Chapter 48: Estrogens and Progestins: Basic Pharmacology and Noncontraceptive Applications, Chapter 49: Birth Control, Chapter 50: Androgens, Chapter 51: Drugs for Erectile Dysfunction and Benign Prostatic Hyperplasia, Chapter 43: Drugs for Angina Pe...

517. A 14-year-old male patient has not begun puberty. His parents tell the nurse that their son does not want to go to school, because he gets teased. The nurse learns that the boy's father did not begin puberty until age 16 years. Laboratory tests on this child do not reveal true hypogonadism. What will the nurse tell these parents when they ask what can be done for their son? a. "A limited course of androgen therapy may be prescribed, but it is not necessary." b. "He will eventually begin puberty, so this is nothing to worry about." c. "He will probably have to receive injections of androgens for 3 to 4 years." d. "The risk of accelerated growth plate closure is too great to warrant androgen therapy."

ANS: A Although treatment is not required in this patient, the psychologic effects of delayed puberty indicate a limited course of androgen therapy. Telling the parents not to worry does not address their concerns. This patient will not be a candidate for long-term androgen replacement therapy. Limited treatment can minimize the risk of epiphyseal closure, especially with close monitoring and radiographs.

453. A nurse is reviewing a patient's most recent blood count and notes that the patient has a hemoglobin of 9.6 gm/dL and a hematocrit of 33%. The nurse will notify the provider and will expect initial treatment to include: a. determining the cause of the anemia. b. giving intravenous iron dextran. c. giving oral carbonyl iron [Feosol]. d. teaching about dietary iron.

ANS: A Before therapy for iron deficiency anemia is started, the cause must be determined so that the appropriate treatment is given. Oral iron is safer and, most of the time, as effective as parenteral iron, so IV iron is not an initial choice. Oral iron will be given once the cause of the deficiency has been determined. Patients who are iron deficient should be taught about dietary iron, but this is not part of the initial treatment when a deficiency is detected.

416. A patient is taking a calcium channel blocker (CCB) for stable angina. The patient's spouse asks how calcium channel blockers relieve pain. The nurse will explain that CCBs: a. help relax peripheral arterioles to reduce afterload. b. improve coronary artery perfusion. c. increase the heart rate to improve myocardial contractility. d. increase the QT interval.

ANS: A CCBs promote relaxation of peripheral arterioles, resulting in a decrease in afterload, which reduces the cardiac oxygen demand. CCBs do not improve coronary artery perfusion. CCBs reduce the heart rate and suppress contractility; they do not affect the QT interval.

457. A patient is receiving oral iron for iron deficiency anemia. Which antibiotic drug, taken concurrently with iron, would most concern the nurse? a. Tetracycline b. Cephalosporin c. Metronidazole [Flagyl] d. Penicillin

ANS: A Coadministration of tetracycline and iron reduces absorption of both iron and tetracycline. Cephalosporin, metronidazole, and penicillin have no significant drug-to-drug interaction with iron.

585. A nurse is teaching a patient who has taken glucocorticoids for over a year about glucocorticoid withdrawal. Which statement by the patient indicates a need for further teaching? a. "I should reduce the dose by half each day until I stop taking the drug." b. "I will need to have cortisol levels monitored during the withdrawal process." c. "The withdrawal schedule may take several months." d. "If I have surgery, I may need to take the drug for a while, even after I have stopped."

ANS: A Glucocorticoid therapy can suppress adrenal function, so withdrawal should be done slowly to allow recovery of adrenal function. Reducing the dose of a glucocorticoid by half each day is not recommended. Patients should have their cortisol levels monitored to determine when therapy can be stopped. The withdrawal schedule may take several months. Patients who have stopped the drug may still experience adrenal insufficiency in times of physiologic stress, such as surgery.

582. A nurse is discussing glucocorticoids with a group of nursing students. Which statement by a student indicates understanding of the teaching? a. "Glucocorticoids have both endocrine and nonendocrine uses." b. "Patients treated for adrenocortical insufficiency receive pharmacologic doses." c. "Pharmacologic effects are achieved with low doses of glucocorticoids." d. "Physiologic doses are used to treat inflammatory disorders."

ANS: A Glucocorticoids have applications for both endocrine and nonendocrine disorders. Adrenocortical insufficiency requires physiologic, or low-dose, treatment. Pharmacologic doses are used when large doses are required, such as to suppress inflammation. Physiologic doses are used to treat endocrine disorders.

587. A patient taking high doses of a glucocorticoid develops weakness in the muscles of the upper arms and in the legs. What will the nurse do? a. Contact the provider to ask about reducing the dose. b. Encourage the patient to restrict sodium intake. c. Reassure the patient that this is an expected side effect. d. Tell the patient to stop taking the drug.

ANS: A High-dose glucocorticoid therapy can cause myopathy, manifesting as weakness. If muscle weakness occurs, the dose should be reduced. Reducing the sodium intake is recommended to minimize sodium and water retention. Muscle weakness is not an expected side effect, because it indicates myopathy. It is incorrect to tell the patient to stop taking the drug, because a glucocorticoid must be withdrawn slowly to allow time for recovery of adrenal function.

529. A patient receiving doxazosin presents for a routine evaluation. Which assessment finding would be most concerning? a. Blood pressure 96/58 b. Dizziness when standing c. Increased nasal congestion d. Diminished ejaculate volume

ANS: A Hypotension, dizziness, and nasal congestion are all adverse effects of doxazosin, an alpha1- adrenergic antagonist. However, hypotension would be the most concerning because it can lead to inadequate peripheral tissue perfusion. Diminished ejaculate volume is seen with administration of 5-alpha-reductase inhibitors, not with doxazosin administration.

451. A patient who has recently immigrated to the United States from an impoverished country appears malnourished. The patient's folic acid levels are low, and the vitamin B12 levels are normal. The nurse expects this patient's treatment to include: a. a diet high in folic acid. b. intramuscular folic acid. c. oral folic acid and vitamin B12. d. oral folic acid supplements.

ANS: A If a folic acid deficiency is caused by poor diet, it should be corrected with dietary measures, not supplements. IM or oral supplements of folic acid are not indicated. Vitamin B12 is not recommended.

499. A patient calls a family planning clinic and tells the nurse that her vaginal ring, which has been in place for 2 weeks, came out sometime during the night while she was sleeping. The nurse will instruct her to: a. clean the ring with warm water, reinsert it, and use condoms for 7 days. b. discard the ring and insert a new ring after 1 week has passed. c. discard the ring and insert a new one to begin a new cycle. d. wash the ring in hot, soapy water, and reinsert it.

ANS: A If a ring is expelled before 3 weeks have passed, it can be reinserted after being washed in warm water. If the ring has been out longer than 3 hours, backup contraception should be used for 7 days. Because this ring was expelled while the patient was sleeping, using backup contraception is prudent. Discarding the ring is not indicated if it can be cleaned. The ring should not be washed in hot water.

492. A patient who will begin combination estrogen/progestin therapy (EPT) for menopause asks the nurse why she cannot take an estrogen-only preparation. The patient has not had a hysterectomy, has a slightly increased risk of cardiovascular disease, and has mild osteopenia. The nurse will tell her that the progestin is necessary to: a. decrease her risk of endometrial cancer. b. increase bone resorption to prevent fractures. c. lower her risk of myocardial infarction (MI). d. prevent deep vein thrombosis (DVT).

ANS: A In patients who still have a uterus, progestin is necessary to reduce the risk of endometrial carcinoma. Progestins do not have effects on bone density and do not decrease risk of MI or DVT.

509. A patient has just purchased a 1-year supply of 28-day-cycle oral contraceptives. She tells the nurse she wishes she had planned things better, because she has calculated that her period will begin during her upcoming honeymoon. What will the nurse suggest? a. She should discard the inert pills and start a new pack during the honeymoon. b. She should discontinue the oral contraceptives and use an alternative form of birth control. c. She should discuss a prescription for an extended-cycle product with her provider. d. She should discuss DMPA (Depo-Provera) injections in addition to the OC with her provider.

ANS: A OC users can achieve an extended-cycle schedule by discarding the inert pills and beginning a new pack for up to four cycles. It is not necessary to discontinue OCs. Because this woman has already purchased a 1-year supply, using the 28-day-cycle product as described is appropriate. If this woman opts for a long-term product, she should discontinue the OC.

519. A clinic nurse is assessing an adolescent male patient who has been receiving androgen therapy for hypogonadism via a transdermal patch. The patient's last clinic visit was 4 weeks earlier. Which part of the interval history is of most concern to the nurse? a. Five-pound weight gain b. Increased growth of pubic hair c. Rash at the site of the patch d. Presence of acne

ANS: A Patients receiving testosterone may experience edema secondary to sodium and water retention. Treatment involves discontinuing the drug and giving diuretics if needed. Masculinization of both females and males may occur and boys may experience growth of pubic hair, which is an expected effect. Patients may develop a sensitivity rash at the site of transdermal application. Acne is an expected effect.

