Chapter 37: Cardiac Glycosides, Antianginals, and Antidysrhythmics, Chapter 40: Anticoagulants, Antiplatelets, and Thrombolytics, Chapter 41: Antihyperlipidemics and Peripheral Vasodilators, Chapter 54: Drugs for Hemophilia, Chapter 53: Management of...

A patient, who has intermittent claudication, has been taking 400 mg of pentoxifylline (Trental) three times daily with meals for 2 weeks. The patient calls the clinic and reports mild flushing, occasional gastrointestinal upset, and continued pain in both legs. How will the nurse advise the patient? a. "Expect side effects to diminish as drug effects increase in several weeks." b. "Notify the provider of the continued pain and request increasing the dose." c. "Take a daily aspirin tablet to enhance the effects of pentoxifylline." d. "Take the medication 1 hour before or 2 hours after a meal."

A "Expect side effects to diminish as drug effects increase in several weeks." Patients should be counseled that the desired therapeutic effects may take to 3 months. This patient's side effects are mild and therefore do not warrant discontinuing the drug. This patient is receiving the maximum recommended dose. Aspirin is not indicated. Taking the medication with meals and not on an empty stomach minimizes gastrointestinal effects.

A patient will begin taking rosuvastatin calcium (Crestor) to treat hyperlipidemia. The patient asks the nurse how to take the medication for best effect. Which statement by the nurse is correct? a. "Increase your fluid intake while taking this medication." b. "Stop taking the medication if you develop muscle aches." c. "Take the medication with food to improve absorption." d. "You may increase dietary fat while taking this medication."

A "Increase your fluid intake while taking this medication." Patients taking antihyperlipidemics should be advised to increase fluid intake. It is not necessary to take with food. Patients should never stop taking a statin without consulting the provider. Patients should continue a low-fat diet while taking statins.

A patient experiences a blood clot in one leg, and the provider has ordered a thrombolytic medication. The patient learns that the medication is expensive and asks the nurse if it is necessary. Which response by the nurse is correct? a. "The drug will decrease the likelihood of permanent tissue damage." b. "This medication also acts to prevent future blood clots from forming." c. "You could take aspirin instead of this drug to achieve the same effect." d. "Your body will break down the clot, so the drug is not necessary."

A "The drug will decrease the likelihood of permanent tissue damage." Thrombolytic medications are given primarily to prevent permanent tissue damage caused by compromised blood flow to the affected area. Thrombolytics do not prevent clots from forming. Aspirin prevents, but does not dissolve, clots. Although the body will break down the clot, the drug is needed to prevent tissue damage due to active ischemia.

A patient has a serum cholesterol level of 270 mg/dL. The patient asks the nurse what this level means. Which response by the nurse is correct? a. "You have a high risk for coronary artery disease." b. "You have a moderate risk for coronary artery disease." c. "You have a low risk for coronary artery disease." d. "You have no risk for coronary artery disease."

A "You have a high risk for coronary artery disease." A value of 270 mg/dL for serum cholesterol puts the patient at high risk.

A patient who has recently had a myocardial infarction (MI) will begin taking clopidogrel (Plavix) to prevent a second MI. Which medication will the nurse expect the provider to order as adjunctive therapy for this patient? a. Aspirin b. Enoxaparin sodium (Lovenox) c. Ticagrelor (Brilinta) d. Warfarin (Coumadin)

A Aspirin Aspirin is often used with clopidogrel to inhibit platelet aggregation to increase the effectiveness of this drug. Enoxaparin is used to prevent venous thrombosis. Ticagrelor is similar to clopidogrel and is not used along with clopidogrel. Warfarin is used to prevent thrombosis.

A patient who has stable angina pectoris is given nitroglycerin to use as needed. In addition to pharmacotherapy, the nurse will give the patient which instruction? a. Avoid extremes in weather. b. Begin a rigorous exercise program. c. Drink glass of red wine daily. d. Seek medical care at first sign of pain.

A Avoid extremes in weather Avoiding extreme weather conditions is important to help prevent anginal attacks. Patients should be instructed to avoid strenuous exercise; avoid alcohol, which can enhance hypotensive effects of nitrates; and use nitroglycerin at the first sign of pain.

A patient begins taking nicotinic acid (Niacin) and reports dizziness and flushing of the skin. The nurse will perform which action? a. Contact the provider to discuss decreasing the dose. b. Counsel the patient to increase fluid intake. c. Request an order for renal function tests. d. Schedule the medication to be taken with meals.

A Contact the provider to discuss decreasing the dose. Flushing of the skin and dizziness are common side effects of nicotinic acid, but with careful drug titration and concomitant use of aspirin, these effects can be minimized. Increasing fluid intake or taking with food does not alter these adverse effects. Nicotinic acid can affect liver enzymes not renal function.

The nurse administers a dose of digoxin (Lanoxin) to a patient who has HF and returns to the room later to reassess the patient. Which finding indicates that the medication is effective? a. Decreased dyspnea b. Decreased urine output c. Increased blood pressure d. Increased heart rate

A Decreased dyspnea The patient should show improvement in breathing and oxygenation. Urine output should increase. Blood pressure and heart rate will decrease.

A patient is taking clopidogrel bisulfate (Plavix). When teaching this patient about dietary restrictions while taking this medication, the nurse will instruct the patient to avoid excessive consumption of which food? a. Garlic b. Grapefruit c. Green, leafy vegetables d. Red meats

A Garlic Patients taking this drug may experience increased bleeding when taken with garlic. There is no restriction for grapefruit as there is with many other medications. Green, leafy vegetables should be restricted in patients taking warfarin. Red meats are not contraindicated.

A patient begins taking cholestyramine (Questran) to treat hyperlipidemia. The patient reports abdominal discomfort and constipation. The nurse will provide which instruction to the patient? a. Increase fluid and slowly increase fiber intake. b. Stop taking the medication immediately. c. Take an over-the-counter laxative. d. Take the medication on an empty stomach.

A Increase fluid and slowly increase fiber intake. Cholestyramine can cause gastrointestinal upset and constipation, and these symptoms can be reduced with increased fluids and foods high in fiber. Stopping the medication is not indicated. Over-the-counter laxatives are not recommended until other methods have been tried. Giving the medication on an empty stomach will not relieve the discomfort.

The nurse is caring for a patient who is receiving warfarin (Coumadin) and notes bruising and petechiae on the patient's extremities. The nurse will request an order for which laboratory test? a. International normalized ratio (INR) b. Platelet level c. PTT and aPTT d. Vitamin K level

A International normalized ratio (INR) The INR is the test used most frequently to report prothrombin time results in patients taking warfarin. Warfarin is not an antiplatelet drug, so platelet levels are not indicated. PTT and aPTT are used to monitor heparin therapy. Vitamin K is an antidote for warfarin; levels are not routinely checked.

A patient has been taking cholestyramine (Questran) to treat hyperlipidemia type II. The patient reports abdominal cramping and constipation. The patient's serum low-density lipoprotein (LDL) has decreased from 170 to 110 mg/dL, and triglycerides have not changed from 150 mg/dL since beginning the medication. The provider changes the medication to colesevelam HCl (Welchol). The patient asks the nurse why the medication was changed, and the nurse will explain that colesevelam HCl is ordered for which reason? a. It has fewer side effects. b. It has more convenient dosing. c. It provides greater LDL reduction. d. It provides greater triglyceride reduction.

A It has fewer side effects Colesevelam is similar to cholestyramine but has fewer gastrointestinal side effects. This patient has demonstrated good results with the bile acid sequestrant, so the provider needs to offer a preparation with fewer adverse effects. Both drugs are given twice daily.

The nurse is preparing to administer a first dose of clopidogrel (Plavix) to a patient. As part of the history, the nurse learns that the patient has a previous history of peptic ulcers, diabetes, and hypertension. The nurse understands that it will be necessary to notify the provider and obtain an order for a. a proton pump inhibitor (PPI) medication. b. frequent serum glucose monitoring. c. increased antihypertensive medications. d. nonsteroidal anti-inflammatory medications.

A a proton pum inhibitor (PPI) medication Patients with a previous history of peptic ulcer are at increased risk for gastric bleeding and should take a PPI or histamine2 blocker to prevent this. There is no indication for increased glucose monitoring or an increase in antihypertensive drugs. NSAIDs are contraindicated.

A patient is receiving a thrombolytic medication. The patient calls the nurse to report having bloody diarrhea. The nurse will anticipate administering which medication? a. Aminocaproic acid (Amicar) b. Enoxaparin sodium (Lovenox) c. Protamine sulfate d. Vitamin K

A aninocaproic acid (Amicar) The antithrombotic drug aminocaproic acid is used to treat hemorrhage. Nurses giving thrombolytic drugs should monitor patients for bleeding from the mouth and rectum. Enoxaparin is given for DIC. Protamine sulfate is an antidote for heparin. Vitamin K is an antidote for warfarin.

A patient who takes digoxin to treat HF will begin taking a vasodilator. The patient asks the nurse why this new drug has been ordered. The nurse will explain that the vasodilator is used to a. decrease ventricular stretching. b. improve renal perfusion. c. increase cardiac output. d. promote peripheral fluid loss.

A decrease ventricular stretching. Vasodilators are given to decrease venous blood return to the heart, resulting in decreased cardiac filling and decreased ventricular stretching, in turn reducing preload, contractility, and oxygen demand of the heart.

A patient who has received heparin after previous surgeries will be given enoxaparin sodium (Lovenox) after knee-replacement surgery. The patient asks how this drug is different from heparin. The nurse will explain that enoxaparin a. decreases the need for laboratory tests. b. has a shorter half-life than heparin. c. increases the risk of hemorrhage. d. may be taken orally instead of subcutaneously.

A decreases the need for laboratory tests. Enoxaparin is a low-molecular-weight heparin, which produces more stable responses at lower doses, thus reducing the need for frequent lab monitoring. It has a longer half-life than heparin. It decreases the risk of hemorrhage because it is more stable at lower doses. It is given subcutaneously.

The nurse is assessing a patient who takes warfarin (Coumadin). The nurse notes a heart rate of 92 beats per minute and a blood pressure of 88/78 mm Hg. To evaluate the reason for these vital signs, the nurse will assess the patient's a. gums, nose, and skin. b. lung sounds and respiratory effort. c. skin turgor and oral mucous membranes. d. urine output and level of consciousness.

