• Pharmacology Made Easy:
•
• 20 NCLEX Practice Questions on Drug
Interactions, Adverse Effects & Nursing
Interventions
Question 1
Clinical Scenario
A 72-year-old male with a history of hypertension, type 2
diabetes, and chronic kidney disease stage 3 is admitted to the
medical-surgical unit with pneumonia. The nurse is reviewing
the patient's home medication list during admission. The
patient reports taking lisinopril 20 mg daily, metformin 1000 mg
twice daily, and atorvastatin 40 mg daily. The patient's serum
creatinine is 2.1 mg/dL, and estimated GFR is 32
mL/min/1.73m².
Question Stem
Which action should the nurse prioritize during medication
reconciliation for this patient?
,A. Request an order to hold the atorvastatin until renal function
improves
B. Notify the provider that metformin may need to be held or
discontinued
C. Administer all home medications as prescribed to maintain
therapeutic levels
D. Increase the lisinopril dose to achieve better blood pressure
control
Correct Answer
B. Notify the provider that metformin may need to be held or
discontinued
Detailed Rationale
Correct Answer Explanation: Metformin carries a Black Box
Warning for lactic acidosis, particularly in patients with renal
impairment. With a GFR below 30 mL/min/1.73m², metformin
is generally contraindicated, and at a GFR of 30-45
mL/min/1.73m², dose reduction or discontinuation is
recommended depending on clinical factors. This patient's GFR
of 32 mL/min/1.73m² places him at significantly increased risk
for metformin accumulation and subsequent lactic acidosis,
which can be fatal. The nurse should notify the provider to
discuss whether to hold or adjust the metformin dose.
Why Incorrect Options Are Wrong:
, • Option A (Hold atorvastatin): While atorvastatin requires
dose adjustment in renal impairment, holding it is not the
priority. Atorvastatin is primarily metabolized by the liver
and is safer in renal impairment compared to other statins.
The medication can be continued with monitoring.
• Option C (Administer all medications): This demonstrates
a dangerous lack of clinical judgment. Administering all
home medications without recognizing the
contraindication in renal impairment could lead to serious
adverse events. Medication reconciliation requires critical
evaluation of each medication in the context of the
patient's current condition.
• Option D (Increase lisinopril): Increasing lisinopril in a
patient with renal impairment could worsen renal function
and cause hyperkalemia. ACE inhibitors require careful
monitoring and dose adjustment in renal disease, not
automatic upward titration.
Pharmacology Principles: Metformin is excreted unchanged by
the kidneys. Accumulation leads to increased lactate production
and decreased hepatic gluconeogenesis, creating a metabolic
environment conducive to lactic acidosis. Risk factors include
renal impairment, hepatic disease, acute illness, and concurrent
use of medications that affect renal function.
, Nursing Considerations: When a patient with renal impairment
presents for admission, the nurse must identify potentially
nephrotoxic or renally-cleared medications and communicate
concerns to the provider. Monitoring for signs of lactic acidosis
includes assessing for malaise, myalgia, respiratory distress,
abdominal pain, and altered mental status.
Clinical Reasoning Process: The nurse must apply
pharmacokinetic principles to recognize that medications
cleared by the kidneys will accumulate when renal function
declines, necessitating dose adjustment or discontinuation.
Patient Teaching: Patients taking metformin should be
educated about the signs of lactic acidosis and the importance
of reporting symptoms promptly. They should understand that
their medication may need to be held during acute illness,
dehydration, or when kidney function declines.
Learning Objective
After completing this question, the learner should be able to:
• Identify contraindications and precautions for metformin
use in renal impairment
• Recognize the importance of medication reconciliation in
identifying high-risk medication-disease interactions
• Prioritize nursing actions to prevent medication-related
adverse events
•
• 20 NCLEX Practice Questions on Drug
Interactions, Adverse Effects & Nursing
Interventions
Question 1
Clinical Scenario
A 72-year-old male with a history of hypertension, type 2
diabetes, and chronic kidney disease stage 3 is admitted to the
medical-surgical unit with pneumonia. The nurse is reviewing
the patient's home medication list during admission. The
patient reports taking lisinopril 20 mg daily, metformin 1000 mg
twice daily, and atorvastatin 40 mg daily. The patient's serum
creatinine is 2.1 mg/dL, and estimated GFR is 32
mL/min/1.73m².
Question Stem
Which action should the nurse prioritize during medication
reconciliation for this patient?
,A. Request an order to hold the atorvastatin until renal function
improves
B. Notify the provider that metformin may need to be held or
discontinued
C. Administer all home medications as prescribed to maintain
therapeutic levels
D. Increase the lisinopril dose to achieve better blood pressure
control
Correct Answer
B. Notify the provider that metformin may need to be held or
discontinued
Detailed Rationale
Correct Answer Explanation: Metformin carries a Black Box
Warning for lactic acidosis, particularly in patients with renal
impairment. With a GFR below 30 mL/min/1.73m², metformin
is generally contraindicated, and at a GFR of 30-45
mL/min/1.73m², dose reduction or discontinuation is
recommended depending on clinical factors. This patient's GFR
of 32 mL/min/1.73m² places him at significantly increased risk
for metformin accumulation and subsequent lactic acidosis,
which can be fatal. The nurse should notify the provider to
discuss whether to hold or adjust the metformin dose.
Why Incorrect Options Are Wrong:
, • Option A (Hold atorvastatin): While atorvastatin requires
dose adjustment in renal impairment, holding it is not the
priority. Atorvastatin is primarily metabolized by the liver
and is safer in renal impairment compared to other statins.
The medication can be continued with monitoring.
• Option C (Administer all medications): This demonstrates
a dangerous lack of clinical judgment. Administering all
home medications without recognizing the
contraindication in renal impairment could lead to serious
adverse events. Medication reconciliation requires critical
evaluation of each medication in the context of the
patient's current condition.
• Option D (Increase lisinopril): Increasing lisinopril in a
patient with renal impairment could worsen renal function
and cause hyperkalemia. ACE inhibitors require careful
monitoring and dose adjustment in renal disease, not
automatic upward titration.
Pharmacology Principles: Metformin is excreted unchanged by
the kidneys. Accumulation leads to increased lactate production
and decreased hepatic gluconeogenesis, creating a metabolic
environment conducive to lactic acidosis. Risk factors include
renal impairment, hepatic disease, acute illness, and concurrent
use of medications that affect renal function.
, Nursing Considerations: When a patient with renal impairment
presents for admission, the nurse must identify potentially
nephrotoxic or renally-cleared medications and communicate
concerns to the provider. Monitoring for signs of lactic acidosis
includes assessing for malaise, myalgia, respiratory distress,
abdominal pain, and altered mental status.
Clinical Reasoning Process: The nurse must apply
pharmacokinetic principles to recognize that medications
cleared by the kidneys will accumulate when renal function
declines, necessitating dose adjustment or discontinuation.
Patient Teaching: Patients taking metformin should be
educated about the signs of lactic acidosis and the importance
of reporting symptoms promptly. They should understand that
their medication may need to be held during acute illness,
dehydration, or when kidney function declines.
Learning Objective
After completing this question, the learner should be able to:
• Identify contraindications and precautions for metformin
use in renal impairment
• Recognize the importance of medication reconciliation in
identifying high-risk medication-disease interactions
• Prioritize nursing actions to prevent medication-related
adverse events
