Pharm Final part 3

25. When a nondepolarizing neuromuscular junction blocker is used as an adjunct to surgery, what classification of medications could reverse the neuromuscular blockage leading to early arousal and return of muscle function? A) Xanthines B) Barbiturates C) Opiates D) Antihypertensives

Ans: A Feedback: Administering xanthines (e.g., theophylline, aminophylline) could result in reversal of the neuromuscular blockage. Patients receiving this combination of drugs should be monitored very closely during the procedure for the potential of early arousal and return of muscle function. Barbiturates, opiates, and antihypertensives do not reverse neuromuscular blockage.

4. The nurse is providing drug teaching about quinidine in preparation for the patient's discharge. The nurse discusses drug-food interactions and advises the patient to drink what? A) Apple juice B) Grapefruit juice C) Milk D) Orange juice

Ans: A Feedback: Apple juice would be the best choice. Quinidine requires a slightly acidic urine (normal state) for excretion. Patients receiving quinidine should avoid foods that alkalinize the urine (e.g., citrus juices, vegetables, antacids, milk products), which could lead to increased quinidine levels and toxicity. Grapefruit juice has been shown to interfere with the metabolism of quinidine, leading to increased serum levels and toxic effects; this combination should be avoided.

2. When causing depolarization of the muscle membranes, what neurotransmitter interacts with the nicotinic cholinergic receptors leading to the release of calcium ions? A) Acetylcholine B) Serotonin C) D-gluconamidoethyl methacrylate (GAMA) D) Epinephrine

Ans: A Feedback: At the acetylcholine receptor site on the effector's side of the synapse, the acetylcholine interacts with the nicotinic cholinergic receptors causing the depolarization. Serotonin, GAMA, and epinephrine are not part of muscle contraction and relaxation.

23. The nurse reviews the patient's medical history and determines class II antiarrhythmics are contraindicated due to the patient's history of what condition? A) Asthma B) Colitis C) Migraine headache D) Antidiarrheals

Ans: A Feedback: Class II antiarrhythmics are contraindicated in patients with asthma because they could worsen the condition due to blockage of beta-receptors. They are not contraindicated in patients with colitis, migraine headache, or diarrhea.

5. A patient scheduled for surgery is to have a nondepolarizing neuromuscular junction (NMJ) blocker as adjunctive anesthesia. The nurse will have cause for concern about prolonged paralysis if the patient has been taking what medication? A) An aminoglycoside B) Aminophylline C) A barbiturate anesthetic D) A cephalosporin

Ans: A Feedback: Combining nondepolarizing NMJ blockers with aminoglycosides can result in prolonged paralysis, and this combination should be avoided. This interaction does not occur with barbiturate anesthetics, cephalosporins, or aminophylline.

6. What drug would the nurse administer to the patient to control angina caused by atherosclerosis that would also slow the development of further plaque buildup on the arterial wall? A) Diltiazem (Cardizem) B) Propranolol (Inderal) C) Amyl Nitrates (generic) D) Isosorbide dinitrate (Isordil)

Ans: A Feedback: Diltiazem is a calcium channel blocker that is indicated to treat Prinzmetal's angina, chronic angina, effort-associated angina, and hypertension. Research has indicated these agents slow the development of atherosclerosis. Beta-blockers are indicated for long-term management of angina caused by atherosclerosis, but they do not slow the development of plaque deposits on the artery wall. Propranolol is a beta-blocker. Isosorbide dinitrate and amyl nitrate are nitrates and are indicated for relief acute anginal pain, but they are not used to prevent angina and have no effect on the progression of atherosclerosis.

31. What drug will the nurse administer to reverse the actions of neuromuscular junction (NMJ) blocker? A) Cholinesterase inhibitor B) Xanthine C) Halothane D) Aminoglycoside

Ans: A Feedback: Ensure that a cholinesterase inhibitor is readily available to overcome excessive neuromuscular blockade caused by nondepolarizing NMJ blockers. Although xanthines reverse NMJ blocking effects, they would not be administered for that purpose because their effects are not predictable. Halothane and aminoglycosides enhance paralytic effects of NMJ blockers.

32. How can the nurse assess the degree of neuromuscular blockage the patient is experiencing? A) Peripheral nerve stimulator B) Measure vital signs C) Assess response to painful stimuli D) Test reflexes

Ans: A Feedback: Have a peripheral nerve stimulator on standby to assess the degree of neuromuscular blockade, if appropriate. Vital signs can indicate degree of sedation and assess pain sensation, but they are not an indicator of the degree of neuromuscular blockade. Response to painful stimuli would be more of an indication of effects of sedation and/or analgesic than degree of muscular blockade. Any neuromuscular junction blockage would reduce or eliminate reflexes so it would not be a means of assessing degree of blockage.

30. The nurse is admitting a patient to the postanesthesia care unit (PACU) who received halothane and ketamine as anesthesia. What is the nurse's priority assessment? A) Blood pressure and pulse B) Respirations and airway C) Pain and respirations D) Temperature and airway

Ans: A Feedback: If halothane and ketamine are used in combination, severe cardiac depression with hypotension and bradycardia may occur. If these agents must be used together, the patient should be monitored closely. Pain, respirations, airway, and temperature are all assessments the nurse will collect on any patient in the PACU, but they are not priority assessments associated with combining ketamine and halothane.

29. The nurse performs an electrocardiogram and finds the older adult patient is in atrial fibrillation (AF). Time of onset is unknown but could be as long as 3 months earlier when the patient was last assessed. What drug will the nurse expect to be ordered? A) Anticoagulant B) Digoxin C) Quinidine D) Ibutilide

Ans: A Feedback: If the onset of AF is not known and it is suspected that the atria may have been fibrillating for longer than 1 week, the patient is better off staying in AF without drug therapy or electrocardioversion. Prophylactic oral anticoagulants are given to decrease the risk of clot formation and emboli being pumped into the system. In 2011, the American Heart Association and American College of Cardiology endorsed dabigatran (Pradaxa) as the anticoagulant of choice for prophylaxis in AF. Conversion in this case could result in potentially life-threatening embolization of the lungs, brain, or other tissues. Administration of other antiarrhythmics would not be indicated.

10. The nurse should recognize what drug is classified as an amide local anesthetic? A) Lidocaine (Xylocaine) B) Benzocaine (Dermoplast) C) Chloroprocaine (Nesacaine) D) Tetracaine (Pontocaine)

Ans: A Feedback: Lidocaine is an example of an amide anesthetic. Benzocaine, chloroprocaine, and tetracaine are ester anesthetics.

29. The patient has been mechanically ventilated for the past week and is receiving a neuromuscular junction (NMJ) blocker, an analgesic, and a sedative. The goal is to extubate the patient. What medication will the nurse stop administering first? A) NMJ blocker B) Sedative C) Analgesic D) All three medications will be stopped at the same time.

Ans: A Feedback: NMJ blockers have no effect on pain perception or consciousness and should not be used without sedation so the NMJ blocker should be removed first. Because the patient has been receiving analgesics for a week, he or she will have to be weaned off them to overcome dependence. Sedatives can be removed more quickly after the NMJ blocker's effects are gone.

25. The nurse assesses the patient's rhythm strip and notes several premature ventricular contractions, which the nurse recognizes is caused by what? A) Stimulation of the ventricles from an ectopic focus in the ventricles B) Stimulation of the ventricles from the atrioventricular node C) Stimulation of the ventricles from the Purkinje fibers D) Stimulation of the ventricles from the bundle of His

Ans: A Feedback: Premature ventricular contractions are stimulations of the cells caused by an ectopic focus in the ventricles causing an early contraction. The source of these ectopic foci could be anywhere within the ventricles, but the end result is reduced cardiac output due to reduced force of contraction.

15. The nurse is caring for a patient who is scheduled for abdominal surgery in the morning and is scheduled to receive rocuronium (Zemuron). The patient asks the nurse to describe the adverse effects of rocuronium. What would the nurse describe for the patient? A) "This drug is associated with pulmonary hypertension." B) "This drug contains benzyl alcohol." C) "This drug is associated with bradycardia." D) "This drug is associated with an increased heart rate."

