Pharm E2 - Study Guide+

How long does it take for Aldactone to have an effect?

48 hours

A nurse is teaching a patient who will begin taking verapamil [Calan] for hypertension about the drug's side effects. Which statement by the patient indicates understanding of the teaching?

A. "I may become constipated, so I should increase fluids and fiber."Constipation is common with verapamil and can be minimized by increasing dietary fiber and fluids. Verapamil lowers the heart rate. Peripheral edema may occur secondary to vasodilation, and patients should notify their prescriber if this occurs, because the prescriber may use diuretics to treat the condition. Verapamil and digoxin have similar cardiac effects; also, verapamil may increase plasma levels of digoxin by as much as 60%, so digoxin doses may need to be reduced.

A patient with diabetes develops hypertension. The nurse will anticipate administering which type of medication to treat hypertension in this patient?

A. ACE inhibitors ACE inhibitors slow the progression of kidney injury in diabetic patients with renal damage. Beta blockers can mask signs of hypoglycemia and must be used with caution in diabetics. Direct-acting vasodilators are third-line drugs for chronic hypertension. Thiazide diuretics promote hyperglycemia.

The potassium-sparing diuretic spironolactone [Aldactone] prolongs survival and improves heart failure symptoms by which mechanism?

A. Blocking aldosterone receptors Spironolactone prolongs survival in patients with HF primarily by blocking receptors for aldosterone. Spironolactone cause only minimal diuresis. It does not reduce afterload, and it does not reduce venous pressure enough to prolong survival, because it causes only minimal diuresis.

A nurse is concerned about renal function in an 84-year-old patient who is taking several medications. What will the nurse assess?

A. Creatinine clearance The proper index of renal function in older adults is creatinine clearance, which indicates renal function in older patients whose organs are undergoing age-related deterioration. Sodium and potassium levels are not indicative of renal function. Serum creatinine levels do not reflect kidney function in older adults because lean muscle mass, which is the source of creatinine in serum, declines and may be low even with reduced kidney function.

A thin older adult woman is admitted to the hospital after several days of vomiting, diarrhea, and poor intake of foods and fluids. She has not voided since admission. In preparing to care for this patient, the nurse will look for what laboratory values to help guide medication administration? (Select all that apply.)

A. Creatinine clearance C. Plasma drug levels D. Serum albumin Creatinine clearance is the best way to evaluate renal function in the older adult. Plasma drug levels are important for determining if the patient has toxic or subtherapeutic drug levels. Serum albumin may be decreased, especially in patients who are thin, are chronically undernourished, or have been vomiting, and the decreased level may result in higher levels of drugs that normally bind to proteins. Gastric pH is not important; most GI changes result in lowered absorption and less free drug. Serum creatinine levels are related to the amount of lean muscle mass, which may be low in older adult patients, and do not reflect renal function.

A patient is admitted to the hospital after several days of vomiting and diarrhea. After an initial bolus of isotonic (0.9%) sodium chloride solution, the prescriber orders dextrose 5% in normal saline (D5NS) with 20 mEq potassium chloride to infuse at a maintenance rate. What should the nurse review before implementing this order? (Select all that apply.)

A. Electrocardiogram C. Serum electrolyte levels E. Urine output Patients receiving potassium should be monitored for cardiovascular toxicity; an ECG before and during administration can help monitor for this adverse effect. Serum electrolyte levels should be reviewed to make sure the patient is not already hyperkalemic. Because potassium is excreted via the kidneys, it is important to determine that renal function is intact. Intravenous potassium should never be given if the patient has not voided. Patients who are hyperkalemic can be treated with sodium bicarbonate to increase pH and insulin to promote uptake of potassium by cells, but it is not necessary to evaluate the blood gas or glucose levels before administering potassium.

A patient is admitted to the hospital after several days of vomiting and diarrhea. After an initial bolus of isotonic (0.9%) sodium chloride solution, the prescriber orders dextrose 5% in normal saline (D5NS) with 20 mEq potassium chloride to infuse at a maintenance rate. What should the nurse review before implementing this order? (Select all that apply.)

