pharm week 8 textbook NCLEX questions
The nurse is caring for a group of patients taking warfarin [Coumadin]. Which patients are at moderate to high risk for harm as a result of warfarin therapy? (Select all that apply.) A. A patient with variant genes that code for VKORC1 and CYP2CP B. A patient with a current INR of 2.2 treated for deep vein thrombosis C. A woman with a new onset of symptoms of a pulmonary embolus D. A patient on day 4 after hip replacement with a new order for warfarin E. A patient with a prosthetic heart valve, for whom an interacting drug is being deleted from the regimen
A. A patient with variant genes that code for VKORC1 and CYP2CP Correct C. A woman with a new onset of symptoms of a pulmonary embolus Correct E. A patient with a prosthetic heart valve, for whom an interacting drug is being deleted from the regimen Correct Patients with genetic alterations in VKORC1 and CYP2CP are at increased risk of warfarin-induced bleeding. An INR of 2.2 indicates a therapeutic warfarin level. Warfarin can cause fetal hemorrhage and is listed as Pregnancy Risk Category X. Warfarin could be prescribed for the prevention of deep vein thrombosis after hip replacement surgery. The day of prescription would not likely be a day to expect a dangerous adverse effect from warfarin, because its half-life is 1.5 to 2 days. Warfarin interacts with many other agents. The greatest risk for harm is when an interacting drug is being added to or deleted from the regimen.
Which nursing action should prevent an adverse effect of a liquid iron preparation? A. Administer the iron preparation through a dropper. B. Administer the liquid iron preparation along with vitamin C. C. Administer the liquid buccally to delay absorption and lessen adverse effects. D. Mix the liquid iron preparation with an antacid for patients with underlying peptic ulcer disease.
A. Administer the iron preparation through a dropper An adverse effect of liquid iron preparations is staining of the teeth, which can be prevented by (1) diluting the liquid iron with juice or water; (2) administering the iron through a straw or dropper; and (3) rinsing the mouth after administration. Whether liquid or tablet, vitamin C promotes the absorption of iron but also increases its adverse effects. Buccal administration increases the risk for contact with the teeth, leading to staining. Antacids reduce the effects of iron. Oral preparations should not be administered to patients with peptic ulcers, because the GI effects can aggravate the ulcers.
The nurse in the emergency department is receiving a report on a patient diagnosed with ST-elevation myocardial infarction (STEMI). What are the common biochemical markers and symptoms for an STEMI? (Select all that apply.) A. Chest pain and electrocardiographic (ECG) changes B. Decreased troponin I level C. Elevated troponin T level D. Elevated creatinine kinase level E. Weakness and diaphoresis
A. Chest pain and electrocardiographic (ECG) changes Correct C. Elevated troponin T level Correct D. Elevated creatinine kinase level Correct E. Weakness and diaphoresis Correct Patients experiencing STEMI typically present with chest pain, an elevated ST segment on the ECG, elevated levels of cardiac cell components (eg, troponin and creatinine kinase), sweating, weakness, and a sense of impending doom.
The nurse is administering iron dextran (INFeD) by intravenous (IV) infusion to a patient with iron deficiency. Which is the priority nursing action during the administration of this drug? A. Ensure that epinephrine is available as needed. B. Assess the lung sounds and respiratory rate. C. Monitor the blood urea nitrogen and creatinine levels. D. Use Y-connector tubing to connect to the primary line.
A. Ensure that epinephrine is available as needed. An anaphylactic reaction is the most serious potential adverse reaction to iron dextran administration. Epinephrine and resuscitation equipment should be readily available.
