PTCB Pharmacy Technician (PTCE) — All Questions

A patient has taken metoprolol for high blood pressure for two years and asks whether she can simply stop it now that her home readings are normal. Which counselling point applies to beta blockers?

• a.It may be stopped whenever the readings return to normal for a full week
• b.It is only needed on days when blood pressure feels high
• c.It can be switched to every other day once home readings are normal
• d.It should not be stopped suddenly; the prescriber tapers the dose✓

Long-term beta blockade up-regulates beta receptors, so stopping the drug abruptly can produce rebound tachycardia and hypertension and, in a patient with coronary disease, angina or infarction; prescribers step the dose down instead. Normal readings mean the drug is working, not that it is no longer needed. Moving to alternate days is self-tapering by another name and leaves the pressure uncovered on the off days, and beta blockers are never taken as needed for how blood pressure 'feels' — hypertension has no reliable symptoms.

Swelling of the ankles and feet that is not caused by fluid overload is a recognized, dose-related effect of which cardiovascular drug class?

• a.Calcium channel blockers such as amlodipine✓
• b.ACE inhibitors such as enalapril
• c.Loop diuretics such as furosemide
• d.Thiazide diuretics such as hydrochlorothiazide

Amlodipine, nifedipine and the other dihydropyridine calcium channel blockers dilate arterioles far more than veins, which raises pressure in the capillary bed and pushes fluid into the tissue, producing dose-related ankle edema that is not heart failure and responds poorly to a diuretic. ACE inhibitors are the tempting answer because bradykinin build-up is a well-known class effect, but bradykinin produces a dry cough and angioedema of the face and airway rather than gradual ankle swelling. Loop and thiazide diuretics remove fluid rather than causing swelling; thiazides do lower potassium, but potassium loss does not cause edema.

A woman of childbearing age was switched from lisinopril to losartan because of a persistent dry cough. Which precaution still applies after the switch?

• a.Potassium levels no longer need monitoring on losartan
• b.Losartan may be used safely during pregnancy, unlike lisinopril
• c.Both classes carry a boxed warning against use in pregnancy✓
• d.The cough should resolve within a few days

ACE inhibitors and ARBs both carry a boxed warning for fetal toxicity and are stopped as soon as pregnancy is detected, so moving from lisinopril to losartan removes the cough but not that risk. Assuming an ARB is safe in pregnancy because it is a different class is the misconception this question targets. Both classes also raise serum potassium, so monitoring continues, and ACE-inhibitor cough typically fades over one to several weeks after stopping, not within days.

A patient starting spironolactone should be cautioned about routinely using which everyday grocery product?

• a.Bananas and other high-potassium fruit
• b.Aged cheese and cured meats
• c.Salt substitutes✓
• d.Cranberry juice cocktail

Spironolactone is a potassium-sparing diuretic: it holds potassium back rather than wasting it, so an extra potassium load can push the serum level high enough to cause dangerous arrhythmias. Most supermarket salt substitutes replace sodium chloride with potassium chloride and are then shaken freely over food at every meal, so the amount taken in is unmeasured and repeated — which is why salt substitutes, along with potassium supplements, are the products named in the counselling. High-potassium foods such as bananas are the defensible second answer and are worth raising, but a portion of fruit is a fixed, self-limiting amount that most patients with normal kidney function tolerate. Aged cheese and cured meats carry the tyramine caution taught for MAO inhibitors, and cranberry juice is the product patients associate with warfarin; neither affects spironolactone.

Digoxin is a narrow-therapeutic-index drug. Which set of complaints is classically associated with digoxin toxicity?

• a.Dry cough, hoarseness, and a metallic taste in the mouth
• b.Ringing in the ears and hearing loss developing over several days
• c.Nausea, loss of appetite, and visual disturbances such as yellow-green halos✓
• d.Swollen gums and unusual hair growth on the arms

Because the toxic and therapeutic concentrations of digoxin sit so close together, technicians are taught the early picture: gastrointestinal upset with nausea and anorexia, confusion or fatigue, and the characteristic visual changes of blurred or yellow-green tinted vision with haloes around lights. Tinnitus with hearing loss points instead to salicylate or aminoglycoside toxicity, while gum overgrowth with increased body hair is the classic phenytoin picture.

