Exam4-Anticoagulants - EvolveQuestions&StudyGuide

The nurse is preparing to administer a daily dose of digoxin [Lanoxin]. What is the priority nursing intervention? A. Analyze heart rate and rhythm. B. Assess for Homans' sign. C. Check blood pressure. D. Palpate the pedal pulses.

A. Analyze heart rate and rhythm.

D. Salicylate

Celecoxib [Celebrex] is an NSAID. It is a selective COX-2 inhibitor.

D. Morphine [Duramorph] 30 mg every 3 to 4 hours Correct

For persistent pain, medication should be given on a fixed schedule to prevent opioid levels from becoming subtherapeutic. Meperidine causes accumulation of a toxic metabolite when used on a long-term basis. Pentazocine produces a limited amount of analgesia, and IM injections generally should be avoided. Morphine 30 mg is an appropriate dose and should be given as indicated around the clock.

D. Greater risk of paresthesias and numbness in the lower extremities

Intraspinal administration of opioids carries the same risk of side effects and tolerance as administration by other routes. However, it also poses a risk of delayed respiratory depression and catheter-related infections. Because breakthrough pain may occur, patients receiving intraspinal opioids may need rescue medication. Paresthesias and numbness are not effects commonly associated with intraspinal opioid administration.

E. The healthcare system often places a low priority on pain management. Correct

Most cancer pain is nociceptive and responds well to opioids and other pain relievers. Cancer pain can be relieved in 90% of patients. Healthcare professionals often fear patient addiction, and the healthcare system tends to place a low priority on pain management and control.

E. Rotating different opioids Correct

Opioid-induced neurotoxicity symptoms include delirium, agitation, myoclonus, and hyperalgesia. Management consists of hydration, dose reduction, and opioid rotation. Narcan and NSAIDs are not specific management measures for opioid-induced neurotoxicity.

E. Reducing fluid secretion into the intestinal lumen Correct

Opioids promote constipation by decreasing propulsive intestinal contractions, increasing nonpropulsive contractions, increasing the tone of the anal sphincter, and reducing fluid secretion into the intestinal lumen. They do not delay gastric transit time.

D. Nausea and vomiting

Over time, tolerance to sedation, respiratory depression, nausea, and vomiting develops. However, constipation is a long-term problem with opioids.

D. 2 mL

The dose ordered is 10 mg, and the drug available is 20 mg/mL, so the nurse will administer 1/2 or 0.5 mL to equal 10 mg.

D. 3

The order is for 200 mg, and the medication available is 200 mg, so the correct number of capsules is 1.

D. Tolerance

The patient is at risk for abstinence syndrome because the order is for half of the pain medication he normally takes at home, a significant decrease in his medication. He is probably already physically dependent on the medication and has developed a tolerance to many of the side effects. With pain, patients are at a low risk for addiction.

D. Patient's nonverbal behavior Incorrect

The patient is the expert on his or her pain experience. The patient's description is the most accurate and useful information. The other data may help with the assessment, but no information is more important than the patient's description.

D. "The fentanyl patch is heat resistant, so I will get you a warm pack."

Warn patients using fentanyl patches to avoid exposing the patch to direct heat (eg, heating pad, hot tub) because doing so can accelerate fentanyl release. Patches should not be removed and reapplied; use a new patch as ordered if one is removed. Patches should not cause pain, and they are not heat resistant.

The patient's heparin is infusing at 11 mL/hr. The bag of fluid is mixed 25,000 units of heparin in 250 mL D5W. What hourly dose is the patient receiving? (Fill in the blank and record your answer.)

X = 1100 units/hr

The healthcare provider prescribes heparin 2500 units subcutaneous daily. The drug is available in 10,000 units per mL. How may milliliters will the nurse give? (Fill in the blank and record your answer using one decimal place.)

0.25 mL

The healthcare provider prescribes heparin 900 units/hr. The label on the IV bag reads Heparin 10,000 units in 500 mL D5W. How many mL/hr will deliver the correct dose? (Fill in the blank and record your answer.)

45 mL

A teaching plan for a patient who is taking lispro [Humalog] should include which instruction by the nurse? A. "Inject this insulin with your first bite of food, because it is very fast acting." B. "The duration of action for this insulin is about 8 to 10 hours, so you'll need a snack." C. "This insulin needs to be mixed with regular insulin to enhance the effects." D. "To achieve tight glycemic control, this is the only type of insulin you'll need."

A. "Inject this insulin with your first bite of food, because it is very fast acting." RATIONAL: SEE NEXT PAGE

Which instruction should the nurse provide when teaching a patient to mix regular insulin and NPH insulin in the same syringe? A. "Draw up the clear regular insulin first, followed by the cloudy NPH insulin." Correct B. "It is not necessary to rotate the NPH insulin vial when it is mixed with regular insulin." C. "The order of drawing up insulin does not matter as long as the insulin is refrigerated." D. "Rotate subcutaneous injection sites each day among the arm, thigh, and abdomen."

A. "Draw up the clear regular insulin first, followed by the cloudy NPH insulin." RATIONAL: SEE NEXT PAGE

A patient with nonvalvular atrial fibrillation is to be discharged on dabigatran etexilate [Pradaxa]. Which statement should the nurse include in the discharge teaching? A. "The medication must be stored in the manufacturer-supplied bottle." B. "Once a new bottle is opened, the capsules maintain efficacy for 90 days." C. "If you have difficulty swallowing the capsule, you can open it and mix it with food." D."You will need to learn how to give yourself a subcutaneous injection in your abdomen."

