Pharm Final 100 Questions

4. A 65-year-old patient who receives glucocorticoids for arthritis is admitted to the hospital for treatment of a urinary tract infection. The prescriber has ordered intravenous ciprofloxacin [Cipro]. Before administering the third dose of this drug, the nurse reviews the bacterial culture report and notes that the causative organism is Escherichia coli. The bacterial sensitivity report is pending. The patient complains of right ankle pain. What will the nurse do? a. Withhold the dose of ciprofloxacin and notify the provider of the patient's symptoms. b. Instruct the patient to exercise the right foot and ankle to minimize the pain. c. Question the patient about the consumption of milk and any other dairy products. d. Request an order to increase this patient's dose of glucocorticoids.

A A rare but serious adverse effect associated with fluoroquinolones is tendon rupture, and those at highest risk are children, patients older than 60 years, transplant patients, and any patients taking glucocorticoids. Any pain in either heel should be reported and the drug should be discontinued. Patients should be instructed not to exercise until tendonitis has been ruled out. Dairy products can reduce the absorption of ciprofloxacin, so this is not a concern with this patient. Because the pain may be caused by tendonitis associated with ciprofloxacin, it is not correct to request an increase in the glucocorticoid dosing.

32. A nurse is teaching parents how to use an Epi-Pen for their child, who has a peanut allergy. Which statement by the parents indicates understanding of the teaching? a. "After using the Epi-Pen, we must go to the emergency department." b. "The Epi-Pen should be stored in the refrigerator, because epinephrine is sensitive to heat." c. "The teacher should call us when symptoms start so that we can bring the Epi-Pen to school." d. "We should jab the device into the thigh until it is empty of solution."

A After using the Epi-Pen, it is important that the individual get medical attention as quickly as possible. The effects of epinephrine fade in 10 to 20 minutes, and the anaphylactic reaction can be biphasic and prolonged. Epinephrine is sensitive to heat, but storing the device in the refrigerator can compromise the injection mechanism; the device should be stored at room temperature in a dark place. Individuals who need an Epi-Pen must have the device with them at all times; any delay in treatment can be fatal, because anaphylaxis can occur within minutes after exposure. The Epi-Pen contains 2 mL of epinephrine, but only 0.3 mL is injected; the device will not be empty with a successful injection.

95. A child with an ear infection is not responding to treatment with amoxicillin [Amoxil]. The nurse will expect the provider to order: a. amoxicillin-clavulanic acid [Augmentin]. b. ampicillin. c. nafcillin. d. penicillin G [Benzylpenicillin].

A Beta-lactamase inhibitors are drugs that inhibit bacterial beta-lactamases. These drugs are always given in combination with a penicillinase-sensitive penicillin. Augmentin contains amoxicillin and clavulanic acid and is often used when patients fail to respond to amoxicillin alone. Ampicillin is similar to amoxicillin, but amoxicillin is preferred and, if drug resistance occurs, ampicillin is equally ineffective. Pharmaceutical chemists have developed a group of penicillins that are resistant to inactivation by beta-lactamases (eg, nafcillin), but these drugs are indicated only for penicillinase-producing strains of staphylococci. Penicillin G would be as ineffective as amoxicillin if beta-lactamase is present.

25. A patient who has been taking an SSRI tells the nurse that the drug has caused reduced sexual performance, weight gain, and sedation. The nurse will suggest that the patient ask the provider about using which drug? a. Bupropion [Wellbutrin] b. Imipramine [Tofranil] c. Isocarboxazid [Marplan] d. Trazodone [Oleptro]

A Bupropion does not cause weight gain, sexual dysfunction, or sedation, so it may be a useful adjunct to or substitute for an SSRI when those side effects become intolerable. Imipramine causes sedation. Isocarboxazid is an MAOI and is not used unless other drugs are ineffective. Trazodone causes sedation.

35. 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.

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.

31. 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

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.

100. A nurse administers an ACE inhibitor to a patient who is taking the drug for the first time. What will the nurse do? a. Instruct the patient not to get up without assistance. b. Make sure the patient takes a potassium supplement. c. Report the presence of a dry cough to the prescriber. d. Request an order for a diuretic to counter the side effects of the ACE inhibitor.

A Severe hypotension can result with the first dose of an ACE inhibitor. The patient should be discouraged from getting up without assistance. Potassium supplements are contraindicated. A dry cough is an expected side effect that eventually may cause a patient to discontinue the drug; however, it is not a contraindication to treatment. Diuretics can exacerbate hypotension and should be discontinued temporarily when a patient starts an ACE inhibitor.

10. An older adult patient has confusion, memory loss, and disorientation in familiar surroundings. The patient has been taking donepezil [Aricept] 10 mg once daily for 6 months. The patient's symptoms have begun to worsen, and the patient's spouse asks if the medication dose can be increased. What will the nurse tell the spouse? a. The dose can be increased, because the patient has been taking the drug for longer than 3 months. b. The dose can be increased to twice daily dosing instead of once daily dosing. c. The increase in symptoms is the result of hepatotoxicity from the medication's side effects. d. The patient must take the drug for longer than 1 year before the dose can be increased.

A Donepezil is given for mild, moderate, and severe AD, and dosing may be increased, although it must be titrated up slowly. For patients with moderate to severe AD who have taken 10 mg once daily for at least 3 months, the dose can be increased to 23 mg once daily. Donepezil is not given twice daily. Donepezil does not cause hepatotoxicity; hepatotoxicity occurs with tacrine, the first acetylcholinesterase (AChE) inhibitor, which now is rarely used. Dosing is increased after 3 months, not 1 year.

69. A nurse is providing education to a patient who will begin taking alendronate [Fosamax]. Which complication should the patient be instructed to report immediately? a. Difficulty swallowing b. Dizziness c. Drowsiness d. Pallor

A Esophagitis is the most serious adverse effect of alendronate, sometimes resulting in ulceration. The nurse should instruct the patient to report difficulty swallowing immediately, because it can be a sign of esophageal injury. Dizziness is not an adverse effect of alendronate. Drowsiness is not a symptom associated with alendronate. Pallor is not a symptom associated with alendronate.

93. A prescriber has ordered filgrastim (granulocyte colony-stimulating factor) for a patient undergoing myelosuppressive chemotherapy. The nurse will prepare the patient for which potential side effect? a. Bone pain b. Fatigue c. Headache d. Hemorrhage

A Filgrastim causes bone pain in about 25% of patients. The pain is dose related and usually mild to moderate. Fatigue, bleeding, and headache are not common side effects of filgrastim.

99. 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] b. Hydrochlorothiazide [HydroDIURIL] c. Mannitol [Osmitrol] d. Spironolactone [Aldactone]

A 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.

87. A patient is diagnosed with an infection caused by Staphylococcus aureus, and the prescriber orders intravenous gentamicin and penicillin (PCN). Both drugs will be given twice daily. What will the nurse do? a. Administer gentamicin, flush the line, and then give the penicillin. b. Give the gentamicin intravenously and the penicillin intramuscularly. c. Infuse the gentamicin and the penicillin together to prevent fluid overload. d. Request an order to change the penicillin to vancomycin.

A Gentamicin should not be infused with penicillins in the same solution, because PCN inactivates gentamicin; therefore, the nurse should give one first, flush the line, and then give the other. The nurse cannot give a drug IM when it is ordered IV without an order from the prescriber. These two drugs should not be infused in the same solution. There is no indication for changing the PCN to vancomycin; that should be done for serious infections.

42. A patient receives an epidural anesthetic during labor and delivery. The nurse caring for the newborn in the immediate postpartum period will observe the infant for: a. bradycardia. b. hypoglycemia. c. jitteriness. d. tachypnea.

