PTCB Pharmacy Technician (PTCE) — All Questions

Which adverse effect is the subject of a boxed warning shared by fluoroquinolones such as levofloxacin and ciprofloxacin?

• a.Permanent blue-grey discoloration of the skin and nails
• b.Tendinitis and tendon rupture✓
• c.Aortic aneurysm and aortic dissection
• d.Irreversible hearing loss with prolonged treatment

The fluoroquinolone boxed warning covers tendinitis and tendon rupture — most often the Achilles tendon — with the risk highest in older patients, in those also taking a corticosteroid and in transplant recipients, so patients are told to report new tendon pain or swelling and to rest the limb. The same boxed warning also names peripheral neuropathy, central-nervous-system effects and worsening of myasthenia gravis. Aortic aneurysm and dissection is the defensible second answer, because the FDA did add that risk to fluoroquinolone labelling, but it sits in Warnings and Precautions rather than in the boxed warning. Blue-grey skin and nail discoloration belongs to minocycline, and hearing loss to the aminoglycosides.

Why is amoxicillin/clavulanate prescribed instead of plain amoxicillin for some infections?

• a.Clavulanate is a second antibiotic that kills organisms amoxicillin cannot reach
• b.Clavulanate inactivates bacterial beta-lactamase enzymes✓
• c.Clavulanate slows kidney clearance so amoxicillin levels stay higher
• d.Clavulanate reduces the diarrhea amoxicillin can cause

Clavulanate has almost no useful antibacterial activity of its own; it binds and inactivates the beta-lactamase enzymes that resistant organisms use to destroy amoxicillin, which restores the amoxicillin's effect. Calling it a second antibiotic is the tempting answer because the product name lists two ingredients, but the roles are drug and protector, not two drugs. Blocking renal clearance to raise penicillin levels describes probenecid, and clavulanate does not settle the gut — it is the component most associated with the extra diarrhea the combination causes.

Nystatin oral suspension is dispensed to an adult for oral thrush. Which patient direction is correct?

• a.Dilute the dose in a full glass of water and drink it quickly
• b.Apply the dose to the gums with a cotton swab only
• c.Take the dose with a meal to improve absorption
• d.Swish in the mouth, then swallow✓

Nystatin is essentially not absorbed from the gastrointestinal tract; it works by direct contact with the yeast, so the dose is held and swished around the mouth as long as possible to coat the lesions before it is swallowed. Diluting it and drinking it straight down destroys that contact time, which is the whole mechanism. Painting the dose onto the mucosa with a swab is a technique used for an infant who cannot swish, not the direction for an adult, and taking it with food cannot improve absorption because systemic absorption is not how the drug works.

A patient starting sertraline for depression asks when she should expect to feel better. What is the accurate counselling point?

• a.No change in the first week means the drug has failed
• b.Mood should lift within two or three doses; if not, the dose is too low
• c.Full antidepressant benefit usually takes several weeks✓
• d.The drug works best taken only on bad days

SSRIs are taken every day, and while sleep, appetite and anxiety often improve first, the full effect on mood builds over several weeks — which is why patients are urged to keep taking the drug through an unchanged first week instead of concluding that it has failed. Expecting relief within two or three doses is the misconception that drives early discontinuation, and it also pushes patients to demand dose increases the prescriber has not judged necessary. An SSRI taken only on bad days will not work at all.

A patient stabilized on lithium asks whether she can buy ibuprofen for her sore back. Why does this combination matter?

• a.Ibuprofen inactivates lithium in the stomach, so the mood benefit is lost
• b.NSAIDs can reduce lithium clearance and push lithium levels into the toxic range✓
• c.Lithium blocks the pain relief that ibuprofen would give
• d.NSAIDs speed lithium removal, so the level falls below the effective range

Lithium is cleared almost entirely by the kidney and has a narrow therapeutic range, so anything that cuts renal excretion can raise the level into toxicity; NSAIDs reduce the prostaglandin-mediated renal blood flow that lithium clearance depends on. Dehydration, a low-salt diet and thiazide diuretics act the same way, which is why lithium patients are told to keep fluid and salt intake steady. The direction of the interaction is what has to be right: NSAIDs push the lithium level up, not down. Ibuprofen does not chemically destroy lithium, and lithium does not block analgesia.

