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1. A teenage patient is admitted to the hospital because of acetaminophen (Tylenol) overdose. Overdoses ofacetaminophen can precipitate life-threatening abnormalities in which of the following organs?1. lungs2. liver3. kidneys4. adrenal glands
(2) Acetaminophen is extensively metabolized by pathways in the liver. Toxic doses of acetaminophen deplete hepaticglutathione, resulting in accumulation of the intermediate agent, quinine, which leads to hepatic necrosis. Prolongeduse of acetaminophen may result in an increased risk of renal dysfunction, but a single overdose does not precipitatelife-threatening problems in the respiratory system, renal system, or adrenal glands.
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2. A contraindication for topical corticosteroid usage in a patient with atopic dermatitis (eczema) is:1. parasite infection.2. viral infection.3. bacterial infection.4. spirochete infection.
(2) Topical agents produce a localized, rather than systemic effect. When treating atopic dermatitis with a steroidalpreparation, the site is vulnerable to invasion by organisms. Viruses, such as herpes simplex or varicella-zoster, presenta risk of disseminated infection. Educate the patient using topical corticosteroids to avoid crowds or people known tohave infections and to report even minor signs of an infection. Topical corticosteroid usage results in little danger ofconcurrent infection with these agents.
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3. In infants and children, the side effects of first generation over-the-counter (OTC) antihistamines, such asdiphenhydramine (Benedryl) and hydroxyzine (Atarax) include:1. Reye’s syndrome.2. cholinergic effects.3. paradoxical CNS stimulation.4. nausea and diarrhea.
(3) Typically, first generation OTC antihistamines have a sedating effect because of passage into the CNS. However, insome individuals, especially infants and children, paradoxical CNS stimulation occurs and is manifested by excitement,euphoria, restlessness, and confusion. For this reason, use of first generation OTC antihistamines has declined, and secondgeneration product usage has increased. Reye’s syndrome is a systemic response to a virus. First generation OTCantihistamines do not exhibit a cholinergic effect. Nausea and diarrhea are uncommon when first generation OTC antihistaminesare taken.
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4. Reye’s syndrome, a potentially fatal illness associated with liver failure and encephalopathy is associated withthe administration of which over-the-counter (OTC) medication?1. acetaminophen (Tylenol)2. ibuprofen (Motrin)3. aspirin4. brompheniramine/psudoephedrine (Dimetapp)
(3) Virus-infected children who are given aspirin to manage pain, fever, and inflammation are at an increased risk ofdeveloping Reye’s syndrome. Use of acetaminophen has not been associated with Reye’s syndrome and can be safelygiven to patients with fever due to viral illnesses. Ibuprofen adverse effects include GI irritation and bleeding, and intoxic doses, both renal and hepatic failure are reported. However, ibuprofen has not been associated with the onset ofReye’s disease. Brompheniramine/psudoephedrine contains a first generation OTC antihistamine and a decongestant.Neither agent has been associated with the development of Reye’s syndrome.
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5. Patients who are allergic to intravenous contrast media are usually also allergic to which of the followingproducts?1. eggs2. shellfish3. soy4. acidic fruits
(2) Some types of contrast media contain iodine as an ingredient. Shellfish also contain significant amounts of iodine.Therefore, a patient who is allergic to iodine will exhibit an allergic response to both iodine containing contrast mediaand shellfish. These products do not contain iodine.
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6. A 14-month-old child recently arrived in the United States from a foreign country with his parents and needschildhood immunizations. His mother reports that he is allergic to eggs. Upon further questioning, youdetermine that the allergy to eggs is anaphylaxis. Which of the following vaccines should he not receive?1. hepatitis B2. inactivated polio3. diphtheria, acellular pertussis, tetanus (DTaP)4. mumps, measles, rubella (MMR)
(4) The measles portion of the MMR vaccine is grown in chick embryo cells. The current MMR vaccine does not containa significant amount of egg proteins, and even children with dramatic egg allergies are extremely unlikely to havean anaphylactic reaction. However, patients that do respond to egg contact with anaphylaxis should be in a medicallycontrolled setting where full resuscitation efforts can be administered if anaphylaxis results. The vaccines in options1–3 do not contain egg protein.
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7. The Gell and Coombs classification system categorizes allergic reactions and is useful in describing andclassifying patient reactions to drugs. Type I reactions are immediate hypersensitivity reactions and aremediated by:1. immunoglobulin E (IgE).2. immunoglobulin G (IgG).3. immunoglobulin A (IgA).4. immunoglobulin M (IgM).