A Local anesthetics can cross the placenta, causing bradycardia and central nervous system (CNS) depression in the infant. They do not affect blood glucose. Jitteriness is a sign of CNS excitation. Increased respirations are not an adverse effect in the newborn.

13. 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. b. reduce renal perfusion. c. reduce peripheral edema. d. restore extracellular fluid.

A 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.

15. A patient with type 1 diabetes reports mixing NPH and regular insulin to allow for one injection. What should the nurse tell the patient? a. This is an acceptable practice. b. These two forms of insulin are not compatible and cannot be mixed. c. Mixing these two forms of insulin may increase the overall potency of the products. d. NPH insulin should only be mixed with insulin glargine.

A NPH insulin is the only insulin suitable for mixing with short-acting insulins, such as insulin aspart [NovoLog]. These insulins are compatible and are mixed frequently for management of diabetics. The overall potency of each insulin is not increased by mixing them. Insulin glargine cannot be mixed with any other insulin for administration.

18. A patient has received two doses of dinoprostone [Prepidil] to initiate labor. It has been 6 hours since the last dose. The nurse assesses the patient and notes that the cervix is ripe and dilated to 4 cm, but contractions are diminishing in intensity and frequency. What will the nurse expect to do? a. Administer oxytocin. b. Monitor urine output. c. Prepare for a cesarean section. d. Watch closely for fetal distress.

A Once the cervix is ripe and labor has occurred, labor should progress, with contractions increasing in duration and frequency. This woman is showing signs of stalled labor and, because the cervix is ripe, can be induced with oxytocin. Large doses of oxytocin can cause water intoxication, which is not a risk at this point in this patient. There is no indication for a cesarean section at this point. The risk of fetal distress is not increased at this point.

59. The nurse working on a high-acuity medical-surgical unit is prioritizing care for four patients who were just admitted. Which patient should the nurse assess first? a. The NPO patient with a blood glucose level of 80 mg/dL who just received 20 units of 70/30 Novolin insulin b. The patient with a pulse of 58 beats per minute who is about to receive digoxin [Lanoxin] c. The patient with a blood pressure of 136/92 mm Hg who complains of having a headache d. The patient with an allergy to penicillin who is receiving an infusion of vancomycin [Vancocin]

A The NPO patient with hypoglycemia who just received 70/30 Novolin insulin takes priority, because this patient needs to consume a good source of glucose immediately or perhaps the NPO status will be discontinued for this shift. The digoxin may be withheld for the patient with a pulse of 58 beats per minute, but this is not a priority action. The patient with a headache needs to be followed up, but because the blood pressure is 136/92 mm Hg, the headache is probably not caused by hypertension. The patient with an allergy to penicillin will not have a reaction to the vancomycin.

5. A patient who is an opioid addict has undergone detoxification with buprenorphine [Subutex] and has been given a prescription for buprenorphine with naloxone [Suboxone]. The patient asks the nurse why the drug was changed. Which response by the nurse is correct? a. "Suboxone has a lower risk of abuse." b. "Suboxone has a longer half-life." c. "Subutex causes more respiratory depression." d. "Subutex has more buprenorphine."

A The combination of buprenorphine and naloxone [Suboxone] discourages intravenous abuse, because with IV use, the naloxone precipitates withdrawal; this effect does not occur with sublingual dosing [Subutex]. Suboxone does not differ from Subutex in terms of drug halflife. Subutex does not cause more respiratory depression and does not contain more buprenorphine.

75. A patient who uses an inhaled glucocorticoid for chronic asthma calls the nurse to report hoarseness. What will the nurse do? a. Ask whether the patient is rinsing the mouth after each dose. b. Request an order for an antifungal medication. c. Suggest that the patient be tested for a bronchial infection. d. Tell the patient to discontinue use of the glucocorticoid.

A 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.

57. A nurse is providing education about tetracycline [Sumycin]. Which statement by the patient best demonstrates understanding of the administration of this medication? a. "I should not take this medication with milk or other dairy products." b. "I should not worry if I experience an acnelike rash with this medication." c. "I should take an antacid, such as Tums, if I experience gastrointestinal distress." d. "I should take this antibiotic with a calcium supplement to improve absorption."

A The patient should avoid taking the medication with dairy products to help prevent chelation. An acnelike reaction would indicate an allergic response. Taking the medication with calcium-containing antacids or supplements should be avoided, because this also leads to chelation.

89. When metronidazole [Flagyl] is a component of the H. pylori treatment regimen, the patient must be instructed to do what? a. Avoid any alcoholic beverages b. Avoid foods containing tyramine c. Take the drug on an empty stomach d. Take the drug with food

A The patient should be instructed to avoid alcoholic beverages, because a disulfiram-like reaction can occur if metronidazole is taken with alcohol. Nothing indicates that the patient should avoid foods containing tyramine. Metronidazole may be taken with or without food.

92. A 43-year-old patient with a strong family history of breast cancer considers taking tamoxifen [Nolvadex] for cancer prevention. Which assessment finding is a possible contraindication? a. History of deep vein thrombosis (DVT) b. History of osteoporosis c. Hyperlipidemia d. Prior hysterectomy

A The patient's age and DVT history place her at risk for thrombosis. Tamoxifen would not be indicated for this patient. A prior hysterectomy, osteoporosis, and hyperlipidemia are not contraindications to tamoxifen.

3. 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.

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.

2. A patient with Parkinson's disease is taking levodopa/carbidopa [Sinemet] and reports occasional periods of loss of drug effect lasting from minutes to several hours. The nurse questions the patient further and discovers that these episodes occur at different times related to the medication administration. The nurse will contact the provider to discuss: a. administering a catechol-O-methyltransferase (COMT) inhibitor, such as entacapone. b. adding the DA-releasing agent amantadine to the regimen. c. giving a direct-acting dopamine agonist. d. shortening the dosing interval of levodopa/carbidopa.

A This patient is describing abrupt loss of effect, or the "off" phenomenon, which is treated with entacapone or another COMT inhibitor. Amantadine is used to treat dyskinesias. A direct-acting dopamine agonist is useful for gradual loss of effect, which occurs at the end of the dosing interval as the dose is wearing off. Shortening the dosing interval does not help with abrupt loss of effect.

84. A nurse is preparing to administer medications to a hospitalized patient who has been taking lithium [Lithobid] for 3 days. The patient is complaining of mild nausea and abdominal bloating. The patient's lithium level is 0.8 mEq/L. What will the nurse do? a. Administer the dose and tell the patient that the side effects are temporary. b. Contact the prescriber to request an order for serum electrolytes. c. Hold the dose and notify the prescriber of the patient's lithium level. d. Request an order for amiloride [Midamor].

A This patient is experiencing side effects that are common and that occur at therapeutic levels of the drug. The lithium level is therapeutic and not toxic, so the nurse should give the dose and reassure the patient that the side effects will diminish over time. In the presence of low sodium, lithium can accumulate to toxic doses; therefore, if the lithium level were elevated, evaluating serum electrolytes would be advisable. The dose does not need to be withheld, because the patient does not have toxic levels of lithium. Amiloride is used if patients are experiencing lithium-induced polyuria, which this patient does not have.

