Pharmacology Quiz: Recognizing Adverse Effects
20 questions · exam conditions
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Recognizing Adverse EffectsQuestion 1 of 20

A 35-year-old patient with treatment-resistant schizophrenia, who is maintained on clozapine, calls the clinic triage line. He reports developing a fever of 38.6°C (101.5°F) and a severe sore throat overnight. He is due to take his evening dose of clozapine in two hours. His absolute neutrophil count (ANC) from 4 days ago was 2,500/mm³.

What instruction should the nurse provide to the patient?

Hold the evening dose of clozapine and go to the nearest emergency department for an immediate CBC and evaluation.
Take the scheduled dose of clozapine and come to the clinic in the morning for a CBC.
Take acetaminophen for the fever and use throat lozenges; call back if not better in 48 hours.
Continue the clozapine, but start any leftover antibiotics you may have at home for the sore throat.
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Pharmacology Quiz

Pharmacology Quiz: Recognizing Adverse Effects

Practice Recognizing Adverse Effects in Pharmacology with focused quiz questions that help you check what you know, review explanations, and build confidence with test-style prompts.

What this quiz covers

This quiz focuses on Recognizing Adverse Effects, giving you a quick way to practice the rules, question types, and explanations that matter most for Pharmacology.

How to use this quiz

Try each quiz question before looking at the correct answer. Use the explanations to review missed ideas, then come back to similar questions until the pattern feels familiar.

All questions

Question 1

A 35-year-old patient with treatment-resistant schizophrenia, who is maintained on clozapine, calls the clinic triage line. He reports developing a fever of 38.6°C (101.5°F) and a severe sore throat overnight. He is due to take his evening dose of clozapine in two hours. His absolute neutrophil count (ANC) from 4 days ago was 2,500/mm³.

What instruction should the nurse provide to the patient?

  1. Hold the evening dose of clozapine and go to the nearest emergency department for an immediate CBC and evaluation. (correct answer)
  2. Take the scheduled dose of clozapine and come to the clinic in the morning for a CBC.
  3. Take acetaminophen for the fever and use throat lozenges; call back if not better in 48 hours.
  4. Continue the clozapine, but start any leftover antibiotics you may have at home for the sore throat.
Explanation: When you encounter a clozapine patient reporting fever and sore throat, you must immediately recognize this as a potential hematologic emergency. Clozapine carries a significant risk of agranulocytosis—a severe drop in white blood cells that can be life-threatening. Fever and sore throat are classic early warning signs of neutropenia, as the body loses its ability to fight infections. Answer A is correct because it follows established clozapine safety protocols. The combination of fever (38.6°C) and sore throat in a clozapine patient requires immediate evaluation and CBC to check the neutrophil count. The medication must be held until agranulocytosis is ruled out, as continuing clozapine during neutropenia could worsen the condition. Answer B is dangerous because it delays evaluation for 12+ hours and continues the potentially harmful medication. Answer C treats this as a routine viral illness, completely missing the clozapine-specific risk—this approach could allow progression to severe neutropenia or sepsis. Answer D compounds the error by continuing clozapine and adding unmonitored antibiotics, which won't address the underlying hematologic issue and may mask symptoms. The key protocol is that ANY signs of infection in clozapine patients warrant immediate evaluation and medication hold. While the ANC was normal 4 days ago (2,500/mm³), agranulocytosis can develop rapidly. Study tip: For clozapine questions, memorize the triad: fever + sore throat + clozapine = emergency CBC and hold the drug. This overrides normal clinical judgment about treating minor illnesses conservatively.

Question 2

A 52-year-old female with severe rheumatoid arthritis is treated with weekly oral methotrexate. At a routine follow-up visit, she is asymptomatic, but her monitoring labs show an AST of 210 U/L and an ALT of 255 U/L. Her baseline LFTs three months ago were within normal limits.

What is the most appropriate management decision at this time?