414. A patient who has renal impairment will begin taking ranolazine [Ranexa] as an adjunct to nitroglycerin to treat angina. What will the nurse include when teaching this patient? a. "You will need to monitor your blood pressure closely while taking this drug." b. "You should take this drug 1 hour before or 2 hours after a meal." c. "You may experience rapid heart rate while taking this medication." d. "You do not need to worry about drug interactions with this medication."

ANS: A Ranolazine can elevate blood pressure in patients with renal impairment, so patients taking this drug will need to monitor blood pressure. The drug can be taken without regard to food. It does not cause reflex tachycardia. It has many significant drug interactions.

449. A patient with renal failure is undergoing chronic hemodialysis. The patient's hemoglobin is 10.6 gm/dL. The provider orders sodium-ferric gluconate complex (SFGC [Ferrlecit]). What will the nurse expect to do? a. Administer the drug intravenously with erythropoietin. b. Give a test dose before each administration of the drug. c. Have epinephrine on hand to treat anaphylaxis if needed. d. Infuse the drug rapidly to achieve maximum effects quickly.

ANS: A SFGC is given parenterally for iron deficiency anemia in patients undergoing chronic hemodialysis. It is always used in conjunction with erythropoietin to stimulate the production of red blood cells (RBCs). A test dose is given only with the initial dose and is not necessary with subsequent doses. Anaphylaxis is not a common side effect. The drug should be infused slowly.

445. A nurse has just received an order for tenecteplase [TNKase] for a patient experiencing an acute myocardial infarction. The nurse should administer this drug: a. by bolus injection. b. by infusion pump over 24 hours. c. slowly over 90 minutes. d. via monitored, prolonged infusion.

ANS: A Tenecteplase [TNKase] is given by bolus injection. Tissue plasminogen activator (tPA) must be infused over 90 minutes. Because tenecteplase is given by bolus injection, an infusion pump is not required. Although the patient should be monitored, tenecteplase does not require a prolonged infusion time.

456. The patient with which of the following is most at risk for folic acid deficiency? a. Alcoholism b. Sprue c. Gastrectomy d. Peptic ulcer disease

ANS: A The patient most at risk for folic acid deficiency secondary to a poor diet is a patient with a history of alcoholism. Malabsorption secondary to intestinal disease is another indication for folic acid therapy, but these patients are not most at risk.

435. A patient with atrial fibrillation is receiving warfarin [Coumadin]. The nurse notes that the patient's INR is 2.7. Before giving the next dose of warfarin, the nurse will notify the provider and: a. administer the dose as ordered. b. request an order to decrease the dose. c. request an order to give vitamin K (phytonadione). d. request an order to increase the dose.

ANS: A This patient has an INR in the appropriate range, which is 2 to 3 for most patients and 2.5 to 3.5 for some, so no change in warfarin dosing is necessary. It is not correct to request an order to either decrease or increase the dose of warfarin. It is not necessary to give vitamin K, which is an antidote for warfarin toxicity.

458. A patient with vitamin B12 deficiency is admitted with symptoms of hypoxia, anemia, numbness of hands and feet, and oral stomatitis. The nurse expects the prescriber to order which of the following therapies? a. IM cyanocobalamin and folic acid b. IM cyanocobalamin and antibiotics c. PO cyanocobalamin and folic acid d. PO cyanocobalamin and blood transfusions

ANS: A This patient is showing signs of more severe vitamin B12 deficiency with neurologic symptoms; therefore, cyanocobalamin should be given parenterally along with folic acid. Antibiotics are indicated only when signs of infection are present. Oral cyanocobalamin is not recommended.

584. The prescriber orders 20 mg of hydrocortisone orally once each day. The nurse will make sure the drug is scheduled to be administered at what time? a. 8:00 AM b. 12:00 PM c. 4:00 PM d. 9:00 PM

ANS: A To allow the adrenals to recover, the hydrocortisone dose should be administered before 9:00 AM. The other times are incorrect for oral administration of daily hydrocortisone.

412. A patient with angina who uses sublingual nitroglycerin tells the nurse that the episodes are increasing in frequency and usually occur when the patient walks the dog. The patient reports needing almost daily doses of nitroglycerin and states that one tablet usually provides complete relief. What will the nurse do? a. Contact the provider to suggest ordering a transdermal patch for this patient. b. Question the patient about consumption of grapefruit juice. c. Suggest that the patient limit walking the dog to shorter distances less frequently. d. Suggest that the patient take two tablets of nitroglycerin each time, because the symptoms are increasing in frequency.

ANS: A Transdermal patches are good for sustained prophylaxis for anginal attacks and are especially useful when patients have a regular pattern of attacks. Grapefruit juice does not affect the metabolism of nitroglycerin. Patients with angina should be encouraged to increase, not decrease, exercise. Taking two tablets is not recommended when one is effective.

524. A patient receiving transurethral alprostadil asks about intracavernous administration. Which information would be included in the explanation? a. Transurethral administration has fewer side effects. b. Transurethral administration helps increase arterial flow to the penis. c. The desired effect can be achieved with only 0.1 mL of the medication. d. The required dose is much smaller with transurethral administration.

ANS: A Transurethral administration has fewer side effects than intracavernous administration of alprostadil. Both intracavernous and transurethral administration lead to increased arterial blood flow to the penis. The dosage of alprostadil ranges from 125 to 1000 mcg, which is higher than the dose required for intracavernous administration (5 to 40 mcg).

423. A nursing student is helping to care for a patient who takes verapamil for stable angina. The nurse asks the student to explain the purpose of verapamil in the treatment of this patient. Which statement by the student indicates a need for further teaching? a. "It relaxes coronary artery spasms." b. "It reduces peripheral resistance to reduce oxygen demands." c. "It reduces the heart rate, AV conduction, and contractility." d. "It relaxes the peripheral arterioles to reduce afterload."

ANS: A Verapamil does relax coronary artery spasms, but this is not useful in stable angina. Verapamil is used to relax coronary artery spasms in variant asthma. When used to treat stable angina, verapamil promotes relaxation of peripheral arterioles, which reduces peripheral resistance and decreases afterload. It also reduces the heart rate, AV conduction, and contractility.

432. A patient who is taking warfarin [Coumadin] has just vomited blood. The nurse notifies the provider, who orders laboratory work revealing a PT of 42 seconds and an INR of 3.5. The nurse will expect to administer: a. phytonadione (vitamin K1) 1 mg IV over 1 hour. b. phytonadione (vitamin K1) 2.5 mg PO. c. protamine sulfate 20 mg PO. d. protamine sulfate 20 mg slow IV push.

ANS: A Vitamin K1 is given for warfarin overdose and may be given IV in an emergency. To reduce the incidence of an anaphylactoid reaction, it should be infused slowly. In a nonemergency situation, it would be appropriate to give vitamin K1 orally. Protamine sulfate is used for heparin overdose.

422. A patient with stable exertional angina has been receiving a beta blocker. Before giving the drug, the nurse notes a resting heart rate of 55 beats/minute. Which is an appropriate nursing action? a. Administer the drug as ordered, because this is a desired effect. b. Withhold the dose and notify the provider of the heart rate. c. Request an order for a lower dose of the medication. d. Request an order to change to another antianginal medication.

ANS: A When beta blockers are used for anginal pain, the dosing goal is to reduce the resting heart rate to 50 to 60 beats/minute. Because this heart rate is a desired effect, there is no need to withhold the dose or notify the provider. The dosage does not need to be lowered, because a heart rate of 55 beats/minute is a desired effect. There is no indication of a need to change medications for this patient.

512. A woman has been taking a progestin-only oral contraceptive and will begin using a vaginal ring. The nurse will teach the patient to insert the ring: a. the day the last pill is taken and use backup contraception for 7 days. b. 1 week before taking the last pill. c. 1 to 5 days after taking the last pill and use backup contraception for 2 days. d. within 7 days after taking the last pill.

ANS: A When patients who have been using a progestin-only OC begin using a vaginal ring, they should be instructed to insert the ring on the last day of the pill and use backup contraception for 7 days.

589. A woman who is breastfeeding is prescribed a low pharmacologic dose of a glucocorticoid and asks the nurse about potential effects on her infant. What will the nurse tell her about this medication? a. "At this dose, the concentration in your breast milk is safe." b. "Contact your provider to discuss lowering the dose." c. "There will be reversible side effects for your baby." d. "This drug is likely to cause growth retardation in your baby."

