Pharmacology

The home health nurse visits a client with atrial fibrillation who is newly prescribed digoxin 0.25 mg orally on even-numbered days. Which of the following client statements show that teaching has been effective? Select all that apply. 1. "I need to call the health care provider (HCP) if I have trouble reading." 2. "I need to check my blood pressure before taking my medicine." 3. "I should call the HCP if I develop nausea and vomiting." 4. "I should check my heart rate prior to taking this medication." 5. "I will call the HCP if I feel dizzy and lightheaded."

1. "I need to call the health care provider (HCP) if I have trouble reading." 3. "I should call the HCP if I develop nausea and vomiting." 4. "I should check my heart rate prior to taking this medication." 5. "I will call the HCP if I feel dizzy and lightheaded." Digoxin (Lanoxin) is a cardiac glycoside used to treat heart failure and atrial fibrillation. Cardiac glycosides have positive inotropic effects (eg, increased cardiac output) and negative chronotropic effects (eg, decreased heart rate). However, drug toxicity is common due to digoxin having narrow therapeutic-range levels (0.5-2.0 ng/mL). Cardiac arrhythmias are the most dangerous symptoms. Digoxin toxicity can result in bradycardia and heart block, which can cause dizziness or lightheadedness (Option 5). Clients are instructed to check their pulse and if it is low (<60/min) or has skipped beats to hold the medication and notify the health care provider (Option 4). Other manifestations of digoxin toxicity that clients should report include: Visual symptoms (eg, alterations in color vision, scotomas, blindness) (Option 1) Gastrointestinal symptoms (eg, anorexia, nausea, vomiting, abdominal pain) - frequently the earliest symptoms (Option 3) Neurologic manifestations (eg, lethargy, fatigue, weakness, confusion) Educational objective:Cardiac glycosides (eg, digoxin) have positive inotropic effects (eg, increased cardiac output) and negative chronotropic effects (eg, decreased heart rate). Clients are instructed to check their pulse before administration and to report gastrointestinal (eg, anorexia, nausea), neurologic, and cardiac symptoms and visual changes.

A client with atrial fibrillation is being discharged home after being stabilized with medications, including digoxin. Which of the following statements regarding digoxin toxicity indicates that further teaching is needed? 1. "I must visit my health care provider (HCP) to check my drug levels." 2. "I should report to my HCP if I develop nausea and vomiting." 3. "I should tell my HCP if I feel my heart skip a beat." 4. "I will need to increase my potassium intake."

4. "I will need to increase my potassium intake." Drug toxicity is common with digoxin due to its narrow therapeutic range. Many contributing factors (eg, hypokalemia) can cause toxicity. However, in the absence of other factors, potassium does not need to be increased just because a client is on digoxin. If the client also takes some other potassium-depleting medications, such as diuretics, potassium supplements may be needed. Signs and symptoms of digoxin toxicity include the following: Gastrointestinal symptoms (eg, anorexia, nausea, vomiting, abdominal pain) are frequently the earliest symptoms (Option 2) Neurologic manifestations (eg, lethargy, fatigue, weakness, confusion) Visual symptoms are characteristic and include alterations in color vision, scotomas, or blindness Cardiac arrhythmias - most dangerous Educational objective:Drug toxicity is common with digoxin due to its narrow therapeutic range. Drug levels are frequently monitored. Nonspecific gastrointestinal symptoms similar to gastroenteritis are common and can lead to serious cardiac arrhythmias if not recognized.

The home health nurse visits a client with hypertension whose blood pressure has been well controlled on oral valsartan 320 mg daily. The client's blood pressure is 190/88 mm Hg, significantly higher than it was 2 weeks ago. The client reports a cold, a stuffy nose, and sneezing for 3 days. Which question is most appropriate for the nurse to ask? 1. "Are you taking any over-the-counter medicines for your cold?" 2. "Are you taking extra vitamin C?" 3. "Did you babysit your granddaughter this past week?" 4. "Did you get a flu shot in the past week?"

1. "Are you taking any over-the-counter medicines for your cold?" Clients with hypertension should be instructed not to take potentially high-risk over-the-counter (OTC) medications such as high-sodium antacids, appetite suppressants, and cold and sinus preparations. It is appropriate to ask a client with hypertension about taking OTC cold medications as many cold and sinus medications contain phenylephrine or pseudoephedrine. These sympathomimetic decongestants activate alpha-1 adrenergic receptors, producing vasoconstriction. The resulting decreased nasal blood flow relieves nasal congestion. These agents have both oral and topical forms. With systemic absorption, these agents can cause dangerous hypertensive crisis. Educational objective:Clients with hypertension should be instructed not to take potentially high-risk over-the-counter medications, including high-sodium antacids, appetite suppressants, and cold and sinus preparations, as they can increase blood pressure.

A hospitalized client has been treated for the past 48 hours with a continuous heparin infusion for a deep vein thrombosis (DVT). When the nurse prepares to administer the evening dose of warfarin, the client's spouse says "Wait! My spouse can't have that! My spouse is already getting heparin for DVT." How should the nurse respond? 1. "Both medications will be given for several days until the warfarin has time to take effect." 2. "I will be discontinuing the heparin infusion as soon as I give this dose of warfarin." 3. "The two medications work synergistically to help break down the clot in your spouse's leg." 4. "We will hold the medication until I can call the health care provider (HCP) for clarification."