  1. Continue methotrexate at the same dose and repeat labs in one week.
  2. Decrease the weekly methotrexate dose by 50% and recheck labs in one month.
  3. Hold methotrexate and investigate for other causes of liver injury. (correct answer)
  4. Order a liver ultrasound to assess the degree of fibrosis.
Explanation: Methotrexate is a known hepatotoxin. A significant elevation in liver transaminases (typically >3 times the upper limit of normal) necessitates immediate discontinuation of the drug to prevent further, potentially irreversible, liver damage. Once the drug is held, other potential causes of liver injury should be considered, though methotrexate is the most likely culprit.

Question 3

A 34-year-old patient being treated for major depressive disorder with sertraline 100 mg daily was recently prescribed tramadol for back pain. She presents to the urgent care clinic with agitation, diaphoresis, and a heart rate of 120 bpm. On examination, she has a temperature of 38.8°C, bilateral hyperreflexia, and inducible clonus in her lower extremities.

Which intervention should be implemented first?

  1. Administer intravenous lorazepam for agitation.
  2. Discontinue both sertraline and tramadol immediately. (correct answer)
  3. Obtain a head CT to rule out an intracranial process.
  4. Administer cyproheptadine as an antidote.
Explanation: This patient's presentation is classic for serotonin syndrome, a potentially life-threatening condition caused by excessive serotonergic activity. The combination of an SSRI (sertraline) and tramadol (which also inhibits serotonin reuptake) is a common precipitant. The absolute first step in management is to remove the offending agents.

Question 4

A 71-year-old male is prescribed a 10-day course of levofloxacin for community-acquired pneumonia. On day 7, he calls the clinic reporting a new, sudden pain behind his right ankle that is worse with walking. He denies any trauma to the area.

What is the most appropriate instruction to provide to this patient?

  1. Continue the levofloxacin and apply ice and elevation to the ankle.
  2. Take an over-the-counter NSAID for the pain and follow up if it does not improve.
  3. Complete the course of levofloxacin, as Achilles pain is a common, benign side effect.
  4. Stop taking the levofloxacin immediately and avoid bearing weight on the leg. (correct answer)
Explanation: When you encounter a patient on fluoroquinone antibiotics (like levofloxacin) reporting sudden tendon pain, you should immediately think "tendon rupture risk" — one of the most serious adverse effects of this drug class. Fluoroquinones can cause tendon damage, particularly affecting the Achilles tendon. This risk is highest in patients over 60, those taking corticosteroids, and kidney transplant recipients. The mechanism involves fluoroquinone interference with collagen synthesis, weakening tendon structure. Achilles tendon rupture can occur during treatment or even months after discontinuation. The correct answer is D because immediate discontinuation is essential to prevent complete tendon rupture, which would require surgical repair. Weight-bearing restrictions protect the already-compromised tendon from further damage. Option A is dangerous because continuing levofloxacin will worsen tendon damage, and simple ice/elevation won't address the underlying pathophysiology. Option B misses the urgency — NSAIDs might mask pain but won't prevent rupture, and "follow up if no improvement" delays critical intervention. Option C reflects a dangerous misconception; while musculoskeletal side effects are common with fluoroquinones, sudden tendon pain is never benign and always warrants immediate action. The patient will likely need an alternative antibiotic to complete pneumonia treatment, and orthopedic evaluation may be necessary if tendon damage is suspected. Remember this pattern: sudden tendon pain + fluoroquinone = stop the drug immediately. This is a high-yield safety issue that appears frequently on pharmacology exams because tendon rupture is preventable with prompt recognition.

Question 5

A 29-year-old patient with panic disorder abruptly discontinued paroxetine five days ago because he felt 'cured'. He calls the office in distress, reporting intense bouts of dizziness, fatigue, nausea, and strange 'electric shock' or 'brain zap' sensations that occur when he moves his head.

Which of the following is the most appropriate advice for this patient?