A. "The medication must be stored in the manufacturer-supplied bottle." Rational: SEE NEXT

A patient is scheduled to start taking insulin glargine [Lantus]. On the care plan, a nurse should include which of these outcomes related to the therapeutic effects of the medication? A. Blood glucose control for 24 hours B. Mealtime coverage of blood glucose C. Less frequent blood glucose monitoring D. Peak effect achieved in 2 to 4 hours

A. Blood glucose control for 24 hours RATIONAL: Insulin glargine is administered as a once-daily subcutaneous injection for patients with type 1 diabetes. It is used for basal insulin coverage, not mealtime coverage. It has a prolonged duration, up to 24 hours, with no peaks. Blood glucose monitoring is still an essential component to achieve tight glycemic control.

Before administering metformin [Glucophage], the nurse should notify the prescriber about which laboratory value? A. Creatinine (Cr) level of 2.1 mg/dL B. Hemoglobin (Hgb) level of 9.5 gm/dL C. Sodium (Na) level of 131 mEq/dL D. Platelet count of 120,000/mm3

A. Creatinine (Cr) level of 2.1 mg/dL RATIONAL: Metformin can reach toxic levels in individuals with renal impairment, which is indicated by a rise in the serum creatinine level. The prescriber may have to be notified of the hemoglobin, sodium, and platelet values, but they would not affect the administration of metformin.

Which patient symptoms should cause the nurse to be concerned about digoxin [Lanoxin] toxicity? (Select all that apply.) A. Fatigue Correct B. Vomiting Correct C. Dizziness D. Blurred vision Correct E. Muscle weakness

A. Fatigue B. Vomiting D. Blurred vision RATIONAL: Fatigue, vomiting, and blurred vision are common noncardiac symptoms that can provide advance warning of digoxin toxicity. Muscle weakness is an early sign of hypokalemia. Dizziness is not a symptom of digoxin toxicity.

The nurse is preparing to administer an oral dose of digoxin [Lanoxin]. The apical pulse rate is 64. What nursing action is most appropriate? A. Give the medication. B. Obtain a serum digoxin level. C. Notify the healthcare provider. D. Assess for signs of digoxin toxicity.

A. Give the medication. RATIONAL: Determine heart rate and rhythm prior to administration. If heart rate is less than 60 beats/min or if a change in rhythm is detected, withhold digoxin and notify the healthcare provider.

In the failing heart, arterial pressure falls, stimulating the baroreceptor reflex to increase sympathetic nervous system activity. The nurse understands increased sympathetic activity will produce which response? A. Tachycardia B. Bradypnea C. Hypotension D. Hypoglycemia

A. Tachycardia RATIONAL: Increased sympathetic activity results in an increased heart rate (tachycardia), increased contractility, increased venous tone, and increased arteriolar tone (elevated blood pressure). Sympathetic stimulation also causes bronchodilation (not bradypnea) and possibly hyperglycemia.

The laboratory calls to report a drop in the platelet count to 90,000/mm3 for a patient receiving heparin for the treatment of postoperative deep vein thrombosis. Which action by the nurse is the most appropriate? A. Notify the healthcare provider to discuss the reduction or withdrawal of heparin. B. Call the healthcare provider to discuss increasing the heparin dose to achieve a therapeutic level. C. Obtain vitamin K and prepare to administer it by intramuscular (IM) injection. D. Observe the patient and monitor the activated partial thromboplastin time (aPTT) as indicated.

A. Notify the healthcare provider to discuss the reduction or withdrawal of heparin. Rational: *Heparin-induced thrombocytopenia (HIT) is a potential immune-mediated adverse effect of heparin infusions that can prove fatal. *HIT is suspected when the platelet counts fall significantly. *A platelet count below 100,000/mm3 would warrant discontinuation of the heparin.

A patient is receiving a continuous heparin infusion for venous thromboembolism treatment. Which laboratory results should the nurse monitor? (Select all that apply.) A. Platelets B. Vitamin K C. Prothrombin time (PT) D. International normalized ratio (INR) E. Activated partial thromboplastin time (aPTT)

A. Platelets E. Activated partial thromboplastin time (aPTT) RATIONAL: To reduce the risk of heparin-induced thrombocytopenia (HIT), platelet counts should be monitored. Heparin therapy is monitored by measuring the laboratory test activated partial thromboplastin time (aPTT). Warfarin therapy is monitored by measuring prothrombin time (PT) and results are expressed as an international normalized ratio (INR). Vitamin K is not monitored for a heparin infusion.

A patient who has type 2 diabetes has a glycated hemoglobin A1c (HbA1c) of 10%. The nurse should make which change to the nursing care plan? A. Refer the patient to a diabetes educator because the result reflects poor glycemic control. Correct B. Glycemic control is adequate; no changes are needed. C. Hypoglycemia is a risk; teach the patient the symptoms. D. Instruct the patient to limit activity and weekly exercise.

A. Refer the patient to a diabetes educator because the result reflects poor glycemic control. RATIONAL: Glycated hemoglobin (HbA1c) is a measure of plasma glucose levels on average over the previous 2- to 3-month period. The target value is 6.5% or lower. If it is greater than 6.5%, a diabetes educator is an additional resource who can facilitate lifestyle, exercise, and medication changes. Hypoglycemia is not a concern, because elevated HbA1c levels indicate poor glycemic control. Exercise should be part of an overall management program, because it counteracts insulin resistance.

