Micromedex Clinical Challenges
What are Clinical Challenges?
Clinical Challenges are multiple-choice mini quizzes that both test your knowledge and guide you across the depth and breadth of Micromedex content.
Discover Clinical Challenges by category
Drug administration
A new bag of HUMAN REGULAR INSULIN (Novo Nordisk) is infused with NORMAL SALINE 0.9% (Hospira) following stabilisation of a patient with diabetic ketoacidosis (DKA), a medical emergency. The infusion ends an hour earlier despite correct settings entered into the pump, which was locked. Which of the following interventions would you recommend to that nurse to address this instance?
1. Ensure the pump did not get plugged into the red emergency outlet, overriding pump settings in emergency situations.
2. Inspect the bag to confirm that it did not get pierced by accident and that it does not contain floating particles.
3. Prime the tubing to minimize the effects of adsorption, which can occur upon contact with certain surfaces.
4. Shake the insulin bag gently per manufacturer instructions to ensure that no insulin particles adhere to the bag.The correct answer is 3.
Find answer in: About: Storage and stability: C) Insulin Human Regular 1)b)2): "Some insulin protocols call for priming of the infusion tubing with 50mL of insulin solution at a concentration of 1 units per 1 mL. With an insulin solution concentration of 1 unit per 1 mL, a 20-mL priming volume was found to be sufficient to limit the effects of insulin adsorption loss to IV lines in vitro."
A patient who was brought to the emergency room passed away following abuse of a street drug called TRANQ (a street name for the veterinary medicine XYLAZINE laced with FENTANYL to enhance the euphoric effect of the drug). You discuss this with a colleague following a post-debriefing session. You know that your colleague does NOT understand how TRANQ works when (s)he states:
1. "Although XYLAZINE acts like an opioid, it is not one."
2. "Did you observe severe necrotic skin ulcerations?"
3. "How much NARCAN was administered?"
4. "Toxicology screens are no good for TRANQ."The correct answer is: 3.
Although Xylazine (a component of Tranq) acts like an opioid, it is not one, and therefore, will not respond to Narcan. See Xylazine: Overview: Treatment Overview: C) Patient Disposition: 1) HOME CRITERIA: INTENTIONAL EXPOSURE: "Naloxone (Narcan) has no effect on xylazine"
A 52-year-old female patient is prescribed Fezolinetant to control her hot flashes. It is important to tell the patient to monitor liver function:
1. At baseline and then yearly for as long as she continues therapy.
2. Before starting, then monthly for 3 months, then at 6 and 9 months.
3. Every 3 months the first year, 6 months the second, and then yearly.
4. Upon the onset of decreased appetite, nausea and abdominal pain.
The correct answer is: 2.
The labeling for Fezolinetant has been revised to advise prescribers to conduct hepatic lab testing before initiating therapy. This monitoring is crucial due to the risk of rare but serious liver injury associated with the drug, which requires regular assessment of liver function to ensure patient safety. Nurses should carefully assess patients for symptoms of impairment.
Find this information in the FEZOLINETANT monograph, under the Monitoring section (both Quick Answers and In-Depth Answers).
Following an infusion of EDTA for lead poisoning, a 56-year-old complains of muscle cramps and numbness around his mouth. Inflation of the sphygmomanometer cuff above his systolic blood pressure leads to a characteristic hand posture (Trousseau sign). What intervention should follow?
1. Continue. These adverse effects are common with initial infusion of Disodium EDTA.
2. Hold the infusion of Calcium Disodium EDTA. It is not approved for chelation therapy.
3. Massage his hand. This will override pain receptors, stop cramping and promote comfort.
4. Stop the infusion at once. There has been confusion about this EDTA infusion.
The correct answer is: 4.
EDTA is an abbreviation for two drugs with different purposes. One is (a) Edetate Disodium (primarily used for emergency situations like digitalis poisoning or high calcium), and the other one (b) Edetate Disodium Calcium (preferred for lead poisoning). Search for "Edetate Disodium", and check the "Important Note" atop the monograph page in either Quick Answers or In-Depth. Trousseau sign is a clinical indication of tetany due to hypocalcemia, which manifests as carbopedal spasm due to chelation of serum calcium, which can pose significant risks. To advocate for patient safety, Micromedex will offer "Important Notes" at the top of a drug to notify healthcare workers of important considerations.
A 65-year-old female patient with a history of hypertension and type 2 diabetes presents to the emergency department with chest pain radiating to her left arm. An ECG shows ST-segment elevation in leads II, III, and aVF. Which of the following is the most appropriate initial treatment for this patient?
1. Aspirin
2. Nitroglycerin
3. Morphine
4. Clopidogrel
The correct answer is 1.
Aspirin is the only main staple when it comes to a patient with CAD (coronary disease history such as HTN and diabetes), whereas the others are not. Search the ASPIRIN monograph under FDA uses. CLOPIDOGREL is also part of this, but as an adjunct to ASPIRIN, not an alternative. ASPIRIN is the main staple.
Which of the following treatment modalities is a first-line therapy used to manage symptoms associated with stiff-person syndrome (SPS):
1. Clomipramine 25mg PO in the morning and 50 mg PO at bedtime every day until spasm resolves.
2. Immune globulin, IV, 2g/kg, divided in 2 daily doses, every month for three months.
3. Baclofen, PO, in increments of 15mg, 30mg, 45mg and 60mg for three days and then 90mg/day.
4. Sufentanil, 1mcg/kg/hr for 24 hours, then 0.5 mcg/kg/hr for 24 hours for the duration of episode.
The correct answer is: 3.
Muscle relaxants like Baclofen are prescribed to alleviate muscle stiffness and reduce spasms to help patients regain mobility.