  1. Go to the emergency department immediately for evaluation of a possible transient ischemic attack (TIA).
  2. Take over-the-counter meclizine for dizziness and rest for a few days until the symptoms subside.
  3. These are common anxiety symptoms; practice deep breathing exercises and mindfulness.
  4. Restart paroxetine at the previous dose and schedule an appointment to create a gradual tapering plan. (correct answer)
Explanation: When you encounter a patient who abruptly stopped an SSRI and is experiencing neurological symptoms, think discontinuation syndrome. This is a well-recognized clinical phenomenon that occurs when patients suddenly stop antidepressants, particularly those with shorter half-lives like paroxetine. The patient's symptoms—dizziness, fatigue, nausea, and characteristic "brain zaps"—are classic signs of SSRI discontinuation syndrome. These "electric shock" sensations are pathognomonic (uniquely characteristic) of this condition and occur due to sudden drops in serotonin levels when the medication is abruptly withdrawn. Paroxetine has a particularly short half-life and high receptor affinity, making discontinuation syndrome more likely and severe. Choice D is correct because restarting paroxetine will rapidly alleviate these symptoms by restoring serotonin levels, followed by a proper taper to prevent recurrence. This is the standard medical approach. Choice A misinterprets the symptoms as neurological emergency signs. While TIA can cause dizziness, the constellation of symptoms plus the medication history points clearly to discontinuation syndrome, not stroke. Choice B treats only one symptom and ignores the underlying cause. Meclizine won't address the serotonin-related etiology, and waiting could worsen symptoms. Choice C misattributes these physical symptoms to psychological anxiety. While the patient has panic disorder, these are medication-related physiological effects, not anxiety manifestations. Study tip: Remember the "brain zaps" as a red flag for SSRI discontinuation syndrome—this symptom is virtually diagnostic and should immediately trigger thoughts of medication withdrawal rather than other neurological conditions.

Question 6

A 72-year-old male is on day 5 of intravenous gentamicin for complicated pyelonephritis. His baseline serum creatinine was 1.1 mg/dL. This morning's labs show a serum creatinine of 2.4 mg/dL. His urine output over the past 8 hours has been 150 mL.

What is the nurse's priority action?

  1. Administer a 500 mL normal saline bolus.
  2. Hold the next dose of gentamicin and notify the prescribing provider. (correct answer)
  3. Request an order for peak and trough levels to be drawn immediately.
  4. Document the findings and continue to monitor urine output.
Explanation: The significant rise in serum creatinine and decrease in urine output (oliguria) are clear signs of acute kidney injury, a well-known adverse effect of aminoglycosides like gentamicin (nephrotoxicity). The priority action is to prevent further renal damage by holding the next dose of the offending drug and immediately notifying the provider, who can then reassess the treatment plan.

Question 7

A 66-year-old male is undergoing treatment with a chemotherapy regimen that includes bleomycin for Hodgkin lymphoma. After his third cycle, he develops a persistent, non-productive cough and progressive dyspnea on exertion. A chest x-ray reveals bilateral, diffuse reticular opacities. His oxygen saturation at rest is 94% on room air.

Which intervention is most critical to perform next?

  1. Initiate empiric treatment with broad-spectrum antibiotics for pneumonia.
  2. Administer high-dose intravenous corticosteroids immediately.
  3. Hold further doses of bleomycin and obtain pulmonary function tests (PFTs). (correct answer)
  4. Schedule a PET scan to assess for progression of lymphoma in the lungs.
Explanation: Bleomycin is infamous for causing dose-related pulmonary toxicity, which can progress to fatal pulmonary fibrosis. The patient's symptoms and radiographic findings are highly concerning for this adverse effect. The most critical next step is to stop any further exposure to the causative agent and to quantify the extent of the lung damage by obtaining PFTs, specifically looking at the diffusing capacity for carbon monoxide (DLCO).

Question 8

A 9-year-old child being treated with valproic acid for epilepsy is brought to the emergency department with a 2-day history of lethargy, persistent vomiting, and severe, boring epigastric pain that radiates to the back. Which laboratory test should be prioritized to investigate the likely cause of these symptoms?

  1. Serum valproic acid level.
  2. Complete blood count with differential.
  3. Serum lipase and amylase. (correct answer)
  4. Liver function tests including AST and ALT.
Explanation: The clinical presentation of severe epigastric pain radiating to the back accompanied by vomiting is a classic sign of acute pancreatitis, a rare but life-threatening adverse effect of valproic acid, particularly in children. The most direct and sensitive laboratory tests to diagnose pancreatitis are serum lipase and amylase. While hepatotoxicity (checked by LFTs) and thrombocytopenia (checked by CBC) are also known side effects, the specific symptoms point directly toward pancreatitis, making lipase and amylase the priority.