Ans: A Feedback: Rocuronium may be associated with pulmonary hypertension. Cisatracurium (Nimbex) contains benzyl alcohol; Atracurium (Tracrium) is associated with bradycardia; and Pancuronium (Pavulon) is associated with an increased heart rate.

33. Why will the nurse administer a small dose of nondepolarizing neuromuscular junction (NMJ) blocker before administering succinylcholine? A) To reduce discomfort of depolarization of muscles B) To reduce the risk of malignant hyperthermia C) To reduce negative effects of dantrolene D) To increase the duration of effect for succinylcholine

Ans: A Feedback: Succinylcholine is associated with muscle pain related to the initial muscle contraction reaction. A nondepolarizing NMJ blocker may be given first to prevent some of these contractions and the associated discomfort. Administering a small dose of nondepolarizing NMJ blocker will not reduce the risk of malignant hyperthermia or increase the duration of effects. Dantrolene is a drug given to treat malignant hyperthermia.

20. The patient returns from surgery complaining about muscle pain after receiving succinylcholine during the procedure. After reviewing the postoperative orders, which of these ordered analgesics will the nurse administer to treat this pain? A) Aspirin B) Acetaminophen (Tylenol) C) Ketorolac (Toradol) D) Morphine

Ans: A Feedback: Succinylcholine is associated with muscle pain, related to the initial muscle contraction reaction. A nondepolarizing neuromuscular junction blocker may be given first to prevent some of these contractions and the associated discomfort. Aspirin also alleviates much of this pain after the procedure. Tylenol is not an antiinflammatory medication and would not be appropriate. Toradol and morphine provide stronger pain relief than what is indicated for this discomfort.

28. The emergency room nurse is teaching a class for newly hired graduate nurses on the different types of local anesthetic agents. How would the nurse differentiate lidocaine and procaine as a local anesthetic agent? A) Lidocaine is an amide that is broken down slowly and this can lead to toxicity. B) Lidocaine is an ester that cannot become toxic in the system because of rapid metabolism. C) Procaine is an amide that is broken down immediately in the tissues. D) Procaine is metabolized by the liver with risk of toxicity and is classified as an ester.

Ans: A Feedback: The ester local anesthetics are broken down immediately in the plasma by enzymes known as plasma esterases. The amide local anesthetics are metabolized more slowly in the liver. Serum levels of these drugs can become elevated and lead to toxicity. Lidocaine is an amide and procaine is an ester.

5. The nurse, caring for a patient taking a beta-blocker and a nitrate to treat angina, recognizes the need for careful monitoring as the result of what secondary diagnosis? A) Chronic obstructive pulmonary disease (COPD) B) Rheumatoid arthritis (RA) C) Irritable bowel syndrome (IBS) D) Chronic urinary tract infection (UTI)

Ans: A Feedback: The nurse should assess for COPD, because the effect of beta-blockers in reducing effects of the sympathetic nervous system could exacerbate the respiratory condition. RA, IBS, and chronic UTI are not affected by the use of beta-blockers or nitrates to treat angina.

19. The nurse is providing drug teaching for a patient who is to be discharged taking dofetilide (Tikosyn). What drug will the nurse teach the patient to avoid due to a drug-drug interaction? A) Cimetidine B) Furosemide C) Acetaminophen D) Antacids

Ans: A Feedback: There is an increased risk of serious adverse effects if dofetilide is combined with ketoconazole, cimetidine, or verapamil, so these combinations should be avoided. There is no known increased risk associated with furosemide, acetaminophen, or antacids but other specific drug-drug interaction are reported, so it is important to check a current drug handbook before administering these medications.

21. A student asks the pharmacology instructor how succinylcholine differs from acetylcholine (ACh). What should the instructor respond? A) "Succinylcholine is not broken down instantly." B) "It results in a prolonged contraction of the muscle." C) "The muscle becomes hyper stimulated by succinylcholine." D) Succinylcholine's duration of action is about 2 hours."

Ans: A Feedback: Unlike endogenous ACh, succinylcholine is not broken down instantly. Succinylcholine, a depolarizing NMJ blocker, attaches to the ACh-receptor site on the muscle cell, causing a prolonged depolarization of the muscle. This depolarization causes stimulation of the muscle and muscle contraction (seen as twitching) and then as flaccid paralysis, so the contraction of the muscle is not prolonged and the muscle is incapable of being stimulated. The duration of effects of succinylcholine is 4 to 6 minutes and not 2 hours.

7. A patient with impaired renal function is to receive dofetilide (Tikosyn) for conversion of atrial fibrillation. What is the nurse's priority assessment before administering the drug? A) Check the patient's creatinine level. B) Measure the urine output. C) Listen to breath sounds. D) Measure the PR interval on the electrocardiogram.

Ans: A Feedback: When giving dofetilide to a patient with renal dysfunction, the dosage must be calculated according to the patient's creatinine level to ensure the therapeutic effect while limiting toxicity. This drug can only be administered by oral route. Intake and output as well as breath sounds may need to be assessed but are not related to administering the drug. A patient in atrial fibrillation will not have a measurable PR interval.

22. The pharmacology instructor is explaining balanced anesthesia to the students. What agents would the instructor say are involved in balanced anesthesia? (Select all that apply.) A) Neuromuscular junction blockers B) Narcotics C) Anticholinergics D) Salicylates E) Nonsteriodal anti-inflammatory drugs (NSAIDs)

Ans: A, B, C Feedback: Balanced anesthesia involves giving a variety of drugs with specific effects to achieve analgesia, relax muscles, and invoke unconsciousness and amnesia. Classification of drugs administered includes anticholinergics, rapid intravenous anesthetics, inhaled anesthetics, neuromuscular junction blockers, and narcotics. Balanced anesthesia does not include use of salicylates or nonsteroidal anti-inflammatory drugs.

13. The emergency department nurse is administering IV lidocaine to a patient. What adverse effect of lidocaine therapy should the nurse assess for? A) Dysphagia B) Dizziness C) Excessive bruising D) Tinnitus

Ans: B Feedback: Adverse effects include dizziness, light-headedness, fatigue, arrhythmias, cardiac arrest, nausea, vomiting, anaphylactoid reactions, hypotension, and vasodilation. Dysphagia, bruising, and tinnitus are not usually associated with lidocaine.

23. The nurse administers pancuronium to the mechanically ventilated patient in the pediatric intensive care unit. What assessment finding would the nurse suspect is an adverse effect resulting from the drug? A) Bradycardia B) Bronchospasm C) Should not be used in neonates D) Associated with pulmonary hypertension

Ans: B Feedback: Adverse effects of pancuronium include respiratory depression, apnea, bronchospasm, and cardiac arrhythmias. Rocuronium is associated with pulmonary hypertension, cisatracurium should not be used in neonates, and atracurium is associated with bradycardia.

4. The nurse is caring for a patient who received succinylcholine during surgery. The nurse would expect the patient to spend more time in the postanesthesia care unit due to prolonged paralysis and inability to breathe if the patient was from what ethnic group? A) American Japanese B) Alaskan Eskimos C) Native Americans D) Hawaiian natives

Ans: B Feedback: Alaskan Eskimos belong to a genetic group that is predisposed to low plasma cholinesterase levels, making them susceptible to prolonged paralysis after succinylcholine use. The other ethnic groups do not have this genetic predisposition.

7. A patient is taking aminophylline for their chronic obstructive pulmonary disease. The patient is about to undergo emergency surgery and will receive an neuromuscular junction (NMJ) blocker as part of the procedure. It is important for the nurse to take what action? A) Make sure the patient receives the aminophylline on a regular schedule to maintain therapeutic levels. B) Monitor the patient very closely for signs of early arousal and return of muscle function. C) Carefully explain all that is going on because the patient will be unable to talk. D) Switch the patient to theophyllines before the procedure begins.

Ans: B Feedback: Aminophylline can cause a decreased effectiveness of NMJ blockers, leading to reduced paralysis and early return of movement. If a patient has emergency surgery and has been taking aminophylline, the patient should be carefully monitored for early arousal and return of movement. The patient will not be awake during surgery using an NMJ blocker and will be intubated to ensure respirations. Aminophylline and other xanthine derivatives like the theophyllines will have the same effect.