A gums, nose, and skin An increased heart rate followed by a decreased systolic pressure can indicate a fluid volume deficit caused by internal or external bleeding. The nurse should examine the patient's mouth, nose, and skin for bleeding. These vital signs do not indicate a pulmonary problem. Skin turgor and mucous membranes as well as urine output and level of consciousness may be assessed to determine the level of fluid deficit, but finding the source of blood loss is more important. Signs of gastrointestinal bleeding should also be assessed.

The nurse has just begun administering intravenous streptokinase (Streptase). The nurse assesses vital signs and notes a temperature of 37° C, a heart rate of 70 beats per minute, and a blood pressure of 88/58 mm Hg. The nurse will contact the provider to a. request an adjustment of the streptokinase dose. b. request an order for aminocaproic acid (Amicar). c. request epinephrine to prevent anaphylaxis. d. report potential hemorrhage in this patient.

A request an adjustment of the streptokinase dose Patients receiving streptokinase may experience hypotension when it is first administered and may require an adjustment in dosage. Aminocaproic acid is used to stop bleeding. Epinephrine is given for anaphylaxis, which is characterized by difficulty breathing. A patient with hemorrhage would typically also have tachycardia.

A nursing student asks why the anticoagulant heparin is given to patients who have disseminated intravascular coagulation (DIC) and are at risk for excessive bleeding. The nurse will explain that heparin is used in this case for which reason? a. To decrease the risk of venous thrombosis b. To dissolve blood clots as they form c. To enhance the formation of fibrous clots d. To preserve platelet function

A to decrease the risk of venous thrombosis The primary use of heparin for patients with DIC is to prevent venous thrombosis, which can lead to pulmonary embolism or stroke. Heparin does not break down blood clots, enhance the formation of fibrous clots, or preserve platelet function.

A nurse is reviewing the medications of a patient with diabetes before discharge. The nurse realizes that the patient will be going home on colesevelam, a bile acid sequestrant, and insulin. What patient education should the nurse provide in the discharge teaching for this patient? a. The patient needs to monitor the blood sugar carefully, because colesevelam can cause hypoglycemia. b. The patient needs to monitor the blood sugar carefully, because colesevelam can cause hyperglycemia. c. The patient needs to take the insulin at least 3 hours before the colesevelam. d. The patient needs to use an oral antidiabetic agent or agents, not insulin, with colesevelam.

A ~ Colesevelam can help control hyperglycemia in patients with diabetes; therefore, hypoglycemia is a possible risk. Hyperglycemia is not a risk for patients with diabetes who take colesevelam. Insulin and colesevelam do not interact; therefore, the insulin can be taken at the patient's preferred time or times. Either insulin or oral antidiabetic agents can be taken with colesevelam.

A patient with a history of angina and hypertension is being started on nicotinic acid (Niacin). The nurse is providing patient education. What statement made by the patient demonstrates a need for further teaching? a. "I will take Tylenol with my medication to reduce the inflammatory effects." b. "I will be cautious taking this medication, because I have mild liver damage." c. "I will take an aspirin 30 minutes before my niacin to reduce flushing." d. "This medication will lower my triglyceride levels."

A ~ Intense flushing of the face, neck, and ears occurs in practically all patients taking nicotinic acid in pharmacologic doses. Tylenol will not reduce the flushing or inflammatory effects of the medication; further patient teaching is required. The flushing reaction diminishes in several weeks and can be attenuated by taking 325 mg of aspirin 30 minutes before each dose. Nicotinic acid is hepatotoxic; therefore, the patient should be taught to have the liver enzymes checked and to self-monitor for signs and symptoms. Nicotinic acid reduces low-density lipoprotein (LDL) cholesterol and triglyceride (TG) levels.

Lovastatin (Mevacor) is prescribed for a patient for the first time. The nurse should provide the patient with which instruction? a. "Take lovastatin with your evening meal." b. "Take this medicine before breakfast." c. "You may take lovastatin without regard to meals." d. "Take this medicine on an empty stomach."

A ~ Patients should be instructed to take lovastatin with the evening meal. Statins should be taken with the evening meal, not before breakfast. Statins should not be administered without regard to meals and should not be taken on an empty stomach.

A patient is being started on nicotinic acid (Niaspan) to reduce triglyceride levels. The nurse is providing patient education and should include which adverse effects? (SATA) a. Facial flushing b. Constipation c. Hypoglycemia d. Gastric upset e. Itching

A, D, E ~ Adverse effects of nicotinic acid include intense flushing of the face, neck, and ears; itching; and GI upset (nausea, vomiting, and diarrhea). Constipation and hypoglycemia are not adverse effects of niacin therapy.

A child with moderate hemophilia A who weighs 20 kg is admitted to the hospital after a knee injury with bleeding into the joint. The nurse will expect the provider to order which medication? a. Advate 400 units IV over 10 minutes b. Benefix 800 units slow IV push c. Desmopressin 6 mcg IV over 15 to 30 minutes d. Tranexamic acid [Cyklokapron] 200 mg IV

ANS: A Advate is a third-generation product for factor VIII replacement, which this child needs. Third-generation products are safer, because they are not exposed to BSA or HAS during production; therefore, this is the product of choice. Benefix is a factor IX replacement product and is not indicated for hemophilia A. Desmopressin is used to stop bleeding in patients with mild hemophilia. Tranexamic acid is used as adjunctive therapy.

3. A nurse is teaching a patient who is about to undergo direct-current (DC) cardioversion to treat atrial flutter. The patient has been taking verapamil and warfarin for 6 months. Which statement by the patient indicates understanding of the teaching? a. "I may need long-term therapy with another cardiac medication after the procedure." b. "I should stop taking warfarin a few days before the procedure." c. "I will need to take a beta blocker after the procedure to prevent recurrence of atrial flutter." d. "I will not have to take antidysrhythmia medications after the procedure."

ANS: A After cardioversion for atrial flutter, patients may continue to need long-term therapy with either a class IC agent or a class III agent to prevent recurrence. Patients undergoing DC cardioversion need to take warfarin 3 to 4 weeks before the procedure and for several weeks afterward. Beta blockers are not indicated for postprocedural prophylaxis. Class IC and class III agents are antidysrhythmic drugs.

A patient has heart failure and is taking an ACE inhibitor. The patient has developed fibrotic changes in the heart and vessels. The nurse expects the provider to order which medication to counter this development? a. Aldosterone antagonist b. Angiotensin II receptor blocker (ARB) c. Beta blocker d. Direct renin inhibitor (DRI)

ANS: A Aldosterone antagonists are added to therapy for patients with worsening symptoms of HF. Aldosterone promotes myocardial remodeling and myocardial fibrosis, so aldosterone antagonists can help with this symptom. ARBs are given for patients who do not tolerate ACE inhibitors. Beta blockers do not prevent fibrotic changes. DRIs are not widely used.

A patient with heart failure who has been given digoxin [Lanoxin] daily for a week complains of nausea. Before giving the next dose, the nurse will: a. assess the heart rate (HR) and give the dose if the HR is greater than 60 beats per minute. b. contact the provider to report digoxin toxicity. c. request an order for a decreased dose of digoxin. d. review the serum electrolyte values and withhold the dose if the potassium level is greater than 3.5 mEq/L.

ANS: A Anorexia, nausea, and vomiting are the most common adverse effects of digoxin and should cause nurses to evaluate for more serious signs of toxicity. If the HR is greater than 60 beats per minute, the dose may be given. Nausea by itself is not a sign of toxicity. A decreased dose is not indicated. A serum potassium level less than 3.5 mEq/L is an indication for withholding the dose.

A patient with hemophilia A is undergoing a tooth extraction at the dentist's office. As an adjunct to factor VIII, what other drug should the nurse anticipate being ordered for this patient? a. Tranexamic acid [Cyklokapron] b. Acetaminophen [Tylenol] c. Desmopressin [Stimate] d. Vitamin K

ANS: A Antifibrinolytic drugs (eg, aminocaproic acid and tranexamic acid) can be used as adjuncts to factor VIII and factor IX in special situations, such as a tooth extraction. Acetaminophen is indicated for mild pain. Desmopressin is used as replacement therapy but is not used specifically for tooth extractions. Vitamin K is not indicated in this situation.

A patient newly diagnosed with heart failure is admitted to the hospital. The nurse notes a pulse of 90 beats per minute. The nurse will observe this patient closely for: a. decreased urine output. b. increased blood pressure. c. jugular vein distension. d. shortness of breath.

ANS: A As the heart rate increases, ventricular filling decreases, and cardiac output and renal perfusion decrease. Tachycardia does not elevate blood pressure. Jugular vein distension and shortness of breath occur with fluid volume overload.

A nurse is giving aspirin to a patient during acute management of STEMI. The patient asks why a chewable tablet is given. Which response by the nurse is correct? a. "Aspirin is absorbed more quickly when it is chewed." b. "Chewing aspirin prevents it from being metabolized by the liver." c. "Chewing aspirin prevents stomach irritation." d. "More of the drug is absorbed when aspirin is chewed."

ANS: A Aspirin should be chewed to allow rapid absorption across the buccal mucosa. Chewing aspirin does not affect hepatic metabolism, stomach irritation, or the amount absorbed.

. A nurse is teaching a group of nursing students about antidysrhythmic medications. Which statement by a student indicates understanding of the teaching? a. "Antidysrhythmic drugs can cause new dysrhythmias or worsen existing ones." b. "Adverse effects of these drugs are mainly noncardiac in nature." c. "For most antidysrhythmic drugs, there is evidence of reduced mortality." d. "Use of these drugs may be necessary even if the benefits are unknown."

ANS: A Because antidysrhythmic drugs have prodysrhythmic actions, they can exacerbate existing dysrhythmias or generate new ones. Most adverse effects are cardiac related. There is evidence of increased mortality with many of these drugs. Use of these drugs should be limited to situations in which there is a clear benefit and only if that benefit outweighs any risks

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

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

1. Which two classes of antidysrhythmic drugs have nearly identical cardiac effects? a. Beta blockers and calcium channel blockers b. Beta blockers and potassium channel blockers c. Calcium channel blockers and sodium channel blockers d. Sodium channel blockers and potassium channel blockers

ANS: A Calcium channel blockade has the same impact on cardiac action potentials as does beta blockade, so these agents have nearly identical effects on cardiac function; that is, they reduce automaticity in the SA node, delay conduction through the AV node, and reduce myocardial contractility. Potassium channel blockers act by delaying repolarization of fast potentials. Sodium channel blockers block sodium channels to slow impulse conduction in the atria, ventricles, and His-Purkinje system.