ANS: A Women who are nursing may take physiologic or low pharmacologic doses of glucocorticoids without achieving concentrations in breast milk that affect the nursing infant. It is not necessary to lower the dose. Since there are negligible levels, there are no effects on the infant. Large pharmacologic doses can cause growth retardation and other adverse effects in the infant.

502. A patient at increased risk for thromboembolic disorders will begin taking a progestin-only oral contraceptive. Which statements by the patient indicates understanding of how this oral contraceptive works? (Choose 2) a. "I will need to use backup contraception if I miss a pill." b. "Irregular bleeding is an indication that I should stop using this drug." c. "The mini-pill is safer than combination OCs and is just as effective." d. "The progestin-only mini-pill will prevent me from ovulating."

ANS: A & C When a patient taking a progestin-only OC misses one or more pills, backup contraception should always be used for at least 2 days. Irregular bleeding occurs but is not an indication to stop using the drug, although many women do because of the inconvenience. The mini-pill is slightly safer than combination OCs and equally effective.

454. What are the indications for administration of a parenteral iron preparation? Select all that apply. a. Blood loss of 750 mL/week b. Celiac disease with anemia c. History of alcoholism d. Intestinal disease impairing absorption e. Megaloblastic anemia

ANS: A,B,D Patients who have lost 750 mL/week of iron cannot absorb enough oral iron, so parenteral iron is indicated for these patients. Patients with celiac disease or other diseases that impair iron absorption must receive parenteral iron. Patients with a history of alcoholism are generally deficient in folic acid. Megaloblastic anemia is a symptom of vitamin B12 and/or folic acid deficiency.

420. A patient with asthma and depression develops stable angina. In addition to organic nitrites, which other medications will be used to treat this condition? Select all that apply. a. ACE inhibitors b. Antiplatelet drugs c. Beta blockers d. Calcium channel blockers e. Cholesterol-lowering drugs

ANS: A,B,D,E ACE inhibitors have shown benefit in reducing the incidence of adverse outcomes in patients with coronary artery disease (CAD) and are recommended as part of therapy. Antiplatelet drugs are recommended to reduce the risk of thrombus formation. CCBs are used as adjuncts to nitroglycerin and are safe in patients with asthma and depression. Cholesterol-lowering drugs are recommended to help slow the progression of CAD. Beta blockers are not recommended in patients with asthma or depression.

511. A patient who is taking a combination oral contraceptive begins taking carbamazepine. After several weeks, the patient tells the nurse she has begun experiencing spotting during her cycle. What will the nurse tell her to do? a. Change to condoms instead of oral contraceptives. b. Discuss an oral contraceptive with increased estrogen. c. Request a decreased dose of carbamazepine. d. Stop taking the oral contraceptive immediately.

ANS: B Carbamazepine induces hepatic cytochrome P450 and thus accelerates the metabolism of oral contraceptives. Spotting is a sign of reduced OC blood levels; patients experiencing this symptom may need an increased estrogen dose. If the dose of OC is not changed, the woman may use condoms along with the OC. Reducing the dose of carbamazepine is not correct. Discontinuing the OC immediately is not correct.

443. A patient is admitted to the hospital with unstable angina and will undergo a percutaneous coronary intervention. Which drug regimen will the nurse expect to administer to prevent thrombosis in this patient? a. Aspirin, clopidogrel, omeprazole b. Aspirin, heparin, abciximab [ReoPro] c. Enoxaparin [Lovenox], prasugrel [Effient], warfarin [Coumadin] d. Heparin, alteplase, abciximab [ReoPro]

ANS: B Abciximab, combined with ASA and heparin, is approved for IV therapy for patients undergoing PCI.

424. A patient with angina who is taking ranolazine [Ranexa] has developed a respiratory infection and a dysrhythmia. The provider has ordered azithromycin [Zithromax] for the infection and amlodipine for the dysrhythmia. A nursing student caring for this patient tells the nurse that the patient's heart rate is 70 beats/minute, and the blood pressure is 128/80 mm Hg. The nurse asks the student to discuss the plan for this patient's care. Which action is correct? a. Observe the patient closely for signs of respiratory toxicity. b. Question the order for azithromycin [Zithromax]. c. Report the patient's increase in blood pressure to the provider. d. Request an order for a different calcium channel blocker.

ANS: B Agents that inhibit CYP3A4 can increase levels of ranolazine and also the risk of torsades de pointes. Macrolide antibiotics, such as azithromycin, are CYP3A4 inhibitors. Respiratory toxicity is not an expected effect with this patient. The patient's blood pressure is not elevated enough to notify the provider. Amlodipine is the only CCB that should be used with ranolazine.

415. A nurse provides teaching to a patient with angina who also has type 2 diabetes mellitus, asthma, and hypertension. Which statement by the patient indicates a need for further teaching? a. "An ACE inhibitor, in addition to nitroglycerin, will lower my risk of cardiovascular death." b. "Beta blockers can help me control hypertension." c. "I should begin regular aerobic exercise." d. "Long-acting, slow-release calcium channel blockers can help with anginal pain."

ANS: B Beta blockers can be used for angina in most patients but are contraindicated in patients with asthma, because they cause bronchoconstriction. ACE inhibitors help reduce the risk of death in patients with hypertension. Regular aerobic exercise is recommended to control weight and improve cardiovascular function. Long-acting, slow-release CCBs are recommended for patients who have coexisting type 2 diabetes.

586. A 60-year-old female patient is about to begin long-term therapy with a glucocorticoid. Which of the following will be important for minimizing the risk of osteoporosis? a. Baseline vitamin D level b. Calcium and vitamin D supplements c. Estrogen therapy d. Skeletal x-rays before treatment

ANS: B Calcium and vitamin D supplements can help minimize the patient's risk of developing osteoporosis. A baseline vitamin D level is not recommended. Estrogen therapy can help in postmenopausal women, but its risks outweigh its benefits. Patients should undergo evaluation of the bone mineral density of the lower spine, not skeletal x-rays.

444. A patient who has taken warfarin [Coumadin] for a year begins taking carbamazepine. The nurse will anticipate an order to: a. decrease the dose of carbamazepine. b. increase the dose of warfarin. c. perform more frequent aPTT monitoring. d. provide extra dietary vitamin K.

ANS: B Carbamazepine is a powerful inducer of hepatic drug-metabolizing enzymes and can accelerate warfarin degradation. The warfarin dose should be increased if the patient begins taking carbamazepine. Decreasing the dose of carbamazepine is not indicated. It is not necessary to perform more frequent aPTT monitoring or to add extra vitamin K.

446. A nurse is taking a medication history on a newly admitted patient. The patient reports taking folic acid and vitamin B12. The nurse notifies the provider because of the concern that folic acid can: a. cause fetal malformation. b. mask the signs of vitamin B12 deficiency. c. negatively affect potassium levels. d. worsen megaloblastic anemia.

ANS: B Folic acid can reverse the hematologic effects of vitamin B12 deficiency, but it does not reverse the neurologic effects, so it is important to determine the degree of B12 deficiency to treat it. Folic acid does not cause fetal malformation; in fact, it can help prevent neural tube defects. Folic acid does not worsen megaloblastic anemia. Folic acid does not affect potassium levels.

581. A nurse is teaching a group of nursing students why glucocorticoids are preferred over nonsteroidal anti-inflammatory drugs in the treatment of inflammation. Which statement by a student indicates a need for further teaching? a. "Glucocorticoids act by multiple mechanisms and have more anti-inflammatory effects than NSAIDs." b. "Glucocorticoids have fewer side effects than nonsteroidal anti-inflammatory drugs." c. "Glucocorticoids help avert damage to tissues from lysosomal enzymes." d. "Glucocorticoids reduce the immune component of inflammation."

ANS: B Glucocorticoids have many side effects. They are used because of their multiple mechanisms of action, including their ability to limit tissue damage caused by the inflammatory process and suppression of the immune component of inflammation.

530. After educating a patient about administration of papaverine plus phentolamine for erectile dysfunction, which statement made by the patient indicates a need for further teaching? a. "I can expect rapid onset of an erection." b. "I will take the pill 30 minutes before sex." c. "I should get up from my seat slowly when taking this." d. "I will notify the provider if I feel hard areas on my penis."

ANS: B Papaverine plus phentolamine is administered as an intracavernous injection, not as an oral pill. The patient should be educated about the correct route of administration. Desired effect may be achieved quickly with administration. Adverse effects of administration include orthostatic hypotension and fibrotic nodules in the corpus cavernosum from injection. The patient should be educated about these effects and ways to prevent complications, such as rising slowly from a seated position to prevent dizziness.