22. The nurse is administering an intravenous infusion of amiodarone (Cordarone). What should the nurse be aware of? A) The possible drug-drug interaction with nonsteroidal anti-inflammatory drugs (NSAIDs) B) The possible development of very serious cardiac arrhythmias C) The possible development of peripheral edema D) The possible development of a fatal renal toxicity

Ans: B Feedback: Amiodarone has been associated with a potentially fatal liver toxicity rather than a renal toxicity, ocular abnormalities, and the development of very serious cardiac arrhythmias. Sotalol may have a loss of effectiveness if combined with NSAIDs. Diltiazem is associated with peripheral edema.

10. An elderly patient has received a neuromuscular junction blocker during surgery. What would be an appropriate nursing diagnosis for this patient? A) Excess fluid volume B) Risk for impaired skin integrity C) Deficient fluid volume D) Chronic confusion

Ans: B Feedback: An elderly or frail patient will need extra nursing care to prevent skin breakdown during the period of paralysis because skin tends to be thinner and more susceptible to breakdown. Therefore, risk of impaired skin integrity would be an appropriate nursing diagnosis. Fluid excess or deficit should not be a concern and the patient may be acutely confused when awakening, but there is no reason to think he or she would remain chronically confused if he was not before surgery.

27. The nurse is assisting the nurse practitioner who is preparing to intubate the patient. The nurse practitioner has ordered atracurium and midazolam (Versed), a short acting benzodiazepine used to sedate the patient. In what order will the nurse administer these medications? A) It does not matter; they can be given in any order. B) Give the midazolam first and then atracurium a few moments later. C) Give atracurium and then give midazolam a few moments later. D) Benzodiazepines are contraindicated with atracurium.

Ans: B Feedback: Atracurium induces muscular paralysis resulting in the inability to breath due to paralysis of respiratory muscles but it has no impact on perception of consciousness. Receiving this drug before being sedated would be frightening and extremely anxiety provoking for the patient, so the sedative should be given first to reduce perception and consciousness before administering atracurium. There is no contraindication of benzodiazepines and the order they are given does matter.

33. The nurse is caring for a patient experiencing malignant hyperthermia. What medication will be administered to treat this condition? A) Midazolam B) Dantrolene C) Halothane D) Thiopental

Ans: B Feedback: Dantrolene is the preferred treatment for malignant hyperthermia and should always be readily available whenever anesthetics are used that could trigger the syndrome. Midazolam and thiopental are barbiturates whereas halothane is a volatile gas that can trigger malignant hyperthermia.

12. The pharmacology instructor is discussing nondepolarizing neuromuscular junction blockers (NMJ) blockers with the nursing class. How would the instructor explain the action of nondepolarizing NMJ blockers? A) Blocks acetylcholine (ACh) from acting B) Acts like ACh then prevents repolarization C) Takes the place of ACh in the depolarizing/repolarizing process D) Stops depolarization in the axion

Ans: B Feedback: Depolarizing NMJ blockers cause muscle paralysis by acting like ACh. They excite (depolarize) the muscle and prevent repolarization and further stimulation. Options A, C, and D are incorrect.

9. The operating room nurse is developing the care plan for a 10-year-old child with asthma who is scheduled for a tonsillectomy and who will receive halothane as the anesthetic agent. Why is this an appropriate drug for this patient? A) Halothane is metabolized in the liver. B) Halothane dilates the bronchi. C) Halothane is excreted unchanged in the urine. D) Halothane causes an accumulation of secretions.

Ans: B Feedback: Halothane is of particular benefit to a child with asthma because it dilates bronchi. Halothane is inhaled drug so it is not metabolized in the liver or excreted in the urine. It does not cause an accumulation of secretions.

12. The nurse teaches the patient receiving propranolol (Inderal) at home for management of a ventricular dysrhythmia to monitor what parameter? A) Daily fluid intake B) Daily blood pressure C) Weekly weight D) Weekly pulse

Ans: B Feedback: Hypotension can occur with propranolol, which is a beta-blocker, so patients should check their blood pressure and pulse every day. Propranolol does not require that fluid intake be measured. propranolol also will not require daily weight taking, but it may be necessary with a diagnosis of propranolol.

28. The nurse suspects drug toxicity in the patient who has been receiving lidocaine by infusion over the past 2 days to control a ventricular arrhythmia. What assessment would the nurse perform to determine the accuracy of the suspicion of toxicity? A) Neurological assessment B) Serum lidocaine level C) Renal function studies D) Hepatic function studies

Ans: B Feedback: If lidocaine is used for ventricular arrhythmias related to cardiac surgery or digoxin toxicity, serum levels should be monitored regularly to determine the appropriate dose and to avoid the potential for serious proarrhythmias and other adverse effects. Neurological assessment may indicate adverse effects but would not confirm lidocaine toxicity. Renal and hepatic function would not confirm lidocaine toxicity.

15. The nurse is caring for a patient in the emergency department with a 2-inch laceration to the left arm caused by broken glass. The nurse suspects the local anesthetic will be administered by what method? A) Topical Administration B) Infiltration C) Field block D) Nerve block

Ans: B Feedback: Infiltration local anesthesia involves injecting the anesthetic directly into the tissues to be treated (e.g., sutured, drilled, cut). This injection brings the anesthetic into contact with the nerve endings in the area and prevents them from transmitting nerve impulses to the brain. Topical administration would not be absorbed deeply enough to prevent pain. Field block would be used in a larger area (e.g., the entire area required surgical repair). Nerve block would anesthetize a far larger area than is required for 2-inch laceration.

14. The nurse administers a bolus of lidocaine and follows it with a continuous infusion at what rate? A) 0.25 to 0.75 mg/min B) 1 to 4 mg/min C) 6 to 8 mg/min D) 10 to 20 mg/min

Ans: B Feedback: Lidocaine may be delivered at 1 to 4 mg/min after a bolus. Therefore, the other options are incorrect.

7. An older adult patient who is taking metformin (Glucophage) has just been seen in the clinic. The doctor has ordered metoprolol (Toprol) for angina. What assessment data should the nurse monitor due to this drug combination? A) Blood pressure B) Blood glucose C) Heart rate D) Intake and output

Ans: B Feedback: Metformin is an antidiabetic drug and the nurse should monitor the patient's blood glucose frequently throughout the day. The patient will not have the usual signs and symptoms of hypoglycemia or hyperglycemia. Blood pressure, heart rate, and intake and output would not be affected by this drugdrug combination.

14. The patient received midazolam in combination with an inhaled anesthetic and a narcotic during surgery. The postanesthesia care unit (PACU) nurse anticipates this combination of drugs will have what impact on the patient's stay in the unit? A) Increased use of medications to offset adverse effects B) Extended time needed in the unit C) Decreased nursing support needed D) Increased analgesics needed

Ans: B Feedback: Midazolam is associated with increased toxicity and length of recovery when used in combination with inhaled anesthetics, other central nervous system depressants, narcotics, propofol, or thiopental. Because this patient received both narcotics and inhaled anesthetics, the nurse will anticipate this patient's time in the PACU will be extended. The patient is likely to need fewer analgesics because it will take longer for the patient to wake from anesthesia, which will also mean fewer medications will be used. Until the patient is awake, he or she will need continuous nursing support.

6. An extremely anxious patient is beginning to awaken in the postanesthesia care unit. He or she states that his or her arms and legs feel like tree trunks and that they are hard to move. He or she also complains that his or her head feels fuzzy and that the right words will not come to his or her. What is the priority nursing intervention for this patient? A) Provide analgesic medication for the discomfort. B) Stay with patient as much as possible and provide reassurance. C) Provide fluids to increase his or her wakefulness. D) Encourage the patient to turn from side to side periodically.

Ans: B Feedback: Most patients are disoriented and confused when awaking from anesthesia. It would be most important for the nurse to be with the patient as much as possible and reassure the patient that everything is as expected. Providing pain medication is important and may be needed during recovery if the patient reports pain, but would not be useful in treating the reported symptoms. The nurse would not provide fluids to patients immediately after surgery until ensuring the swallow reflex has returned and bowel motility has resumed. The nurse will help the patient turn from side to side, but this is not the priority nursing action at this time. However, the most effective nursing action for anxious postoperative patients is for the nurse to stay with them as much as possible.

