NCLEX Practice Exam for Pharmacology 2

1. An infection in a central venous access device is not eliminated by giving antibiotics through the catheter. How would bacterial glycocalyx contribute to this?

  1. It protects the bacteria from antibiotic and immunologic destruction.
  2. Glycocalyx neutralizes the antibiotic rendering it ineffective.
  3. It competes with the antibiotic for binding sites on the microbe.
  4. Glycocalyx provides nutrients for microbial growth.

2. Central venous access devices are beneficial in pediatric therapy because:

  1. They don’t frighten children.
  2. Use of the arms is not restricted.
  3. They cannot be dislodged.
  4. They are difficult to see.

3. How can central venous access devices (CVADs) be of value in a patient receiving chemotherapy who has stomatitis and severe diarrhea?

  1. The chemotherapy can be rapidly completed allowing the stomatitis and diarrhea to resolve.
  2. Crystalloid can be administered to prevent dehydration.
  3. Concentrated hyperalimentation fluid can be administered through the CVAD.
  4. The chemotherapy dose can be reduced.

4. Some central venous access devices (CVAD) have more than one lumen. These multi lumen catheters:

  1. Have an increased risk of infiltration.
  2. Only work a short while because the small bore clots off.
  3. Are beneficial to patient care but are prohibitively expensive.
  4. Allow different medications or solutions to be administered simultaneously.

5. Some institutions will not infuse a fat emulsion, such as Intralipid, into central venous access devices (CVAD) because:

  1. Lipid residue may accumulate in the CVAD and occlude the catheter.
  2. If the catheter clogs, there is no treatment other than removal and replacement.
  3. Lipids are necessary only in the most extreme cases to prevent essential fatty acid (EFA) deficiency.
  4. Fat emulsions are very caustic.

6. A male patient needs a percutaneously inserted central catheter (PICC) for prolonged IV therapy. He knows it can be inserted without going to the operating room. He mentions that, “at least the doctor won’t be wearing surgical garb, will he?” How will the nurse answer the patient?

  1. “You are correct. It is a minor procedure performed on the unit and does not necessitate surgical attire.”
  2. “To decrease the risk of infection, the doctor inserting the PICC will wear a cap, mask, and sterile gown and gloves.”
  3. “It depends on the doctor’s preference.”
  4. “Most doctors only wear sterile gloves, not a cap, mask, or sterile gown.”

7. A male patient is to receive a percutaneously inserted central catheter (PICC). He asks the nurse whether the insertion will hurt. How will the nurse reply?

  1. “You will have general anesthesia so you won’t feel anything.”
  2. “It will be inserted rapidly, and any discomfort is fleeting.”
  3. “The insertion site will be anesthetized. Threading the catheter through the vein is not painful.”
  4. “You will receive sedation prior to the procedure.”

8. What volume of air can safely be infused into a patient with a central venous access device (CVAD)?

  1. It is dependent on the patient’s weight and height.
  2. Air entering the patient through a CVAD will follow circulation to the lungs where it will be absorbed and cause no problems.
  3. It is dependent on comorbidities such as asthma or chronic obstructive lung disease.
  4. None.

9. Kent a new staff nurse asks her preceptor nurse how to obtain a blood sample from a patient with a portacath device. The preceptor nurse teaches the new staff nurse:

  1. The sample will be withdrawn into a syringe attached to the portacath needle and then placed into a vacutainer.
  2. Portacath devices are not used to obtain blood samples because of the risk of clot formation.
  3. The vacutainer will be attached to the portacath needle to obtain a direct sample.
  4. Any needle and syringe may be utilized to obtain the sample.

10. What is the purpose of “tunneling” (inserting the catheter 2-4 inches under the skin) when the surgeon inserts a Hickman central catheter device? Tunneling:

  1. Increases the patient’s comfort level.
  2. Decreases the risk of infection.
  3. Prevents the patient’s clothes from having contact with the catheter
  4. Makes the catheter less visible to other people.

11. The primary complication of a central venous access device (CVAD) is:

  1. Thrombus formation in the vein.
  2. Pain and discomfort.
  3. Infection.
  4. Occlusion of the catheter as the result of an intra-lumen clot.

12. Nurse Blessy is doing some patient education related to a patient’s central venous access device. Which of the following statements will the nurse make to the patient?