47. A nurse is screening a patient being admitted to the hospital. The patient reports being fired for drinking at work. On further questioning, the patient reveals a history of daily alcohol consumption of more than a six-pack of beer each day, regular morning drinking, and several unsuccessful attempts to stop drinking. The nurse detects alcohol on the patient's breath. The nurse will inform the provider of these findings and request an order for which medication? a. Chlordiazepoxide [Librium] b. Clonidine c. Disulfiram [Antabuse] d. Naltrexone [ReVia]

A This patient shows signs of alcohol use disorder, according to the AUDIT Screening Instrument, and has a score of at least 21 points from the information included in this history. A score of 8 or higher for men up to age 60 and a score of 4 or higher for others are positive screening results. The patient recently has consumed alcohol, as evidenced by the detectable smell, although the amount consumed and the time since the last drink cannot be determined. Because this patient is an active alcoholic, the risk of withdrawal symptoms is high; therefore, the patient needs medication to facilitate withdrawal. Benzodiazepines are the safest, most effective medications for this purpose, and those with longer half-lives, including chlordiazepoxide, are preferred. Clonidine is useful as an adjunct to help reduce autonomic symptoms associated with withdrawal. Disulfiram is used to maintain abstinence; its use along with alcohol can produce dangerous symptoms. Naltrexone is used to maintain abstinence by reducing cravings; it does not facilitate withdrawal.

50. A patient begins using timolol [Timoptic] to treat primary open-angle glaucoma (POAG). The nurse gives a dose and notes that the patient develops shortness of breath. The nurse assesses the patient and auscultates wheezes in both lungs. The nurse will ask this patient about a history of which condition? a. Asthma b. Atrioventricular heart block c. Pulmonary hypertension d. Sinus bradycardia

A Timolol is a beta blocker and can precipitate bronchoconstriction when absorbed systemically. Patients with asthma will develop shortness of breath and wheezing. These symptoms are not associated with AV block, pulmonary hypertension, or sinus bradycardia.

98. 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: a. AV blockade. b. gingival hyperplasia. c. migraine headaches. d. reflex tachycardia.

A 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.

73. A nurse is teaching a client who has anemia and a new prescription for a liquid Iron supplement. Which of the following information should the nurse include in the teaching? (Select all that apply.) a. "Add foods that are high in fiber to your diet." b. "Rinse your mouth after taking the medication." c. "Expect stools to be green or black in color." d. "Take the medication with a glass of milk." e. "Add red meat to your diet."

A, B, C, E A. Foods high in fiber can prevent constipation, which can occur when taking iron supplements. B. Iron supplements can stain teeth when taken in a liquid form. The client should rinse orally after taking the medication. C. Dark green or black stools can occur when taking iron supplements. The client should anticipate this effect. E. Red meats are high in iron and recommended for a client to improve anemia when taken concurrently with iron supplements.

39. A nurse is transfusing a unit of packed Red blood cells (PRBCs) for a client who has Anemia due to Chemotherapy. The client reports a sudden headache and chills. The client's temperature is 2° F higher than her baseline. In addition to notifying the provider, which of the following actions should the nurse take? (Select all that apply.) a. Stop the transfusion b. Place the client in a upright position with feet down c. Remove the blood bag and tubing from the IV catheter. d. Obtain a urine specimen. e. Infuse dextrose 5% in water through the IV.

A, C, D. A. The nurse should stop the transfusion for a rise in temperature of 2° F and reports of chills and fever. The client can be having a hemolytic reaction to the blood or a febrile reaction C. The nurse should avoid infusing more PRBCs into the client's vein, and should remove the blood bag and tubing from the client's IV catheter. D. Obtaining a urine specimen to check for hemolysis is standard procedure when the client has a reaction to a blood transfusion.

97. A nurse is preparing to administer Leucovorin to a client who has cancer and is receiving chemotherapy with Methotrexate. Which of the following responses should the nurse use when the client asks why Leucovorin is being given? a. Leucovorin protects healthy cells from methotrexate's toxic effect b. Leucovorin increases platelet production and prevents bleeding. c. Leucovorin reduces the risk of a transfusion reaction from methotrexate. d. Leucovorin potentiates the cytotoxic effects of methotrexate.

A. Leucovorin, a folic acid derivative and an antagonist to methotrexate, is given within 12 hr of high doses of methotrexate to protect healthy cells from the toxic effects of methotrexate.

14. A nurse is caring for a client who has diabetes and is experiencing nausea due to gastroparesis. The nurse should anticipate a prescription for which of the following medications? a. Metoclopramide b. Lubiprostone c. Loperamide d. Bisacodyl

A. Metoclopramide is a dopamine antagonist that is used to treat nausea and also increases gastric motility. It can relieve the bloating and nausea of diabetic gastroparesis.

67. A nurse is planning to administer subcutaneous enoxaparin 40 mg using a prefilled syringe of Enoxaparin 40 mg/0.4 mL to an adult client following hip arthroplasty. Which of the following actions should the nurse plan to take? a. Insert the needle completely into the client's tissue. b. Expel the air bubble from the prefilled syringe before injecting. c. Aspirate carefully after inserting the needle into the client's skin. d. Administer the injection in the client's thigh.

A. The nurse should inject the needle on the prefilled syringe completely when administering enoxaparin in order to administer the medication by deep subcutaneous injection.

77. A prescriber orders transdermal nitroglycerin patch for a patient with angina. What will the nurse teach this patient? a. Apply the patch around the same time of day when changing. b. You may not go out in the sun while you wear the patch. c. Apply the patch to intact skin on the forearm or leg. d. Change the patch every week.

A. Transdermal patches are to be changed every day and it is best to change around the same time of day, each day. Medication administered by patch has the same therapeutic effect and adverse effects as that given by other routes, except that localized skin reactions may occur. The patch should be applied to intact, hairless skin on the upper arm or torso.

8. A nurse provides teaching to a patient who will begin taking oral cyclophosphamide to treat non-Hodgkin's lymphoma. Which statement by the patient indicates an understanding about how to minimize side effects while taking this drug? a. "I don't need to worry about bone marrow suppression with this drug." b. "I should drink plenty of fluids while taking this drug." c. "I should take this drug on an empty stomach." d. "If I shampoo less often, I can prevent hair loss."

B Acute hemorrhagic cystitis can occur; this can be minimized by maintaining adequate hydration and taking mesna [Mesnex], a protective agent. Bone marrow suppression is a doselimiting side effect. This drug should be taken with food. Hair loss cannot be prevented by shampooing less often.

66. A nurse is teaching a patient who will begin taking methimazole [Tapazole] for Graves' disease about the medication. Which statement by the patient indicates understanding of the teaching? a. "Because of the risk for liver toxicity, I will need frequent liver function tests." b. "I should report a sore throat or fever to my provider if either occurs." c. "I will need a complete blood count every few months." d. "It is safe to get pregnant while taking this medication."

B Agranulocytosis is rare but can occur with methimazole, so patients should report signs of infection, such as a sore throat or fever. Liver toxicity is not a side effect, so liver function tests are not indicated. Because agranulocytosis often develops rapidly, periodic blood counts do not guarantee early detection. Methimazole is contraindicated in the first trimester of pregnancy.

24. A patient is to begin taking phenytoin [Dilantin] for seizures. The patient tells the nurse that she is taking oral contraceptives. What will the nurse tell the patient? a. She may need to increase her dose of phenytoin while taking oral contraceptives. b. She should consider a different form of birth control while taking phenytoin. c. She should remain on oral contraceptives, because phenytoin causes birth defects. d. She should stop taking oral contraceptives, because they reduce the effectiveness of phenytoin.

B Because phenytoin can reduce the effects of oral contraceptive pills (OCPs) and because avoiding pregnancy is desirable when taking phenytoin, patients should be advised to increase the dose of oral contraceptives or use an alternative method of birth control. Increasing the patient's dose of phenytoin is not necessary; OCPs do not affect phenytoin levels. Phenytoin is linked to birth defects; OCPs have decreased effectiveness in patients treated with phenytoin, and the patient should be advised to increase the OCP dose or to use an alternative form of birth control. OCPs do not alter the effects of phenytoin.

