N5375 Pharm 2024 Exam 2 Sensational Study Guide.docx

**N5375 Pharm 2024 Exam 2 Sensational Study Guide!** **All these points/questions follow along sequentially with the PPT slides** **[Week 4: Endocrine -- Diabetes ]** - What's the difference between Type I and Type II DM in terms of treatment? - What is more dangerous for sudden death fo...

**N5375 Pharm 2024 Exam 2 Sensational Study Guide!** **All these points/questions follow along sequentially with the PPT slides** **[Week 4: Endocrine -- Diabetes ]** - What's the difference between Type I and Type II DM in terms of treatment? - What is more dangerous for sudden death for a diabetic: hypoglycemia or hyperglycemia? - If a diabetic has long term, untreated hyperglycemia, it will most likely cause what 3 problems in the body? - Diabetics are also at increased risk of developing what acute problem? - How is glucose stored in the liver? - We won't fuss with normal or pre-diabetic hemoglobin A1C numbers, but do need to know: above what number is indicative of poorly controlled diabetes (or diagnostic for diabetes if you didn't know you had it)? - Same with blood glucose numbers, it can be hard to learn normal numbers because they vary with testing (fasting or random, etc), so I want you to know the more worrisome numbers. For hyperglycemia, \> 200 is dangerous long term. For hypoglycemia, \_\_\_\_\_\_ is dangerous now! - How does insulin decrease blood glucose? - Which insulin are we able to administer IV? - Most insulin is administered via which route? **The nurse is caring for a client newly diagnosed with diabetes. The client will begin taking insulin. Which of the following statements by the client would indicate that teaching has been effective? (Select all that apply.)** A. "I will try to inject my insulin as close to my belly button as possible." B. "I will check my blood sugar before every meal and give the correct dose of insulin glargine \[Lantus\] for my sugar level" C. "I will notify my provider if my blood sugar drops to 100." D. "I will check my blood sugar if I notice I am sweating or feel my heart racing without a reason." E. "I will store my unopened insulin in my refrigerator." F. "If I run out of insulin syringes, it is okay to use a regular syringe." G. "I will be the boss of my diabetes." - Take home point from that question: be able to provide teaching points about insulin administration and storage. This should include signs of hypoglycemia. - Two words that sound similar: glucagon and glycogen, explain each briefly. - Name the 3 rapid acting insulins. Approximately, when would you see onset of action. When would the effect reach its peak? (No need to differentiate between the 3.) - Which insulin is cloudy and needs to be rolled in your hand before administering? - If you are mixing insulins, it will likely be which 2 types and which one will you pull up into the syringe first? **The nurse is preparing to start an IV insulin drip on a new client. Which of the following laboratory findings would require the nurse to hold the insulin and notify the provider? (Select all that apply.)** A. Potassium 6 mEq/L B. Blood Glucose 300 mg/dL C. Potassium 2 mEq/L D. Blood Glucose 50 mg/dL - Purpose of this question is to understand the relationship between IV insulin and potassium. - Clarify when we would follow IV insulin with D50 or KCl. - Name the 2 long-acting insulins. When is their onset of action? How long is their duration in body? - Prepare for the following question: **The nurse is preparing to administer insulin lispro \[Humalog\]. The bottle reads U-100. The nurse checks the client's blood glucose via fingerstick. The client's blood glucose is 234 mg/dL. The nurse consults the sliding scale below and administers 6 mL of Humalog insulin subcutaneously.** Blood Glucose Dosage of insulin lispro \[Humalog\] in units --------------- ----------------------------------------------- 0-124 0 125-150 2 151-200 4 201-250 6 251-300 8 301 or above Notify provider A. The nurse has delivered the correct dosage of insulin. B. The nurse has underdosed the client's insulin. C. The nurse has overdosed the client's insulin. D. The nurse has used the incorrect route of administration for the client's insulin. - Are you also able to calculate the dose yourself in mL for a fill-in-the-blank? Reminder, if you forget the leading zero or add a trailing zero, the answer will be incorrect. - If you are the nurse on duty administering morning insulin doses, how long after administering a rapid-acting insulin should you be sure the client has their breakfast tray? - How often should a client with an insulin pump check their blood glucose? - Name the 7 classes of non-insulin, anti-diabetic medication and their prototype drug. - Now just memorize everything! JK - Metformin, main MOA? - Metformin, main SE people experience and how to decrease SE? Secondary SE related to nutrition? - Metformin, any hepatic or renal issues? - Metformin, main toxicity and signs of this? Who's at greater risk? - Metformin, worry for hypoglycemia? How about weight gain? - Review practice Qs on slide 32-35. - Which DM drug could you give for gestational diabetes? - Sulfonylureas: suffix(es)? - Compare sulfonylureas and meglitinides in terms of MOA, administration with food, and side effects of weight gain. Why is one of these meds on Beers list and not the other? - -Glinide sounds similar to -ride and -zide of sulfonylureas, keep separate! - Take a moment to review Beers list meds for Endocrine and Cardio. - Not much to say on -glitazones except be careful with HF because increased risk of fluid retention **A client presents with a new fungal infection of the genitals. The nurse most suspects which medication?