A patient is admitted to the emergency department with a diagnosis of ST-segment elevation myocardial infarction (STEMI). Which is the priority nursing action? A. Having the patient chew a 325-mg aspirin B. Administering meperidine [Demerol] for pain relief C. Giving verapamil [Calan] to lower blood pressure D. Preparing an insulin drip to manage complications
A. Having the patient chew a 325-mg aspirin In this situation, the nurse's top priority is to have the patient chew a 325-mg aspirin. Several other nursing actions also are important in patients with STEMI, including oxygen administration, morphine for pain relief and venodilation, beta blockers and nitroglycerin to improve hemodynamics, and reperfusion therapy by means of percutaneous intervention or fibrinolytics. Meperidine would not be an analgesic of choice. Verapamil is a calcium channel blocker, and these drugs are no longer considered beneficial in patients with STEMI. Most agents used for STEMI do not cause hyperglycemia; therefore, an insulin drip is not indicated.
Which organ regulates the body's iron stores? A. Intestines B. Kidneys C. Liver D. Bloodstream
A. Intestines Most of the iron absorbed in the body stays in place and there is not a great deal of iron turnover. Some is lost through the gastrointestinal (GI) tract, and much more can be lost through hemorrhage. The body prevents excessive buildup of iron by controlling the amount of uptake in the intestines. When stores are high, only about 2% to 3% of dietary iron is absorbed. Conversely, when iron levels are low, as much as 20% is absorbed.
The nurse is teaching a patient who has had an ST-segment elevation myocardial infarction (STEMI) about home medications. Which agent represents a drug category that should be taken by all post-MI patients? A. Metoprolol [Lopressor] B. Hydrochlorothiazide (HCTZ) C. Diltiazem [Cardizem] D. Lovastatin [Mevacor]
A. Metoprolol [Lopressor] All post-MI patients should take a beta blocker (metoprolol), an angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB), and an antiplatelet or anticoagulant agent. Although the other agents may be warranted, these three categories are universally indicated after an MI.
The laboratory calls to report a drop in the platelet count to 90,000/mm3 for a patient receiving heparin for the treatment of postoperative deep vein thrombosis. Which action by the nurse is the most appropriate? A. Notify the healthcare provider to discuss the reduction or withdrawal of heparin. B. Call the healthcare provider to discuss increasing the heparin dose to achieve a therapeutic level. C. Obtain vitamin K and prepare to administer it by intramuscular (IM) injection. D. Observe the patient and monitor the activated partial thromboplastin time (aPTT) as indicated
A. Notify the healthcare provider to discuss the reduction or withdrawal of heparin. Heparin-induced thrombocytopenia (HIT) is a potential immune-mediated adverse effect of heparin infusions that can prove fatal. HIT is suspected when the platelet counts fall significantly. A platelet count below 100,000/mm3 would warrant discontinuation of the heparin.
A patient is receiving continuous heparin infusion for venous thromboembolism treatment. Which laboratory results should the nurse monitor? (Select all that apply.) A. Platelets B. Vitamin K C. Prothrombin time (PT) D. International normalized ratio (INR) E. Activated partial thromboplastin time (aPTT)
A. Platelets Correct E. Activated partial thromboplastin time (aPTT) Correct To reduce the risk of heparin-induced thrombocytopenia (HIT), platelet counts should be monitored. Heparin therapy is monitored by measuring the laboratory test activated partial thromboplastin time (aPTT). Warfarin therapy is monitored by measuring prothrombin time (PT) and results are expressed as an international normalized ratio (INR). Vitamin K is not monitored for a heparin infusion.
A patient is being discharged from the hospital on warfarin [Coumadin] for deep vein thrombosis prevention. Which instructions should the nurse include in the patient's discharge teaching plan? (Select all that apply.) A. Wear a medical alert bracelet. B. Check all urine and stool for discoloration. C. Do not start any new medication without first talking to your healthcare provider. D. Enteric-coated aspirin and any aspirin products can be used unless they cause a gastrointestinal ulcer. E. No laboratory or home monitoring of international normalized ratio (INR) is required after the first 6 months
A. Wear a medical alert bracelet. Correct B. Check all urine and stool for discoloration. Correct C. Do not start any new medication without first talking to your healthcare provider. Correct Advise the patient to wear some form of identification (eg, Medic Alert bracelet) to alert emergency personnel to warfarin use. Bleeding is a major complication of warfarin therapy. Inform patients about the signs of bleeding, which include discolored urine or stools. Inform patients that warfarin is subject to a large number of potentially dangerous drug interactions. Instruct them to avoid all prescription and nonprescription drugs that have not been specifically approved by the prescriber. Aspirin and aspirin products should be avoided because aspirin can increase the effects of warfarin to promote bleeding and on the gastrointestinal tract to cause ulcers, thereby initiating bleeding. The INR should be determined frequently: daily during the first 5 days, twice a week for the next 1 to 2 weeks, once a week for the next 1 to 2 months, and every 2 to 4 weeks thereafter.