Patients taking atypical (second-generation) antipsychotics such as olanzapine or quetiapine are routinely monitored for which class effect?

• a.Loss of kidney and thyroid function needing periodic labs
• b.Weight gain with rises in blood glucose and lipids✓
• c.A drop in white cells needing weekly counts
• d.Falling potassium levels that require ongoing supplementation

Second-generation antipsychotics are associated with metabolic effects, so weight, waist measurement, fasting glucose or A1c and a lipid panel are followed on a schedule; olanzapine and clozapine carry the greatest metabolic burden and aripiprazole and ziprasidone the least. Regular white-cell counts are the defensible second answer, but mandatory absolute-neutrophil-count monitoring belongs to clozapine under its REMS program, not to the class as a whole. Periodic kidney and thyroid testing is the monitoring pattern taught for lithium, and these drugs do not waste potassium.

A patient picking up hydrocodone/acetaminophen tablets also brings a multi-symptom OTC cold product to the register. Which risk should be raised?

• a.Duplicate hydrocodone, because most cold products contain an opioid
• b.Duplicate acetaminophen from two products, risking liver injury✓
• c.The cold product will block the opioid from being absorbed
• d.The two products cancel each other's pain relief

Acetaminophen is hidden inside many combination prescription analgesics and inside most multi-symptom cold and flu products, so taking both can add up to an unintended overdose and liver injury; patients are taught to read the active-ingredient panel before combining anything with a prescription analgesic. Worrying about duplicate opioid is the tempting parallel, but hydrocodone is never sold over the counter in a shelf cold remedy. Neither product blocks the absorption or the analgesic effect of the other.

A patient taking naproxen twice daily for arthritis asks about adding ibuprofen for a headache. What is the correct counselling point?

• a.Adding ibuprofen is safe when both are taken with food
• b.Ibuprofen may be added because it works by a different mechanism
• c.Combining them is fine if the doses are taken 6 hours apart
• d.Two NSAIDs should not be combined✓

Naproxen and ibuprofen are both non-selective NSAIDs working through the same cyclo-oxygenase pathway, so stacking them multiplies the gastrointestinal bleeding, kidney and cardiovascular risks without adding useful pain relief; acetaminophen is the usual add-on instead. Spacing the doses by a few hours or taking them with food eases stomach upset but does nothing about the additive risk, which is why those answers are tempting and still wrong.

How is sumatriptan used in the management of migraine?

• a.It is taken on a fixed daily schedule regardless of symptoms
• b.It is saved until the headache becomes severe
• c.It is taken every night to prevent attacks from developing
• d.It is taken to treat a migraine attack once it starts✓

Triptans are abortive, or acute, migraine treatments: the dose is taken when an attack begins and works best when taken early, and the patient is given a limit on how many doses to use in a period. Migraine prevention uses a different group of drugs taken daily whether or not a headache is present — propranolol, topiramate and amitriptyline are typical examples — which is what makes the daily-dosing answers tempting. Waiting until the pain is severe is the common patient habit that makes a triptan work less well, which is why the counselling is to treat as soon as the attack is recognized.

A patient with asthma is dispensed both an albuterol inhaler and a fluticasone inhaler. Which statement describes their roles correctly?

• a.Albuterol relieves attacks; fluticasone prevents them✓
• b.Albuterol is the daily controller and fluticasone is the rescue drug
• c.Both are rescue inhalers, so either may be used during an attack
• d.Fluticasone is used first at the onset of wheezing to open the airways

Albuterol is a short-acting beta-2 agonist that relaxes bronchial smooth muscle within minutes, so it is the rescue inhaler, while inhaled fluticasone is a corticosteroid that reduces airway inflammation over days to weeks and is used every day whether or not the patient has symptoms. Reaching for the steroid inhaler during an attack is the dangerous reversal, because it does nothing quickly. Needing the rescue inhaler often is a signal that the controller regimen should be reviewed.