** A. Pioglitazone B. Nateglinide C. Sitagliptin D. Empagliflozin - For the -gliflozin, remember to get that extra sugar out through the urine. More sugar = more risk of infection - I will ask one matching question on MOA of 4 classes of non-insulin, diabetic drugs. - For hormones: incretin and amylin, are they positive in the treatment of DM or do we need to block them? - The -gliptins different because they work through gut, unique side effects tin for join pain and P-Pancreas, look out for abdominal pain! - Last one! The -glutides act like incretin (distinguish from gliptins that block enzyme that would break down incretin); think of the gliptins and glutides like cousins, they both work in gut so they both have risk of pancreatitis with that abd pain, but what are diffs? Oral vs SQ, thyroid risk with glutides and appetite suppression that's why everyone using for weight loss (-glutides, people trying to get their glutes looking hot) - What to remember about alcohol and DM? Increased risk for both having and masking hypoglycemia. (Bonus: remember what cardio med masks hypoglycemia?) - Know your signs of hypoglycemia! Know your numbers and when to use which treatment. - For ketoacidosis, understand this occurs with Type I, need to know, does this happen when BG is too high or too low? **[Week 5: Cardio I ]** - Main point from RAAS system: increases blood pressure (when body needs it) by causing both vasoconstriction and fluid retention (more fluid retained in body = more blood volume = more blood pressure) SOOOOOOO....we can take meds that BLOCK/INHIBIT this system to treat someone who is struggling with HTN and/or fluid retention. - Know -pril and --(s)artan suffixes - Very similar impact in terms of decreased BP through vasodilation and increased diuresis, but ACE has little more SE, more of coughing, slight more angioedema - We will see at end of this lesson that these are dangerous for preg **For a client with a potassium level of 6.2 mEq/L, the nurse understands that all of the following medications would need to be held EXCEPT:** A. Captopril B. Losartan C. Spironolactone D. Furosemide - Priority SE of ACEs and ARBs is the angioedema due to breathing, even though rare. Put on other BP or diuretic med. - For Entresto, remember: combo med, used to tx what condition? Through what process? - Diuretic time, expect another matching question on MOA of 4 diuretics. Only 1 is different, other 3 you need to know where in the nephron they work. - A common use of a diuretic is pulmonary edema (which is common exacerbation of heart failure). Which diuretic do you think someone might get & via what form of administration, if they are struggling to breath? - Furosemide: Top issue is hypokalemia, but also decreased BP, need to push slow, ototoxicity, careful giving any diuretic to patient with kidney issues - Slide 16: note the risk of taking digoxin with a diuretic, especially one that lowers K; let's pause & mention that relationship between digoxin and potassium is complicated, most important for you to understand that both hypo AND hyperkalemia with dig is dangerous. For exam, always check K+ levels with dig and should express caution is dig taken with diuretic, especially loop. - Your first med math question will be on insulin, your second med math will be similar to slide 17 with furosemide. You will be given prescribed dose for med in mg. You will be told the supply in mg/mL. You have to calculate how many mL to push via IV. This is a common 1-step math calculation. Bumetanide.25mg/mL 4mL Vial **The nurse is caring for a patient with pulmonary edema. The provider prescribes one dose of bumetanide \[Bumex\] 0.5 mg IV push. How many mL does the nurse administer?** - For thiazide diuretic, know two names: HCTZ and chlorthalidone. Note that some patients will be more sensitive sun with diuretics, especially the thiazides, so we will focus that SE here. Have patients take expected precautions. - Know spironolactone is the K-sparing drug. Sometimes they teach low K diet, will need to know! ( I underlined the most important ones) - Note: For furosemide, because K drop is more dramatic, we just give KCl supplementation instead of doing it through foods - No questions on anti-androgen SE, will cover in more detail in second endocrine lecture - What happens if hypo or hyperK? - Mannitol is an "osmotic diuretic" because it uses osmosis to pull fluid out of where? (Think about what it's most used to treat.) Very different than other diuretics. Really can dry someone out so watch what? - Time for Heart Failure! If I tell you a patient is admitted with heart failure exacerbation, what do you expect to see? And what meds might they be on and why? Go through lists of 6. Think like a