lOMoAR cPSD| 22896205
NR 565 Midterm Study Guide Sept 2025 Week 1
• Which schedule drugs can APRNs prescribe?
• DEA license will allow for prescribing of Schedules 2-5. There can be restrictions as
noted in collaborative agreement. May be facility/state dependent.
• Who determines and regulates prescriptive authority?
• Determines: Also known as independent prescribing. APRNS can prescribe without
limitation and is state dependent. Includes "legend" (prescription) and controlled drugs,
health/medical services, DME, etc.
Regulates: regulated by health professional board, state board of nursing or the State
Board of Medicine, or the State Board of Pharmacy, as determined by each state. Federal
government controls drug regulations but has no control over prescriptive authority.
• Prescriptive authority is the legal right to prescribe drugs.
• How does limited prescriptive authority impact patients within the healthcare
system?
• Limited prescriptive authority creates numerous barriers to quality, affordable, and
accessible patient care. For example, restrictions on the distance of the APRN or PA from
the physician providing supervision or collaboration may prevent outreach to area of
greatest need. An increase in patient waits.
• What are the key responsibilities of prescribing?
The ability to prescribe medications is both a privilege and a burden. Have a documented
provider-patient relationship, do not prescribe medications to family or friends or yourself,
Document a thorough history and physical examination, include any discussions you have
with the patient about risk factors, side effects, or therapy options, have documented plan
regarding drug monitoring or titration, if you consult additional providers not that you did
so. Use the references provided in the following boxes to assist in safely and rationally
choosing one medication over another.
pg. 1
, lOMoAR cPSD| 22896205
Be sensible, accept responsibility, do not fear it, know constraints and limitations, always
learn and update, keep Rx pads in safe place, confirm allergies, verify medication list with
patient, do not let insurance dictate quantity of Rx, Charting is key (particularly with off
label use), Provide use and rationale.
• What should be used to make prescribing decisions?
• The best way to keep your patients (and yourself) safe is to be prudent and deliberate in
your decision-making process. Cost, availability, current practice guidelines, medication
interactions including interactions with food, side effects, need for monitoring, how drug
is metabolized (hepatic or renal), special populations (pregnancy, nursing, older adults)
Cost: It is of critical importance that providers ask patients if they have difficulty
obtaining their medication because it is cost-prohibitive.
Guidelines: It is the provider's responsibility to keep abreast of new
recommendations or changes in guidelines and to incorporate these into their
prescribing practices.
Availability: The drug you want may not be available in your facility or at a specific
pharmacy. This can affect your choice of medications.
Interactions: There are very few medications that do not interact with either another
medication or food. Polypharmacy greatly increases the risk of interactions. Some of
these interactions are negligible, but some can have life-threatening consequences.
Side Effects: All drugs have side effects. Some are adverse, and some may
be beneficial.
Allergies: Unfortunately, your patient may have an allergy to that medication or class
of drug. It is of critical importance to determine the type of reaction and to document
it in the patient's chart. Then, the selection of an appropriate drug may begin.
pg. 2
, lOMoAR cPSD| 22896205
Hepatic and Renal Function: Many drugs are metabolized and eliminated by the liver
and kidneys. If these systems are impaired, this can lead to increased adverse effects
and possible medication overdose.
Need for monitoring: Some drugs require frequent monitoring at initiation or
throughout the duration of treatment.
Special Populations: Populations that deserve special mention when thinking about
medications include pregnant or nursing mothers and older adults.
• Be familiar with pharmacokinetic and pharmacodynamic changes of older
adults and how that would translate to baseline information needed to
prescribe.
• Pharmacokinetic is the study of drug absorption, distribution, metabolism,
and excretion in the body; what the body does to the drug.
Pharmacodynamic is what the drug does to the body.
• The ability of older adults to metabolize drugs is commonly decreased.
Drug dosages may need to be reduced to prevent drug toxicity.
• Physiologic Changes That Can Affect Pharmacokinetics in Older Adults
Absorption of Drugs
• Increased gastric pH
• Decreased absorptive surface area
• Decreased splanchnic blood flow
• Decreased gastrointestinal motility
• Delayed gastric emptying
• Distribution of Drugs
• Increased body fat
• Decreased lean body mass
• Decreased total body water
pg. 3
, lOMoAR cPSD| 22896205
• Decreased serum albumin
• Decreased cardiac output
• Metabolism of Drugs
• Decreased hepatic blood flow
• Decreased hepatic mass
• Decreased activity of hepatic enzymes
• Excretion of Drugs
• Decreased renal blood flow
• Decreased glomerular filtration rate
• Decreased tubular secretion
• Decreased number of nephrons
• Measures to Reduce Adverse Drug Reactions in Older Adults
• Take a thorough drug history, including over-the-counter medications, herbal
remedies, and dietary supplements
• Account for the pharmacokinetic and pharmacodynamic changes that occur with
aging
• Initiate therapy with low doses and titrating upward gradually (“start low and go
slow”)
• Monitor clinical responses and plasma drug levels to provide a rational basis for
dosage adjustment
• Employ the simplest medication regimen possible
• Monitor for drug–drug interactions and iatrogenic illness
• Periodically review the need for continued drug therapy, and discontinue
medications as appropriate
• Encourage the patient to dispose of old medications
• Take steps to promote adherence
• Avoid drugs included in Beers Criteria for Potentially Inappropriate Medication
Usein Older Adults (the Beers list) unless benefits outweigh risks.
pg. 4
NR 565 Midterm Study Guide Sept 2025 Week 1
• Which schedule drugs can APRNs prescribe?