Why is a patient using an inhaled corticosteroid told to rinse the mouth and spit after each dose?

• a.Rinsing washes the propellant away before it stains the teeth
• b.Rinsing prevents the bitter taste from lingering
• c.Rinsing stops the inhaler from clogging
• d.Residual steroid in the mouth can cause oral thrush✓

Much of an inhaled corticosteroid dose lands on the mouth and throat rather than the lung, where it locally suppresses defences and lets Candida overgrow, producing oral thrush and hoarseness; rinsing and spitting after each dose removes that residue and also lowers the amount swallowed. Clearing the taste is a genuine side benefit of rinsing but not the reason the direction is given, and the propellant does not stain teeth or block the actuator in a way that rinsing the mouth would fix.

A patient who drives a delivery van asks which antihistamine on the shelf is least likely to make him drowsy. Which product fits?

• a.Chlorpheniramine (Chlor-Trimeton)
• b.Diphenhydramine (Benadryl)
• c.Loratadine (Claritin)✓
• d.Promethazine (Phenergan)

Loratadine is a second-generation antihistamine that crosses into the brain poorly, so it is among the least sedating options along with fexofenadine; cetirizine is also second-generation but causes drowsiness in some people. Diphenhydramine, chlorpheniramine and promethazine are all first-generation agents whose sedation is pronounced — diphenhydramine is sold as an over-the-counter sleep aid for exactly that reason. Any antihistamine can still impair driving, so the patient should judge his own response before a shift.

When should a once-daily proton pump inhibitor such as omeprazole be taken for the best acid-suppressing effect?

• a.At bedtime, several hours after the last meal of the day
• b.Before the first meal of the day✓
• c.Only when heartburn is felt
• d.Immediately after the largest meal of the day

A proton pump inhibitor can only shut down pumps that are actively secreting acid, and the largest pool of active pumps is switched on by the first meal of the day, so the dose is taken before eating in the morning. Taking it right after the meal misses that window, and a PPI is a poor as-needed remedy because full acid suppression builds over several days; an antacid or an H2 blocker is what works on demand.

Ondansetron orally disintegrating tablets are dispensed to a patient who cannot keep liquids down. Which handling instruction is correct?

• a.Peel the foil back and place the tablet on the tongue; do not push it through✓
• b.Push the tablet through the foil and swallow it with a full glass of water
• c.Crush the tablet and mix it into applesauce before each dose
• d.Dissolve the tablet in water and drink the solution

The orally disintegrating tablet is deliberately fragile and crumbles if it is forced through the blister backing, so the foil is peeled open with dry hands and the tablet is laid on the tongue, where it disintegrates in seconds and is swallowed with saliva — no water needed, which is the whole point for a patient who is vomiting. Pushing it through the foil or dissolving it in a glass of water defeats that design and risks losing part of the dose.

Which direction belongs on a prescription for once-weekly oral alendronate?

• a.Take at bedtime with milk so the calcium is absorbed at the same time
• b.Take with juice at any convenient time of day
• c.Take with breakfast, then lie down to rest
• d.Take on rising with plain water and stay upright afterwards✓

Oral bisphosphonates are very poorly absorbed and can irritate or ulcerate the esophagus, so alendronate is taken first thing after getting up with a full glass of plain water, and the patient stays sitting or standing and takes nothing else by mouth for at least 30 minutes. Milk, juice, coffee and calcium supplements all block absorption, so the milk answer is doubly wrong, and lying down after the dose is the specific behavior that causes esophageal injury.

A hospital pharmacy and therapeutics committee has approved a therapeutic interchange protocol for proton pump inhibitors. What does that protocol permit?

