Chapter 11- Antifungal Agents

1.

A 17-year-old male patient with athlete’s foot is extremely upset that he cannot get rid of it. He calls the clinic and asks the nurse whether the doctor can give him an antibiotic to “cure the infection.” What should the nurse include in the explanation of treatment for fungal infections?
A)
“Fungi differ from bacteria in that the fungus has flexible cell walls that allow for free transfer into and out of the cell.”
B)
“Protective layers contain sterols, which change the membrane permeability.”
C)
“The composition of the protective layers of the fungal cell makes the organism resistant to antibiotics.”
D)
“Fungi cell walls contain Candida, which makes the cells rigid.
Ans:
C

Feedback:

The nurse should tell the patient that the composition of the protective layers of the fungal cell makes the organism resistant to antibiotics so that antibiotics would not have any positive effect. Fungi do differ from bacteria, but the fungus has rigid cell walls that allow for free transfer in and out of the cell. The protective layers contain ergosterol, notCandida, that helps keep the cell wall rigid, not permeable.

2.

The nurse admits a 1-year-old child to the pediatric intensive care unit (ICU) with cryptococcal meningitis. What drug will the nurse anticipate receiving an order for to treat this child?
A)
Amphotericin B (Fungizone)
B)
Fluconazole (Diflucan)
C)
Griseofulvin (Fulvicin)
D)
Ketoconazole (Nizoral)
Ans:
B

Feedback:

Fluconazole is used in the treatment of cryptococcal meningitis and is safe to use in a 1-year-old child. Amphotericin B has many unpleasant adverse effects and is very potent, so it would not be the first or best medication to administer initially but would be reserved for use if fluconazole was not effective. Griseofulvin is given to treat tinea pedis and tinea unguium in children. Ketoconazole is not given to children younger than 2 years because safety has not been established.

3.

The nurse is teaching the patient about a newly prescribed systemic antifungal drug. What sign or symptom will the nurse instruct the patient to report to the provider immediately?
A)
Unusual bruising and bleeding
B)
Constipation or diarrhea
C)
Red and dry eyes
D)
Increased appetite with weight gain
Ans:
A

Feedback:

Unusual bruising and bleeding can be an indication of hepatic toxicity, which should be reported immediately. Yellowing of the eyes, not redness, and tearing are also indicative of hepatic toxicity. Usually GI symptoms include nausea and vomiting with antiviral drugs, which could cause decreased appetite and weight loss. These symptoms should be reported if they persist but are not emergency symptoms to report immediately.

4.

A patient who has a tinea infection calls the clinic and complains of intense local burning and irritation with use of a topical antifungal drug. Even before asking the patient, the nurse suspects he or she is applying what medication?
A)
Butoconazole (Gynazole I)
B)
Ciclopirox (Loprox)
C)
Econazole (Spectazole)
D)
Haloprogin (Halotex)
Ans:
C

Feedback:

Econazole can cause intense local burning and irritation in treatment of tinea infections. Butoconazole is used to treat vaginal Candida infections. Ciclopirox is used to treat toenail and fingernail tinea infections and does not produce intense burning and irritation. Haloprogin is used to treat athlete’s foot, jock itch, and ringworm infections and is not associated with burning or irritation.

5.

A patient asks the nurse if he or she should use a topical antifungal. The nurse is aware that the most important contraindication to topical antifungals is what?
A)
Hepatic impairment
B)
Renal impairment
C)
Congestive heart failure
D)
Known allergy to any of the antifungal drugs
Ans:
D

Feedback:

Topical antifungals are not absorbed systemically so they are not metabolized and excreted. As a result, the only contraindication would be an allergy to the drug. Hepatic and renal impairment and congestive heart failure would not be a contraindication because these drugs do not enter the bloodstream and impact these organ systems.

6.

A patient with high cholesterol is taking lovastatin (Mevacor). What drug would the nurse question if it was ordered for this patient?
A)
Nifedipine (Procardia)
B)
Ciprofloxacin (Cipro)
C)
Itraconazole (Sporanox)
D)
Oxazepam (Serax)
Ans:
C

Feedback:

Itraconazole is an azole antifungal drug that has been associated with severe cardiovascular events when taken with lovastatin. Nifedipine, ciprofloxacin, and oxazepam have no drug interactions with lovastatin. Nifedipine is an antihypertensive drug whose effects can be increased when taken with cimetidine. The effects of ciprofloxacin are altered when taken with antacids and theophyllines. Oxazepam is an antianxiety drug that should not be taken with alcohol or theophyllines.

7.