1. "Both medications will be given for several days until the warfarin has time to take effect" Warfarin begins to take effect in 48-72 hours and then takes several more days to achieve a maximum effect. Therefore, an overlap of a parenteral anticoagulant like heparin with warfarin is required. The typical overlap is 5 days or until the INR reaches the therapeutic level. The nurse will need to explain this overlap of the 2 medications to the client and the spouse. Educational objective:Warfarin requires an overlap of therapy with unfractionated heparin infusion or low-molecular-weight heparin (eg, enoxaparin, dalteparin) for several days until the INR is in the therapeutic range for the client's condition.

A client is admitted to the cardiac care unit with atrial fibrillation. Vital signs are shown in the exhibit. Which prescription should the nurse perform first? Click on the exhibit button for additional information. 1. Administer diltiazem 20 mg IVP 2. Administer rivaroxaban 20 mg PO 3. Draw blood for a thyroid function test 4. Send the client for echocardiogram

1. Administer diltiazem 20 mg IVP Atrial fibrillation is characterized by a disorganization of electrical activity in the atria due to multiple ectopic foci. It results in loss of effective atrial contraction and places the client at risk for embolic stroke due to thrombi formed in the atria from stasis of blood. During atrial fibrillation, the atrial rate may be increased to 350-600/min. The ventricular response (pulse rate) can vary. The higher the ventricular rate, the more likely the client will have symptoms of decreased cardiac output (ie, hypotension). Ventricular rate control is a priority in clients with atrial fibrillation. This client has an irregular heart rate of 140/min and is not currently hypotensive. However, if the high ventricular response is allowed to continue, it is likely that the client will begin to show signs and symptoms of decreased cardiac output such as hypotension. Therefore, giving the client diltiazem (a calcium channel blocker) is the priority as its purpose is to decrease the ventricular response rate to <100/min. Other medications such as beta blockers (metoprolol) or digoxin may also be used to control the ventricular rate. objective:Ventricular rate control is a priority in the client with atrial fibrillation; therefore, the nurse should administer the medication (diltiazem, metoprolol, or digoxin) that will accomplish this first.

The nurse is monitoring a client who has been on clopidogrel therapy. Which assessments are essential? Select all that apply. 1. Assess for bruising 2. Assess for tarry stools 3. Monitor intake and output 4. Monitor liver function tests 5. Monitor platelets

1. Assess for bruising 2. Assess for tarry stools 5. Monitor platelets Antiplatelet therapy (eg, aspirin, clopidogrel, prasugrel, ticagrelor) is initiated to prevent platelet aggregation in clients at risk for myocardial infarction, stroke, or other thrombotic events. This therapy increases bleeding risk, so clients should be assessed for bruising, tarry stools, and other signs of bleeding (eg, hematuria, bleeding gums, epistaxis) (Options 1 and 2). Clients should be taught to self-monitor for these signs. In addition, clopidogrel may cause thrombotic thrombocytopenic purpura, so platelets should be monitored periodically (Option 5). Educational objective:Antiplatelet therapy (eg, aspirin, clopidogrel, prasugrel, ticagrelor) can pose a risk for serious bleeding. Clients should be monitored for bruising, signs of bleeding (eg, tarry stools, hematuria), and decreased platelet counts.

The nurse is providing discharge teaching to several clients with new prescriptions. Which instructions by the nurse are correct in regard to medication administration? Select all that apply. 1. Avoid salt substitutes when taking valsartan for hypertension 2. Take levofloxacin with an aluminum antacid to avoid gastric irritation 3. Take sucralfate after meals to minimize gastric irritation associated with a gastric ulcer 4. When taking ethambutol, notify the health care provider (HCP) of any changes in vision 5. When taking rifampin, notify the HCP if the urine turns red-orange

1. Avoid salt substitutes when taking valsartan for hypertension 4. When taking ethambutol, notify the health care provider (HCP) of any changes in vision Both ACE inhibitors ("prils" - captopril, enalapril, lisinopril, ramipril) and angiotensin receptor blockers ("sartans" - valsartan, losartan, telmisartan) cause hyperkalemia. Salt substitutes contain high potassium and must not be consumed unless approved by the health care provider (HCP) (Option 1). Ethambutol (Myambutol) is used to treat tuberculosis but can cause ocular toxicity, resulting in vision loss and loss of red-green color discrimination. Vision acuity and color discrimination must be monitored regularly (Option 4). Educational objective:The nurse should watch for vision changes with ethambutol. Potassium supplements or salt substitutes should not be given to a client taking an ACE inhibitor or angiotensin receptor blocker. Sucralfate must be given before meals to prevent irritation of the ulcer. Quinolone antibiotics should not be given with antacids or supplements that reduce drug efficacy. Rifampin commonly causes red-orange discoloration of body fluids.