442. A patient will begin taking dabigatran etexilate [Pradaxa] to prevent stroke. The nurse will include which statement when teaching this patient? a. Dabigatran should be taken on an empty stomach to improve absorption. b. It is important not to crush, chew, or open capsules of dabigatran. c. The risk of bleeding with dabigatran is less than that with warfarin [Coumadin]. d. To remember to take dabigatran twice daily, a pill organizer can be useful.

ANS: B Patients should be taught to swallow capsules of dabigatran intact; absorption may be increased as much as 75%, increasing the risk of bleeding, if the capsules are crushed, chewed, or opened. Dabigatran may be taken with or without food. The risk of bleeding is not less than that of warfarin. Dabigatran is unstable when exposed to moisture, so using a pill organizer is not recommended.

498. A patient is taking a combination oral contraceptive (OC) and tells the nurse that she is planning to undergo knee replacement surgery in 2 months. What will the nurse recommend for this patient? a. The patient should ask her provider about an OC with less progestin. b. The patient should discuss an alternative method of birth control prior to surgery. c. The patient should request an OC containing less estrogen after surgery. d. The patient should take the OC at bedtime after her surgery to reduce side effects.

ANS: B Patients taking an OC who undergo surgery in which immobilization increases the risk of postoperative thrombosis should stop taking the OC at least 4 weeks prior to surgery. The patient should discuss an alternate method of birth control with her provider. Estrogen, not progestin, increases the risk of thrombosis. The estrogen-containing OC should be stopped 4 weeks prior to surgery. Taking the OC at bedtime does not decrease the risk.

504. A patient has been taking a progestin-only, or "minipill," OC for 3 months and reports spotting and irregular menstrual cycles. The nurse will: a. question the patient about any possible missed doses of the pill. b. reassure the patient that this is normal with this form of contraception. c. recommend that she take a pregnancy test to rule out pregnancy. d. suggest that she use a backup form of contraception until these symptoms resolve.

ANS: B Patients taking the progestin-only OC may expect irregular bleeding, including spotting and irregular periods. This symptom does not indicate lack of compliance with the regimen. A pregnancy test is not indicated. It is not necessary to use a backup form of contraception.

436. A postoperative patient will begin anticoagulant therapy with rivaroxaban [Xarelto] after knee replacement surgery. The nurse performs a history and learns that the patient is taking erythromycin. The patient's creatinine clearance is 50 mL/minute. The nurse will: a. administer the first dose of rivaroxaban as ordered. b. notify the provider to discuss changing the patient's antibiotic. c. request an order for a different anticoagulant medication. d. request an order to increase the dose of rivaroxaban.

ANS: B Patients with impaired renal function who are taking macrolide antibiotics will experience increased levels of rivaroxaban, increasing the risk of bleeding. It is correct to discuss using a different antibiotic if possible. The nurse should not administer the dose without discussing the situation with the provider. The patient's renal impairment is minor; if it were more severe, using a different anticoagulant might be appropriate. It is not correct to increase the dose of rivaroxaban.

450. A patient tells a nurse that she is thinking about getting pregnant and asks about nutritional supplements. What will the nurse recommend? a. A balanced diet high in green vegetables and grains b. 400 to 800 mg of folic acid per day c. A multivitamin with iron d. Vitamin B12 supplements

ANS: B The current recommendation is that all women of childbearing age receive folic acid supplementation to prevent the development of neural tube defects that can occur early in pregnancy. Dietary folic acid is not sufficient to provide this amount. Iron supplements are given when pregnancy occurs and are not necessary before becoming pregnant. Vitamin B12 supplements are not recommended.

448. A 12-year-old female patient is admitted to the hospital before sinus surgery. The nurse preparing to care for this patient notes that the admission hemoglobin is 10.2 gm/dL, and the hematocrit is 32%. The nurse will ask the child's parents which question about their daughter? a. "Does she eat green, leafy vegetables?" b. "Has she begun menstruating?" c. "Is she a vegetarian?" d. "Is there a chance she might be pregnant?"

ANS: B The most common cause of iron deficiency anemia in adolescent females is heavy periods, so asking about menses is an appropriate first question when evaluating the cause of low iron in young females. Iron deficiency only rarely occurs because of poor dietary intake. Although pregnancy is not unheard of in 12-year-old girls, a question about possible pregnancy should not be the first question asked.

500. An adolescent female patient with multiple sexual partners asks a nurse about birth control methods. The patient tells the nurse she tried oral contraceptives once but often forgot to take her pills. The nurse will recommend discussing which contraceptive method with the provider? a. An intrauterine device with a spermicide b. DMPA (Depo-Provera) and condoms c. Tubal ligation and condoms d. Progestin-only oral contraceptives

ANS: B This patient has demonstrated a previous history of nonadherence, so a long-acting contraceptive would be more effective for her. Because she has multiple sexual partners, she should use a condom for protection against STDs. An IUD is not indicated for her; patients with multiple sexual partners who use IUDs are at greater risk for STDs. Tubal ligation carries surgical risks and should not be used by young women because it is irreversible. Progestin-only oral contraceptives must be taken every day.

425. A patient with new-onset exertional angina has taken three nitroglycerin sublingual tablets at 5-minute intervals, but the pain has intensified. The nurse notes that the patient has a heart rate of 76 beats/minute and a blood pressure of 120/82 mm Hg. The electrocardiogram is normal. The patient's lips and nail beds are pink, and there is no respiratory distress. The nurse will anticipate providing: a. an angiotensin-converting enzyme (ACE) inhibitor. b. intravenous nitroglycerin and a beta blocker. c. ranolazine (Ranexa) and quinidine. d. supplemental oxygen and intravenous morphine.

ANS: B This patient has unstable angina, and the next step, when pain is unrelieved by sublingual nitroglycerin, is to give intravenous nitroglycerin and a beta blocker. ACE inhibitors should be given to patients with persistent hypertension if they have left ventricular dysfunction or congestive heart failure (CHF). Ranolazine is a first-line angina drug, but it should not be given with quinidine because of the risk of increasing the QT interval. Supplemental oxygen is indicated if cyanosis or respiratory distress is present. IV morphine may be given if the pain is unrelieved by nitroglycerin.

441. A nurse caring for a patient receiving heparin therapy notes that the patient has a heart rate of 98 beats/minute and a blood pressure of 110/72 mm Hg. The patient's fingertips are purplish in color. A stat CBC shows a platelet count of less than 100,000 mm3. The nurse will: a. administer oxygen and notify the provider. b. discontinue the heparin and notify the provider. c. request an order for protamine sulfate. d. request an order for vitamin K (phytonadione).

ANS: B This patient is showing signs of heparin-induced thrombocytopenia, so the heparin should be discontinued immediately and the provider should be notified. The purplish color of the fingertips is caused by thrombosis, not hypoxia, so oxygen is not indicated. This patient may need continued anticoagulation therapy, so a request for protamine sulfate is not correct. Heparin is not a vitamin K inhibitor.

447. A nurse is caring for a patient after hip replacement surgery. The patient has been receiving iron replacement therapy for 2 days. The nurse notes that the patient's stools appear black. The patient is pale and complains of feeling tired. The patient's heart rate is 98 beats/minute, respirations are 20 breaths/minute, and the blood pressure is 100/50 mm Hg. The nurse will contact the provider to: a. report possible gastrointestinal hemorrhage. b. request a hemoglobin and hematocrit (H&H). c. request an order for a stool guaiac. d. suggest giving a hypertonic fluid bolu

ANS: B This patient is showing signs of iron deficiency anemia, as manifested by tachycardia and pallor. Because this patient's blood pressure is low, the anemia probably has occurred secondary to blood loss, a common occurrence with hip replacement surgery. The first response should be to obtain an H&H to assess the anemia. GI hemorrhage is not a concern in this patient; black stools are an expected effect of oral iron administration. A stool guaiac is not indicated. If the patient has blood loss that is causing hypotension, an isotonic fluid bolus and packed red blood cells (PRBCs) are indicated to treat this.

522. An adult male patient will begin androgen therapy for testicular failure. Which statement by the patient indicates understanding of the treatment regimen? a. "I will need to have x-rays of my hands and feet every 6 months." b. "My libido may improve while I am taking this medication." c. "Taking this drug may lead to the development of prostate cancer." d. "This will restore fertility, so I can have a child."

ANS: B Treatment with androgen replacement therapy in patients with testicular failure helps to restore libido. A side effect of androgens is premature epiphyseal closure; this is not a concern in adults, so radiographs to evaluate this are not indicated. Androgens can promote the growth of prostate cancer when it occurs, but they do not cause it. Androgens do not restore fertility.