A. Electrocardiogram C. Serum electrolyte levels E. Urine output Patients receiving potassium should be monitored for cardiovascular toxicity; an ECG before and during administration can help monitor for this adverse effect. Serum electrolyte levels should be reviewed to make sure the patient is not already hyperkalemic. Because potassium is excreted via the kidneys, it is important to determine that renal function is intact. Intravenous potassium should never be given if the patient has not voided. Patients who are hyperkalemic can be treated with sodium bicarbonate to increase pH and insulin to promote uptake of potassium by cells, but it is not necessary to evaluate the blood gas or glucose levels before administering potassium.

An older adult patient with congestive heart failure develops crackles in both lungs and pitting edema of all extremities. The physician orders hydrochlorothiazide [HydroDIURIL]. Before administering this medication, the nurse reviews the patient's chart. Which laboratory value causes the nurse the most concern?

A. Elevated creatinine clearance Hydrochlorothiazide should not be given to patients with severe renal impairment; therefore, an elevated creatinine clearance would cause the most concern. Thiazide diuretics are potassium-wasting drugs and thus may actually improve the patient's potassium level. Thiazides may elevate the serum glucose level in diabetic patients. Thiazides increase LDL cholesterol; however, this patient's levels are low, so this is not a risk.

A patient is brought to the emergency department with shortness of breath, a respiratory rate of 30 breaths per minute, intercostal retractions, and frothy, pink sputum. The nurse caring for this patient will expect to administer which drug?

A. Furosemide [Lasix] Furosemide, a potent diuretic, is used when rapid or massive mobilization of fluids is needed. This patient shows severe signs of congestive heart failure with respiratory distress and pulmonary edema and needs immediate mobilization of fluid. Hydrochlorothiazide and spironolactone are not indicated for pulmonary edema, because their diuretic effects are less rapid. Mannitol is indicated for patients with increased intracranial pressure and must be discontinued immediately if signs of pulmonary congestion or heart failure occur.

A patient who was in a motor vehicle accident sustained a severe head injury and is brought into the emergency department. The provider orders intravenous Mannitol [Osmitrol]. The nurse knows that this is given to:

A. Reduce intracranial pressure Mannitol is an osmotic diuretic that is used to reduce intracranial pressure by relieving cerebral edema. The presence of mannitol in blood vessels in the brain creates an osmotic force that draws edematous fluid from the brain into the blood. Mannitol can also be used to increase renal perfusion. It can cause peripheral edema and is not used to restore extracellular fluid.

A patient is recovering from a myocardial infarction but does not have symptoms of heart failure. The nurse will expect to teach this patient about:

ACE inhibitors and beta blockers. This patient is classified as having Stage B heart failure with no current symptoms but with structural heart disease strongly associated with the development of heart failure. Treatment at this stage includes an ACE inhibitor and a beta blocker to help prevent the progression of symptoms. Biventricular pacemakers are used for patients in Stage C heart failure and have more advanced structural disease and symptoms. Dietary supplements and exercise have not been proven to prevent structural heart disease. Diuretics and digoxin are used for patients with Stage C heart failure.

A nurse is caring for a patient who is receiving verapamil [Calan] for hypertension and digoxin [Lanoxin] for heart failure. The nurse will observe this patient for:

AV blockade Verapamil and digoxin both suppress impulse conduction through the AV node; when the two drugs are used concurrently, the risk of AV blockade is increased. Gingival hyperplasia can occur in rare cases with verapamil, but it is not an acute symptom. Verapamil can be used to prevent migraine, and its use for this purpose is under investigation. Verapamil and digoxin both suppress the heart rate. Nifedipine causes reflex tachycardia.

A patient who uses an inhaled glucocorticoid for chronic asthma calls the nurse to report hoarseness. What will the nurse do?

Ask whether the patient is rinsing the mouth after each dose. The most common side effects of inhaled glucocorticoids are oropharyngeal candidiasis and dysphonia. To minimize these, patients should be advised to gargle after each administration. Antifungal medications are used after a fungal infection has been diagnosed. Hoarseness is not a sign of a bronchial infection. There is no need to discontinue the glucocorticoid

A patient who uses an inhaled glucocorticoid for chronic asthma calls the nurse to report hoarseness. What will the nurse do?