A patient's profile shows both insulin lispro and insulin glargine. How do the two products differ in category?

• a.Lispro is intermediate-acting and glargine is short-acting mealtime insulin
• b.Both are basal insulins, so the pair duplicates therapy
• c.Lispro is basal; glargine is given with meals
• d.Lispro is rapid-acting; glargine is long-acting basal✓

Insulin lispro is a rapid-acting analogue given around meals to cover the carbohydrate in that meal, while insulin glargine is a long-acting analogue that supplies steady background coverage; a basal-plus-mealtime pair on one profile is a normal regimen, not a duplication, which is why the duplicate-therapy answer is tempting but wrong. Reversing the two roles is the dangerous error, because glargine is not sized to a meal and lispro cannot hold glucose steady overnight.

Which class of oral antidiabetic drugs most often requires the patient to be counselled on recognizing and treating low blood sugar?

• a.Sulfonylureas such as glipizide and glyburide✓
• b.Biguanides such as metformin
• c.Alpha-glucosidase inhibitors such as acarbose and miglitol
• d.SGLT2 inhibitors such as empagliflozin

Sulfonylureas stimulate the pancreas to release insulin whether or not blood glucose is high, so a missed meal, extra exercise or a dose taken twice can drop blood sugar too far — the patient needs to recognize the shakiness-and-sweating picture and keep glucose tablets to hand. Metformin is the tempting choice because it is the most-dispensed oral diabetes drug, but it works by lowering hepatic glucose output and does not force insulin release, so on its own it rarely causes hypoglycemia. Acarbose and miglitol slow the digestion of carbohydrate and empagliflozin sends glucose out in the urine; neither pushes insulin out of the pancreas, so hypoglycemia with them is uncommon unless they are combined with insulin or a sulfonylurea.

Which administration instruction belongs on a levothyroxine prescription label?

• a.Take together with the morning calcium and iron supplements
• b.Take in the morning on an empty stomach✓
• c.Take at bedtime with a snack to prevent insomnia
• d.Take with the largest meal of the day to reduce nausea

Levothyroxine absorption is reduced by food and cut sharply by calcium salts, iron salts and some antacids, so the standard direction is to take it in the morning on an empty stomach with water and to separate those products by several hours. Taking the tablet alongside the morning calcium and iron is the specific habit that produces unexplained treatment failure and repeated dose increases. Levothyroxine is not a sedating drug and is not given with a snack.

A patient who has taken prednisone daily for several weeks is given a new prescription written as a stepwise decreasing dose. Why is the dose stepped down instead of simply stopped?

• a.The taper prevents the allergic reactions that follow sudden steroid withdrawal
• b.The falling dose is needed to stop the drug from accumulating in fat tissue
• c.The taper prevents opioid-style withdrawal and craving
• d.Abrupt withdrawal can leave adrenal hormone output suppressed✓

Weeks of an oral corticosteroid suppress the hypothalamic-pituitary-adrenal axis, so the adrenal glands need time to resume making cortisol; stepping the dose down lets that recovery happen. Stopping abruptly risks adrenal insufficiency — fatigue, weakness, nausea and low blood pressure — which candidates often mislabel as an allergic reaction, but this withdrawal is a hormone problem, not an immune one, and it is not opioid-type dependence with craving either. Prednisone is not stored in fat tissue in a way that would dictate the schedule.

A patient is dispensed doxycycline capsules. Which counselling point matters most?

• a.Store the capsules in the refrigerator
• b.Take each dose with a glass of milk to prevent stomach upset from the drug
• c.Take it with an antacid to protect the stomach
• d.Separate it from dairy, antacids and iron, and avoid strong sun✓

Tetracyclines bind calcium, magnesium, aluminium and iron, so milk, antacids and iron salts sharply reduce how much doxycycline is absorbed and must be separated from the dose; the class also causes photosensitivity, so sun protection is advised. Taking it with milk is the intuitive answer for a drug that upsets the stomach, and it is exactly what defeats the antibiotic. Doxycycline is stored at controlled room temperature, not refrigerated.

