Chapter 11: Anti-Infectives: Antitubercular and Antifungal Drugs Nursing School Test Banks

Workman: Understanding Pharmacology

Chapter 11: Anti-Infectives: Antitubercular and Antifungal Drugs

Test Bank

MULTIPLE CHOICE

1. A patient received a tuberculosis skin test injection of purified protein derivative (PPD) 72 hours ago. Which assessment finding of the test site does the nurse interpret as a positive reaction?
a. The injected area has a blister-like swelling about 2 mm high and 2 mm in diameter.
b. The injection site is puffy and soft with pus oozing from the needle hole.
c. The skin is red and very hard for 12 mm around the injection site.
d. There is a large bruise surrounding the injection site.
ANS: C
A positive reaction to a TB skin test requires that the skin around the injection site be indurated, not just red. Induration is caused by infiltration of the skin around the test site with many white blood cells, making the area red and swollen, and the tissue much harder than the surrounding normal skin. Bruising is a result of bleeding into the injection site, not infiltration and induration from white blood cells.

PTS: 1 DIF: Cognitive Level: Applying (Application) or higher
TOP: Nursing Process Step: Assessment MSC: Client Needs Category: Physiological Integrity

2. A patient with which findings requires drug therapy for active tuberculosis (TB)?
a. Negative TB skin test and chest x-ray but who has productive cough, fever, and shortness of breath
b. Positive TB skin test, productive cough, and a cavitation on chest x-ray
c. Positive TB skin test and a TB scar on chest x-ray
d. Positive TB skin test as the only symptom
ANS: B
A positive skin test for TB only means that the patient was infected with TB at one time. A TB scar also only indicates old, inactive disease. Cavitation and productive cough along with a positive skin test are indicators of active disease that can be spread to others, and this person must be treated. The person with a negative skin test and chest x-ray but with other symptoms probably has another type of respiratory infection.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension)
REF: p. 190 TOP: Nursing Process Step: N/A
MSC: Client Needs Category: Physiological Integrity

3. How long is the minimum course of drug therapy for an immunocompetent patient with active tuberculosis?
a. 7 to 10 days
b. 6 weeks
c. 6 months
d. 2 years
ANS: C
A patient who has nondrug-resistant tuberculosis must remain on the prescribed medications for at least 6 months. The organism is slow growing and is harder to control than other types of bacteria.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge)
REF: p. 190 TOP: Nursing Process Step: N/A
MSC: Client Needs Category: Physiological Integrity

4. A patient with active tuberculosis who has been taking isoniazid (INH, Nydrazid) and rifampin (RIF, Rifadin) reports having urine that is an orange color. What is the nurses best action?
a. Obtain a specimen for culture and test the urine for occult blood.
b. Reassure the patient that this is a normal drug side effect.
c. Hold the dose and contact the prescriber.
d. Document the report as the only action.
ANS: B
Rifampin normally turns urine an orange color. No intervention is needed; however, the color change can be very distressing to patients. The patient should be reassured that this color change is normal and be taught how to manage this change so that clothing does not become stained.

PTS: 1 DIF: Cognitive Level: Applying (Application) or higher
TOP: Nursing Process Step: Implementation
MSC: Client Needs Category: Health Promotion and Maintenance

5. A male patient who has been prescribed isoniazid (INH, Nydrazid) reports that his breasts have enlarged since starting therapy. What is the nurses best response?
a. This is common with isoniazid and will disappear after you stop drug therapy.
b. Is the enlargement the same on both sides or is one breast larger than the other?
c. If you are not having difficulty getting an erection, do not worry about this change.
d. I will report this problem to your prescriber and see if it is possible for you to stop taking this drug.
ANS: A
Breast enlargement in men (gynecomastia) is a common side effect of isoniazid. This physical change can be very distressing and embarrassing to men, and they should be reassured that the problem is temporary. Even though it is distressing, breast enlargement is not a reason to stop drug therapy.

