NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDA, Exams of Nursing

Download NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDA and more Exams Nursing in PDF only on Docsity! NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ MODULE 1 1. What are the BON rules and regulations for prescriptive authority for the advance practice nurse? 1. Texas is very restricted 2. Describe the pharmacokinetic processes of absorption, distribution, metabolism and elimination and how differences in these areas affect drug action. 1. Absorption 1. Drug’s movement from the site of administration into the blood. 2. Distribution 1. Drug’s movement from the blood into the interstitial space of tissues and from there into cells. 3. Metabolism 1. Biotransformation is the enzymatically mediated alteration of drug structure. 4. Elimination 1. Combination of metabolism and excretion 3. Compare and contrast pharmacokinetics and pharmacodynamics of special populations—pediatrics, older adults and those that are pregnant. 1. Pediatrics—they have organ immaturity, elderly—they have NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ before entering the systemic circulation. If the capacity of the liver to metabolize the drug is extremely high, this drug can be completely inactivated on its first pass through the liver. 10. Discuss the significance of the Cytochrome P450 system on metabolism of drugs. 1. It is a group of 12 closely related enzyme families. CYP1, CYP2, CYP3 metabolize drugs. The other 9 families metabolize endogenous compounds (ex. Fatty acids, steroids). 11. Discuss the major hepatotoxic drugs and possible effects on drug metabolism. 1. 12. List various routes of drug elimination—review normal renal function including glomerular filtration, passive tubular reabsorption and active tubular secretion; describe the implications on drug clearance and how elimination affects prescribing. 1. 13. Discuss terms used to describe drug actions-agonist, partial agonist, antagonist. 1. Agonist: molecules that activate receptors 2. Partial agonist: Only has moderate intrinsic activity. Maximal effect that a partial agonist can produce is lower than that of a full agonist. 3. Antagonist: Produce their effects by preventing receptor NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ activation by endogenous regulatory molecules and drugs. 14. Discuss the impact of food on drug absorption, drug metabolism and on drug toxicity and action—as well as the timing of drug administration. LIFESPAN 1. Hepatic metabolism and GFR increase during pregnancy, dosages of some drugs may need to be increased. 2. Rate of albumin to water decreases 1. Third trimester: Renal blood flow is doubled and renal excretion is accelerated (drugs excreted rapidly) 2. Tone and mobility of bowel decrease 3. Prolongation of drug effects Total (½ life increases) 3. Understand stages of development in pregnancy 1. Conception: through week 2 2. Embryonic period: week 3-week 8 a) Gross malformations can be produced by teratogens 3. Fetal period: week 9-delivery 4. Understand pregnancy labeling 1. 3 categories now a) Pregnancy, lactation, male & female reproductive potential 5. How do you decrease risk in the infant during breastfeeding? 1. Take meds immediately after breastfeeding, avoid NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ 3. Metabolism a) Hepatic function? 1. Liver hasn’t reached full maturation— sensitive to drugs eliminated by the CYP450. Liver’s ability to metabolize drugs increases about one month after birth. b) T half life 1. Decreased by as much as 48-72 hours 4. Excretion a) Renal? 1. GFR is significantly reduced at birth, drugs eliminated by the kidneys must be given in a reduced dosage and longer dosing intervals. 7. What education needs to be given to parents? 1. What to do if child spits out medication or throws it up 2. Effective education: dosage size and timing, route, technique of administration, duration of treatment, how to store the drug, nature and time course of the desired response, nature and time course of adverse reactions. 8. How do you convert pounds to KG? 1. Divide weight by 2.2 9. What is definition of polypharmacy? Is polypharmacy always NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ inappropriate? What is Beer’s List? 1. Polypharmacy: 3 or more prescription drugs in conjunction-+ with 3 or more dietary supplements. 