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.

While a technician is entering a new prescription, the system fires a drug-interaction alert that the technician's log-in cannot bypass. What does this hard stop mean?

• a.The technician may key in the pharmacist's override code kept at the workstation
• b.The technician should delete one of the interacting drugs from the profile so the alert clears
• c.Only the pharmacist may review the alert and clear it before the fill continues✓
• d.The alert is informational and may simply be documented

A hard stop is built so that the clinical judgement behind an override is made and documented by the pharmacist; the technician's role is to leave the order in the queue and hand it over. Keying in a borrowed override code is the closest wrong answer because it does move the queue along, but it puts the technician's hands on a clinical decision and falsifies who reviewed the interaction. Deleting a drug from the profile destroys the very data the interaction check runs on.

Two strengths of the same manufacturer's product arrive in cartons that are identical except for a small color band. Which practice best reduces wrong-carton selection?

• a.Store the two strengths in separate labelled bins with an auxiliary warning on each✓
• b.Cover the manufacturer's color band with the pharmacy's own strength label
• c.Apply tall man lettering to both shelf labels, since that is the standard fix for look-alike products
• d.Shelve them side by side in strength order so the difference is obvious

When the confusable feature is the packaging rather than the name, the control has to be physical: separate the strengths and add a warning that forces a second look. Tall man lettering is the tempting answer because it is the standard look-alike remedy, but it differentiates spelling, and here the two names are identical, so it changes nothing. Shelving them adjacently in strength order actually raises the risk, because the near-identical cartons then sit within one reach, and covering manufacturer labelling obscures information the pharmacist needs at verification.

A community pharmacy runs an automatic refill program for maintenance prescriptions. Which control matters most to the safety of that program?

• a.Enrolling every maintenance prescription automatically so that no chronic therapy ever lapses
• b.Adding Schedule II prescriptions to the program so that patients do not run out between visits
• c.Letting the pharmacist catch any discontinued drug at the final verification step
• d.Confirming with the patient each cycle that the drug is still being taken as prescribed✓

The characteristic auto-refill harm is a drug that the prescriber stopped or changed being filled, delivered and then taken again, so the program needs a live confirmation from the patient at each cycle. Waiting for the pharmacist's final verification is the closest wrong answer, because that check does happen, but it compares the label to the prescription on file and cannot see a change the pharmacy was never told about. Auto-enrolling everything removes the patient's consent, and Schedule II prescriptions cannot be refilled at all under federal law, so they can never be part of a refill program.

A recall notice arrives naming one specific lot number of a tablet the pharmacy stocks. What should the technician do with the pharmacy's stock of that drug?

• a.Pull the named lot, quarantine it away from active stock, and follow the notice✓
• b.Leave the lot on the shelf but flag the computer record so that it is never dispensed
• c.Pull every bottle of the drug regardless of lot and send all of it back
• d.Discard the affected bottles in the pharmaceutical waste bin

A lot-specific recall is handled by removing that lot from where anyone can reach it, holding it in a marked quarantine area separate from dispensable stock, and doing exactly what the notice instructs about return or destruction. Flagging the computer record is the closest wrong answer because it does block the sale, but the physical bottle stays within arm's reach of the fill station, and a computer flag cannot stop a hand. Pulling every lot destroys usable inventory the notice never covered, and discarding the bottles gives up the documented return the manufacturer needs.

A patient returns a sealed, unopened bottle of tablets the pharmacy dispensed last week and asks that it be restocked and credited. In most states, what should the pharmacy do?