A home health nurse is preparing to start a milrinone infusion via a peripherally inserted central catheter for a client with end-stage heart failure. What equipment is most important to be present in the home? Select all that apply. 1. Bathroom scale for daily weights 2. Blood pressure cuff 3. Central line dressing change kits 4. Infusion pump 5. Intermittent urinary catheterization kits

1. Bathroom scale for daily weights 2. Blood pressure cuff 3. Central line dressing change kits 4. Infusion pump Milrinone (Primacor) is a phosphodiesterase-3 inhibitor given via IV infusion to increase contractility and promote vasodilation. Milrinone, an inotropic agent, is often prescribed to clients with heart failure unresponsive to other pharmacologic therapies. The medication is usually infused over 48-72 hours in a hospital setting; however, home infusion through a central line is becoming more common as a palliative measure for end-stage heart failure. Milrinone infusion requires central venous access (eg, peripherally inserted central catheter) as the medication is a vesicant and can cause extravasation if infused through a peripheral IV line. The home health nurse should perform the following: Ensure that an infusion pump is used to control the rate, and instruct the family on basic troubleshooting. Evaluate medication effectiveness and possible side effects. Monitor the central line insertion site for infection. Change the central line dressing as prescribed. Monitor daily weight. Monitor blood pressure for possible hypotension. Implement safety precautions as hypotension increases the client's risk of falling. A client may receive a milrinone infusion in the home for palliative treatment of end-stage heart failure. The infusion is set up via an infusion pump and infused through a central line. The client and family should be instructed on basic pump troubleshooting as well as the importance of measuring daily weight and blood pressure.

A client with coronary artery disease and atrial fibrillation is being discharged home following coronary artery stent placement. Discharge medications are shown in the exhibit. The nurse identifies which educational topic as the highest priority for this client? Discharge medications A spirin: 81 mg by mouth, once daily Clopidogrel: 75 mg by mouth, once daily Rivaroxaban: 20 mg by mouth, once daily Metoprolol: 25 mg by mouth, twice daily Rosuvastatin: 20 mg by mouth, once daily Lisinopril: 10 mg by mouth, once daily 1. Bleeding risk 2. Bronchospasm 3. Muscle injury 4. Tinnitus

1. Bleeding risk This client is on 3 different medications that affect bleeding risk (aspirin, clopidogrel, and rivaroxaban); this drug combination places the client at increased risk for bleeding. Teaching the client about the signs and symptoms of bleeding and risk reduction is the highest priority. The nurse should instruct the client to monitor for black, tarry stools, bleeding gums, and excessive bruising. The client should also use a soft bristle toothbrush, shave with an electric razor, and refrain from playing contact sports. Clients taking a combination of antiplatelet agents (eg, aspirin, clopidogrel, ticagrelor, prasugrel) and anticoagulants (eg, warfarin, rivaroxaban, apixaban) are at very high risk for life-threatening bleeding complications. The nurse should teach the client how to recognize and prevent signs and symptoms of increased bleeding.

The nurse prepares to administer 9:00 AM medications to a client. Which data should the nurse evaluate prior to administration? Medication administration record Allergies: None MedicationsSchedule Aspirin: 81 mg orally, daily 0900 Metoprolol: 50 mg orally, twice daily 0900 & 1700 Quinapril: 10 mg orally, daily 0900 1. Blood pressure 2. Blood sugar 3. Heart rate 4. International Normalized Ratio 5. Potassium level

1. Blood pressure 3. Heart rate 5. Potassium level Beta blockers (eg, metoprolol, carvedilol) and angiotensin-converting enzyme (ACE) inhibitors (eg, quinapril, lisinopril, enalapril) are antihypertensive medications. The nurse should assess blood pressure prior to administration. Beta blockers lower heart rate by blocking the action of beta receptors that increase heart rate and contractility. The nurse should assess blood pressure and heart rate prior to administration. ACE inhibitors increase serum potassium by decreasing urinary potassium excretion. The nurse should assess blood pressure and serum potassium levels prior to administration. Beta blockers lower blood pressure and heart rate. Angiotensin-converting enzyme inhibitors lower blood pressure and increase potassium. Aspirin, an antiplatelet medication, increases the risk for bleeding.

A client with a history of heart failure calls the clinic and reports a 3-lb (1.4-kg) weight gain over the past 2 days and increased ankle swelling. The nurse reviews the client's medications and anticipates the immediate need for dosage adjustment of which medication? 1. Bumetanide 2. Candesartan 3. Carvedilol 4.Isosorbide

1. Bumetanide Most clients with heart failure are prescribed a loop diuretic (eg, furosemide, torsemide, bumetanide) to reduce fluid retention. If the client has signs and symptoms of excessive fluid accumulation, the nurse will need to assess the situation by asking the client about dietary and fluid intake, adherence to prescribed medications, and the presence of any other associated symptoms (eg, shortness of breath). If the client is stable, the nurse may anticipate the need to increase the dosage of the prescribed loop diuretic (eg, bumetanide). (Option 2) Losartan, valsartan, and candesartan (sartans) are the commonly used angiotensin II receptor blockers. They are used in clients who cannot take ACE inhibitors (eg, lisinopril, ramipril). They block the renin-angiotensin-aldosterone system but will not affect the fluid status of the client with acute heart failure. Educational objective:A client who reports weight gain and edema requires evaluation for additional symptoms of fluid volume overload (eg, shortness of breath) and adherence to the current treatment plan. If the client is stable, an increase in the dosage of loop diuretic (eg, furosemide, torsemide, bumetanide) is anticipated.