28. The nurse is preparing to administer a dose of epoetin alfa to a patient and notes that the patient has a hemoglobin level of 11.7 gm/dL. Which action by the nurse is correct? a. Administer the dose as ordered. b. Hold the dose and notify the provider. c. Request an order for a reduced dose. d. Suggest that the provider increase the dose.

B Because the risks of severe cardiovascular events and death are higher in patients whose hemoglobin levels exceed 11 gm/dL, the nurse should hold the dose and notify the provider of this level. It is not correct to administer the dose. Reducing the dose and increasing the dose are not correct because the patient's hemoglobin level is already too high.

91. A woman with moderate migraine headaches asks a nurse why the provider has ordered metoclopramide [Reglan] as an adjunct to aspirin therapy, because she does not usually experience nausea and vomiting with her migraines. The nurse will tell her that the metoclopramide is used to: a. help induce sleep. b. improve absorption of the aspirin. c. prevent gastric irritation caused by the aspirin. d. prolong the effects of the aspirin.

B Besides reducing nausea and vomiting, metoclopramide also reverses gastric stasis and improves absorption of oral antimigraine drugs. When aspirin-like analgesics are combined with metoclopramide, they may work as well as sumatriptan. Metoclopramide is not used to induce sleep. It does not prevent gastric irritation or prolong the effects of the aspirin.

21. A nurse is obtaining a drug history from an older adult patient who is taking multiple medications prescribed by different providers. Which two medications taken together create a reason for concern? a. Acetaminophen [Tylenol] and oxycodone b. Amitriptyline [Elavil] and diphenhydramine [Benadryl] c. Fexofenadine [Allegra] and an over-the-counter laxative d. Zolpidem [Ambien] and sertraline [Zoloft]

B Both amitriptyline and diphenhydramine are on the BEERS list, amitriptyline for anticholinergic effects and diphenhydramine because it causes blurred vision. Additionally, they both have CNS effects that can compound each other when the drugs are given together. Acetaminophen and oxycodone are both acceptable and may be given together. Fexofenadine is a second-generation antihistamine with fewer side effects, and it is not contraindicated for use with a laxative. Zolpidem is a sedative that has less risk of physical dependence and less risk of confusion, falls, and cognitive impairment; sertraline is a safer antidepressant, because it has a shorter half-life than others.

54. 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.

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.

78. Dopamine is administered to a patient who has been experiencing hypotensive episodes. Other than an increase in blood pressure, which indicator would the nurse use to evaluate a successful response? a. Decrease in pulse b. Increase in urine output c. Weight gain d. Improved gastric motility

B Dopamine would cause an increase in urine output, because cardiac output is increased as a result of the increase in blood pressure. The effectiveness of dopamine would not be measured by a decrease in pulse, because dopamine's primary effect is to increase blood pressure. Dopamine's effectiveness would not be evaluated by a weight gain. Dopamine's effectiveness would not be evaluated by improved gastric motility.

52. A nursing student asks the nurse why epinephrine, and not other adrenergic agonists, is used to treat anaphylactic shock. What will the nurse tell the student? a. "Epinephrine is the only adrenergic agonist that may be given parenterally." b. "Epinephrine has the ability to activate multiple types of adrenergic receptors." c. "Other adrenergic agonists have more severe adverse effects and are not safe in the doses needed to treat anaphylaxis." d. "Other adrenergic agonists have little or no effects on betá-adrenergic receptors."

B Epinephrine is used to treat anaphylactic shock because of its ability to activate multiple adrenergic receptor types. Activation of betā receptors helps to increase cardiac output and improve blood pressure as well as suppress glottal edema. Activation of betá receptors helps to counteract bronchoconstriction. Activation of alphā receptors also causes vasoconstriction, which improves blood pressure. Isoproterenol may also be given parenterally but does not activate multiple receptor types. Other adrenergic agonists, such as albuterol, are more specific to betá receptors and have fewer side effects.

56. A patient with a cough has been advised to use guaifenesin. The patient asks the nurse to explain the purpose of the drug. The nurse will explain that guaifenesin: a. dries secretions to help suppress coughing so patients can rest. b. helps stimulate the flow of secretions to increase cough productivity. c. helps to relieve chest pain associated with a cough. d. stimulates the body's natural immune responses.

B Expectorants stimulate the flow of respiratory tract secretions to improve cough productivity. Guaifenesin does not dry secretions, because it does not have anticholinergic effects. Guaifenesin does not alleviate pain associated with cough. Guaifenesin does not stimulate immune responses.

20. A patient who has diabetes mellitus is diagnosed with schizophrenia and the provider orders thioridazine. The patient asks the nurse why the provider hasn't ordered olanzapine [Zyprexa], which the patient has seen advertised on television. Which response by the nurse is the most important reason that this patient is not receiving olanzapine? a. "Olanzapine is more expensive than thioridazine." b. "Olanzapine causes more metabolic side effects than thioridazine." c. "Thioridazine has fewer side effects than olanzapine." d. "Thioridazine has a faster onset of action than olanzapine."

B Olanzapine is an SGA and, although it has fewer extrapyramidal side effects than the FGA the provider has ordered, it has an increased risk of metabolic side effects, which is contraindicated in patients with diabetes. It is more expensive, but this is not the most important reason for not prescribing it. Thioridazine has more side effects than olanzapine, but the side effects caused by olanzapine are more critical for this patient. Thioridazine does not have a faster onset of action.

36. A prescriber has ordered pilocarpine [Pilocar]. A nurse understands that the drug stimulates muscarinic receptors and would expect the drug to have which action? a. Reduction of excessive secretions in a postoperative patient b. Lowering of intraocular pressure in patients with glaucoma c. Inhibition of muscular activity in the bladder d. Prevention of hypertensive crisis

B Pilocarpine is a muscarinic agonist used mainly for topical therapy of glaucoma to reduce intraocular pressure. Pilocarpine is not indicated for the treatment of excessive secretions and mucus; in fact, pilocarpine is used to treat dry mouth. Pilocarpine does not inhibit muscular activity in the bladder. Pilocarpine is not used to prevent hypertensive crisis.

72. 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? a. Give the digoxin and maintain close cardiac monitoring. b. Hold the digoxin and report the laboratory values to the provider. c. Hold the thiazide diuretic and give the digoxin. d. Request an order for an electrocardiogram (ECG).

B 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.

63. The nurse is caring for a patient who is receiving vancomycin [Vancocin]. The nurse notes that the patient is experiencing flushing, rash, pruritus, and urticaria. The patient's heart rate is 120 beats per minute, and the blood pressure is 92/57 mm Hg. The nurse understands that these findings are consistent with: a. allergic reaction. b. red man syndrome. c. rhabdomyolysis. d. Stevens-Johnson syndrome.

B Rapid infusion of vancomycin can cause flushing, rash, pruritus, urticaria, tachycardia, and hypotension, a collection of symptoms known as red man syndrome. Rhabdomyolysis is not associated with the administration of vancomycin. The patient's symptoms may seem to indicate an allergic reaction, but this is specifically red man syndrome. The symptoms are not those of Stevens-Johnson syndrome, which manifests as blisters or sores (or both) on the lips and mucous membranes after exposure to the sun.

81. Two nurses are discussing the major differences between physostigmine [Antilirium] and neostigmine [Prostigmin]. One nurse correctly makes which statement about physostigmine [Antilirium]? a. "It is not effective for treating poisoning by muscarinic blocking drugs." b. "It can readily cross the blood-brain barrier." c. "It does not cause any side effects." d. "It can be given by all routes."

