Safe Prescribing Practice Questions

Question 1

According to the Mental Capacity Act 2005, which of the following statements about the hierarchy of decision-makers for a patient lacking capacity is correct?

Accepted Answer

Valid advance decision to refuse treatment takes precedence over Lasting Power of Attorney for Health and Welfare

Answer

Court-appointed deputy takes precedence over a registered Lasting Power of Attorney

Answer

Lasting Power of Attorney for Health and Welfare takes precedence over advance decisions

Answer

Next of kin have legal authority to make treatment decisions if no LPA exists

Answer

Independent Mental Capacity Advocate can make binding treatment decisions

Question 2

An 82-year-old woman with severe dementia (MMSE 6/30) and recurrent urosepsis is admitted from a nursing home. She has no advance decision or LPA. Her son (only relative) says 'Mum always said if she got dementia she wouldn't want to be kept alive with antibiotics'. There is no documented evidence of this. She appears comfortable but has sepsis requiring IV antibiotics. What weight should be given to the son's account?

Accepted Answer

It forms part of the best interests assessment but is not binding

Answer

No weight as there is no written advance decision to refuse treatment

Answer

It should be determinative as he is the next of kin

Answer

It constitutes a valid oral advance decision and antibiotics should be withheld

Answer

It should be ignored as the son may have ulterior motives

Question 3

A 28-year-old woman presents with a 3-day history of dysuria, urinary frequency, and suprapubic pain. She is otherwise well with no fever. Urine dipstick shows nitrites positive, leucocytes positive. What is the most appropriate first-line antibiotic treatment?

Accepted Answer

Trimethoprim 200mg BD for 3 days

Answer

Amoxicillin 500mg TDS for 7 days

Answer

Ciprofloxacin 500mg BD for 7 days

Answer

Nitrofurantoin 50mg QDS for 3 days

Answer

Co-amoxiclav 625mg TDS for 7 days

Question 4

A 59-year-old man with type 1 diabetes for 25 years is admitted with acute pancreatitis. His usual insulin regimen is insulin glargine 32 units at bedtime and insulin lispro 8 units with meals. He is kept nil by mouth and started on intravenous fluids. His admission glucose is 16.2 mmol/L. According to best practice for managing insulin in acute illness with nil-by-mouth status, what is the most appropriate insulin management?

Accepted Answer

Continue insulin glargine at usual dose; omit insulin lispro while nil by mouth

Answer

Continue insulin glargine; give insulin lispro based on blood glucose readings every 4 hours

Answer

Stop all insulin until he is eating and drinking again

Answer

Convert to variable-rate intravenous insulin infusion at 0.05 units/kg/hour

Answer

Give half the usual total daily insulin dose as basal insulin only

Question 5

A 68-year-old woman with non-valvular atrial fibrillation (CHA₂DS₂-VASc score 4) is on apixaban 5mg twice daily. She is diagnosed with intermediate-risk myelodysplastic syndrome requiring treatment with azacitidine chemotherapy, which carries significant thrombocytopenia risk (expected platelet nadir 20-50 × 10⁹/L). What is the most appropriate anticoagulation strategy during chemotherapy?

Accepted Answer

Temporarily stop all anticoagulation during chemotherapy cycles; restart when platelets >50 × 10⁹/L

Answer

Continue apixaban 5mg twice daily throughout chemotherapy; monitor platelets weekly

Answer

Reduce apixaban to 2.5mg twice daily during chemotherapy cycles

Answer

Switch to prophylactic-dose LMWH during chemotherapy cycles

Answer

Switch to warfarin with target INR 2-3 as it can be more easily reversed

Question 6

A 55-year-old woman with type 2 diabetes is on insulin detemir 38 units at 22:00 and metformin 1g twice daily. Her blood glucose readings show: fasting 6-8 mmol/L, pre-lunch 12-15 mmol/L, pre-dinner 10-13 mmol/L, bedtime 8-10 mmol/L. HbA1c is 68 mmol/mol (8.4%). Understanding insulin pharmacodynamics, what is the most appropriate next step in optimizing her insulin regimen?

Accepted Answer

Add prandial rapid-acting insulin with main meals

Answer

Split insulin detemir to twice-daily dosing (20 units morning, 20 units evening)

Answer

Increase insulin detemir to 44 units at 22:00

Answer

Switch from insulin detemir to insulin glargine

Answer

Add a GLP-1 receptor agonist

Question 7

A 64-year-old man with atrial fibrillation is on rivaroxaban 20mg once daily. He requires emergency laparotomy for perforated diverticulitis within 2 hours. He took his last dose of rivaroxaban 8 hours ago. His renal function shows eGFR 58 ml/min/1.73m². Pre-operative blood tests show Hb 118 g/L. What is the most appropriate management of his anticoagulation?

Accepted Answer

Give 4-factor prothrombin complex concentrate 50 units/kg before surgery

Answer

Proceed to surgery; accept increased bleeding risk as surgery is life-saving

Answer

Give fresh frozen plasma 15 ml/kg before surgery

Answer

Delay surgery 12 hours to allow rivaroxaban clearance

Answer

Give tranexamic acid 1g IV before surgery

Question 8

A 46-year-old man with type 1 diabetes for 20 years presents with a 3-month history of unpredictable blood glucose control despite good insulin adherence. He reports that his hypoglycaemic episodes now occur without warning symptoms. Investigations show HbA1c 58 mmol/mol (7.5%) but frequent hypoglycaemia on continuous glucose monitoring. What is the most appropriate modification to his insulin regimen?

Accepted Answer

Relax blood glucose targets and accept higher HbA1c to restore hypoglycaemia awareness

Answer

Switch to insulin pump therapy with continuous glucose monitoring

Answer

Increase overall insulin doses to improve HbA1c

Answer

Add acarbose to slow carbohydrate absorption

Answer

Switch from rapid-acting to regular insulin analogues

Question 9

A 58-year-old woman with atrial fibrillation is on edoxaban 60mg once daily. She develops acute bacterial endocarditis affecting the mitral valve and requires valve replacement surgery in 48 hours. Current renal function shows eGFR 65 ml/min/1.73m². What is the most appropriate approach to managing her anticoagulation perioperatively?

Accepted Answer

Stop edoxaban now, give PCC for reversal, start warfarin post-operatively with LMWH bridge

Answer

Continue edoxaban until 24 hours before surgery, then restart 6 hours post-operatively

Answer

Stop edoxaban 48 hours before surgery, bridge with LMWH, restart edoxaban post-operatively

Answer

Stop edoxaban now, start intravenous heparin infusion, restart edoxaban post-operatively

Answer

Stop edoxaban now, no bridging required, restart edoxaban 24-48 hours post-operatively

Question 10

A 52-year-old woman with type 2 diabetes is established on insulin glargine 42 units at bedtime and metformin 1g twice daily. She is about to commence treatment for latent tuberculosis with rifampicin 600mg daily for 3 months. What is the most important consideration regarding her diabetes management?

Accepted Answer

Rifampicin may increase insulin requirements significantly due to enzyme induction

Answer

Rifampicin has no effect on insulin requirements

Answer

Rifampicin may decrease insulin requirements due to improved insulin sensitivity

Answer

Metformin dose should be reduced due to interaction with rifampicin

Answer

Insulin glargine should be switched to NPH insulin due to rifampicin interaction

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