2. The nurse cautions the patient taking nadolol (Corgard) for angina that they may experience what adverse effect? A) Dry mouth B) Decreased exercise tolerance C) Constipation D) Problems with urination

Ans: B Feedback: Nadolol is a beta-blocker that can cause a decreased tolerance to exercise because of the inability to experience the effects of the stress reaction. Dry mouth, constipation, and problems with urination are effects often seen with anticholinergic drugs but not with beta-blockers.

17. The nurse is caring for a patient who will receive an epidural block. What procedure is this patient likely to be having? A) Rhinoplasty B) Inguinal hernia repair C) Removal of a brain tumor D) Closed reduction of the right humerus

Ans: B Feedback: Nerve block is a method of administering local anesthesia by injecting the anesthetic at some point along the nerve or nerves that run to and from the region in which the loss of pain sensation or muscle paralysis is desired. Several types of nerve blocks are possible. Epidural anesthesia is an injection of the drug into the epidural space where the nerves emerge from the spinal cord. As a result, only an inguinal hernia repair would be an appropriate procedure for administering an epidural. Surgery performed about the spinal cord, such as surgery on the nose or brain, could not be anesthetized by injection of medication into the spinal cord.

3. A patient who has been taking cyclosporine to prevent rejection of a kidney transplant has had diltiazem ordered. Why would the nurse question this order? A) Serious diltiazem toxicity could occur. B) The combination may result in elevated or even toxic cyclosporine levels. C) The combination could lead to kidney rejection. D) A kidney recipient would not effectively excrete the diltiazem.

Ans: B Feedback: Potentially serious adverse effects to keep in mind include increased serum levels and toxicity of cyclosporine if they are taken with diltiazem. This combination is not associated with diltiazem toxicity. A functioning implanted kidney should still excrete diltiazem. This drug would not cause rejection of a transplanted kidney.

17. The nurse is caring for a patient who takes an antiarrhythmic agent and is reporting a complete lack of appetite. Which cardiac antiarrhythmic agent would the nurse suspect the patient is taking? A) Diltiazem (Cardizem) B) Propranolol (Inderal) C) Lidocaine (Lidocaine Parenteral) D) Amiodarone (Cordarone)

Ans: B Feedback: Propranolol frequently causes gastrointestinal (GI) problems such as nausea, vomiting, anorexia, constipation, and diarrhea. Diltiazem could cause nausea and vomiting but would not cause anorexia. Lidocaine can lead to changes in taste, nausea, and vomiting but does not cause anorexia. Amiodarone has adverse effects including nausea, vomiting, GI distress, weakness, dizziness, hypotension, heart failure, arrhythmia, a potentially fatal liver toxicity, and ocular abnormalities but does not cause anorexia.

19. The nurse is caring for a very anxious 33-year-old female patient scheduled for abdominal surgery today. The patient says the anesthesiologist said she would receive succinylcholine (Anectine) during surgery and asks the nurse how long it will take before the medicine starts to work. What is the nurse's best response? A) 1 to 2 minutes B) 30 to 60 seconds C) 5 to 10 minutes D) 30 minutes

Ans: B Feedback: Succinylcholine has an onset of action of 30 to 60 seconds. The other options are incorrect.

16. The postanesthesia care unit (PACU) nurse is caring for a patient that had succinylcholine (Anectine) as an adjunct to anesthesia. What is the nurse's priority assessment while caring for this patient? A) Movement B) Temperature C) Mental status D) Heart rate

Ans: B Feedback: Succinylcholine is more likely to cause malignant hyperthermia than other drugs so it is very important that the nurse carefully monitor the patient's temperature while in the PACU. Movement, mental status, and heart rate monitoring are all routine components of PACU care, but after receiving this medication, temperature monitoring becomes the priority.

20. The patient asks the nurse, "Will I have to take this antiarrhythmic agent for the rest of my life?" The nurse, having reviewed the CAST study, responds by saying what? A) "Yes, you will have to take this drug for life." B) "The drug is indicated for short-term treatment of life-threatening ventricular arrhythmias." C) "This drug may need to be changed but you'll take an antiarrhythmic for life." D) "After the arrhythmia is corrected, the drug will be stopped."

Ans: B Feedback: The CAST study, a large research study run by the National Heart and Lung Institute, found that long-term treatment of arrhythmias may have an uncertain effect on mortality, and in some cases may actually lead to increased cardiac death, which is the basis for the current indication for antiarrhythmics to be used only short-term to treat life-threatening ventricular arrhythmias.

9. The patient, diagnosed with angina, tells the nurse he is having chest pain. There is an order for oral sublingual nitroglycerin as needed. What action should the nurse take? A) Place two nitroglycerin tablets under the patient's tongue and call the physician. B) Place one tablet under the patient's tongue and repeat every 5 minutes for total of three tablets until pain has been relieved. C) Have the patient swallow a tablet with a full glass of water and repeat in 10 minutes. D) Apply a nitroglycerin transdermal patch to the patient's back.

Ans: B Feedback: The correct administration for sublingual administration is to place one tablet under the patient's tongue and repeat every 5 minutes for a total of three tablets until pain is relieved. If pain is not relieved after three sublingual tablets, the health care provider should be notified. Transdermal application would be inappropriate and nitroglycerin is not swallowed. Administering two tablets at one time would be an inappropriate dosage and could cause serious adverse effects.

26. The nursing instructor asks the student nurse what causes the respiratory obstruction that can occur with many of the depolarizing neuromuscular junction (NMJ) blockers. What is the student's most accurate response? A) Acetylcholine (ACh) B) Histamine release C) Serotonin D) Hyperkalemia

Ans: B Feedback: The histamine release associated with many of the depolarizing NMJ blockers can cause respiratory obstruction with wheezing and bronchospasm. Hyperkalemia is an adverse effect of the depolarizing NMJ blockers, ACh is what is acted on by the NMJ blockers, and serotonin is a distracter for this question.

30. The student asks the physiology instructor where the motor neuron communicates with a skeletal muscle fiber. What would the instructor respond? A) Synapse B) Neuromuscular junction C) Synaptic cleft D) Afferent junction

Ans: B Feedback: The neuromuscular junction (NMJ) simply is the point at which a motor neuron communicates with a skeletal muscle fiber. The synapse and synaptic cleft are part of the NMJ. The afferent junction is a distracter for this question.

18. The operating room nurse is taking the patient into the operating room when the patient says his grandmother almost died from a high fever in surgery 15 years ago. The nurse shares this information with the surgical team, recognizing this information indicates the patient is at risk for what? A) An allergic reaction to anesthesia B) Malignant hyperthermia C) Anxiety D) Hypothermia

Ans: B Feedback: The nurse assesses for a personal or family history of malignant hyperthermia, which may be triggered by the use of general anesthetics. Identifying patients at risk is imperative because the mortality rate is very high. All of these drugs have the potential to trigger malignant hyperthermia and should be used with caution in any patient at high risk. The patient's anxiety is to be expected, all patients are at risk for hypothermia because they are often uncovered in a cold room. Allergy to anesthesia must always be considered a possibility but there is no indication of a higher than normal risk in this patient.

35. The nurse applies a topical anesthetic to reduce sensation at the site while starting an IV. What age group is at greatest risk for systemic absorption of the topical anesthetic? A) Older adult B) Infant C) Toddler D) Adolescent

Ans: B Feedback: When topically applying a local anesthetic, it is important to remember that there is greater risk of systemic absorption and toxicity with infants. Therefore, the other options are incorrect.

1. According to the sliding filament theory, what is the initial action in a muscle contraction? A) Troponin is freed and prevents actin and myosin from reacting with each other. B) Calcium binds to troponin, which causes the release of actin and myosin binding sites. C) Actin and myosin molecules react with each other sliding along the filament and making it shorter. D) Muscle filament relaxes or slides back to the resting position.