Question 9

A patient is receiving their first dose of intravenous vancomycin for a MRSA infection. Twenty minutes into the infusion, the nurse observes that the patient's face, neck, and upper chest have become flushed and red. The patient complains of itching. The patient's blood pressure has dropped from 120/80 mmHg to 105/70 mmHg, but they deny shortness of breath.

What is the most appropriate initial action by the nurse?

  1. Slow the infusion rate and continue to monitor the patient closely. (correct answer)
  2. Stop the infusion immediately and administer intramuscular epinephrine.
  3. Administer a dose of intravenous diphenhydramine.
  4. Discontinue the vancomycin and notify the provider to order a different antibiotic.
Explanation: When you encounter a patient experiencing adverse reactions during drug infusion, your priority is distinguishing between mild infusion-related reactions and true anaphylaxis, as this determines the urgency and type of intervention needed. This patient is experiencing "red man syndrome," a common non-allergic reaction to vancomycin caused by rapid histamine release. The key clues are the characteristic flushing pattern (face, neck, upper chest), itching, mild hypotension, and notably the absence of respiratory symptoms. This is a rate-dependent reaction, not a true allergic response. Choice A is correct because slowing the infusion rate is the standard first-line management for red man syndrome. This allows continued treatment while minimizing the reaction, as the syndrome is directly related to infusion speed rather than the drug itself. Choice B is wrong because this isn't anaphylaxis - the patient has no respiratory distress, and the hypotension is mild. Epinephrine would be excessive and potentially harmful for a non-allergic reaction. Choice C is incorrect as the initial action. While antihistamines like diphenhydramine may be used adjunctively, the priority is addressing the cause (rapid infusion) rather than just treating symptoms. Choice D is wrong because discontinuing vancomycin entirely is unnecessary. Red man syndrome doesn't contraindicate future vancomycin use - it just requires slower administration rates. Remember: Red man syndrome presents with flushing and mild hypotension but lacks the respiratory compromise seen in anaphylaxis. Always assess for breathing difficulties to distinguish between these two very different clinical scenarios requiring different management approaches.

Question 10

A 52-year-old female with severe rheumatoid arthritis is treated with weekly oral methotrexate. At a routine follow-up visit, she is asymptomatic, but her monitoring labs show an AST of 210 U/L and an ALT of 255 U/L. Her baseline LFTs three months ago were within normal limits.

What is the most appropriate management decision at this time?

  1. Continue methotrexate at the same dose and repeat labs in one week.
  2. Decrease the weekly methotrexate dose by 50% and recheck labs in one month.
  3. Hold methotrexate and investigate for other causes of liver injury. (correct answer)
  4. Order a liver ultrasound to assess the degree of fibrosis.
Explanation: Methotrexate is a known hepatotoxin. A significant elevation in liver transaminases (typically >3 times the upper limit of normal) necessitates immediate discontinuation of the drug to prevent further, potentially irreversible, liver damage. Once the drug is held, other potential causes of liver injury should be considered, though methotrexate is the most likely culprit.

Question 11

A 68-year-old male with hypertension, managed with lisinopril 20 mg daily, presents to the emergency department. He reports that over the past two hours, his tongue has felt thick and his lips have become progressively swollen. He denies any new foods, insect bites, or environmental exposures. His voice is slightly muffled, but he is not in respiratory distress at this moment.

Which of the following interventions is the highest priority for this patient?

  1. Administer intravenous diphenhydramine.
  2. Prepare for immediate airway management. (correct answer)
  3. Discontinue lisinopril and plan to switch to an ARB.
  4. Obtain a complete blood count with differential.
Explanation: The patient is presenting with classic signs of angioedema, a rare but life-threatening adverse effect of ACE inhibitors like lisinopril. The swelling can rapidly progress to compromise the airway. Therefore, the highest priority is to prepare for potential intubation or cricothyrotomy to secure the airway, following the ABCs (Airway, Breathing, Circulation) of resuscitation.