nurse, how would you know patient is getting better? - Dig: we already reviewed importance of checking K+. For sure know signs of toxicity, know toxic drug level, what does it mean to have a narrow therapeutic range, to be a positive inotrope and why it has that inotropic effect (based on the MOA). Even though arrhythmias in next unit, why would dig be helpful for arrhythmias? (Note: don't confuse dose of dig with serum drug level of dig). - For CCB, not for HF. Know non-dhp and dhp division and relate to arrythmias. Does it vasodilate or vasoconstrict? Know 4 names. - SE for CCB: headache, name another med in cardio that vasodilates and causes HA? Orthostatic hypotension again. **Which of the following client statements would indicate that teaching on calcium channel blockers has been [effective]?** A. "I will notify my provider immediately if I feel dizzy or light-headed." B. "Some swelling of my face is expected." C. "I know I need to stop drinking my grapefruit juice now that I'm taking the med." D. "I should call for help if I feel a headache." - Grapefruit, also St John Wort makes a comeback. - What other cardio drugs would show dangerous increased effect with grapefruit? Statins & amio - If any drug says "extended release", either ER or XR or controlled or sustained release (no matter the med), don't split or crush med. - Slide 40 notes says "meds to know": let's do matching (but won't be a matching Q on exam) **Match the anti-hypertensive medication with the body system through which it produces its effect.** **Med** **Body system** **Main Vasodilator? Slide 42** --------------------- ----------------- -------------------------------- Clonidine Metoprolol \*\* Hydrochlorothiazide Hydralazine Losartan Lisinopril Spironolactone Terazosin Amlodipine LOL BB will feature heavily, do review that B1 blocking is \_\_\_\_\_ and B2 blocking is \_\_\_\_\_\_. Already know to check HR and BP. Please know hold values. Do you remember what is special about carvedilol? Metoprolol? Timolol? Propranolol? Already mentioned: BB masks hypoglycemia tachycardia. Nitrates are divided between Cardio I and II. Here we focused on how to take NTG SL. Know 3 cardio med classes that are too risky for elderly (Beers) **A student nurse is providing discharge teaching for a client newly prescribed clonidine for blood pressure and ADHD with the assistance of a staff RN. Which of the following would be an [incorrect] statement for the student nurse to make and require correction by the RN?** A. "You can use gum and hard candies to treat a feeling of dry mouth." B. "You may experience a fast heart rate (tachycardia)." C. "Caution with drowsiness." D. "If you stop med suddenly, you may experience rebound hypertension, which is your BP shooting up." - Know hydralazine as a really effective med for lowering BP through vasodilation. Again, if we need effect fast, what route of admin should we take? - Always good to know any point that is special about a drug, in this case reflex tachy. May need to treat with what? - Although nitroprusside and minoxidil good to know for Kaplan, won't be on this exam. - Big finish for Cardio I with cholesterol lowering meds, of course know statins. (One side note, smart student reminded me that nystatin has the name statin in it. Actually it does have an effect on cholesterol! But please know that one only for antifungal effect. Bonus: when is that used?) - Back to main statins: for MOA, should know acronym for enzyme: HMG-CoA Reductase and that statins inhibit this enzyme and that prevents actual synthesis of cholesterol - Leave out diet for now - Know SE for sure, especially myopathy, good to connect to rhabdo and how does this connect to kidney injury? - I gave you an acronym for common cardio drugs that are teratogenic during pregnancy. Name those 3 classes of drugs. (Bonus: was there anywhere else in the notes that pregnancy was mentioned? Perhaps gestational diabetes?) - Which statins to know? Of course know suffix. One thing that is quite unique is that super famous atorvastatin \[Lipitor\] isn't impacted by kidney disease and that is really helpful. - Almost all statins have double-sided risk of hepatic impairment, meaning can cause hepatic impairment as SE and if hepatic impairment already exists, will lead to dangerous increase in statin. So ultimately what? Watch liver enzymes! (Don't need to know 2 drugs that have less risk of this.) - Will have 1 missed dose question, so review slide 55 - Bile sequestrants, one of the few meds that doesn't impact the kidneys \*\* very special, not metabolized by kidney or liver, know colesevelam \[Welchol\], sounds like cole slaw, get the cholesterol out through GI track! - How does ezetimibe work? Blocks the absorption of cholesterol from intestines, but remember we get most of our cholesterol endogenously, so that's why not as effective as a statin. Plus, has risk of myopathy, so still not winning there. - Finally, need to know gemfibrozil because of it's special place in lowering triglycerides. But also SE of myopathy. See how reoccurring SE could make a good test Q? Couple more practice questions for this unit: **An older adult who is receiving a blood transfusion develops an increase in blood pressure and crackles bilaterally. Which of the following medications should the nurse administer?