418. A patient with variant angina wants to know why a beta blocker cannot be used to treat the angina. Which response by the nurse is correct? a. "A beta1-selective beta blocker could be used for variant angina." b. "Beta blockers do not help relax coronary artery spasm." c. "Beta blockers do not help to improve the cardiac oxygen supply." d. "Beta blockers promote constriction of arterial smooth muscle."

ANS: B Variant angina occurs when coronary arteries go into spasm, thus reducing the circulation and oxygen supply to the heart. CCBs help to reduce coronary artery spasm; beta blockers do not. Beta1-selective beta blockers are used for stable angina for patients who also have asthma, because they do not activate beta2 receptors in the lungs to cause bronchoconstriction. Beta blockers help improve the oxygen supply in stable angina, but they do not relieve coronary artery spasm, so they are not useful in variant angina. Beta blockers do not constrict arterial smooth muscle.

433. A patient is admitted to the emergency department with chest pain. An electrocardiogram shows changes consistent with an evolving myocardial infarction. The patient's cardiac enzymes are pending. The nurse caring for this patient will expect to: a. administer aspirin when cardiac enzymes are completed. b. give alteplase [Activase] within 2 hours. c. give tenecteplase [TNKase] immediately. d. obtain an order for an INR.

ANS: B When alteplase is given within 2 hours after symptom onset, the death rate for MI has been shown to be 5.4%, compared with 9.4% if given 4 to 6 hours after symptom onset. ASA may be given at the first sign of MI; it is not necessary to wait for cardiac enzyme results. Tenecteplase may be given more than 2 hours after onset of symptoms. Obtaining an order for an INR is not indicated.

505. A patient has been experiencing side effects with a combination oral contraceptive, and her provider has ordered a different combination product. The nurse will instruct the patient to do what? a. Begin taking the new product immediately. b. Change products at the beginning of her next cycle. c. Stop taking the old OC 1 week before starting the new OC. d. Use an alternate method of contraception for 1 month before starting the new OC.

ANS: B When changing one combination OC for another, the change is best made at the beginning of a new cycle. It is not correct to begin taking the new product immediately; to stop the old product 1 week before starting the new product; or to use an alternate method of birth control between regimens.

523. A 14-year-old male patient who plays football is admitted to the hospital. The nurse notes that the patient has short stature for his age according to a standard growth chart. The patient is muscular, has a deep voice, and needs to shave. The nurse notifies the provider of these findings. Which test will the nurse expect the provider to order? a. Coagulation studies b. Complete blood count (CBC) with differential c. Liver function tests and serum cholesterol d. Serum glucose and hemoglobin A1c

ANS: C Adverse effects of androgen abuse can cause hepatotoxicity and an elevated serum cholesterol level, with a decrease in HDL cholesterol and an increase in LDL cholesterol. Blood coagulation is not affected. A CBC is not indicated. Serum glucose and hemoglobin A1c levels are not indicated.

421. A hospitalized patient complains of acute chest pain. The nurse administers a 0.3-mg sublingual nitroglycerin tablet, but the patient continues to complain of pain. Vital signs remain stable. What is the nurse's next step? a. Apply a nitroglycerin transdermal patch. b. Continue dosing at 10-minute intervals. c. Give a second dose of nitroglycerin in 5 minutes. d. Request an order for intravenous nitroglycerin.

ANS: C An initial dose of sublingual nitroglycerin is taken, and if the chest pain persists, as in this case, the patient should take another dose in 5 minutes. Transdermal delivery systems are not useful for terminating an ongoing attack. Dosing at 10-minute intervals is incorrect. If the patient fails to respond or if the pain intensifies, intravenous nitroglycerin may be indicated.

588. A clinic patient who has been taking a glucocorticoid for arthritis for several months remarks to the nurse, "It is a good thing my symptoms are better, because my mother has been quite ill, and I have to take care of her." The patient's blood pressure is 100/60 mm Hg. The nurse will report this to the provider and ask about: a. reducing the patient's dose. b. using every-other-day dosing. c. increasing the patient's dose. d. tapering the dose.

ANS: C Because of their adrenal suppression, patients taking glucocorticoids long-term require increased doses at times of stress and even for a time after stopping the drug until adrenal function returns. This patient's lower blood pressure is an indication that glucocorticoid levels may be depleted. Reducing the dose would only exacerbate the patient's problems. Every-other-day dosing is used early in glucocorticoid therapy to reduce adrenal suppression, but it would not be useful now. Tapering of doses is used to allow adrenal function to recover as the drug is discontinued.

507. A patient is taking a combination oral contraceptive (OC) and reports breast tenderness, edema, and occasional nausea. What will the nurse recommend? a. The patient should ask her provider about an OC with less progestin. b. The patient should discuss an alternate method of birth control. c. The patient should request an OC containing less estrogen. d. The patient should take the OC at bedtime to reduce side effect

ANS: C Breast tenderness, edema, and nausea are associated with estrogen; women experiencing these side effects may benefit from an OC with a lower estrogen dose. Lowering the progestin will not decrease these symptoms. It is not necessary to change birth control methods if side effects can be managed by altering the estrogen dose. Taking the OC at bedtime will not affect the symptoms.

431. A postoperative patient reports pain in the left lower extremity. The nurse notes swelling in the lower leg, which feels warm to the touch. The nurse will anticipate giving which medication? a. Aspirin b. Clopidogrel [Plavix] c. Enoxaparin [Lovenox] d. Warfarin [Coumadin]

ANS: C Enoxaparin is a low-molecular-weight heparin and is used in situations requiring rapid onset of anticoagulant effects, such as massive DVT. Aspirin, clopidogrel, and warfarin are useful for primary prevention but are not used when rapid anticoagulation is required.

493. A nurse provides teaching to a patient who has had a hysterectomy and is about to begin hormone therapy to manage menopausal symptoms. Which statement by the patient indicates understanding of the teaching? a. "Because I am not at risk for uterine cancer, I can take hormones indefinitely." b. "I can take estrogen to reduce my risk of cardiovascular disease." c. "I should take the lowest effective dose for the shortest time needed." d. "I will need a progestin/estrogen combination since I have had a hysterectomy."

ANS: C For patients who have undergone hysterectomy, progestin is unnecessary; estrogen-only preparations still carry increased risk of breast cancer and should be taken in the lowest effective dose for the shortest time possible. Even though uterine cancer is no longer a possibility, breast cancer is still a risk. Studies have shown no protection against coronary heart disease but increased risk of stroke and breast cancer with estrogens.

515. A 12-year-old male patient diagnosed with hypogonadism will begin testosterone injections. What will the nurse include when teaching the family about this therapy? a. Annual x-rays of the hands and wrists are necessary to monitor epiphyseal closure. b. Gynecomastia may occur and is a common side effect. c. Injections are given every 2 to 4 weeks for 3 to 4 years. d. Use of this drug may lead to prostate cancer later in life.

ANS: C For the treatment of male hypogonadism, patients receive IM injections of testosterone every 2 to 4 weeks for 3 to 4 years. Evaluation for epiphyseal closure should be done with radiographs every 6 months, not annually. Gynecomastia is a rare side effect that usually occurs in patients taking testosterone in high doses. Testosterone only accelerates the growth of prostate cancer when it occurs; it does not cause it.

428. A patient has been receiving heparin while in the hospital to treat deep vein thromboses and will be discharged home with a prescription for enoxaparin [Lovenox]. The nurse provides teaching for the nursing student who asks about the advantages of enoxaparin over heparin. Which statement by the student indicates a need for further teaching? a. "Enoxaparin does not require coagulation monitoring." b. "Enoxaparin has greater bioavailability than heparin." c. "Enoxaparin is more cost-effective than heparin." d. "Enoxaparin may be given using a fixed dosage."

ANS: C Low-molecular-weight (LMW) heparins have higher bioavailability and longer half-lives, so routine coagulation monitoring is not necessary and fixed dosing is possible. LMW heparins are more expensive, however, so this statement indicates a need for further teaching.

503. A nurse is discussing various ways to obtain a medical abortion with a patient. Which statement by the patient best demonstrates understanding of mifepristone (RU 486) [Mifeprex]? "This drug is most effective if I use it: a. before the first missed menstrual period." b. the day after unprotected intercourse." c. within 7 weeks of conception." d. immediately after ovulation."

ANS: C Mifepristone is most effective if it is used within 7 weeks of conception. The timing specified in the other responses is incorrect.

426. A nurse is providing teaching for a patient with stable angina who will begin taking nitroglycerin. Which statement by the patient indicates understanding of the teaching? a. "I should not participate in aerobic exercise while taking this drug." b. "I should take aspirin daily to reduce my need for nitroglycerin." c. "If I take nitroglycerin before exertion, I can reduce the chance of an anginal attack." d. "I take nitroglycerin to increase the amount of oxygen to my heart."