A client in the emergency department has an acute myocardial infarction. The health care provider (HCP) has prescribed thrombolytic therapy. Which assessment data should the nurse report immediately to the HCP? 1. Client has a history of cerebral arteriovenous malformation 2. Client is currently menstruating 3. Client rates chest pain as 8 on a scale of 0-10 4. Current blood pressure is 170/92 mm Hg

1. Client has a history of cerebral arteriovenous malformation Absolute contraindications to thrombolytics Prior intracranial hemorrhage Structural cerebrovascular lesion (eg, arteriovenousmalformation, aneurysm) Ischemic stroke within 3 months (except within 3 hr) Suspected aortic dissection Active bleeding or bleeding diathesis Significant head trauma within 3 months Thrombolytic therapy aims to stop the infarction process, dissolve the thrombus in the coronary artery, and reperfuse the myocardium. This treatment is used when facilities do not have an interventional cardiac catheterization laboratory or when such a facility is too far away to transfer the client safely. Client selection is important because all thrombolytics lyse the pathologic clot but may also lyse other clots (eg, at a postoperative site). Minor or major bleeding can be a complication. Inclusion criteria for thrombolytic therapy in clients with acute myocardial infarction include chest pain lasting ≤12 hours, 12-lead ECG findings indicating acute ST-elevation myocardial infarction, and no absolute contraindications (eg, history of cerebral arteriovenous malformation) (Option 1). Educational objective:The candidate for thrombolytic therapy should be screened for absolute and relative contraindications. The nurse should immediately notify the health care provider if the client has history of arteriovenous malformation, which is an absolute contraindication to the use of thrombolytics.

The nurse is reviewing the medication administration record of a client with atrial fibrillation. Which of the following should the nurse monitor before giving these medications? Select all that apply. Medication administration record Allergies: None MedicationsTime Prednisone: 20 mg by mouth, daily 0900 Metoprolol: 50 mg by mouth, daily 0900 Digoxin: 0.5 mg by mouth, daily 1300 Enoxaparin: 40 mg subcutaneously, every 12 hours 0900 and 2100 1. Digoxin level 2. Glucose 3. INR 4. Platelet count 5. Serum potassium

1. Digoxin level 2. Glucose 4. Platelet count 5. Serum potassium The complete blood count (hemoglobin, hematocrit, platelet count) should be assessed periodically with the administration of enoxaparin, an anticoagulant that can cause bleeding and thrombocytopenia (Option 4). Digoxin levels are monitored for suspicion of digoxin toxicity (ie, serum levels >2 ng/mL) (Option 1). Potassium levels should also be monitored in clients receiving digoxin, as hypokalemia can potentiate digoxin toxicity (Option 5). Prednisone is a glucocorticoid that can cause hyperglycemia. Glucose levels should be monitored periodically in clients receiving this medication (Option 2). (Option 3) Low-molecular-weight heparins (eg, enoxaparin, dalteparin) produce a stable response at recommended dosages and negate the need for monitoring of activated partial thromboplastin time (aPTT) or international normalized ratio (INR) levels. aPTT is monitored when administering unfractionated heparin. INR is monitored in clients receiving warfarin (Coumadin). Educational objective:The nurse should routinely monitor laboratory values prior to administering medications. A complete blood count should be assessed periodically in clients receiving enoxaparin to monitor for bleeding and thrombocytopenia. Digoxin and potassium levels should be assessed with the administration of digoxin. Glucose levels should be monitored in the client receiving glucocorticoids. Additional Information Pharmacological and Parenteral

The nurse provides instructions to a client discharged on warfarin, after being treated for a pulmonary embolism (PE) following surgery. Which statements made by the client indicate the need for further teaching? Select all that apply. 1. "I will need to take my blood thinner for about 3-6 months." 2. "I will place small rugs on my wood floors to cushion a fall." 3. "I will take a baby aspirin if I have mild chest pain." 4. "I will use a soft-bristled toothbrush to clean my teeth." 5. "I will wear a blood thinner MedicAlert tag."

2. "I will place small rugs on my wood floors to cushion a fall." 3. "I will take a baby aspirin if I have mild chest pain." Clients discharged on warfarin (Coumadin) are taught interventions to prevent injury, such as removing scatter rugs in the home to reduce the risk of tripping and falling (especially in elderly) (Option 2). Clients are educated to avoid aspirin, drugs containing aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), and alcohol when taking warfarin due to an increased risk for bleeding (Option 3). Educational objective:Clients on warfarin or heparin should avoid using aspirin or nonsteroidal anti-inflammatory drugs, wear a MedicAlert device, avoid activities that increase the risk for bleeding, and limit alcohol intake.

A client with chronic stable angina is reporting chest pain. The nurse notices that the transdermal nitroglycerin patch that was applied 1 hour ago has peeled off. The client's vital signs are stable. What is the nurse's priority action? Medication administration record MedicationsSchedule Aspirin tablet: 81 mg, PO, daily 0800 Metoprolol 25 mg, PO, every 12 hours 0800 & 2000 Nitroglycerin patch: 0.4 mg, transdermal, daily, remove after 12 hours 0800 Morphine sulfate: 2 mg, IV push, every 6 hours PRN for pain PRN Nitroglycerin tablets: 0.4 mg sublingual, q5 minutes PRN, up to 2 additional doses PRN 1. Administer PRN morphine 2. Administer PRN sublingual nitroglycerin 3. Apply a new transdermal nitroglycerin patch 4. Obtain a 12-lead electrocardiogram

2. Administer PRN sublingual nitroglycerin Angina is chest pain due to myocardial ischemia. A client with chronic stable angina experiences intermittent chest pain relieved with rest or administration of nitroglycerin. The priority action for acute angina is administration of rapid-acting (1-3 minutes) sublingual nitroglycerin to restore cardiac perfusion. Nitroglycerin is a vasodilator that decreases cardiac workload (decreasing oxygen consumption), reduces preload, and increases myocardial perfusion. Onset and duration of action of nitroglycerin varies with route of administration. Acute stable angina is managed with nitroglycerin, which causes vasodilation and restores myocardial perfusion. Sublingual nitroglycerin has a rapid onset and is used to treat acute angina by increasing myocardial perfusion; transdermal patches have a delayed onset and are used prophylactically.