Question 12

An 80-year-old female on warfarin for chronic atrial fibrillation is brought to the emergency department after a witnessed fall where she hit her head. She has no visible injuries and her neurological exam is normal. A stat INR result is 9.2. A non-contrast head CT is negative for intracranial hemorrhage.

Which of the following is the most appropriate immediate intervention?

  1. Hold the next dose of warfarin and recheck the INR in 12 hours.
  2. Administer 5 mg of oral vitamin K. (correct answer)
  3. Transfuse four units of fresh frozen plasma (FFP).
  4. Admit for observation without providing a reversal agent.
Explanation: An INR of >9.0 represents a critically high level of anticoagulation, placing the patient at extreme risk for bleeding, especially after head trauma. In a non-bleeding patient, guidelines recommend holding warfarin and administering oral vitamin K to rapidly but controllably reverse the anticoagulation. This lowers the INR over 24-48 hours, mitigating the high risk of hemorrhage.

Question 13

A 65-year-old male with type 2 diabetes and recently diagnosed severe systolic heart failure (ejection fraction 25%) is taking metformin 1000 mg twice daily. He is scheduled for a cardiac catheterization with iodinated contrast media tomorrow. His current serum creatinine is 1.6 mg/dL.

Which order is most important for the provider to write regarding the patient's metformin?

  1. Hold metformin today and for 48 hours post-procedure. (correct answer)
  2. Continue metformin to maintain glycemic control during the procedure.
  3. Decrease metformin to 500 mg twice daily until the procedure.
  4. Administer N-acetylcysteine to protect the kidneys and continue metformin.
Explanation: When you encounter a diabetes patient receiving iodinated contrast media, immediately think about contrast-induced nephropathy (CIN) and metformin's potential for causing lactic acidosis. This scenario tests your understanding of drug safety protocols around procedures that can compromise kidney function. Metformin must be held before contrast procedures because iodinated contrast can cause acute kidney injury, which impairs metformin elimination. When metformin accumulates in patients with reduced kidney function, it can cause potentially fatal lactic acidosis. The standard protocol is to hold metformin at least 48 hours before the procedure and restart only after confirming stable kidney function post-procedure. This patient's elevated creatinine (1.6 mg/dL) and heart failure further increase his CIN risk, making metformin cessation even more critical. Option A correctly follows evidence-based guidelines for metformin management around contrast procedures. Option B is dangerous because it ignores the lactic acidosis risk - short-term hyperglycemia is far safer than potential lactic acidosis. Option C (dose reduction) doesn't eliminate the risk since any amount of metformin can accumulate if kidney function deteriorates. Option D shows a common misconception - while N-acetylcysteine was once thought to prevent CIN, recent evidence shows it's ineffective, and continuing metformin remains risky regardless. Remember this pattern: metformin + contrast media = automatic hold for 48+ hours. The risk of lactic acidosis always outweighs short-term glycemic concerns. Look for this safety protocol on any exam question involving metformin and procedures using iodinated contrast.

Question 14

A 42-year-old patient on long-term phenytoin for a seizure disorder presents for follow-up. He reports feeling more 'off-balance' than usual and has noticed some double vision. On exam, he has prominent gingival hyperplasia, nystagmus on lateral gaze, and ataxia. A serum phenytoin level is 26 mcg/mL (therapeutic range: 10-20 mcg/mL).

Which of the provider's orders should be prioritized?