  1. “These type of devices are essentially risk free.”
  2. “These devices seldom work for more than a week or two necessitating replacement.”
  3. “The dressing should only the changed by your doctor.”
  4. “Heparin in instilled into the lumen of the catheter to decrease the risk of clotting.”

13. The chemotherapeutic DNA alkylating agents such as nitrogen mustards are effective because they:

  1. Cross-link DNA strands with covalent bonds between alkyl groups on the drug and guanine bases on DNA.
  2. Have few, if any, side effects.
  3. Are used to treat multiple types of cancer.
  4. Are cell cycle-specific agents.

14. Hormonal agents are used to treat some cancers. An example would be:

  1. Thyroxine to treat thyroid cancer.
  2. ACTH to treat adrenal carcinoma.
  3. Estrogen antagonists to treat breast cancer.
  4. Glucagon to treat pancreatic carcinoma.

15. Chemotherapeutic agents often produce a certain degree of myelosuppression including leukopenia. Leukopenia does not present immediately but is delayed several days to weeks because:

  1. The patient’s hemoglobin and hematocrit are normal.
  2. Red blood cells are affected first.
  3. Folic acid levels are normal.
  4. The current white cell count is not affected by chemotherapy.

16. Currently, there is no way to prevent myelosuppression. However, there are medications available to elicit a more rapid bone marrow recovery. An example is:

  1. Epoetin alfa (Epogen, Procrit).
  2. Glucagon.
  3. Fenofibrate (Tricor).
  4. Lamotrigine (Lamictal).

17. Estrogen antagonists are used to treat estrogen hormone-dependent cancer, such as breast carcinoma. Androgen antagonists block testosterone stimulation of androgen-dependent cancers. An example of an androgen-dependent cancer would be:

  1. Prostate cancer.
  2. Thyroid cancer.
  3. Renal carcinoma.
  4. neuroblastoma.

18. Serotonin release stimulates vomiting following chemotherapy. Therefore, serotonin antagonists are effective in preventing and treating nausea and vomiting related to chemotherapy. An example of an effective serotonin antagonist antiemetic is:

  1. ondansetron (Zofran).
  2. fluoxetine (Prozac).
  3. paroxetine (Paxil).
  4. sertraline (Zoloft).

19. Methotrexate, the most widely used antimetabolite in cancer chemotherapy does not penetrate the central nervous system (CNS). To treat CNS disease this drug must be administered:

  1. Intravenously.
  2. Subcutaneously.
  3. Intrathecally.
  4. By inhalation.

20. Methotrexate is a folate antagonist. It inhibits enzymes required for DNA base synthesis. To prevent harm to normal cells, a fully activated form of folic
acid known as leucovorin (folinic acid; citrovorum factor) can be administered. Administration of leucovorin is known as:

  1. Induction therapy.
  2. Consolidation therapy.
  3. Pulse therapy.
  4. Rescue therapy.

21. A male Patient is undergoing chemotherapy may also be given the drug allopurinol (Zyloprim, Aloprim). Allopurinol inhibits the synthesis of uric acid. Concomitant administration of allopurinol prevents:

  1. Myelosuppression.
  2. Gout and hyperuricemia.
  3. Pancytopenia.
  4. Cancer cell growth and replication

22. Superficial bladder cancer can be treated by direct instillation of the antineoplastic antibiotic agent mitomycin (Mutamycin). This process is termed:

  1. Intraventricular administration.
  2. Intravesical administration.
  3. Intravascular administration.
  4. Intrathecal administration.

23. The most common dose-limiting toxicity of chemotherapy is:

  1. Nausea and vomiting.
  2. Bloody stools.
  3. Myelosuppression.
  4. Inability to ingest food orally due to stomatitis and mucositis.

24. Chemotherapy induces vomiting by:

  1. Stimulating neuroreceptors in the medulla.
  2. Inhibiting the release of catecholamines.
  3. Autonomic instability.
  4. Irritating the gastric mucosa.

25. Myeloablation using chemotherapeutic agents is useful in cancer treatment because:

  1. It destroys the myelocytes (muscle cells).
  2. It reduces the size of the cancer tumor.
  3. After surgery, it reduces the amount of chemotherapy needed.
  4. It destroys the bone marrow prior to transplant.