13. A prescriber orders verapamil [Covera-HS] for a patient who is taking digoxin [Lanoxin] and warfarin. The nurse will expect the prescriber to ____ the dose of ____. a. lower; digoxin b. increase; digoxin c. lower; warfarin d. increase; warfarin

ANS: A Calcium channel blockers, such as verapamil, can increase levels of digoxin, so patients taking these drugs may need to have their digoxin dose reduced. Increasing the dose of digoxin can result in digoxin toxicity. Verapamil does not affect warfarin levels. PTS: 1 DIF: Cog

A patient with volume overload begins taking a thiazide diuretic. The nurse will tell the patient to expect which outcome when taking this drug? a. Improved exercise tolerance b. Increased cardiac output c. Prevention of cardiac remodeling d. Prolonged survival

ANS: A Diuretics help reduce fluid volume overload, which, by reducing pulmonary edema, can improve exercise tolerance. Diuretics do not improve cardiac output. ACE inhibitors are used to prevent cardiac remodeling and to improve long-term survival.

9. A prescriber has ordered propranolol [Inderal] for a patient with recurrent ventricular tachycardia. The nurse preparing to administer this drug will be concerned about what in the patient's history? a. Asthma b. Exercise-induced tachyarrhythmias c. Hypertension d. Paroxysmal atrial tachycardia associated with emotion

ANS: A Propranolol is contraindicated in patients with asthma, because it is a nonselective beta-adrenergic antagonist and can cause bronchoconstriction and exacerbate asthma. It is used to treat tachyarrhythmias and paroxysmal atrial tachycardia evoked by emotion, so it is not contraindicated for patients with these conditions. It lowers blood pressure, so it would be helpful in patients with hypertension.

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

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

A patient with Stage C heart failure (HF) who has been taking an ACE inhibitor, a beta blocker, and a diuretic begins to have increased dyspnea, weight gain, and decreased urine output. The provider orders spironolactone [Aldactone]. The nurse will instruct the patient to: a. avoid potassium supplements. b. monitor for a decreased heart rate. c. take extra fluids. d. use a salt substitute instead of salt.

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

The potassium-sparing diuretic spironolactone [Aldactone] prolongs survival and improves heart failure symptoms by which mechanism? a. Blocking aldosterone receptors b. Increasing diuresis c. Reducing venous pressure d. Reducing afterload

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

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

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

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

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

A patient is recovering from a myocardial infarction but does not have symptoms of heart failure. The nurse will expect to teach this patient about: a. ACE inhibitors and beta blockers. b. biventricular pacemakers. c. dietary supplements and exercise. d. diuretics and digoxin.

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

A patient arrives in the emergency department complaining of chest pain that has lasted longer than 1 hour and is unrelieved by nitroglycerin. The patient's electrocardiogram reveals elevation of the ST segment. Initial cardiac troponin levels are negative. The patient is receiving oxygen via nasal cannula. Which drug should be given immediately? a. Aspirin 325 mg chewable b. Beta blocker given IV c. Ibuprofen 400 mg orally d. Morphine intravenously

ANS: A This patient shows signs of acute ST-elevation myocardial infarction (STEMI). Because cardiac troponin levels usually are not detectable until 2 to 4 hours after the onset of symptoms, treatment should begin as symptoms evolve. Chewable aspirin (ASA) should be given immediately to suppress platelet aggregation and produce an antithrombotic effect. Beta blockers are indicated but do not have to be given immediately. Ibuprofen is contraindicated. Morphine is indicated for pain management and should be administered after aspirin has been given.

A nurse is caring for a child who has hemophilia. While reviewing this child's immunization records, the nurse notes that the child needs the tetanus and reduced diphtheria toxoids and acellular pertussis (Tdap) vaccine and the hepatitis A vaccine. The nurse should notify the provider and obtain an order to give: a. both vaccines intramuscularly. b. both vaccines subcutaneously. c. the hepatitis A vaccine only subcutaneously. d. the Tdap vaccine only intramuscularly.

ANS: A To minimize the risk of hepatitis, all patients with hemophilia should be fully vaccinated, and all newly diagnosed patients should receive both the hepatitis A and hepatitis B vaccines to minimize the risk of hepatitis from infusions. Clinicians should inject vaccines intramuscularly, taking precautions to prevent excessive bleeding, because subcutaneous administration does not guarantee efficacy. There is no reason to withhold any vaccine in children with hemophilia.

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

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

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

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

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

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

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

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

A patient has been taking digoxin [Lanoxin] 0.25 mg, and furosemide [Lasix] 40 mg, daily. Upon routine assessment by the nurse, the patient states, "I see yellow halos around the lights." The nurse should perform which action based on this assessment? a. Check the patient for other symptoms of digitalis toxicity. b. Withhold the next dose of furosemide. c. Continue to monitor the patient for heart failure. d. Document the findings and reassess in 1 hour.

ANS: A Yellow halos around lights indicate digoxin toxicity. The use of furosemide increases the risk of hypokalemia, which in turn potentiates digoxin toxicity. The patient should also be assessed for headache, nausea, and vomiting, and blood should be drawn for measurement of the serum digoxin level. The nurse should not withhold the dose of furosemide until further assessment is done, including measurement of a serum digoxin level. No evidence indicates that the patient is in worsening heart failure. Documentation of findings is secondary to further assessment and prevention of digoxin toxicity.

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

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

The nurse is conducting a nursing education class on hemophilia. The nurse correctly states that which characteristics are most likely to be seen in a patient with hemophilia? (Select all that apply.) a. Male gender b. Female gender c. Mother is a carrier. d. All races and ethnicities are susceptible. e. Both parents are carriers.

ANS: A, C, D Hemophilia is more common in males. The female carries this sex-linked recessive gene. The risk of acquiring hemophilia is shared by all races and ethnic groups. Females typically are carriers but do not have hemophilia. Both parents do not have to carry the gene for their children to inherit the disease.

Patients with a history of myocardial infarction should take which medications indefinitely? (Select all that apply.) a. ACE inhibitors b. Alteplase c. Aspirin d. Beta blockers e. Clopidogrel

ANS: A, C, D Patients who have had an MI should take ACE inhibitors, ASA, and beta blockers indefinitely to prevent recurrence and to minimize continuing cardiac remodeling. Alteplase is given during acute management, and clopidogrel is used during acute management and as an adjunct to reperfusion therapy.

2. A patient will be taking amiodarone [Cordarone]. Which baseline tests are necessary before this medication is started? (Select all that apply.) a. Chest radiograph and pulmonary function tests b. Complete blood count with differential c. Ophthalmologic examination d. Renal function tests e. Thyroid function tests

ANS: A, C, E Amiodarone has many potential toxic side effects, including pulmonary toxicity, ophthalmic effects, and thyroid toxicity, so these systems should be evaluated at baseline and periodically while the patient is taking the drug. A complete blood count is not indicated. Renal function tests are not indicated.

Which medications are included in first-line therapy for heart failure? (Select all that apply.) a. Agents that inhibit the renin-angiotensin-aldosterone system (RAAS) b. Aldosterone antagonists c. Beta blockers d. Cardiac glycosides e. Diuretics

ANS: A, C, E For routine therapy, heart failure is treated with agents that inhibit the RAAS, beta blockers, and diuretics. Aldosterone antagonists and cardiac glycosides are not first-line drugs for HF.

A patient is admitted to the coronary care unit from the emergency department after initial management of STEMI. A primary percutaneous coronary intervention has been performed. The nurse notes an initial heart rate of 56 beats per minute and a blood pressure of 120/80 mm Hg. The patient has a history of stroke and a previous myocardial infarction. Which order will the nurse question? a. Aspirin b. Beta blocker c. Clopidogrel d. Heparin

ANS: B A beta blocker would be contraindicated in this patient, because it slows the heart, and this patient is already bradycardic. Aspirin, clopidogrel, and heparin are recommended in patients who have had a primary PCI.

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

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

14. A nurse is discussing adenosine with a nursing student. Which statement by the student indicates a need for further teaching? a. "Adenosine acts by suppressing action potentials in the SA and AV nodes." b. "Adenosine can be used to prevent paroxysmal supraventricular tachycardia and Wolff-Parkinson-White syndrome." c. "Adenosine has a half-life that lasts only a few seconds and must be given intravenously." d. "Adenosine is not effective for treating atrial fibrillation, atrial flutter, or ventricular dysrhythmias."

ANS: B Adenosine is used to terminate paroxysmal supraventricular tachycardia (SVT) and Wolff-Parkinson-White (WPW) syndrome, not to prevent symptoms. Adenosine suppresses action potentials in the SA and AV nodes. Because it has a very short half-life of 1.5 to 10 seconds, it must be given IV bolus, as close to the heart as possible. Adenosine is not active against atrial fibrillation, atrial flutter, or ventricular dysrhythmias.

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

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

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

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

6. A nurse provides teaching for a patient who will begin taking procainamide [Procanbid] for long-term suppression of a dysrhythmia. Which statement by the patient indicates a need for further teaching? a. "I need to take this drug at evenly spaced intervals around the clock." b. "I may have increased bruising, but this is a temporary side effect." c. "I should report pain and swelling in my joints when taking this drug." d. "I will need to have blood tests at regular intervals while taking this drug."

ANS: B Blood dyscrasias are a rare but potentially fatal side effect of procainamide and are an indication for withdrawing the drug. Procainamide should be taken around the clock at evenly spaced intervals. Lupus-like symptoms may occur; inflammation of the joints is one manifestation and should be reported so that antinuclear antibody (ANA) titers can be monitored. Because of the risk of lupus-like symptoms and blood dyscrasias, blood tests need to be done weekly at first and then periodically thereafter.

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

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

A child with hemophilia A who weighs 30 kg receives factor VIII on an ongoing basis as prophylaxis. The provider orders desmopressin [Stimate] to be used for nosebleeds. The nurse will instruct the child's parents to give the medication as ____ nostril as needed. a. 1 spray in each b. 1 spray in one c. 2 sprays in each d. 2 sprays in one

ANS: B Children who weigh less than 50 kg should use 1 spray in one nostril for a dose of 150 mcg. Each spray delivers 150 mcg, so 1 spray in both nostrils would give a dose of 300 mcg. Using 2 sprays in one nostril would give a dose of 300 mcg; using 2 sprays in both nostrils would give a dose of 600 mcg.