The nurse is providing discharge teaching to a client with a new prescription for warfarin. The nurse should instruct the client to avoid excess or inconsistent intake of which foods? Select all that apply. 1. Bananas 2. Broccoli 3. Liver 4. Oranges 5. Spinach

2. Broccoli 3. Liver 5. Spinach Warfarin (Coumadin) is a vitamin K antagonist used to prevent blood clots in clients with atrial fibrillation, artificial heart valves, or a history of thrombosis. Excessive intake of vitamin K-rich foods (eg, broccoli, spinach, liver) can decrease the anticoagulant effects of warfarin therapy (Options 2, 3, and 5). Clients should be consistent with intake of foods high in vitamin K after initiation of warfarin because dosing is individualized to the client and dietary changes may require dose adjustment. Educational objective:Clients receiving warfarin therapy should maintain consistent intake of foods high in vitamin K; it is not necessary to remove vitamin K-rich foods completely. Clients should avoid excess or inconsistent intake of green vegetables (eg, broccoli, spinach) and liver to promote steady warfarin efficacy.

The nurse is preparing medications for a group of clients. Which prescription should the nurse clarify with the health care provider before administering? 1. Client diagnosed with cirrhosis had 2 stools today; laxative lactulose prescribed daily. 2. Client is prescribed lisinopril PO daily; serum potassium level is 5.6 mEq/L (5.6 mmol/L). 3. Client is receiving vancomycin IV; mild facial flushing noted after 30 minutes 4. Client with diabetes has insulin glargine prescribed; current blood glucose is 100 mg/dL.

2. Client is prescribed lisinopril PO daily; serum potassium level is 5.6 mEq/L (5.6 mmol/L) ACE inhibitors ("-prils") and angiotensin II receptor blockers (ARBs) ("-sartans") may potentiate hyperkalemia. ACE inhibitors decrease the excretion of aldosterone. Aldosterone promotes sodium retention and causes potassium excretion. However, when the ACE inhibitor suppresses aldosterone, potassium rises, placing clients at risk for hyperkalemia, especially in the presence of impaired renal function. The nurse should question the administration of an ACE inhibitor in a client with hyperkalemia (Option 2). Educational objective:Clients receiving ACE inhibitors should be monitored for hyperkalemia, especially in the presence of renal insufficiency. The nurse should clarify a prescription for ACE inhibitor administration in a client with hyperkalemia.

A male client with hypertension was prescribed amlodipine. Which of these adverse effects is most important to teach the client to watch for? 1. Erectile dysfunction 2. Dizziness 3. Dry cougH 4. Leg edema

2. Dizziness Calcium channel blockers (nifedipine, amlodipine, felodipine, nicardipine) are vasodilators used to treat hypertension and chronic stable angina. They promote relaxation of vascular smooth muscles leading to decreased systemic vascular resistance and arterial blood pressure. The most important adverse effects of calcium channel blockers include dizziness (Option 2), flushing, headache, peripheral edema (Option 4), and constipation. The reduced blood pressure may initially cause orthostatic hypotension. The client should be taught to change positions slowly to prevent falls. Leg elevation and compression can help to reduce the edema. Constipation should be prevented with daily exercise and increased intake of fluids, fruits/vegetables, and high-fiber foods. Educational objective:Calcium channel blockers are utilized to treat hypertension and chronic stable angina. Adverse effects of these medications include dizziness, flushing, headache, peripheral edema, and constipation.

The nurse is preparing to administer medications to a client admitted with atrial fibrillation. The nurse notes the vital signs shown in the exhibit. Which medications due at this time are safe to administer? Select all that apply. Vital signs Temperature98.4 F (36.9 C) Blood pressure124/78 mm Hg Heart rate46/min and irregularly irregular Respirations22/min 1. Diltiazem extended-release PO 2. Heparin subcutaneous injection 3. Lisinopril PO 4. Metoprolol PO 5. Timolol ophthalmic

2. Heparin subcutaneous injection 3. Lisinopril PO Clients with atrial fibrillation can have either bradycardia (slow ventricular response) or tachycardia (rapid ventricular response). This client's vital signs are significant for bradycardia (heart rate [HR] <60/min). Therefore, medications that can decrease HR should be held and the health care provider (HCP) notified. The reason for holding the medication (HR 46/min) and an HCP contact note should be documented. Heparin is an anticoagulant; the subcutaneous injection is most commonly used to prevent deep venous thrombosis in hospitalized clients on bed rest. This medication will not affect the vital signs and is safe to administer Lisinopril, an ACE inhibitor, does not lower HR and is not contraindicated in clients with bradycardia (Option 3). The client is not hypotensive; therefore, lisinopril is safe to administer. Medications that decrease the heart rate should be held in clients with bradycardia. These include beta blockers such as metoprolol and timolol (including eye drops) and some types of calcium channel blockers (eg, diltiazem, verapamil).