The nurse is teaching the parent of a young child about administering ferrous sulfate to the child at home. Which teaching point should receive the highest priority? A. "Give the liquid iron with a straw to reduce tooth staining." B. "Store the ferrous sulfate in a childproof container and keep it out of the child's reach." C. "This medicine may cause the child's stool to look dark green or black." D. "Do not give iron with any other medications or vitamins."
B. "Store the ferrous sulfate in a childproof container and keep it out of the child's reach." All these answers may be included in the parent teaching about iron. However, keeping the medication away from the child is the top priority, because death from overdose of iron-containing products is a leading cause of poisoning fatalities in the United States.
The nurse is ready to begin a heparin infusion for a patient with evolving stroke. The baseline activated partial thromboplastin time (aPTT) is 40 seconds. Which aPTT value indicates that a therapeutic dose has been achieved? A. 50 B. 70 C. 90 D. 110
B. 70 The therapeutic level of heparin is achieved when the aPTT reaches 1.5 to 2 times normal. Thus, a range of 60 to 80 seconds would be appropriate for this patient.
Which is the priority nursing intervention for a patient receiving parenteral iron dextran (INFeD) infusion? A. The medication must be administered by deep subcutaneous injection. B. An intravenous test dose of 25 mg over 5 minutes must be administered. C. Erythropoietin must also be given when a patient is receiving parenteral iron dextran. D. After administration of a test dose of intramuscular (IM) iron dextran, the patient must be observed for 15 minutes before the full therapeutic dose is given.
B. An intravenous test dose of 25 mg over 5 minutes must be administered. To reduce the risk of a fatal anaphylactic reaction to parenteral iron dextran, each full dose should be preceded by a small test dose of 25 mg given intravenously over 5 minutes. Iron dextran should not be administered subcutaneously. It can be administered by deep intramuscular injection using the Z-track technique to prevent leakage and surface discoloration. Sodium-ferric gluconate complex [Ferrlecit], not iron dextran, is always used in conjunction with erythropoietin. If the test dose of iron dextran is administered IM, the patient must be observed for 1 hour before the full dose is administered.
The nurse is caring for a patient with anemia. What is a common cause of iron deficiency in the United States? A. Decreased intestinal uptake of iron B. Chronic blood loss through the GI tract C. Vegetarian eating patterns D. Rapid growth during adolescence
B. Chronic blood loss through the GI tract The most common causes of anemia in the United States are changes in blood volume during pregnancy, infancy, and early childhood and chronic blood loss (usually of GI or uterine origin). In rare cases, decreased iron uptake is a cause of anemia.
A patient is admitted to the emergency department complaining of chest pain, and the electrocardiogram (ECG) shows an evolving ST-segment elevation myocardial infarction (STEMI). What intervention should the nurse anticipate? A. Administer 400 mg of ibuprofen. B. Have the patient chew a 325-mg aspirin. C. Administer an ACE inhibitor within 1 week of the onset of chest pain. D. Provide oxygen by nasal cannula to achieve an arterial oxygen saturation of 94%.
