ATI RN COMPREHENSIVE EXIT EXAM NG QUESTIONS&ANSWERS THIS DOCUMENT CONTAINS NEXT GEN QUESTIONS WITH CASE STUDIES 2023 1. Your patient is a 43 -year -old male who is initiating phenytoin maintenance treatment for generalized seizure disorder. He will take phenytoin 100mg PO TID with a goal plasma concentration between 10 – 20 mg/L. Resource As a supplement resource to Dr. Vicini’s lecture, please read the following article on the Principles of Nonlinear Pharmacokinetics. Mehvar R. Principles of Nonlinear Pharmacokinetics. Am J Pharm Edu 2001 (65): 178 -184. A. What type of pharmacokinetics are anticipated with phenytoin: linear or nonlinear? ▪ Nonlinear kinetics B. What equation should be used to calculate the elimination rate of phenytoin at steady state? ▪ Phenytoin is eliminated completely by metabolism and the kinetics can be defined b y the Michaelis -
Menten equation. At steady state, the elimination rate equals the metabolism rate. ▪ v = __Vmax ∙ Css___ KM + Css v=metabolism rate (which equals elimination rate in this scenario) Vmax=maximum rate of metabolism KM=Michaelis -Menten con stant Css=steady state concentration C. If your patient’s dose of phenytoin is increased from 300mg/day to 450mg/day, would you anticipate the AUC will be increased proportionally? ▪ No, the AUC of phenytoin would not be expected to increase proportion ally when the dose is increased because phenytoin exhibits nonlinear kinetics. For example, when the dose of phenytoin is increased by 50% from 300mg/day to 450mg/day, the average steady state concentration may increase by as much as ten -fold. 2 . A cl ient enters the emergency department unconscious via ambulance from the client’s work place. What document should be given priority to guide the direction of care for this client? C) A notarized original of advance directives brought in by the partner 3. The charge nurse has a health car e team that consists of 1 PN, 1 unlicensed assistive personnel (UAP) and 1 PN nursing student. Which assignment should be questioned by the nurse manager? A) An admission at the change of shifts with atrial fib rillation and heart failure 4. A mother brings her 3 month -old into the cli nic, complaining that the child seems to be spitting up all the time and has a lot of gas. The nurse expects to find which of the following on the initial history and physical as sessment? B) Restlessness and increased mucus production 5. A 69 -year -old male client is admitted to the ambulatory surgery unit for laparoscopic knee surgery. He reports past medical history of hypertension, hyperlipidemia, osteoarthritis, and atrial fi brillation. He is 6 feet tall and weighs 175 pounds. He denies any allergies to food or medications. Pre-op Orders: NPO IV 1000 mL LR @ 100 mL/hr Ondansetron hydrochloride 4 mg IV stat before anesthesia induction Fentanyl 75 mcg IVP stat Transfe r to OR Post -op Orders: NPO, advance to clear liquids as tolerated IV 1000 mL D5NS @ 125 mL/hr Nexium (esomeprazole magnesium) 20 mg IVP stat Morphine sulfate 2 mg IV once prn severe pain VS q 15 min X 4, q 30 min X 2 hr, q 1 hr X 2 hr Cold co mpresses to right knee 20 min q 1 hr Discharge when stable Discharge Orders: Losartan potassium -hydrochlorothiazide 100/12.5 mg PO daily Lovastatin 20 mg PO daily Warfarin 3.75 mg PO daily Nexium (esomeprazole magnesium) 20 mg PO 1 hr ac daily Hydrocodone 5 mg/Acetaminophen 500 mg PO q 6 hr prn pain Cold compresses to right knee 20 min q 1 hr Follow up appointment with surgeon in 1 week A. The ondansetron hydrochloride is supplied in vials labeled 32 mg/5 mL. a. Calculate how many mL the nurse will draw up for the prescribed dose. - The nurse will draw up 0.6 mL. b. What type of syringe will the nurse use to draw up the prescribed dose? - The nurse will use a 1 mL syringe. B. The fentanyl is supplied in vials labeled 0.05 mg/mL. a. Calculate how many mL the nurse will draw up for the prescribed dose. - The nurse will draw up 1.5 mL. b. What type of syringe will the nurse use to draw up the prescribed dose? - The nurse will use a 3 mL syr inge. C. Morphine sulfate is supplied as DURAMORPH (morphine sulfate injection, USP) 5 mg/10 mL in