• a.Dispensing a different drug in the same class under the approved protocol✓
• b.Dispensing the same drug from a different manufacturer at the same strength
• c.Dispensing a different drug in the same class whenever the ordered one is unavailable
• d.Dispensing an AB-rated generic of the drug the prescriber ordered

Therapeutic interchange substitutes a chemically different drug expected to give a comparable outcome — one proton pump inhibitor for another at the protocol's equivalent dose — under authority the prescribers granted in advance through the approved protocol. Making the swap because the ordered product is unavailable is the closest wrong answer: a shortage may trigger the conversation, but the authority comes from the protocol, not from the stock situation, and without a protocol the prescriber must approve each change. Dispensing an AB-rated generic or the same molecule from another manufacturer is generic substitution, which involves the identical active ingredient.

A patient cannot swallow a delayed-release capsule that contains enteric-coated pellets, and the product labeling addresses this situation. What does such labeling typically direct?

• a.Crush the pellets with the capsule shell and mix the powder into applesauce
• b.Dissolve the whole capsule in warm water until the shell breaks apart
• c.Chew the pellets thoroughly so the coating breaks before swallowing
• d.Sprinkle the intact pellets on applesauce, swallowed whole✓

In this dosage form the protection is on each individual pellet, not on the capsule shell, so the labeling allows the shell to be opened and the pellets sprinkled on a spoonful of soft food and swallowed without chewing. Crushing is the tempting answer because it also gets the drug out of the capsule, but it destroys the enteric coating and dumps the whole dose into the stomach, where acid degrades the drug and can cause irritation. Chewing does the same damage, and soaking the capsule in warm water is not a labeled administration method.

A prescription is filled for regular insulin U-500. Which statement about this product is correct?

• a.It is diluted by the pharmacy to U-100 before being dispensed
• b.It is a long-acting analog that may not be mixed with other insulins
• c.It contains five times as much insulin per mL as a U-100 product✓
• d.It contains 500 units in the vial rather than 100 units

The 'U' number always states units per milliliter, so U-500 regular insulin holds 500 units/mL — five times the concentration of U-100 — which is why it is a high-alert product dispensed with its own dedicated U-500 syringe or pen so units are never misread as volume. The idea that the number describes the total content of the vial is the classic misconception and the most tempting wrong answer. U-500 is regular human insulin, short-acting rather than a long-acting analog, and it is dispensed as supplied rather than diluted by the pharmacy.

A patient who regularly fills sildenafil brings in a new prescription for sublingual nitroglycerin, and the system fires an interaction alert. Why does this combination matter?

• a.Together they can cause severe, life-threatening hypotension✓
• b.Nitroglycerin blocks the enzyme that clears sildenafil, causing priapism
• c.Together they raise blood pressure enough to trigger a hypertensive emergency
• d.Sildenafil makes nitroglycerin lose potency in the bottle

Both drugs act on the same nitric-oxide pathway and amplify vasodilation, so a nitrate taken by someone who has recently used a PDE-5 inhibitor can drop blood pressure catastrophically; this is a contraindication rather than a caution, and the alert belongs in front of the pharmacist before the prescription goes out. The hypertensive-emergency answer inverts the mechanism, since both agents lower blood pressure rather than raise it. Sildenafil does not degrade nitroglycerin tablets, and priapism with PDE-5 inhibitors is not produced by nitrate-induced enzyme blockade.

A lyophilized vaccine is supplied with a separate diluent. How should that diluent be handled in the pharmacy?

• a.Store it in the refrigerator door so it cannot freeze at the back wall
• b.Use any manufacturer's sterile water, since vaccine diluents are interchangeable
• c.Store it at room temperature or refrigerated, and keep it out of the freezer✓
• d.Store it in the freezer with the lyophilized vaccine it belongs to

Diluents are stored as their own labeling directs — at room temperature or refrigerated — and must never be frozen, because freezing can crack the vial and damage the stabilizers the diluent carries. Freezing it alongside the vaccine is the tempting answer, since some lyophilized vaccines are themselves stored frozen, but only the vaccine goes into the freezer. Each diluent is formulated for its specific vaccine and may not be swapped for another product or for plain sterile water, and the refrigerator door is not an acceptable storage location for any vaccine component.