A patient is being discharged from the hospital on warfarin [Coumadin] for deep vein thrombosis prevention. Which instructions should the nurse include in the patient's discharge teaching plan? (Select all that apply.) A. Wear a medical alert bracelet. Correct B. Check all urine and stool for discoloration. Correct C. Do not start any new medication without first talking to your healthcare provider. Correct D. Enteric-coated aspirin and any aspirin products can be used unless they cause a gastrointestinal ulcer. E. No laboratory or home monitoring of international normalized ratio (INR) is required after the first 6 months.

A. Wear a medical alert bracelet. B. Check all urine and stool for discoloration. C. Do not start any new medication without first talking to your healthcare provider. RATIONAL: SEE NEXT PAGE

The nurse is caring for a group of patients taking warfarin [Coumadin]. Which patients are at moderate to high risk for harm as a result of warfarin therapy? (Select all that apply.) A. A patient with variant genes that code for VKORC1 and CYP2CP Correct B. A patient with a current INR of 2.2 treated for deep vein thrombosis C. A woman with a new onset of symptoms of a pulmonary embolus Correct D. A patient on day 4 after hip replacement with a new order for warfarin E. A patient with a prosthetic heart valve, for whom an interacting drug is being deleted from the regiment

ANSWERS = A., C., E.: A. A patient with variant genes that code for VKORC1 and CYP2CP and: C. A woman with a new onset of symptoms of a pulmonary embolus E. A patient with a prosthetic heart valve, for whom an interacting drug is being deleted from the regimen RATIONAL: SEE NEXT PAGE

A patient diagnosed with a pulmonary embolism is receiving a continuous heparin infusion at 1000 units/hr. Of which findings should the nurse immediately notify the healthcare provider? (Select all that apply.) A. aPTT of 65 seconds B. aPTT of 40 seconds Correct C. Nosebleeds Correct D. aPTT of 100 seconds Correct E. Platelet count of 300,000/mcL

ANSWERS: B,C,D. B. aPTT of 40 seconds C. Nosebleeds D. aPTT of 100 seconds RATIONAL: SEE NEXT PAGE

Which statement is the most important for a nurse to make to a patient who is taking methimazole? A. "You need to notify your doctor if you have a sore throat and fever." Correct B. "Another medication can be given if you experience any nausea." C. "You may experience some muscle soreness with this medicine." D. "Headache and dizziness may occur but not very frequently."

Agranulocytosis (the absence of granulocytes to fight infection) is the most serious toxicity associated with methimazole. Sore throat and fever may be the earliest signs. Nausea, muscle soreness, and headache and dizziness are other adverse effects of methimazole that are not as serious as agranulocytosis.

A nurse should consider which diagnostic test a priority to obtain before a patient receives iodine-131? A. White blood cell (WBC) count Incorrect B. Electrocardiogram (ECG) C. Beta human chorionic gonadotropin (hCG) test Correct D. Creatinine level

Any female patient of reproductive age requires a negative result on a beta hCG (pregnancy hormone) test before iodine-131 (131I) can be administered. 131I is a radioactive isotope used to treat hyperthyroidism and is contraindicated in pregnancy and lactation. A WBC count, ECG, and creatinine level are not indicated before treatment with iodine-131.

Which needle length and gauge should the nurse choose to administer subcutaneous heparin? A. ½ inch; 20 gauge B. 5/8 inch; 25 gauge C. 1½ inch; 18 gauge D. 1 inch; 26 gauge

B. 5/8 inch; 25 gauge RATIONAL: Heparin should be administered subcutaneously into the fatty layer of the abdomen with a ½- to -inch needle, 25 or 26 gauge. The only appropriate option for injection in the list shown is the -inch, 25-gauge needle.

The nurse is ready to begin a heparin infusion for a patient with evolving stroke. The baseline activated partial thromboplastin time (aPTT) is 40 seconds. Which aPTT value indicates that a therapeutic dose has been achieved? A. 50 B. 70 C. 90 D. 110

B. 70 Rational: *The therapeutic level of heparin is achieved when the aPTT reaches 1.5 to 2 times normal. *Thus, a range of 60 to 80 seconds would be appropriate for this patient.

About which patient should the nurse notify the healthcare provider immediately? A. A patient who takes digoxin [Lanoxin] 0.125 mg orally daily with a serum digoxin level of 0.8 ng/mL B. A patient who takes oral spironolactone [Aldactone] 25 mg daily and enalapril [Vasotec] 5 mg daily with a serum potassium level of 5.5 mEq/L C. A patient who takes digoxin [Lanoxin] 0.25 mg orally daily with a serum potassium level of 4.0 mEq/L D. A patient who takes oral lisinopril [Zestril] 5 mg daily and digoxin 0.125 mg daily with a serum digoxin level of 0.5 ng/mL

B. A patient who takes oral spironolactone [Aldactone] 25 mg daily and enalapril [Vasotec] 5 mg daily with a serum potassium level of 5.5 mEq/L

A nurse caring for a patient who has diabetic ketoacidosis recognizes which characteristics in the patient? (Select all that apply.) A. Type 2 diabetes B. Altered fat metabolism leading to ketones C. Arterial blood pH of 7.35 to 7.45 D. Sudden onset, triggered by acute illness E. Plasma osmolality of 300 to 320 mOsm/L

B. Altered fat metabolism leading to ketones D. Sudden onset, triggered by acute illness E. Plasma osmolality of 300 to 320 mOsm/L RATIONAL: SEE NEXT PAGE

What is the primary benefit of spironolactone [Aldactone] in patients with heart failure? A. Increase in diuresis and fluid loss B. Blockage of aldosterone receptors C. Inhibition of beta activation by norepinephrine D. Stimulation of the renin-angiotensin-aldosterone system

B. Blockage of aldosterone receptors RATIONAL: Spironolactone is a potassium-sparing diuretic that has been shown to prolong survival in patients with heart failure. It has only weak diuretic properties. The primary benefit of this drug is blockage of aldosterone receptors. It does not inhibit beta receptors, nor does it stimulate the renin-angiotensin-aldosterone system.