Clomipramine is a tricyclic antidepressant. Though antidepressants may be used to address underlying anxiety or depression, they are not primarily aimed at treating the core symptoms of SPS.
Immunotherapy has been found to be quite effective if response to standard treatment (Baclofen) was poor.
Sufentanil is an analgesic of which spasms are adverse effects.
A 30-year-old patient with hemophilia A presents to the emergency department with a swollen and painful right knee after a minor fall. He reports a history of similar episodes and is currently on factor VIII replacement therapy. The provider considers adding MARSTACIMAB-HNCQ (Hympavzi) for better management of their condition. How could this benefit this patient?
1. It replaces factor VIII, facilitating the clotting cascade.
2. It stimulates the release of endogenous Factor VIII, promoting clotting.
3. It inhibits thrombin, leading to decreased fibrin formation.
4. It blocks tissue factor pathway inhibitor, leading to increased thrombin.
The correct answer is: 4.
#1 describes the mechanism of action of Factor VIII concentrates.
#2 describes the mechanism of action of Desmopressin.
#3 describes the mechanism of action of direct thrombin inhibitors.
The answer can be found under the "Mechanism of Action" section in the monograph.
A 34-year-old male, weighing 75 kg, presents with osteomyelitis in his right tibia following a traumatic injury. The patient has serum creatinine of 0.8 mg/dL and an estimated GFR of 120 mL/min. The patient exhibits localized warmth, tenderness, and swelling over the affected area. The patient also reports a fever of 101.5°F and a history of dull, constant pain in the area for the past two weeks. The organism responsible for the infection is identified as Methicillin-resistant Staphylococcus aureus (MRSA), and the patient has been started on appropriate antibiotic therapy with Vancomycin. When treating the patient with Vancomycin, what is the recommended optimal AUC/MIC ratio for the best clinical outcome?
1. 500-600
2. 250-350
3. 400-600
4. 200-300
The correct answer is: 3.
Within the Vancomycin drug monograph in the Adult Dosing and Monitoring sections. Vacomycin: Monitoring: Vancomycin Hydrochloride: Therapeutic: Adult: 2) AUC/MIC Ratio a)1)
An 80-year-old female with a history of atrial fibrillation (AF) and chronic mitral valve disease presents for routine follow-up after undergoing a mechanical mitral valve replacement. The patient is post-operative day 3 following her mechanical mitral valve replacement surgery. She is stable, with no signs of infection, and her surgical site is healing well. She was started on warfarin therapy immediately after surgery to maintain adequate anticoagulation. What is the target INR range for patients with mechanical hearl valves?
1. 2-3
2. 4-5
3. 1-2
4. 2.5-3.5
The correct answer is: 4.
See the Warfarin drug monograph > Monitoring.
Which of the following is a biosimilar for Infliximab?
1. Inflectra
2. Keytruda
3. Skyrizi
4. Humira
The correct answer is: 1.
See the Infliximab drug monograph > About > Trade Names (leads to the Tox & Drug Product / Substance Results page).
Toxicology
You attend a post-mortem exam. Which would most likely make you suspicious of cyanide poisoning?
1. Acrid pear-like odor.
2. Bitter almond odor.
3. Foul cabbage odor.
4. Rotten apple-like odor.
The correct answer is: 2.
Cyanide monograph (PDX): Clinical Effects: Gastrointestinal: 3.8.2) CLINICAL EFFECTS A) VOMITING 1) WITH POISONING EXPOSURE b) "Odor of bitter almonds in expired breath or gastric contents of patients may not be detected by a significant portion of the population."
A patient who was brought to the emergency room passed away following abuse of a street drug called TRANQ (a street name for the veterinary medicine XYLAZINE laced with FENTANYL to enhance the euphoric effect of the drug). You discuss this with a colleague following a post-debriefing session. You know that your colleague does NOT understand how TRANQ works when (s)he states:
1. "Although XYLAZINE acts like an opioid, it is not one."
2. "Did you observe severe necrotic skin ulcerations?"
3. "How much NARCAN was administered?"
4. "Toxicology screens are no good for TRANQ."
The correct answer is: 3.
Although Xylazine (a component of Tranq) acts like an opioid, it is not one, and therefore, will not respond to Narcan. See Xylazine: Overview: Treatment Overview: C) Patient Disposition: 1) HOME CRITERIA: INTENTIONAL EXPOSURE: "Naloxone (Narcan) has no effect on xylazine".
Following an infusion of EDTA for lead poisoning, a 56-year-old complains of muscle cramps and numbness around his mouth. Inflation of the sphygmomanometer cuff above his systolic blood pressure leads to a characteristic hand posture (Trousseau sign). What intervention should follow?
1. Continue. These adverse effects are common with initial infusion of Disodium EDTA.
2. Hold the infusion of Calcium Disodium EDTA. It is not approved for chelation therapy.
3. Massage his hand. This will override pain receptors, stop cramping and promote comfort.
4. Stop the infusion at once. There has been confusion about this EDTA infusion.
The correct answer is: 4.
EDTA is an abbreviation for two drugs with different purposes. One is (a) Edetate Disodium (primarily used for emergency situations like digitalis poisoning or high calcium), and the other one (b) Edetate Disodium Calcium (preferred for lead poisoning). Search for "Edetate Disodium", and check the "Important Note" atop the monograph page in either Quick Answers or In-Depth. Trousseau sign is a clinical indication of tetany due to hypocalcemia, which manifests as carbopedal spasm due to chelation of serum calcium, which can pose significant risks. To advocate for patient safety, Micromedex will offer "Important Notes" at the top of a drug to notify healthcare workers of important considerations.