• a.Decline to restock it; medication that has left the pharmacy cannot be verified✓
• b.Repackage the tablets into a new vial for the next patient on the same drug
• c.Restock it after the pharmacist inspects the tablets and matches the lot
• d.Restock it, because the manufacturer's seal is unbroken and the fill is under 30 days old

Once a dispensed medication leaves the pharmacy's control, nobody can confirm how it was stored or handled, so in most states it cannot go back into dispensable stock even if the seal looks untouched. Pharmacist inspection is the closest wrong answer, because inspection and lot matching are real controls, but neither reconstructs the temperature history of a bottle that spent a week in a car or a bathroom. Repackaging it for another patient carries the same unverifiable product forward under a new label.

A refrigerated biologic has to reach a patient's home by pharmacy courier. Which practice best protects the product in transit?

• a.Send it by ordinary courier and tell the patient to refrigerate it on arrival
• b.Pack it in an insulated bag with ice cubes and leave it at the door if nobody answers
• c.Freeze the product before it leaves so that it stays cold for the entire trip
• d.Pack it in a validated insulated shipper with a temperature indicator and obtain a signature on delivery✓

Cold-chain transport is only defensible when the container has been validated to hold the range for the expected trip time and the indicator lets someone read afterwards whether it actually did, with a signature proving the product was not left in the sun. Ice cubes plus a doorstep drop is the closest wrong answer because the insulation is at least present, but melting ice gives no record and an unattended package has no controlled temperature at all. Freezing is worse than doing nothing for most refrigerated biologics, which are damaged by it.

In a long-term-care pharmacy a technician fills unit-dose medication carts for the next 24 hours. Which check best keeps a cart-fill error from reaching a resident?

• a.Filling from the previous cycle's cart list, since residents' regimens rarely change much
• b.Filling from the current medication administration record and having the pharmacist verify the cart before it leaves✓
• c.Having a second technician confirm that the drawer count matches the resident census
• d.Relying on the nurse's check at the bedside as the last chance to catch the error

Cart fill is only as good as the document it is filled from, so the fill must start from the current medication administration record and end with a pharmacist verification while the cart is still in the pharmacy and errors are cheap to fix. The bedside nurse check is the closest wrong answer, because it is a genuine last line of defense, but it happens after the cart has travelled and it is the control the pharmacy cannot manage. Counting drawers against the census confirms quantity, not that the right drug reached the right resident.

A prescription reads: instill 1 drop into each eye three times daily. One 5 mL bottle is dispensed, and the manufacturer states the bottle delivers 20 drops per mL. Rounded down to whole days, what is the day supply?

• a.8 days
• b.33 days
• c.16 days✓
• d.17 days

The bottle holds 5 mL x 20 drops/mL = 100 drops, and the patient uses 1 drop x 2 eyes x 3 times daily = 6 drops a day, so 100 / 6 = 16.7, reported as 16 whole days. Reading 'each eye' as a single drop per dose leaves 3 drops a day and 100 / 3 = 33 days; doubling the dose to two drops in each eye gives 12 drops a day and 100 / 12 = 8 days. The 17-day figure is the same 16.7 rounded the wrong way, and that rounding is the call worth pausing over, since 16.7 sits closer to 17: a day supply is always rounded down, because on the seventeenth day there is not a full day of drops left.

An inhaler canister is labelled 200 metered actuations. The sig reads: inhale 2 puffs by mouth four times daily. One canister is dispensed. What is the day supply?

• a.100 days
• b.25 days✓
• c.12 days
• d.50 days

The patient uses 2 puffs x 4 times daily = 8 actuations a day, so 200 / 8 = 25 days exactly. Dividing 200 by the 4 daily doses while forgetting that each dose is 2 puffs gives 50 days, and counting only the 2 actuations of a single daily dose gives 200 / 2 = 100 days. Doubling the daily use to 16 actuations gives 200 / 16 = 12.5, reported as 12 days, but nothing in the sig supports 16 puffs a day.

A box of five insulin pens is dispensed. Each pen holds 3 mL of insulin labelled 100 units/mL. The sig reads: inject 35 units subcutaneously twice daily. Rounded down to whole days, what is the day supply?