PTS: 1 DIF: Cognitive Level: Applying (Application) or higher
TOP: Nursing Process Step: Implementation
MSC: Client Needs Category: Psychosocial Integrity

6. Which statement made by a patient indicates to the nurse the need for more teaching about first-line drug therapy for tuberculosis (TB)?
a. To prevent nausea and vomiting, I have been taking my drugs at night with a small snack.
b. I have stopped taking all herbal supplements and stopped drinking beer until I finish this drug therapy.
c. Now that my symptoms have disappeared after a month of drug therapy, I can no longer infect my family.
d. Now that my symptoms have disappeared after a month of drug therapy, I can stop taking all of these drugs.
ANS: D
Usually TB is no longer contagious and clinical improvement is seen after drugs have been taken for 2 to 3 consecutive weeks. However, the organism growth has only been suppressed and the immune system and drugs have not had sufficient time to eradicate it. Stopping treatment after only a month will allow the disease to again become active and the organisms can become resistant to these drugs. The patient must continue taking the drugs for 6 months or longer, exactly as prescribed.

PTS: 1 DIF: Cognitive Level: Applying (Application) or higher
TOP: Nursing Process Step: Implementation
MSC: Client Needs Category: Health Promotion and Maintenance

7. What is the most important question the nurse must ask a patient before administering rifampin (RIF) intravenously?
a. Have you ever had gout?
b. Are you allergic to sulfa drugs?
c. Are you allergic to sulfite preservatives?
d. Have you had any alcoholic beverages within the last month?
ANS: C
The IV form of rifampin contains a sulfite preservative that can cause hypersensitivity reactions in patients allergic to sulfite preservatives such as sodium metabisulfite or potassium metabisulfite. This problem is not the same as an allergy to sulfa drugs.

PTS: 1 DIF: Cognitive Level: Applying (Application) or higher
TOP: Nursing Process Step: Implementation
MSC: Client Needs Category: Safe and Effective Care Environment

8. A patient is prescribed 420 mg of rifampin to be added to 500 mL of dextrose 5% in water (D5W). The vial contains rifampin 60 mg/mL. How many milliliters does the nurse add to the D5W?
a. 0.16
b. 5
c. 7
d. 8
ANS: C
Want 420 mg/Have 60 mg in 1 mL. 420/60 = 7 mL.

PTS: 1 DIF: Cognitive Level: Applying (Application) or higher
TOP: Nursing Process Step: Implementation
MSC: Client Needs Category: Safe and Effective Care Environment

9. A patient has been prescribed all four first-line drugs for tuberculosis (TB). Which laboratory blood value is most important for the nurse to report to the prescriber first?
a. Red blood cells (RBCs) 2.2 million/mm3
b. International normalized ratio 1.6
c. White blood cells 6000/mm3
d. Sodium 134 mEq/L
ANS: A
All of these values are abnormal; however, only the RBC count is seriously out of the normal range. One of the most serious adverse effects of rifampin (a major part of first-line drug therapy for TB) is suppression of RBC production, leading to anemia. This patients RBC level is only about half of normal.

PTS: 1 DIF: Cognitive Level: Applying (Application) or higher
TOP: Nursing Process Step: Implementation
MSC: Client Needs Category: Physiological Integrity

10. Which administration technique does the nurse teach the family of a patient with memory problems for best adherence to first-line drug therapy for tuberculosis?
a. Having one family member responsible for giving the drugs and watching the patient swallow them
b. Setting up the patients drugs using a daily pill dispenser that has separate slots for each individual drug
c. Asking the patient every night whether he or she has remembered to take all the drug doses that day
d. Administering all the drugs together at the same time every day and ensuring that the patient drinks plenty of water
ANS: A
Successful drug therapy for TB requires that all first line drugs be taken correctly without missing doses. Patients who have memory problems usually need some form of directly observed therapy (DOT) to ensure absolute adherence to this important therapy. Having one family member responsible for giving the drugs fulfills the requirements of DOT and reduces the risk that the patient will receive either too many drug doses or too few doses to be effective.

PTS: 1 DIF: Cognitive Level: Applying (Application) or higher
TOP: Nursing Process Step: Implementation
MSC: Client Needs Category: Health Promotion and Maintenance

11. Which precaution is most important for the nurse to teach a patient who is prescribed isoniazid (INH, Nydrazid)?
a. Use another form of birth control in addition to oral contraceptives to prevent an unplanned pregnancy.
b. Do not drive or operate dangerous equipment until you know how this drug affects you.
c. Wear glasses rather than contact lenses throughout this drug therapy.
d. Avoid coffee and any foods or beverages that contain caffeine.
ANS: D
Isoniazid raises blood pressure. When this drug is taken in combination with other drugs or agents that also raise blood pressure, the patient can develop dangerous hypertension. Caffeine is a common food ingredient that greatly increases the risk for hypertension when taken in combination with isoniazid.