A patient asks a nurse why he cannot use digoxin [Lanoxin] for his heart failure, because both of his parents used it for HF. The nurse will explain that digoxin is not the first-line therapy for which reason? a. It causes tachycardia and increases the cardiac workload. b. It does not correct the underlying pathology of heart failure. c. It has a wide therapeutic range that makes dosing difficult. d. It may actually shorten the patient's life expectancy.

ANS: B Digoxin improves cardiac output, alters electrical effects, and helps to decrease sympathetic outflow from the central nervous system (CNS) through its neurohormonal effects; however, it does not alter the underlying pathology of heart failure or prevent cardiac remodeling. Digoxin causes bradycardia and increases the cardiac workload by increasing contractility. It has a narrow therapeutic range and many adverse effects. Digoxin does not improve life expectancy; in women it may actually shorten life expectancy.

15. A nursing student asks a nurse how digoxin causes dysrhythmias. The nurse correctly states that digoxin: a. reduces automaticity in the AV node. b. increases automaticity in the Purkinje fibers. c. increases automaticity in the SA node. d. speeds up AV conduction.

ANS: B Digoxin increases automaticity in the Purkinje fibers, which contributes to dysrhythmias caused by digoxin. Decreased automaticity in the AV node is a desired effect of digoxin. Digoxin does not increase automaticity in the SA node. It does not increase AV node conduction.

2. A patient with atrial fibrillation is taking verapamil [Calan]. The patient has read about the drug on the Internet and wants to know why a drug that affects the rate of ventricular contraction is used to treat an abnormal atrial contraction. What will the nurse tell the patient? a. "Drugs that treat ventricular dysrhythmias help to restore normal sinus rhythm." b. "Atrial dysrhythmias can have life-threatening effects on ventricular function." c. "Treating ventricular dysrhythmias helps prevent the likelihood of stroke." d. "When ventricular contraction slows, atrial contraction is also slowed."

ANS: B Dysrhythmic activity in the atria does not significantly reduce cardiac output but can be dangerous when dysrhythmic impulses cross the AV node, causing ventricular dysrhythmias, which can be life threatening. Treating ventricular dysrhythmia helps improve ventricular pumping. These drugs do not restore normal sinus rhythm. To prevent stroke, an anticoagulant, such as warfarin, is used. Slowing ventricular contraction does not affect the rate of atrial contraction. Restoring normal sinus rhythm requires cardioversion, short-term treatment with amiodarone or sotalol, or RF ablation of the dysrhythmia source.

An 88-year-old patient with heart failure has progressed to Stage D and is hospitalized for the third time in a month. The nurse will expect to discuss which topic with the patient's family? a. Antidysrhythmic medications b. End-of-life care c. Heart transplantation d. Implantable mechanical assist devices

ANS: B Patients in Stage D heart failure have advanced structural heart disease. For eligible patients, the best long-term solution is heart transplantation, but this patient probably is not eligible, given his advanced age. End-of-life care should be discussed. Antidysrhythmic medications are not indicated and may make symptoms worse. An implantable mechanical assist device is used in patients awaiting heart transplantation.

A patient who is receiving reperfusion therapy has a history of heparin-induced thrombosis (HIT). The patient has a creatinine clearance of 28 mL/min. In addition to the fibrinolytic agent, which medication will the nurse expect to administer to this patient? a. Aspirin b. Bivalirudin [Angiomax] c. Clopidogrel [Plavix] d. Fondaparinux [Arixtra]

ANS: B Patients receiving a fibrinolytic medication will also need an anticoagulant to reduce the risk of thrombosis. This patient cannot receive heparin because of the history of HIT, so he or she will need either bivalirudin or fondaparinux. Bivalirudin may be used at reduced doses in patients with a creatinine clearance less than 30 mL/min, but fondaparinux is contraindicated in such patients. Antiplatelet drugs such as aspirin or clopidogrel are not used for this purpose.

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

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

A patient has undergone a primary percutaneous coronary intervention with a stent placement. The provider has ordered a daily dose of 81 mg of aspirin and clopidogrel. The patient asks the nurse how long the medications must be taken. What will the nurse tell this patient about the medication regimen? a. This drug regimen will continue indefinitely. b. The clopidogrel will be discontinued in one year and the aspirin will be given indefinitely. c. The aspirin will be discontinued in one year and the clopidogrel will be given indefinitely. d. Both drugs will be discontinued in one year.

ANS: B Patients who have undergone PCI with a stent will take ASA indefinitely along with an antiplatelet drug for one year. The clopidogrel will be discontinued in one year, but the aspirin will be given indefinitely.

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

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

A nurse is preparing to administer digoxin [Lanoxin] to a patient. The patient's heart rate is 62 beats per minute, and the blood pressure is 120/60 mm Hg. The last serum electrolyte value showed a potassium level of 5.2 mEq/L. What will the nurse do? a. Contact the provider to request an increased dose of digoxin. b. Give the dose of digoxin and notify the provider of the potassium level. c. Request an order for a diuretic. d. Withhold the dose and notify the provider of the heart rate.

ANS: B The patient's serum potassium level is above normal limits, but only slightly. An elevated potassium level can reduce the effects of digoxin, so there is no risk of toxicity. There is no indication that an increased dose of digoxin is needed. There is no indication for a diuretic. The heart rate is acceptable; doses should be withheld if the heart rate is less than 60 beats per minute.

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

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

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

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

7. A nurse is caring for a patient in the intensive care unit who is receiving intravenous lidocaine. The patient is drowsy and confused and reports numbness of the fingers and toes. Which standing order will the nurse initiate at this time? a. Administer diazepam. b. Reduce the rate of infusion. c. Discontinue the infusion. d. Prepare for mechanical ventilation.

ANS: B This patient is showing signs that are common with high therapeutic levels of lidocaine. Because lidocaine is rapidly degraded, slowing the rate of infusion can help remove excess drug from the circulation. Seizures are possible with toxic doses; diazepam should be used to control seizures. It is not necessary to discontinue the infusion, because this patient is showing signs common to high therapeutic doses. Respiratory arrest is possible with toxic doses; mechanical ventilation may be needed.

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

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

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

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

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."

ANS: 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.

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

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

A patient with hemophilia is hospitalized for infusion of factor VIII replacement through a venous port. While giving the drug, the nurse notes that the patient's temperature is 101.5°F. The nurse will contact the provider to report which possibility? a. Anaphylactic reaction b. Contamination of factor replacement c. Port infection d. Thrombolytic event

ANS: C Central venous access devices are used to facilitate frequent IV administration of factor replacement but pose the risks of infection and thrombosis. This patient has a fever, which is a symptom of infection. Anaphylactic reactions to factor replacement can occur but are characterized by wheezing and shortness of breath, along with swelling in the face. Viral contamination of factor replacement is rare with factor VIII. Thrombolytic events would have symptoms associated with clot formation in certain organs and are not associated with fever.

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

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

A patient who is receiving a factor VIII concentrate to treat hemophilia A develops hives, a low-grade temperature elevation, and a stuffy nose. The nurse will prepare to: a. administer subcutaneous epinephrine. b. give an antipyretic medication. c. give oral diphenhydramine. d. provide respiratory support.

ANS: C Factor VIII concentrates can cause allergic reactions, which can range from mild to severe. This patient is showing signs of a mild reaction and can be managed with an antihistamine such as diphenhydramine. Epinephrine is used if there are signs of anaphylaxis, such as wheezing and shortness of breath. Antipyretics are not indicated for low-grade fevers. Respiratory support may be necessary with severe anaphylaxis.

17. The nurse educator is providing patient education about the Cardiac Arrhythmia Suppression Trial (CAST). The nurse correctly explains that the trial demonstrated what effect from the pharmacologic suppression of dysrhythmias? a. It reduced mortality by 50% but increased morbidity. b. It significantly reduced the risk of a second myocardial infarction (MI). c. It doubled the risk of a second MI. d. It should be used in all patients who have had an MI, regardless of rhythm.

ANS: C In the CAST, class IC dysrhythmic drugs were used to prevent dysrhythmias after MI. These drugs were found to actually double the rate of mortality. The antidysrhythmic drugs did not reduce mortality or the risk of a second MI. They should not be used for any MI patients with associated dysrhythmias unless the dysrhythmias are life threatening.

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

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

8. A patient with diabetes develops ventricular tachycardia and is in the hospital for evaluation of this condition. The nurse reviews the history and learns that the patient takes mexiletine [Mexitil] for pain caused by peripheral neuropathy. What should the nurse do? a. Discuss common side effects associated with taking mexiletine with cardiac agents. b. Understand that this drug will help with both peripheral neuropathy and dysrhythmias. c. Notify the provider to request that another drug be used for peripheral neuropathy pain. d. Request an order for renal function and hepatic function tests.

ANS: C Mexiletine is an antidysrhythmic medication that can also cause dysrhythmias. It is used to treat the pain associated with peripheral neuropathy in diabetic patients, but it is contraindicated in diabetic patients with heart disease, and so it should be stopped now that this patient has developed a heart disorder. Because it is contraindicated, the nurse will not teach the patient about side effects with other agents. It can exacerbate cardiac symptoms, so it should not be used to treat dysrhythmias in diabetic patients. There is no indication for tests of renal and hepatic function. PTS: 1 DIF: Cognitive Level: Evaluation

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

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

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.

ANS: 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.

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

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

A patient has undergone a PCI, and the provider orders clopidogrel to be given for 12 months, along with an ACE inhibitor and heparin. What will the nurse do? a. Question the need for heparin. b. Request an order for a beta blocker. c. Request an order for aspirin. d. Suggest ordering clopidogrel for 14 days.

ANS: C Patients who have undergone a PCI should receive heparin, ASA, and a fibrinolytic; therefore, this patient needs ASA added to the drug regimen. Heparin should be given before, during, and for at least 48 to 72 hours after the procedure. Beta blockers are not necessarily indicated. Clopidogrel should be given at least 12 months after the procedure.

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.

ANS: 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.

A nurse is discussing fibrinolytic therapy for the acute phase of STEMI management with a group of nursing students. Which statement by a student indicates understanding of this therapy? a. "Fibrinolytics are effective when the first dose is given up to 24 hours after symptom onset." b. "Fibrinolytics should be given once cardiac troponins reveal the presence of STEMI." c. "Fibrinolytics should be used with caution in patients with a history of cerebrovascular accident." d. "Patients should receive either an anticoagulant or an antiplatelet agent with a fibrinolytic drug."