2. No 3. List that identifies drugs with a high likelihood of causing adverse effects in the elderly NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ 10. What are pharmacodynamic and pharmacokinetic differences in geri patients? 1. Absorption? a) GI 1. Produce less acid and fewer parietal cells 2. Bioavailability decreased 3. Rate of absorption decreased 2. Distribution? a) Lean Body Mass 1. Drugs accumulate in adipose tissues because lean muscle mass decreases by 20% b) Body Water 1. Decrease by 10-15%-drugs reach higher serum concentrations c) Albumin 1. Lowered—leads to higher levels of free or unbound drugs 3. Metabolism? a) Hepatic 1. Decreased with age—decreases drug clearance b) T half life drug sensitivity then you can use narrow antibiotic. Which antibiotics work by weakening the cell wall? Penicillins NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ 1. Initiate treatment before you know what the results of the test-- Treat with broad-spectrum antibiotic for initial treatment and once you get culture and spectrum NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ 7. Beta Lactam? 1. Penicillins (penicillin G, Ampicillin, amoxicillin, pipercillin) 2. Carbapenems (ztreonam, Imipenem, Meropenem, Ertapenem) 3. Cephalosporins (Cefazolin, ceftriaxone, cefotetan) 4. Vancomycin 5. Lypoglycoproteins (telavancin) 6. Monobactrams (aztreonam) 7. Fosfomycin 8. What are the medications that react with PCN? 1. Aminoglycosides, bacteriostatic agents, and probenecid 9. What organisms are susceptible to PCN? 1. Gram-positive bacteria and gram-negative 10. Beta lactams 1. Penicillins, cephalosporins and carbapenems (drugs that end in -nem and -nam) b) Mechanism of action: weaken cell wall and promote bacterial lysis and death. Active only against bacteria that is undergoing growth and cell division. NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ c) allergy potential between penicillin and cephalosporins* d) Allergic Reaction Mediated by 1. Immediate: 2-30 minutes after doIsgeE antibodies 2. Accelerated: 1-72 hours after dose 3. Delayed: days to weeks 4. Treatment: epinephrine (IM or SubQ or IV), respiratory support. e) Drug-drug interactions: aminoglycosides, bacteriostatic agents, probenecid f) Penicillin G AKA Penicillin 1. Bactericidal to gram-positive and gram-negative bacteria. 2. Drug of choice g) Ampicillin and Amoxicillin 1. Broad spectrum 2. Gram-negative bacilli i. Haemophilus influenza ii. E. Coli iii. Salmonella iv. Shigella Ceftriaxone-do not give with calcium Adverse effects: allergic reaction, bleeding, thrombophlebitis 1st: 3. 2n d NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ d) Cefazolin & Ceftriaxone-do not give with alcohol e) Cefotetan & Ceftriaxone (decreases vitamin K metabolism)-do not give with warfarin 3rd 2. NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ i. Destroyed by beta-lactamases ii. No CSF iii. Gram + iv. Narrow spectrum v. Used for prophylaxis, surgical prophylaxis vi. Rarely used for active infections i. Less sensitive to destruction ii. No CSF iii. Less gram + more gram – iv. Rarely used for active infections v. Effective against H. Influenza, klebsiella, pneumococci, and staphylococci vi. Good for upper respiratory infections, otitis media, bacterial sinusitis i. Highly resistant ii. Enters CSF* (good treatment for meningitis) iii. Highly active against gram - iv. Preferred for severe infections NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ 4. 4 t h 5. 5 t h i. Highly resistant ii. Enters CSF iii. Excellent gram – coverage iv. Commonly used to treat healthcare & hospital associated pneumonia (especially caused from pseudomonas) i. Used for infections associated with MRSA h) Thrombophlebitis with cephalosporins 1. Give by slow IV piggyback 2. Dilute drug (50-100 mL IV solution) 3. Carbapenems (Imipenem, meropenem, ertapenem, doripenem) a) Very broad antimicrobial spectrum b) Not effective against MRSA c) Imipenem 1. Good for treating mixed infections ii. staph aureus iii. gram – bacilli 2. binds to PBP1 and PBP2 NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ i. Gram + bacteria ii. Only given IV iii. ONLY used in vancomycin- resistant infections 2. Adverse Effects i. Taste disturbance ii. Nausea iii. Vomiting iv. Foamy urine v. Red man syndrome vi. Prolong QT interval vii. BLACK BOX WARNING: mortality increases in pts. With hospital-acquired or ventilator-associated pneumonia and creatinine clearance <50. 