** - A. Lisinopril - B. Ampicillin - C. Furosemide - D. Diphenhydramine **A client asks the nurse "how does lovastatin work"? Which is the nurse's best response?** - A. "Lovastatin prevents the reabsorption of bile acids in the small intestine." - B. "Lovastatin prevents an enzyme in the liver from making more cholesterol." - C. "Lovastatin is a vitamin that increases the activity of lipoprotein lipase" - D. "Lovastatin is a fibric acid agent that activates lipoprotein lipase." **[Week 6: Cardio II and Respiratory]** - Let's start with an anti-arrhythmic practice question: **A client is admitted to the critical care unit with new onset atrial fibrillation. VS as follows: HR 126, BP 108/70, RR 16, T 37C and SpO2 98% on RA. The nurse anticipates which of the following actions is a [first priority]?** - A. Diltiazem 20 mg IV push - B. Rivaroxaban 20 mg PO - C. Check blood sugar - D. Prepare client for echocardiogram - This is a very important question! First of all, let's name all the meds that can treat arrythmias. (Note that all these can treat a fib.). - What do you think about choice B in questions above? Let's talk about why this is important but second priority. - For all arrhythmia, EKG is a priority, but ECHO is not. Didn't really cover this, but want to note it. - For sure know SE of QT prolongation: that it causes torsades, which is lethal, and that who is at higher risk? And what 4 classes of meds put you at higher risk? (There are more than 4, but we focused on 4.) - Already did BB and CCB enough. So focus on Class I Na blocks and Class II Potassium blockers. Know names. - For amio, know that this is often first choice for a fib (but can also treat those other rhythms listed) & SE (cardio ones, hepatic, BBB, and then tissues where it accumulates), clotting issue already mentioned but very important - We already did Dig, but don't forget about atropine, used for? - Adenosine: literally binds receptors in SA node that's why asystole, no conduction can go through for a second (fast half life, why we push fast), patients feel very badly with tx, but temporary, know for SVT **The nurse is caring for a client who is receiving treatment for a pulmonary embolism. The nurse notices that the client's platelet level is 75,000 compared to 160,000 the previous day. What do you think is going on?** - Can you also identify which med for blood thinning would be given when? - MI? - PE in hospital? - PE at home? - Post op at home? - Prophylaxis DVT in hospital? - A fib at home? What if they have transportation issues or trouble leaving work for Dr appts? - Knowing which meds are administered via which route if very important - Know your coagulation labs: aPTT, PT/INR, platelets - Know your antidote meds - **A DELIGHTFUL 3-minute video on anticoags and the clotting cascade, explains extrinsic, intrinsic and difference between heparin, warfarin and DOACs (which they call NOACs): ** - Here you will see how these drugs ultimately inhibit thrombin and therefore, fibrin. That is sufficient for this exam. **A client is taking apixaban \[Eloquis\]. Which of the following statements indicates understanding?** A. "I am eating less spinach and collard greens." B. "I know I need to get my blood tested every week for this drug." C. "I will let my nurse practitioner know if I have any new nosebleeds or from my gums after brushing my teeth." D. "I will rotate my injection sites every day." - All the bleeding teaching make great Q - Know normal ASA dosing (baby 81, reg 325) - For clopidogrel and ticagrelor, know basic receptor blocking on the platelet, check plates! - Already talked about afib and clotting, but very important - For angina and MI, already talked about CCB and BB - Let's do more on nitrates, need to know connection to NO for MOA - Difference between PRN and daily treatment - Main SE we already mentioned - How to take we touched on in Cardio 1, but add the teaching points about the bottle, the temp, the timing (for admin and for refill), and the reaction with Viagra - Know the names of the phosphodiesterase 5 inhibitors - Let's review the list of 7 items for MI on slide 44 - Big finish! Respiratory: - Bronchodilation vs anti-inflammatory tx to keep organized - Know which meds treat during an asthma attack or COPD exacerbation (2 we discussed) - Know timing of meds - Of course, albuterol will be on exam, know effect, know receptors, short acting means works in a few minutes - Very important to know expected SE vs dangerous SE **A client has just completed an albuterol nebulizer for a COPD exacerbation. The nurse notes that the client's HR is 105, they have a slight tremor of their hand, RR is 20 and their CP is 8/10. What would require follow up?** - Lastly, theophylline great for questions on narrow therapeutic index, so know numbers and toxic signs - Know glucocorticoid main use (and that it takes weeks to work!) and a few common side effects that match with our current topics - We already mentioned nystatin, here it is. Know use. - Finish with montelukast, oral admin is nice, impacts leukotrienes, but worrisome connect to mental health SE - Lastly, will be inhaler ed Q