ANS: C Nitroglycerin can be taken before stressful events or exertion to reduce the chance of an attack of angina. Aerobic exercise is an important part of nondrug therapy to reduce the risk of heart attack. Aspirin therapy is an important adjunct to treatment to prevent coronary thrombus formation, but it does not reduce the need for nitroglycerin. Nitroglycerin reduces cardiac oxygen demand, but it does not increase the amount of oxygen available to the heart.

437. A patient who is taking clopidogrel [Plavix] calls the nurse to report black, tarry stools and coffee-ground emesis. The nurse will tell the patient to: a. ask the provider about using aspirin instead of clopidogrel. b. consume a diet high in vitamin K. c. continue taking the clopidogrel until talking to the provider. d. stop taking the clopidogrel immediately.

ANS: C Patients who experience bleeding should be warned not to stop taking the clopidogrel until the prescriber says they should, since abrupt withdrawal may precipitate a thrombotic event. Taking aspirin with an active GI bleed is contraindicated. Warfarin is a vitamin K inhibitor; consuming extra vitamin K will not reverse the effects of clopidogrel.

460. A patient is diagnosed with moderate vitamin B12 deficiency. The nurse reviews the laboratory work and notes that the plasma B12 is low; also, a Schilling test reveals B12 malabsorption. The provider orders oral cyanocobalamin 500 mcg/day. The nurse will contact the provider to: a. discuss IM dosing. b. request an order for folic acid. c. suggest an increased dose. d. suggest platelet transfusion therapy.

ANS: C Patients with vitamin B12 deficiency associated with B12 malabsorption need increased doses of oral cyanocobalamin of 1000 to 10,000 mcg/day. It is not necessary to give this drug intramuscularly. Folic acid is indicated when B12 deficiency is severe. Platelets are given when B12 deficiency is severe.

528. Which finding would indicate that terazosin has been effective for a patient with BPH? a. Decreased prostate size b. Increased urinary frequency c. Improved urinary hesitation d. Decreased serum PSA levels

ANS: C Terazosin is an alpha1-adrenergic antagonist. These medications relax the smooth muscles of the bladder neck to improve urinary symptoms experienced with BPH. They do not decrease the size of the prostate. Increased urinary frequency is a sign of worsening BPH, not improvement.

514. A nurse is teaching a male adult patient about the use of testosterone gel. Which statement by the patient indicates an understanding of the teaching? a. "I should apply this to my forearms and neck after showering." b. "I should keep treated areas exposed to the air so that they can dry." c. "I should not let my child touch the gel to prevent behavioral problems." d. "I should not swim or bathe for 3 to 4 hours after applying the gel."

ANS: C Testosterone administered via gels can be transferred to others by skin-to-skin contact. In children, virilization can occur, as well as aggressive behaviors. The gel should be applied to clean, dry skin on the upper arms, shoulders, or abdomen and should be covered with clothing. Swimming and bathing are allowed 5 to 6 hours after application.

411. A patient who takes nitroglycerin to treat stable angina reports having erectile dysfunction and states that he plans to ask his primary provider for a prescription for tadalafil [Cialis]. What will the nurse tell this patient? a. "You may take these two drugs together safely as long as you take them as directed." b. "You should not take tadalafil and nitroglycerin within 30 to 60 minutes of each other." c. "You should discuss another antianginal medication with your provider." d. "You should avoid sexual activity since this increases oxygen demands on the heart."

ANS: C Use of nitroglycerin with any phosphodiesterase type 5 inhibitor, such as sildenafil or tadalafil, is absolutely contraindicated. The patient should be advised to discuss another antianginal agent with the provider. Patients should be taught to increase all activity to maintain as normal a lifestyle as possible.

430. A nursing student who is preparing to care for a postoperative patient with deep vein thrombosis asks the nurse why the patient must take heparin rather than warfarin. Which response by the nurse is correct? a. "Heparin has a longer half-life." b. "Heparin has fewer adverse effects." c. "The onset of warfarin is delayed." d. "Warfarin prevents platelet aggregation."

ANS: C Warfarin is not useful for treating existing thromboses or for emergencies because the onset of action is delayed. Heparin has a shorter half-life and has more side effects. Warfarin does not prevent platelet aggregation.

513. A nurse is teaching an adolescent female patient about 28-day monophasic combination oral contraceptives. The provider has instructed the patient to begin taking the pills on the first Sunday after the onset of her next period. What will the nurse tell the patient? a. "If breakthrough spotting occurs, you should begin taking a new pack of pills." b. "Protection from pregnancy will begin immediately." c. "Use another form of contraception for the next month." d. "You may take the pills at different times of day."

ANS: C When beginning oral contraceptives, it is important that the patient use another form of contraception for the first month, because protection is not immediate. Breakthrough spotting is common and is not an indication for starting a new cycle. Protection from pregnancy is not immediate. It is important to take the pills at the same time each day.

583. A nurse tells a nursing student that the glucocorticoids given for rheumatoid arthritis are nearly identical to substances produced naturally by the body. The student remarks that the drug must be very safe. Which response by the nurse is correct? a. "As long as the drug is taken as prescribed, side effects usually do not occur." b. "By interrupting the inflammatory process, these drugs inhibit side effects." c. "Side effects can occur and are dependent on the dose and duration of treatment." d. "The negative feedback loop prevents side effects."

ANS: C When taken in pharmacologic doses, as for inflammatory disorders, glucocorticoids can cause an array of serious adverse effects. When glucocorticoids are given in pharmacologic doses, side effects can occur even when the drugs are taken as prescribed. Interruption of the inflammatory process causes some of the adverse effects. The negative feedback loop does not inhibit side effects.

501. A nurse working in a family planning clinic is teaching a class on intrauterine devices (IUDs). Which patient should be advised against using an IUD for contraception? a. A 45-year-old married woman with four children. b. A 30-year-old monogamous married woman. c. An 18-year-old woman with multiple sexual partners. d. A 35-year-old woman with a history of rosacea.

ANS: C Women at risk for sexually transmitted diseases (STDs) should not use an IUD, because the risk of infection is higher. Women who have multiple sexual partners are especially at risk for STDs. Monogamous married women are less apt to contract STDs. Women with rosacea can use an IUD.

439. A 50-year-old female patient asks a nurse about taking aspirin to prevent heart disease. The patient does not have a history of myocardial infarction. Her cholesterol and blood pressure are normal, and she does not smoke. What will the nurse tell the patient? a. Aspirin is useful only for preventing a second myocardial infarction. b. She should ask her provider about using a P2Y12 ADP receptor antagonist. c. She should take one 81-mg tablet per day to prevent myocardial infarction. d. There is most likely no protective benefit for patients her age.

ANS: D ASA is used for primary prevention of myocardial infarction (MI) in men and in women older than 65 years. Aspirin for primary prevention may be used in women ages 55 to 79 years when the potential benefit of a reduction in MI outweighs the potential harm of increased GI hemorrhage. This patient has no previous history of MI, so the use of ASA is not indicated. ASA is useful for primary prevention, but only when indicated by cardiovascular risk, based on age, gender, cholesterol levels, blood pressure, and smoking status. A P2Y12 ADP receptor antagonist is used as secondary prevention. This patient should not begin taking ASA unless her risk factors change, or until she is 65 years old.

525. A patient with erectile dysfunction is prescribed sildenafil (Viagra) 50 mg PRN. Which assessment finding would be most concerning? a. Blood pressure reading of 118/76 b. Patient notes erection lasting 3 hours c. Patient reports of blurred vision d. Snoring now wakens the patient's wife

ANS: D All the assessment findings are indicative of potential side effects of sildenafil. However, snoring that has worsened indicates intensification of obstructive sleep apnea, which can lead to airway obstruction. This patient report would be most concerning.

494. A patient with osteopenia asks a nurse about the benefits of hormone therapy in preventing osteoporosis. Which statement by the nurse is correct? a. "Estrogen can help reverse bone loss." b. "Hormone therapy increases bone resorption." c. "Hormone therapy does not decrease fracture risk." d. "When hormone therapy is discontinued, bone mass is quickly lost."

ANS: D Benefits of HT for patients with osteopenia are not permanent; bone loss resumes when HT is discontinued. HT does not reverse bone loss that has already occurred. HT reduces bone resorption. HT can decrease fracture risk by a small amount.

419. A nursing student asks a nurse how beta blockers increase the oxygen supply to the heart in the treatment of anginal pain. The nurse tells the student that beta blockers: a. dilate arterioles to improve myocardial circulation. b. improve cardiac contractility, which makes the heart more efficient. c. increase arterial pressure to improve cardiac afterload. d. increase the time the heart is in diastole.