A 72-year-old female with a medical history significant for atrial fibrillation (AF) and hypertension, presenting to the emergency department with an acute intracranial hemorrhage (ICH). She was on Apixaban 5 mg BID for stroke prevention, with the last dose administered 6 hours ago. Upon presentation, the patient is experiencing headache, dizziness, and vomiting, with a Glasgow Coma Scale (GCS) score of 13. Imaging confirms a moderate-sized ICH in the left frontal lobe. What would be indicated as a reversal agent for life-threatening bleeding in an emergency situation? (Select the BEST answer.)
1. Andexxa
2. Kcentra
3. NovoSeven
4. Benefix
The best answer is: 1.
Andexxa (coagulation factor Xa [recombinant], inactivated-zhzo).
See the Andexxa drug monograph > Drug Consults > Management of bleeding in patients on oral anticoagulants expert opinion. See also Poisindex: Coagulation Factor Xa Recombinant, Inactivated-Zhzo: Substances Included/Synonyms: Therapeutic/Toxic Class: A) "for patients that develop life-threatening or uncontrolled bleeding following rivaroxaban or apixaban therapy". Kcentra may be used as a non-specific alternative when Andexxa is unavailable or in other Direct Oral AntiCoagulants (DOAC)-associated bleeds. NovoSeen (a recombinant factor VIIa) is used off-label for refractory hemorrhage but carries a high thrombotic risk and is not a first-line antidote to DOAC. BeneFIX is a recombinant Factor IX concentrate for hemophilia and has no role in anticoagulant reversal.
Dosing
A 34-year-old woman taking lithium for bipolar disorder is scheduled for a full hysterectomy. What are some perioperative considerations for her lithium therapy? Choose all that are applicable.
1. Her lithium should be discontinued 24 hours prior to the surgical procedure.
2. Her lithium should be discontinued 72 hours prior to the surgical procedure.
3. There are no concerns, and lithium can be continued throughout the perioperative period.
4. If lithium is continued throughout the perioperative period, medications that could alter renal clearance should be avoided.
5. If neuromuscular blocking agents are used, careful titration and neuromonitoring is required.
The correct answer is: 2, 4 and 5.
Lithium should be stopped, so #3 would be de facto wrong. You may hold Lithium for 24 hours for a MINOR surgery. A full hysterectomy is a MAJOR surgery. All the other answers are best practice. See Lithium: Dosing/Administration: Adult Dosage: Lithium Carbonate: General Dosage Information: Perioperative Medication Management.
Which of the following treatment modalities is a first-line therapy used to manage symptoms associated with stiff-person syndrome (SPS):
1. Clomipramine 25mg PO in the morning and 50 mg PO at bedtime every day until spasm resolves.
2. Immune globulin, IV, 2g/kg, divided in 2 daily doses, every month for three months.
3. Baclofen, PO, in increments of 15mg, 30mg, 45mg and 60mg for three days and then 90mg/day.
4. Sufentanil, 1mcg/kg/hr for 24 hours, then 0.5 mcg/kg/hr for 24 hours for the duration of episode.
The correct answer is: 3.
Muscle relaxants like Baclofen are prescribed to alleviate muscle stiffness and reduce spasms to help patients regain mobility.
Clomipramine is a tricyclic antidepressant. Though antidepressants may be used to address underlying anxiety or depression, they are not primarily aimed at treating the core symptoms of SPS.
Immunotherapy has been found to be quite effective if response to standard treatment (Baclofen) was poor.
Sufentanil is an analgesic of which spasms are adverse effects.
A 72-year-old female with a medical history significant for atrial fibrillation (AF) and hypertension, presenting to the emergency department with an acute intracranial hemorrhage (ICH). She was on Apixaban 5 mg BID for stroke prevention, with the last dose administered 6 hours ago. Upon presentation, the patient is experiencing headache, dizziness, and vomiting, with a Glasgow Coma Scale (GCS) score of 13. Imaging confirms a moderate-sized ICH in the left frontal lobe. What would be indicated as a reversal agent for life-threatening bleeding in an emergency situation? (Select the BEST answer.)
1. Andexxa
2. Kcentra
3. NovoSeven
4. Benefix
The best answer is: 1.
Andexxa (coagulation factor Xa [recombinant], inactivated-zhzo).
See the Andexxa drug monograph > Drug Consults > Management of bleeding in patients on oral anticoagulants expert opinion.See also Poisindex: Coagulation Factor Xa Recombinant, Inactivated-Zhzo: Substances Included/Synonyms: Therapeutic/Toxic Class: A) "for patients that develop life-threatening or uncontrolled bleeding following rivaroxaban or apixaban therapy". Kcentra may be used as a non-specific alternative when Andexxa is unavailable or in other Direct Oral AntiCoagulants (DOAC)-associated bleeds. NovoSeen (a recombinant factor VIIa) is used off-label for refractory hemorrhage but carries a high thrombotic risk and is not a first-line antidote to DOAC. BeneFIX is a recombinant Factor IX concentrate for hemophilia and has no role in anticoagulant reversal.
A 34-year-old male, weighing 75 kg, presents with osteomyelitis in his right tibia following a traumatic injury. The patient has serum creatinine of 0.8 mg/dL and an estimated GFR of 120 mL/min. The patient exhibits localized warmth, tenderness, and swelling over the affected area. The patient also reports a fever of 101.5°F and a history of dull, constant pain in the area for the past two weeks. The organism responsible for the infection is identified as Methicillin-resistant Staphylococcus aureus (MRSA), and the patient has been started on appropriate antibiotic therapy with Vancomycin. When treating the patient with Vancomycin, what is the recommended optimal AUC/MIC ratio for the best clinical outcome?
1. 500-600
2. 250-350
3. 400-600
4. 200-300
The correct answer is: 3.
