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A pharmacist is reviewing a new prescription prepared by a pharmacy technician. The prescription label reads: Precose 25mg PO TID x 30 days; Qty: 90 5 Refills. Which of the following acts done by the pharmacist is the most appropriate?
 
a. Fill as it is.
b. Call the prescriber to verify the Precose dose.
c. Call the prescriber to verify the number of refills.
d. Ask the technician to add an auxiliary label: "Take With Meals".
e. Counsel the patient that this drug may cause "Severe Constipation".


A pharmacist is reviewing a new prescription prepared by a pharmacy technician. The prescription label reads: Precose 25mg PO TID x 30 days; Qty: 90 5 Refills. Which of the following acts done by the pharmacist is the most appropriate?
 
a. Fill as it is.
b. Call the prescriber to verify the Precose dose.
c. Call the prescriber to verify the number of refills.
d. Ask the technician to add an auxiliary label: "Take With Meals".
e. Counsel the patient that this drug may cause "Severe Constipation".
 
Answer: d. Acarbose (Precose) is an oral alpha-glucosidase inhibitor for use in the management of type 2 diabetes mellitus. It delays the digestion of ingested carbohydrates, thereby resulting in a smaller rise in blood glucose concentration following meals. As a consequence of plasma glucose reduction, Precose reduces levels of glycosylated hemoglobin in patients with type 2 diabetes mellitus.
 
In contrast to sulfonylureas, Precose does not enhance insulin secretion. The antihyperglycemics action of acarbose results from a competitive, reversible inhibition of pancreatic alpha-amylase and membrane-bound intestinal alpha-glucoside hydrolase enzymes. Pancreatic alpha-amylase hydrolyzes complex starches to oligosaccharides in the lumen of the small intestine, while the membrane-bound intestinal alpha-glucosidases hydrolyze oligosaccharides, trisaccharides, and disaccharides to glucose and other monosaccharides in the brush border of the small intestine. In diabetic patients, this enzyme inhibition results in a delayed glucose absorption and a lowering of postprandial hyperglycemia.
 
The recommended starting dosage of Acarbose (Precose) is 25 mg given orally three times daily at the start (with the first bite) of each main meal . However, some patients may benefit from more gradual dose titration to minimize gastrointestinal side effects. This may be achieved by initiating treatment at 25 mg once per day and subsequently increasing the frequency of administration to achieve 25 mg t.i.d.
 
Hypoglycemia, gas, bloating and diarrhea are commonly reported side effects of Acarbose (Precose).

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For compounding purposes, if neither USP/NF grade substances nor FDA-approved substances are available, or when food, cosmetics, or other substances are, or must be used, the substance shall be of a chemical grade from:
 
I. Chemically Pure
II. Analytical Reagent
III. American Chemical Society
 
a. I only
b. I and II only
c. II and III only
d. All


For compounding purposes, if neither USP/NF grade substances nor FDA-approved substances are available, or when food, cosmetics, or other substances are, or must be used, the substance shall be of a chemical grade from:
 
I. Chemically Pure
II. Analytical Reagent
III. American Chemical Society
 
a. I only
b. I and II only
c. II and III only
d. All

Answer: (d) All. Ingredients used in a compounded preparation shall either originate from FDA-approved sources, if available, or be USP/NF grade substances. If neither USP/NF grade substances nor FDA-approved substances are available, or when food, cosmetics, or other substances are, or must be used, the substance shall be of a chemical grade in one of the following categories:
 
(1). Chemically Pure (CP); 
(2). Analytical Reagent (AR); or 
(3). American Chemical Society (ACS); or 
(4). Food Chemical Codex.
 


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Who may fall to a major statin benefit groups?
 
I. Patients with LDL 190 mg/dL or higher.
II. Patients age 40 to 75 years of age with diabetes and LDL 70 to 189 mg/dL.
III. Patients without clinical atherosclerotic cardiovascular disease or diabetes with LDL 70 to 189 mg/dL.

a. I only
b. I and II only
c. II and III only
d. All


Who may fall to a major statin benefit groups?
 