An 85-year-old man who is a resident in an extended-care facility has athlete’s foot. After applying an antifungal cream, what is the nurse’s next action?
A)
Wipe away excess medication from the affected area.
B)
Wrap a sterile kling dressing around both feet.
C)
Elevate the feet for 30 minutes.
D)
Apply clean dry socks.
Ans:
D

Feedback:

Clean dry socks should be applied when treating athlete’s foot to help eradicate the infection because they will keep the feet dry as well as prevent the cream from being wiped away. A kling dressing is not necessary as it would bind the feet and interfere with mobility and increase the risk of systemic absorption. Medication should not be removed once applied, and there is no need to elevate the feet unless another medical condition warrants this action.

8.

A patient comes to the clinic and is diagnosed with a vaginal fungal infection. The nurse provides patient information for self-administration of a vaginal antifungal medication. What will the nurse include in the instructions?
A)
“Insert low into the opening of the vagina.”
B)
“Discontinue use during menstruation.”
C)
“Remain recumbent for at least 15 minutes after insertion.”
D)
“Rub the cream into the vaginal wall after insertion.”
Ans:
C

Feedback:

The patient should remain recumbent at least 10 to 15 minutes after the medication is deposited high in the vagina so that leakage will not occur and absorption will take place. The effectiveness of the medication is determined by the consistent application for each specified dose for maximal results. The nurse would instruct the patient to continue the medication during menstruation. Stopping the drug and restarting it later can lead to the development of resistant strains of the drug. The cream need not be rubbed into the vaginal wall as it will coat the wall naturally after insertion.

9.

A patient who is using a topical antifungal agent to treat mycosis calls the clinic to report a severe rash that is accompanied by blisters. What will the nurse instruct the patient to do?
A)
“Continue the drug as the prescription indicates.”
B)
“Scrub the rash with soap and water.”
C)
“Stop using the drug immediately.”
D)
“Decrease the amount of the medication used.”
Ans:
C

Feedback:

The patient should stop using the drug. The rash could indicate sensitivity to the drug or worsening of the condition being treated. Scrubbing the rash could cause further irritation and increase the risk for other infections. Continuing the drug could cause further complications. Decreasing the medication would be ineffective in treating the infection while continuing to risk further complications.

10.

The nurse admitted a 25-year-old woman to the unit. What would be the most important thing for the nurse to assess before administering ketoconazole?
A)
Complete blood count (CBC) and blood glucose
B)
Eating and sleeping habits
C)
Height and weight
D)
Renal and hepatic function
Ans:
D

Feedback:

It would be important for the nurse to know the patient’s CBC, blood glucose level, eating and sleeping habits, and height and weight. All of these factors could help determine a specific dosage. However, the most important factor would be the patient’s renal and hepatic function because hepatic or renal toxicity could occur quickly if the organs are not functioning properly.

11.

What drug would the nurse administer orally without the need to question when treating infections caused by Candida albicans?
A)
Amphotericin B (Abelcet)
B)
Tolnaftate (Tinactin)
C)
Griseofulvin (Fulvicin)
D)
Fluconazole (Diflucan)
Ans:
D

Feedback:

Fluconazole is available for oral use and is effective in treating C. albicans. Amphotericin B is reserved for severe and potentially fatal infections, so it would not be used for a C. albicansinfection. Tolnaftate is used to treat athlete’s foot and is applied topically, not given orally. Griseofulvin is applied topically and is used to treat tinea, notC. albicans.

12.

When administering a topical antifungal via the vaginal route, what action would the nurse take?
A)
Place the patient in left lateral Sims’ position.
B)
Applied using sterile technique
C)
Administered high into the vagina.
D)
Insert a tampon after insertion.
Ans:
C

Feedback:

Vaginal antifungals should be administered high into the vagina. The patient should be placed in a recumbent position for insertion. Clean technique (not sterile) should be used. Inserting a tampon after administration is not necessary.

13.

By what route would the nurse administer amphotericin B?
A)
Intravenously
B)
Intramuscularly
C)
Orally
D)
Topically
Ans:
A

Feedback:

Amphotericin B is only administered by the IV route. It cannot be given intramuscularly, orally, or topically.

14.

What classification of medication will the nurse administer concurrently with amphotericin B (Fungizone) to help minimize the adverse reactions to this medication?
A)
Sedatives
B)
Antipyretics
C)
Beta-adrenergic blockers
D)
Diuretics
Ans:
B

Feedback:

Amphotericin B is often given with antipyretics to improve patient comfort and to minimize adverse reactions. Sedatives, beta-adrenergic blockers, and diuretics are not indicated for use with amphotericin B unless the patient has a coexisting diagnosis that would indicate a need for these drugs.

15.

