Digoxin heparin warfarin (Coumadin)

3. A patient is taking Digoxin. What medication on the patient's medication list increases the patient's risk of experiencing Digoxin toxicity? A. Furosemide B. Metformin C. Nitroglycerin D. Coumadin

The answer is A. Furosemide is a loop-diuretic and this medication wastes potassium. Remember hypokalemia (low potassium level) increases the risk of a patient developing Digoxin toxicity. Hypercalcemia (>10.2 mg/dL) and hypomagnesemia ( < 1.5 mg/dL)also increases Digoxin toxicity.

14. What is the antidote for Heparin? A. Protamine sulfate B. Vitamin K C. Flumazenil D. Narcan

The answer is A. Protamine sulfate is the antidote for Heparin.

13. A patient develops Heparin-Induced Thrombocytopenia (HIT). As the nurse you would expect the Heparin to be discontinued and the patient to be started on what other type of anticoagulant? A. Direct thrombin inhibitor B. Protamine sulfate C. Switched to subcutaneous Heparin injections D. Vitamin-K agonist

The answer is A. The Heparin is discontinued and direct thrombin inhibitors can be started like: Argatroban, Bivalirudin etc.

8. A patient is prescribed Warfarin (Coumadin) for the treatment of a blood clot. What is the therapeutic INR range for this medication? A. 2-3 B. 1-3 C. 4-8 D. 0.5-2.5

The answer is A. The therapeutic INR range is 2-3. It may be slightly higher if a patient is at a high risk for clot formation....(ex: up to 4.5)

9. A patient is scheduled to take a dose of Warfarin (Coumadin) at 1800. The patient's INR level is 6. As the nurse you will? A. Administer the dose as scheduled B. Hold the dose and notify the physician C. Double the dose D. Hold today's dose but administer tomorrow's dose as scheduled.

The answer is B. A therapeutic INR level should be 2-3 (it may be up to 4.5 if the patient is at a HIGH risk for blood clot formation). A level of 6 is HIGH and places the patient at risk for bleeding. The nurse should hold the dose and notify the physician.

9. Which patient below is at MOST risk for developing Digoxin toxicity? A. A 30-year-old male patient with heart failure and hyperglycemia B. A 82-year-old male patient with atrial fibrillation and magnesium level of 1 mg/dL. C. A 45-year-old female with potassium level of 4.2 mEq/L. D. A 50-year-old female with a calcium level of 9 mg/dL.

The answer is B. Elderly patients are at a very high risk of Digoxin toxicity due to a decrease of function in the liver and renal system. Also, this patient in option B is experiencing hypomagnesemia (<1.5 mg/dL) which increases the risk of Digoxin toxicity even more.

1. Heparin is an anticoagulant. What family of anticoagulant medications does this drug belong to? A. Direct thrombin inhibitors B. Indirect thrombin inhibitors C. Vitamin K antagonists D. Factor Xa inhibitors

The answer is B. Heparin is an anticoagulant that belongs to the Indirect Thrombin Inhibitors family.

12. A patient is taking Warfarin (Coumadin). What order received from the physician requires that you ask for an order clarification? A. Check PT/INR daily B. Administer Prednisone IM daily C. Ambulate three times per day D. Draw CBC in the morning

The answer is B. IM (intramuscular) injections should be AVOIDED in patients taking Warfarin (Coumadin) due to the bleeding risk. Other routes should be ordered.

14. A patient who is taking Warfarin (Coumadin) asks what he should do if he misses a dose. Your response would be: A. Double the dose the next day and notify the physician. B. Take the dose when remembered if on the same day. However if not remembered on the same day but the next day skip the missed dose and take the next dose at the regular scheduled time. C. Hold all doses and call the doctor. D. Split the dose the next day.

The answer is B. If a dose is missed the patient should take the dose when remembered IF on the SAME day. However if not remembered on the SAME day but the next day the patient should skip the missed dose and take the next scheduled dose at its regular scheduled time.