Within the Vancomycin drug monograph in the Adult Dosing and Monitoring sections. Vacomycin: Monitoring: Vancomycin Hydrochloride: Therapeutic: Adult: 2) AUC/MIC Ratio a)1)
Frontotemporal Dementia (FTD) is a condition that is also known as Pick Disease. Actor Bruce Willis was diagnosed with this condition in 2023. It primarily affects individuals 45-64 years of age, who exhibit decline in behavior, language, and/or movement. Which of the following interventions would be LEAST useful in managing FTD?
1. The caregiver distracts the patient with a new activity when behavioral problems occur.
2. The nurse practitioner prescribes 50mg TRAZODONE for agitation and restlessness at bedtime.
3. The physician orders 5 mg MEMANTINE for early onset dementia.
4. The speech therapist evaluates the patient for swallowing problems as needed.
The correct answer is: 3.
The LEAST useful intervention in managing frontotemporal dementia (FTD) is #3. MEMANTINE is NOT specifically approved for FTD and in trials, its effectiveness is uncertain. Whilst it may be used off-label, the evidence supporting its benefit is weak, especially at the subtherapeutic dosage of 5 mg, which is unlikely to have meaningful impact on FTD symptoms at that level. All the other options are more aligned with FTD management. Behavioral strategies are key in managing FTD-related agitation and impulsivity. TRAZODONE is often used to manage agitation, restlessness and sleep disturbances in dementia. And because FTD can affect motor functions, including swallowing, a speech therapist evaluation is useful.
Drug consults
A 68-year-old male with a medical history of Type 2 Diabetes Mellitus (T2DM), hypertension, and chronic kidney disease (CKD), presents to the outpatient clinic for routine follow-up. The patient has been on metformin for diabetes management for several years, but his blood glucose levels have been poorly controlled over the past few months. The patient also has Stage 3b CKD, with an estimated glomerular filtration rate (eGFR) of 45 mL/min/1.73m² (previously 55 mL/min/1.73m² six months ago). His A1C is 8.2%, and his blood pressure is well-controlled on lisinopril 10 mg daily. The patient also reports increasing fatigue, frequent urination, and moderate lower extremity edema. Given his current clinical picture of uncontrolled diabetes and kidney disease, the healthcare team is considering starting which medication to help improve glycemic control and reduce the risk of further kidney damage?
1. Dapagliflozin
2. Glipizide
3. Semaglutide
4. Insulin
The correct answer is: 1.
Review the Dose Adjustments section within each monograph to find appropriate dosing for eGFR. Also see Drug Consults: "Diabetes: Drug Therapy Standards".
A 72-year-old female with a medical history significant for atrial fibrillation (AF) and hypertension, presenting to the emergency department with an acute intracranial hemorrhage (ICH). She was on Apixaban 5 mg BID for stroke prevention, with the last dose administered 6 hours ago. Upon presentation, the patient is experiencing headache, dizziness, and vomiting, with a Glasgow Coma Scale (GCS) score of 13. Imaging confirms a moderate-sized ICH in the left frontal lobe. What would be indicated as a reversal agent for life-threatening bleeding in an emergency situation? (Select the BEST answer.)
1. Andexxa
2. Kcentra
3. NovoSeven
4. Benefix
The best answer is: 1.
Andexxa (coagulation factor Xa [recombinant], inactivated-zhzo).
See the Andexxa drug monograph > Drug Consults > Management of bleeding in patients on oral anticoagulants expert opinion.See also Poisindex: Coagulation Factor Xa Recombinant, Inactivated-Zhzo: Substances Included/Synonyms: Therapeutic/Toxic Class: A) "for patients that develop life-threatening or uncontrolled bleeding following rivaroxaban or apixaban therapy". Kcentra may be used as a non-specific alternative when Andexxa is unavailable or in other Direct Oral AntiCoagulants (DOAC)-associated bleeds. NovoSeen (a recombinant factor VIIa) is used off-label for refractory hemorrhage but carries a high thrombotic risk and is not a first-line antidote to DOAC. BeneFIX is a recombinant Factor IX concentrate for hemophilia and has no role in anticoagulant reversal.
Patient monitoring
A new bag of HUMAN REGULAR INSULIN (Novo Nordisk) is infused with NORMAL SALINE 0.9% (Hospira) following stabilisation of a patient with diabetic ketoacidosis (DKA), a medical emergency. The infusion ends an hour earlier despite correct settings entered into the pump, which was locked. Which of the following interventions would you recommend to that nurse to address this instance?
1. Ensure the pump did not get plugged into the red emergency outlet, overriding pump settings in emergency situations.
2. Inspect the bag to confirm that it did not get pierced by accident and that it does not contain floating particles.
3. Prime the tubing to minimize the effects of adsorption, which can occur upon contact with certain surfaces.
4. Shake the insulin bag gently per manufacturer instructions to ensure that no insulin particles adhere to the bag.
The correct answer is 3.
Find answer in: About: Storage and stability: C) Insulin Human Regular 1)b)2): "Some insulin protocols call for priming of the infusion tubing with 50mL of insulin solution at a concentration of 1 units per 1 mL. With an insulin solution concentration of 1 unit per 1 mL, a 20-mL priming volume was found to be sufficient to limit the effects of insulin adsorption loss to IV lines in vitro."
Percy, five years old, is scheduled to receive his IPV (INACTIVATED POLIOVIRUS VACCINE) booster. What statement from the Percy's mother during the visit would have you hold the immunization?
1. "All I can say is that I am glad this is not that STREPTOMYCIN jab. He really did not like that!"
2. "I hope his thigh will not be red and swollen like last time he got that shot. It really scared me!"
3. "It has been a tough week for him with his bouts of diarrhea. He really got so dehydrated!"