I. Patients with LDL 190 mg/dL or higher.
II. Patients age 40 to 75 years of age with diabetes and LDL 70 to 189 mg/dL.
III. Patients without clinical atherosclerotic cardiovascular disease or diabetes with LDL 70 to 189 mg/dL.
 
a. I only
b. I and II only
c. II and III only
d. All
 
Answer: d, All. There are four major statin benefit groups:

a. Patients with clinical atherosclerotic cardiovascular disease.

b. Patients with LDL 190 mg/dL (5 mmol/L) or higher.

c. Patients age 40 to 75 years of age with diabetes (but without clinical atherosclerotic cardiovascular disease) and LDL 70 to 189 mg/dL (1.8 to 4.9 mmol/L).

d. Patients without clinical atherosclerotic cardiovascular disease or diabetes with LDL 70 to 189 mg/dL (1.8 to 4.9 mmol/L), with an estimated 10-year risk of atherosclerotic cardiovascular disease of 7.5% or higher.

If a patient does not fit into one of the four statin benefit groups (e.g., LDL 70 to 189 mg/dL [1.8 to 4.9 mmol/L] with 10-year risk 5% to 7.5%), but there is clinical suspicion that they may benefit from a statin, additional factors can be taken into consideration:

a. LDL 160 mg/dL or higher or other evidence of genetic hyperlipidemia.

b. Cardiovascular disease onset in a first degree male relative before age 55, or in a first degree female relative before age 65.

c. High-sensitivity C-reactive protein 2 mg/dL or higher.

d. Elevated lifetime risk of atherosclerotic cardiovascular disease.

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Which of the following statements is/are NOT TRUE about hypertension therapy according to NEW JNC8 guidelines? [Select ALL THAT APPLY].
 
a. African Americans respond to ACE Inhibitors/Angiotensin Receptor blocker quite well.
b. Beta or alpha blockers are recommended initial therapy for nonblack patients.
c. Thiazides produce better cardiovascular outcomes than ACE inhibitors in African Americans.
d. Most African Americans will need at least three antihypertensives to control blood pressure.
e. In nonblack patients with diabetes, ACE Inhibitors/Angiotensin Receptor blockers are considered to be initial therapy.
 


Which of the following statements is/are NOT TRUE about hypertension therapy according to NEW JNC8 guidelines? [Select ALL THAT APPLY].
 
a. African Americans respond to ACE Inhibitors/Angiotensin Receptor blocker quite well.
b. Beta or alpha blockers are recommended initial therapy for nonblack patients.
c. Thiazides produce better cardiovascular outcomes than ACE inhibitors in African Americans.
d. Most African Americans will need at least three antihypertensives to control blood pressure.
e. In nonblack patients with diabetes, ACE Inhibitors/Angiotensin Receptor blockers are considered to be initial therapy.
 
Answer: a,b,d. NEW JNC8 guidelines for treating hypertension patients:
 
1. Thiazides no longer given preference as initial therapy.
 
2. Because patients with diabetes are at increased risk of nephropathy, coronary artery disease, and heart failure, conditions known to benefit from ACE Inhibitors and Angiotensin II Receptor Blockers, it makes sense to choose one of them first-line for hypertension in patients with diabetes.
 
3. For HTN, beta- and alpha-blockers have worse cardio vascular outcomes data than the recommended agents.
 
4. African Americans have high stroke risk. Calcium channel blockers provide better stroke prevention and blood pressure reduction in African Americans vs ACE Inhbitors.1
 
5.Thiazides produce better cardio vascular outcomes (including reduced stroke risk) than ACE inhibitors in African Americans.
 
6. African Americans tend to be “salt-sensitive.” This may explain their relatively poor response to ACE inhibitors. Encourage sodium restriction.
 