ANS: D Beta blockers increase the time the heart is in diastole, which increases the time during which blood flows through the myocardial vessels, allowing more oxygen to reach the heart. Beta blockers do not dilate arterioles. They do not increase cardiac contractility; they decrease it, which reduces the cardiac oxygen demand. They do not increase arterial pressure, which would increase the cardiac oxygen demand.

496. A nurse provides teaching to a group of nursing students about the risks and benefits of hormone therapy (HT), including estrogen therapy (ET) and combination estrogen/progestin therapy (EPT). Which statement by a student indicates understanding of the teaching? a. "ET can provide protection against coronary heart disease and reverse osteoporosis." b. "EPT is generally safer than ET, especially in women who have undergone hysterectomies." c. "In women with established coronary heart disease, EPT can protect against myocardial infarction." d. "Principal benefits of ET are suppression of menopausal symptoms and prevention of bone loss."

ANS: D ET can be used to suppress menopausal symptoms and to prevent osteoporosis, but it carries risks of breast cancer and stroke, while conferring no preventive benefit for coronary heart disease. ET does not reverse osteoporosis but may help prevent it. EPT is not safer than ET; progestins appear to increase the risk of breast cancer. EPT does not prevent myocardial infarction in patients with coronary heart disease.

490. A postmenopausal patient who has had a hysterectomy and who has a family history of coronary heart disease reports experiencing vaginal dryness and pain with intercourse but tells the nurse that she does not want to take hormones because she is afraid of adverse effects. The nurse will suggest that the woman ask her provider about: a. Depo Provera. b. Estraderm. c. low-dose estrogens. d. Premarin vaginal.

ANS: D Estrogens for intravaginal administration are used for local effects, primarily to treat vulval and vaginal atrophy. Because these preparations bypass the liver, the total dose is reduced and there is a lower risk of systemic effects. Depo Provera is a progesterone and is not indicated. Transdermal estrogen is used to treat hot flushes. Low-dose estrogens still have systemic effects.

429. A patient is receiving heparin postoperatively to prevent deep vein thrombosis. The nurse notes that the patient has a blood pressure of 90/50 mm Hg and a heart rate of 98 beats/minute. The patient's most recent aPTT is greater than 90 seconds. The patient reports lumbar pain. The nurse will request an order for: a. a repeat aPTT to be drawn immediately. b. analgesic medication. c. changing heparin to aspirin. d. protamine sulfate.

ANS: D Heparin overdose may cause hemorrhage, which can be characterized by low blood pressure, tachycardia, and lumbar pain. Protamine sulfate should be given, and the heparin should be discontinued. An aPTT may be drawn later to monitor the effectiveness of protamine sulfate. Analgesics are not indicated because the lumbar pain is likely caused by adrenal hemorrhage. Aspirin will only increase the risk of hemorrhage.

508. A patient calls the nurse to report that she forgot to take a combination OC pill during the third week of her cycle. She tells the nurse that she missed another pill earlier that week. The nurse will tell her to: a. continue the pack, skip the inert pills, and use an additional form of contraception for 7 days. b. not to worry, because up to 7 days can be missed without an increased risk of pregnancy. c. take a pill immediately, continue the pack, and use an additional form of contraception for 1 month. d. take a pill now, continue the pack, skip the placebo pills, and start a new pack on week 4.

ANS: D If one or two pills are missed during the second or third week of a 28-day cycle, the patient should be instructed to take one pill as soon as possible, continue the pack, skip the placebo pills, and go straight to a new pack. It is not necessary to use an alternative form of contraception. If three or more pills are missed, the risk of pregnancy increases.

459. A patient who has been prescribed oral ferrous sulfate reports taking extra doses for the past few months. The patient's serum iron level is 560 mcg/dL. What will the nurse expect the provider to order for this patient? a. Discontinuing the ferrous sulfate and rechecking the iron level in 1 month b. Gastric lavage and treatment for acidosis and shock c. Giving oral deferasirox [Exjade] d. Giving parenteral deferoxamine [Desferal]

ANS: D If the plasma level of iron is high (above 500 mcg/dL), it should be lowered with parenteral deferoxamine. This level is toxic and must be treated. Gastric lavage is used if unabsorbed tablets are present. Oral deferasirox is used for chronic overload caused by blood transfusions.

527. A patient prescribed dutasteride 2 weeks ago presents with continued complaints of urinary hesitancy. Which action is most appropriate? a. Obtain a urine sample. b. Double the daily dose. c. Perform a prostate examination. d. Document these findings.

ANS: D It may take up to 1 month for the effects of dutasteride to take effect. The patient should be educated about the time taken for positive effects to be achieved. A urine sample would not be necessary. Doubling the dose is not appropriate because the medication has not had sufficient time to take effect. A prostate examination may be performed, but would not reveal findings related to the use of dutasteride.

521. A nurse is obtaining a history and reviewing the chart of an adult male patient who has been taking oral androgens. Which assessment would warrant notifying the provider? a. Acne and increased facial hair b. Breast enlargement c. Increased libido d. Nausea, anorexia, and fatigue

ANS: D Nausea, anorexia, and fatigue can indicate hepatotoxicity and should be reported to the provider. Virilization effects, gynecomastia, and an increase in libido are common, expected effects.

427. A patient asks a nurse how nitroglycerin works to relieve anginal pain. The nurse correctly states, "Nitroglycerin: a. dilates coronary arteries to increase the blood flow to the heart." b. increases the oxygen supply to the cardiac muscle." c. increases ventricular filling to improve cardiac output." d. promotes vasodilation, which reduces preload and oxygen demand."

ANS: D Nitroglycerin dilates the veins, which reduces venous return to the heart, which in turn decreases ventricular filling. The resulting decrease in preload reduces the oxygen requirements of the heart. Nitroglycerin does not increase the blood flow or oxygen supply to the heart. An increase in ventricular filling would increase oxygen demand and result in increased anginal pain.

413. A patient who has begun using transdermal nitroglycerin for angina reports occasional periods of tachycardia. The nurse will expect the prescriber to order: a. digoxin [Lanoxin] to slow the heart rate. b. immediate discontinuation of the nitroglycerin. c. periods of rest when the heart rate increases. d. verapamil as an adjunct to nitroglycerin therapy.

ANS: D Nitroglycerin lowers blood pressure by reducing venous return and dilating the arterioles. The lowered blood pressure activates the baroreceptor reflex, causing reflex tachycardia, which can increase cardiac demand and negate the therapeutic effects of nitroglycerin. Treatment with a beta blocker or verapamil suppresses the heart to slow the rate. Digoxin is not recommended. Discontinuation of the nitroglycerin is not indicated. Resting does not slow the heart when the baroreceptor reflex is the cause of the tachycardia.

497. A patient who is at risk for osteoporosis will begin taking the selective estrogen receptor modulator raloxifene [Evista]. Which statement will the nurse include when teaching this patient about the medication? a. Raloxifene reduces the risk of thromboembolism. b. The drug is associated with an increased risk of breast cancer. c. Use of this drug increases the risk of endometrial carcinoma. d. Vasomotor symptoms are a common side effect of this drug.

ANS: D Raloxifene can induce hot flashes in patients taking this drug. It increases the risk for thromboembolism. It protects against breast cancer and does not pose a risk of uterine cancer.

506. A nurse is teaching a community education class on contraceptives. The nurse tells the class that if spermicides containing nonoxynol-9 are used, the patient should take special precautions, because these spermicides have been linked to: a. human papillomavirus (HPV) infections. b. spontaneous abortions. c. endometrial cancer. d. increased transmission of the human immunodeficiency virus (HIV).

ANS: D Spermicides that contain nonoxynol-9 have been linked to the increased transmission of HIV. Spermicides containing nonoxynol-9 have not been linked to HPV infections, spontaneous abortions, or endometrial cancer.

520. A nurse provides teaching for a female patient with anemia who has had cancer chemotherapy and who will begin treatment with testosterone. Which statement by the patient indicates understanding of the teaching? a. "Facial hair may develop with this drug but will go away over time." b. "I may experience an increase in breast size while taking this drug." c. "Testosterone may increase my high-density lipoprotein (HDL) cholesterol and reduce my low-density lipoprotein (LDL) cholesterol." d. "Testosterone treats anemia by stimulating the synthesis of a renal hormone."

ANS: D Testosterone can be used to treat refractory anemias in men and women. It works by stimulating the synthesis of erythropoietin, a renal hormone that stimulates the production of red blood cells. Virilization effects can be permanent if the hormone is not withdrawn, so patients developing facial hair and other signs should be told to report this to the provider. Breast enlargement occurs in males taking this drug. Testosterone reduces HDL cholesterol and increases LDL cholesterol.