B The basic pharmacology of physostigmine is nearly identical to that of neostigmine, except that physostigmine readily crosses membranes, including the blood-brain barrier; neostigmine does not. Physostigmine and neostigmine are both effective for treating poisoning by muscarinic blocking drugs. Neither physostigmine nor neostigmine is devoid of side effects. Physostigmine can be given only intramuscularly (IM) or intravenously (IV); neostigmine is given orally (PO), IM, IV, and subcutaneously (subQ).

16. A nurse in a provider's office is reviewing the medical record of a client who is pregnant and is at her first prenatal visit. Which of the following immunizations may the nurse administer safely to this client? a. Rubella vaccine b. Inactivated influenza vaccine c. Varicella vaccine d. Measles vaccine

B. During influenza season, providers recommend the inactivated influenza vaccine for women who are pregnant.

79. A nurse is preparing to administer Filgrastim for the first time to a client who has just undergone a bone marrow transplant. Which of the following interventions is appropriate? a. Ensure that the medication is refrigerated until just prior to administration. b. Discard vial after removing one dose of the medication c. Administer IM in a large muscle mass to prevent injury. d. Shake vial gently to mix well before withdrawing dose.

B. Only one dose of filgrastim should be withdrawn from the vial and the vial should then be discarded.

58. A nurse is evaluating teaching for a client who has rheumatoid arthritis and a new prescription for methotrexate. Which of the following statements by the client indicates understanding of the teaching? a. "I will be sure to return to the clinic at least once a year to have my blood drawn while I'm taking methotrexate." b. "I'll let the doctor know if I develop sores in my mouth while taking this medication. c. "I should stop taking oral contraceptives while I'm taking methotrexate." d. "I will take this medication on an empty stomach."

B. Ulcerations in the mouth, tongue, or throat are often the first signs of methotrexate toxicity and should be reported to the provider immediately.

48. A nurse is admitting a patient to the hospital. The patient reports taking oral baclofen [Lioresal] but stopped taking the drug the day before admission. The nurse would be correct to anticipate which adverse effects? a. Weakness and dizziness b. Fatigue and drowsiness c. Seizures and hallucinations d. Respiratory depression and coma

C Abrupt discontinuation of baclofen is associated with visual hallucinations, paranoid ideation, and seizures. Central nervous system effects of baclofen include weakness, dizziness, fatigue, and drowsiness. Respiratory depression is a result of overdose of baclofen.

53. A patient with schizophrenia has been taking an antipsychotic drug for several days. The nurse enters the patient's room to administer a dose of haloperidol [Haldol] and finds the patient having facial spasms. The patient's head is thrust back, and the patient is unable to speak. What will the nurse do? a. Administer the haloperidol as ordered. b. Discuss increasing the haloperidol dose with the provider. c. Request an order to give diphenhydramine. d. Request an order to give levodopa.

C An early reaction to antipsychotic drugs is acute dystonia. Initial treatment consists of an anticholinergic medication, such as diphenhydramine. Administering more antipsychotic medication would increase the symptoms and could be life threatening. Levodopa is not given for extrapyramidal symptoms, because it could counteract the beneficial effects of antipsychotic treatment.

44. 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.

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.

83. A patient with type 1 diabetes is taking NPH insulin, 30 units every day. A nurse notes that the patient is also taking metoprolol [Lopressor]. What education should the nurse provide to the patient? a. "Metoprolol has no effect on diabetes mellitus or on your insulin requirements." b. "Metoprolol interferes with the effects of insulin, so you may need to increase your insulin dose." c. "Metoprolol may mask signs of hypoglycemia, so you need to monitor your blood glucose closely." d. "Metoprolol may potentiate the effects of the insulin, so the dose should be reduced."

C Because metoprolol may mask the signs of hypoglycemia, the patient should monitor the blood glucose closely and report changes to the prescriber. Metoprolol does have an indirect effect on diabetes mellitus and/or insulin requirements in that it may mask the signs of hypoglycemia, causing the patient to make a healthcare decision based on the drug-to-drug interaction rather than actual physiologic factors. The patient should not increase the insulin, because metoprolol will cause a decrease in blood glucose, increasing the risk of a hypoglycemic reaction. The patient should not reduce the dose of insulin when taking metoprolol, because this might alter serum glucose levels.

6. A clinic patient who has been taking a glucocorticoid for arthritis for several months remarks to the nurse, "It's 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.

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.

68. 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 effects.

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.

45. A patient receives topical atropine to facilitate an eye examination. The nurse will tell the patient to remain in a darkened room or to wear sunglasses for several hours until the effects of the medication wear off. This teaching is based on the nurse's knowledge that muscarinic antagonists cause: a. elevation of intraocular pressure. b. miosis and ciliary muscle contraction. c. paralysis of the iris sphincter. d. relaxation of ciliary muscles.

C By blocking muscarinic receptors in the eye, atropine causes paralysis of the iris sphincter, which prevents constriction of the pupil; consequently, the eye cannot adapt to bright light. This also causes an elevation in intraocular pressure, which increases the risk of glaucoma. However, it is not an indication for wearing darkened glasses. Muscarinic agonists cause miosis; atropine causes mydriasis. The effect of relaxing ciliary muscles focuses the eye for far vision, causing blurred vision.

7. A 30-year-old male patient will begin a three-drug regimen to treat peptic ulcer disease. The regimen will consist of bismuth subsalicylate, tetracycline, and cimetidine [Tagamet]. The nurse will include which information when teaching this patient about this drug regimen? a. Black discoloration of the tongue and stools should be reported immediately. b. Central nervous system depression and confusion are likely to occur. c. Decreased libido, impotence, and gynecomastia are reversible side effects. d. Staining of the teeth may occur and is an indication for discontinuation of these drugs.

C Cimetidine has antiandrogenic effects and can cause decreased libido, impotence, and gynecomastia. These effects are reversible. Black stools and discoloration of the tongue are side effects associated with bismuth but are not harmful. Central nervous system (CNS) depression and confusion are not likely. Staining of the teeth associated with tetracycline use occurs only in developing teeth; it is a problem in children younger than 8 years and in pregnant woman because of this risk to the fetus.

33. A patient with schizophrenia shows suicidal behaviors, and the provider orders clozapine [Clozaril]. The nurse teaches the family about the medication and its side effects. Which statement by a family member indicates a need for further teaching about this drug? a. "Blood counts are necessary for several weeks after discontinuation of the drug." b. "Fever, sore throat, and sores in the mouth should be reported immediately." c. "If the ANC is less than 3000, the drug will be discontinued permanently." d. "Use of this drug requires weekly evaluation of blood work."

C Clozapine can cause agranulocytosis. If the absolute neutrophil count (ANC) drops below 1000/mcL, the drug must be discontinued permanently. Blood counts must be evaluated weekly, and this evaluation should be continued for several weeks after withdrawal of the drug. Fever, sore throat, and mouth ulcers are symptoms of agranulocytosis and should be reported immediately.

74. A nurse is reviewing a patient's medications and realizes that gemfibrozil [Lopid] and warfarin [Coumadin] are to be administered concomitantly. Which effect will the nurse anticipate in this patient? a. Increased levels of gemfibrozil b. Decreased levels of gemfibrozil c. Increased anticoagulant effects d. Reduced anticoagulant effects

C Gemfibrozil displaces warfarin from the plasma albumin, thereby increasing anticoagulant effects. The level of gemfibrozil will not be increased or decreased. The anticoagulation effects will not be reduced, because free-floating drug is present in the system; the dosage of warfarin may have to be reduced.