Coreg is the brand name for which generic medication?

• a.captopril
• b.clonidine
• c.chlorthalidone
• d.carvedilol✓

Coreg is carvedilol, a beta blocker that also blocks alpha-1 receptors. Captopril is an ACE inhibitor (Capoten), clonidine is a central alpha-2 agonist (Catapres), and chlorthalidone is a thiazide-type diuretic. All four names start with the same letter, which is exactly why the selection has to be made from the label, not from memory of the first syllable.

A prescription is written for Cozaar 50 mg. Which generic name should appear on the dispensing label?

• a.loperamide hydrochloride
• b.lisinopril
• c.lovastatin
• d.losartan potassium✓

Cozaar is losartan potassium, an angiotensin II receptor blocker. Lisinopril is an ACE inhibitor sold as Prinivil and Zestril, lovastatin is a statin (Mevacor), and loperamide is an antidiarrheal (Imodium). None of the other three is marketed as Cozaar.

Esomeprazole is dispensed under which brand name?

• a.Nexium✓
• b.Prevacid
• c.Prilosec
• d.Protonix

Esomeprazole is Nexium. Protonix is pantoprazole, Prevacid is lansoprazole and Prilosec is omeprazole. All four are proton pump inhibitors, so the class is the same and only the individual molecule tells them apart.

Toprol-XL contains which salt of metoprolol?

• a.metoprolol succinate✓
• b.metoprolol tartrate
• c.metoprolol fumarate dihydrate
• d.metoprolol maleate

Toprol-XL is metoprolol succinate, the extended-release salt given once daily. Metoprolol tartrate is the immediate-release salt sold as Lopressor and usually given twice daily; fumarate and maleate salts of metoprolol are not marketed in the United States. Substituting tartrate for succinate changes the release profile, so the salt has to match the prescription.

Rivaroxaban (Xarelto) belongs to which drug class?

• a.vitamin K antagonist
• b.direct factor Xa inhibitor✓
• c.antiplatelet agent
• d.low-molecular-weight heparin

Rivaroxaban is an oral direct factor Xa inhibitor. Warfarin is the vitamin K antagonist, enoxaparin is the low-molecular-weight heparin given by injection, and clopidogrel and aspirin are antiplatelet agents that act on platelets rather than on a clotting factor.

Diflucan is the brand name of which antifungal medication?

• a.nystatin
• b.griseofulvin
• c.fluconazole✓
• d.terbinafine

Diflucan is fluconazole, an oral azole antifungal. Nystatin is dispensed as an oral suspension or topical product and is not sold as Diflucan, griseofulvin is an older antifungal used for hair and nail infections, and terbinafine is Lamisil.

Valtrex is the brand name for which generic drug?

• a.vancomycin
• b.valsartan
• c.valproic acid
• d.valacyclovir✓

Valtrex is valacyclovir, an oral antiviral for herpes simplex and herpes zoster. Valsartan is an angiotensin II receptor blocker (Diovan), valproic acid is an anticonvulsant, and vancomycin is an antibiotic. The first three letters are shared, so the full name on the label has to be read.

Bactrim DS contains which two active ingredients?

• a.amoxicillin and clavulanate potassium
• b.erythromycin and sulfisoxazole
• c.ampicillin and sulbactam
• d.sulfamethoxazole and trimethoprim✓

Bactrim is a fixed combination of sulfamethoxazole and trimethoprim. Amoxicillin with clavulanate is Augmentin, ampicillin with sulbactam is the injectable Unasyn, and erythromycin with sulfisoxazole is a separate pediatric product. Only the sulfamethoxazole/trimethoprim pair is Bactrim.

Augmentin 875/125 tablets contain amoxicillin together with which second ingredient?