The nurse prepares to administer morning medications to assigned clients. Which prescription should the nurse clarify with the health care provider? 1. Clopidogrel for client with history of stroke and platelet count of 154,000/mm3 (154 × 109/L) 2. Losartan for client with hypertension who is 8 weeks pregnant 3. Prednisone for client with herpes simplex lesions and Bell palsy 4. Tiotropium for client with pneumonia and chronic obstructive pulmonary disease

2. Losartan for client with hypertension who is 8 weeks pregnant Losartan is an angiotensin II receptor blocker (ARB) prescribed to treat hypertension. ACE inhibitors (eg, lisinopril, enalapril) and ARBs are teratogenic, causing renal and cardiac defects or death of the fetus. ARBs and ACE inhibitors have black box warnings that indicate contraindication in pregnancy. The nurse should not give an ARB to a pregnant client (Option 2). The health care provider should be notified so that an alternate antihypertensive may be prescribed that is safe to take during pregnancy (eg, labetalol, methyldopa). Education objective:Angiotensin II receptor blockers and ACE inhibitors are teratogenic, causing fetal injury or death, and are contraindicated in pregnancy.

The health care provider has prescribed spironolactone to be given in addition to hydrochlorothiazide to a client with hypertension. Which finding by the nurse indicates that the spironolactone is having the desired effect? 1. Blood glucose of 95 mg/dL (5.3 mmol/L) 2. Potassium level of 4.2 mEq/L (4.2 mmol/L) 3. Reduction in dizziness 4. Sodium level of 138 mEq/L (138 mmol/L)(

2. Potassium level of 4.2 mEq/L (4.2 mmol/L) Potassium-sparing diuretics (eg, spironolactone, amiloride, triamterene eplerenone) are generally very weak diuretics and antihypertensives. However, they are useful when combined with thiazide diuretics to reduce potassium (K+) loss. Thiazide diuretics can cause hypokalemia when used as monotherapy. A potassium level of 4.2 mEq/L (4.2 mmol/L) falls in the normal range (3.5-5.0 mEq/L [3.5-5.0 mmol/L]), which indicates that spironolactone has been effective in preventing hypokalemia in this client receiving a thiazide diuretic (eg, hydrochlorothiazide, chlorthalidone) (Option 2). (Option 1) Blood glucose levels can be increased by thiazide diuretics but are not affected by potassium-sparing diuretics. Educational objective:Potassium-sparing diuretics (eg, spironolactone, amiloride, triamterene, eplerenone) are often combined with thiazide diuretics to reduce potassium loss.

A client with coronary artery disease and stable angina is being discharged home on sublingual nitroglycerin (NTG). The nurse has completed discharge teaching related to this medication. Which statement by the client indicates that the teaching has been effective? 1. "I can keep a few pills in a plastic bag in my pocket in case I need them while I'm out." 2. "I can still take this with my vardenafil prescription." 3. "I can take up to 3 pills in a 15-minute period if I am experiencing chest pain." 4. "I should stop taking the pills if I experience a headache."

3. "I can take up to 3 pills in a 15-minute period if I am experiencing chest pain." Current evidence shows that up to 50% of clients lack knowledge about NTG administration procedures, storage, and side effects. Proper teaching can prevent many hospital visits for chest pain due to stable angina. Instructions for proper NTG administration include: Tablets are heat and light sensitive: They should be kept in a dark bottle and capped tightly. An opened bottle should be discarded after 6 months (Option 1). Take up to 3 pills in a 15-minute period: Take 1 pill every 5 minutes (up to 3 doses). Emergency medical services (EMS) should be called if pain does not improve or worsens 5 minutes after the first tablet has been taken. Previously, clients were taught to call after the third dose was taken, but newer studies suggest this causes a significant delay in treatment (Option 3). Avoid fatal drug interactions: Concurrent use of erectile dysfunction drugs (sildenafil, tadalafil, vardenafil) or alpha blockers (terazosin, tamsulosin) is contraindicated due to potentially fatal hypotension (Option 2). Headache may occur: Headache and flushing are common side effects of NTG due to systemic vasodilation and do not warrant medication discontinuation (Option 4). Educational objective:The nurse should instruct the client who is taking sublingual NTG to keep the tablets in a tightly capped, dark bottle away from heat and light. The client should be taught to take 1 tablet every 5 minutes (up to 3 tablets), but notify EMS if the pain does not improve or worsens 5 minutes after the first pill has been taken. These instructions should be reinforced at each appointment.

A client is in the cardiovascular clinic for a 3-month follow-up visit. At the first visit, the client was prescribed hydrochlorothiazide and amlodipine for hypertension. Which statement by the client would be concerning to the nurse and should be reported to the primary health care provider (PHCP)? 1. "I like to have a banana every morning with my breakfast." 2. "I occasionally experience slight dizziness when I get up in the morning." 3. "I started taking licorice root for my occasional heartburn." 4. "I usually take my hydrochlorothiazide first thing in the morning."