4. "Wouldn't it be great it this could also help that nasty cough he's been struggling with?"
The correct answer is: 1.
IPV vaccine: Medication Safety: Precautions: B) Poliovirus Vaccine, Live: 3)
Frontotemporal Dementia (FTD) is a condition that is also known as Pick Disease. Actor Bruce Willis was diagnosed with this condition in 2023. It primarily affects individuals 45-64 years of age, who exhibit decline in behavior, language, and/or movement. Which of the following interventions would be LEAST useful in managing FTD?
1. The caregiver distracts the patient with a new activity when behavioral problems occur.
2. The nurse practitioner prescribes 50mg TRAZODONE for agitation and restlessness at bedtime.
3. The physician orders 5 mg MEMANTINE for early onset dementia.
4. The speech therapist evaluates the patient for swallowing problems as needed.
The correct answer is: 3.
The LEAST useful intervention in managing frontotemporal dementia (FTD) is #3. MEMANTINE is NOT specifically approved for FTD and in trials, its effectiveness is uncertain. Whilst it may be used off-label, the evidence supporting its benefit is weak, especially at the subtherapeutic dosage of 5 mg, which is unlikely to have meaningful impact on FTD symptoms at that level. All the other options are more aligned with FTD management. Behavioral strategies are key in managing FTD-related agitation and impulsivity. TRAZODONE is often used to manage agitation, restlessness and sleep disturbances in dementia. And because FTD can affect motor functions, including swallowing, a speech therapist evaluation is useful.
A 68-year-old male with a medical history of Type 2 Diabetes Mellitus (T2DM), hypertension, and chronic kidney disease (CKD), presents to the outpatient clinic for routine follow-up. The patient has been on metformin for diabetes management for several years, but his blood glucose levels have been poorly controlled over the past few months. The patient also has Stage 3b CKD, with an estimated glomerular filtration rate (eGFR) of 45 mL/min/1.73m² (previously 55 mL/min/1.73m² six months ago). His A1C is 8.2%, and his blood pressure is well-controlled on lisinopril 10 mg daily. The patient also reports increasing fatigue, frequent urination, and moderate lower extremity edema. Given his current clinical picture of uncontrolled diabetes and kidney disease, the healthcare team is considering starting which medication to help improve glycemic control and reduce the risk of further kidney damage?
1. Dapagliflozin
2. Glipizide
3. Semaglutide
4. Insulin
The correct answer is: 1.
Review the Dose Adjustments section within each monograph to find appropriate dosing for eGFR. Also see Drug Consults: "Diabetes: Drug Therapy Standards".
An 80-year-old female with a history of atrial fibrillation (AF) and chronic mitral valve disease presents for routine follow-up after undergoing a mechanical mitral valve replacement. The patient is post-operative day 3 following her mechanical mitral valve replacement surgery. She is stable, with no signs of infection, and her surgical site is healing well. She was started on warfarin therapy immediately after surgery to maintain adequate anticoagulation. What is the target INR range for patients with mechanical hearl valves?
1. 2-3
2. 4-5
3. 1-2
4. 2.5-3.5
The correct answer is: 4.
See the Warfarin drug monograph > Monitoring.
A 34-year-old male, weighing 75 kg, presents with osteomyelitis in his right tibia following a traumatic injury. The patient has serum creatinine of 0.8 mg/dL and an estimated GFR of 120 mL/min. The patient exhibits localized warmth, tenderness, and swelling over the affected area. The patient also reports a fever of 101.5°F and a history of dull, constant pain in the area for the past two weeks. The organism responsible for the infection is identified as Methicillin-resistant Staphylococcus aureus (MRSA), and the patient has been started on appropriate antibiotic therapy with Vancomycin. When treating the patient with Vancomycin, what is the recommended optimal AUC/MIC ratio for the best clinical outcome?
1. 500-600
2. 250-350
3. 400-600
4. 200-300
The correct answer is: 3.
Within the Vancomycin drug monograph in the Adult Dosing and Monitoring sections. Vacomycin: Monitoring: Vancomycin Hydrochloride: Therapeutic: Adult: 2) AUC/MIC Ratio a)1)
Following an infusion of EDTA for lead poisoning, a 56-year-old complains of muscle cramps and numbness around his mouth. Inflation of the sphygmomanometer cuff above his systolic blood pressure leads to a characteristic hand posture (Trousseau sign). What intervention should follow?
1. Continue. These adverse effects are common with initial infusion of Disodium EDTA.
2. Hold the infusion of Calcium Disodium EDTA. It is not approved for chelation therapy.
3. Massage his hand. This will override pain receptors, stop cramping and promote comfort.
4. Stop the infusion at once. There has been confusion about this EDTA infusion.
The correct answer is: 4.
EDTA is an abbreviation for two drugs with different purposes. One is (a) Edetate Disodium (primarily used for emergency situations like digitalis poisoning or high calcium), and the other one (b) Edetate Disodium Calcium (preferred for lead poisoning). Search for "Edetate Disodium", and check the "Important Note" atop the monograph page in either Quick Answers or In-Depth. Trousseau sign is a clinical indication of tetany due to hypocalcemia, which manifests as carbopedal spasm due to chelation of serum calcium, which can pose significant risks. To advocate for patient safety, Micromedex will offer "Important Notes" at the top of a drug to notify healthcare workers of important considerations.
A 34-year-old woman taking lithium for bipolar disorder is scheduled for a full hysterectomy. What are some perioperative considerations for her lithium therapy? Choose all that are applicable.
1. Her lithium should be discontinued 24 hours prior to the surgical procedure.
2. Her lithium should be discontinued 72 hours prior to the surgical procedure.
3. There are no concerns, and lithium can be continued throughout the perioperative period.
4. If lithium is continued throughout the perioperative period, medications that could alter renal clearance should be avoided.