Ask whether the patient is rinsing the mouth after each dose. The most common side effects of inhaled glucocorticoids are oropharyngeal candidiasis and dysphonia. To minimize these, patients should be advised to gargle after each administration. Antifungal medications are used after a fungal infection has been diagnosed. Hoarseness is not a sign of a bronchial infection. There is no need to discontinue the glucocorticoid.

A patient with Stage C heart failure (HF) who has been taking an ACE inhibitor, a beta blocker, and a diuretic begins to have increased dyspnea, weight gain, and decreased urine output. The provider orders spironolactone [Aldactone]. The nurse will instruct the patient to:

Avoid potassium supplements. Spironolactone is added to therapy for patients with worsening symptoms of HF. Because spironolactone is a potassium-sparing diuretic, patients should not take supplemental potassium. Patients taking digoxin need to monitor their heart rate. Extra fluids are not indicated. Salt substitutes contain potassium.

A patient with chronic congestive heart failure has repeated hospitalizations in spite of ongoing treatment with hydrochlorothiazide [HydroDIURIL] and digoxin. The prescriber has ordered spironolactone [Aldactone] to be added to this patient's drug regimen, and the nurse provides education about this medication. Which statement by the patient indicates understanding of the teaching?

B. "I need to stop taking potassium supplements." Spironolactone is a potassium-sparing diuretic used to counter the potassium-wasting effects of hydrochlorothiazides. Patients taking potassium supplements are at risk for hyperkalemia when taking this medication, so they should be advised to stop the supplements. Spironolactone takes up to 48 hours to have effects. Salt substitutes contain high levels of potassium and are contraindicated. Spironolactone is a weak diuretic, so the risk of dehydration is not increased.

Which order for potassium (KCl) would the nurse question? (Select all that apply.)

B. D5 NS with 60 mEq KCl for a patient with a serum potassium of 3.2 mEq/L C. K-Dur, 1 tablet daily for a patient in diabetic ketoacidosis E. Potassium chloride, 10 mEq rapid IV push Patients receiving potassium should not receive potassium in solution diluted at more than 40 mEq/L. Diabetic ketoacidosis causes decreased cellular uptake of potassium, and patients in whom acidosis is present should also receive sodium bicarbonate if they need potassium. IV potassium should not be infused faster than 10 mEq/hr. NS with 20 mEq KCl is an appropriate solution for a patient with intact renal function. Oral potassium should be given with a full glass of water to minimize gastrointestinal (GI) effects.

A patient with congestive heart failure is admitted to the hospital. During the admission assessment, the nurse learns that the patient is taking a thiazide diuretic. The nurse notes that the admission electrolyte levels include a sodium level of 142 mEq/L, a chloride level of 95 mEq/L, and a potassium level of 3 mEq/L. The prescriber has ordered digoxin to be given immediately. What will the nurse do initially?

B. Hold the digoxin and report the laboratory values to the provider. Potassium depletion is common with thiazide diuretics, and hypokalemia is especially dangerous for patients receiving digoxin, because the drug can precipitate a fatal dysrhythmia and digoxin toxicity. The provider should be notified of the serum potassium level so that it can be corrected before the digoxin is administered. Giving the digoxin could produce a fatal adverse effect, so this is not an appropriate course of action. Holding the thiazide diuretic will not correct the potassium deficiency. An ECG is not the initial priority.

A patient with chronic hypertension is admitted to the hospital. During the admission assessment, the nurse notes a heart rate of 96 beats per minute, a blood pressure of 150/90 mm Hg, bibasilar crackles, 2+ pitting edema of the ankles, and distension of the jugular veins. The nurse will contact the provider to request an order for which medication?