3. "I started taking licorice root for my occasional heartburn." A client is in the cardiovascular clinic for a 3-month follow-up visit. At the first visit, the client was prescribed hydrochlorothiazide and amlodipine for hypertension. Which statement by the client would be concerning to the nurse and should be reported to the primary health care provider (PHCP)? 1. "I like to have a banana every morning with my breakfast."(8%) 2. "I occasionally experience slight dizziness when I get up in the morning."(8%) 3. "I started taking licorice root for my occasional heartburn."(79%) 4. "I usually take my hydrochlorothiazide first thing in the morning."(2%) IncorrectCorrect answer 3 Collecting Statistics 79%Answered correctly 01 min, 06 secsTime Spent 01/22/2021Last Updated Other Possible Answers × Explanation Explanation: Licorice root is an herbal remedy sometimes used for gastrointestinal disorders such as stomach ulcers, heartburn, colitis, and chronic gastritis. Clients with heart disease or hypertension should be cautious about using licorice root. When used in combination with a diuretic such as hydrochlorothiazide, it can increase potassium loss, leading to hypokalemia. Hypokalemia can cause dangerous cardiac dysrhythmias. Thiazide diuretics are considered "potassium-wasting" diuretics, so this client is already at risk for hypokalemia. The addition of licorice root could potentiate the potassium loss. The nurse should discourage the client from using this herbal remedy and report the client's use to the PHCP. Educational objective:The nurse should discourage the client from using the herbal remedy licorice root when taking thiazide diuretics. Licorice root can potentiate potassium loss and increase the client's risk for hypokalemia. Use of licorice root should be reported to the PCHP.

The nurse reinforces teaching a client on prescribed dabigatran for chronic atrial fibrillation. Which statement by the client indicates a need for further teaching? 1. "I will call my health care provider if I notice red urine or blood in my stool." 2. "I will not stop taking dabigatran even if I get a stomachache." 3. "I will place capsules in my pill box so I will not forget to take a dose." 4. "I will swallow the capsule whole with a full glass of water."

3. "I will place capsules in my pill box so I will not forget to take a dose." Thrombin inhibitors such as dabigatran (Pradaxa) reduce the risk of clot formation and stroke in clients with chronic atrial fibrillation. The nurse should educate the client about implementing bleeding precautions (eg, using a soft-bristle toothbrush, shaving with an electric razor). Dabigatran capsules should be kept in their original container or blister pack until time of use to prevent moisture contamination (Option 3). Educational objective: Thrombin inhibitors such as dabigatran reduce the risk for clots and stroke in clients with chronic atrial fibrillation. The nurse should teach the client to use bleeding precautions and monitor for symptoms of bleeding, swallow capsules whole with a full glass of water, and keep capsules in their original container until time of use.

The nurse is performing discharge teaching for the parents of a 4-year-old with heart failure. Which statement by the parents indicates the need for further teaching related to the administration of digoxin? 1. "If our child vomits after a dose, we won't give a second one." 2. "Symptoms of nausea and vomiting should be reported to our health care provider (HCP)." 3. "We will hold the dose if our child's heart rate is above 90/min." 4. "We will not mix the medication with other foods or liquids."

3. "We will hold the dose if our child's heart rate is above 90/min." Digoxin is a cardiac glycoside given to infants and children in heart failure. It is given to increase myocardial contraction, which increases cardiac output and improves circulation and tissue perfusion. Digoxin is a potentially dangerous drug due to its narrow margin of safety in dosage. Parents should receive thorough education and in return demonstrate appropriate administration procedures for this medication. Parent teaching for administration of digoxin includes the following: Inform parents of the pulse rate at which to hold the medication based on HCP prescription. In general, digoxin is held if pulse <90-110/min for infants and young children or <70/min for an older child. Administer oral liquid in the side and back of the mouth Do not mix the drug with food or liquids as the refusal to take these would result in inaccurate intake of medication (Option 4) If a dose is missed, do not give an extra dose or increase the dose. Stay on the same schedule. If more than 2 doses are missed, notify the HCP If the child vomits, do not give a second dose (Option 1). Nausea, vomiting, or slow pulse rate could indicate toxicity. Notify the HCP (Option 2). Give water or brush the client's teeth after administration to remove the sweetened liquid Educational objective:Nausea, vomiting, or slow pulse rate can indicate digoxin toxicity. General guidelines are to hold digoxin for pulse <90-110/min in infants and young children and <70/min in older children.

A client with a diagnosis of atrial fibrillation has just been placed on warfarin therapy. The registered nurse (RN) overhears a student nurse teaching the client about potential food-drug interactions. Which statement made by the student nurse requires an intervention by the RN? 1. "Do you take any nutritional supplements?" 2. "You will need to monitor your intake of foods containing vitamin K." 3. "You will not be able to eat green, leafy vegetables while taking this medication." 4. "Your blood will be tested at regular intervals."