B. Have the patient chew a 325-mg aspirin. The first dose of aspirin (162 to 325 mg) should be given immediately after the onset of symptoms or as soon as possible. Each baby aspirin (81 mg) should be chewed to allow rapid absorption across the buccal mucosa. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, are avoided, because they increase the risk of mortality, reinfarction, hypertension, heart failure, and myocardial rupture. Current guidelines recommend administration of oxygen by nasal cannula only if the arterial oxygen saturation is below 90%. Treatment with ACE inhibitors should begin within 24 hours of symptom onset.
A patient with deep vein thrombosis receiving an intravenous (IV) heparin infusion asks the nurse how this medication works. What is the nurse's best response? A. Heparin prevents the activation of vitamin K and thus blocks synthesis of some clotting factors. B. Heparin suppresses coagulation by helping antithrombin perform its natural functions. C. Heparin works by converting plasminogen to plasmin, which in turn dissolves the clot matrix. D. Heparin inhibits the enzyme responsible for platelet activation and aggregation within vessels.
B. Heparin suppresses coagulation by helping antithrombin perform its natural functions. Heparin is an anticoagulant that works by helping antithrombin inactivate thrombin and factor Xa, reducing the production of fibrin and thus decreasing the formation of clots.
Which adverse effect is the greatest concern with thrombolytic therapy? A. Anaphylaxis B. Intracranial hemorrhage C. Cerebral edema D. Hemophilia
B. Intracranial hemorrhage The major complication of thrombolytic therapy is bleeding. Intracranial hemorrhage (ICH) is the greatest concern.
The nurse is caring for a patient receiving clopidogrel [Plavix] to prevent blockage of coronary artery stents. Which other drug on the patient's medication administration record may reduce the antiplatelet effects of clopidogrel? A. Aspirin [Bayer] B. Omeprazole [Prilosec] C. Acetaminophen [Tylenol] D. Warfarin [Coumadin]
B. Omeprazole [Prilosec] Omeprazole and other proton pump inhibitors may reduce the antiplatelet effects of clopidogrel. Patients sometimes take them to reduce gastric acidity and the risk of gastrointestinal (GI) bleeding. DRUG INTERACTION
A patient diagnosed with a pulmonary embolism is receiving a continuous heparin infusion at 1000 units/hr. Of which findings should the nurse immediately notify the healthcare provider? (Select all that apply.) A.aPTT of 65 seconds B. aPTT of 40 seconds C. Nosebleeds D. aPTT of 100 seconds E. Platelet count of 300,000/mcL
B. aPTT of 40 seconds Correct C. Nosebleeds Correct D. aPTT of 100 seconds Correct Measurement of the aPTT is essential to determine whether the heparin infusion is having the desired effect. If the normal value of the aPTT is 40 seconds, the goal is to achieve a therapeutic range of a factor of 1.5 to 2 (60 to 80 seconds). Because 40 seconds is too short (increases the risk for clotting) and 100 seconds is too long (increases the risk for bleeding), the physician requires notification for adjustment of the infusion rate. Evidence of bleeding, such as nosebleeds, hematuria, and red or tarry stools, warrant a call to the physician. An aPTT of 65 seconds indicates that a therapeutic effect has been achieved, and a platelet count of 300,000/mcL is within normal limits, indicating no evidence of thrombocytopenia.
Which instruction about clopidogrel [Plavix] should the nurse include in the discharge teaching for a patient who has received a drug-eluting coronary stent? A. "Constipation is a common side effect of clopidogrel, so take a stool softener daily." B. "If you see blood in your urine or black stools, stop the clopidogrel immediately." C. "Check with your healthcare provider before taking any over-the-counter medications for gastric acidity." D. "Keep the amount of food containing vitamin K, such as mayonnaise, canola and soybean oil, and green, leafy vegetables, consistent in your diet."