Ans: C Feedback: Actin and myosin molecules react with each other again and again, sliding along the filament and making it shorter. This is a contraction of the muscle fiber according to the sliding filament theory. As the calcium is removed from the cell during repolarization of the muscle membrane, the troponin is freed and once again prevents the actin and myosin from reacting with each other. The muscle filament then relaxes or slides back to the resting position. Muscle tone results from a dynamic balance between excitatory and inhibitory impulses to the muscle.

11. A 21-year-old patient is positioned on the operating room table in preparation for knee surgery. After the anesthesiologist induces the patient, what is the next phase of anesthesia? A) Induction B) Maintenance C) Recovery D) Medullary paralysis

Ans: D Feedback: Induction is the period from the beginning of anesthesia until stage 3, or surgical anesthesia, is reached. After induction comes the maintenance phase from stage 3 until the surgical procedure is complete. A slower, more predictable anesthetic, such as a gas anesthetic, may be used to maintain the anesthesia after the patient is in stage 3. This is followed by the recovery period that begins with the discontinuation of anesthesia. Medullary paralysis is the depth of anesthesia known as stage 4. Option C is a distracter.

27. The nurse receives a patient into the postanaesthesia care unit who has had surgery using the anesthetic agent methohexital. The nurse anticipates the patient's need for what in the postoperative period? A) Assistance in maintaining respirations B) Assistance in moving lower extremities C) Positioning in Semi-Fowler's position D) Analgesia to control the patient's pain

Ans: D Feedback: Methohexital lacks analgesic properties so the patient may require postoperative analgesics to control pain. The patient who has surgery under methohexital does not generally require assistance in maintaining respirations or assistance in moving their lower extremities. They also do not generally require positioning in a semi-Fowler's position.

28. When a normal muscle functions, several actions take place. In what order do these actions occur? 1. Acetylcholine (ACh) is broken down by acetylcholinesterase. 2. ACh interacts with the nicotinic cholinergic receptors. 3. ACh is released by the motor nerve. 4. ACh crosses the synaptic cleft. 5. The muscle membrane is depolarized. 6. The muscle membrane is repolarized. Put these actions in the correct order. A) 1, 3, 5, 2, 4, 6 B) 2, 4, 6, 5, 3, 1 C) 6, 5, 4, 1, 2, 3 D) 3, 4, 2, 5, 1, 6

Ans: D Feedback: Normal muscle function involves the arrival of a nerve impulse at the motor nerve terminal, followed by the release of the neurotransmitter, ACh into the synaptic cleft. At the acetylcholine receptor site on the effector side of the synapse, ACh interacts with the nicotinic cholinergic receptors, causing depolarization of the muscle membrane. ACh is then broken down by acetylcholinesterase (an enzyme), freeing the receptor for further stimulation.

24. The nursing student asks the mental health nurse why pancuronium was administered to the patient before electroconvulsive therapy was performed. What is the mental health nurse's best response? A) To prevent aspiration of vomitus B) To reduce the pain of the procedure C) To put the patient to sleep D) To reduce the intensity of muscle contractions

Ans: D Feedback: Pancuronium is used, in this case, to induce skeletal muscle relaxation and to reduce the intensity of muscle contractions in electroconvulsive therapy. Pancuronium has no analgesic or amnesic effects. It would not reduce the risk of aspiration unless an endotracheal tube was placed with the cuff inflated and then it would not be the drug that was preventing aspiration.

1. A patient with a history of atrial fibrillation has had a worsening of his or her condition. The nurse knows that the drug of choice for long-term stabilization of atrial fibrillation following electrocardioversion is what? A) Disopyramide (Norpace) B) Moricizine (Ethmozine) C) Procainamide (Pronestyl) D) Quinidine (generic)

Ans: D Feedback: Quinidine is often the drug of choice for long-term stabilization of atrial fibrillation after the rhythm is converted by electrocardioversion. Quinidine is a class I antiarrhythmic and stabilizes the cell membrane by binding to sodium channels, depressing phase 0 of the action potential, and changing the duration of the action potential. Disopyramide, moricizine, and procainamide are all used in the treatment of life-threatening ventricular arrhythmias.

A patient is having outpatient surgery that should last only 45 minutes. The patient is planning to go home immediately after the surgery is complete. What nondepolarizing neuromuscular junction blocker will most likely be used as an adjunct therapy to general anesthesia for this patient? Atracurium (Tracrium) Cisatracurium (Nimbex) Pancuronium (Pavulon) Rocuronium (Zemuron)

Ans: D Feedback: Rocuronium has a rapid onset of action and a short duration, making it a drug of choice for outpatient surgical procedures when the patient will be leaving to go home and will need to be awake, alert, and mobile. Atracurium, cisatracurium, and pancuronium are associated with longer paralysis and recovery.

1. To decrease sympathetic stimulation in balanced anesthesia type of what agent would be used? A) Antihistamines B) Antiemetics C) Narcotics D) Sedative-hypnotics

Ans: D Feedback: Sedative-hypnotics relax the patient, facilitate amnesia, and decrease sympathetic stimulation. Antihistamines decrease the chance of allergic reaction and help dry secretions. Antiemetics decrease the nausea and vomiting associated with gastrointestinal (GI) depression. Narcotics aid in the analgesic and sedative effects.

32. What class of antiarrhythmic agents does the nurse administer to slow the outward movement of potassium during phase 3 of the action potential? A) Class Ib B) Class Ic C) Class II D) Class III

Ans: D Feedback: The class III antiarrhythmics block potassium channels and slow the outward movement of potassium during phase 3 of the action potential, prolonging it. Class Ib drugs depress phase 0 somewhat and actually shorten the duration of the action potential. Class Ic drugs markedly depress phase 0, with a resultant extreme slowing of conduction, but have little effect on the duration of the action potential. The class II antiarrhythmics are beta-adrenergic blockers that block beta-receptors, causing a depression of phase 4 of the action potential.

25. The nurse is admitting a 35-year-old patient to the preoperative unit in preparation for an elective inguinal hernia repair procedure to be performed under general anesthesia. What is the nurse's initial priority nursing assessment? A) Assess the patient's anxiety. B) Start an IV. C) Show the family the waiting area. D) Weigh the patient.

Ans: D Feedback: Weighing the patient is an initial priority because his or her weight will be used to determine appropriate dosing of all medications and will establish a baseline used for evaluation of any potential adverse effects. Other options are all actions the nurse will need to perform, but none are of higher priority than weighing the patient.

15. The nurse administers what drug to terminate supraventricular tachycardia? A) Lidocaine (Lidocaine Parenteral) B) Flecainide (Tambocor) C) Adenosine (Adenocard) D) Dronedarone (Multaq)

Ans: C Feedback: Adenosine depresses conduction at the atrioventricular node and is used to restore NSR (normal sinus rhythm) in patients with paroxysmal supraventricular tachycardia. Adenosine is used to treat supraventricular tachycardias, including those caused by the use of alternate conduction pathways in adults. Lidocaine is used to treat life-threatening ventricular arrhythmias during myocardial infarction or cardiac surgery; it is also used as a bolus injection in emergencies when monitoring is not available to document exact arrhythmia. Flecainide is used to treat life-threatening ventricular arrhythmias in adults; prevention of paroxysmal atrial tachycardia (PAT) in symptomatic patients with no structural heart defect. Dronedarone is used to treat paroxysmal or persistent atrial fibrillation or atrial flutter in patients with multiple risk factors for coronary artery disease who are currently in sinus rhythm or scheduled for conversion.

8. The nurse is caring for a patient who is being maintained on mechanical ventilation. Atracurium is administered to limit the resistance to mechanical ventilation. What is the nurse's priority assessment? A) Hypotension B) Tachycardia C) Bradycardia D) Increased secretions

Ans: C Feedback: Bradycardia is a common adverse effect associated with atracurium. The nurse should monitor the patient regularly to avoid serious adverse effects. Increased secretions and hypotension are common with tubocurarine. Option B is a distracter.

21. What patient factor would result in the nurse administering a reduced dosage of disopyramide (Norpace)? A) Dehydration B) Hypertension C) Renal impairment D) Chronic diarrhea

Ans: C Feedback: Caution should be used with renal or hepatic dysfunction, which could interfere with the biotransformation and excretion of these drugs. Caution is not indicated with the findings of dehydration, hypertension, or chronic diarrhea.