• DEA license will allow for prescribing of Schedules 2-5. There can be restrictions as
noted in collaborative agreement. May be facility/state dependent.
• Who determines and regulates prescriptive authority?
• Determines: Also known as independent prescribing. APRNS can prescribe without
limitation and is state dependent. Includes "legend" (prescription) and controlled drugs,
health/medical services, DME, etc.
Regulates: regulated by health professional board, state board of nursing or the State
Board of Medicine, or the State Board of Pharmacy, as determined by each state. Federal
government controls drug regulations but has no control over prescriptive authority.
• Prescriptive authority is the legal right to prescribe drugs.
• How does limited prescriptive authority impact patients within the healthcare
system?
• Limited prescriptive authority creates numerous barriers to quality, affordable, and
accessible patient care. For example, restrictions on the distance of the APRN or PA from
the physician providing supervision or collaboration may prevent outreach to area of
greatest need. An increase in patient waits.
• What are the key responsibilities of prescribing?
The ability to prescribe medications is both a privilege and a burden. Have a documented
provider-patient relationship, do not prescribe medications to family or friends or yourself,
Document a thorough history and physical examination, include any discussions you have
with the patient about risk factors, side effects, or therapy options, have documented plan
regarding drug monitoring or titration, if you consult additional providers not that you did
so. Use the references provided in the following boxes to assist in safely and rationally
choosing one medication over another.
pg. 1
, lOMoAR cPSD| 22896205
Be sensible, accept responsibility, do not fear it, know constraints and limitations, always
learn and update, keep Rx pads in safe place, confirm allergies, verify medication list with
patient, do not let insurance dictate quantity of Rx, Charting is key (particularly with off
label use), Provide use and rationale.
• What should be used to make prescribing decisions?
• The best way to keep your patients (and yourself) safe is to be prudent and deliberate in
your decision-making process. Cost, availability, current practice guidelines, medication
interactions including interactions with food, side effects, need for monitoring, how drug
is metabolized (hepatic or renal), special populations (pregnancy, nursing, older adults)
Cost: It is of critical importance that providers ask patients if they have difficulty
obtaining their medication because it is cost-prohibitive.
Guidelines: It is the provider's responsibility to keep abreast of new
recommendations or changes in guidelines and to incorporate these into their
prescribing practices.
Availability: The drug you want may not be available in your facility or at a specific
pharmacy. This can affect your choice of medications.
Interactions: There are very few medications that do not interact with either another
medication or food. Polypharmacy greatly increases the risk of interactions. Some of
these interactions are negligible, but some can have life-threatening consequences.
Side Effects: All drugs have side effects. Some are adverse, and some may
be beneficial.
Allergies: Unfortunately, your patient may have an allergy to that medication or class
of drug. It is of critical importance to determine the type of reaction and to document
it in the patient's chart. Then, the selection of an appropriate drug may begin.
pg. 2
, lOMoAR cPSD| 22896205
Hepatic and Renal Function: Many drugs are metabolized and eliminated by the liver
and kidneys. If these systems are impaired, this can lead to increased adverse effects
and possible medication overdose.
Need for monitoring: Some drugs require frequent monitoring at initiation or
throughout the duration of treatment.
Special Populations: Populations that deserve special mention when thinking about
medications include pregnant or nursing mothers and older adults.
• Be familiar with pharmacokinetic and pharmacodynamic changes of older
adults and how that would translate to baseline information needed to
prescribe.
• Pharmacokinetic is the study of drug absorption, distribution, metabolism,
and excretion in the body; what the body does to the drug.
Pharmacodynamic is what the drug does to the body.
• The ability of older adults to metabolize drugs is commonly decreased.
Drug dosages may need to be reduced to prevent drug toxicity.
• Physiologic Changes That Can Affect Pharmacokinetics in Older Adults
Absorption of Drugs
• Increased gastric pH
• Decreased absorptive surface area
• Decreased splanchnic blood flow
• Decreased gastrointestinal motility
• Delayed gastric emptying
• Distribution of Drugs
• Increased body fat
• Decreased lean body mass
• Decreased total body water
pg. 3
, lOMoAR cPSD| 22896205
• Decreased serum albumin
• Decreased cardiac output
• Metabolism of Drugs
• Decreased hepatic blood flow
• Decreased hepatic mass
• Decreased activity of hepatic enzymes
• Excretion of Drugs
• Decreased renal blood flow
• Decreased glomerular filtration rate
• Decreased tubular secretion
• Decreased number of nephrons
• Measures to Reduce Adverse Drug Reactions in Older Adults
• Take a thorough drug history, including over-the-counter medications, herbal
remedies, and dietary supplements
• Account for the pharmacokinetic and pharmacodynamic changes that occur with
aging
• Initiate therapy with low doses and titrating upward gradually (“start low and go
slow”)
• Monitor clinical responses and plasma drug levels to provide a rational basis for
dosage adjustment
• Employ the simplest medication regimen possible
• Monitor for drug–drug interactions and iatrogenic illness
• Periodically review the need for continued drug therapy, and discontinue
medications as appropriate
• Encourage the patient to dispose of old medications
• Take steps to promote adherence
• Avoid drugs included in Beers Criteria for Potentially Inappropriate Medication
Usein Older Adults (the Beers list) unless benefits outweigh risks.
pg. 4