C. "Check with your healthcare provider before taking any over-the-counter medications for gastric acidity." Proton pump inhibitors (PPIs), such as omeprazole [Prilosec], and CYP2C1 inhibitors, such as cimetidine [Tagamet], can be purchased over the counter to treat heartburn. However, patients taking clopidogrel should consult their healthcare provider before using them. PPIs and CYP2C1 inhibitors can reduce the antiplatelet effects of clopidogrel. Diarrhea (5% incidence), not constipation, is a side effect of clopidogrel. Patients should immediately contact their healthcare provider if signs of bleeding occur, such as bloody urine, stool, or emesis. The drug should not be stopped until the prescriber advises it, because this could lead to coronary stent restenosis. Consistency of vitamin K intake is indicated while taking warfarin [Coumadin].
After 3 weeks of therapy with oral ferrous sulfate, a patient calls the clinic nurse, complaining of continuous nausea and vomiting with this drug. Which is the most appropriate response to this patient? A. "This may indicate a serious adverse effect of this drug. You need to come into the clinic." B. "Try to take your medication with meals. This should reduce your nausea and vomiting." C. "You may need a lower dose, I will contact your primary healthcare provider and call you back." D. "Try taking an antacid just before taking your medication. This can help reduce stomach acid, which causes nausea."
C. "You may need a lower dose, I will contact your primary healthcare provider and call you back." Nausea and vomiting are common adverse effects of ferrous sulfate. Early in treatment, patients may take the medication with food to reduce nausea; however, this significantly reduces absorption. If nausea persists, patients may need a decreased dosage to help mitigate GI effects. Nausea and vomiting are not considered serious adverse effects of the drug. The drug should not be taken with antacids, which reduce iron absorption.
The nurse is preparing to administer an intravenous (IV) nitroglycerin infusion. For which patient should the nurse question the healthcare provider's prescription to administer IV nitroglycerin infusion? A. A patient with an inferior wall myocardial infarction (MI); blood pressure of 170/60 mm Hg B. A patient with an anterior wall MI who has pulmonary congestion; heart rate of 92 beats/min C. A patient with a right ventricular infarction, confirmed by right-sided ECG changes D. A patient with chest pain unrelieved to 3 sublingual nitroglycerin tablets; took tadalafil 4 days ago
C. A patient with a right ventricular infarction, confirmed by right-sided ECG changes Nitroglycerin should be avoided in patients with hypotension (systolic BP below 90 mm Hg), severe bradycardia (heart rate below 50 beats/min), marked tachycardia (heart rate above 100 beats/min), or suspected right ventricular infarction. If the patient has taken sildenafil, avanafil, or vardenafil in the past 24 hours or tadalafil in the past 48 hours, nitroglycerin should not be given. According to current guidelines, the patient should receive 3 doses of sublingual nitroglycerin before a continuous infusion is considered. Signs of pulmonary congestion also warrant use of IV nitroglycerin.
A patient presents to the emergency department with symptoms of acute myocardial infarction. After a diagnostic workup, the healthcare provider prescribes a 15-mg IV bolus of alteplase (tPA), followed by 50 mg infused over 30 minutes. In monitoring this patient, which finding by the nurse most likely indicates an adverse reaction to this drug? A. Urticaria, itching, and flushing B. Blood pressure of 90/50 mm Hg C. Decreasing level of consciousness D. Potassium level of 5.5 mEq/L
C. Decreasing level of consciousness The greatest risk with this drug is BLEEDING, with intracranial bleeding being the greatest concern. A decreasing level of consciousness indicates intracranial BLEEDING. Alteplase does not cause an allergic reaction or hypotension. Thrombolytic agents, such as alteplase, do not typically cause an elevated potassium level.
Which drug would not be included in the treatment plan for a patient who will undergo a primary percutaneous coronary intervention (PCI)? A. Aspirin B. Heparin C. Diltiazem [Cardizem] D. Clopidogrel [Plavix]
C. Diltiazem [Cardizem] Diltiazem is not indicated for a patient undergoing primary PCI. All patients undergoing PCI should receive an anticoagulant (IV heparin, bivalirudin) combined with antiplatelet drugs: aspirin plus either clopidogrel, ticagrelor, or prasugrel.