The nurse provides teaching about amphotericin B (Fungizone) for an 82-year-old patient. The nurse evaluates the patient understood teaching when he says he could develop what condition?
A)
Diabetes
B)
Liver necrosis
C)
Kidney damage
D)
Pancreatitis
Ans:
C

Feedback:

Amphotericin B is nephrotoxic so the patient needs to understand the risk of kidney damage. Other risks of amphotericin B include bone marrow suppression; GI irritation with nausea, vomiting, and potentially severe diarrhea; anorexia and weight loss; and pain at the injection site with the possibility of phlebitis or thrombophlebitis, but it does not cause diabetes, liver necrosis, or pancreatitis.

16.

The nurse is reviewing the patient’s medications and sees fluconazole has been ordered. The nurse will question this order when finding the patient is taking what other medication?
A)
Digoxin
B)
Humulin insulin
C)
Acetaminophen
D)
Hydrochlorothiazide
Ans:
A

Feedback:

Fluconazole strongly inhibit the cytochrome P450 (CYP450) enzyme system in the liver and are associated with many drug–drug interactions, such as increased serum levels of the following agents: cyclosporine, digoxin, oral hypoglycemics, warfarin, oral anticoagulants, and phenytoin. Diphenhydramine, acetaminophen, and hydrochlorothiazide have no impact on fluconazole. There is no indication that humulin insulin, acetaminophen, and hydrochlorothiazide are contraindicated when taking fluconazole.

17.

The nurse administers nystatin (Mycostatin) to a patient with thrush (oral candidiasis). How does the medication work in the body?
A)
Changes membrane permeability
B)
Prevents reproduction of fungal cells
C)
Fungistatic
D)
Inhibits glucan synthesis
Ans:
A

Feedback:

Nystatin binds to sterols in the cell wall, changing membrane permeability and allowing leaking of the cellular components, which will result in cell death. Nystatin is not a fungistatic (prevents reproduction of fungal cells) and it does not inhibit glucan synthesis.

18.

The nurse teaches the patient to administer butoconazole (Gynazole) for vaginal candidal infection. What instructions will the nurse supply?
A)
“Fill the applicator with the medication and insert it into the vagina at bedtime.”
B)
“Apply the medication to the perineal area twice a day and wear white cotton underwear.”
C)
“Soak in a sitz bath twice daily and insert the medication into the vagina after the bath.”
D)
“Take one tablet by mouth and be sure to follow the medication with a full glass of water.”
Ans:
A

Feedback:

Butoconazole (Gynazole) is administered once daily and should be inserted high into the vagina with the patient remaining recumbent for at least 10 to 15 minutes after insertion. Using the medication at bedtime helps decrease losing the medication by gravity and extends the time the medication will be in contact with the vaginal wall. The medication is not usually applied to the perineum unless the infection has traveled outside the vagina. Sitz baths are contraindicated because fungi flourish in moist environments. This medication is not administered orally and can only be applied topically.

19.

What medication could the nurse administer in a single dose for effective treatment of the patient’s vaginal candidal infection?
A)
Caspofungin (Cancidas)
B)
Terbinafine (Lamisil)
C)
Ketoconazole (Nizoral)
D)
Tioconazole (Monistat-1)
Ans:
D

Feedback:

Tioconazole may be given as one dose for treatment of vaginal candidal infection. Caspofungin is given IV to treat invasive aspergillosis in patients who did not respond to other treatments and would not be used for a vaginal candidal infection. Terbinafine is administered twice daily for 1 to 4 weeks to treat topical mycosis. Ketoconazole is administered orally or topically to treat aspergillosis, leishmaniasis, cryptococcosis, blastomycosis, moniliasis, coccidioidomycosis, histoplasmosis, and mucormycosis but would not be used to treat vaginal candidal infections.

20.

The nurse works on a renal transplant unit and receives an order for posaconazole (Noxafil) for the patient which the nurse interprets to mean the patient has what infection?
A)
Blastomycosis
B)
Aspergillus
C)
Mucormycosis
D)
Coccidioidomycosis
Ans:
B

Feedback:

Posaconazole is used for prophylaxis treatment of invasive Aspergillus and Candidainfections in adults and children older than 13 years who are immunosuppressed secondary to antineoplastic, chemotherapy, graft-versus-host disease following transplants, or hematological malignancies. Posaconazole would not be used to treat blastomycosis, mucormycosis, or coccidioidomycosis.

21.