5. If neuromuscular blocking agents are used, careful titration and neuromonitoring is required.
The correct answer is: 2, 4 and 5.
Lithium should be stopped, so #3 would be de facto wrong. You may hold Lithium for 24 hours for a MINOR surgery. A full hysterectomy is a MAJOR surgery. All the other answers are best practice. See Lithium: Dosing/Administration: Adult Dosage: Lithium Carbonate: General Dosage Information: Perioperative Medication Management.
Patient safety
A patient who was brought to the emergency room passed away following abuse of a street drug called TRANQ (a street name for the veterinary medicine XYLAZINE laced with FENTANYL to enhance the euphoric effect of the drug). You discuss this with a colleague following a post-debriefing session. You know that your colleague does NOT understand how TRANQ works when (s)he states:
1. "Although XYLAZINE acts like an opioid, it is not one."
2. "Did you observe severe necrotic skin ulcerations?"
3. "How much NARCAN was administered?"
4. "Toxicology screens are no good for TRANQ."
The correct answer is: 3.
Althought Xylazine (a component of Tranq) acts like an opioid, it is not one, and therefore, will not respond to Narcan. See Xylazine: Overview: Treatment Overview: C) Patient Disposition: 1) HOME CRITERIA: INTENTIONAL EXPOSURE: "Naloxone (Narcan) has no effect on xylazine"
A 34-year-old woman taking lithium for bipolar disorder is scheduled for a full hysterectomy. What are some perioperative considerations for her lithium therapy? Choose all that are applicable.
1. Her lithium should be discontinued 24 hours prior to the surgical procedure.
2. Her lithium should be discontinued 72 hours prior to the surgical procedure.
3. There are no concerns, and lithium can be continued throughout the perioperative period.
4. If lithium is continued throughout the perioperative period, medications that could alter renal clearance should be avoided.
5. If neuromuscular blocking agents are used, careful titration and neuromonitoring is required.
The correct answer is: 2, 4 and 5.
Lithium should be stopped, so #3 would be de facto wrong. You may hold Lithium for 24 hours for a MINOR surgery. A full hysterectomy is a MAJOR surgery. All the other answers are best practice. See Lithium: Dosing/Administration: Adult Dosage: Lithium Carbonate: General Dosage Information: Perioperative Medication Management.
A 65-year-old female patient with a history of hypertension and type 2 diabetes presents to the emergency department with chest pain radiating to her left arm. An ECG shows ST-segment elevation in leads II, III, and aVF. Which of the following is the most appropriate initial treatment for this patient?
1. Aspirin
2. Nitroglycerin
3. Morphine
4. Clopidogrel
The correct answer is 1.
Aspirin is the only main staple when it comes to a patient with CAD (coronary disease history such as HTN and diabetes), whereas the others are not. Search the ASPIRIN monograph under FDA uses. CLOPIDOGREL is also part of this, but as an adjunct to ASPIRIN, not an alternative. ASPIRIN is the main staple.
Percy, five years old, is scheduled to receive his IPV (INACTIVATED POLIOVIRUS VACCINE) booster. What statement from the Percy's mother during the visit would have you hold the immunization?
1. "All I can say is that I am glad this is not that STREPTOMYCIN jab. He really did not like that!"
2. "I hope his thigh will not be red and swollen like last time he got that shot. It really scared me!"
3. "It has been a tough week for him with his bouts of diarrhea. He really got so dehydrated!"
4. "Wouldn't it be great it this could also help that nasty cough he's been struggling with?"
The correct answer is: 1.
IPV vaccine: Medication Safety: Precautions: B) Poliovirus Vaccine, Live: 3)
A 62-year old male with a history of type 2 diabetes mellitus (DM), hypertension, and chronic kidney disease (stage 3) presents for a routine follow-up. His HbA1c is 8.2%, and he has a BMI of 32kg/m2. He reports no symptoms of heart failure but has a history of myocardial infarction two years ago. His current medications include Metformin, Ramipril and Atorvastatin. You are the prescriber considering adding a medication to improve his glycemic control whilst reducing his cardiovascular and renal risks. Which of the following would be the most appropriate choice?
1. Dapagliflozin
2. Glipizide
3. Semaglutide
4. Sitagliptin
The correct answer is: 1.
SGLT2 inhibitors (Dapagliflozin) and GLP-1s (Semaglutide) both improve cardiovascular outcomes, but only SGLT2 inhibitors ALSO reduce the risk of heart failure and renal failure. Sulfonylureas (Glipizide) lack reno- or cardioprotective effects. DDP-4 inhibitors (Sitagliptin) has a neutral effect and does not confer significant cardiorenal protection, whilst other findings suggest a possible increased risk of heart failure hospitalisation.
A 72-year-old female with a medical history significant for atrial fibrillation (AF) and hypertension, presenting to the emergency department with an acute intracranial hemorrhage (ICH). She was on Apixaban 5 mg BID for stroke prevention, with the last dose administered 6 hours ago. Upon presentation, the patient is experiencing headache, dizziness, and vomiting, with a Glasgow Coma Scale (GCS) score of 13. Imaging confirms a moderate-sized ICH in the left frontal lobe. What would be indicated as a reversal agent for life-threatening bleeding in an emergency situation? (Select the BEST answer.)
1. Andexxa
2. Kcentra
3. NovoSeven
4. Benefix
The best answer is: 1.
Andexxa (coagulation factor Xa [recombinant], inactivated-zhzo).