• a.clavulanate potassium✓
• b.tazobactam
• c.sulbactam, a beta-lactamase inhibitor
• d.probenecid

Augmentin is amoxicillin with clavulanate potassium, a beta-lactamase inhibitor. Sulbactam is paired with ampicillin and tazobactam with piperacillin, both injectable products, and probenecid is a uricosuric that was once combined with penicillin but is not part of Augmentin.

Macrobid (nitrofurantoin monohydrate/macrocrystals) capsules are dispensed for a urinary tract infection. Which administration instruction belongs on the label?

• a.Take on an empty stomach one hour before meals.
• b.Take with a full glass of water and remain upright for 30 minutes.
• c.Take with food to improve absorption.✓
• d.Take at bedtime only, separated from all other medicines.

The Macrobid labeling directs that the capsules be taken with food, which improves both absorption and gastrointestinal tolerance. The empty-stomach instruction belongs to drugs such as levothyroxine, the upright-for-30-minutes instruction belongs to oral bisphosphonates, and there is no requirement to restrict nitrofurantoin to bedtime or to separate it from all other medicines.

Generic names ending in the stem '-pril', such as enalapril and ramipril, identify which drug class?

• a.angiotensin II receptor blockers such as losartan
• b.beta blockers
• c.calcium channel blockers
• d.angiotensin-converting enzyme inhibitors✓

The '-pril' stem marks angiotensin-converting enzyme (ACE) inhibitors. Angiotensin II receptor blockers carry the '-sartan' stem, calcium channel blockers of the dihydropyridine type end in '-dipine', and beta blockers end in '-olol'.

A prescription arrives for rabeprazole. The '-prazole' stem tells the technician the drug is which type of agent?

• a.a proton pump inhibitor✓
• b.a histamine-2 receptor antagonist
• c.an antacid
• d.a prokinetic agent

The '-prazole' stem identifies proton pump inhibitors such as omeprazole, pantoprazole and rabeprazole. Histamine-2 blockers carry the '-tidine' stem, antacids are salts such as calcium carbonate and have no stem, and metoclopramide is the common prokinetic and shares neither stem.

A generic name ending in '-mab', such as adalimumab, tells the technician the product is what kind of molecule?

• a.a small-molecule enzyme inhibitor
• b.a synthetic corticosteroid
• c.a monoclonal antibody✓
• d.an inhaled bronchodilator

The '-mab' stem is reserved for monoclonal antibodies, which are large protein biologics. Small-molecule enzyme inhibitors carry stems such as '-statin' or '-prazole', corticosteroid generic names usually end in '-sone' or '-onide', and inhaled bronchodilators end in '-terol' or '-tropium'.

Minocycline and doxycycline share the '-cycline' stem. Which antibiotic class does that stem identify?

• a.macrolides
• b.tetracyclines✓
• c.aminoglycosides
• d.cephalosporins

The '-cycline' stem identifies the tetracyclines. Macrolides end in '-thromycin', cephalosporin generic names begin with 'cef-' or 'ceph-', and aminoglycosides end in '-micin' or '-mycin' as in gentamicin and tobramycin.

Sitagliptin (Januvia) is an oral antidiabetic agent of which class?

• a.second-generation sulfonylurea secretagogue
• b.dipeptidyl peptidase-4 inhibitor✓
• c.biguanide
• d.thiazolidinedione

Sitagliptin is a DPP-4 inhibitor; the '-gliptin' stem names the class. Sulfonylureas are glipizide and glyburide, the only biguanide in use is metformin, and pioglitazone is the thiazolidinedione.

Empagliflozin (Jardiance) works by which mechanism?

• a.it reduces hepatic glucose production
• b.it stimulates the pancreatic beta cells to release more insulin
• c.it blocks SGLT2 in the kidney✓
• d.it slows carbohydrate absorption in the gut

Empagliflozin is an SGLT2 inhibitor, so glucose is lost in the urine rather than reabsorbed by the kidney. Stimulating insulin release describes the sulfonylureas, reducing hepatic glucose production describes metformin, and slowing carbohydrate absorption describes acarbose.