The nurse admits a patient diagnosed with a systemic fungal infection and is ordered IV fluconazole. When developing the plan of care for this patient, the nurse would use what nursing diagnosis related to this medication?
A)
Chronic pain related to the gastrointestinal (GI) system, central nervous system (CNS), and local effects of drug
B)
Risk for altered perfusion secondary to system cardiovascular effects of drug
C)
Disturbed sensory perception (kinesthetic) related to CNS effects
D)
Monitor IV sites to ensure that phlebitis or infiltration does not occur.
Ans:
C

Feedback:

Nursing diagnoses related to drug therapy might include disturbed sensory perception (kinesthetic) related to CNS effects. Cardiovascular effects are not a concern with this medication; acute, not chronic, pain is associated with GI, CNS, and local effects of the drug; option D is an intervention, not a nursing diagnosis.

22.

The nurse is caring for a patient receiving an oral fungicide to treat a systemic fungal infection. What intervention would the nurse include in the plan of care?
A)
Maintain complete bed rest.
B)
Assess for cyanosis every 4 hours.
C)
Administer medication 1 hour before meals.
D)
Monitor nutritional status.
Ans:
D

Feedback:

Monitor nutritional status and arrange a dietary consultation as needed to ensure nutritional status secondary to gastrointestinal (GI) upset related to medication. Complete bed rest is unnecessary. Cyanosis is not an anticipated problem. Medications should be given with food not before meals.

23.

What factors would the nurse indicate as contributing to an increase in diagnosed fungal infections? (Select all that apply.)
A)
Acquired immunodeficiency syndrome (AIDS)-related complex
B)
Increased prevalence of cancer
C)
Rise in birth rates across the country
D)
Greater number of older adults
E)
Increased use of immunosuppressants
Ans:
A, D, E

Feedback:

The incidence of fungal infections has increased with the rising number of immunocompromised people—patients with AIDS and AIDS-related complex (ARC), those taking immunosuppressant drugs, those who have undergone transplantation surgery or cancer treatment, and members of the increasingly larger elderly population, who are no longer able to protect themselves from the many fungi that are found throughout the environment. Cancer rates and birth rates are declining and do not contribute to the increase in diagnosis of fungal infection.

24.

A patient who has received a heart transplant is taking cyclosporine. The patient is found to have a systemic Aspergillus infection. What drug would the nurse question if ordered for this patient?
A)
Terbinafine
B)
Posaconazole
C)
Itraconazole
D)
Ketoconazole
Ans:
D

Feedback:

Ketoconzaole and fluconazole strongly inhibit the cytochrome P450 (CYP450) enzyme system in the liver and is associated with many drug–drug interactions such as increased serum levels of the following agents: cyclosporine, digoxin, oral hypoglycemics, warfarin, oral anticoagulants, and phenytoin. There is no known drug interaction between cyclosporins and terbinafine, posaconazole, or itraconazole.

25.

When caring for a patient with a secondary immunodeficiency disease following kidney transplantation being treated for candidemia the nurse can anticipate receiving an order for what medication?
A)
Amphotericin B
B)
Anidulafungin
C)
Flucytosine
D)
Butoconazole
Ans:
B

Feedback:

Anidulafungin (Eraxis) is used for the treatment of candidemia (infection of the bloodstream) and other forms of candidal infections, intra-abdominal infections, and esophageal candidiasis. Amphotericin B is not indicated in the treatment of candidemia. Flucytosine is indicated for the treatment of candidemia but is excreted primarily in the urine so would be contraindicated in a patient with a transplanted kidney. Butoconazole is a topical medication that would not be appropriate for use treating a systemic bloodborne fungal infection.

26.

Which antifungal would the nurse explain works by inhibiting glucan synthesis
A)
Flucytosine
B)
Terbinafine
C)
Micafungin
D)
Ketoconazole
Ans:
C

Feedback:

The antifungal medications called echinocandins work by inhibiting glucan synthesis and micafungin is one of the drugs in this classification. Flucytosine is a miscellaneous antifungal agent, whereas terbinafine and ketoconazole are topical agents.

27.

What antifungal would be appropriate for the nurse to administer to treat a patient with an oropharyngeal candidiasis?
A)
Itraconazole
B)
Fluconazole
C)
Posaconazole
D)
Clotrimazole
Ans:
D

Feedback:

Clotrimazole is an effective treatment for oropharyngeal candidiasis (in troche form) or to prevent oropharyngeal candidiasis in patients receiving radiation or chemotherapy. Itraconazole, fluconazole, and posaconazole would not be appropriate for this patient because they do not treat oropharyngeal candidiasis infections.

28.