(1) IgE, the least common serum immunoglobulin (Ig) binds very tightly to receptors on basophils and mast cells andis involved in allergic reactions. Binding of the allergen to the IgE on the cells results in the release of various pharmacologicalmediators that result in allergic symptoms. IgG is the major Ig (75 percent of serum Ig is IgG). Most versatileIg because it is capable of carrying out all of the functions of Ig molecules. IgG is the only class of Ig that crosses theplacenta. It is an opsonin, a substance that enhances phagocytosis. IgA, the second most common serum Ig is found insecretions (tears, saliva, colostrum, and mucus). It is important in local (mucosal) immunity. IgM, the third most commonserum Ig, is the first Ig to be made by the fetus and the first Ig to be made by a virgin B cell when it is stimulatedby antigen. IgM antibodies are very efficient in leading to the lysis of microorganisms.
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8. Drugs can cause adverse events in a patient. Bone marrow toxicity is one of the most frequent types of druginducedtoxicity. The most serious form of bone marrow toxicity is:1. aplastic anemia.2. thrombocytosis.3. leukocytosis.4. granulocytosis.
(1) Aplastic anemia is the result of a hypersensitivity reaction and is often irreversible. It leads to pancytopenia, asevere decrease in all cell types: red blood cells, white blood cells, and platelets. A reduced number of red blood cellscauses hemoglobin to drop. A reduced number of white blood cells makes the patient susceptible to infection. And, areduced number of platelets causes the blood not to clot as easily. Treatment for mild cases is supportive. Transfusionsmay be necessary. Severe cases require a bone marrow transplant. Option 2 is an elevated platelet count. Option 3 is anelevated white count. Option 4 is an elevated granulocyte count. A granulocyte is a type of white blood cell.
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9. Serious adverse effects of oral contraceptives include:1. increase in skin oil followed by acne.2. headache and dizziness.3. early or mid-cycle bleeding.4. thromboembolic complications.
(4) Oral contraceptives have been associated with an increased risk of stroke, myocardial infarction, and deep veinthrombosis. These risks are increased in women who smoke. Increased skin oil and acne are effects of progestin excess.Headache and dizziness are effects of estrogen excess. Early or mid-cycle bleeding are effects of estrogen deficiency.
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10. The most serious adverse effect of Alprostadil (Prostin VR pediatric injection) administration in neonates is:1. apnea.2. bleeding tendencies.3. hypotension.4. pyrexia.
(1) All items are adverse reactions of the drug. However, apnea appearing during the first hour of drug infusion occursin 10–12 percent of neonates with congenital heart defects. Clinicians deciding to utilize alprostadil must be prepared tointubate and mechanically ventilate the infant. Careful monitoring for apnea or respiratory depression is mandatory. Insome institutions, elective intubation occurs prior to initiation of the medication.
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11. Your patient calls the clinic today because he is taking atorvastatin (Lipitor) to treat his high cholesterol and ishaving pain in both of his legs. You instruct him to:1. stop taking the drug and make an appointment to be seen next week.2. continue taking the drug and make an appointment to be seen next week.3. stop taking the drug and come to the clinic to be seen today.4. walk for at least 30 minutes and call if symptoms continue.
(3) Muscle aches, soreness, and weakness may be early signs of myopathy such as rhabdomyolysis associated with theHMG-CoA reducatase class of antilipemic agents. This patient will need an immediate evaluation to rule out myopathy.Additional doses may exacerbate the problem. Exercise will not reverse myopathy and delays diagnosis.
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12. Which of the following adverse effects is associated with levothyroxine (Synthroid) therapy?1. tachycardia2. bradycardia3. hypotension4. constipation
(1) Levothyroxine, especially in higher doses, can induce hyperthyroid-like symptoms including tachycardia. An agentthat increases the basal metabolic rate would not be expected to induce a slow heart rate. Hypotension would be a sideeffect of bradycardia. Constipation is a symptom of hypothyroid disease.
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13. Which of the following adverse effects is specific to the biguanide diabetic drug metformin (Glucophage)therapy?1. hypoglycemia2. GI distress3. lactic acidosis4. somulence
(3) Lactic acidosis is the most dangerous adverse effect of metformin administration with death resulting in approximately50 percent of individuals who develop lactic acidosis while on this drug. Metformin does not induce insulinproduction; thus, administration does not result in hypoglycemic events. Some nausea, vomiting, and diarrhea maydevelop but is usually not severe. NVD is not specific for metformin. Metformin does not induce sleepiness.
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14. The most serious adverse effect of tricyclic antidepressant (TCA) overdose is:1. seizures.2. hyperpyrexia.3. metabolic acidosis.4. cardiac arrhythmias.
(4) Excessive ingestion of TCAs result in life-threatening wide QRS complex tachycardia. TCA overdose can induceseizures, but they are typically not life-threatening. TCAs do not cause an elevation in body temperature. TCAs do notcause metabolic acidosis.