15. You're providing care to a patient who has been receiving long-term doses of Heparin. What finding in this patient demonstrates the patient may be experiencing a complication that can occur due to long-term use of this drug? A. Uncontrolled hypertension B. Bone fractures C. Hyperkalemia D. Raynaud's Syndrome

The answer is B. Osteoporosis can occur due to long-term, high doses of Heparin. Bone fractures would indicate this patient is experiencing this complication. Heparin can stimulate osteoclasts and inhibits osteoblast, which affects the strength of the bones.

5. A patient is ordered to start an IV continuous Heparin drip. Prior to starting the medication the nurse would ensure what information is gathered correctly before initiating the drip? A. Vital signs B. Weight C. PT/INR level D. EKG

The answer is B. The nurse would want to make sure the documented weight of the patient is current and accurate. This medication is weight-based. Therefore, for proper dosing to be administered, a correct weight should be used.

10. Your patient is being discharged home and will be required to self-administer injectable Heparin. You are observing the patient administer their scheduled dose of Heparin to confirm that the patient knows how to do it correctly. What action by the patient requires you to re-educate them about how to administer Heparin? A. The patient injects the needle into the fatty tissue of the abdomen. B. The patient injects the needle 1 inch away from the umbilicus. C. The patient rotated the injection site from the previous dose of Heparin. D. The patient does not massage the injection site after administering the medication.

The answer is B. The patient should inject the needle 2 inches (NOT 1 inch) away from the umbilicus. All the other options are correct.

7. What is considered a normal INR level in a person who is NOT taking Warfarin (Coumadin)? A. 10-12 seconds B. 0.75-1.25 C. 2-3 D. 5-7

The answer is B. This is considered a normal INR level in someone who is NOT taking Warfarin (Coumadin).

5. What is the therapeutic range of the drug Digoxin? A. 2-3.5 ng/mL B. 0.1-2 ng/mL C. 0.5-2 ng/mL D. 3.5-5 ng/mL

The answer is C. A normal Digoxin level should be 0.5 - 2 ng/mL. Any levels greater than 2 ng/mL is considered toxic.

6. A patient is receiving continuous IV Heparin. In order for this medication to have a therapeutic effect on the patient the aPTT should be? A. 0.5-2.5 times the normal value range B. 2-3 times the normal value range C. 1.5-2.5 times the normal value range D. 1-3.5 times the normal value range

The answer is C. An aPTT should be 1.5-2.5 times the normal value range for Heparin to achieve a therapeutic effect in a patient to prevent blood clots. If the aPTT is too low, blood clots can form. If the aPTT is too high, bleeding can occur.

7. What is the approximate NORMAL level range for an activated partial thromboplastin time (aPTT)? A. 20-25 seconds B. 2-3 seconds C. 30-40 seconds D. 60-80 seconds

The answer is C. This is considered a (approximate...varies in labs) normal aPTT level in someone who is NOT on Heparin.

1. Warfarin (Coumadin) is an anticoagulant. What family of anticoagulant medications does this drug belong to? A. Direct thrombin inhibitors B. Indirect thrombin inhibitors C. Vitamin K antagonists D. Factor Xa inhibitors

The answer is C. Warfarin (Coumadin) is an anticoagulant that belongs to the Vitamin K antagonists.

4. Your patient is started on a Heparin drip. You administer a bolus of Heparin and start the drip per protocol as ordered by the physician. What will be your next important nursing action? A. Collect a PT level in 6 hours per protocol. B. Collect an INR level in 4 hours per protocol. C. Collect a Troponin level in 6 hours per protocol. D. Collect an aPTT level in 6 hours per protocol.