PTS: 1 DIF: Cognitive Level: Applying (Application) or higher
TOP: Nursing Process Step: Implementation
MSC: Client Needs Category: Health Promotion and Maintenance

12. A patient who is prescribed ethambutol (EMB, Myambutol) reports trouble distinguishing colors. What is the nurses best action?
a. Document the report as the only action.
b. Hold the dose and notify the prescriber immediately.
c. Caution the patient to wear sunglasses and a hat when outside.
d. Reassure the patient that this is a common side effect of the drug.
ANS: B
Ethambutol at high doses can cause optic neuritis vision changes that include reduced color vision, blurred vision, and reduced visual fields. This problem can lead to blindness. When the problem is discovered early, the eye problems are usually reversed when the drug is stopped.

PTS: 1 DIF: Cognitive Level: Applying (Application) or higher
TOP: Nursing Process Step: Implementation
MSC: Client Needs Category: Physiological Integrity

13. Why are the side effects of antifungal therapy often more common and severe than for other types of anti-infective drugs?
a. Fungal DNA closely resembles human DNA.
b. Fungi do not respond to antibacterial therapy.
c. Humans have no immunologic resistance to fungus.
d. Most fungal infections are considered pathologic rather than opportunistic.
ANS: A
The genetic material of fungi is DNA. Its construction is very similar to human DNA, and drugs that affect fungal DNA are more likely also to affect human DNA. This is one reason that humans respond with more side effects to antifungal therapy than to many antibacterial or antiviral drugs.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension)
REF: p. 195 TOP: Nursing Process Step: N/A
MSC: Client Needs Category: Physiological Integrity

14. A patient prescribed a systemic antifungal drug reports a change in how food tastes. What is the nurses best action?
a. Document the report as the only action.
b. Hold the dose and notify the prescriber immediately.
c. Caution the patient to wear sunglasses and a hat when outside.
d. Reassure the patient that this is a common side effect of the drug.
ANS: D
Systemic antifungal drugs have many common side effects, including loss of taste or changes in how food tastes. Unless this problem interferes with the patients nutritional status, it is of no consequence. The patient should be reassured that the taste changes are an expected side effect and that normal taste sensation will return after the drug has been stopped after several days or a week.

PTS: 1 DIF: Cognitive Level: Applying (Application) or higher
TOP: Nursing Process Step: Implementation
MSC: Client Needs Category: Psychosocial Integrity

15. A patient taking ketoconazole (Nizoral) for the last 2 weeks has all of the following blood laboratory test values. Which value does the nurse report to the prescriber immediately?
a. White blood cell count (WBC) 10,500 cells/mm3
b. Lactate dehydrogenase 880 IU/L
c. Potassium 3.6 mEq/L
d. Hematocrit 32%
ANS: B
The WBC count, lactate dehydrogenase, and hematocrit values are abnormal; however, only the lactate dehydrogenase level is very high (three to four times normal). This value indicates liver impairment, which can be caused by taking ketoconazole. This value must be reported immediately so that liver function can be explored and any needed changes in drug therapy made before irreversible liver damage occurs.

PTS: 1 DIF: Cognitive Level: Applying (Application) or higher
TOP: Nursing Process Step: Implementation
MSC: Client Needs Category: Physiological Integrity

16. A patient about to start systemic antifungal therapy has a white blood cell (WBC) count of 3200 cells/mm3. Which antifungal drug must be avoided for this patient?
a. fluconazole (Diflucan)
b. ketoconazole (Nizoral)
c. micafungin (Mycamine)
d. terbinafine (Lamisil)
ANS: D
This WBC count is lower than normal. Terbinafine and flucytosine (Ancobon) can further reduce this patients WBC count and greatly increase his or her risk for infection.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension)
REF: p. 199 TOP: Nursing Process Step: N/A
MSC: Client Needs Category: Physiological Integrity

17. A patient is prescribed 50 mg of amphotericin B (Fungizone) by intravenous infusion in 500 mL of dextrose 5% in water (D5W) over 6 hours. How many milliliters per minute does the nurse set the pump to infuse?
a. 1.4
b. 2.2
c. 4.2
d. 6.2
ANS: A
500 mL 6 = 83.3 mL/hr. Divide 83.3 mL by 60 minutes = 1.38 mL per minute. Round up to 1.4.