• a.42 days
• b.7 days
• c.21 days✓
• d.22 days

Each pen holds 3 mL x 100 units/mL = 300 units, so five pens hold 1,500 units; the patient uses 35 x 2 = 70 units a day, and 1,500 / 70 = 21.4, reported as 21 whole days. Treating 100 units/mL as 100 units per pen ignores the 3 mL volume and leaves 500 units, or 500 / 70 = 7 days. Counting only one 35-unit dose a day gives 1,500 / 35 = 42 days. The 22-day figure is that same 21.4 rounded up, and a day supply is rounded down because the final partial day is not a full day of therapy.

A patient is directed to apply 0.5 g of a cream to the affected area three times daily. One 45 g tube is dispensed. What is the day supply?

• a.90 days
• b.10 days
• c.30 days✓
• d.15 days

The patient uses 0.5 g x 3 = 1.5 g a day, so 45 g / 1.5 g per day = 30 days. Treating 1.5 g as the amount per application rather than per day triples the daily use to 4.5 g and gives 45 / 4.5 = 10 days. Counting a single 0.5 g application a day gives 45 / 0.5 = 90 days, and using 3 g a day gives 45 / 3 = 15 days.

A prednisone taper is written with 20 mg tablets: 60 mg daily for 5 days, then 40 mg daily for 5 days, then 20 mg daily for 5 days. What quantity should be dispensed?

• a.60 tablets
• b.18 tablets
• c.6 tablets
• d.30 tablets✓

With 20 mg tablets the three steps are 3, 2 and 1 tablets a day, so the totals are 3 x 5 = 15, 2 x 5 = 10 and 1 x 5 = 5 tablets, giving 15 + 10 + 5 = 30 tablets. The 60-tablet figure is what the same taper needs if 10 mg tablets are used, since the steps would be 6, 4 and 2 a day; the strength written on the prescription decides which applies, and this one says 20 mg. Adding 3 + 2 + 1 without ever multiplying by the 5 days gives 6 tablets, and multiplying that 6 by 3 days instead of 5 gives 18 tablets.

An antineoplastic is ordered at 75 mg/m2 for a patient whose body surface area is documented on the order as 1.6 m2. The vial is labelled 6 mg/mL. What volume contains the ordered dose?

• a.7.8 mL
• b.12.5 mL
• c.20 mL✓
• d.120 mL

The dose is 75 mg/m2 x 1.6 m2 = 120 mg, and 120 mg / 6 mg/mL = 20 mL. The 12.5 mL figure is the most tempting because it uses the right vial concentration but never applies the body surface area, dividing the bare 75 mg by 6 mg/mL. Dividing by 1.6 instead of multiplying gives 46.9 mg and 46.9 / 6 = 7.8 mL, and carrying the milligram number straight across as a volume gives 120 mL, which would only be right if the vial were 1 mg/mL.

A child weighing 33 lb is ordered an antibiotic at 40 mg/kg/day divided every 8 hours. The suspension supplied is 250 mg/5 mL. What volume should be given per dose?

• a.12 mL
• b.6 mL
• c.8.8 mL
• d.4 mL✓

The child weighs 33 lb / 2.2 = 15 kg, so the daily dose is 15 kg x 40 mg/kg = 600 mg; every 8 hours means 3 doses, so each dose is 600 / 3 = 200 mg, and 200 mg / (250 mg per 5 mL, that is 50 mg/mL) = 4 mL. The 6 mL figure is the most tempting because every step is right except the last, splitting the day into two doses of 300 mg. Taking the 33 lb as kilograms gives 33 x 40 = 1,320 mg a day, 440 mg a dose and 8.8 mL, and giving the whole 600 mg at once is 12 mL.

How many milligrams of lidocaine are contained in 20 mL of a 2% (w/v) lidocaine solution?

• a.400 mg✓
• b.20 mg
• c.4,000 mg
• d.40 mg

A percentage strength expressed w/v means grams of drug per 100 mL, so 2% is 2 g per 100 mL, which is 2,000 mg / 100 mL = 20 mg/mL, and 20 mg/mL x 20 mL = 400 mg. Reading the 2 as 2 mg/mL without converting the grams first gives 2 x 20 = 40 mg, and inflating that same conversion tenfold to 200 mg/mL gives 4,000 mg. The 20 mg figure stops at the per-millilitre strength and never multiplies by the 20 mL volume.