22. The certified registered nurse anesthetist documents the anesthesia plan as using a depolarizing neuromuscular junction (NMJ) blocker as adjunct to other anesthetics on the patient when they go to surgery. The nurse would understand from this note that the patient will receive what drug? A) Rocuronium (Zemuron) B) Pancuronium (Pavulon) C) Succinylcholine (Anectine, Quelicin) D) Cisatracurium (Nimbex)

Ans: C Feedback: Currently the only agent classified as a depolarizing NMJ blocker is succinylcholine. rocuronium, pancuronium, and cisatracurium are all nondepolarizing NMJ blockers.

26. When the nurse is caring for a patient with a cardiac arrhythmia, the priority goal for the patient is what? A) To maintain nutritional intake B) To maintain fluid intake C) To maintain cardiac output D) To maintain urine output

Ans: C Feedback: Disruptions in the normal rhythm of the heart can interfere with myocardial contractions and affect the cardiac output, the amount of blood pumped with each beat. Arrhythmias that seriously disrupt cardiac output can be fatal. Therefore, the primary goal of treating a cardiac arrhythmia is to maintain adequate cardiac output to support life. The other goals may be important to individual patient care, but sustaining life takes priority.

26. A very anxious patient asks the nurse what type of anesthesia they will have for a scheduled tooth extraction. The nurse would describe what type of local anesthetic in laymen's terms? A) Topical B) Infiltration C) Field block D) Nerve block

Ans: C Feedback: Field block local anesthesia involves injecting the anesthetic all around the area that will be affected by the procedure or surgery. This is more intense than infiltration anesthesia because the anesthetic agent comes in contact with all of the nerve endings surrounding the area. This type of block is often used for tooth extractions. Topical would not be appropriate because it would not absorb deeply enough to block pain impulses in the root of the tooth. Nerve block would not be possible for oral surgery.

8. Which nonbarbiturate anesthetic when used with halothane (Fluothane) can cause severe cardiac depression? A) Droperidol (Inapsine) B) Etomidate (Amidate) C) Ketamine (Ketalar) D) Propofol (Diprivan)

Ans: C Feedback: If ketamine and halothane are used in combination, severe cardiac depression with hypotension and bradycardia may occur. Use of droperidol, etomidate, and propofol with halothane should not be a concern.

24. What would the nurse teach the diabetic patient to monitor for when beginning a class II antidysrhythmic drug regimen in addition to insulin? A) Weight loss B) Reduced peripheral perfusion C) Hypoglycemia D) Exercise intolerance

Ans: C Feedback: Increased hypoglycemia is possible if these drugs are combined with insulin; so patients should be taught to monitor their blood sugar levels often. Recurrent hypoglycemic episodes may indicate the need to reduce insulin dosage, but this advice would need to come from the health care provider. Class II antiarrhythmic drugs are normally not associated with weight loss, reduced peripheral perfusion, or exercise intolerance.

7. The patient appears awake but is unconscious and has no response to painful stimuli. What medication does the nurse suspect this patient has received? A) Thiopental (Pentothal) B) Midazolam (Generic) C) Ketamine (Ketalar) D) Propofol (Diprivan)

Ans: C Feedback: Ketamine has been associated with a bizarre state of unconsciousness in which the patient appears to be awake but is unconscious and cannot feel pain. This drug, which causes sympathetic stimulation with increase in blood pressure and heart rate, may be helpful in situations when cardiac depression is dangerous. Thiopental is a barbiturate anesthetic. Midazolam and propofol are nonbarbiturate anesthetics. None of these medications have this type of effect.

16. For what condition would the nurse expect to administer lidocaine via IV drip? A) Decrease in arterial oxygen saturation (SaO2) B) Increase in blood pressure C) Multiple premature ventricular contractions (PVCs) D) Increase in intracranial pressure (ICP)

Ans: C Feedback: Lidocaine drips are indicated for the treatment of life-threatening ventricular arrhythmias such as long or frequent runs of PVCs. Lidocaine would not be indicated for the treatment of hypoxia, hypertension, or increased ICP.

13. A patient is to have surgery and it is planned that atracurium (Tracrium) is to be used as an adjunct to general anesthesia. How will the atracurium work? A) Act as agonist to acetylcholine B) Stops depolarization in the axion C) Act as antagonist to acetylcholine D) Stops repolarization in the axion

Ans: C Feedback: Nondepolarizing neuromuscular junction blockers compete with acetylcholine (ACh) for the ACh receptor site and after they occupy the site, stimulation cannot occur. This results in paralysis because the muscle cannot respond. Other options are incorrect.

5. What nursing interventions would help minimize the risk of a headache in a patient recovering from spinal anesthesia? A) Administer a triptan intramuscularly. B) Administer morphine intravenously. C) Maintain patient in recumbent position. D) Place patient in Trendelenburg position.

Ans: C Feedback: Patients receiving spinal anesthesia should remain in a recumbent position for as long as 12 hours. Triptan would not be effective because it is indicated for treatment of migraine headaches. Morphine would treat the headache but would not prevent it.

2. What class of antiarrhythmics drug blocks potassium channels, prolonging phase 3 of the action potential and slowing the rate and conduction of the heart? A) I B) II C) III D) IV

Ans: C Feedback: The class III antiarrhythmics block potassium, prolonging phase 3 of the action potential, which prolongs repolarization and slows the rate and conduction of the heart. Class I drugs block the sodium channels in the cell membrane during an action potential. Class II drugs are beta-adrenergic blockers that block beta-receptors, causing a depression of phase 4 of the action potential. Class IV drugs block calcium channels in the cell membrane leading to a depression of depolarization and a prolongation of phases I and II of repolarization, which slows automaticity.

10. The nurse is caring for a patient who is complaining of chest pain. The nurse is to administer 40 mg of isosorbide dinitrate (Isordil) to the patient. What is the nurse's priority assessment before administering the drug? A) Jaundice B) Headache C) Anemia D) Sinusitis

Ans: C Feedback: The nurse should assess for anemia because the decrease in cardiac output could be detrimental in a patient who already has a decreased ability to deliver oxygen because of a low red blood cell count. Jaundice and sinusitis would not be a contraindication to the drug. Headache is an adverse effect of isosorbide and would be expected after administration of the drug.

10. You are caring for a patient who takes an antiarrhythmic agent. What would be a priority nursing assessment before administering this drug? A) Assess mental status. B) Assess breath sounds. C) Assess pulses and blood pressure. D) Assess urine output.

Ans: C Feedback: The nurse should continually monitor cardiac rate and rhythm when administering an antiarrhythmic agent to detect potentially serious adverse effects and to evaluate drug effectiveness. All of the other options are appropriate assessments but are not the priority assessment.

4. A nurse is teaching the patient newly prescribed sublingual nitroglycerin how to take the medication. What will the nurse instruct the patient to do first? A) To check his radial pulse B) To place the tablet in the buccal cavity C) To take a sip of water D) To lie down for 15 minutes before administration

Ans: C Feedback: The nurse should instruct the patient to take a sip of water to moisten the mucous membranes so the tablet will dissolve quickly. The patient does not need to take his pulse or lie down before drug administration. For sublingual administration, the patient will place the tablet under his tongue and not in the buccal cavity (cheek area).

21. The patient receives lidocaine as a local anesthetic before insertion of a chest tube. After the procedure the patient tells the nurse, "The area is still numb. How long will this last?" What is the nurse's best response? A) 15 minutes B) 1 hour C) 2 hours D) 4 hours

Ans: C Feedback: The onset of intramuscular lidocaine is 5 to 10 minutes, peaks within 5 to 15 minutes, and the duration of action is 2 hours. Options A, B, and D are distracters.

9. The nurse sees a patient in an outpatient setting who is given a new prescription for an antiarrhythmic medication to treat premature atrial contractions (PAC). The nurse has limited time with the patient and addresses what priority nursing diagnosis? A) Decreased cardiac output B) Alteration in comfort C) Deficient knowledge D) Potential for injury

Ans: C Feedback: The patient received a new prescription and needs information about how to take the medication, when to call the provider, and potential adverse effects so the priority nursing diagnosis is deficient knowledge. It is unknown what arrhythmia the patient is treating and without this information it is impossible to know what the impact on cardiac output, comfort and potential for injury may be.