7. Most African Americans will need at least two antihypertensives to control blood pressure. African Americans and nonblacks have similar responses to combination therapy (i.e., thiazide plus ACE Inhibitor; Calcium channel blocker plus ACE Inhibitor).
 
8. Do not use an ACE Inhibitor plus an Angiotensin II Receptor Blocker; no added benefit, more side effects (e.g., hyperkalemia).
 
9. Thiazides and Calcium channel blockers reduce systolic BP more than diastolic BP.

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A pharmacist receives a new prescription for Augmentin 500 mg. The prescription reads 1 tab po bid x 10 days. A technician in the pharmacy fills and processes the prescription using 250 mg of Augmentin instead, since the pharmacy is out of stock of 500 mg Augmentin tablets. The pharmacist who is doing the final check of the prescription should:

a. Fill the prescription as it is.
b. Call the physician and get approval regarding this switch.
c. Not fill the prescription.
d. Fill the prescription but counsel and inform the patient about this switch.

Answer:


A pharmacist receives a new prescription for Augmentin 500 mg. The prescription reads 1 tab po bid x 10 days. A technician in the pharmacy fills and processes the prescription using 250 mg of Augmentin instead, since the pharmacy is out of stock of 500 mg Augmentin tablets. The pharmacist who is doing the final check of the prescription should:

a. Fill the prescription as it is.
b. Call the physician and get approval regarding this switch.
c. Not fill the prescription.
d. Fill the prescription but counsel and inform the patient about this switch.

Answer: (c) Since both the 250 mg and 500 mg tablets of amoxicillin/clavulanate potassium contain the same amount of clavulanic acid (125 mg, as the potassium salt), two amoxicillin/clavulanate potassium 250 mg tablets are not equivalent to one 500 mg amoxicillin/clavulanate potassium tablet.

Therefore two 250 mg amoxicillin/clavulanate potassium tablets should not be substituted for one 500 mg amoxicillin/clavulanate potassium tablet.

**This question is taken from Clinical Naplex Test-5. Visit www.pharmacyexam.com**


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Which of the following statements is NOT TRUE about vaccines or immunizations?

a. Two live vaccines may be given at the same time.
b. parenteral or intranasal administration of a live vaccine is not thought to affect the immune response of a subsequently administered oral live vaccine.
c. A live vaccine and an inactivated vaccine can be administered without regard to the timing of the other.
d. Antipyretics/analgesics such as acetaminophen or ibuprofen should routinely be given prior to immunization to reduce the discomfort.


Which of the following statements is NOT TRUE about vaccines or immunizations?

a. Two live vaccines may be given at the same time.
b. parenteral or intranasal administration of a live vaccine is not thought to affect the immune response of a subsequently administered oral live vaccine.
c. A live vaccine and an inactivated vaccine can be administered without regard to the timing of the other.
d. Antipyretics/analgesics such as acetaminophen or ibuprofen should routinely be given prior to immunization to reduce the discomfort.

Answer:(d). If more than one non-oral live vaccine (e.g., live attenuated influenza vaccine [LAIV], varicella, mumps) needs to be administered, it is recommended that the vaccines be given on the same day. However, if this is not possible, doses of the live vaccines should be separated by at least four weeks. The four-week interval reduces the interference of immune response to the first vaccine by the second vaccine.
 
This rule for separation does not apply to the administration of oral live vaccines not given on the same day: typhoid and rotavirus. These vaccines can be given less than four weeks apart. However, this scenario isn't likely to occur because the age groups for which these vaccines are recommended do not overlap. In addition, parenteral or intranasal administration of a live vaccine is not thought to affect the immune response of a subsequently administered oral live vaccine.
 
A live vaccine and an inactivated vaccine can be administered without regard to the timing of the other.
 
Antipyretics/analgesics such as acetaminophen or ibuprofen should not routinely be given prior to immunization. They might reduce a patient's immune response. However, if needed, these meds can be used for treatment of fever and pain as needed following vaccination.