The answer is D. An activated partial thromboplastin time (aPTT) is used to measure clotting time in patients who are on Heparin. It is important that the nurse collect an aPTT in 6 hours (some protocols may say 4 hours) after starting the drip. PT and INR are used to measure clotting times in patients who are taking Warfarin (Coumadin). Troponin levels are used in cardiac patients to detect a myocardial infarction.

2. Which statement below BEST describes how Heparin works as an anticoagulant? A. "It inhibits clotting factors from synthesizing Vitamin K." B. "It inactivates the extrinsic pathways of coagulation." C. "It prevents Factor Xa from activating prothrombin to fibrinogen." D. "It enhances the activation of antihrombin III which prevents the activation of thrombin and the conversion of fibrinogen to fibrin."

The answer is D. Heparin enhances the activation of antihrombin III which prevents the activation of thrombin and the conversion of fibrinogen to fibrin. Therefore this medication INDIRECTLY inhibits thrombin via antithrombin III.

8. A patient who is receiving continuous IV Heparin has an aPTT of 105 seconds. What is your next nursing action per protocol? A. Continue with the infusion because no change is needed based on this aPTT. B. Increase the drip rate per protocol because the aPTT is too low. C. Re-draw the aPTT STAT. D. Hold the infusion for 1 hour and decrease the rate per protocol because the aPTT is too high.

The answer is D. The aPTT is 105 seconds, which is too high. Any aPTT value greater than 80 seconds places the patient at risk for bleeding. Most Heparin protocols dictate that the nurse would hold the infusion for 1 hour and to decrease the rate of infusion. If the aPTT is less than 60 seconds, the dose would need to be increased and a bolus may be needed. aPTT values should be around 60-80 seconds to achieve a therapeutic response for Heparin.

8. An infant is ordered a scheduled dose of Digoxin. The patient's apical pulse rate is 87 bpm. The nurse would: A. Administer the dose as ordered B. Hold the dose and reassess the apical pulse rate in 1 hour C. Skip this dose but administer the next scheduled dose D. Hold the dose and notify the physician

The answer is D. The nurse should hold a dose of Digoxin and notify the physician if the INFANT'S heart rate is less than 90-110 bpm.

4. Your patient who is 55-years-old is prescribed to take Digoxin. What patient finding requires that the nurse hold the dose of Digoxin and notify the physician? A. Digoxin level of 1.2 ng/mL B. Blood glucose 82 C. Heart rate 61 bpm D. Potassium 2.8 mEq/L

The answer is D. The patient's potassium level is low (<3.5 mEq/L). Remember hypokalemia increases the chances of Digoxin toxicity developing. The nurse should notify the MD and hold the ordered dose until further instructions are given by the doctor.

11. What is the antidote for Warfarin (Coumadin)? A. Flumazenil B. Narcan C. Protamine Sulfate D. Vitamin K

The answer is D. Vitamin K is the antidote for Warfarin (Coumadin).

2. Which statement below BEST describes how Warfarin (Coumadin) works as an anticoagulant? A. "It inhibits the formation of thrombin and fibrin in the clotting process." B. "It increases the production of Factor Xa which blocks thrombin and decreases the clotting process." C. "It binds to antithrombin and reverses the clotting process." D. "It stops the coagulation process by blocking the formation of clotting factors in the liver that require Vitamin K to form."

The answer is D. Warfarin (Coumadin) stops the coagulation process by blocking the formation of clotting factors in the liver that require Vitamin K to form. This is why this drug is part of the Vitamin K antagonist family.

1. Digoxin is part of what family of drugs? A. Angiotensin-converting enzyme inhibitors B. Beta-blockers C. Angiotensin II receptor blockers D. Cardiac glycosides

The answer is D: cardiac glycosides

10. TRUE OR FALSE: If a patient's INR level falls too low there is a risk of clot formation and the Warfarin (Coumadin) dose needs to be decreased.

The answer is False. If a patient's INR level falls too low, there is a risk of clot formation and the Warfarin (Coumadin) dose needs to be INCREASED (not decreased).