A patient with a deep vein thrombosis receiving an intravenous (IV) heparin infusion asks the nurse how this medication works. What is the nurse's best response? A. Heparin prevents the activation of vitamin K and thus blocks synthesis of some clotting factors. B. Heparin suppresses coagulation by helping antithrombin perform its natural functions. C. Heparin works by converting plasminogen to plasmin, which in turn dissolves the clot matrix. D. Heparin inhibits the enzyme responsible for platelet activation and aggregation within vessels.

B. Heparin suppresses coagulation by helping antithrombin perform its natural functions. Rational: Heparin is an anticoagulant that works by helping antithrombin inactivate thrombin and factor Xa, reducing the production of fibrin and thus decreasing the formation of clots.

A patient admitted with deep vein thrombosis (DVT) and subsequent pulmonary embolism (PE) requires immediate anticoagulation. What medication would be appropriate for this patient who has a history of heparin-induced thrombocytopenia (HIT)? A. Warfarin [Coumadin] B. Lepirudin [Refludan] C. Bivalirudin [Angiomax] D. Eptifibatide [Integrilin]

B. Lepirudin [Refludan] RATIONAL: SEE NEXT

The nurse is caring for a patient receiving clopidogrel [Plavix] to prevent blockage of coronary artery stents. Which other drug on the patient's medication administration record may reduce the antiplatelet effects of clopidogrel? A. Aspirin [Bayer] B. Omeprazole [Prilosec] C. Acetaminophen [Tylenol] D. Warfarin [Coumadin]

B. Omeprazole [Prilosec] Rational: Omeprazole and other proton pump inhibitors may reduce the antiplatelet effects of clopidogrel. Patients sometimes take them to reduce gastric acidity and the risk of gastrointestinal (GI) bleeding.

A patient who has type 2 diabetes is taking nateglinide [Starlix]. Which response should a nurse expect the patient to have if the medication is achieving the desired therapeutic effect? A. Inhibition of carbohydrate digestion B. Promotion of insulin secretion C. Decreased insulin resistance D. Inhibition of ketone formation

B. Promotion of insulin secretion RATIONAL: Nateglinide is a meglitinide medication that acts to increase pancreatic insulin release. It is used as an adjunct to calorie restriction and exercise to maintain glycemic control in patients with type 2 diabetes. It does not act to reduce insulin resistance or inhibit carbohydrate digestion. It should not be used to manage diabetic ketone formation, because its glucose-lowering effects are too slow to be of benefit.

A nurse assesses a patient who is taking pramlintide [Symlin] with mealtime insulin. Which finding requires immediate follow-up by the nurse? A. Skin rash B. Sweating C. Itching D. Pedal edema

B. Sweating RATIONAL: Pramlintide is a new type of antidiabetic medication used as a supplement to mealtime insulin in patients with type 1 and 2 diabetes. Hypoglycemia, which is manifested by sweating, tremors, and tachycardia, is the adverse reaction of most concern. Skin rash, itching, and edema are not adverse effects of pramlintide.

The heart undergoes cardiac remodeling during the initial phase of heart failure. Which cardiac geometric change occurs during heart failure? A. Ventricular constriction Incorrect B. Ventricular wall thickening Correct C. Ventricular atrophy D. Ventricles become more cylindric

B. Ventricular wall thickening RATIONAL: An increase in ventricular wall thickness, also called ventricular hypertrophy, is characteristic of the remodeling process during the initial phase of heart failure. The ventricles also dilate and become more spherical (less cylindric). This change in cardiac shape typically occurs after cardiac injury under the influence of the neurohormonal systems, such as the sympathetic nervous system and renin-angiotensin-aldosterone system.

RATIONAL

Before giving digoxin, the nurse will assess the heart rate and rhythm. The dosage will be held and the prescriber notified if the heart rate is below 60 beats per minute or if the cardiac rhythm has changed. Digoxin can cause bradycardia and electrical changes in the heart.

RATIONAL:

Both spironolactone, a potassium-sparing diuretic, and quinapril, an angiotensin-converting enzyme (ACE) inhibitor, can increase potassium levels. These agents together do not increase quinapril levels, lower the heart rate, or raise the blood glucose level.

Which instruction about clopidogrel [Plavix] should the nurse include in the discharge teaching for a patient who has received a drug-eluting coronary stent? A. "Constipation is a common side effect of clopidogrel, so take a stool softener daily." Incorrect B. "If you see blood in your urine or black stools, stop the clopidogrel immediately." C. "Check with your healthcare provider before taking any over-the-counter medications for gastric acidity." D. "Keep the amounts of foods containing vitamin K, such as mayonnaise, canola and soybean oil, and green, leafy vegetables, consistent in your diet."

C. "Check with your healthcare provider before taking any over-the-counter medications for gastric acidity." RATIONAL: SEE NEXT PAGE

A patient with an acute myocardial infarction is prescribed an intravenous (IV) bolus of tenecteplase [TNKase]. The patient weighs 160 pounds. The nurse will administer what dosage? A. 30 mg B. 35 mg C. 40 mg D. 45 mg

C. 40 mg RATIONAL: 160 lbs is 72.72 kg. Body weight of 70 to 79.9 kg is prescribed 40 mg of tenecteplase as a single IV bolus.