An epinephrine solution is labelled with the ratio strength 1:1,000. What concentration does that ratio strength represent?

• a.1,000 mg/mL
• b.10 mg/mL
• c.1 mg/mL✓
• d.0.1 mg/mL

A ratio strength for a solution means grams of drug in that many millilitres, so 1:1,000 is 1 g in 1,000 mL, which is 1,000 mg / 1,000 mL = 1 mg/mL, the same as 0.1% w/v. The 0.1 mg/mL figure is the one worth pausing over, because it is a real epinephrine concentration a technician handles, but it belongs to the 1:10,000 label, where the same 1 g is spread through ten times the volume. Reading the label as 1 g in 100 mL gives 10 mg/mL, and reading it as 1,000 mg in each millilitre gives 1,000 mg/mL.

You must prepare 500 mL of 60% isopropyl alcohol using a 90% and a 40% isopropyl alcohol. What volume of each is required?

• a.250 mL of 90% and 250 mL of 40%
• b.200 mL of 90% and 300 mL of 40%✓
• c.300 mL of 90% and 200 mL of 40%
• d.100 mL of 90% and 400 mL of 40%

By alligation the 90% contributes 60 - 40 = 20 parts and the 40% contributes 90 - 60 = 30 parts, giving 50 parts in all, so the 90% supplies 20/50 x 500 = 200 mL and the 40% supplies 30/50 x 500 = 300 mL. Checking by mass balance, 200 x 0.90 = 180 g plus 300 x 0.40 = 120 g is 300 g of alcohol in 500 mL, which is 60%. Reversing the parts to 300 mL and 200 mL is the commonest error and yields 270 + 80 = 350 g in 500 mL, or 70%. Mixing 250 mL of each averages the two strengths to 65%, and the 1-to-4 split yields 90 + 160 = 250 g in 500 mL, or 50%.

A vial of lyophilised antibiotic powder is reconstituted with 8.6 mL of sterile water and the resulting solution measures 10 mL. What is the powder volume?

• a.1.4 mL✓
• b.18.6 mL
• c.10 mL
• d.8.6 mL

Powder volume is the space the dry drug itself occupies, found as final volume minus diluent volume: 10 mL - 8.6 mL = 1.4 mL. The 8.6 mL figure is the most tempting because that number is the one printed on the reconstitution instructions, but it is the diluent, not the powder. The 10 mL figure is the final volume the label concentration is based on, and adding the two volumes to reach 18.6 mL counts the diluent twice.

An order reads: infuse 1,500 mL of 0.9% sodium chloride over 12 hours using an administration set calibrated at 20 gtt/mL. What is the drip rate in gtt/min?

• a.42 gtt/min✓
• b.31 gtt/min
• c.125 gtt/min
• d.21 gtt/min

The infusion delivers 1,500 mL x 20 gtt/mL = 30,000 drops over 12 x 60 = 720 minutes, so 30,000 / 720 = 41.7, rounded to 42 gtt/min. Checking the other way, 1,500 / 12 = 125 mL/hr and 125 / 60 x 20 = 41.7 gtt/min. The 125 figure is the most tempting because that number really does appear in the working, but it is the hourly volume, not a drip rate. A 15 gtt/mL set would give 125 / 60 x 15 = 31 gtt/min and a 10 gtt/mL set 125 / 60 x 10 = 21 gtt/min, but this order specifies a 20 gtt/mL set.

A 1,000 mL bag is started at 100 mL/hr. After 4 hours the prescriber lowers the rate to 60 mL/hr. How much longer will the bag run?

• a.6 hours
• b.16.7 hours
• c.14 hours
• d.10 hours✓

In the first 4 hours the pump delivered 4 x 100 = 400 mL, leaving 1,000 - 400 = 600 mL, and 600 mL / 60 mL/hr = 10 more hours. The 16.7-hour figure is the most tempting because it applies the new rate correctly but to the whole 1,000 mL, ignoring the 400 mL already infused. Running the remaining 600 mL at the old 100 mL/hr gives 6 hours, and adding the 4 hours already elapsed onto the 10 gives 14 hours, which answers total run time rather than the time still to go.