ANS: C Patients with a history of cerebrovascular accident (CVA) should not receive fibrinolytic agents because of the increased risk of intracranial hemorrhage. Fibrinolytics are most effective when given within 30 minutes of arrival in the emergency department. Because cardiac troponins are not detectable until 2 to 4 hours after the onset of symptoms, fibrinolytics should be administered before these laboratory values are available. Patients receiving fibrinolytics should receive both an anticoagulant and an antiplatelet drug.

The parents of a boy with hemophilia A want to know why their son will receive factor replacement on an ongoing basis rather than when needed for bleeding episodes. They tell the nurse that the boy's grandfather, who had the same disease, received the drug only when he had bleeding. The nurse will give the parents which information about ongoing therapy? a. It can reverse progression of the disease. b. It is cheaper, because the amounts of the drug used are less. c. It is used to minimize long-term damage to the joints. d. It prevents the development of inhibitors.

ANS: C Primary prophylaxis, especially in young children, minimizes bleeding episodes and long-term damage to joints. Ongoing treatment does not reverse the progression of the disease. Ongoing therapy is not less expensive, nor does it prevent the development of inhibitors.

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.

ANS: 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.

A nurse is discussing heart failure with a group of nursing students. Which statement by a student reflects an understanding of how compensatory mechanisms can compound existing problems in patients with heart failure? a. "An increase in arteriolar tone to improve tissue perfusion can decrease resistance." b. "An increase in contractility to increase cardiac output can cause pulmonary edema." c. "When the heart rate increases to increase cardiac output, it can prevent adequate filling of the ventricles." d. "When venous tone increases to increase ventricular filling, an increase in arterial pressure occurs."

ANS: C The heart rate increases to improve cardiac output, but it may prevent adequate ventricular filling. An increase in arteriole tone improves tissue perfusion but also increases both the resistance to the pumping of the heart and the cardiac workload. Increased contractility helps improve cardiac output but is detrimental because it increases the oxygen demand of the heart. An increase in venous tone improves ventricular filling, but as the ventricles fail, blood can back up and cause pulmonary edema.

A patient with heart failure who takes a thiazide diuretic and digoxin [Lanoxin] is admitted for shortness of breath. The patient's heart rate is 66 beats per minute, and the blood pressure is 130/88 mm Hg. The serum potassium level is 3.8 mEq/L, and the digoxin level is 0.8 ng/mL. The nurse admitting this patient understands that the patient: a. has digoxin toxicity. b. is showing signs of renal failure. c. is experiencing worsening of the disease. d. needs a potassium-sparing diuretic.

ANS: C This patient has a normal serum potassium level, and the digoxin level is normal. The patient is showing signs of pulmonary edema, which indicates progression of heart failure. The digoxin level is within normal limits, and the heart rate is above 60 beats per minute, so digoxin toxicity is not likely. There is no sign of renal failure. A potassium-sparing diuretic is not indicated.

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

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

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

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

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

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

A nurse is caring for an African American patient with severe hemophilia A who has been admitted for bleeding into the knee joint. The prescriber has ordered intravenous factor VIIa [NovoSeven RT]. A nursing student wants to know why this patient is not receiving factor VIII. Which statement by the nurse is correct? a. "Factor VIIa is stronger than factor VIII and will work faster." b. "Factor VIII is used for prophylaxis, and factor VIIa is used for acute episodes." c. "Factor VIIa is used when patients develop antibodies against factor VIII." d. "Factor VIIa provides immune tolerance therapy so that factor VIII will be more effective."

ANS: C When patients develop antibodies against factor VIII, activated factor VII is used, because it has the same actions as factor VIII. Patients with severe hemophilia A have a 20% to 30% likelihood of developing antibodies to factor VIII and the risk of inhibitor development is unusually high in African American and Hispanic patients, so this patient has an increased risk. Factor VIIa is not stronger than factor VIII. It is not used for prophylaxis only. Immune tolerance therapy describes the use of repeated administration of factor replacement products to eliminate inhibitor production.

Which are expected effects of cardiac glycosides? (Select all that apply.) a. Decreased cardiac output b. Decreased force of contraction c. Decreased heart rate d. Modulation of neurohormonal systems e. Positive inotropic effects

ANS: C, D, E Digoxin slows the heart rate, modulates the activity of neurohormonal systems, and increases the force of contraction. It does not decrease cardiac output or reduce the force of contraction.

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

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

A patient with hemophilia B is admitted to the hospital for surgery. The patient's history reveals long-term use of factor replacement as prophylaxis for bleeding episodes. The nurse anticipates that the provider will order which medication to prevent excessive perioperative bleeding? a. Desmopressin b. Factor VIII c. Ibuprofen d. Tranexamic acid

ANS: D Antifibrinolytic drugs, such as tranexamic acid, which prevent the breakdown of fibrin, are used as adjuncts to replacement factor in special cases in which bleeding is likely. Desmopressin is used in patients with mild hemophilia A to help control bleeding episodes. Hemophilia B is a deficiency of factor IX, so giving factor VIII would not be appropriate. Ibuprofen would only reduce clotting and should not be used.

12. A prescriber is considering prescribing the amiodarone derivative dronedarone [Multaq] for a patient with atrial flutter. The nurse should be concerned about which of the following? a. History of asthma b. History of hypothyroidism c. PR interval of 260 msec d. QT interval of 520 msec

ANS: D Because dronedarone prolongs the QT interval by about 10 msec, it should not be used in patients with a QT interval of more than 500 msec. It does not have significant pulmonary or thyroid toxicity. It should not be used in patients with a PR interval of more than 280 msec.

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

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

A child with severe hemophilia A receives factor VIII. The nurse expects this drug to be given: a. on demand when bleeding occurs. b. on demand when plasma factor VIII activity is less than 1% above normal. c. prophylactically once weekly to maintain normal factor VIII activity. d. prophylactically three times weekly to maintain factor VIII activity above 1% of normal.

ANS: D Children with severe hemophilia are primary candidates for prophylactic therapy with factor VIII, and this is given every other day or three times weekly with a goal of maintaining factor VIII activity above 1% of normal. On-demand therapy is indicated when patients are bleeding or are about to undergo surgery.

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.

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

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

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

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

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

A patient with heart failure who has been taking an ACE inhibitor, a thiazide diuretic, and a beta blocker for several months comes to the clinic for evaluation. As part of the ongoing assessment of this patient, the nurse will expect the provider to evaluate: a. complete blood count. b. ejection fraction. c. maximal exercise capacity. d. serum electrolyte levels.

ANS: D Patients taking thiazide diuretics can develop hypokalemia, which can increase the risk for dysrhythmias; therefore, the serum electrolyte levels should be monitored closely. A complete blood count is not recommended. This patient is taking the drugs recommended for patients with Stage C heart failure; although the patient's quality of life and ability to participate in activities should be monitored, routine measurement of the ejection fraction and maximal exercise capacity is not recommended.

A patient diagnosed with STEMI is about to undergo a primary percutaneous coronary intervention (PCI). Which combination of pharmacotherapeutic agents will be given to augment this procedure? a. Beta blocker and nitroglycerin b. Abciximab and a fibrinolytic drug c. Angiotensin-converting enzyme (ACE) inhibitor and aspirin d. Heparin, aspirin, and clopidogrel

ANS: D Patients undergoing a primary PCI should receive heparin intravenously combined with aspirin and either clopidogrel or prasugrel. Abciximab and fibrinolytic drugs are not indicated. Beta blockers and nitroglycerin do not prevent thromboses. ACE inhibitors do not prevent thromboses

5. A patient is taking digoxin [Lanoxin] and quinidine to treat sustained ventricular tachycardia. Before giving medications, the nurse reviews the patient's electrocardiogram (ECG) and notes a QRS complex that has widened by 50% from the baseline ECG. What will the nurse do? a. Administer the medications as ordered, because this indicates improvement. b. Contact the provider to discuss reducing the digoxin dose. c. Contact the provider to request an increase in the quinidine dose. d. Withhold the quinidine and contact the provider to report the ECG finding.

ANS: D Quinidine widens the QRS complex by slowing depolarization of the ventricles. As cardiotoxicity develops as a result of quinidine toxicity, the QRS complex widens excessively. Any widening of the QRS complex of 50% or more warrants notifying the provider, so the nurse should withhold the medication and contact the provider. Widening of the QRS complex by more than 50% of baseline indicates cardiotoxicity. Quinidine can double digoxin levels, so it is not likely that the digoxin dose would need to be increased, and an increase in the QRS complex does not indicate a need for more digoxin. The quinidine dose should not be increased, because the findings indicate cardiotoxicity from the quinidine.

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.

ANS: 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.

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

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

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

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

A patient who is recovering from a STEMI 3 months prior is in the clinic for a follow-up evaluation. The patient is taking 81 mg of aspirin, a beta blocker, and an ACE inhibitor daily and uses nitroglycerine as needed for angina. The patient's BMI is 24.5 kg/m2, and serum LDL is 150 mg/dL. The patient has a blood pressure of 135/80 mm Hg. What will the nurse expect the provider to order for this patient? a. An antihypertensive medication b. Counseling about a weight loss diet c. Discontinuing the ACE inhibitor d. High-dose statin therapy

ANS: D To help prevent recurrence of MI in patients post-STEMI, a high-dose statin should be given to patients with elevated cholesterol. This patient's blood pressure and BMI are normal, so antihypertensives and a weight loss diet are not recommended. The three drugs should be continued indefinitely.

1. A patient is in the intensive care unit after a myocardial infarction. The nurse notes that the QT interval on this patient's electrocardiogram has been elongating. The nurse is concerned that which cardiac dysrhythmia may occur? a. AV block b. Bradycardia c. Supraventricular tachycardia d. Torsades de pointes

ANS: D Torsades de pointes is a dysrhythmia that can occur with prolongation of the QT interval and can progress to fatal ventricular fibrillation. A prolonged QT interval does not signal the development of AV block, bradycardia, or SVT.

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

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

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

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

16. The nurse is teaching a class on dysrhythmias and associated therapy. The nurse asks the class, "Which cardiac dysrhythmia would result in the lowest cardiac output, and what treatment would be effective?" The class best demonstrates understanding by responding that ____ results in the lowest cardiac output, and treatment includes ____. a. atrial flutter; lidocaine b. tachycardia; atropine c. first-degree heart block; verapamil [Calan] d. ventricular fibrillation; defibrillation

ANS: D With ventricular fibrillation there is no cardiac output, because the pumping action of the heart stops. Treatment with electrical countershock is indicated to restore cardiac function. Atrial flutter, tachycardia, and first-degree heart block do not result in the lowest cardiac output.