26. Anticipatory nausea and vomiting associated with chemotherapy occurs:

  1. Within the first 24 hours after chemotherapy.
  2. 1-5 days after chemotherapy.
  3. Before chemotherapy administration.
  4. While chemotherapy is being administered.

27. Medications bound to protein have the following effect:

  1. Enhancement of drug availability.
  2. Rapid distribution of the drug to receptor sites.
  3. The more drug bound to protein, the less available for desired effect.
  4. Increased metabolism of the drug by the liver.

28. Some drugs are excreted into bile and delivered to the intestines. Prior to elimination from the body, the drug may be absorbed. This process is known as:

  1. Hepatic clearance.
  2. Total clearance.
  3. Enterohepatic cycling.
  4. First-pass effect.

29. An adult patient has been taking a drug (Drug A) that is highly metabolized by the cytochrome p-450 system. He has been on this medication for 6 months. At this time, he is started on a second medication (Drug B) that is an inducer of the cytochrome p-450 system. You should monitor this patient for:

  1. Increased therapeutic effects of Drug A.
  2. Increased adverse effects of Drug B.
  3. Decreased therapeutic effects of Drug A.
  4. Decreased therapeutic effects of Drug B.

30. Epinephrine is administered to a female patient. The nurse should expect this agent to rapidly affect:

  1. Adrenergic receptors.
  2. Muscarinic receptors.
  3. Cholinergic receptors.
  4. Nicotinic receptors.
Answers and Rationales
  1. Answer C. Glycocalyx is a viscous polysaccharide or polypeptide slime that covers microbes. It enhances adherence to surfaces, resists phagocytic engulfment by the white blood cells, and prevents antibiotics from contacting the microbe. Glycocalyx does not have the effects in options B-D.
  2. Answer B. The child can move his extremities and function in a normal fashion. This lessens stress associated with position restriction and promotes normal activity. Fear may not be eliminated. All lines can be dislodged. Even small catheters can be readily seen.
  3. Answer C. In patients unable to take oral nutrition, parenteral hyperalimentation is an option for providing nutritional support. High concentrations of dextrose, protein, minerals, vitamins, and trace elements can be provided. Dosing is not affected with options a and d. Crystalloid can provide free water but has very little nutritional benefits. Hyperalimentation can provide free water and considerable nutritional benefits.
  4. Answer D. A multilumen catheter contains separate ports and means to administer agents. An agent infusing in one port cannot mix with an agent infusing into another port. Thus, agents that would be incompatible if given together can be given in separate ports simultaneously.
  5. Answer A. Occlusion occurs with slow infusion rates and concurrent administration of some medications. Lipid occlusions may be treated with 70 percent ethanol or with 0.1 mmol/mL NaOH. Lipids provide essential fatty acids. It is recommended that approximately 4 percent of daily calories be EFAs. A deficiency can quickly develop. Daily essential fatty acids are necessary for constant prostaglandin production. Lipids are almost isotonic with blood.
  6. Answer C. Strict aseptic technique including the use of cap, mask, and sterile gown and gloves is require when placing a central venous line including a PICC. Options A, B, and D are incorrect statements. They increase the risk of infection.
  7. Answer C. Pain related to PICC insertion occurs with puncture of the skin. When inserting PICC lines, the insertion site is anesthetized so no pain is felt. The patient will not receive general anesthesia or sedation. Statement 2 is false. Unnecessary pain should be prevented.
  8. Answer B. Any air entering the right heart can lead to a pulmonary embolus. All air should be purged from central venous lines; none should enter the patient.
  9. Answer A. A special portacath needle is used to access the portacath device. A syringe is attached and the sample is obtained. One of the primary reasons for insertion of a portacath device is the need for frequent or long-term blood sampling. A vacutainer will exert too much suction on the central line resulting in collapse of the line. Only special portacath needles should be used to access the portacath device.
  10. Answer B. The actual access to the subclavian vein is still just under the clavicle, but by tunneling the distal portion of the catheter several inches under the skin the risk of migratory infection is reduces compared to a catheter that enters the subclavian vein directly and is not tunneled. The catheter is tunneled to prevent infection.