A patient who took NPH insulin at 0800 reports feeling weak and tremulous at 1700. Which action should the nurse take? A. Take the patient's blood pressure. B. Give the patient's PRN dose of insulin. C. Check the patient's capillary blood sugar. D. Advise the patient to lie down with the legs elevated.

C. Check the patient's capillary blood sugar. RATIONAL:

A patient presents to the emergency department with symptoms of acute myocardial infarction. After a diagnostic workup, the healthcare provider prescribes a 15-mg IV bolus of alteplase (tPA), followed by 50 mg infused over 30 minutes. In monitoring this patient, which finding by the nurse most likely indicates an adverse reaction to this drug? A. Urticaria, itching, and flushing B. Blood pressure of 90/50 mm Hg C. Decreasing level of consciousness D. Potassium level of 5.5 mEq/L

C. Decreasing level of consciousness Rational: The greatest risk with this drug is bleeding, with intracranial bleeding being the greatest concern. A decreasing level of consciousness indicates intracranial bleeding. Alteplase does not cause an allergic reaction or hypotension. Thrombolytic agents, such as alteplase, do not typically cause an elevated potassium level.

The nurse is monitoring a patient receiving a heparin infusion for the treatment of pulmonary embolism. Which assessment finding most likely relates to an adverse effect of heparin? A. Heart rate of 60 beats per minute B. Blood pressure of 160/88 mm Hg C. Discolored urine D. Inspiratory wheezing

C. Discolored urine Rational: -The primary and most serious adverse effect of heparin is bleeding. -Bleeding can occur from any site and may be manifested in various ways, including reduced blood pressure, increased heart rate, bruises, petechiae, hematomas, red or black stools, cloudy or discolored urine, pelvic pain, headache, and lumbar pain.

The nurse knows that which statement is accurate for enoxaparin [Lovenox]? A. It equally reduces the activity of thrombin and factor Xa. B. It has selective inhibition of factor Xa and no effect on thrombin. C. It reduces the activity of factor Xa more than the activity of thrombin. D. It has a lower bioavailability and shorter half-life than unfractionated heparin.

C. It reduces the activity of factor Xa more than the activity of thrombin. Rational: Enoxaparin acts primarily on factor Xa and also, but to a lesser degree, on thrombin. Unfractionated heparin equally reduces the action of thrombin and factor Xa. Fondaparinux [Arixtra] causes selective inhibition of factor Xa. Low-molecular-weight (LMW) heparins, such as enoxaparin, have greater bioavailability and a longer half-life than unfractionated heparin.

The nurse is caring for a patient who takes spironolactone [Aldactone] and quinapril [Accupril] for treatment of heart failure. What finding indicates a potential interaction between these two drugs? A. Elevated serum quinapril level B. Heart rate of 58 beats per minute C. Potassium level of 5.7 mEq/L D. Glucose level of 180 mg/dL

C. Potassium level of 5.7 mEq/L

A patient is taking glipizide [Glucotrol] and a beta-adrenergic medication. A nurse is teaching hypoglycemia awareness and should warn the patient about the presence of which symptom? A. Vomiting B. Muscle cramps C. Tachycardia D. Chills

C. Tachycardia RATIONAL: Glipizide is a sulfonylurea oral hypoglycemic medication that acts to promote insulin release from the pancreas. Beta-adrenergic blockers can mask early signs of sympathetic system responses to hypoglycemia; the most important of these is tachycardia, which is the most common adverse effect of glipizide. Vomiting, muscle cramps, and chills are not symptoms of activation of the sympathetic nervous system that arise when glucose levels fall.

The nurse is caring for a patient prescribed digoxin [Lanoxin] for heart failure. Which finding would require immediate attention by the nurse? A. Potassium level of 3.7 mEq/L B. Digoxin level of 0.7 ng/mL C. Vomiting and diarrhea D. Heart rate of 68 beats per minute

C. Vomiting and diarrhea

A patient admitted to the hospital with a diagnosis of pneumonia asks the nurse, "Why am I receiving codeine? I don't have any pain." The nurse's response is based on the knowledge that codeine also has which effect? A. Immunostimulant Incorrect B. Antitussive Correct C. Expectorant D. Decongestant

Codeine provides analgesic and antitussive therapeutic effects.

A patient with heart failure has developed a cough while taking an angiotensin-converting enzyme (ACE) inhibitor. The health care provider discontinued the ACE inhibitor and prescribed an angiotensin II receptor blocker (ARB) as an alternative to the ACE inhibitor. The patient continues to have symptoms of heart failure despite using an ARB. Which medication should the nurse anticipate will be prescribed? A. Eplerenone [Inspra] B. Triamterene [Dyrenium] C. Hydrochlorothiazide [Microzide] D. BiDil [Isosorbide Dinitrate and Hydralazine]

D. BiDil [Isosorbide Dinitrate and Hydralazine] RATIONAL: BiDil is a fixed-dose combination of isosorbide dinitrate plus hydralazine and it can be used for patients who cannot tolerate ACE inhibitors or ARBs. BiDil is approved specifically for treating heart failure in blacks.

The nurse is caring for a patient who takes warfarin [Coumadin] for prevention of deep vein thrombosis. The patient has an international normalized ratio (INR) of 1.2. Which action by the nurse is most appropriate? A. Administer intravenous (IV) push protamine sulfate. B. Continue with the current prescription. C. Prepare to administer vitamin K. D. Call the healthcare provider to increase the dose.