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15. Which of the following solutions is routinely used to flush an IV device before and after the administration ofblood to a patient?1. 0.9 percent sodium chloride2. 5 percent dextrose in water solution3. sterile water4. heparin sodium
(1) 0.9 percent sodium chloride is normal saline. This solution has the same osmolarity as blood. Its use prevents redcell lysis. The solutions given in options 2 and 3 are hypotonic solutions and can cause red cell lysis. The solution inoption 4 may anticoagulate the patient and result in bleeding.
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16. A patient asks the nurse whether all donor blood products are cross-matched with the recipient to prevent atransfusion reaction. Which of the following always require cross-matching?1. packed red blood cells2. platelets3. plasma4. granulocytes
(1) Red blood cells contain antigens and antibodies that must be matched between donor and recipient. The bloodproducts in options 2–4 do not contain red cells. Thus, they require no cross-match.
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17. A month after receiving a blood transfusion an immunocompromised patient develops fever, liverabnormalities, a rash, and diarrhea. The nurse would suspect this patient has:1. nothing related to the blood transfusion.2. graft-versus-host disease (GVHD).3. myelosuppression.4. an allergic response to a recent medication.
(2) GVHD occurs when white blood cells in donor blood attack the tissues of an immunocompromised recipient. Thisprocess can occur within a month of the transfusion. Options 1 and 4 may be a thought, but the nurse must rememberthat immunocompromised transfusion recipients are at risk for GVHD.
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18. A client comes into the local blood donation center. He says he is here to donate platelets only today. The nurseknows this process is called:1. directed donation.2. autologous donation.3. allogenic donation.4. apheresis.
(4) The process of apheresis involves removal of whole blood from a donor. Within an instrument that is essentiallydesigned as a centrifuge, the components of whole blood are separated. One of the separated portions is then withdrawn,and the remaining components are retransfused into the donor. Directed donation is collected from a blooddonor other than the recipient, but the donor is known to the recipient and is usually a family member or friend.Autologous donation is the collection and reinfusion of the patient’s own blood. Allogenic donation is collectedfrom a blood donor other than the recipient.
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19. The nurse knows that the age group that uses the most units of blood and blood products is:1. premature infants.2. children ages 1–20 years.3. adults ages 21–64 years.4. the elderly above age 65 years.
(4) People older than 65 years use 43 percent of donated blood. This number is expected to increase as the populationages.
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20. A child is admitted with a serious infection. After two days of antibiotics, he is severely neutropenic. Thephysician orders granulocyte transfusions for the next four days. The mother asks the nurse why? The nurseresponds:1. “This is the only treatment left to offer the child.”2. “This therapy is fast and reliable in treating infections in children.”3. “The physician will have to explain his rationale to you.”4. “Granulocyte transfusions replenish the low white blood cells until the body can produce its own.”
(4) Granulocyte (neutrophil) replacement therapy is given until the patient’s blood values are normal and he is able tofight the infection himself. Options 1 and 3 are not therapeutic responses. The treatment in option 2 takes days and isnot always able to prevent morbidity and mortality.
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21. A neighbor tells a nurse he has to have surgery and is reluctant to have any blood product transfusions becauseof a fear of contracting an infection. He asks the nurse what are his options. The nurse teaches the person thatthe safest blood product is:1. an allogenic product.2. a directed donation product.3. an autologous product.4. a cross-matched product.
(3) This process is the collection and reinfusion of the patient’s own blood. It is recommended by the AmericanMedical Association’s Council on Scientific Affairs as the safest product since it eliminates recipient incompatibilityand infection. The product in option 1 is collected from a blood donor other than the recipient. The process in option 2is also collected from a blood donor other than the recipient, but the donor is known to the recipient and is usually afamily member or friend. Cross-matching significantly enhances compatibility. It does not detect infection.
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22. A severely immunocompromised patient requires a blood transfusion. To prevent GVHD, the physician willorder:1. diphenhydramine hydrochloride (Benadryl).2. the transfusion to be administered slowly over several hours.3. irradiation of the donor blood.
(3) This process eliminates white blood cell functioning, thus, preventing GVHD. Diphenhydramine HCl is an antihistamine.It’s use prior to a blood transfusion decreases the likelihood of a transfusion reaction. Option 2 will not preventGVHD. Use of acetaminophen prevents and treats the common side effects of blood administration caused by the presenceof white blood cells in the transfusion product: fever, headache, and chills.
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23. A patient who is to receive a blood transfusion asks the nurse what is the most common type of infection hecould receive from the transfusion. The nurse teaches him that approximately 1 in 250,000 patients contract:1. human immunodeficiency disease (HIV).2. hepatitis C infection.3. hepatitis B infection.4. West Nile viral disease.
(3) Hepatitis B is the most common infection spread via blood transfusion. Donors are screened by a questionnaire thatincludes symptoms. The donated blood is also tested for infection. The risk of infection with the agents in options 2 and3 has decreased to approximately 1 in 2 million secondary to donor questioning and donor blood testing. The incidenceof West Nile viral transmission is unknown, but donor infection is still relatively rare.