PTS: 1 DIF: Cognitive Level: Applying (Application) or higher
TOP: Nursing Process Step: Implementation
MSC: Client Needs Category: Safe and Effective Care Environment

18. A patient is receiving IV amphotericin B (Fungizone) for a systemic fungal infection. Which assessment parameter does the nurse perform to determine whether the patient is having an adverse reaction to the therapy?
a. Measure abdominal girth for presence of ascites
b. Assess mouth and oral cavity for candidiasis
c. Assess infusion site for phlebitis
d. Assess calves for pain
ANS: C
Among its many adverse effects, amphotericin B is very irritating and causes phlebitis at the site of infusion. This can occur quickly, sometimes after only one drug dose. When it is present, the IV site needs to be changed to prevent more complications and patient discomfort.

PTS: 1 DIF: Cognitive Level: Applying (Application) or higher
TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Safe and Effective Care Environment

19. A patient is prescribed amphotericin B (Fungizone) 400 mg intravenously. How fast does the nurse infuse this drug?
a. Immediately by intravenous (IV) push
b. Over a period of 60 minutes
c. Over a period of 2 hours
d. Over a minimum of 6 hours
ANS: D
Rapid administration of IV amphotericin B is associated with more severe rigors, hyperkalemia, and a more rapid onset of renal insufficiency. It is recommended that the drug be administered over a 6-hour time period regardless of the dose.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension)
REF: p. 200 TOP: Nursing Process Step: N/A
MSC: Client Needs Category: Physiological Integrity

20. A patient who has been prescribed flucytosine (Ancobon) reports reduced sensation in the fingers and toes. What is the nurses best action?
a. Document the report as the only action.
b. Hold the dose and notify the prescriber.
c. Remind the patient to continue the drug as usual and to take a multiple vitamin daily.
d. Reassure the patient that this is an expected drug side effect and to use injury precautions.
ANS: D
Peripheral neuropathy with loss of sensation in the extremities is a common and expected side effect of flucytosine therapy. Drug therapy is not stopped for this effect. The patient must implement precautions to prevent injury from not having full sensation for touch, temperature, and pressure.

PTS: 1 DIF: Cognitive Level: Applying (Application) or higher
TOP: Nursing Process Step: Implementation
MSC: Client Needs Category: Health Promotion and Maintenance

21. Which food, drink, or herbal supplement does the nurse warn a patient who is prescribed any of the azole class of antifungal drugs to avoid?
a. Caffeinated beverages
b. Grapefruit juice
c. St. Johns wort
d. Dairy products
ANS: B
The activity of azole antifungal drugs can be reduced by grapefruit juice in large quantities. Patients should not take an azole with grapefruit juice and should limit their total grapefruit juice intake to no more than 24 ounces per day.

PTS: 1 DIF: Cognitive Level: Applying (Application) or higher
TOP: Nursing Process Step: Implementation
MSC: Client Needs Category: Health Promotion and Maintenance

MULTIPLE RESPONSE

1. A pregnant patient is taking all four first-line drugs for tuberculosis (TB). Which additional health care actions are needed for this patient? (Select all that apply.)
a. Ensuring that no weight is gained
b. Checking liver function tests monthly
c. Checking vision and intraocular pressure monthly
d. Testing urine for the presence of the TB organism
e. Supplementing with B-complex vitamins
f. Avoiding alcoholic beverages
ANS: B, E, F
The risk for liver toxicity is higher when taking TB drug therapy during pregnancy, and close monitoring of liver function is needed. In addition, the pregnant woman needs higher doses of a B-complex vitamin supplement when taking INH. Avoiding alcohol during TB therapy is very important for all patients and is critical for pregnant women because of the increased risk for liver toxicity as well as fetal alcohol syndrome.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension)
REF: p. 194 TOP: Nursing Process Step: N/A
MSC: Client Needs Category: Physiological Integrity