9. Insulin glargine is prescribed for a hospitalized patient who has diabetes. When will the nurse expect to administer this drug? a. Approximately 15 to 30 minutes before each meal b. In the morning and at 4:00 PM c. Once daily at bedtime d. After meals and at bedtime

C Glargine insulin is indicated for once daily subcutaneous administration to treat adults and children with type 1 diabetes and adults with type 2 diabetes. According to the package labeling, the once-daily injection should be given at bedtime. Glargine insulin should not be given more than once a day, although some patients require bid dosing to achieve a full 24 hours of basal coverage.

64. A patient in her twenties with Graves' disease who takes methimazole [Tapazole] tells a nurse that she is trying to conceive and asks about disease management during pregnancy. What will the nurse tell her? a. Methimazole is safe to take throughout pregnancy. b. Propylthiouracil should be taken throughout her pregnancy. c. The patient should discuss changing to propylthiouracil from now until her second trimester with her provider. d. The patient should discuss therapy with iodine-131 instead of medications with her provider.

C Methimazole is not safe during the first trimester of pregnancy, because it is associated with neonatal hypothyroidism, goiter, and cretinism; however, it is safe in the second and third trimesters. Propylthiouracil is recommended for pregnant patients only in the first trimester and during lactation only if a thionamide is absolutely necessary. Iodine-131 is used in women older than 30 years who have not responded to medication therapy and is contraindicated during pregnancy.

55. A patient is taking enalapril [Vasotec]. The nurse understands that patients taking this type of drug for heart failure need to be monitored carefully for: a. hypernatremia. b. hypertension. c. hyperkalemia. d. hypokalemia.

C One of the principal effects of angiotensin-converting enzyme (ACE) inhibitors is hyperkalemia, which is due to decreased aldosterone release arising from blockage of angiotensin II. There is no indication that careful monitoring of sodium for increased levels is indicated. Vasotec is indicated for heart failure, not hypertension. The drug therapy should be monitored to ascertain its effectiveness, but hyperkalemia is the main concern. Hyperkalemia, not hypokalemia, is a concern because of the decreased aldosterone release that occurs with blockage of angiotensin II.

62. The nurse is caring for a patient who begins to complain of shortness of breath. The nurse assesses the patient and notes 3+ pitting edema bilaterally in the lower extremities. Which medication taken by the patient causes the most concern? a. Epoetin alfa b. Filgrastim (granulocyte colony-stimulating factor) c. Oprelvekin (interleukin-11) d. Sargramostim (granulocyte-macrophage colony-stimulating factor)

C Oprelvekin causes the kidneys to retain sodium and water, which causes peripheral edema and expansion of plasma volume. Some patients experience dyspnea. Fluid retention is not an adverse effect of epoetin alfa, filgrastim, or sargramostim.

34. A patient has been taking isoniazid [Nydrazid] for 4 months for latent tuberculosis. The patient reports bilateral tingling and numbness of the hands and feet, as well as feeling clumsy. The nurse expects the provider to: a. discontinue the isoniazid. b. lower the isoniazid dose and add rifampin. c. order pyridoxine 100 mg per day. d. recheck the tuberculin skin test to see whether it worsens.

C Patients sometimes develop peripheral neuropathy, characterized by paresthesias, clumsiness, and muscle aches. If these occur, they may be reversed by administering pyridoxine (vitamin B6). It is not necessary to discontinue the isoniazid. Lowering the isoniazid dose and adding rifampin is not indicated. Rechecking the TST is not indicated.

37. A patient taking an MAOI is seen in the clinic with a blood pressure of 170/96 mm Hg. What will the nurse ask this patient? a. Whether any antihypertensive medications are used b. Whether the patient drinks grapefruit juice c. To list all foods eaten that day d. Whether SSRIs are taken in addition to the MAOI

C Patients taking an MAOI should be counseled to follow strict dietary restrictions and to avoid all foods containing tyramine. Patients who consume such foods when taking an MAOI experience a hypertensive episode. Antihypertensive medications, given with an MAOI, will result in hypotension. Grapefruit juice does not alter the metabolism of an MAOI. SSRIs and MAOIs, when administered together, cause a serotonin syndrome.

65. A patient is taking gentamicin [Garamycin] and furosemide [Lasix]. The nurse should counsel this patient to report which symptom? a. Frequent nocturia b. Headaches c. Ringing in the ears d. Urinary retention

C 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.

27. A patient who has chronic adrenal insufficiency is admitted to the hospital for an open cholecystectomy. The nurse obtaining the admission history learns that the patient takes hydrocortisone 25 mg PO daily in the morning. The patient's surgery is scheduled for the next morning. The nurse will expect an order to: a. administer the usual morning dose of hydrocortisone 25 mg PO. b. administer hydrocortisone 50 mg PO in the morning. c. administer hydrocortisone 50 mg IV before surgery. d. withhold the morning dose of hydrocortisone and give it after surgery.

C Patients who take steroids need extra steroid before situations that cause stress, such as surgery. Failure to administer the increased dose can prove fatal. For surgeries that cause moderate stress, such as a cholecystectomy, patients should be given 50 mg of hydrocortisone intravenously the day of the procedure, followed by a taper over 1 to 2 days to the usual replacement dose. Giving the usual dose or giving an increased oral dose is not indicated.

49. A nurse is evaluating a patient admitted to the emergency department with an evolving STEMI for possible administration of thrombolytic therapy. Which information, identified during history taking, would contraindicate this type of therapy? a. The patient just completed her last menstrual cycle. b. The patient states that the chest pain started 1 hour ago. c. The patient has a history of a small cerebral aneurysm. d. The patient has hypertension that is well controlled by diuretic therapy.

C Patients with a history of CVA should not receive fibrinolytic therapy. This patient has had a known cerebral aneurysm. Active internal bleeding is a contraindication for thrombolysis except for menses, but the patient has indicated she has completed her last cycle. Fibrinolytic therapy should be administered for chest pain that has been present for no longer than 12 hours. Poorly controlled or severe hypertension is a relative contraindication. Thrombolytics can be administered with caution.

43. A patient is taking a thiazide diuretic for hypertension and quinidine to treat a dysrhythmia. The prescriber orders digoxin 0.125 mg to improve this patient's cardiac output. The nurse should contact the provider to request: a. adding spironolactone [Aldactone]. b. reducing the dose of digoxin. c. discontinuing the quinidine. d. giving potassium supplements.

C Quinidine can cause plasma levels of digoxin to rise; concurrent use of quinidine and digoxin is contraindicated. There is no indication for adding spironolactone unless this patient's potassium level is elevated. The dose of digoxin ordered is a low dose. Potassium supplements are contraindicated with digoxin.

26. A child will begin taking methylphenidate [Ritalin] for attention-deficit/hyperactivity disorder. Important baseline information about this patient will include: a. results of an electrocardiogram (ECG). b. family history of psychosis. c. height and weight. d. renal function.

C Side effects of methylphenidate include a reduced appetite, and children taking these drugs should be monitored for growth suppression. Baseline height and weight measurements help with this ongoing assessment. The value of an ECG for children has not been proven, except when known heart disease is a factor. Excessive use of stimulants can produce a state of psychosis but is not related to the family history. Renal function tests are not indicated.