  11. Answer C. A foreign body in a blood vessel increases the risk of infection. Catheters that come outside the body have an even higher risk of infection. Most infections are caused by skin bacteria. Other infective organisms include yeasts and fungi. Options 1 and 4 are complications of a CVAD but are not the primary problem. Once placed, these lines do not cause pain and discomfort.
  12. Answer D. A solution containing heparin is used to reduce catheter clotting and maintain patency. The concentration of heparin used depends on the patient’s age, comorbidities, and the frequency of catheter access/flushing. Although patients have few complications, the device is not risk free. Patients may develop infection, catheter clots, vascular obstruction, pneumothorax, hemothorax, or mechanical problems (catheter breakage). Strict adherence to protocol enhances the longevity of central access devices. They routinely last weeks to months and sometimes years. The patient will be taught how to perform dressing changes at home.
  13. Answer A. Alkylating agents are highly reactive chemicals that introduce alkyl radicals into biologically active molecules and thereby prevent their proper functioning, replication, and transcription. Alkylating agents have numerous side effects including alopecia, nausea, vomiting, and myelosuppression. Nitrogen mustards have a broad spectrum of activity against chronic lymphocytic leukemia, non-Hodgkin’s lymphoma, and breast and ovarian cancer, but they are effective chemotherapeutic agents because of DNA cross-linkage. Alkylating agents are noncell cycle-specific agents.
  14. Answer C. Estrogen antagonists are used to treat estrogen hormone-dependent cancer, such as breast carcinoma. A well-known estrogen antagonist used in breast cancer therapy is tamoxifen (Nolvadex). This drug, in combination with surgery and other chemotherapeutic drugs reduces breast cancer recurrence by 30 percent. Estrogen antagonists can also be administered to prevent breast cancer in women who have a strong family history of the disease. Thyroxine is a natural thyroid hormone. It does not treat thyroid cancer. ACTH is an anterior pituitary hormone, which stimulates the adrenal glands to release glucocorticoids. It does not treat adrenal cancer. Glucagon is a pancreatic alpha cell hormone, which stimulates glycogenolysis and gluconeogenesis. It does not treat pancreatic cancer.
  15. Answer D. The time required to clear circulating cells before the effect that chemotherapeutic drugs have on precursor cell maturation in the bone marrow becomes evident. Leukopenia is an abnormally low white blood cell count. Answers A-C pertain to red blood cells.
  16. Answer A. Epoetin alfa (Epogen, Procrit) is a recombinant form of endogenous erythropoietin, a hematopoietic growth factor normally produced by the kidney that is used to induce red blood cell production in the bone marrow and reduce the need for blood transfusion. Glucagon is a pancreatic alpha cell hormone, which cause glycogenolysis and gluconeogenesis. Fenofibrate (Tricor) is an antihyperlipidemic agent that lowers plasma triglycerides. Lamotrigine (Lamictal) is an anticonvulsant.
  17. Answer A. Prostate tissue is stimulated by androgens and suppressed by estrogens. Androgen antagonists will block testosterone stimulation of prostate carcinoma cells. The types of cancer in options 2-4 are not androgen dependent.
  18. Answer A. Chemotherapy often induces vomiting centrally by stimulating the chemoreceptor trigger zone (CTZ) and peripherally by stimulating visceral afferent nerves in the GI tract. Ondansetron (Zofran) is a serotonin antagonist that bocks the effects of serotonin and prevents and treats nausea and vomiting. It is especially useful in single-day highly emetogenic cancer chemotherapy (for example, cisplatin). The agents in options 2-4 are selective serotonin reuptake inhibitors. They increase the available levels of serotonin.
  19. Answer C. With intrathecal administration chemotherapy is injected through the theca of the spinal cord and into the subarachnoid space entering into the cerebrospinal fluid surrounding the brain and spinal cord. The methods in options A, B, and D are ineffective because the medication cannot enter the CNS.
  20. Answer B. Leucovorin is used to save or “rescue” normal cells from the damaging effects of chemotherapy allowing them to survive while the cancer cells die. Therapy to rapidly reduce the number of cancerous cells is the induction phase. Consolidation therapy seeks to complete or extend the initial remission and often uses a different combination of drugs than that used for induction. Chemotherapy is often administered in intermittent courses called pulse therapy. Pulse therapy allows the bone marrow to recover function before another course of chemotherapy is given.