2. Which precautions are important to teach a woman using a vaginal cream form of an antifungal drug? (Select all that apply.)
a. Wear gloves to insert the cream.
b. Wash the applicator with soap and water.
c. Do not tub bathe until treatment is completed.
d. Avoid sexual intercourse during the treatment period.
e. Remind the patient that the cream can make holes in a condom or diaphragm.
f. Stop the drug immediately if you think you are pregnant.
g. Stop the drug when symptoms have disappeared to avoid unnecessary exposure to it.
ANS: B, D, E
Sexual intercourse should be avoided for several reasons: the drug can make holes in a condom or diaphragm and increase the risk for an unplanned pregnancy; in addition, the infection can be spread to a sexual partner. The applicator should be washed regularly with soap and water after each use. Although hands should be washed before and after applying the drug, the vagina is not a sterile body cavity, so it is not necessary to wear gloves during the application. There are no bathing restrictions while using the drug. Vaginal application of the drug does not affect pregnancy (however, a vaginal infection can have adverse effects on the pregnancy). To ensure eradication of the infection and prevent the development of resistant organisms, the drug should be used for as long as prescribed even after symptoms are no longer present.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension)
REF: p. 197 TOP: Nursing Process Step: Implementation
MSC: Client Needs Category: Health Promotion and Maintenance

3. A patient is receiving IV caspofungin (Cancidas). Which assessments are most important for the nurse to perform daily? (Select all that apply.)
a. Assessing both calves for swelling, redness, and pain
b. Examining the skin for rash and blisters
c. Assessing capillary refill in fingers and toes
d. Assessing the injection site for irritation or phlebitis
e. Reviewing laboratory reports of white blood cell counts
f. Listening for bowel sounds in all four abdominal quadrants
g. Reviewing laboratory reports for blood urea nitrogen (BUN) and creatinine
ANS: A, B, D, G
Echinocandins can increase the rate of clot formation, which increases the risk for deep vein thrombosis (DVT). DVT is most likely to occur in the veins of the lower legs and in the pelvis. Symptoms of DVT in an extremity include swelling, warmth, and pain or discomfort. All the systemic antifungal agents can cause renal insufficiency. Anyone prescribed these drugs must have renal function monitored. Any intravenous antifungal drug can irritate veins and cause phlebitis. Skin irritation and rashes can occur with systemic antifungal therapy. Rashes may be severe with many types of lesions (Stevens-Johnson syndrome). If the rashes become widespread with crusting, fever, and tissue necrosis, the condition can be life-threatening. Echinocandins do not affect intestinal motility or capillary refill. They also do not directly affect bone marrow production of white blood cells.

PTS: 1 DIF: Cognitive Level: Applying (Application) or higher
TOP: Nursing Process Step: Implementation
MSC: Client Needs Category: Physiological Integrity

4. An older adult patient is prescribed systemic antifungal therapy for 1 month. Which precautions are important for the nurse to teach this patient? (Select all that apply.)
a. Avoid drinking coffee or any other beverages or food that contain caffeine.
b. Check your pulse daily and report any new irregularities to your prescriber.
c. Examine all bowel movements and any vomit for the presence of pus and report it to your prescriber.
d. Look at the whites of your eyes daily and if a yellow color appears, report it to your prescriber.
e. If your daily urine output drops below a liter less than your daily fluid intake, notify your prescriber immediately.
f. If you should develop abdominal bloating and diarrhea, go to the nearest emergency department as soon as possible.
ANS: B, D, E
Most of the antifungal drugs can affect cardiac rhythm. Patients should check their pulse daily for a full minute, and if new irregularities are present or the rate is slow, the prescriber should be notified. The risk for drug-induced liver toxicity is higher among older adults; often the first symptom of reduced liver function is yellowing of the sclera and skin. Older adults are also more likely to have some degree of renal insufficiency and can develop kidney problems more quickly while taking an antifungal drug; normal daily urine output should be very close to the volume of fluid taken in each day. There is no recommendation to avoid caffeine with any antifungal drug. GI infection is not a specific risk associated with antifungal therapy. Abdominal bloating and diarrhea are not especially associated with antifungal therapy and are not indications of the need to seek immediate medical attention.

PTS: 1 DIF: Cognitive Level: Applying (Application) or higher
TOP: Nursing Process Step: Implementation
MSC: Client Needs Category: Health Promotion and Maintenance

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