C. Furosemide [Lasix] This patient shows signs of fluid volume overload and needs a diuretic. Furosemide is a loop diuretic, which can produce profound diuresis very quickly even when the glomerular filtration rate (GFR) is low. An ACE inhibitor will not reduce fluid volume overload. Digoxin has a positive inotropic effect on the heart, which may improve renal perfusion, but this is not its primary effect. Spironolactone is a potassium-sparing diuretic with weak diuresis effects; it is used in conjunction with other diuretics to improve electrolyte balance.

A patient with hypertension will begin taking an alpha1 blocker. What will the nurse teach this patient?

C. Move slowly from sitting to standing when taking this drug. The most disturbing side effect of alpha blockers is orthostatic hypotension. Patients taking these drugs should be cautioned to stand up slowly to avoid lightheadedness or falls. A persistent cough is a common side effect of ACE inhibitors. It is not necessary to increase dietary potassium intake when taking this drug. Shortness of breath may occur in individuals with asthma who are taking beta blockers.

A patient who is taking digoxin is admitted to the hospital for treatment of congestive heart failure. The prescriber has ordered furosemide [Lasix]. The nurse notes an irregular heart rate of 86 beats per minute, a respiratory rate of 22 breaths per minute, and a blood pressure of 130/82 mm Hg. The nurse auscultates crackles in both lungs. Which laboratory value causes the nurse the most concern?

C. Potassium level of 3.5 mEq/L This patient has an irregular, rapid heartbeat that might be caused by a dysrhythmia. This patient's serum potassium level is low, which can trigger fatal dysrhythmias, especially in patients taking digoxin. Furosemide contributes to loss of potassium through its effects on the distal nephron. Potassium-sparing diuretics often are used in conjunction with furosemide to prevent this complication. This patient's serum glucose and sodium levels are normal and of no concern at this point, although they can be affected by furosemide. The oxygen saturation is somewhat low and needs to be monitored, although it may improve with diuresis.

A nursing student asks a nurse why a patient in hypertensive crisis is receiving both intravenous sodium nitroprusside [Nitropress] and oral hydralazine. The nurse will explain that this is done to prevent:

C. Rebound hypertension Sodium nitroprusside acts rapidly and is given only intravenously. Rebound hypertension occurs immediately when the IV is stopped, so an oral antihypertensive should be given simultaneously. Cyanide poisoning can occur with sodium nitroprusside, but giving hydralazine does not counter this adverse effect. Hydralazine does not prevent fluid retention or reflex tachycardia.

A patient is taking gentamicin [Garamycin] and furosemide [Lasix]. The nurse should counsel this patient to report which symptom?

C. Ringing in the ears Patients taking furosemide should be advised that the risk of furosemide-induced hearing loss can be increased when other ototoxic drugs, such as gentamicin, are also taken. Patients should be told to report tinnitus, dizziness, or hearing loss. Nocturia may be an expected effect of furosemide. Headaches are not likely to occur with concomitant use of gentamicin and furosemide. Urinary retention is not an expected side effect.

A nursing student asks the nurse why multi-drug therapy is often used to treat hypertension. Which statement by the student indicates a need for further teaching?

D. "Two or more drugs will lower blood pressure more quickly." Multi-drug therapy does not lower blood pressure more quickly. Using more than one drug often means that doses can be decreased. Some agents can offset adverse effects of other agents. Treatment via different mechanisms increases the likelihood of success.

A nurse preparing to administer morning medications notes that a patient with a history of hypertension has been prescribed spironolactone [Aldactone]. The nurse assesses the patient and notes dyspnea, bilateral crackles, and pitting edema in both feet. Which intervention is appropriate?

D. Request an order for furosemide [Lasix]. Spironolactone takes up to 48 hours for its effects to develop, so it should not be used when the patient needs immediate diuresis. This patient has shortness of breath, crackles, and edema and needs a short-acting diuretic, such as furosemide. Asking the patient about the use of salt substitutes is not indicated. The patient does not need assessment of serum electrolytes.

A patient is admitted with severe hypertensive crisis. The nurse will anticipate administering which medication?