See the Andexxa drug monograph > Drug Consults > Management of bleeding in patients on oral anticoagulants expert opinion.See also Poisindex: Coagulation Factor Xa Recombinant, Inactivated-Zhzo: Substances Included/Synonyms: Therapeutic/Toxic Class: A) "for patients that develop life-threatening or uncontrolled bleeding following rivaroxaban or apixaban therapy". Kcentra may be used as a non-specific alternative when Andexxa is unavailable or in other Direct Oral AntiCoagulants (DOAC)-associated bleeds. NovoSeen (a recombinant factor VIIa) is used off-label for refractory hemorrhage but carries a high thrombotic risk and is not a first-line antidote to DOAC. BeneFIX is a recombinant Factor IX concentrate for hemophilia and has no role in anticoagulant reversal.
A 34-year-old male, weighing 75 kg, presents with osteomyelitis in his right tibia following a traumatic injury. The patient has serum creatinine of 0.8 mg/dL and an estimated GFR of 120 mL/min. The patient exhibits localized warmth, tenderness, and swelling over the affected area. The patient also reports a fever of 101.5°F and a history of dull, constant pain in the area for the past two weeks. The organism responsible for the infection is identified as Methicillin-resistant Staphylococcus aureus (MRSA), and the patient has been started on appropriate antibiotic therapy with Vancomycin. When treating the patient with Vancomycin, what is the recommended optimal AUC/MIC ratio for the best clinical outcome?
1. 500-600
2. 250-350
3. 400-600
4. 200-300
The correct answer is: 3.
Within the Vancomycin drug monograph in the Adult Dosing and Monitoring sections. Vacomycin: Monitoring: Vancomycin Hydrochloride: Therapeutic: Adult: 2) AUC/MIC Ratio a)1)
An 80-year-old female with a history of atrial fibrillation (AF) and chronic mitral valve disease presents for routine follow-up after undergoing a mechanical mitral valve replacement. The patient is post-operative day 3 following her mechanical mitral valve replacement surgery. She is stable, with no signs of infection, and her surgical site is healing well. She was started on warfarin therapy immediately after surgery to maintain adequate anticoagulation. What is the target INR range for patients with mechanical hearl valves?
1. 2-3
2. 4-5
3. 1-2
4. 2.5-3.5
The correct answer is: 4.
See the Warfarin drug monograph > Monitoring.
Following an infusion of EDTA for lead poisoning, a 56-year-old complains of muscle cramps and numbness around his mouth. Inflation of the sphygmomanometer cuff above his systolic blood pressure leads to a characteristic hand posture (Trousseau sign). What intervention should follow?
1. Continue. These adverse effects are common with initial infusion of Disodium EDTA.
2. Hold the infusion of Calcium Disodium EDTA. It is not approved for chelation therapy.
3. Massage his hand. This will override pain receptors, stop cramping and promote comfort.
4. Stop the infusion at once. There has been confusion about this EDTA infusion.
The correct answer is: 4.
EDTA is an abbreviation for two drugs with different purposes. One is (a) Edetate Disodium (primarily used for emergency situations like digitalis poisoning or high calcium), and the other one (b) Edetate Disodium Calcium (preferred for lead poisoning). Search for "Edetate Disodium", and check the "Important Note" atop the monograph page in either Quick Answers or In-Depth. Trousseau sign is a clinical indication of tetany due to hypocalcemia, which manifests as carbopedal spasm due to chelation of serum calcium, which can pose significant risks. To advocate for patient safety, Micromedex will offer "Important Notes" at the top of a drug to notify healthcare workers of important considerations.
Comparative efficacy
Frontotemporal Dementia (FTD) is a condition that is also known as Pick Disease. Actor Bruce Willis was diagnosed with this condition in 2023. It primarily affects individuals 45-64 years of age, who exhibit decline in behavior, language, and/or movement. Which of the following interventions would be LEAST useful in managing FTD?
1. The caregiver distracts the patient with a new activity when behavioral problems occur.
2. The nurse practitioner prescribes 50mg TRAZODONE for agitation and restlessness at bedtime.
3. The physician orders 5 mg MEMANTINE for early onset dementia.
4. The speech therapist evaluates the patient for swallowing problems as needed.
The correct answer is: 3.
The LEAST useful intervention in managing frontotemporal dementia (FTD) is #3. MEMANTINE is NOT specifically approved for FTD and in trials, its effectiveness is uncertain. Whilst it may be used off-label, the evidence supporting its benefit is weak, especially at the subtherapeutic dosage of 5 mg, which is unlikely to have meaningful impact on FTD symptoms at that level. All the other options are more aligned with FTD management. Behavioral strategies are key in managing FTD-related agitation and impulsivity. TRAZODONE is often used to manage agitation, restlessness and sleep disturbances in dementia. And because FTD can affect motor functions, including swallowing, a speech therapist evaluation is useful.
A 62-year old male with a history of type 2 diabetes mellitus (DM), hypertension, and chronic kidney disease (stage 3) presents for a routine follow-up. His HbA1c is 8.2%, and he has a BMI of 32kg/m2. He reports no symptoms of heart failure but has a history of myocardial infarction two years ago. His current medications include Metformin, Ramipril and Atorvastatin. You are the prescriber considering adding a medication to improve his glycemic control whilst reducing his cardiovascular and renal risks. Which of the following would be the most appropriate choice?
1. Dapagliflozin
2. Glipizide
3. Semaglutide
4. Sitagliptin
The correct answer is: 1.
SGLT2 inhibitors (Dapagliflozin) and GLP-1s (Semaglutide) both improve cardiovascular outcomes, but only SGLT2 inhibitors ALSO reduce the risk of heart failure and renal failure. Sulfonylureas (Glipizide) lack reno- or cardioprotective effects. DDP-4 inhibitors (Sitagliptin) has a neutral effect and does not confer significant cardiorenal protection, whilst other findings suggest a possible increased risk of heart failure hospitalization.