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24. A patient with blood type AB, Rh factor positive needs a blood transfusion. The Transfusion Service (bloodbank) sends type O, Rh factor negative blood to the unit for the nurse to infuse into this patient. The nurseknows that:1. this donor blood is incompatible with the patient’s blood.2. premedicating the patient with diphenhydramine hydrochloride (Benadryl) and acetaminophen (Tylenol)will prevent any transfusion reactions or side effects.3. this is a compatible match.4. the patient is at minimal risk receiving this product since it is the first time he has been transfused withtype O, Rh negative blood.
(3) Type O, Rh negative blood has none of the major antigens and is safely administered to patients of all blood types.It is also known as the universal donor. Premedicating with these agents will not prevent a major transfusion reaction ifthe blood type and Rh factors of the donor blood are incompatible with the recipient’s blood.
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25. The physician orders 250 milliliters of packed red blood cells (RBC) for a patient. This therapy is administeredfor treatment of:1. thrombocytopenia.2. anemia.3. leukopenia.4. hypoalbuminemia.
(2) A red blood cell transfusion is used to correct anemia in patients in which the low red blood cell count must berapidly corrected. RBC transfusion will not correct a low platelet count. RBC transfusion will not correct a low whiteblood cell count. Packed RBCs contain very little plasma and, thus, only a small amount of albumin. This amount willnot correct low albumin levels.
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26. A patient needs a whole blood transfusion. In order for transfusion services (the blood bank) to prepare thecorrect product a sample of the patient’s blood must be obtained for:1. a complete blood count and differential.2. a blood type and cross-match.3. a blood culture and sensitivity.4. a blood type and antibody screen.
(2) This is needed to utilize the correct type of donor blood and to match the donor product with the patient. Incompatiblematches would result in severe adverse events and possible death. The tests in options 1 and 3 are unnecessary. The test inoption 4 is utilized to determine the patient’s blood type and presence of antibodies to blood antigens. It does not determinedonor blood compatibility with the patient.
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27. A patient needs to receive a unit of whole blood. What type of intravenous (IV) device should the nurse considerstarting?1. a small catheter to decrease patient discomfort2. the type of IV device the patient has had in the past, which worked well3. a large bore catheter4. the type of device the physician prefers
(3) Large bore catheters prevent damage to blood components and are less likely to develop clotting problems than asmall bore catheter. The nurse should determine the correct device without asking the patient what type has been usedbefore or asking the physician which type he prefers and start the IV.
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28. The physician orders a gram of human salt poor albumin product for a patient. The product is available in a 50milliliter vial with a concentration of 25 percent. What dosage will the nurse administer?1. The nurse should use the entire 50 milliliter vial.2. The nurse should determine the volume to administer from the physician.3. This concentration of product should not be used.4. The nurse will administer 4 milliliters.
(4) A 25 percent solution contains one quarter of a gram per milliliter. Thus, the nurse will administer 4 milliliters toprovide a complete gram of albumin. The volume in option 1 would provide 12.5 grams of albumin. The nurse shoulddetermine the volume. It is unnecessary to seek the answer from the physician. A 25 percent solution is an acceptableproduct and can safely be used.
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29. Central venous access devices (CVADs) are frequently utilized to administer chemotherapy. What is a distinctadvantage of using the CVAD for chemotherapeutic agent administration?1. CVADs are less expensive than a peripheral IV.2. Once a week administration is possible.3. Caustic agents in small veins can be avoided.4. The patient or his family can administer the drug at home.
(3) Many chemotherapeutic drugs are vesicants (highly active corrosive materials that can produce tissue damage evenin low concentrations). Extravasations of a vesicant can result in significant tissue necrosis. Administration into a largevein is optimal. CVADs are more expensive than a peripheral IV. Dosing depends on the drug. IV chemotherapeuticagents are not administered at home. They are given in an outpatient or clinic setting if not given during hospitalization.
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30. A patient’s central venous access device (CVAD) becomes infected. Why would the physician order antibioticsto be given through the line rather than through a peripheral IV line?1. to prevent infiltration of the peripheral line2. to reduce the pain and discomfort associated with antibiotic administration in a small vein3. to lessen the chance of an allergic reaction to the antibiotic4. to attempt to sterilize the catheter and prevent having to remove it
(4) Microorganisms that infect CVADs are often coagulase-negative staphylococci, which can be eliminated by antibioticadministration through the catheter. If unsuccessful in eliminating the microorganism, the CVAD must be removed.CVAD use lessens the need for peripheral IV lines and, thus, the risk of infiltration. In this case however, the antibioticsare given to eradicate microorganisms from the CVAD. CVAD use has this effect, but in this case, the antibiotics aregiven through the CVAD to eliminate the infective agent. The third option would not occur.
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