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A consulting pharmacist in a skilled nursing facility is asked by a nurse: "What is meant by peak digoxin body stores in the following chart order?" The patient has received the following new orders:

Lanoxin (Digoxin)

Administer (immediately) a dose to get peak digoxin body stores of 10 mcg/kg. Administer a second dose 6 hours later, after confirming with the prescriber.

The pharmacist may tell her that:

a. He hasn't heard of it before.
b. It means a loading dose of the drug.
c. It means a maintenance dose of the drug.
d. It should be clarified with the prescribing physician.
e. It means AUC at t1/2.

Answer:

**This sample question is from Clinical NAPLEX Practice Test 3.** For more information please visit www.pharmacyexam.com


A consulting pharmacist in a skilled nursing facility is asked by a nurse: "What is meant by peak digoxin body stores in the following chart order?" The patient has received the following new orders:

Lanoxin (Digoxin)

Administer (immediately) a dose to get peak digoxin body stores of 10 mcg/kg. Administer a second dose 6 hours later, after confirming with the prescriber.

The pharmacist may tell her that:

a. He hasn't heard of it before.
b. It means a loading dose of the drug.
c. It means a maintenance dose of the drug.
d. It should be clarified with the prescribing physician.
e. It means AUC at t1/2.

Answer:(b). Digitalization may be accomplished by either of two general approaches that vary in dosage and frequency of administration, but reach the same endpoint in terms of total amount of digoxin accumulated in the body.

If rapid digitalization is considered medically appropriate, it may be achieved by administering a loading dose based upon projected peak digoxin body stores. Maintenance doses can be calculated as a percentage of the loading dose.

Peak digoxin body stores (i.e. loading dose) of 8 to 12 mcg/kg should provide therapeutic effect with minimum risk of toxicity in most patients with heart failure and normal sinus rhythm. Because of altered digoxin distribution and elimination, projected peak body stores for patients with renal insufficiency should be conservative (i.e. 6 to 10 mcg/kg).

The loading dose should be administered in several portions, with roughly half the total given as the first dose. Additional fractions of this planned total dose may be given at 6- to 8-hour intervals, with careful assessment of clinical response before each additional dose.

**This sample question is from Clinical NAPLEX Practice Test 3.** For more information please visit www.pharmacyexam.com


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Which of the following information regarding Pneumovax 23 is TRUE?
 
a. Pneumococcal vaccine is administered intradermally as one 0.5-mL dose.
b. Pneumococcal vaccine MUST NOT be administered at the same time as influenza vaccine.
c. For any person who has received a dose of pneumococcal vaccine at age greater than 65 years, revaccination is not indicated.
d. PNEUMOVAX 23 is approved for use in children older than 1 year of age.


Which of the following information regarding Pneumovax 23 is TRUE?
 
a. Pneumococcal vaccine is administered intradermally as one 0.5-mL dose.
b. Pneumococcal vaccine MUST NOT be administered at the same time as influenza vaccine.
c. For any person who has received a dose of pneumococcal vaccine at age greater than 65 years, revaccination is not indicated.
d. PNEUMOVAX 23 is approved for use in children older than 1 year of age.
 
Answer:(c). PNEUMOVAX 23 is a vaccine indicated for active immunization for the prevention of pneumococcal disease caused by the 23 serotypes contained in the vaccine.
 
PNEUMOVAX 23 is NOT approved for use in children younger than 2 years of age because children in this age group do not develop an effective immune response to capsular types contained in the polysaccharide vaccine.
 
The Advisory Committee on Immunization Practices (ACIP) has recommendations for revaccination against pneumococcal disease for persons at high risk who were previously vaccinated with PNEUMOVAX 23. Routine revaccination of immunocompetent persons previously vaccinated with a 23-valent vaccine, is not recommended.
 