In adult patients with hypertension, how does the efficacy of LOSARTAN compare to LISINOPRIL in reducing blood pressure and improving cardiovascular outcomes?
1. LOSARTAN is more effective than LISINOPRIL in reducing blood pressure and improving cardiovascular outcomes.
2. LISINOPRIL is more effective than LOSARTAN in reducing blood pressure but has a higher incidence of cough as a side effect.
3. Both LOSARTAN and LISINOPRIL are equally effective in managing hypertension, but LOSARTAN is preferred due to fewer side effects.
4. LOSARTAN is less effective than LISINOPRIL in managing hypertension but is used more frequently in patients with diabetes.
The correct answer is: 1.
Whilst both LOSARTAN and LISINOPRIL are effective in managing hypertension, #1 reflects a growing body of evidence suggesting that, in certain contexts, LOSARTAN may be more effective in achieving optimal blood pressure control and improving cardiovascular outcomes. However, it's important to note that individual patient responses can vary, and treatment should always be tailored to the specific needs of the patient.
#2: misrepresents the comparative efficacy regarding blood pressure reductions whilst correctly noting a common side effect of LISINOPRIL.
#3: suggests equal effectiveness, which may not be aligned with current evidence, favoring LOSARTAN (and the entire class of Angiotension II Receptor Blockers, ARBs, that LOSARTAN is part of in certain populations).
#4: incorrectly states that LOSARTAN is less effective, which contradicts evidence.
You can find this information within the LOSARTAN monograph.
A 52-year-old female patient is prescribed Fezolinetant to control her hot flashes. It is important to tell the patient to monitor liver function:
1. At baseline and then yearly for as long as she continues therapy.
2. Before starting, then monthly for 3 months, then at 6 and 9 months.
3. Every 3 months the first year, 6 months the second, and then yearly.
4. Upon the onset of decreased appetite, nausea and abdominal pain.
The correct answer is: 2.
The labeling for Fezolinetant has been revised to advise prescribers to conduct hepatic lab testing before initiating therapy. This monitoring is crucial due to the risk of rare but serious liver injury associated with the drug, which requires regular assessment of liver function to ensure patient safety. Nurses should carefully assess patients for symptoms of impairment.
Find this information in the FEZOLINETANT monograph, under the Monitoring section (both Quick Answers and In-Depth Answers).
Which of the following statements are TRUE about Micromedex solutions to manage drug shortage questions? Select all that apply.
1. I can find evidence-based approaches based on monotherapy and combination therapy for neuropathic pain.
2. I can identify alternative treatment modalities for anxiety within a drug class.
3. I can search for drugs for asthma and get a list of all drugs based on level of recommendation.
4. I can use equianalgesic dosage data to administer the right dose for a patient in palliative care.
The correct answer is: ALL statements are correct.
They all provide an opportunity to not be limited to one therapeutic regimen, and provides alternatives. #1-2 This is included within the Comparative Efficacy section. #3: is the quick search for "Drugs that treat..." #4: Drug consult found by typing: " Equianalgesic Doses".
Patient education
XANOMELINE/TROSPIUM CHLORIDE (Cobenfy) is the first anticholinergic drug approved for schizophrenia. During a home visit, the nurse understands that there is a need for additional education when the patient’s guardian states:
1. “He cannot wait to drive again as soon as the drug had time to do its thing.”
2. “The need to do ongoing liver tests is a bit of a pain, to be honest, but it is what it is.”
3. “He forgot to take it before eating, but I gave it right when he was done eating.”
4. “We both regularly check his body for any signs of swelling. So far, so good.”
The correct answer is: 3 (meaning the statement is wrong).
It should be taken 1 hour before or 2 hours after meals (See Administration section). The presence of food affects how the drug is absorbed. All the other options are correct. All of these can be found in various sections of the monographs, including Patient Education and Top of the monograph page under "Important Note".
A 52-year-old female patient is prescribed Fezolinetant to control her hot flashes. It is important to tell the patient to monitor liver function:
1. At baseline and then yearly for as long as she continues therapy.
2. Before starting, then monthly for 3 months, then at 6 and 9 months.
3. Every 3 months the first year, 6 months the second, and then yearly.
4. Upon the onset of decreased appetite, nausea and abdominal pain.
The correct answer is: 2.
The labeling for Fezolinetant has been revised to advise prescribers to conduct hepatic lab testing before initiating therapy. This monitoring is crucial due to the risk of rare but serious liver injury associated with the drug, which requires regular assessment of liver function to ensure patient safety. Nurses should carefully assess patients for symptoms of impairment.
Find this information in the FEZOLINETANT monograph, under the Monitoring section (both Quick Answers and In-Depth Answers).
Drug shortages
Which of the following statements are TRUE about Micromedex solutions to manage drug shortage questions? Select all that apply.
1. I can find evidence-based approaches based on monotherapy and combination therapy for neuropathic pain.
2. I can identify alternative treatment modalities for anxiety within a drug class.
3. I can search for drugs for asthma and get a list of all drugs based on level of recommendation.
4. I can use equianalgesic dosage data to administer the right dose for a patient in palliative care.
The correct answer is: ALL statements are correct.
They all provide an opportunity to not be limited to one therapeutic regimen, and provides alternatives. #1-2 This is included within the Comparative Efficacy section. #3: is the quick search for "Drugs that treat..." #4: Drug consult found by typing: " Equianalgesic Doses".
Looking for more? Explore the “Did You Know” quick tips
“Did You Know” quick tips are short, helpful hints relating to easier ways of navigating or searching, new content, or evidence you might not find elsewhere. Click on the topics on the left to reveal more.