38. A patient has 2+ pitting edema of the lower extremities bilaterally. Auscultation of the lungs reveals crackles bilaterally, and the serum potassium level is 6 mEq/L. Which diuretic agent ordered by the prescriber should the nurse question? a. Bumetanide [Bumex] b. Furosemide [Lasix] c. Spironolactone [Aldactone] d. Hydrochlorothiazide [HydroDIURIL]

C Spironolactone is a non-potassium-wasting diuretic; therefore, if the patient has a serum potassium level of 6 mEq/L, indicating hyperkalemia, an order for this drug should be questioned. Bumetanide, furosemide, and hydrochlorothiazide are potassium-wasting diuretics and would be appropriate to administer in a patient with hyperkalemia.

86. A patient who is taking simvastatin [Zocor] develops an infection and the provider orders azithromycin [Zithromax] to treat the infection. The nurse should be concerned if the patient complains of: a. nausea. b. tiredness. c. muscle pain. d. headache.

C Statins can injure muscle tissue, causing muscle aches and pain known as myopathy/rhabdomyolysis. Daptomycin also can cause myopathy and therefore should be used with caution in patients concurrently taking simvastatin. Nausea, tiredness, and headache would not cause the nurse as much concern as the likelihood of myopathy.

30. A prescriber orders sumatriptan [Imitrex] for a patient for a migraine headache. Before administration of this drug, it would be most important for the nurse to assess whether the patient: a. has a family history of migraines. b. has taken acetaminophen in the past 3 hours. c. has taken ergotamine in the past 24 hours. d. is allergic to sulfa compounds.

C Sumatriptan, other triptans, and ergot alkaloids all cause vasoconstriction and should not be combined, or excessive and prolonged vasospasm could result. Sumatriptan should not be used within 24 hours of an ergot derivative and another triptan. A family history is important, but it is not vital assessment data as it relates to this scenario. Acetaminophen has no drug-todrug interaction with sumatriptan. Sulfa is not a component of sumatriptan and therefore is not relevant.

90. A nurse is teaching a group of nursing students about tricyclic antidepressants (TCAs). Which statement by a student indicates a need for further teaching? a. "TCAs block receptors for histamine, acetylcholine, and norepinephrine." b. "TCAs block the uptake of norepinephrine and 5-HT." c. "TCAs have many side effects, but none of them are serious." d. "TCAs have other uses than for depression."

C TCAs can adversely affect cardiac function, and these effects can be serious in patients with preexisting cardiac impairment. TCAs do block receptors for histamine, acetylcholine, and norepinephrine; they do block the uptake of norepinephrine and 5-HT; and they do have other uses besides depression.

46. A patient with hypertension will begin taking an alphā blocker. What will the nurse teach this patient? a. A persistent cough is a known side effect of this drug. b. Eat foods rich in potassium while taking this drug. c. Move slowly from sitting to standing when taking this drug. d. Report shortness of breath while taking this drug.

C 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.

71. A patient in the emergency department is given intravenous diazepam [Valium] for seizures. When the seizures stop, the nurse notes that the patient is lethargic and confused and has a respiratory rate of 10 breaths per minute. The nurse will expect to administer which of the following? a. Flumazenil [Romazicon] b. Gastric lavage c. Respiratory support d. Toxicology testing

C When benzodiazepines are administered IV, severe effects, including profound hypotension, respiratory arrest, and cardiac arrest, can occur. Respiration should be monitored, and the airway must be managed if necessary. Flumazenil [Romazicon] is a competitive benzodiazepine receptor antagonist and is used to reverse the sedative effects but may not reverse respiratory depression. Gastric lavage would not be effective, because the benzodiazepine has been given IV. Without further indication of the ingestion of other drugs, toxicology testing is not a priority.

41. A nurse is teaching a client who has a new prescription for Nitroglycerin transdermal patch for Angina Pectoris. Which of the following instructions should the nurse include? a. Cut each patch in half if angina attacks are under control. b. Apply a new patch every 48 hours. c. Remove the patch each evening. d. Take off the nitroglycerin patch for 30 minutes if a headache occurs.

C. In order to prevent tolerance to nitroglycerin, the client should remove the patch for 10 to 12 hours during each 24‑hr period.

76. A nurse is reviewing the health care record of a client who reports urinary incontinence and asks about a prescription for Oxybutynin. The nurse should recognize that Oxybutynin is contraindicated in the presence of which of the following conditions? a. Bursitis b. Depression c. Glaucoma d. Sinusitis

C. Oxybutynin is anticholinergic and can increase intraocular pressure. It is contraindicated for clients who have glaucoma.

40. A nurse is assessing a client who is taking Amiodarone to treat Atrial Fibrillation. Which of the following findings is a manifestation of Amiodarone toxicity? a. Blue-gray skin discoloration b. Report of tinnitis c. Productive cough d. Light yellow urine

C. Productive cough can indicate pulmonary toxicity or heart failure. The nurse should assess for cough, chest pain, and shortness of breath.

61. A nurse prepares to administer propranolol [Inderal] to a patient recovering from acute myocardial infarction. The patient's heart rate is 52 beats per minute, and the rhythm is regular. What action should the nurse take next? a. Administer the drug as prescribed. b. Request an order for atropine. c. Withhold the dose and document the pulse rate. d. Withhold the dose and notify the prescriber.

D A beta blocker, such as propranolol, should not be given if the pulse is lower than 60 beats per minute; therefore, the nurse should withhold the dose and notify the prescriber. Administering the dose as prescribed would not be appropriate, because the patient's pulse rate is too slow at this time. The dose should be withheld and the prescriber notified. The patient's heart rate is slow, and atropine may be necessary if the bradycardia persists, but the first step is to withhold the dose of propranolol. Withholding the dose and documenting the pulse rate is an appropriate but incomplete nursing intervention. The nurse must notify the prescriber to obtain further orders related to the medication.

23. A female patient taking an ACE inhibitor learns that she is pregnant. What will the nurse tell this patient? a. The fetus most likely will have serious congenital defects. b. The fetus must be monitored closely while the patient is taking this drug. c. The patient's prescriber probably will change her medication to an ARB. d. The patient should stop taking the medication and contact her provider immediately.

D ACE inhibitors are known to cause serious fetal injury during the second and third trimesters of pregnancy. Whether injury occurs earlier in pregnancy is unknown, and the incidence probably is low. However, women should be counseled to stop taking the drug if they become pregnant, and they should not take it if they are contemplating becoming pregnant. Women who take ACE inhibitors in the first trimester should be counseled that the risk to the fetus is probably low. Women should stop taking the drug when pregnant. ARBs carry the same risk as ACE inhibitors.

88. A patient with type 1 diabetes who takes insulin reports taking propranolol for hypertension. Why is the nurse concerned? a. The beta blocker can cause insulin resistance. b. Using the two agents together increases the risk of ketoacidosis. c. Propranolol increases insulin requirements because of receptor blocking. d. The beta blocker can mask the symptoms of hypoglycemia.

D Beta blockers can delay awareness of and response to hypoglycemia by masking signs associated with stimulation of the sympathetic nervous system (eg, tachycardia, palpitations) that hypoglycemia normally causes. Furthermore, beta blockade impairs glycogenolysis, which is one means by which the body can counteract a fall in blood glucose; beta blockers, therefore, can worsen insulin-induced hypoglycemia. Propranolol does not cause insulin resistance. The incidence of DKA is not increased by concurrent use of propranolol and insulin. Insulin requirements are not increased because of receptor blocking by propranolol.