The nurse is monitoring a patient receiving a heparin infusion for the treatment of pulmonary embolism. Which assessment finding most likely relates to an adverse effect of heparin? A. Heart rate of 60 beats/min B. Blood pressure of 160/88 mm Hg C. Discolored urine D> Inspiratory wheezing
C. Discolored urine (from blood) The primary and most serious adverse effect of heparin is bleeding. Bleeding can occur from any site and may be manifested in various ways, including reduced blood pressure, increased heart rate, bruises, petechiae, hematomas, red or black stools, cloudy or DISCOLORED URINE, pelvic pain, headache, and lumbar pain.
Which medication is the treatment of choice for ST-segment elevation myocardial infarction (STEMI)-associated pain? A. Aspirin B. Lorazepam [Ativan] C. Morphine D. Hydromorphone hydrochloride [Dilaudid]
C. Morphine Morphine improves hemodynamics. By promoting venodilation, the drug reduces cardiac preload. By promoting modest arterial dilation, it may cause some reduction in afterload. The combined reductions in preload and afterload lower the cardiac oxygen demand, thereby helping to preserve the ischemic myocardium and relieving the patient's pain.
Which is the most beneficial treatment for patients experiencing an ST-segment elevation myocardial infarction (STEMI)? A. Oxygen administration B. Metoprolol [Lopressor] C. Reperfusion therapy D. Lidocaine [Xylocaine]
C. Reperfusion therapy Reperfusion therapy restores blood flow through the blocked coronary arteries responsible for the MI. Reperfusion therapy can be accomplished through percutaneous coronary intervention or fibrinolytic therapy.
The nurse understands that ventricular fibrillation is a common cause of death after myocardial infarction (MI). Which drug should be readily available to treat ventricular fibrillation? A. Propranolol [Inderal] B. Dobutamine C. Valsartan [Diovan] D. Amiodarone [Cordarone]
D. Amiodarone [Cordarone] The priority treatment of ventricular fibrillation involves defibrillation, followed by intravenous (IV) amiodarone infusion for 24 to 48 hours. The other agents may be used in the treatment of a patient with MI, but amiodarone is the specific agent used to treat ventricular fibrillation.
For all patients undergoing percutaneous coronary intervention (PCI), which drug is recommended to be combined with clopidogrel [Plavix]? A. Heparin B. ACE inhibitor C. Alteplase [Activase] D. Aspirin
D. Aspirin In patients undergoing PCI, clopidogrel is used in combination with aspirin. Aspirin suppresses platelet aggregation, thereby reducing mortality by reducing the likelihood of reinfarction or stroke.
The nurse is caring for a patient who takes warfarin [Coumadin] for prevention of deep vein thrombosis. The patient has an international normalized ratio (INR) of 1.2. Which action by the nurse is most appropriate? A. Administer intravenous (IV) push protamine sulfate. B. Continue with the current prescription. C. Prepare to administer vitamin K. D. Call the healthcare provider to increase the dose.
D. Call the healthcare provider to increase the dose. An INR in the range of 2 to 3 is considered the level for warfarin therapy (GOOD). For a level of 1.2 (TOO LOW), the nurse should contact the healthcare provider to discuss an order for an increased dose.
Fondaparinux [Arixtra] is not approved for use in which circumstance? A. Prevention of deep vein thrombosis (DVT) after knee replacement B. Treatment of acute pulmonary embolism (PE) (in conjunction with warfarin) C. Prevention of deep vein thrombosis (DVT) after abdominal surgery D. Prevention of ischemic complications in patients with unstable angina
D. Prevention of ischemic complications in patients with unstable angina Enoxaparin [Lovenox], not Arixtra, is approved for use in preventing ischemic complications in patients with unstable angina, non-Q-wave myocardial infarction (MI), and ST-segment elevation myocardial infarction (STEMI). Arixtra is approved for (1) preventing DVT after hip surgery, knee replacement, and abdominal surgery and (2) treating acute PE and acute DVT in conjunction with warfarin.