31. The nurse is assisting while the physician is suturing a wound in the urgent care clinic. The physician asks for lidocaine with epinephrine. The nurse identifies the primary reason for adding epinephrine to the lidocaine is what effect? A) It will sting more when it is injected into the tissue. B) Risk of systemic absorption is increased. C) Local effect is increased. D) Bleeding at the wound site is increased.

Ans: C Feedback: There is less risk of systemic absorption and increased local effects if these drugs are combined with epinephrine. Epinephrine causes vasoconstriction, which reduces bleeding, slows absorption, and makes the duration of effect longer. It does sting more when injected, but that is not a reason to use it.

5. A patient has had sotalol (Betapace) ordered for treatment of a ventricular arrhythmia. What will the nurse consider when administering the drug? A) Sotalol has a very short duration of action B) Food increases the bioavailability of the drug C) Absorption of sotalol is decreased by the presence of food D) The drug is best administered intramuscularly

Ans: C Feedback: This drug should not be taken with food because absorption is decreased. The drug should be given 1 hour before or 2 hours after a meal. Adenosine, not sotalol, has a very short duration of action and food increases the bioavailability of propranolol. Sotalol is administered by oral route only.

1. A nurse is providing patient teaching to a patient who has been experiencing unstable angina. What will the nurse's explanation of this condition include? A) A coronary vessel has become completely occluded and is unable to deliver blood to your heart. B) The pain is caused by a spasm of a blood vessel, not just from the vessel narrowing. C) There is serious narrowing of a coronary artery that is causing a reduction in oxygen to the heart. D) Your body's response to a lack of oxygen in the heart muscle is pain.

Ans: C Feedback: Unstable angina is described as increased narrowing of coronary arteries with the heart experiencing episodes of ischemia even at rest. If a coronary vessel is completely occluded and unable to deliver blood to the cardiac muscle, a myocardial infarction has occurred. Prinzmetal's angina is an unusual form of angina caused by spasm of the blood vessel and not just by vessel narrowing. Although pain is the body's response to ischemia in the heart muscle, this description could encompass angina or a myocardial infarction and is not specific enough to explain the condition.

18. A 92-year-old patient is being sent home on disopyramide (Norpace) for a ventricular arrhythmia. He asks the nurse why he must continue to take this drug. The nurse's best response would be that failure to treat a ventricular arrhythmia may what? A) Lead to renal failure B) Result in hypertension C) Result in death D) Cause heart failure

Ans: C Feedback: Ventricular arrhythmias cause a dramatic reduction in cardiac output and will result in death if not treated. The patient needs to be taught the importance of taking his medication every day as ordered. Generally, ventricular arrhythmias are not associated with renal failure, hypertension, or heart failure.

8. A nurse is caring for a patient who has had disopyramide (Norpace), ordered. Before administering disopyramide (Norpace) what is the nurse's priority action to maintain safety? A) Offer the patient something to drink. B) Ask the patient if he or she needs to void. C) Raise all side rails. D) Place the call button within reach.

Ans: C Feedback: When administering disopyramide, the nurse should make sure that all side-rails are up. The central nervous system effects of the drug can include dizziness, drowsiness, fatigue, twitching, mouth numbness, slurred speech, vision changes, and tremors that can progress to convulsions. The other three options are appropriate and placing the call button within reach can also be considered a safety measure; however nothing has a higher priority than raising the bed's side-rails.

9. The nurse is preparing a patient for surgery who will receive a neuromuscular junction blocker during the procedure. It is important for the nurse to review the patient's medication history for concurrent use of what? A) Angiotensin-converting enzyme (ACE) inhibitors B) Beta blockers C) Calcium channel blockers D) Montelukast

Ans: C Feedback: When calcium channel blockers are used concurrently with neuromuscular junction blockers, the patient is at increased risk of prolonged paralysis. The dose of the neuromuscular junction blocker should be lowered if this combination cannot be avoided and the patient should be monitored closely. There is no anticipated drug-drug interaction with ACE inhibitors, beta blockers, or montelukast.

19. The circulating nurse in the day surgery center is caring for a patient who is to receive a local anesthetic. What potential complications will the nurse monitor for? (Select all that apply.) A) Malignant hypothermia B) Pain C) Blurred vision D) Peripheral vasodilation E) Nausea

Ans: C, D, E Feedback: Adverse effects of local anesthetics are associated with the route of administration and the amount of drug that is absorbed systemically. These effects are related to the blockade of nerve depolarization throughout the system. Effects that may occur include central nervous system effects such as headache (especially with epidural and spinal anesthesia), restlessness, anxiety, dizziness, tremors, blurred vision, and backache; gastrointestinal (GI) effects such as nausea and vomiting; cardiovascular effects such as peripheral vasodilation, myocardial depression, arrhythmias, and blood pressure changes, all of which may lead to fatal cardiac arrest; and respiratory arrest. There is no such problem as malignant hypothermia (the condition is malignant hyperthermia) and pain may be caused by the procedure but not the anesthetic.

32. The nurse is caring for a patient scheduled for surgery who is to receive a barbiturate as part of the planned balanced anesthesia. What drugs, if taken by the patient, could result in a clinically important drug-drug interaction with the barbiturate? (Select all that apply.) A) Thyroid hormone B) Ibuprofen C) Oral contraceptive D) Theophylline E) Anticoagulant

Ans: C, D, E Feedback: Caution must be used when these drugs are used with any other central nervous system suppressants. Barbiturates can cause decreased effectiveness of theophylline, oral anticoagulants, beta-blockers, corticosteroids, hormonal contraceptives, phenylbutazones, metronidazole, quinidine, and carbamazepine. Combinations of barbiturate anesthetics and narcotics may produce apnea more commonly than occurs with other analgesics. Thyroid hormone and ibuprofen have no known drug interactions with barbiturates.

11. The nurse is caring for a patient receiving propranolol. What problems, reported by the patient, does the nurse suspect is caused by the drug? (Select all that apply.) A) Seizures B) Rash C) Atrioventricular (AV) block D) Bronchospasm E) Dreams

Ans: C, D, E Feedback: The adverse effects associated with class II antiarrhythmics are related to the effects of blocking beta-receptors in the sympathetic nervous system. Central nervous system effects include dizziness, insomnia, unusual dreams, and fatigue. Cardiovascular symptoms can include hypotension, bradycardia, AV block, arrhythmias, and alterations in peripheral perfusion. Respiratory effects can include bronchospasm and dyspnea. GI problems frequently include nausea, vomiting, anorexia, constipation, and diarrhea. Other effects to anticipate include a loss of libido, decreased exercise tolerance, and alterations in blood glucose levels. Seizures and rash are not usually associated with the adverse effects of propranolol.

16. A nurse is caring for a patient who received thiopental as an anesthetic agent during surgery. What adverse effects would the nurse attribute to the medication? A) Tachycardia B) Urinary retention C) Tachypnea D) Headache

Ans: D Feedback: Adverse effects of thiopental include emergence delirium, headache, restlessness, anxiety, cardiovascular depression, respiratory depression, apnea, salivation, hiccups, and rashes. Tachycardia, tachypnea, and urinary retention are not usually associated with this drug.

30. What nursing assessment will the nurse perform to determine the hemodynamic effect of the patient's arrhythmia? A) Obtain an electrocardiographic rhythm strip. B) Obtain a serum drug level. C) Assess the patient's level of consciousness. D) Assess the patient's blood pressure (BP) and pulse rate.

Ans: D Feedback: BP and pulse rate are indicators of the hemodynamic effect of arrhythmias and are nursing measures that do not require a physician's order. Obtaining an electrocardiogram or checking drug levels requires a physician's order. The patient will be conscious and alert with non-life-threatening arrhythmias, even when cardiac output is reduced. Serum drug levels would indicate the therapeutic or toxic level of drugs in the body but would not indicate hemodynamic effects of the drug.