11. A patient who has a seizure disorder is admitted to the hospital after an increase in seizure frequency, and the prescriber orders carbamazepine [Tegretol] 100 mg twice daily to be added to the patient's medication regimen. The nurse reviewing the patient's medical history notes that the patient is already taking lamotrigine [Lamictal] 375 mg twice daily. The nurse will contact the provider to discuss which action? a. Reducing the carbamazepine dose to 50 mg twice daily b. Reducing the lamotrigine dose to 225 mg twice daily c. Increasing the carbamazepine dose to 200 mg twice daily d. Increasing the lamotrigine dose to 500 mg twice daily

D Carbamazepine induces hepatic drug-metabolizing enzymes and can increase the rate at which lamotrigine and other drugs are metabolized; therefore, patients taking any of these drugs would need an increased dose. Reducing the dose of either drug is not indicated. Increasing the dose of carbamazepine may be necessary but only after serum drug levels have been checked.

94. 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: a. the patient should inhale suddenly to receive the maximum dose. b. the patient should activate the device and then inhale. c. the patient should store the MDI in the refrigerator between doses. d. the patient should wait 1 minute between puffs.

D 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.

85. A patient with gout who has increasingly frequent acute gouty attacks will begin receiving allopurinol [Zyloprim] and colchicine. The nurse will include which statement when teaching the patient about this drug regimen? a. "Allopurinol helps reduce the gastrointestinal side effects of colchicine." b. "Allopurinol reduces the likelihood of gouty episodes that usually occur with initial colchicine therapy." c. "The colchicine is given to enhance the effects of the allopurinol." d. "You will take both drugs initially and then stop taking the colchicine."

D Colchicine is used for prophylaxis when urate-lowering drugs, such as allopurinol, are initiated, because gouty episodes have a tendency to increase during this time. Patients start with both drugs, and ultimately the colchicine is withdrawn. Allopurinol does not affect the GI side effects caused by colchicine. Allopurinol may precipitate an acute gouty attack when treatment is begun; colchicine is given to prevent a gouty episode. Colchicine does not enhance the effects of allopurinol.

80. 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 per 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.

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.

12. A patient in the emergency department has severe chest pain. The nurse administers morphine intravenously. The patient asks the nurse why morphine is given. Which response by the nurse is correct? a. "Morphine helps by reducing anxiety and relieving pain." b. "Morphine helps by reducing pain and dissolving clots." c. "Morphine helps by relieving pain and lowering blood pressure." d. "Morphine helps by relieving pain and reducing the cardiac oxygen demand."

D IV morphine is the treatment of choice for STEMI-associated pain. Besides relieving pain, it promotes vasodilation and reduces cardiac preload, which lowers the cardiac oxygen demand. It does not reduce anxiety, dissolve clots, or lower blood pressure.

60. A patient is admitted with severe hypertensive crisis. The nurse will anticipate administering which medication? a. Captopril PO b. Hydralazine [Apresoline] 25 mg PO c. Minoxidil 20 mg PO d. Sodium nitroprusside [Nitropress] IV

D Sodium 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.

19. While preparing a patient for a second esophageal dilation procedure, the nurse explains that succinylcholine [Anectine] will be used for muscle relaxation. The patient is anxious and reports not being able to swallow for several hours after the previous procedure. What will the nurse do? a. Be prepared to provide mechanical ventilation after the procedure. b. Have dantrolene available, because this patient is at increased risk for side effects. c. Reassure the patient that this is expected after neuromuscular blockade. d. Request an order for a pseudocholinesterase level.

D Succinylcholine is used for muscle relaxation during short procedures, such as esophageal dilation, because of its short duration. The effects wear off minutes after the drug is withdrawn, because plasma pseudocholinesterase quickly degrades it. Patients who have prolonged effects may have low plasma pseudocholinesterase levels and should be evaluated if this is suspected. Mechanical ventilation may be necessary if the drug is given, but the prudent nurse would rather avoid this by taking preventive measures instead of treating the adverse reaction after the fact. Dantrolene should always be available when succinylcholine is used because of the risk of malignant hyperthermia; however, nothing indicates that this particular patient is at greater risk than others. Prolonged neuromuscular blockade is not a normal reaction.

29. A nurse prepares to administer a scheduled dose of digoxin. The nurse finds a new laboratory report showing a plasma digoxin level of 0.7 ng/mL. What action should the nurse take? a. Withhold the drug for an hour and reassess the level. b. Withhold the drug and notify the prescriber immediately. c. Administer Digibind to counteract the toxicity. d. Check the patient's apical pulse, and if it is within a safe range, administer the digoxin.

D The optimum plasma digoxin range is 0.5 to 0.8 ng/mL. The patient's pulse should be checked before administration, as always, and the digoxin should be administered. The digoxin does not have to be withheld, nor does the prescriber need to be notified. If the digoxin level is demonstrating a trend of increasing, the issue should be discussed in rounds. Digibind is not indicated, because the digoxin level is therapeutic.

96. An adolescent patient with moderate acne has begun a regimen consisting of combination clindamycin/benzoyl peroxide [BenzaClin] and tretinoin [Retin-A]. Which statement by the patient indicates understanding of this medication regimen? a. "I should apply the Retin-A immediately after bathing." b. "I should apply the Retin-A twice daily." c. "I should augment this therapy with an abrasive soap." d. "I should use sunscreen every day."

D Tretinoin increases susceptibility to sunburn, so patients should be warned to apply a sunscreen and wear protective clothing. Before applying Retin-A, the skin should be washed, toweled dry, and allowed to dry fully for 15 to 30 minutes. Retin-A is applied once daily. Abrasive soaps intensify localized reactions to Retin-A and should not be used.

22. A nurse is performing a physical assessment on a patient with tuberculosis who takes rifampin [Rifadin]. What would be an expected finding? a. Crystalluria b. Myopathy c. Peripheral neuropathy d. Red-orange-tinged urine

D Urine tinged red-orange is a normal finding associated with rifampin's adverse effects. Peripheral neuropathy, myopathy, and crystalluria are not manifestations of adverse effects of rifampin.

1. A nurse is monitoring a client who is receiving Epoetin alfa for adverse effects. The nurse should identify which of the following findings as an adverse effect of this medication? a. Edema and hematuria b. Blurred vision and edema c. Urinary retention and abdominal pain d. Hypertension and headache

D. Hypertension and headache.

82. A nurse is teaching a client who is taking Sucralfate PO for Peptic Ulcer Disease has a new prescription for phenytoin to control seizures. Which of the following instructions should the nurse include? a. Take sucralfate with a glass of milk b. Take an antacid with the sucralfate c. Chew the sucralfate thoroughly before swallowing d. All a 2 hour interval between these medications

D. Sucralfate can interfere with the absorption of phenytoin, so the client should allow a 2‑hr interval between the sucralfate and phenytoin.

70. A nurse is teaching a client who has angina how to use nitroglycerin transdermal ointment. The nurse should include which of the following instructions? a. "Apply the ointment to the same skin area each time." b. "Rub the ointment directly into your skin until it is no longer visible." c. "Cover the applied ointment with a clean gauze pad." d. "Remove the prior dose before applying a new dose."

D. The client should remove the prior dose before applying a new dose to prevent toxicity.

17. A nurse is caring for a client who is receiving daily doses of Oprelvekin. Which of the following laboratory values should the nurse monitor to determine effectiveness of this medication? a. Total white blood cell count b. Hemoglobin c. Absolute neutrophil count d. Platelet count

D. The expected outcome for oprelvekin is a platelet count greater than 50,000/mm^3.

51. A nurse is providing instructions to a female client who has a new prescription for Zolpidem. Which of the following instructions should the nurse include? a. "Allow at least six hours for sleep when taking zolpidem" b. "Take the medication one hour before you plan to go to sleep." c. "To increase the effectiveness of zolpidem, take it with a bedtime snack." d. "Notify the provider if you plan to become pregnant."

D. Zolpidem is Pregnancy Risk Category C. The client should notify the provider if she plans to become pregnant.