516. An adolescent male patient is beginning androgen therapy for delayed puberty. His parents ask the nurse when this treatment may be stopped. The nurse will offer which response? a. After 3 to 4 years of therapy b. If acne and facial hair develop c. When complete sexual maturation has occurred d. When testicular enlargement occurs

ANS: D Testosterone therapy is used to treat delayed maturity, but only for a limited course. Testicular enlargement is the first change associated with puberty and is a sign that puberty has begun. Males with hypogonadism need treatment for 3 to 4 years. Acne and facial hair are common side effects. Attaining complete sexual maturation is not necessary.

518. A nurse is providing education to a patient who is beginning therapy with AndroGel testosterone gel. Which statement made by the patient demonstrates a need for further teaching? a. "I should not shower or swim for at least 5 to 6 hours after application." b. "I should avoid direct skin-to-skin contact with my spouse where the medication was applied." c. "I should have my blood drawn for laboratory tests in 14 days." d. "I should apply the medication to my genitals for best results."

ANS: D The medication should be applied to the arms, shoulders, and abdomen, not to the genitalia; this statement indicates a need for further teaching. The patient should be instructed not to shower, bathe, or swim for 5 to 6 hours after applying the medication. The patient should be instructed to keep areas where the medication was applied covered to prevent direct skin-to-skin contact with others. The patient should be advised to return to the clinic within 2 weeks for blood tests.

495. The nurse is providing patient education about the application of transdermal estrogen spray. Which statement made by the patient best demonstrates understanding of the application of this medication? "I should apply this medication to my: a. waistline and shoulders." b. abdomen and arms." c. breasts and abdomen." d. thighs and calves."

ANS: D The top of the thighs and the back of the calves are the preferred sites for application of the transdermal spray. The waistline and abdomen are used for the patches. The gel is applied to arms. Breasts are never used for application of transdermal estrogen.

440. A patient who takes warfarin [Coumadin] is brought to the emergency department after accidentally taking too much warfarin. The patient's heart rate is 78 beats/minute and the blood pressure is 120/80 mm Hg. A dipstick urinalysis is normal. The patient does not have any obvious hematoma or petechiae and does not complain of pain. The nurse will anticipate an order for: a. vitamin K (phytonadione). b. protamine sulfate. c. a PTT. d. aPTandanINR.

ANS: D This patient does not exhibit any signs of bleeding from a warfarin overdose. The vital signs are stable, there are no hematomas or petechiae, and the patient does not have pain. A PT and INR should be drawn to evaluate the anticoagulant effects. Vitamin K may be given if laboratory values indicate overdose. Protamine sulfate is given for heparin overdose. PTT evaluation is used to monitor heparin therapy.

434. A patient who takes warfarin for atrial fibrillation undergoes hip replacement surgery. On the second postoperative day, the nurse assesses the patient and notes an oxygen saturation of 83%, pleuritic chest pain, shortness of breath, and hemoptysis. The nurse will contact the provider to report possible __ and request an order for __. a. congestive heart failure; furosemide [Lasix] b. hemorrhage; vitamin K (phytonadione) c. myocardial infarction; tissue plasminogen activator (tPA) d. pulmonary embolism; heparin

ANS: D This patient is exhibiting signs of pulmonary embolism. Heparin is used when rapid onset of anticoagulants is needed, as with pulmonary embolism. The patient would have respiratory cracks and a cough with congestive heart failure. Hemorrhage involves a decrease in blood pressure, bruising, and lumbar pain. The patient has pleuritic pain, which is not consistent with the chest pain of a myocardial infarction.

510. A nurse working in a family planning clinic is preparing to administer a first dose of intramuscular DMPA [Depo-Provera] to a young adult patient. The woman tells the nurse she has just finished her period. What will the nurse do? a. Administer the injection today and counsel backup contraception for 7 days. b. Administer the injection today and tell her that protection is immediate. c. Obtain a pregnancy test to rule out pregnancy before administering the drug. d. Schedule an appointment for her to receive the injection in 3 weeks.

ANS: D To ensure that patients are not pregnant when they receive DMPA, the first injection should be given during the first 5 days of a normal menstrual period.

491. A 50-year-old postmenopausal patient who has had a hysterectomy has moderate to severe vasomotor symptoms and is discussing estrogen therapy (ET) with the nurse. The patient is concerned about adverse effects of ET. The nurse will tell her that: a. an estrogen-progesterone product will reduce side effects. b. an intravaginal preparation may be best for her. c. side effects of ET are uncommon among women her age. d. transdermal preparations have fewer side effects.

ANS: D Transdermal preparations of estrogen have fewer adverse effects, use lower doses of estrogen, and have less fluctuation of estrogen levels than do oral preparations. Progesterone is contraindicated in women who have undergone hysterectomy. Intravaginal preparations are most useful for treating local estrogen deficiency such as vaginal and vulvar atrophy. Side effects of ET are the same at the patient's age as for other women using ET.

526. A patient with erectile dysfunction is prescribed tadalafil (Cialis) 2.5 mg daily. Which medication history finding would indicate the need to discontinue this prescription? a. Labetolol 25 mg PO BID b. Nitrofurantoin 100 mg daily c. Carvedilol 6.25 mg twice daily d. Nitro-tab 0.4 mg sublingual PRN

ANS: D Use of PDE-5 inhibitors is contraindicated in patients receiving nitrate preparations due to the risk of profound hypotension. Labetolol is administered for hypertension. Carvedilol is administered for chronic heart failure. Tadalafil should be used with caution in these patients, but may still be administered. Nitrofurantoin is an antimicrobial that does not affect tadalafil administration.

417. A nurse is discussing the difference between stable and variant angina with a group of nursing students. Which statement by a student indicates the need for further teaching? a. "Beta blockers are effective in stable angina but not in variant angina." b. "In both types of angina, prophylactic treatment is possible." c. "Variant angina is primarily treated with vasodilators to increase oxygen supply." d. "Variant angina is the result of increased oxygen demand by the heart."

ANS: D Variant angina is caused by coronary artery spasm, which reduces the oxygen supply to the heart. Beta blockers are not effective in variant angina but are useful with stable angina. Medications may be given to prevent anginal attacks in both types of angina. Vasodilators are used in variant angina to relieve coronary artery spasm and increase the oxygen supply to the heart.

452. A patient is admitted to the hospital. The patient's initial laboratory results reveal megaloblastic anemia. The patient complains of tingling of the hands and appears confused. The nurse suspects what in this patient? a. Celiac disease b. Folic acid deficiency c. Iron deficiency anemia d. Vitamin B12 deficiency

ANS: D When patients present with megaloblastic anemia, it is essential to distinguish between folic acid deficiency and vitamin B12 deficiency. If neurologic deficits are observed, vitamin B12 deficiency is more likely to be the cause. This patient does not have signs of celiac disease. Iron deficiency anemia would be indicated by a low hemoglobin and hematocrit.

438. A patient has been taking warfarin [Coumadin] for atrial fibrillation. The provider has ordered dabigatran etexilate [Pradaxa] to replace the warfarin. The nurse teaches the patient about the change in drug regimen. Which statement by the patient indicates understanding of the teaching? a. "I may need to adjust the dose of dabigatran after weaning off the warfarin." b. "I should continue to take the warfarin after beginning the dabigatran until my INR is greater than 3." c. "I should stop taking the warfarin 3 days before starting the dabigatran." d. "I will stop taking the warfarin and will start taking the dabigatran when my INR is less than 2."

ANS: D When switching from warfarin to dabigatran, patients should stop taking the warfarin and begin taking the dabigatran when the INR is less than 2. It is not correct to begin taking the dabigatran before stopping the warfarin. While warfarin is stopped before beginning the dabigatran, the decision to start taking the dabigatran is based on the patient's INR and not on the amount of time that has elapsed.

455. A patient was given a 30-day supply of Feosol and has been taking the drug for 4 weeks for iron deficiency anemia. The patient's initial hemoglobin was 8.9 gm/dL. The nurse notes that the hemoglobin has risen to 9.7 gm/dL. What will the nurse ask the patient about? a. Dietary iron intake b. Gastrointestinal (GI) upset c. Whether stools have been tarry or black d. Whether the prescription needs to be refilled

ANS: D When therapy is successful, the hemoglobin level increases by 2 gm/dL within 1 month. If the hemoglobin does not increase as expected, patients should be asked about compliance. If a patient reports that the prescription does not need to be refilled, the medication probably has not been taken as prescribed. Dietary iron intake is not a part of iron replacement therapy but is an important part of the prevention of anemia. GI upset and tarry, black stools are expected side effects of iron products.