D. Call the healthcare provider to increase the dose. Rational: An INR in the range of 2 to 3 is considered the level for warfarin therapy. For a level of 1.2, the nurse should contact the healthcare provider to discuss an order for an increased dose.

A patient newly diagnosed with type 1 diabetes asks a nurse, "How does insulin normally work in my body?" The nurse explains that normal insulin has which action in the body? A. It stimulates the pancreas to reabsorb glucose. B. It promotes the synthesis of amino acids into glucose. C. It stimulates the liver to convert glycogen to glucose. D. It promotes the passage of glucose into cells for energy.

D. It promotes the passage of glucose into cells for energy. RATIONAL: The hormone insulin promotes the passage of glucose into cells, where it is metabolized for energy. Insulin does not stimulate the pancreas to reabsorb glucose or synthesize amino acids into glucose. It does not stimulate the liver to convert glycogen into glucose.

Fondaparinux [Arixtra] is not approved for use in which circumstance? A. Prevention of deep vein thrombosis (DVT) after knee replacement B. Treatment of acute pulmonary embolism (PE) (in conjunction with warfarin) C. Prevention of deep vein thrombosis (DVT) after abdominal surgery D. Prevention of ischemic complications in patients with unstable angina

D. Prevention of ischemic complications in patients with unstable angina Correct Rational: Enoxaparin [Lovenox], not Arixtra, is approved for use in preventing ischemic complications in patients with unstable angina, non-Q-wave myocardial infarction (MI), and ST-segment elevation myocardial infarction (STEMI). Arixtra is approved for (1) preventing DVT after hip surgery, knee replacement, and abdominal surgery and (2) treating acute PE and acute DVT in conjunction with warfarin.

RATIONAL:

Diabetic ketoacidosis is the most severe manifestation of insulin deficiency in patients with type 1 diabetes. It develops and worsens acutely over several hours to days. Alterations in fat metabolism lead to the production of ketones and ketoacids. Increased ketoacid levels lead to a fall in arterial blood pH below 7.35. Altered glucose metabolism leads to hyperglycemia, water loss, and an elevated plasma osmolality (285 to 295 mOsm/L).

The nurse is teaching a patient with cancer about a new prescription for a fentanyl [Sublimaze] patch, 25 mcg/hr, for chronic back pain. Which statement is the most appropriate to include in the teaching plan? A. "You will need to change this patch every day, regardless of your pain level." Incorrect B. "This type of pain medication is not as likely to cause breathing problems." C. "With the first patch, it will take about 24 hours before you feel the full effects." Correct D. "Use your heating pad for the back pain. It will also improve the patch's effectiveness."

Full analgesic effects can take up to 24 hours to develop with fentanyl patches. Most patches are changed every 72 hours. Fentanyl has the same adverse effects as other opioids, including respiratory depression. Patients should avoid exposing the patch to external heat sources, because this may increase the risk of toxicity.

Which manifestations should a nurse investigate first when monitoring a patient who is taking levothyroxine [Synthroid]? A. Tachycardia Correct B. Tremors C. Insomnia D. Irritability

High doses of levothyroxine may cause thyrotoxicosis, a condition of profound excessive thyroid activity. Tachycardia is the priority assessment, because it can lead to severe cardiac dysfunction. Tremors, insomnia, and irritability are other symptoms of thyrotoxicosis and should be assessed after tachycardia.

The patient reports that she had to switch pharmacies to save money. She noticed that her "thyroid pill" looks different. The nurse anticipates that the healthcare provider will order what? A. Thyroid stimulating hormone (TSH) Correct B. Electrocardiogram (ECG) C. Beta human chorionic gonadotropin (hCG) test D. Creatinine level

If a switch is made (from one branded product to another, from a branded product to a generic product, or from one generic product to another), retest serum TSH in 6 weeks, and adjust the levothyroxine dosage as indicated.

A patient with Graves' disease is treated with iodine-131 therapy. Which statement by the patient would indicate understanding of the treatment's effects? A. "I'll have to isolate myself from my family so I don't expose them to radiation." Incorrect B. "I'm looking forward to feeling better immediately after this treatment." C. "I'll tell my doctor if I have fatigue, hair loss, or cold intolerance." Correct D. "I'll need to take this drug on a daily basis for at least 1 year."

Iodine-131 usually is given as a single treatment to produce remission of Graves' disease. Fatigue, hair loss, and cold intolerance are signs of hypothyroidism, which is a complication of the treatment. Iodine-131 has a quick radioactive decay and half-life; therefore, isolation is not needed, but it can take up to 2 months for the desired response to develop.

Which finding in a patient taking levothyroxine [Synthroid] and warfarin [Coumadin] would require follow-up by a nurse? A. Cardiac dysrhythmias Incorrect B. Excessive bruising Correct C. Weight loss of 5 kg D. Shortness of breath

Levothyroxine intensifies the effect of warfarin, an anticoagulant that increases the patient's risk for bleeding. The warfarin dose may need to be reduced. Bruising, weight loss, and shortness of breath are not effects associated with interactions of levothyroxine and warfarin.

Which statements about levothyroxine [Synthroid] are correct? (Select all that apply.) A. Levothyroxine should be taken with food. Incorrect B. Levothyroxine can be given by IV but is usually taken orally. Correct C. Levothyroxine brands should not be changed if possible. Correct D. Levothyroxine should be taken at night to avoid adverse effects. E. Levothyroxine can affect the metabolism of other medications. Correct

Levothyroxine is almost always administered by mouth. Oral doses should be taken once daily on an empty stomach (to enhance absorption). Dosing is usually done in the morning, at least 30 to 60 minutes before breakfast. Maintain patients on the same brand-name levothyroxine product. Intravenous administration is used for myxedema coma and for patients who cannot take levothyroxine orally. Levothyroxine affects the metabolism of other medications, including warfarin.