6. The nurse is caring for a patient who reports insomnia since starting the antiarrhythmic agent prescribed for him or her. What antiarrhythmic agent would the nurse expect this patient is taking? A) Disopyramide (Norpace) B) Amiodarone (Cordarone) C) Procainamide (Pronestyl) D) Propranolol (Inderal)

Ans: D Feedback: Class II antiarrhythmics can cause insomnia. The adverse effects associated with class II antiarrhythmics are related to the effects of blocking beta-receptors in the sympathetic nervous system. CNS effects include dizziness, insomnia, unusual dreams, and fatigue. Disopyramide and procainamide are class I agents and do not cause insomnia. Amiodarone is a class III drug and is not associated with insomnia.

14. The nurse is caring for a patient who is receiving pancuronium (Pavulon) to facilitate mechanical ventilation. The patient is also receiving a barbiturate. How will the nurse administer these two medications? A) They can be mixed and given in the same syringe. B) Administer IM quickly after mixing the two drugs. C) Shake vigorously when mixed in one syringe. D) If given together, a precipitate may form.

Ans: D Feedback: Do not mix this drug with any alkaline solutions such as barbiturates because a precipitate may form, making it inappropriate for use. Pancuronium is only given IV. Shaking does not prevent precipitation.

34. The nurse administers a sedative followed by a neuromuscular junction (NMJ) blocker after which the neonatologist attempts to intubate the patient without success. While waiting for the anesthesiologist to come to the unit to establish an artificial airway, what is the nurse's priority of care? A) Reposition the patient frequently. B) Monitor oxygen saturation. C) Monitor respirations and pulse rate. D) Use a bag-valve-mask to ventilate the patient.

Ans: D Feedback: Following administration of an NMJ blocker, the patient will be unable to breathe independently so maintaining an airway and breathing for the patient using a bag-valve mask is the nurse's number-one priority. The patient will not be repositioned until after the artificial airway is placed (endotracheal tube or tracheostomy). Monitoring oxygen saturation and pulse will be second in priority after providing breathing for the patient. The patient will have no independent respirations until the NMJ is metabolized.

34. The nurse is teaching a class for newly hired cardiac care nurses and is discussing dronedarone (Multaq). What statement, if made by the nurse, is accurate? (Select all that apply.) A) "Dronedarone has properties of all four classes of antiarrhythmics." B) "Dronedarone reduces the risk of hospitalization in patients in atrial fibrillation." C) "Dronedarone has many drug-drug interactions that need to be reviewed." D) "It is an oral drug taken once a day." E) "Common adverse effects of dronedarone include ventricular arrhythmias."

Ans: A, B, C Feedback: Dronedarone has properties of all four classes of antiarrhythmics and the mechanism by which it helps suppress atrial arrhythmias is not fully understood. It is used to reduce the risk of hospitalization in patients with paroxysmal or persistent atrial fibrillation or flutter who have risk factors for cardiovascular disease and who are in sinus rhythm or are scheduled to be converted to sinus rhythm. The drug is taken orally twice a day. Many drug-drug interactions have been associated with the drug and this situation should always be reviewed before starting or stopping any drugs while on this drug. Grapefruit juice should not be consumed while taking this drug. The most common adverse effects seen with dronedarone are heart failure, prolonged QT interval, nausea, diarrhea, and rash. It should never be used during pregnancy because it has been associated with fetal abnormalities.

35. The nurse is caring for the intensive care unit patient who is mechanically ventilated and receiving a neuromuscular junction (NMJ) blocker, a sedative, and an analgesic. What are priorities of nursing care for this patient? (Select all that apply.) A) Reposition patient frequently. B) Ensure care of the patient's eyes. C) Monitor temperature. D) Provide a means for patient communication. E) Increase ventilator breaths per minute as needed.

Ans: A, B, C Feedback: Frequent repositioning is important because the patient is unable to move and protect skin integrity independently. The loss of blink reflex due to muscle paralysis from NMJ blockers can result in conjunctival damage so eye care is very important. Monitor patient temperature for prompt detection and treatment of malignant hyperthermia. The patient cannot communicate while receiving NMJ blocker. Ventilator changes are made by physician order in most facilities and are usually based on arterial blood gas results.

34. The nurse is caring for a patient who will undergo cardioversion in the patient's room this morning. The patient will receive propofol as anesthetic during the procedure. What are the benefits of using propofol for this procedure? (Select all that apply.) A) It has a very rapid clearance. B) It produces less of a hangover effect. C) It allows for quick recovery from anesthesia. D) Its onset of action is 5 minutes. E) It is painless to inject IV.

Ans: A, B, C Feedback: Propofol often is used for short procedures because it has a very rapid clearance and produces much less of a hangover effect and allows for quick recovery. It is a very short-acting anesthetic with a rapid onset of action of 30 to 60 seconds. Propofol often causes local burning on injection.

18. The nurse is caring for a patient in the intensive care unit who has been receiving neuromuscular junction (NMJ) blockers, sedatives, and analgesics for the past 2 weeks. The NMJ blocker therapy has been discontinued and the other medications are being reduced gradually. The patient is now alert and awake, communicating with his or her family by using paper and pencil. The family asks why the patient cannot sustain normal respirations. What is the nurse's best response? (Select all that apply.) A) "His or her muscles need to get their strength back again." B) "This is a common occurrence in situations like this." C) "He or she is likely to breathe better each day." D) "The drugs created temporary muscle damage." E) "He or she will not be taken off the mechanical ventilator until he is ready."

Ans: A, B, C, E Feedback: After 2 weeks of muscle paralysis, the muscles are weak and will take time to strengthen as the patient begins using them again. Profound and prolonged muscle paralysis is always possible; patients must be supported until they are able to resume voluntary and involuntary muscle movement. When the respiratory muscles are paralyzed, depressed respiration, bronchospasm, and apnea are anticipated adverse effects so the patient will remain ventilated until he or she can demonstrate adequate respiratory effort. The drugs did not damage the muscle, but lack of use has weakened them.

3. The nurse, working in the preoperative holding area, is caring for a 70-year-old patient who is scheduled to receive succinylcholine as part of general anesthesia. When collecting the nursing history, what condition would require the nurse to notify the anesthesiologist of the need for caution? A) Bone fracture B) Malnutrition C) Fluid volume overload D) Narrow-angle glaucoma E) Pregnancy

Ans: A, B, D Feedback: Succinylcholine should be used with caution in patients with fractures because the muscle contractions it causes might lead to additional trauma; in patients with narrow-angle glaucoma or penetrating eye injuries because intraocular pressure increases. Extreme caution is necessary in the presence of genetic or disease-related conditions causing low plasma cholinesterase levels (e.g., cirrhosis, metabolic disorders, carcinoma, burns, dehydration, malnutrition, hyperpyrexia, thyroid toxicosis, collagen diseases, exposure to neurotoxic insecticides).

What are the primary uses of neuromuscular junction blockers (NMJ) blockers? (Select all that apply.) A) To facilitate endotracheal intubation B) To sedate patient for general anesthesia C) To prevent injury during electroconvulsive therapy D) To provide greater ease in extubating patient E) To facilitate mechanical ventilation

Ans: A, C, E Feedback: NMJ blockers are primarily used as adjuncts to general anesthesia, to facilitate endotracheal intubation, to facilitate mechanical ventilation, and to prevent injury during electroconvulsive therapy. NMJ blockers do not sedate the patient who will be paralyzed after administration but will remain alert unless another medication is given. These medications would not be given before extubation because respiratory muscles would be paralyzed, resulting in the inability to breathe.

20. What nursing diagnosis would a circulating nurse use on his or her intraoperative patients who receive general anesthesia? (Select all that apply.) A) Disturbed sensory perception B) Risk for hypovolemia C) Risk for latex allergy response D) Disturbed body image E) Anxiety

Ans: A, C, E Feedback: Nursing care of patients receiving general or local anesthetics should include safety precautions to prevent injury and skin breakdown, support and reassurance to deal with the loss of sensation and mobility, and patient teaching regarding what to expect to decrease stress and anxiety. Risk for hypovolemia and disturbed body image would be applicable to some surgical procedures but would not be related to general anesthesia.