The nurse is preparing to administer digoxin to a patient who has a serum digoxin level of 2.5 ng/mL. The patient takes 0.25 mg of digoxin per day. What action will the nurse take? a. Administer the next dose as ordered. b. Notify the provider of digoxin toxicity. c. Request an order to decrease the digoxin dose. d. Suggest that the patient may need an increased digoxin dose.

B Notify the provider of digoxin toxicity. The therapeutic range of digoxin is between 0.8 and 2 ng/mL. This patient's level is high, indicating toxicity. The nurse should not give the next dose or request a change in dose.

A patient with chronic obstructive pulmonary disease (COPD) has increasing dyspnea and is being evaluated for HF. Which test will be ordered to help differentiate between dyspnea due to lung dysfunction and dyspnea due to HF? a. Atrial natriuretic hormone (ANH) level b. Brain natriuretic peptide (BNP) level c. Cardiac enzymes d. Electrocardiogram (ECG)

B Brain natriuretic peptide (BNP) level The BNP is used to differentiate that dyspnea is due to HF and not lung dysfunction. The other tests will all be a part of the diagnostic workup but do not help with this distinction.

The nurse is preparing to administer digoxin to a patient who has HF. The patient reports nausea, vomiting, and a headache. The nurse notes a respiratory rate of 18 breaths per minute, a heart rate of 58 beats per minute, and a blood pressure of 120/78 mm Hg. What will the nurse do next? a. Administer the next dose as ordered since these are mild side effects. b. Hold the dose and notify the provider of possible digoxin toxicity. c. Reassure the patient that these are common, self-limiting side effects. d. Request an order for an antiemetic and an analgesic medication.

B Hold the dose and notify the provider of possible digoxin toxicity. Nausea, vomiting, and headache are common signs of digoxin toxicity as is a heart rate less than 60 beats per minute. The nurse should hold the dose and notify the provider.

A patient has been receiving intravenous heparin. When laboratory tests are drawn, the nurse has difficulty stopping bleeding at the puncture site. The patient has bloody stools and is reporting abdominal pain. The nurse notes elevated partial thromboplastin time (PTT) and activated PPT (aPTT). Which action will the nurse perform? a. Ask for an order for oral warfarin (Coumadin). b. Obtain an order for protamine sulfate. c. Request an order for vitamin K. d. Suggest that the patient receive subcutaneous heparin.

B Obtain an order for protamine sulfate. Protamine sulfate is given as an antidote to heparin when patient's clotting times are elevated. Oral warfarin will not stop the anticoagulant effects of heparin. Vitamin K is used as an antidote for warfarin. Administering heparin by another route is not indicated when there is a need to reverse the effects of heparin.

A patient asks the nurse why nitroglycerin is given sublingually. The nurse will explain that nitroglycerin is administered by this route for which reason? a. To avoid hypotension b. To increase absorption c. To minimize gastrointestinal upset d. To prevent hepatotoxicity

B To increase absorption Nitroglycerin is given sublingually to avoid first-pass metabolism by the liver, which would occur if the drug is swallowed. It does not prevent hypotension. Gastrointestinal upset and hepatotoxicity usually do not occur.

The nurse is caring for a patient who is receiving clopidogrel (Plavix). The patient calls the nurse to report flulike symptoms. The nurse notes a heart rate of 76 beats per minute, a blood pressure of 110/76 mm Hg, and a respiratory rate of 20 breaths per minute. The nurse suspects that the patient is experiencing which condition? a. Anaphylaxis b. An expected drug side effect c. Hemorrhage d. Possible MI

B an expected drug side effect Flulike symptoms are a side effect of clopidogrel. The patient has normal vital signs. Anaphylaxis is characterized by respiratory distress and hypotension. Hemorrhage is characterized by tachycardia and hypotension.

The nurse is caring for a postoperative patient who is receiving alteplase tPA (Activase) after developing a blood clot. The nurse notes a heart rate of 110 beats per minute and a blood pressure of 90/60 mm Hg. The nurse will perform which action? a. Ask the patient about itching or shortness of breath. b. Assess the surgical dressing for bleeding. c. Evaluate the patient's urine output and fluid intake. d. Recheck the patient's vital signs in 15 minutes.

B assess the surgical dressing for bleeding Tachycardia and hypotension indicate bleeding. The nurse should check the patient's surgical dressing to assess for bleeding. These signs do not indicate anaphylaxis. They may indicate dehydration, but bleeding is the more likely cause of fluid volume deficit. The nurse should continue to evaluate vital signs, but it is imperative that the nurse assess the patient to explore the potential cause.

A patient has been taking atorvastatin (Lipitor) for several months to treat hyperlipidemia. The patient reports muscle weakness and tenderness. The nurse will counsel the patient to a. ask the provider about switching to simvastatin. b. contact the provider to report these symptoms. c. start taking ibuprofen to combat these effects. d. stop taking the medication immediately.

B contact the provider to report these symptoms. Patients taking statins should report immediately any muscle aches or weakness, which can lead to rhabdomyolysis, a muscle disintegration that can become fatal. All statins carry this risk, so changing to another statin is not indicated. Ibuprofen may be useful, but notifying the provider is essential. Patients should not abruptly discontinue statins without discussing this with the provider.

A patient has congestive HF and has been taking digoxin (Lanoxin) for 9 years. The patient is admitted with signs and symptoms of digoxin toxicity. Which signs and symptoms are associated with digoxin toxicity? (Select all that apply.) a. Dysuria b. Vomiting c. Tachycardia d. Yellow haloes in the visual field e. Diarrhea f. Insomnia

B vomiting D yellow haloes in the visual field E diarrhea Vomiting, yellow haloes in the visual field, and diarrhea are classic signs of digoxin toxicity. Bradycardia, not tachycardia, will likely be noted.

A patient has begun taking an HMG-COA reductase inhibitor. Which statement about this class of drugs made by the nurse during patient education would be inappropriate? a. "Statins reduce the risk of stroke." b. "You should come into the clinic for liver enzymes in 1 month." c. "Statins reduce the risk of coronary events in people with normal LDL levels." d. "You should maintain a healthy lifestyle and avoid high-fat foods."

B ~ Baseline liver enzyme tests should be done before a patient starts taking an HMG-COA reductase inhibitor. They should be measured again in 6 to 12 months unless the patient has poor liver function, in which case the tests are indicated every 3 months. Statins do reduce the risk of stroke and coronary events in people with normal LDL levels. Maintaining a healthy lifestyle is important, as is avoiding high-fat foods.

A patient who recently started therapy with an HMG-COA reductase inhibitor asks the nurse, "How long will it take until I see an effect on my LDL cholesterol?" The nurse gives which correct answer? a. "At least 6 months is required to see a change." b. "A reduction usually is seen within 2 weeks." c. "Blood levels normalize immediately after the drug is started." d. "Cholesterol will not be affected, but triglycerides will fall within the first week."

B ~ Reductions in LDL cholesterol are significant within 2 weeks and maximal within 4 to 6 weeks. It does not take 6 months too see a change. The blood level of LDL cholesterol is not reduced immediately upon starting the drug; a reduction is seen within 2 weeks. Blood cholesterol is affected, specifically LDL cholesterol, not triglycerides.

A patient has been prescribed cilostazol. Which statement by the client indicates the need for further teaching? a. "I can take the medication with food if it causes nausea." b. "This medication is used to improve blood flow." c. "I can continue to take ginkgo biloba to improve my memory." d. "I should be cautious when standing."

C "I can continue to take ginkgo biloba to improve my memory." Cilostazol should not be taken with ginkgo biloba because bleeding time can be prolonged. It can cause nausea so the nurse should recommend taking the medication with food. Cilostazol does cause vasodilation and improves blood flow which can also cause peripheral edema. Caution should be taken when standing for long periods.

The nurse is teaching a patient about the use of a transdermal nitroglycerin patch. Which statement by the patient indicates understanding of the teaching? a. "I will apply the patch as needed when I experience anginal pain." b. "I will remove the old patch and replace it with a new one at bedtime each day." c. "I should rotate sites when changing the patch to prevent skin irritation." d. "When I am symptom-free, I may stop using the patch on a regular basis."

C "I should rotate sites when changing the patch to prevent skin irritation." Patients should be taught to rotate application sites when using the transdermal nitroglycerin. Transdermal nitroglycerin is not used as needed. Patients should remove the patch at bedtime to provide an 8- to 12-hour nitrate-free interval. Patients should use the patch even when symptom-free unless otherwise instructed by the provider.

The nurse provides teaching to a patient who will begin taking simvastatin (Zocor) to treat hyperlipidemia. Which statement by the patient indicates understanding of the teaching? a. "I may have diarrhea as a result of taking this medication." b. "I may stop taking this medication when my lipid levels are normal." c. "I will need an annual eye examination while taking this medication." d. "I will increase my intake of vitamins A, D, and E while taking this medication.

C "I will need an annual eye examination while taking this medication." The statins can affect visual acuity, so patients should be counseled to have annual eye examinations for assessment of cataract formation. The bile acid sequestrants, not statins, cause diarrhea. Statin drug therapy is lifelong or until behavioral changes prove equally effective (uncommon). Bile acid sequestrants, not statins, decrease the absorption of fat-soluble vitamins.

The nurse is caring for a patient who is taking digoxin to treat HF. The patient's ECG shows a ventricular dysrhythmia. The nurse will notify the provider and will anticipate an order for which medication? a. Digoxin immune Fab (Digibind) b. Furosemide (Lasix) c. Phenytoin (Dilantin) d. Potassium

C Phenytoin (Dilantin) The antidysrhythmics phenytoin and lidocaine are effective in treating digoxin-induced ventricular dysrhythmias. Digoxin immune Fab is used to treat severe digitalis toxicity, characterized by bradycardia, nausea, and vomiting. Unless a potassium deficit is present, giving potassium could worsen the dysrhythmia.

A patient will begin taking simvastatin (Zocor) to decrease serum cholesterol. When teaching the patient about this medication, the nurse will counsel the patient to take which action? a. Return to the clinic annually for laboratory testing. b. Take care when rising from a sitting to standing position. c. Take the medication in the evening for best effect. d. Use ibuprofen as needed for muscle aches and pain.

C Take the medication in the evening for best effect. Simvastatin is given in the evening. Laboratory tests are performed every 3 to 6 months, not annually. Statins do not cause postural hypotension. Patients taking statins should report muscle aches and weakness immediately.