12. Your patient on Heparin develops Heparin-Induced Thrombocytopenia (HIT). What signs and symptoms in the patient confirm this diagnosis? Select all that apply: A. Decrease in platelet level B. Increase in platelet level C. Development of a new thrombus D. Increase in hemoglobin level

The answers are A and C. HIT is where the body makes antibodies against Heparin because it's binding to platelet factor 4 (a blood protein). This creates antibodies that will bind to the heparin and PF4 complex, which activate the platelets. Small clots will form (hence new clots or worsening of clots) and the platelet count falls...hence thrombocytopenia.

3. Which patients below would be at a HIGH risk for developing adverse effects of Heparin drug therapy? Select all that apply: A. A 55-year-old male patient who is post-op day 1 from brain surgery. B. A 45-year-old female patient with a pulmonary embolism. C. A 36-year-old male patient with active peptic ulcer disease. D. A 43-year-old female with uncontrolled atrial fibrillation.

The answers are A and C. These patients are both at risk for major bleeding if placed on an anticoagulant due to their condition (one patient is post-op from brain surgery and the other patient has ulcers that could bleed). Option B and D are candidates from Heparin therapy because the patient in option B has a blood clot (Heparin can prevent it from getting bigger and developing new blood clots) and the patient in option D is at risk for developing a blood clot.

3. You're educating a patient's family member about Warfarin (Coumadin) and how it is used to treat blood clots. Which statements by the family member require you to re-educate them about how this medication works? Select all that apply: A. "This medication will help dissolve the blood clot." B. "This medication will prevent another blood clot from forming." C. "This medication will help prevent the blood clot from becoming bigger in size." D. "This medication starts working immediately after the first dose."

The answers are A and D. Warfarin (Coumadin) does NOT dissolve blood clots. It prevents blood clots from forming, and if one is present, it will help prevent it from becoming bigger. If the blood clot becomes bigger it may break off and travel in blood circulation. This can lead to a pulmonary embolism, heart attack, or stroke. Warfarin (Coumadin) does NOT start working immediately. It takes about 3-5 days of scheduled doses to start achieving a therapeutic INR level. It is very common that a patient will be on Heparin while taking Warfarin until INR levels are therapeutic.

11. A patient is on a continuous IV Heparin drip. As the nurse you are monitoring for any adverse reactions. Select all the signs and symptoms that would indicate this patient is having an adverse reaction to this medication: A. Hematuria B. Decreasing platelets C. Increased blood glucose D. Low hemoglobin and hematocrit E. Positive stool guaiac test

The answers are A, B, D and E. Hematuria, low hbg/hct and positive stool guaiac test all indicate the patient is bleeding. A decrease in platelet level could indicate the patient is developing Heparin-induced thrombocytopenia, which is also an adverse reaction to Heparin.

6. Your patient was started on Warfarin (Coumadin) a week ago for the treatment of a DVT. Which findings below would indicate an adverse reaction to this medication? Select all that apply: A. Patient reports a severe and sudden headache B. Melena C. Chvostek's Sign D. Hematuria E. Coffee ground emesis F. Bleeding gums

The answers are A, B, D, E, and F. An adverse reaction would be associated with bleeding. Patients who take Warfarin should be monitored for signs and symptoms that bleeding is occurring internally. Example would be: sudden/severe headache (represents intracranial bleed), melena (dark, tarry stools...represent blood), hematuria (urine reddish or pink), coffee ground emesis (bleeding in the stomach), or bleeding gums....along with tachycardia, hypotension, nosebleeds, or bruising for no reason. Chvostek's Sign is associated with a low calcium level (hypocalcemia).

9. Select all the TRUE statements about the medication Heparin: A. Heparin can be used during pregnancy. B. Heparin has a short half-life. C. Heparin works to affect the intrinsic pathways of clotting. D. Heparin can be administered orally intravenously or subcutaneously.