Carbidopa/levodopa (Sinemet) is prescribed for which condition?

• a.Alzheimer's disease
• b.multiple sclerosis
• c.benign essential tremor
• d.Parkinson's disease✓

Carbidopa/levodopa replaces dopamine in Parkinson's disease; carbidopa keeps levodopa from being broken down before it reaches the brain. Donepezil and memantine are used in Alzheimer's disease, disease-modifying injectables and infusions are used in multiple sclerosis, and propranolol and primidone are typical for essential tremor.

Donepezil (Aricept) is most commonly prescribed for which condition?

• a.Alzheimer's dementia✓
• b.generalized anxiety disorder
• c.major depressive disorder
• d.attention deficit hyperactivity disorder

Donepezil is a cholinesterase inhibitor used in dementia of the Alzheimer's type. Antidepressants such as sertraline treat major depression, benzodiazepines and SSRIs are used in generalized anxiety, and stimulants such as methylphenidate are used in ADHD.

Levetiracetam (Keppra) is classified as which type of medication?

• a.a muscle relaxant
• b.an antipsychotic
• c.an antiepileptic drug✓
• d.a proton pump inhibitor

Levetiracetam is an antiepileptic used to control seizures. Antipsychotics include quetiapine and risperidone, muscle relaxants include cyclobenzaprine and methocarbamol, and proton pump inhibitors end in '-prazole'.

Dilantin is the brand name for which generic drug?

• a.phenytoin✓
• b.diltiazem
• c.digoxin
• d.diphenhydramine

Dilantin is phenytoin, an antiepileptic with a narrow therapeutic index. Diltiazem is a calcium channel blocker sold as Cardizem, digoxin is a cardiac glycoside sold as Lanoxin, and diphenhydramine is the antihistamine in Benadryl.

A patient with COPD is dispensed tiotropium (Spiriva) and asks whether it can be used when she suddenly becomes short of breath. What is correct?

• a.It may be used for sudden shortness of breath as long as the daily dose has not been taken yet.
• b.It works within seconds, so it is the preferred product for an attack.
• c.It should be stopped whenever a rescue inhaler is prescribed.
• d.It is a once-daily maintenance bronchodilator and is not indicated for relief of acute bronchospasm.✓

The tiotropium labeling states plainly that the product is a once-daily maintenance treatment and is not indicated for the relief of acute bronchospasm; a rapid-acting beta-2 agonist such as albuterol is used for an attack. It does not act within seconds, it is not made safe for acute use by skipping the daily dose, and it is continued, not stopped, when a rescue inhaler is added.

Metformin-containing products carry a boxed warning about which risk?

• a.severe neutropenia
• b.lactic acidosis✓
• c.tendon rupture
• d.QT prolongation

The metformin boxed warning is titled 'WARNING: LACTIC ACIDOSIS' and describes postmarketing cases that resulted in death. Severe neutropenia is the boxed warning for clozapine, QT prolongation is a labeled concern for drugs such as amiodarone, and tendon rupture is part of the fluoroquinolone boxed warning.

An epinephrine auto-injector is dispensed to a patient with a severe food allergy. Which storage instruction is correct?

• a.Keep it in the refrigerator between 2 and 8 degrees Celsius with the other injectable products.
• b.Store it in the freezer and thaw before use.
• c.Store at room temperature; do not refrigerate.✓
• d.Keep it in the car's glove box so it is always available.

The auto-injector labeling directs storage at 20 to 25 degrees Celsius in the carrier tube that protects it from light, and states 'Do not refrigerate'. Refrigeration and freezing are both excluded by that instruction, and a glove box exposes the device to extreme heat and cold, which the labeling specifically warns against.

A patient asks how long an insulin glargine (Lantus) vial may be used once it has been opened and kept at room temperature below 30 degrees Celsius. What does the labeling say?