All persons in this category should receive the pneumococcal vaccine, including previously unvaccinated persons and persons who have not received vaccine within 5 years (and were <65 years of age at the time of vaccination). For any person who has received a dose of pneumococcal vaccine at age greater than 65 years, revaccination is not indicated.
 
Pneumococcal vaccine is administered intramuscularly or subcutaneously as one 0.5-mL dose. Pneumococcal vaccine may be administered at the same time as influenza vaccine (by separate injection in the other arm) without an increase in side effects or decreased antibody response to either vaccine.

Pneumococcal vaccine also may be administered concurrently with other vaccines. The administration of pneumococcal vaccine with combined diphtheria, tetanus, and pertussis (DTP); poliovirus; or other vaccines does not increase the severity of reactions or diminish antibody responses.
 
Canadian and U.S. product labeling do say to consider separating administration of Zostavax and Pneumovax 23 by at least four weeks, since concurrent administration of these vaccines can reduce patients' immune responses to Zostavax.

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What would be the new Acetaminophen strength in a reformulated Vicodin?
 
a. 500 mg
b. 300 mg
c. 325 mg
d. None of the above


What would be the new Acetaminophen strength in a reformulated Vicodin?
 
a. 500 mg
b. 300 mg
c. 325 mg
d. None of the above
 
Answer(b): 300 mg. On January 13, 2011, the U.S. Food and Drug Administration (FDA) asked drug manufacturers to limit the strength of acetaminophen in prescription drug products, including combination acetaminophen and opioid products, to no more than 325 mg per dosage unit.
 
The FDA has stated that limiting the amount of acetaminophen per dosage unit in prescription products may reduce the risk of severe liver injury from acetaminophen overdosing.
 
The FDA requested this change be effected by January 2014. Abbott, the manufacturer of Vicodin, has complied with this directive ahead of the FDA's requested date and has introduced new formulations of Vicodin (Hydrocodone bitartrate and Acetaminophen tablets, USP) with reduced acetaminophen content in the third quarter of 2012.
 
Vicodin is available in the following new formulations:

1. VICODIN® (hydrocodone bitartrate and acetaminophen tablets, USP) 5 mg/300 mg
2. VICODIN ES® (hydrocodone bitartrate and acetaminophen tablets, USP) 7.5 mg/300 mg
3. VICODIN HP® (hydrocodone bitartrate and acetaminophen tablets, USP) 10 mg/300 mg
 
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Brintellix is indicated for the treatment of:
 
a. Hypertension
b. Major Depressive Disorder
c. Arthritis
d. Diabetes mellitus
e. Male pattern baldness


Brintellix is indicated for the treatment of:
 
a. Hypertension
b. Major Depressive Disorder
c. Arthritis
d. Diabetes mellitus
e. Male pattern baldness

Answer(b): Major depressive disorder. The active ingredient found in Vortioxetine (Brintellix) is Vortioxetine. Each Vortioxetine (Brintellix) tablet contains 5 mg, 10 mg, 15 mg, or 20 mg of Vortioxetine, respectively. Vortioxetine (Brintellix) is indicated for the treatment of major depressive disorder (MDD).
 
The recommended starting dose is 10 mg administered orally once daily without regard to meals. Dosage should then be increased to 20 mg/day, as tolerated, because higher doses demonstrated better treatment effects in trials conducted in the United States. The efficacy and safety of doses above 20 mg/day have not been evaluated in controlled clinical trials. A dose decrease down to 5 mg/day may be considered for patients who do not tolerate higher doses.
 
At least 14 days should elapse between discontinuation of a MAOI intended to treat psychiatric disorders and initiation of therapy with Vortioxetine (Brintellix) to avoid the risk of Serotonin Syndrome. Conversely, at least 21 days should be allowed after stopping Vortioxetine (Brintellix) before starting an MAOI intended to treat psychiatric disorders.
 
Nausea, constipation, vomiting, serotonin toxicity and serotonin syndrome are commonly reported side effects of Vortioxetine (Brintellix).
 
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