A patient with high cholesterol is ordered to take atorvastatin (Lipitor). What information will be included in the patient teaching? (Select all that apply.) a. Dietary management is not a priority with this medication. b. The medication should be taken on an empty stomach. c. The medicine should be taken with a full glass of water. d. The patient should watch for body aches or gastrointestinal upset as side effects. e. The patient should have renal function tests frequently. f. The patient should have liver function tests frequently.

C The medicine should be taken with a full glass of water. D The patient should watch for body aches or gastrointestinal upset as side effects. F The patient should have liver function tests frequently. This medication is most effective with careful monitoring of diet. Atorvastatin does not affect renal function.

The nurse is assessing a patient prior to administering thrombolytic therapy. Which is an important assessment for this patient? a. Determining whether the patient has a history of diabetes b. Finding out about a history of renal disease c. Assessing which medications are taken for discomfort d. Assessing whether the patient eats green, leafy vegetables

C assessing which medications are taken for discomfort Patients who take aspirin or NSAIDs should be monitored closely for excessive bleeding when given thrombolytics. There are no contraindications or precautions for patients with diabetes or renal disease. Foods rich in vitamin K are of concern for patients taking warfarin.

A patient who is taking warfarin has an international normalized ratio (INR) of 5.5. The nurse will anticipate giving a. fresh frozen plasma. b. intravenous iron. c. oral vitamin K. d. protamine sulfate.

C oral vitamin K. Vitamin K is an antagonist against warfarin, an oral anticoagulant. Patients with an INR of 5.5 should be given a low dose of oral vitamin K. Too much vitamin K may reduce the effectiveness of warfarin for up to 2 weeks. Fresh frozen plasma and intravenous iron are given for anemia caused by blood loss. Protamine sulfate is given for heparin overdose.

A prescriber has ordered rosuvastatin (Crestor) for a patient with non-alcoholic-related cirrhosis. Which intervention would be most appropriate for the nurse before administration of this drug? a. Question the order, because rosuvastatin is contraindicated in patients with liver disease. b. No intervention is necessary; just administer the drug as ordered. c. Review the baseline liver function test results. d. Assess the patient for liver disease.

C ~ Before administering rosuvastatin, the nurse should review the results of the baseline liver function tests (LFTs). Statins can be used by patients with liver disease but not by those with alcoholic or viral hepatitis. Administering the drug before obtaining baseline LFT results would not allow for an accurate baseline. The patient clearly already has liver disease

A nurse is providing discharge teaching instructions for a patient taking cholestyramine (Questran). Which statement made by the patient demonstrates a need for further teaching? a. "I will take warfarin (Coumadin) 1 hour before my medicine." b. "I will increase the fluids and fiber in my diet." c. "I can take cholestyramine with my hydrochlorothiazide." d. "I will take digoxin 4 hours after taking the cholestyramine."

C ~ Drugs known to form complexes with the sequestrants include thiazide diuretics, such as hydrochlorothiazide, digoxin, warfarin, and some antibiotics. To reduce the formation of sequestrant-drug complexes, oral medication should be administered either 1 hour before the sequestrant or 4 hours after. Further teaching is needed. Warfarin should be taken 1 hour before or 4 hours after cholestyramine. Adverse effects of Questran are limited to the gastrointestinal (GI) tract. Constipation, the principal complaint, can be minimized by increasing dietary fiber and fluids. Digoxin should be taken 1 hour before or 4 hours after cholestyramine.

A nurse is reviewing a patient's medications and realizes that gemfibrozil (Lopid) and warfarin (Coumadin) are to be administered concomitantly. This finding concerns the nurse, who is aware that the _____ will be _____. a. level of gemfibrozil; increased b. level of gemfibrozil; reduced c. anticoagulant effects; increased d. anticoagulant effects; reduced

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 need to be reduced.

During discharge instruction, a nurse wants to assess a patient's understanding of treatment with cholestyramine (Questran). Which statement made by the patient best demonstrates a need for additional teaching? a. "I will take cholestyramine (Questran) 1 hour before my other medications." b. "I will increase fluids and fiber in my diet." c. "I will weigh myself weekly." d. "I will have my blood pressure checked weekly."

C ~ Patients need not weigh themselves weekly when taking cholestyramine. Cholestyramine should be taken at least 1 hour before other medications. When taken with other medications, cholestyramine can inhibit the absorption of the other drugs. Constipation is the principal complaint with cholestyramine. It can be minimized by increasing dietary fiber and fluids. Regular blood pressure checks are a good idea. The patient is taking cholestyramine because of high cholesterol, which contributes to hypertension.

A patient with malaise has been taking daptomycin (Cubicin) for an infection and is concurrently taking simvastatin (Zocor). 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.

A patient presents to the clinic with complaints of muscle aches, muscle pain, and weakness. Upon review of the individual's medications, the nurse notes that the patient is concurrently taking gemfibrozil (Lopid) and atorvastatin (Lipitor). The nurse should assess the patient for the development of: a. migraines. b. hypothyroidism. c. myopathy. d. heart failure.

C ~ When gemfibrozil and a statin are taken concurrently, the risk of myopathy is increased more than with either agent alone. Migraines, hypothyroidism, and heart failure are not drug-to-drug interactions.

A patient who has Wolff-Parkinson-White syndrome is given intravenous adenosine (Adenocard). The nurse will explain that the medication is effective because it a. controls atrial flutter. b. deepens myocardial excitability. c. prevents multifocal ventricular contractions. d. prolongs repolarization.

D prolongs repolarization. Adenosine is a class III drug that prolongs repolarization by increasing the refractory period and prolonging the action potential to slow heart rate. It does not control atrial flutter, deepen myocardial excitability, or prevent multifocal contractions.

The nurse provides teaching for a patient who has a ventricular dysrhythmia who is prescribed acebutolol (Spectral) 200 mg twice daily. Which statement by the patient indicates understanding of the teaching? a. "Diuretics may decrease the effectiveness of this drug." b. "Dizziness, nausea, and vomiting indicate a severe reaction." c. "I should eat fruits and vegetables to increase potassium intake." d. "I should not stop taking this drug abruptly to avoid palpitations."

D "I should not stop taking this drug abruptly to avoid palpitations." Patients who stop taking this drug abruptly can experience palpitations. Diuretics do not decrease drug effectiveness. Dizziness and nausea and vomiting are common side effects.

The nurse is teaching a patient who will begin taking warfarin (Coumadin) for atrial fibrillation. Which statement by the patient indicates understanding of the teaching? a. "I should eat plenty of green, leafy vegetables while taking this drug." b. "I should take a nonsteroidal anti-inflammatory drug (NSAID) instead of acetaminophen for pain or fever." c. "I will take cimetidine (Tagamet) to prevent gastric irritation and bleeding." d. "I will tell my dentist that I am taking this medication."

D "I will tell my dentist that I am taking this medication." Patients taking warfarin should tell their dentists that they are taking the medication because of the increased risk for bleeding. Patients should avoid foods high in vitamin K, which can decrease the effects of warfarin. Patients should not take NSAIDs or cimetidine (Tagamet) because they can displace warfarin from protein-binding sites.

A patient is diagnosed with heart failure (HF), and the prescriber has ordered digoxin. The patient asks what lifestyle changes will help in the management of this condition. The nurse will recommend which changes? a. Aerobic exercise and weight lifting 2 or 3 times weekly b. Changing from cigarette smoking to pipe smoking c. Consuming 2 teaspoons or less of salt every day d. Having no more than one alcoholic beverage per day

D Having no more than one alcoholic beverage per day Alcohol should either be completely avoided or restricted to no more than one per day. Mild exercise, such as walking, is recommended. All nicotines deprive the heart of oxygen. Salt should be limited to no more than one teaspoon per day.

The nurse is caring for a postoperative patient. The nurse will anticipate administering which medication to this patient to help prevent thrombus formation caused by slow venous blood flow? a. Alteplase (Activase) b. Aspirin c. Clopidogrel (Plavix) d. Low-molecular-weight heparin

D Low-molecular-weight heparin Low-molecular-weight heparin is an anticoagulant, which is used to inhibit clot formation and is used prophylactically to prevent postoperative deep vein thrombosis. Alteplase is a thrombolytic, which is used to break down clots after they form; alteplase is contraindicated in any patient with recent surgery. Aspirin and clopidogrel are antiplatelet drugs and are used to prevent arterial thrombosis.

A female patient has serum lipid levels performed, which reveal a total cholesterol of 285 mg/dL, triglycerides of 188 mg/dL, a low-density lipoprotein (LDL) of 175 mg/dL, and a high-density lipoprotein (HDL) of 40 mg/dL. The patient's blood pressure is 138/72 mm Hg. The nurse may expect the provider to order which medication for this patient? a. Amlodipine and atorvastatin (Caduet) b. Colestipol HCl (Colestid) c. Fenofibrate (TriCor) d. Niacin and lovastatin (Advicor)

D Niacin and lovastatin (Advicor) The combination drug of niacin and lovastatin is indicated for hypercholesterolemia and mixed dyslipidemia. Niacin raises HDL, so would be helpful in this patient who has low HDL. Combination drugs are used to enhance the antihyperlipidemic effect. Amlodipine and atorvastatin in combination are used for patients with hyperlipidemia and elevated blood pressure. Colestipol HCl is used to reduce cholesterol and LDL levels but has no effect on HDL or triglycerides. Fenofibrate is used to treat type IV and V hyperlipidemia, characterized by elevated very-low-density lipoprotein and triglycerides.

The nurse performs a medication history and learns that the patient takes a thiazide diuretic and digoxin (Lanoxin). The nurse will question the patient to ensure that the patient is also taking which medication? a. Cortisone b. Lidocaine c. Nitroglycerin d. Potassium

D Potassium If a patient is taking digoxin and a potassium-wasting diuretic such as thiazide, the patient should also take a potassium supplement to prevent hypokalemia that could result in digoxin toxicity. It is not necessary to take cortisone, lidocaine, or nitroglycerin unless the patient has symptoms that warrant these drugs.

A patient is ordered to receive a nitrate to relieve stable angina. What side effect(s) will the nurse anticipate in a patient receiving this medication? a. Nausea and vomiting b. Increased blood pressure c. Pruritus and skin rash d. Pounding headache

D Pounding headache The pounding headache is related to vasodilation of the cerebral vessels. Nitrates decrease blood pressure.

A patient who uses transdermal nitroglycerin reports having headaches. The nurse will counsel the patient to perform which action? a. Call 911 when this occurs. b. Notify the provider. c. Reapply the patch three times daily. d. Take acetaminophen as needed.