  1. Hold the next dose of phenytoin and reassess the treatment plan. (correct answer)
  2. Refer the patient to a dentist for evaluation of gingival hyperplasia.
  3. Obtain a brain MRI to evaluate for cerebellar atrophy.
  4. Encourage meticulous oral hygiene and schedule a follow-up in 3 months.
Explanation: When you encounter a patient on phenytoin with neurological symptoms, always consider drug toxicity first, especially when serum levels are elevated. Phenytoin has a narrow therapeutic window and exhibits dose-dependent toxicity that primarily affects the central nervous system. This patient's presentation is classic for phenytoin toxicity: ataxia, nystagmus, and diplopia are hallmark neurological signs that appear when serum levels exceed the therapeutic range. With a level of 26 mcg/mL (normal: 10-20 mcg/mL), immediate intervention is needed to prevent progression to more severe toxicity like confusion, slurred speech, or even coma. Choice A is correct because holding the medication addresses the immediate cause of toxicity and prevents further accumulation. The treatment plan must be reassessed to determine appropriate dosing going forward. Choice B misses the urgency. While gingival hyperplasia is a common chronic side effect of phenytoin, it's cosmetic and doesn't require immediate attention when the patient has acute toxicity symptoms. Choice C is unnecessary and delays treatment. The neurological signs here are from drug toxicity, not structural brain damage. Cerebellar atrophy from chronic phenytoin use is rare and wouldn't cause acute symptoms. Choice D completely ignores the toxicity. The oral hygiene advice addresses gingival hyperplasia but doesn't address the dangerous elevation in drug levels causing neurological impairment. Remember: when you see elevated drug levels with corresponding symptoms of toxicity, your first priority is always to stop or reduce the offending medication. Treat the cause, not just the symptoms.

Question 15

A 55-year-old female is being treated with atorvastatin 40 mg for hyperlipidemia. She presents to her primary care provider complaining of debilitating, diffuse muscle pain and weakness for the past week. She also notes that her urine has become dark, similar in color to cola. Her vital signs are stable.

Which of the following is the most critical initial action?

  1. Advise the patient to take the atorvastatin at bedtime to minimize myalgias.
  2. Immediately check a serum creatine kinase (CK) and basic metabolic panel. (correct answer)
  3. Discontinue the atorvastatin and switch to a lower intensity statin like pravastatin.
  4. Order liver function tests to assess for statin-induced hepatitis.
Explanation: The combination of severe myalgias and dark urine is highly suggestive of rhabdomyolysis, a serious adverse effect of statin therapy where muscle breakdown releases myoglobin, causing kidney damage. The most critical initial action is to confirm the diagnosis by checking a serum CK level (which will be markedly elevated) and assess for acute kidney injury by checking a basic metabolic panel (creatinine, BUN, electrolytes).

Question 16

A 45-year-old renal transplant recipient presents for a follow-up appointment. His immunosuppressive regimen includes tacrolimus. He complains of a new tremor in his hands and a persistent headache. His blood pressure is 165/98 mmHg. Lab work reveals a serum potassium of 5.9 mEq/L and a serum creatinine of 2.0 mg/dL (his baseline is 1.3 mg/dL).

What is the most important initial diagnostic test to order?

  1. A 24-hour urine collection for protein.
  2. A renal ultrasound to rule out obstruction.
  3. A CT scan of the head to evaluate the headache.
  4. A serum tacrolimus trough level. (correct answer)
Explanation: When you encounter a transplant patient on immunosuppressive therapy presenting with new symptoms, always consider drug toxicity first. Tacrolimus is a calcineurin inhibitor with a narrow therapeutic window and significant dose-related side effects. The correct answer is D because this patient exhibits classic signs of tacrolimus toxicity: tremor, headache, hypertension, hyperkalemia, and rising creatinine. These symptoms directly correlate with tacrolimus levels, making a trough level the most urgent diagnostic test. If levels are toxic, immediate dose adjustment can prevent irreversible organ damage. A is incorrect because while proteinuria could indicate chronic rejection or drug nephrotoxicity, a 24-hour urine collection takes too long when acute toxicity is suspected. The rising creatinine already suggests kidney dysfunction. B is wrong because obstruction typically presents with different symptoms (flank pain, sudden anuria) and wouldn't explain the neurological symptoms or hyperkalemia. The constellation of findings points to systemic drug toxicity, not mechanical obstruction. C is incorrect because while tacrolimus can cause headaches, a head CT would only be indicated if you suspected intracranial pathology. The headache combined with tremor and other systemic symptoms suggests drug toxicity rather than a structural brain lesion. Study tip: For transplant patients, always prioritize checking immunosuppressive drug levels when they present with new symptoms that match known side effects. Tacrolimus toxicity presents with the "4 N's": Nephrotoxicity, Neurotoxicity (tremor, headache), hypertensioN, and hyperkalemia (high potassium).