The answers are A, B, and C. The option that is wrong is D. Heparin can NOT be administered orally....only subq or IV.

13. You're providing discharge teaching to a patient who will be going home on Warfarin (Coumadin). Which statements by the patient demonstrate they understood the educational material provided? Select all that apply: A. "I will switch and use a hard bristle toothbrush." B. "When I shave I will be sure to use an electric razor." C. "I will be sure that I eat a diet rich in spinach kale and broccoli." D. "I will avoid drinking any alcoholic beverages."

The answers are B and D. A patient should use a SOFT bristle toothbrush rather than a hard bristle to prevent damaging the gums (this can lead to bleeding). Also, the patient should maintain a normal diet, but avoid consuming excessive amounts of green leafy vegetables (like spinach, kale, broccoli, lettuce etc.) because this can alter how the medication works. The patient should AVOID alcoholic beverages and use electric razors.

7. What EARLY signs and symptoms should the nurse assess for in a patient taking Digoxin that could indicate toxicity of this drug? Select all that apply: A. Dysrhythmias B. Anorexia C. Drowsiness D. Nausea E. Vomiting

The answers are B, D, and E. GI-related signs and symptoms are the earliest indications that the patient may be having Digoxin toxicity. The other signs and symptoms occur later, especially dysrhythmias.

6. An adult patient is being discharged home on Digoxin. Which statements below verbalized by the patient demonstrates they understand how to properly take this medication? Select all that apply: A. "I will limit by intake of foods high in potassium." B. "I will not take this medication and notify the physician if my heart rate is less than 70 bpm." C. "I will measure my pulse rate before every dose I take." D. "It is important that I immediately report any vision changes I may experience while taking this medication."

The answers are C and D. The patient should always measure their pulse rate before taking each dose of Digoxin and hold the dose if it is less than 60 bpm (this is for adults). The patient should not restrict foods high in potassium because this could lead to hypokalemia, which can lead to Digoxin toxicity. Vision changes should be reported because this could indicate Digoxin toxicity.

5. Which patients below are NOT candidates for Warfarin (Coumadin)? Select all that apply: A. A 45-year-old male patient with alcoholism and an active GI ulcer. B. A 55-year-old female with a heart valve replacement. C. A 36-year-old female with a deep vein thrombosis. D. A 52-year-old male who needs a liver transplant.

The answers are: A and D...Option A is NOT a candidate because active ulcer disease places the patient at risk for bleeding while taking Warfarin (Coumadin). In addition, patients should NOT drink alcohol while taking Warfarin (Coumadin) because it majorly affects how the drug works. Option D is NOT a candidate because of the liver disease. Warfarin affects the liver's clotting factors. Option B and D would benefit because both are at risk for a blood clots (especially option B). While Option C already has a blood clot, Warfarin (Coumadin) would help prevent it from becoming larger and new clots from forming.

2. Digoxin helps the heart pump more efficiently by altering the inotropic chronotropic and dromotropic actions of the heart. Select all the options below that accurately describe these actions created by Digoxin: a. Positive Chronotropic b. Positive Inotropic c. Negative Inotropic d. Negative Dromotropic e. Negative Chrontropic f. Positive Dromotropic

The answers are: B, D, and E. Digoxin creates a positive inotropic, negative chronotropic, and negative dromotropic action on the heart. This helps the heart's contraction to be stronger while it pumps at a slower rate. Therefore, the heart will empty more efficiently (less back flow of blood) and this will increase stroke volume, which will increase cardiac output.

4. Warfarin (Coumadin) affects the formation of certain clotting factors. Select below ALL the clotting factors this medication affects: A. I B. V C. II D. VII E. XI F. X G. IX

The answers are: C, D, F, and G. Warfarin (Coumadin) affects FOUR clotting factors that require vitamin K to form. These clotting factors are: 2, 7, 9, and 10 (II, VII, IX, X)