3. Drug-drug interactions: NSAIDS or ACE Inhibitors (damage kidneys), Clarithromycin, ketoconazole (cause prolonged QT interval) 6. Monobactrams l) Aztreonam 1. Binds to PBP3 NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ 2. Narrow spectrum 3. Active against gram – bacteria i. Neisseria species ii. H. Influenza iii. Pseudomonas iv. Klebsiella v. Proteus vi. Serratia vii. Salmonella viii. Shigella 4. Highly resistant to beta lactamases 7. Fosfomycin a) Single dose therapy b) UTI caused by E. Coli or enterococcus faecalis c) Mechanism of action 1. Kills bacteria by partially preventing cross-linking of peptidoglycan strands d) Adverse effects 1. Diarrhea 2. Headache 3. Vaginitis NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ Drowsiness Dizziness e) Take with or without food 4. Nausea 5. Abdominal pain 6. Rhinitis NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ carbamazepine, warfarin, verapamil, diltiazem, HIV protease inhibitors, simvastatin cipro 3. Food increases absorption 4. Metabolized by CYP3A4 system 5. Drug-drug interactions: theophylline, NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ 6. Uses i. Alternative to PCN in allergic patients ii. Atypical infections 1. Group A strep 2. Corynebacterium diphtheriae 3. Whooping cough 4. Chlamydia and Mycoplasma (walking pneumonia) 7. Side effects i. GI difficulties most common with oral erythromycin 1. N/V/D, abdominal cramping, hepatotoxicity ii. Less side effects with newer macrolides c) Azithromycin 1. Cause QT prolongations** d) Clindamycin (Cleocin) 1. Bacteriostatic 2. BLACK BOX WARNING: Promote severe c. diff in elderly patients 3. Uses i. Anaerobic bacteria, gram – and + NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ Blood dyscrasias Diarrhea Hypersensitivity reactions Oxazolidiones (Zyvox or Linezolid) Used to treat VRE and MRSA Very expensive Limited use due to resistance Gram + bacteria, NO gram - bacteria Enterococcus MRSA Staphylococcus epidermidis Strep pneumonia Adverse effects Diarrhea Nausea 4. Used as alternate to penicillin 5. Adverse effects i. Hepatic toxicity e) 3. Vomiting 4. Headache NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ 2. Adverse effects i. Reversible bone marrow depression ii. Fatal aplastic anemia (BLACK BOX WARNING) iii. Gray syndrome iv. GI effects v. Peripheral neuropathy 6. Tigecycline a) Broad spectrum bacteria b) Causes increased mortality (not used unless other infection isn’t responding to other agents) 7. Retapamulin and mupirocin a) Topical used for impetigo 8. Mupirocin a) Used in nostrils for MRSA for people who are carriers 9. Aminoglycosides (gentamycin, tobramycin, amikacin) a) Uses and coverage 1. Gram negative only i. Serious or life-threatening infections* 1. Alone or with other antibiotics NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ b) Sensitive organisms** ii. Local treatment (ear/eye infection) 2. Bactericidal 3. Narrow spectrum NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ 1. E. coli, Klebseilla pneumoniae, serratia marcescens, proteus mirabilis, pseudomonas aeruginosa c) Peaks and troughs** 1. Daily dosing i. Peak levels need to be drawn 30 minutes after IM injection or IV infusion ii. Trough levels need to be drawn one hour before next dose—value should be close to zero 2. Divide dosing iii. Trough levels need to be drawn just before the next dose 3. Peak iv. Measures the adequacy of dose (needs to be high enough to kill bacteria) 4. Trough v. If elevated=toxicity (love enough to minimize toxicity) d) Adverse effects** 1. Nephrotoxicity and ototoxicity* NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ 1. UTIs (main use) 2. Gram negative 3. Others i. Nocardiosis ii. Malaria iii. Ulcerative colitis iv. Toxoplasmosis v. Chlamydia d) Adverse effects 1. Skin, skin, skin i. Skin rashes & itching ii. Stevens-Johnson syndrome iii. Photosensitivity 2. Hematologic effects i. Hemolytic anemia ii. Kernicterus 