• a.7 days, after which any insulin left in the vial must be returned to the refrigerator
• b.until the expiration date printed on the vial
• c.90 days from the date it was first punctured
• d.28 days, after which the vial is discarded even if insulin remains✓

The Lantus instructions for use state that an in-use vial stored in the refrigerator or at room temperature below 30 degrees Celsius is used for up to 28 days and then thrown away even if insulin is left in it. The printed expiration date governs unopened vials kept refrigerated, not in-use vials, and neither 90 days nor 7 days appears anywhere in that labeling.

Clozapine is dispensed under a shared REMS program. What must be documented before each dispensing?

• a.a current absolute neutrophil count✓
• b.the patient's most recent blood pressure reading
• c.a signed patient-prescriber agreement renewed at every anniversary of therapy
• d.a negative pregnancy test within the last seven days

Clozapine carries a boxed warning for severe neutropenia and its REMS is built around absolute neutrophil count monitoring, so a current ANC must be on file before the prescription is released. Pregnancy testing every seven days belongs to the isotretinoin iPLEDGE program, blood pressure is not a clozapine REMS requirement, and an annually renewed agreement is not what governs each individual fill.

Isotretinoin capsules may only be dispensed by a pharmacy that is enrolled and activated in which program?

• a.the iPLEDGE REMS✓
• b.the Opioid Analgesic REMS
• c.the Clozapine REMS
• d.the Vaccines For Children program

Because of the risk of severe birth defects, isotretinoin is marketed only under the iPLEDGE restricted distribution program, and the labeling states that the capsules must be dispensed by a pharmacy enrolled and activated with iPLEDGE. The Clozapine REMS covers neutropenia monitoring, the Opioid Analgesic REMS is an education-based program with no pharmacy activation requirement of this kind, and Vaccines For Children is a federal vaccine supply program rather than a REMS.

Which patient direction belongs on a prescription for a rectal suppository?

• a.Dissolve one suppository in warm water and drink the solution.
• b.Unwrap and insert one suppository into the rectum.✓
• c.Swallow one suppository whole with a full glass of water.
• d.Place one suppository under the tongue and allow it to dissolve.

A suppository is unwrapped and inserted into the rectum, where the base melts at body temperature and releases the drug. Dissolving it in water, swallowing it or placing it under the tongue would all deliver the product by the wrong route and would not give the intended dose.

A spacer (valved holding chamber) is dispensed with a metered-dose inhaler. What does the spacer do?

• a.It increases the dose delivered by each actuation.
• b.It converts the inhaler into a dry powder device.
• c.It holds the released plume so more drug reaches the lungs and less lands in the mouth.✓
• d.It replaces the need to shake the canister before use.

A spacer holds the aerosol plume for a moment so the patient does not have to coordinate pressing and inhaling perfectly; more of the dose reaches the lower airway and less is deposited in the mouth and throat. It does not change the metered dose itself, it does not turn a pressurised inhaler into a dry powder inhaler, and the canister still has to be shaken when the labeling says so.

Which of these dosage forms must be sterile?

• a.an oral suspension
• b.a topical cream
• c.a compressed oral tablet
• d.an ophthalmic solution instilled into the eye✓

Products instilled into the eye must be sterile, because the eye has no barrier comparable to the skin or the gut and a contaminated drop can cause a sight-threatening infection. Oral suspensions, topical creams and compressed tablets are made to microbial limits but are not required to be sterile.

A stock bottle is labelled 'Protect from light.' Which dispensing practice satisfies that instruction?

• a.Store the bottle in the refrigerator.
• b.Transfer the tablets to a clear vial so the patient can see them.
• c.Dispense in a light-resistant container and leave the protective carton in place until use.✓
• d.Double-bag the prescription at the register.

A light-protection statement is met by keeping the product in a light-resistant container and leaving the manufacturer's carton, foil or amber packaging intact until the dose is taken. Refrigeration addresses temperature rather than light, a clear vial defeats the requirement entirely, and an outer bag at the register offers no lasting protection once the bag is opened at home.