Menten equation. At steady state, the elimination rate equals the metabolism rate. ▪ v = __Vmax ∙ Css___ KM + Css v=metabolism rate (which equals elimination rate in this scenario) Vmax=maximum rate of metabolism KM=Michaelis -Menten con stant Css=steady state concentration C. If your patient’s dose of phenytoin is increased from 300mg/day to 450mg/day, would you anticipate the AUC will be increased proportionally? ▪ No, the AUC of phenytoin would not be expected to increase proportion ally when the dose is increased because phenytoin exhibits nonlinear kinetics. For example, when the dose of phenytoin is increased by 50% from 300mg/day to 450mg/day, the average steady state concentration may increase by as much as ten -fold. 2 . A cl ient enters the emergency department unconscious via ambulance from the client’s work place. What document should be given priority to guide the direction of care for this client? C) A notarized original of advance directives brought in by the partner 3. The charge nurse has a health car e team that consists of 1 PN, 1 unlicensed assistive personnel (UAP) and 1 PN nursing student. Which assignment should be questioned by the nurse manager? A) An admission at the change of shifts with atrial fib rillation and heart failure 4. A mother brings her 3 month -old into the cli nic, complaining that the child seems to be spitting up all the time and has a lot of gas. The nurse expects to find which of the following on the initial history and physical as sessment? B) Restlessness and increased mucus production 5. A 69 -year -old male client is admitted to the ambulatory surgery unit for laparoscopic knee surgery. He reports past medical history of hypertension, hyperlipidemia, osteoarthritis, and atrial fi brillation. He is 6 feet tall and weighs 175 pounds. He denies any allergies to food or medications. Pre-op Orders: NPO IV 1000 mL LR @ 100 mL/hr Ondansetron hydrochloride 4 mg IV stat before anesthesia induction Fentanyl 75 mcg IVP stat Transfe r to OR Post -op Orders: NPO, advance to clear liquids as tolerated IV 1000 mL D5NS @ 125 mL/hr Nexium (esomeprazole magnesium) 20 mg IVP stat Morphine sulfate 2 mg IV once prn severe pain VS q 15 min X 4, q 30 min X 2 hr, q 1 hr X 2 hr Cold co mpresses to right knee 20 min q 1 hr Discharge when stable Discharge Orders: Losartan potassium -hydrochlorothiazide 100/12.5 mg PO daily Lovastatin 20 mg PO daily Warfarin 3.75 mg PO daily Nexium (esomeprazole magnesium) 20 mg PO 1 hr ac daily Hydrocodone 5 mg/Acetaminophen 500 mg PO q 6 hr prn pain Cold compresses to right knee 20 min q 1 hr Follow up appointment with surgeon in 1 week A. The ondansetron hydrochloride is supplied in vials labeled 32 mg/5 mL. a. Calculate how many mL the nurse will draw up for the prescribed dose. - The nurse will draw up 0.6 mL. b. What type of syringe will the nurse use to draw up the prescribed dose? - The nurse will use a 1 mL syringe. B. The fentanyl is supplied in vials labeled 0.05 mg/mL. a. Calculate how many mL the nurse will draw up for the prescribed dose. - The nurse will draw up 1.5 mL. b. What type of syringe will the nurse use to draw up the prescribed dose? - The nurse will use a 3 mL syr inge. C. Morphine sulfate is supplied as DURAMORPH (morphine sulfate injection, USP) 5 mg/10 mL in