3. Renal damage e) Drug-drug interactions** 1. Phenytoin, glipizide, glyburide (inhibit hepatic metabolism) 2. Thiazide (Celebrex) diuretics and sulfides (cross- hypersensitivity) NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ f) Resistance to sulfonamides 1. Gonococci, meningococci, streptococci, shigellae g) Topical sulfonamides (silver sulfadiazine and mafenide) 1. Used to suppress colonization in pt. with 2nd and 3rd degree burns 2. Mafenide application painful i. Can cause acidosis 3. Sulfadiazine application pain free i. Systemic absorption, be careful in pt. with sulfa allergies 11. Trimethoprim a) Uses 1. Acute and uncomplicated UTIs 2. E. coli, proteus, klebsiella, Enterobacter, and staph b) Adverse effects 1. Hematologic 2. Hyperkalemia c) Do not use in pregnancy or lactation 12. Trimethoprim PLUS sulfamethoxazole (AKA Bactrim DS) a) Need to watch the plasma levels NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ c) Dosage in CHILDREN is based on trimethoprim and not sulfamethoxazole (not the case in adults) b) Therapeutic uses 1. UTI, otitis media, bronchitis, shigellosis, pneumocystis pneumonia, GI infection NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ 6. Prostatitis** urinary frequency b) Causes NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ a) Signs & Symptoms 1. High fever, chills, malaise, myalgia, localized pain, dysuria, nocturia, urinary urgency, NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ 1. E. coli, indwelling urethral catheters, urethral instrumentation, or transurethral prosthetic resection c) Treatment 1. 2-4 weeks of fluroquinolone or doxycycline 7. UTI antiseptics a) Nitrofurantoin and methenamine** 1. Bacteriostatic 2. High concentrations=bactericidal 3. Uses i. Lower UTI ii. Prophylaxis iii. Recurrent infections 4. Not absorbed systemically (doesn’t work for kidney infections) 5. Adverse effects i. GI ii. Pulmonary iii. Hematologic (agranulocytosis, leukopenia, thrombocytopenia, megaloblastic anemia) iv. Peripheral neuropathy (irreversible) NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ 1. FDA black box warning: increase risk of tendonitis and tendon rupture—not dose dependent* ii. Photosensitivity 1. Wear sunscreen iii. Confusion in elderly iv. N/V/D v. Dizziness vi. Headaches vii. Restlessness viii. Occasionally seizures ix. Candida infections of pharynx & vagina x. C. diff xi. Increased risk for aortic dissection or ruptured abdominal aortic aneurysm. 3. Drug-drug interactions** i. Glucocorticoids ii. Antacids, magnesium, arm salts, zinc salts, sucralfate, milk, dairy products (absorption is reduced) Quinolones interfere with warfarin so you must watch the PT/INR because it would be high NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ iii. Theophylline, warfarin, tinidazole (causes elevations of these meds) 4. Contraindications i. Don’t give to pregnant or lactating women and children <18* ii. Myasthenia gravis (causes muscle weakness) e) Ofloxacin, Moxifloxacin, Levofloxacin 1. Uses i. Respiratory tract ii. UTI iii. GI tract iv. Skin and soft tissues f) Gemifloxacin 1. Uses i. CAP and bacterial bronchitis g) Delafloxacin 1. Uses i. Skin and skin structure infections h) Flagyl (metronidazole) 1. Uses** Peptococcus peptostreptococcus 2. Adverse effects** NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ i. Bacteroides fragilis ii. Fusobacterium iii. Gardnerella vaginalis 2. Disseminated-ceftriaxone 1g IM or IV every 24 hrs + azithromycin 1g once b) Neonatal infection NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ 1. Ceftriaxone 250mg once + azithromycin 1g PO once for urethritis, cervicitis, proctitis, pharyngitis, conjunctivitis NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ 1. Ophthalmia can cause blindness iii. Single dose of ceftriaxone IM or IV 2. Prevention iv. 0.5% erythromycin ophthalmic ointment @ birth required by law c) Preadolescent 1. Weight >45kg: treatment same as adults 2. Weight <45kg: single dose of ceftiaxon for vaginitis, cervicitis, urethritis, pharyngitis, proctitis 3. Systemic is IM or IV ceftriaxone daily for 7 days 4. Nongonococcal urethritis a) Diagnosis: presence of polymorphonuclear leukocytes and negative culture for gonorrhea b) Azithromycin or doxycycline 