescribed, meaning it
has survived first-pass metabolism.
• Common Clinical Misconception: Confusing the concept of
first-pass metabolism with the overall metabolism and
clearance of a drug from the body.
• Potential Medication Safety Risk: Underestimating the
impact of hepatic impairment on already prescribed drugs
by focusing on the initial absorption phase.
• Appropriate Nursing Consideration: Monitor for
therapeutic and adverse effects, as the drug’s
concentration will be higher and last longer than expected.
• Why It Is Incorrect (D): This option is incorrect. Absorption
is the process of drug movement from the site of
administration into the bloodstream. It is influenced by
factors like route of administration, gastric pH, and blood
flow to the absorption site, not by the liver’s metabolic
capacity.
• Common Clinical Misconception: Attributing all aspects of
drug processing to a single organ.