D. Sodium nitroprusside [Nitropress] IVSodium nitroprusside is the drug of choice for hypertensive emergencies and is given intravenously. ACE inhibitors, such as captopril, are not used. Hydralazine may be used but should be given IV. Minoxidil is effective, but its severe side effects make it a second-line drug.

A patient with hypertension is taking furosemide [Lasix] for congestive heart failure. The prescriber orders digoxin to help increase cardiac output. What other medication will the nurse expect to be ordered for this patient?

D. Spironolactone [Aldactone] Spironolactone is used in conjunction with furosemide because of its potassium-sparing effects. Furosemide can contribute to hypokalemia, which can increase the risk of fatal dysrhythmias, especially with digoxin administration. The other diuretics listed are all potassium-wasting diuretics.

A patient who has been newly diagnosed with asthma is referred to an asthma clinic. The patient reports daily symptoms requiring short-acting beta2-agonist treatments for relief. The patient has used oral glucocorticoids three times in the past 3 months and reports awakening at night with symptoms about once a week. The patient's forced expiratory volume in 1 second (FEV1) is 75% of predicted values. The nurse will expect this patient to be started on which regimen?

Daily low-dose inhaled glucocorticoid/LABA with a SABA as needed This patient has moderate persistent asthma, which requires step 3 management for initial treatment. Step 3 includes daily inhalation of a low-dose glucocorticoid/LABA combination supplemented with a SABA as needed. A daily low-dose glucocorticoid with an as-needed SABA is used for step 2 management. A daily medium-dose glucocorticoid/LABA is used for step 4 management. Patients requiring step 1 management do not need daily medications.

A patient who has been newly diagnosed with asthma is referred to an asthma clinic. The patient reports daily symptoms requiring short-acting beta2-agonist treatments for relief. The patient has used oral glucocorticoids three times in the past 3 months and reports awakening at night with symptoms about once a week. The patient's forced expiratory volume in 1 second (FEV1) is 75% of predicted values. The nurse will expect this patient to be started on which regimen?

Daily low-dose inhaled glucocorticoid/LABA with a SABA as needed. This patient has moderate persistent asthma, which requires step 3 management for initial treatment. Step 3 includes daily inhalation of a low-dose glucocorticoid/LABA combination supplemented with a SABA as needed. A daily low-dose glucocorticoid with an as-needed SABA is used for step 2 management. A daily medium-dose glucocorticoid/LABA is used for step 4 management. Patients requiring step 1 management do not need daily medications.

A patient takes an ACE inhibitor to treat hypertension and tells the nurse that she wants to become pregnant. She asks whether she should continue taking the medication while she is pregnant. What will the nurse tell her?

Discuss using methyldopa instead while she is pregnant. Methyldopa has limited effects on uteroplacental and fetal hemodynamics and does not adversely affect the fetus or neonate. Controlling blood pressure does not lower the risk of preeclampsia. ACE inhibitors and ARBs are specifically contraindicated during pregnancy.

A nurse and a nursing student are reviewing the care of a 30-kg patient who will receive intravenous aminophylline. Which statement by the student indicates an understanding of the administration of this medication?

Dosing is titrated based on the serum theophylline levels. Dosing for aminophylline is based on each patient's serum theophylline levels. The loading dose usually is 6 mg/kg; after that, the maintenance infusion is titrated according to the theophylline levels. A serum theophylline level of 15 mcg/mL is within the therapeutic range, so dosing would not need to change. The patient's total loading dose will be 180 mg, but infusions should never be given at a rate faster than 25 mg/min.

A parent asks a nurse about growth suppression resulting from the use of an inhaled glucocorticoid in children. What will the nurse tell the parent?

Growth may be slowed, but eventual adult height will not be reduced. Glucocorticoids can slow growth in children and adolescents, but they do not reduce the eventual adult height. The growth rate will return to normal within a year, even when the drug is continued. Long-term use does not affect the eventual adult height.

A patient begins taking an ACE inhibitor and complains of a dry cough. What does the nurse correctly tell the patient about this symptom?