1. Alternatives: erythromycin, levofloxacin or ofloxacin, metronidazole, tinidazole for trichomonas. c) Pelvic inflammatory disease 1. Cause: gonorrhea or chlamydia 2. Causes infertility 3. Broad coverage and combo therapy is required NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ i. Inpatient: IV cefoxitin or cefotetan and doxycycline followed by oral doxycycline ii. Outpatient: ceftriaxone or cefoxitin and doxycycline, used with/without metronidazole d) Acute epididymitis (pain in back and testes) 1. Treat according to the organism 2. Ceftriaxone plus doxycycline or ofloxacin 3. Levofloxacin is added if pt. has anal intercourse e) Non-sexually transmitted disease (urinary tract instrumentation) 1. Ofloxacin f) Syphilis** 1. Primary: chancre, red, hard, protruding, and painless sore 2. Secondary: 2 weeks after chancre heals 3. Tertiary: 5-40 years after initial infection 4. Highly responsive to Penicillin G g) Bacterial vaginosis (fishy odor, pH <4.5)** 1. Non-pregnant women i. Metronidazole or clindamycin cream 2. Pregnant women NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ 2. Fungicidal or fungistatic c) Adverse effects 1. Infusion reactions i. Phle bitis 2. Renal damag e causes hypoka lemia (may need potassi um and monito r creatin ine) 3. Fever, chills, rigors, nausea, headache. 4. Hematologic effects: bone marrow suppression and normochromic normocytic anemia (monitor h&h) d) Drug-drug reactions 1. Hydrocortisone-high incidence of phlebitis 2. Aminogylcosides-nephrotoxic 3. Cyclosporins-nephrotoxic 4. NSAIDS-nephrotoxic e) BLACK BOX WARNING 1. Highly toxic, only used in the setting of life threatening infections. 6. Azoles (Itraconazole, fluconazole, voriconazole, ketoconazole, Posaconazole, isavuconazonium) a) Uses (orally) 1. Systemic mycoses b) Mechanism of Action 1. Inhibits the synthesis of the ergosterol and disrupts the fungal cell membrane . Inhibits fungal cytochrome p450 NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ c) Adverse effects liver enzymes) NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ 1. Liver damage (monitor 3. Ciclopirox (topical) NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ a) Tinea pedis 1. Terbinafine (topical) 2. Butenafine (topical) NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ b) Tinea corporis 1. Terbinafine (topical) 2. Butenafine (topical) 3. Ciclopirox (topical) c) Tinea cruris 1. Terbinafine (topical) 2. Butenafine (topical) 3. Ciclopirox (topical) d) Tinea capitis 1. Fluconazole 2. Terbinafine 3. Itraconazole 4. Butenafine e) Vulvovaginal candidiasis 1. Topical antifungals 2. 1 dose of fluconazole 150mg f) Onychomycosis 1. Terbinafine (topical) and itraconazole TUBERCULOSIS DRUGS 1. Two species of bacteria NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ a) Tubercular bacilli b) 2. When is treatment considered effective? a) 3. How are drugs chosen for treatment? a) Initial drug selection is empiric based on patterns of drug resistance in the community and immunocompetence of the patient. Once culture sputum results come back, regimen should be adjusted accordingly. 4. What are first line drugs? Second line? a) 1st line: Isoniazid, Rifampin, Pyrazinamide, Ethambutol, Rifapentine, and Rifabutin b) 2nd line: Cycloserine, Ethionamide, Capreomycin, Para- aminosalicylic acid, aminoglycosides, quinolones. 5. What is the induction phase of treatment? Continuation Phase? a) Induction phase: eliminate actively dividing extracellular tubercle bacilli b) Continuation phase: eliminate persistent intracellular NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ a) Adverse effects GI disturbances Photosensitivity Ethambutol Adverse effects Optic neuritis Hyperuricemia Dermatitis GI upset Peripheral neuropathy Renal damage Thrombocytopenia Levofloxacin and Moxifloxacin (quinolones) Adverse effects Look at “fluoroquinolones” Drug-drug interactions Look at “fluoroquinolones” Capreomycin (injectable) NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ 1. Hepatotoxic 2. Non-gouty polyarthralgia 3. Hyperuricemia a) Adverse effects 1. Renal damage NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ 2. Eighth cranial nerve damage 3. Hearing loss 4. Tinnitus 2. Isoniazid and rifampin NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ ii. Continuation phase (18 weeks) 1. Eliminate persistent intracellular organisms NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ b) Multi drug resistant? 