RATIONAL:

Lispro is a rapid-acting insulin and has an onset of action of 15 to 30 minutes with a peak action of about 2 hours, not 8 to 10 hours. Because of its rapid onset, it is administered immediately before a meal or with meals to control the blood glucose rise after meals. Lispro insulin must be combined with an intermediate- or a long-acting insulin, not regular insulin (which also is a short-duration insulin), for glucose control between meals and at night. To achieve tight glycemic control, patients must combine different types of insulin based on their duration of action.

The nurse is planning care for a patient receiving morphine sulfate [Duramorph] by means of a patient-controlled analgesia (PCA) pump. Which intervention may be required because of a potential adverse effect of this drug? A. Administering a cough suppressant Incorrect B. Inserting a Foley catheter Correct C. Administering an antidiarrheal D. Monitoring liver function tests

Morphine can cause urinary hesitancy and urinary retention. If bladder distention or inability to void is noted, the prescriber should be notified. Urinary catheterization may be required. Morphine acts as a cough suppressant and an antidiarrheal, so neither of those types of drugs would be needed to counteract an adverse effect of morphine. Liver toxicity is not a common adverse effect of morphine.

Which agent is most likely to cause serious respiratory depression as a potential adverse reaction? A. Morphine [Duramorph] Correct B. Pentazocine [Talwin] C. Hydrocodone [Lortab] D. Nalmefene [Revex]

Morphine is a strong opioid agonist and as such has the highest likelihood of causing respiratory depression. Pentazocine, a partial agonist, and hydrocodone, a moderate to strong agonist, may cause respiratory depression, but they do not do so as often or as seriously as morphine. Nalmefene, an opioid antagonist, would be used to reverse respiratory depression with opioids.

A postoperative patient has an epidural infusion of morphine sulfate [Astramorph]. The patient's respiratory rate declines to 8 breaths per minute. Which medication would the nurse anticipate administering? A. Naloxone [Narcan] Correct B. Acetylcysteine [Mucomyst] C. Methylprednisolone [Solu-Medrol] D. Protamine sulfate

Naloxone is a narcotic antagonist that can reverse the effects, both adverse and therapeutic, of opioid narcotic analgesics.

D. Nausea and vomiting

Naloxone reverses the effects of narcotics. Although the patient's respiratory status will improve after administration of naloxone, the pain will be more acute.

A patient takes oxycodone [OxyContin] 40 mg PO twice daily for the management of chronic pain. Which intervention should be added to the plan of care to minimize the gastrointestinal adverse effects? A. The patient should take an antacid with each dose. Incorrect B. The patient should eat foods high in lactobacilli. C. The patient should take the medication on an empty stomach. D. The patient should increase fluid and fiber in the diet. Correct

Narcotic analgesics reduce intestinal motility, leading to constipation. Increasing fluid and fiber in the diet can help manage this adverse effect. If increased fluid and fiber is not sufficiently effective, use of a laxative may be considered.

RATIONAL Dabigatran is unstable, especially when exposed to moisture, and should be stored in the manufacturer-supplied bottle, which has a desiccant cap. Current labeling of the pill bottle indicates that once the bottle is opened, the pills should be used within 30 days. However, recent evidence indicates that they maintain efficacy for 60 days, provided they have been stored in the original container. AND...

RATIONAL CONT... Capsules should be swallowed intact, because chewing, crushing, or opening enhances absorption by 75% and increases the risk of bleeding. The medication is administered orally, not subcutaneously.

RATIONAL: Proton pump inhibitors (PPIs), such as omeprazole [Prilosec], and CYP2C1 inhibitors, such as cimetidine [Tagamet], can be purchased over the counter to treat heartburn. However, patients taking clopidogrel should consult their healthcare provider before using them. PPIs and CYP2C1 inhibitors can reduce the antiplatelet effects of clopidogrel.

RATIONAL CONT... Diarrhea (5% incidence), not constipation, is a side effect of clopidogrel. Patients should immediately contact their healthcare provider if signs of bleeding occur, such as bloody urine, stool, or emesis. The drug should not be stopped until the prescriber advises it, because this could lead to coronary stent restenosis. Consistency of vitamin K intake is indicated while taking warfarin [Coumadin].

RATIONAL: Measurement of the aPTT is essential to determine whether the heparin infusion is having the desired effect. If the normal value of the aPTT is 40 seconds, the goal is to achieve a therapeutic range of a factor of 1.5 to 2 (60 to 80 seconds). Because 40 seconds is too short (increases the risk for clotting) and 100 seconds is too long (increases the risk for bleeding), the physician requires notification for adjustment of the infusion rate.

RATIONAL CONT... Evidence of bleeding, such as nosebleeds, hematuria, and red or tarry stools, warrant a call to the physician. An aPTT of 65 seconds indicates that a therapeutic effect has been achieved, and a platelet count of 300,000/mcL is within normal limits, indicating no evidence of thrombocytopenia.

RATIONAL Lepirudin [Refludan] and argatroban are indicated for the treatment of thrombosis in patients with a history of HIT. Because these medications are given as an initial IV bolus followed by a continuous infusion, the desired effect of direct thrombin inhibition is achieved more quickly. Because of warfarin's delayed onset of effects, it is not useful in emergency situations, such as pulmonary embolism (PE).