A plan charges a $10.00 copay plus 20% coinsurance on the balance of the prescription price. The total price of the prescription is $210.00. What does the patient pay?

• a.$52.00
• b.$50.00✓
• c.$42.00
• d.$10.00

The copay comes off first, leaving $210.00 - $10.00 = $200.00; the coinsurance is 20% x $200.00 = $40.00, so the patient owes $40.00 + $10.00 = $50.00. The $52.00 figure is the most tempting because it also adds the copay, but it takes the 20% from the full $210.00 instead of from the balance, charging the patient twice on that first $10.00. Taking 20% of $210.00 and forgetting the copay altogether gives $42.00, and $10.00 assumes the plan absorbs everything above the copay.

A pharmacy acquires a bottle for $80.00 and sells it for $100.00. What are the gross profit and the percentage markup on cost?

• a.$20.00 gross profit and a 25% markup✓
• b.$20.00 gross profit and a 125% markup
• c.$20.00 gross profit and a 20% markup
• d.$100.00 gross profit and a 25% markup

Gross profit is selling price minus cost, $100.00 - $80.00 = $20.00, and markup on cost divides that profit by the cost: $20.00 / $80.00 = 0.25, or 25%. The 20% figure is the hardest to discard, because $20.00 / $100.00 really is 20%, but dividing by the selling price gives the gross margin; this question asks for markup on cost, so the denominator has to be the $80.00. The 125% figure is $100.00 / $80.00, the price as a percentage of cost rather than the increase over it, and the $100.00 profit figure mistakes the whole selling price for the profit and never subtracts what the bottle cost.

A prescription sig reads: ii gtts AU tid. Which set of patient directions is correct?

• a.Instill 2 drops into the left ear three times daily
• b.Instill 2 drops into each eye three times daily
• c.Instill 2 drops into both ears three times daily✓
• d.Instill 2 drops into both ears twice daily

The Roman numeral ii is 2, gtts is drops, AU is auris uterque or both ears, and tid is three times daily. The each-eye version is the trap worth thinking about, because AU and OU differ by one letter and both mean the paired organ; the A stands for auris, the ear, while OU would be oculus uterque, both eyes. AS would be the left ear alone, and twice daily would be written bid.

A prescriber writes 'dispense as written' on a prescription for a brand-name drug that has an AB-rated generic. Which DAW code should be transmitted on the claim?

• a.DAW 1✓
• b.DAW 0
• c.DAW 2
• d.DAW 4

A dispense-as-written instruction from the prescriber on the face of the prescription is DAW 1, which is defined as substitution not allowed by the prescriber. DAW 2 is the closest call, because it also ends with the brand being dispensed, but it records the patient as the source of the request; billing it that way misstates who made the decision and often shifts the extra cost onto the patient. DAW 0 means no product selection was indicated by anyone, and DAW 4 means substitution was allowed but the generic was not in stock.

A claim for a 90-day supply of a maintenance drug is rejected as 'plan limitations exceeded'. The plan covers this drug in 30-day quantities at retail. What is the correct resolution?

• a.Bill the whole 90-day supply as a cash sale
• b.Resubmit the same 90-day claim with a DAW 1 code
• c.Split the 90 tablets into three claims submitted the same day
• d.Rebill the claim for a 30-day quantity and dispense that amount✓

A plan-limitation rejection is a quantity problem, so the fix is to cut the fill back to the quantity the plan actually covers, bill that, and let the patient decide about mail order for the longer supply. Splitting the fill into three same-day claims is the closest wrong answer because it does reach the same 90 days, but the second and third claims reject as refill-too-soon or duplicates, and deliberately structuring claims to defeat a plan limit is a billing offense. A DAW code addresses brand substitution and has no effect on a quantity limit, and moving the patient to cash without telling them takes away a choice that is theirs to make.