1. Isoniazid resistant i. Treated for 6 months with 3 drugs 1. Rifampin, ethambutol, pyrazinamide 2. Rifampin resistant i. Treated for 18-24 months with 3 drugs 1. Isoniazid, ethambutol, pyrazinamide c) Extensively drug resistant? 1. Treatment is prolonged to at least 24 months 2. Use 2nd and 3rd line drug—less effective 3. Initial therapy can consist of 5,6,7 drugs i. Isoniazid, rifampin, pyrazinamide, ethambutol, amikacin or capreomycin, levofloxacin, cycloserine, ethionamide or PAS. 4. Last resort i. Infected tissue removed by surgery d) Patients with TB and HIV? 1. Rifabutin can be used but it can accelerate the metabolism of protease inhibitors and NNRTIs but not as much as rifampin. NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ e) Latent TB? 1. Treated with one or two drugs 2. TB must be ruled out 3. Isoniazid alone daily or twice weekly for nine months or isoniazid daily or twice weekly for 6 months 4. Rifampin alone daily for 4 months, isoniazid plus rifapentines taken weekly for three months f) How do you promote treatment adherence? 1. Directly observed therapy i. Administration of each dose is done in front of representative of the health department 2. Intermittent dosing (2-3 times a week) g) How do you evaluate? 1. Three primary modes i. Bacteriologic evaluation of sputum 1. Evaluated monthly until 2 consecutives are negative ii. Chest radiographs 1. Done in pt with negative NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ 2. Oral i. GI effects ii. Vertigo 2. Valacyclovir a) Uses 1. Herpes zoster, genital herpes, herpes labialis, cold sores, varicella, chicken pox b) Adverse effects 1. Hematologic affects: thrombocytopenia, aplastic anemia 2. Neurologic: psychosis, encephalopathy, seizures 3. GI affects 3. Famciclovir a) Uses 1. Genital HSV, herpes zoster, orolabial HSV b) Adverse effects 1. Blood dyscrasias i. Neutropenia ii. Thrombocytopenia 2. Stevens Johnson Syndrome 3. CNS—hallucinations, delirium c) Drug-drug interactions NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ 1. Live varicella & zoster vaccine 4. Ganciclovir a) Uses NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ 1. Herpes simplex viruses, CMV virus (prevention and tx in immunocompromised pt—transplant pt, HIV, and those receiving immunosuppressing drugs) b) Adverse effects 1. Granulocytopenia 2. Thrombocytopenia 3. Reproductive toxicity 4. Teratogenic and carcinogenic effects 5. Nausea, fever, rash, anemia, liver dysfunction, confusion, other CNS symptoms 5. Valganciclovir a) Uses 1. CMV, retinitis, prevention of CMV disease in high-risk organ transplant recipients b) Adverse effects 1. Blood dyscrasias i. Bone marrow suppression ii. Granulocytopenia iii. Anemia iv. Thrombocytopenia 2. N/V/D NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ 2. DAAs a. NS3/4A protease inhibitor b. NS5A inhibitor c. NS5B nucleoside polymerase inhibitors d. NS5B non-nucleoside polymerase inhibitors i. Tamiflu ii. Relenza iii. Rapivab iv. Xofluza ii. Hep B 1. Interferon alpha 2. Peginterferon alpha 3. Lamivudine 4. Adefovir 5. Entecavir 6. Telbivudine 7. Tenofovir b. What are the medications used in treatment of flu? ANTIVIRAL DRUGS FOR HIV INFECTIONS a. What are the 5 classes of antivirals used in treatment of NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ HIV? What is MOA for each? i. Reverse transcriptase inhibitors 1. Inhibits the HIV replication by suppressing synthesis of the viral DNA. ii. Non nucleoside reverse transfer inhibitors 1. Bind to the active center of reverse transcriptase and cause direct inhibition iii. Protease inhibitors 1. Reduce viral load to an undetectable level iv. Integrase strand transfer inhibitors 1. Treat those infected with HIV-1 v. Fusion inhibitors 1. Blocks entry of the HIV into the CD4 T cells vi. CCR5 antagonists 1. Used for those infected with CCR5-tropic HIV-1 strain b. Know major side effects and drug interactions with each i. Reverse transcriptase inhibitors (zidovudine) 1. Adverse effects a. Hematologic toxicity, lactic acidosis, myopathy ii. Non nucleoside reverse transfer inhibitors NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ (efavirenz, nevirapine, delavirdine, etravirine, rilpirvirine) iii. Protease inhibitors (lopinavir, ritonavir, indinavir, squinavir, nelfinavir, fosamprenavir, atazanavir, tipranavir, darunavir) 1. Adverse effects NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ LOCAL ANESTHESIA 1. What is MOA of local anesthetics? a. Suppress pain by blocking sodium channels and impulses, conduction along the axons and the selectivity of the anesthetic effects, only neurons located near the side of administration are affected and they suppress pain without generalized depression of the CNS 2. What 3 properties determines the ability of anesthetic to penetrate axon membrane? a. Molecular size, lipid solubility, degree of ionization at the tissue pH 3. Why are vasoconstrictors used in conjunction with local anesthetics? a. Delays the systemic absorption and prolongs anesthesia and reduces the risk of toxicity 4. What blood dyscrasia can occur from benzocaine? a. Methemoglobinemia-hgb is modified so it cant release O2 into the tissues and if enough hgb is converted to methemoglobin, death can result. 5. What are application guidelines for topical anesthetics to prevent systemic reactions? a. Apply the smallest amount needed, avoid application to large areas, avoid broken or irritated skin, avoid strenuous exercise, wrapping the site and heating the site. NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ DRUGS FOR HEADACHES 1. What is pathophysiology of migraine? a. Neurovascular disorder that involves the dilation and inflammation of intracranial blood vessels. Vasodilation causes the pain. 2. What foods can trigger migraines? a. Aged cheeses, wine, cured meats, hot dogs, lunch meat, chocolate, Chinese food, canned soups, diet sodas, artificial sweeteners, yellow food coloring. 3. What drug classes are abortive medications? a. NSAIDs/aspirin b. Opioid analgesics: butorphanol and meperidine c. Serotonin 1B/1D receptor agonists: triptan d. Ergot alkaloids 4. What drug classes are preventive? What can happen with all preventive medications have if taken too frequently? a. Beta blockers, antiepileptic drug, tricyclic antidepressants, calcium channel blockers, botulism toxin, ACE inhibitors, Angiotensin 2 receptor blockers. b. Chronic headache 5. What are some herbal meds effective with migraines? What are their NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ What is treatment for menstrual migraine? Tricyclic antidepressants, estrogen gel and patches HEADACHES NSAIDs: First line Seratonin 1B1D Receptor Agonists/Triptans What is MOA? side effects? a. riboflavin B2 and coenzyme Q-10 b. Side effects: GI, liver damage and cancer NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ 3. 4. Strong opioid agonist a. Morphine i. What are therapeutic uses? 1. Relieve pain without affecting any other senses, no loss of consciousness ii. Side effects? BB warning? 1. Respiratory depression (BLACK BOX WARNING) 2. Constipation, orthostatic hypotension, urinary retention and hesitancy, N/V, euphoria, sedation, drowsiness, neurotoxic, delirium, agitation, myoclonus, hyperalgesia, renal NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ impairment, pre- NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ NURS 5344PHARM STUDY GUIDE QUIZ 1 Q & As BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2023 GRADED A+ existing cognitive impairment. iii. What is tolerance? Cross tolerance? Dependence? 1. Tolerance: increased doses are needed to obtain the same response. 2. Cross tolerance: tolerance to another opioid agonists will develop, but there’s no tolerance to the miosis or constipation. 3. Dependence: abstinence syndrome with abrupt discontinuation, occurs about 10 hours after the last dose. a. Initial: yawning, rhinorrhea, sweating b. Progess: violent sneezing, weakness, n/v/d, bone & muscle pain, muscle spasms and kicking movement. iv. What are the medications available to treat opioid induced constipation (OIC)? 1. Naloxegol, methylnaltrexone, lubiprostone v. What is the reversal drug? Naloxene vi. Drug designed to discourage abuse? Naltrexone b. Others: fentanyl 5. Mod-strong opioid agonist a. Codeine: Class II alone, III with acetaminophen, V as cough