  21. Answer B. Prevent uric acid nephropathy, uric acid lithiasis, and gout during cancer therapy since chemotherapy causes the rapid destruction of cancer cells leading to excessive purine catabolism and uric acid formation. Allopurinol can induce myelosuppression and pancytopenia. Allopurinol does not have this function.
  22. Answer B. Medications administered intravesically are instilled into the bladder. Intraventricular administration involves the ventricles of the brain. Intravascular administration involves blood vessels. Intrathecal administration involves the fluid surrounding the brain and spinal cord.
  23. Answer C. The overall goal of cancer chemotherapy is to give a dose large enough to be lethal to the cancer cells, but small enough to be tolerable for normal cells. Unfortunately, some normal cells are affected including the bone marrow. Myelosuppression limits the body’s ability to prevent and fight infection, produce platelets for clotting, and manufacture red blood cells for oxygen portage. Even though the effects in options a, b, and d are uncomfortable and distressing to the patient, they do not have the potential for lethal outcomes that myelosuppression has.
  24. Answer A. Vomiting (emesis) is initiated by a nucleus of cells located in the medulla called the vomiting center. This center coordinates a complex series of events involving pharyngeal, gastrointestinal, and abdominal wall contractions that lead to expulsion of gastric contents. Catecholamine inhibition does not induce vomiting. Chemotherapy does not induce vomiting from autonomic instability. Chemotherapy, especially oral agents, may have an irritating effect on the gastric mucosa, which could result in afferent messages to the solitary tract nucleus, but these pathways do not project to the vomiting center.
  25. Answer D. Myelo comes from the Greek word myelos, which means marrow. Ablation comes from the Latin word ablatio, which means removal. Thus, myeloablative chemotherapeurtic agents destroy the bone marrow. This procedure destroys normal bone marrow as well as the cancerous marrow. The patient’s bone marrow will be replaced with a bone marrow transplant. Myelocytes are not muscle cells Tumors are solid masses typically located in organs. Surgery may be performed to reduce tumor burden and require less chemotherapy afterward.
  26. Answer C. Nausea and vomiting (N&V) are common side effects of chemotherapy. Some patients are able to trigger these events prior to actually receiving chemotherapy by anticipating, or expecting, to have these effects. N&V occurring post-chemotherapeutic administration is not an anticipatory event but rather an effect of the drug. N&V occurring during the administration of chemotherapy is an effect of the drug.
  27. Answer C. Only an unbound drug can be distributed to active receptor sites. Therefore, the more of a drug that is bound to protein, the less it is available for the desired drug effect. Less drug is available if bound to protein. Distribution to receptor sites is irrelevant since the drug bound to protein cannot bind with a receptor site. Metabolism would not be increased. The liver will first have to remove the drug from the protein molecule before metabolism can occur. The protein is then free to return to circulation and be used again.
  28. Answer C. Drugs and drug metabolites with molecular weights higher than 300 may be excreted via the bile, stored in the gallbladder, delivered to the intestines by the bile duct, and then reabsorbed into the circulation. This process reduces the elimination of drugs and prolongs their half-life and duration of action in the body. Hepatic clearance is the amount of drug eliminated by the liver. Total clearance is the sum of all types of clearance including renal, hepatic, and respiratory. First-pass effect is the amount of drug absorbed from the GI tract and then metabolized by the liver; thus, reducing the amount of drug making it into circulation.
  29. Answer C. Drug B will induce the cytochrome p-450 enzyme system of the liver; thus, increasing the metabolism of Drug A. Therefore, Drug A will be broken down faster and exert decreased therapeutic effects. Drug A will be metabolized faster, thus reducing, not increasing its therapeutic effect. Inducing the cytochrome p-450 system will not increase the adverse effects of Drug B. Drug B induces the cytochrome p-450 system but is not metabolized faster. Thus, the therapeutic effects of Drug B will not be decreased.
  30. Answer A. Epinephrine (adrenaline) rapidly affects both alpha and beta adrenergic receptors eliciting a sympathetic (fight or flight) response. Muscarinic receptors are cholinergic receptors and are primarily located at parasympathetic junctions. Cholinergic receptors respond to acetylcholine stimulation. Cholinergic receptors include muscarinic and nicotinic receptors. Nicotinic receptors are cholinergic receptors activated by nicotine and found in autonomic ganglia and somatic neuromuscular junctions.