RATIONAL CONT... Intravenous bivalirudin given in combination with aspirin helps prevent clot formation in patients undergoing coronary angioplasty. Eptifibatide [Integrilin], a glycoprotein IIb/IIIa receptor inhibitor, is an antiplatelet drug that is used short term to prevent ischemic events in patients who have acute coronary syndrome or who are undergoing percutaneous coronary intervention.

RATIONAL: Patients with genetic alterations in VKORC1 and CYP2CP are at increased risk of warfarin-induced bleeding. An INR of 2.2 indicates a therapeutic warfarin level. Warfarin can cause fetal hemorrhage and is listed as Pregnancy Risk Category X.

RATIONAL CONT... Warfarin could be prescribed for the prevention of deep vein thrombosis after hip replacement surgery. The day of prescription would not likely be a day to expect a dangerous adverse effect from warfarin, because its half-life is 1.5 to 2 days. Warfarin interacts with many other agents. The greatest risk for harm is when an interacting drug is being added to or deleted from the regimen.

RATIONAL: To ensure a consistent response, only NPH insulin is appropriate for mixing with a short-acting insulin. Unopened vials of insulin should be refrigerated; current vials can be kept at room temperature for up to 1 month. Drawing up the regular insulin into the syringe first prevents accidental mixture of NPH insulin into the vial of regular insulin, which could alter the pharmacokinetics of subsequent doses taken out of the regular insulin vial.

RATIONAL CONT.... NPH insulin is a cloudy solution, and it should always be rotated gently to disperse the particles evenly before loading the syringe. Subcutaneous injections should be made using one region of the body (eg, the abdomen or thigh) and rotated within that region for 1 month.

RATIONAL: Advise the patient to wear some form of identification (eg, Medic Alert bracelet) to alert emergency personnel to warfarin use. Bleeding is a major complication of warfarin therapy. Inform patients about the signs of bleeding, which include discolored urine or stools. Inform patients that warfarin is subject to a large number of potentially dangerous drug interactions. Instruct them to avoid all prescription and nonprescription drugs that have not been specifically approved by the prescriber.

RATIONAL CONT: Aspirin and aspirin products should be avoided because aspirin can increase the effects of warfarin to promote bleeding and on the gastrointestinal tract to cause ulcers, thereby initiating bleeding. The INR should be determined frequently: daily during the first 5 days, twice a week for the next 1 to 2 weeks, once a week for the next 1 to 2 months, and every 2 to 4 weeks thereafter.

A nurse is caring for a patient with decreased triiodothyronine (T3) and thyroxine (T4) and elevated thyroid-stimulating hormone (TSH) levels. The nurse knows the patient is likely suffering from what? A. Thyrotoxicosis Incorrect B. Hypothyroidism Correct C. Hyperthyroidism D. Graves' disease

The anterior pituitary increases production of TSH when thyroid hormone levels of T3 and T4, are reduced, reflecting primary hypothyroidism. Patients may experience fatigue caused by a lowered basal metabolic rate. Thyrotoxicosis, hyperthyroidism, and Graves' disease are medical conditions indicative of excessive thyroid activity.

D. The use of PRN (as needed) dosing provides the most consistent pain relief without risk of addiction.

The development of dependence on or addiction to opioids as a result of clinical exposure is extremely rare. In fact, some estimate that only 25% of patients receive doses of opioids that are sufficient to relieve suffering. Only about 8% of the population is estimated to be prone to drug abuse. Morphine is a drug of abuse, but this fact is not helpful in guiding clinical practice. A patient-controlled analgesia (PCA) pump provides the most consistent pain relief, better than PRN and fixed-dosing schedules.

The healthcare provider orders 150 mcg of levothyroxine [Synthroid] PO every morning. The medication available is levothyroxine [Synthroid] 75 mcg tablets. How many tablets will the nurse administer? A. 0.5 Incorrect B. 1 C. 2 Correct D. 4

The ordered dose is 150 mcg. The available tablets are 75 mcg. 75 multiplied by 2 equals 150. Therefore, 2 tablets is the correct dose.

RATIONAL:

The patient is showing symptoms of hypoglycemia at 5 PM. NPH has a peak action of 8 to 10 hours after administration. Based on the duration of action of NPH insulin, the patient's hypoglycemic symptoms are from the 8 AM injection of NPH insulin. An injection of NPH insulin at 2 AM, 1 PM, or 3 PM would not cause hypoglycemic symptoms based on the average duration of action of NPH insulin.

RATIONAL: Patients who take an aldosterone antagonist (spironolactone) are at risk for developing hyperkalemia. The risk is increased if an aldosterone antagonist and an ACE inhibitor (enalapril) are used together. The normal serum potassium level ranges from 3.5 to 5.0 mEq/mL.

This patient is hyperkalemic, which increases the risk for electrocardiographic changes. The optimal range for the serum digoxin level is 0.5 to 0.8 ng/mL. The risk of digoxin toxicity increases when hypokalemia is present (potassium level below 3.5 mEq/L).

RATIONAL:

Vomiting and diarrhea can lead to hypokalemia, which increases the risk of digoxin toxicity. These symptoms, along with nausea, fatigue, and visual disturbances, also may precede digoxin toxicity and warrant further attention. The heart rate, potassium level, and digoxin level are within the normal range.

The patient's heparin is infusing at 28 mL/hr. The bag of fluid is mixed 20,000 units of heparin in 500 mL D5W. What hourly dose is the patient receiving? (Fill in the blank and record your answer.)

X = 1120 units/hr