It may be uncomfortable enough that the drug will need to be discontinued. The most disturbing side effect of alpha blockers is orthostatic hypotension. Patients taking these drugs should be cautioned to stand up slowly to avoid lightheadedness or falls. A persistent cough is a common side effect of ACE inhibitors. It is not necessary to increase dietary potassium intake when taking this drug. Shortness of breath may occur in individuals with asthma who are taking beta blockers.

A patient with persistent, frequent asthma exacerbations asks a nurse about a long-acting beta2-agonist medication. What will the nurse tell this patient?

LABAs should be combined with an inhaled glucocorticoid. LABAs can increase the risk of asthma-related deaths when used improperly; this risk is minimized when LABAs are combined with an inhaled glucocorticoid. LABAs are not safer than SABAs, and they are not used PRN. LABAs increase the risk of asthma-related deaths.

A young adult woman will begin using an inhaled glucocorticoid to treat asthma. The nurse will teach this patient about the importance of which action?

Participating in weight-bearing exercises on a regular basis. Like oral glucocorticoids, inhaled glucocorticoids can promote bone loss in premenopausal women. Patients should be encouraged to participate in weight-bearing exercises to help minimize this side effect. Patients should increase both their calcium and vitamin D intakes. Patients taking oral glucocorticoids need increased steroids in times of stress. It is not necessary to use two reliable forms of birth control.

A patient who takes oral theophylline [Theochron] twice daily for chronic stable asthma develops an infection and will take ciprofloxacin. The nurse will contact the provider to discuss:

Reducing the theophylline dose. Fluoroquinolone antibiotics increase theophylline levels, so the dose of theophylline may need to be reduced to prevent theophylline toxicity. Changing antibiotics, giving the theophylline once daily, and changing to a LABA are not indicated.

A child with seasonal rhinitis has used budesonide [Rhinocort Aqua] for several years. The parents are concerned that the child's rate of growth has slowed. What will the nurse do?

Suggest that the parents discuss using fluticasone [Flonase] with the provider. A worrisome systemic effect of intranasal glucocorticoids is suppression of linear growth in children. Although rare, it can occur; however, it is less likely with fluticasone and mometasone, so these two preparations are better options for children. Reassuring parents that this is an expected side effect is incorrect. Intranasal glucocorticoids should be given daily and not as needed. Antihistamines are not as effective as glucocorticoids, because antihistamines work only against one mediator of allergic inflammation.

A prescriber orders ramipril [Altace] for an obese patient with type 2 diabetes mellitus who has developed hypertension. The nurse provides teaching before dismissing the patient home. Which statement by the patient indicates understanding of the teaching?

Taking this medication helps reduce my risk of stroke and heart attack. Ramipril [Altace] is approved for reducing the risk of stroke and myocardial infarction (MI) in patients at high risk for a major cardiovascular event because they have hypertension in conjunction with a history of stroke or MI or because they have diabetes. ACE inhibitors cannot be used for primary prevention of diabetic nephropathy, but they can delay the onset of overt nephropathy in patients who already have less advanced nephropathy. ACE inhibitors do not affect serum electrolytes or glucose. One ACE inhibitor, enalapril, can reduce the risk of diabetic retinopathy in some patients with type 1 diabetes mellitus.

A patient with stable COPD receives prescriptions for an inhaled glucocorticoid and an inhaled beta2-adrenergic agonist. Which statement by the patient indicates understanding of this medication regimen?

The glucocorticoid is used as prophylaxis to prevent exacerbations. Inhaled glucocorticoids are used daily to prevent acute attacks. They are not used PRN. The beta2-adrenergic agonist drugs should not be used daily; they are used to treat symptoms as needed. They do not suppress mediators of inflammation.

A patient with asthma will be using a metered-dose inhaler (MDI) for delivery of an inhaled medication. The provider has ordered 2 puffs to be given twice daily. It is important for the nurse to teach this patient that:

d. the patient should wait 1 minute between puffs. When two puffs are needed, an interval of at least 1 minute should separate the first puff from the second. Sudden inhalation can cause bronchospasm. The patient should begin inhaling and then activate the device. There is no need to store the drug in the refrigerator.