Question 17

An 82-year-old female with heart failure and stage 4 chronic kidney disease is taking digoxin 0.125 mg daily. She presents with several days of progressive nausea, loss of appetite, and fatigue. When asked how she is feeling, she mentions that colors seem 'off' and she has been seeing yellow-green halos around lights.

Which of the following is the most appropriate first step in evaluating this patient's symptoms?

  1. Administer a dose of digoxin immune Fab (Digibind).
  2. Schedule an urgent ophthalmology consultation.
  3. Check a serum digoxin level and a serum potassium level. (correct answer)
  4. Prescribe an antiemetic and provide dietary counseling.
Explanation: The patient's symptoms, including GI distress (nausea, anorexia) and classic visual disturbances (xanthopsia), are highly suggestive of digoxin toxicity. Her advanced age and chronic kidney disease significantly increase her risk due to decreased drug clearance. The most appropriate first step is to confirm the diagnosis by checking a serum digoxin level and also checking the serum potassium, as hypokalemia potentiates digoxin's toxic effects.

Question 18

A 34-year-old patient being treated for major depressive disorder with sertraline 100 mg daily was recently prescribed tramadol for back pain. She presents to the urgent care clinic with agitation, diaphoresis, and a heart rate of 120 bpm. On examination, she has a temperature of 38.8°C, bilateral hyperreflexia, and inducible clonus in her lower extremities.

Which intervention should be implemented first?

  1. Administer intravenous lorazepam for agitation.
  2. Discontinue both sertraline and tramadol immediately. (correct answer)
  3. Obtain a head CT to rule out an intracranial process.
  4. Administer cyproheptadine as an antidote.
Explanation: This patient's presentation is classic for serotonin syndrome, a potentially life-threatening condition caused by excessive serotonergic activity. The combination of an SSRI (sertraline) and tramadol (which also inhibits serotonin reuptake) is a common precipitant. The absolute first step in management is to remove the offending agents.

Question 19

A 72-year-old male is on day 5 of intravenous gentamicin for complicated pyelonephritis. His baseline serum creatinine was 1.1 mg/dL. This morning's labs show a serum creatinine of 2.4 mg/dL. His urine output over the past 8 hours has been 150 mL.

What is the nurse's priority action?

  1. Administer a 500 mL normal saline bolus.
  2. Hold the next dose of gentamicin and notify the prescribing provider. (correct answer)
  3. Request an order for peak and trough levels to be drawn immediately.
  4. Document the findings and continue to monitor urine output.
Explanation: The significant rise in serum creatinine and decrease in urine output (oliguria) are clear signs of acute kidney injury, a well-known adverse effect of aminoglycosides like gentamicin (nephrotoxicity). The priority action is to prevent further renal damage by holding the next dose of the offending drug and immediately notifying the provider, who can then reassess the treatment plan.

Question 20

A 55-year-old female is being treated with atorvastatin 40 mg for hyperlipidemia. She presents to her primary care provider complaining of debilitating, diffuse muscle pain and weakness for the past week. She also notes that her urine has become dark, similar in color to cola. Her vital signs are stable.

Which of the following is the most critical initial action?

  1. Advise the patient to take the atorvastatin at bedtime to minimize myalgias.
  2. Immediately check a serum creatine kinase (CK) and basic metabolic panel. (correct answer)
  3. Discontinue the atorvastatin and switch to a lower intensity statin like pravastatin.
  4. Order liver function tests to assess for statin-induced hepatitis.
Explanation: The combination of severe myalgias and dark urine is highly suggestive of rhabdomyolysis, a serious adverse effect of statin therapy where muscle breakdown releases myoglobin, causing kidney damage. The most critical initial action is to confirm the diagnosis by checking a serum CK level (which will be markedly elevated) and assess for acute kidney injury by checking a basic metabolic panel (creatinine, BUN, electrolytes).