D Take acetaminophen as needed. Headaches are one of the most common side effects of nitroglycerin, but they may become less frequent; acetaminophen is generally recommended for pain. The headaches are not an emergency, and the patient does not need to call 911 or notify the provider. The patch is applied once daily.

The nurse is teaching a patient about sublingual nitroglycerin administration. What information will the nurse include when teaching this patient? a. Call 911 if pain does not improve after three doses. b. If pain persists after one dose, administer a second dose. c. Swallow the tablet with small sips of water. d. Take the first tablet while sitting or lying down.

D Take the first tablet while sitting or lying down. Because nitroglycerin can cause hypotension, patients should be cautioned to take them while sitting or lying down. If pain is not better or has worsened 5 minutes after the first dose, patients should call 911. The tablets must dissolve under the tongue and should not be swallowed.

A patient who has HF receives digoxin (Lanoxin) and an angiotensin-converting enzyme (ACE) inhibitor. The patient will begin taking spironolactone (Aldactone). The patient asks why the new drug is necessary. The nurse will tell the patient that spironolactone will be given for which reason? a. To enhance potassium excretion b. To increase cardiac contractility c. To minimize fluid losses d. To provide cardioprotective effects

D To provide cardioprotective effects Spironolactone is a potassium-sparing diuretic that blocks production of aldosterone, causing improved heart rate variability and decreased myocardial fibrosis. It is given in congestive HF for its cardioprotective effects. Spironolactone does not directly alter cardiac contractility but may slightly decrease contractility if fluid volume is decreased. It is a mild diuretic but is not given in this instance to minimize fluid losses.

A patient who has been taking nitroglycerin for angina has developed variant angina, and the provider has added verapamil (Calan) to the patient's regimen. The nurse will explain that verapamil is given for which purpose? a. To facilitate oxygen use by the heart b. To improve renal perfusion c. To increase cardiac contractility d. To relax coronary arteries

D To relax coronary arteries Verapamil is a calcium channel blocker and is used to relax coronary artery spasm in patients with variant angina. It does not facilitate coronary muscle oxygen use, improve renal function, or increase cardiac contractility.

A patient who has atrial fibrillation is taking digoxin. The nurse expects which medication to be given concurrently to treat this condition? a. Hydrochlorothiazide (HydroDIURIL) b. Inamrinone (Inocor) c. Milrinone (Primacor) d. Warfarin (Coumadin)

D Warfarin (Coumadin) Digoxin is given for atrial fibrillation to restore a normal heart rhythm. To prevent thromboemboli, warfarin is given concurrently. Hydrochlorothiazide is a diuretic medication. Inamrinone and milrinone are inotropic agents that would be used instead of digoxin.

A patient is admitted to the hospital, and the provider orders gemfibrozil (Lopid) 600 mg twice daily, 30 minutes prior to meals. The nurse learns that the patient takes warfarin (Coumadin) once daily. The nurse will contact the provider to discuss a. decreasing the dose of gemfibrozil. b. giving the warfarin at noon. c. increasing the dose of warfarin. d. ordering frequent INR levels.

D ordering frequent INR levels Gemfibrozil is highly protein-bound and competes for receptor sites with drugs such as warfarin. The anticoagulant dose should be decreased, and the international normalized ratio (INR) should be closely monitored. Decreasing the dose of gemfibrozil is not recommended. Giving the warfarin at a different time of day does not change this drug interaction. The warfarin dose should be decreased, not increased.

A patient who is taking clopidogrel (Plavix) and aspirin is preparing for orthopedic surgery. The nurse will consult with the surgeon and provide which instruction to the patient? a. Continue taking aspirin and stop taking clopidogrel 2 weeks prior to surgery. b. Continue taking clopidogrel and stop taking aspirin 5 days prior to surgery. c. Continue both medications to prevent thromboembolic events during surgery. d. Stop taking both medications 7 days prior to surgery.

D stop taking both medications 7 days prior to surgery Because both drugs can prolong bleeding time, patients should discontinue the drugs 7 days prior to surgery.

A patient who has begun taking nifedipine (Procardia) to treat variant angina has had a recurrent blood pressure of 90/60 mm Hg or less. The nurse will anticipate that the provider will a. add digoxin to the drug regimen. b. change to a beta blocker. c. order serum liver enzymes. d. switch to diltiazem (Cardizem).

D switch to diltiazem (Cardizem). Hypotension is a common effect of calcium channel blockers and is more common with nifedipine. It is less common with diltiazem, so the provider may order that drug. Adding digoxin, changing to a beta blocker, or ordering serum liver enzymes are not indicated.

A patient taking gemfibrozil (Lopid) and rosuvastatin (Crestor) concurrently begins to complain of muscle aches, fatigue, and weakness. What should the nurse monitor? a. For tendon tenderness b. For a lupuslike syndrome c. The patient's LFT results d. The patient's creatinine kinase levels

D ~ Creatinine kinase levels are the best laboratory indicator of myopathy and/or rhabdomyolysis, which may lead to renal failure. As can the statins, gemfibrozil and other fibrates can cause myopathy. Fibrates must be used with caution in patients taking statins. Concurrent use of gemfibrozil and rosuvastatin does not cause tendon tenderness or a lupuslike syndrome. Liver function levels should be determined at the start of statin therapy and every 6 months thereafter in patients who do not have liver disease.

A nurse is providing patient education about colesevelam (Welchol), a bile acid sequestrant. Which statement made by the patient demonstrates a need for further teaching? a. "Colesevelam will reduce my levels of low-density lipoprotein." b. "Colesevelam will augment my statin drug therapy." c. "I will not have to worry about having as many drug interactions as I did when I took cholestyramine." d. "I cannot take digoxin while on this medication."

D ~ Digoxin can be taken 1 hour before or 4 hours after taking a bile acid sequestrant. Colesevelam reduces the LDL cholesterol level, which is one of its therapeutic uses. Colesevelam augments statin therapy. Colesevelam does not significantly interact with or reduce the absorption of statins, digoxin, warfarin, or most other drugs.

A nurse is instructing a patient receiving a cholesterol-lowering agent. Which information should the nurse include in the patient education? a. "This medication will replace other interventions you have been trying." b. "It is important for you to double your dose if you miss one to maintain therapeutic blood levels." c. "Stop taking the medication if you experience constipation." d. "You should continue your exercise program to increase your HDL serum levels."

D ~ Regular exercise can reduce LDL cholesterol and elevate high-density lipoprotein (HDL) cholesterol, thereby reducing the risk of coronary heart disease (CHD). The patient should consider the cholesterol-lowering drug an adjunct to a proper diet and exercise. Drug therapy cannot replace other important interventions, such as diet and exercise. The patient should never be instructed to double the dose. Constipation is a side effect of most cholesterol-lowering agents. The patient should be encouraged to eat a high-fiber diet and increase fluids if not contraindicated.

An Asian patient comes to the clinic. Upon assessment, the nurse notes a slight yellow tint to the skin and sclera, edema, and hepatomegaly. The drug history reveals that the patient has been taking rosuvastatin (Crestor) for 6 months. The nurse is concerned, because rosuvastatin (Crestor) has been shown to do what? a. Cause renal and pancreatic toxicity specifically in Asian patients b. Cause renal failure c. Create myoglobin in the urine d. Reach levels twice as high in Asians as in Caucasians, resulting in a greater chance of hepatotoxicity

D ~ Rosuvastatin reaches abnormally high levels in people of Asian heritage. Consequently, hepatotoxicity may occur more often in Asian patients because of the high level of the drug in the blood. Rosuvastatin does not cause renal or pancreatic toxicity. Rosuvastatin does not cause renal failure. Rosuvastatin does not create myoglobin in the urine.

10. A nurse is providing teaching to a patient who is admitted to the hospital for initiation of treatment with amiodarone [Cordarone] for atrial fibrillation that has been refractory to other medications. Which statement by the patient indicates a need for further teaching? a. "I may have itching, malaise, and jaundice, but these symptoms will subside." b. "I need to use sunblock to help keep my skin from turning bluish gray." c. "I should not drink grapefruit juice while taking this medication." d. "I should report shortness of breath and cough and stop taking the drug immediately."

NS: A Amiodarone has many toxic effects. Liver toxicity is rare but serious and should be reported and the drug discontinued. Dermatologic toxicity can occur, and sunblock helps protect the skin, which, with prolonged exposure to the sun, can turn bluish gray. Drinking grapefruit juice can increase amiodarone levels. Pulmonary toxicity is the greatest concern, and patients with pulmonary symptoms should report these to the provider.

18. The nurse is teaching a group of nursing students about dofetilide [Tikosyn] to treat dysrhythmias. Which statement by a student indicates understanding of the teaching? a. "Dofetilide is a first-line medication to treat atrial flutter or atrial fibrillation." b. "Dofetilide carries a lower risk of causing torsades de pointes than other drugs." c. "Dofetilide is used for patients with severe symptoms of atrial dysrhythmias." d. "Dofetilide may be safely used as outpatient therapy to treat atrial fibrillation."

NS: C Dofetilide is used for patients with severe, highly symptomatic atrial dysrhythmias because of its higher than usual risk of torsades de pointes. It is used only when other medications have not been effective. It is used for hospitalized patients with close ECG monitoring. PTS: 1

1. A patient is taking digoxin [Lanoxin] and develops a dysrhythmia. The nurse reports this finding to the prescriber, who will most likely order what? (Select all that apply.) a. Amiodarone b. Diltiazem c. Phenytoin [Dilantin] d. Quinidine e. Serum electrolytes

NS: C, E Phenytoin is an antiseizure medication used to treat digoxin-induced dysrhythmias. Because digoxin-induced dysrhythmias can be caused by hypokalemia, it is appropriate to evaluate the serum electrolyte levels. Amiodarone, diltiazem, and quinidine increase digoxin levels.

A patient with epistaxis and a history of hemophilia A is admitted to the unit and is scheduled for replacement therapy. The nurse should prepare to administer which medication? a. Tranexamic acid [Cyklokapron] b. Aminocaproic acid [Amicar] c. Desmopressin [Stimate] d. Factor VIII

The cornerstone of treatment for hemophilia A is replacement therapy with factor VIII. Tranexamic acid and aminocaproic acid are antifibrinolytic agents that act primarily by preventing the formation of plasmin from its precursor. Desmopressin promotes the release of factor VIII from the vascular endothelium and has the advantage of being cheaper than factor VIII. Also, it can be administered by nasal spray or by IV infusion. However, repeated use of desmopressin can deplete stored factor VIII.