What drug would the nurse recognize as contraindicated for pediatric use?
A)
Fluconazole
B)
Terbinafine
C)
Griseofulvin
D)
Flucytosine
Ans:
D

Feedback:

Flucytosine does not have proven safety and efficacy in children, and extreme caution should be exercised if it is ordered. Fluconazole, terbinafine, and griseofulvin have established pediatric doses and would be drugs of choice if appropriate for a particular infection.

29.

When caring for a 92-year-old patient, the nurse would anticipate the need for what interventions related to administration of any antifungal medications? (Select all that apply.)
A)
Dose reduction
B)
Frequent monitoring
C)
Frequent testing of liver function
D)
Shorter course of treatment
E)
Continuous cardiorespiratory monitoring
Ans:
A, B, C

Feedback:

Patients over age 85 are at increased risk for some liver dysfunction and require more careful monitoring, lower dosages, and frequent assessment of liver function studies. Course of treatment should not be shortened, but dosage should be reduced. Continuous cardiorespiratory monitoring is not indicated.

30.

A 15-year-old patient is immunocompromised because of the adverse effects of chemotherapy. He or she has developed severe migraine headaches and is being treated with ergot. What drug would be contraindicated in this patient?
A)
Caspofungin
B)
Ketoconazole
C)
Posaconazole
D)
Terbinafine
Ans:
C

Feedback:

Patients being treated with voriconazole or posaconazole should be cautioned about the risk of ergotism if they combine this drug with ergot, an herb frequently used to treat migraine headache and menstrual problems. If the patient is using voriconazole, it should be suggested that ergot not be used until the antifungal therapy is finished. The other options do not have a known drug interaction with ergot.

31.

The nurse is reading the patient’s medical record and discovers the patient has a mycosis and interprets this as meaning what?
A)
An infection caused by a fungus
B)
A fungus normally found on mucous membranes
C)
A systemic fungal infection
D)
A fungal infection with a secondary bacterial infection
Ans:
A

Feedback:

A mycosis is simply a fungal infection. It does not give any indication of type or where it is found and has nothing to do with a bacterial infection.

32.

The nurse admits a patient suspected of having a fungal infection. What action will the nurse need to take before a systemic antifungal can be prescribed? (Select all that apply.)
A)
Initiate IV therapy.
B)
Assess history of liver or kidney disease.
C)
Obtain a culture of the fungus.
D)
Request the patient sign a consent form.
E)
Assess history of lymphatic disease.
Ans:
B, C

Feedback:

The nurse would assess the patient for history of liver or kidney disease because systemic antifungals carry a higher risk of adverse effects and toxicity in patients with disease of these organs. A culture to determine the type of fungus should also be performed to increase the likelihood of the correct medication being prescribed. Not all antifungals are administered IV so this may not be necessary and would not be initiated until a drug was prescribed. A consent form is not needed by most facilities. History of lymphatic disease would not be associated with concern related to antifungal medications.

33.

The patient is admitted for IV administration of antifungal medication with the plan to discharge the patient on oral medication in a few days. What medication would the nurse be able to administer both IV and orally?
A)
Fluconazole
B)
Itraconazole
C)
Posaconazole
D)
Terbinafine
Ans:
A

Feedback:

Fluconazole and voriconazole are available in oral and IV preparations, making it possible to start the drug IV for a serious infection and then switch to an oral form when the patient’s condition improves and he or she is able to take oral medications. Itraconazole, posaconazole, and terbinafine are administered only orally.

34.

The nurse admits a patient diagnosed with diabetes who has been undergoing fertility treatment in the hopes of becoming pregnant but is not pregnant at this time. The patient has a life-threatening fungal infection and requires systemic antifungal therapy. What medication would be contraindicated in this patient?
A)
Ketoconazole
B)
Fluconazole
C)
Posaconazole
D)
Itraconazole
Ans:
A

Feedback:

Ketoconazole is not the drug of choice for patients with endocrine or fertility problems because of its effects on these processes. It is not known whether posaconazole crosses the placenta or enters breast milk, so it should not be used during pregnancy or lactation unless the benefits clearly outweigh the potential risks but has no risk to those with fertility or endocrine problems. Fluconazole and itraconazole would be safe for this patient.

35.

The nurse is assessing the patient’s medication history and learns the patient received a prescription for voriconazole from one provider and a prescription for an ergot alkaloid from another provider. The nurse realizes this patient is at risk for, and needs to be assessed for, what condition?
A)
Liver toxicity
B)
Central nervous system (CNS) depression
C)
Ergotism
D)
Renal toxicity
Ans:
C

Feedback:

This patient is at risk for ergotism and would require an electrocardiographic or rhythm strip to assess the QT interval because ergotism manifests with prolonged QT intervals. The drug combination does not contribute to hepatic or renal toxicity or depression of the central nervous system.