3. "You will not be able to eat green, leafy vegetables while taking this medication." Warfarin (Coumadin) works by blocking the availability of vitamin K, which is essential for blood clotting. As a result, the clotting mechanism is disrupted, reducing the risk of a stroke, venous thrombosis, or pulmonary embolism. Sudden increases or decreases in the consumption of vitamin K-rich foods could inversely alter the effectiveness of warfarin. An increase in vitamin K could decrease the effectiveness of warfarin, placing the client at increased risk of blood clot formation; a decrease could increase the effectiveness of warfarin, placing the client at increased risk for bleeding. (Option 1) Many medications can interfere with warfarin metabolism. Nutritional supplements may contain vitamin K, and so any new medication or nutritional supplement should be approved by the health care provider. Cranberry juice, grapefruit, green tea, and alcohol may also interfere with the effectiveness of warfarin. (Option 2) Rather than avoid vitamin K-rich foods, the client needs to keep vitamin K intake consistent from day to day to keep International Normalized Ratio (INR)/prothrombin time (PT) stable and within the recommended therapeutic range. If the client enjoys vitamin K-rich foods (eg, kale, broccoli, spinach, Brussels sprouts, cabbage, green leafy vegetables), these may be consumed in the same amounts, consistently on a daily basis. There is some evidence that a very low intake of vitamin K could decrease the overall effectiveness of warfarin. (Option 4) INR/PT will be monitored on an ongoing basis to determine the safest, most therapeutic warfarin dosage. Educational objective:Sudden increases or decreases in the consumption of vitamin K-rich foods could inversely alter the effectiveness of warfarin. Rather than avoid vitamin K-rich foods, the client needs to keep vitamin K intake consistent from day to day to keep INR/PT stable and within the recommended therapeutic range. INR/PT is monitored at regular intervals. Pharmacy personnel and dieticians can provide additional teaching.

A client with unstable angina and chronic kidney disease is receiving a continuous infusion of unfractionated heparin. Which value for activated partial thromboplastin time (aPTT) would indicate to the nurse that the heparin therapy is at an optimal therapeutic level? 1. 30 seconds 2. 35 seconds 3. 60 seconds 4. 85 seconds

3. 60 seconds Unfractionated heparin is used as an anticoagulant in unstable angina. It prevents the conversion of fibrinogen to fibrin and prothrombin to thrombin, both components of clot formation. The aPTT is a laboratory test that characterizes blood coagulation. It is used to monitor treatment effects of clients receiving heparin. The normal aPTT is 25-35 seconds. Heparin infusions are titrated to obtain a therapeutic value of aPTT, typically 1.5-2 times the normal value. Therapeutic value for aPTT is 46-70 seconds. The nurse would evaluate the aPTT for a therapeutic value and make adjustments in the rate of infusion of the heparin as needed. Educational objective:The nurse caring for a client receiving a heparin infusion should monitor the aPTT and follow the heparin infusion protocol for titration. A therapeutic level is 1.5-2 times normal, or an aPTT of 46-70 seconds.

A nurse in the emergency department is titrating a continuous infusion of nitroglycerin to a client admitted for acute coronary syndrome. The client's vital signs, including blood pressure (BP), heart rate (HR), and pain level, are being monitored frequently. Which assessment findings indicate that the current rate of administration should be maintained? 1. BP 80/50 mm Hg, HR 110/min; client reports pain is 0 out of 10 2. BP 100/60 mm Hg, HR 90/min; client reports pain is 3 out of 10 3. BP 110/70 mm Hg, HR 80/min; client reports pain is 0 out of 10 4. BP 120/80 mm Hg, HR 70/min; client reports pain is 5 out of 10

3. BP 110/70 mm Hg, HR 80/min; client reports pain is 0 out of 10 Acute coronary syndrome (ACS) is a broad term that encompasses a range of cardiac events, including unstable angina and myocardial infarction (with or without ST-segment elevation). Clients with ACS require immediate treatment to prevent continued ischemia of cardiac muscle. Intravenous nitroglycerin (glyceryl trinitrate) is used to increase cardiac blood flow and provide pain relief for clients with ACS until a definitive treatment plan (eg, percutaneous coronary intervention, thrombolytic therapy, bypass surgery) is determined. Because nitroglycerin is a vasodilator, continuous hemodynamic monitoring is required to prevent severe hypotension. The infusion rate is titrated by the nurse based on pain level and blood pressure (BP), usually every 3-5 minutes until pain is relieved and BP is stable. If systolic BP drops to <90 mm Hg or falls >30 mm Hg below client baseline, the infusion rate should be decreased or stopped. Educational objective:Nitroglycerin and other nitrates increase cardiac blood flow and provide relief from the pain of ischemia in acute coronary syndrome by causing vasodilation. Their infusion should not cause systolic blood pressure to fall to <90 mm Hg or to drop >30 mm Hg below baseline.

The nurse teaches the client taking atorvastatin to call the health care provider (HCP) if experiencing which symptom associated with a serious adverse effect of atorvastatin? 1. Diarrhea 2. Headache 3. Muscle aches 4. Numbness in the feet

3. Muscle aches Atorvastatin (Lipitor) is a statin drug, or HMG-CoA reductase inhibitor, prescribed to lower cholesterol and reduce the risk of atherosclerosis and coronary artery disease. A serious adverse effect of statins, including atorvastatin and rosuvastatin (Crestor), is myopathy with ongoing generalized muscle aches and weakness. A client who develops muscle aches while on a statin drug should call the HCP who will then obtain a blood sample to assess the creatine kinase (CK) level. If myopathy is present, CK will be significantly elevated (≥10x normal), and the drug will then be discontinued. The client taking a statin such as atorvastatin or rosuvastatin should be taught to call the HCP if generalized muscle aches develop as this may be a symptom of myopathy, a serious adverse effect of this type of medication.

A client with stable angina is being discharged home with a prescription for a transdermal nitroglycerin patch. The nurse has reviewed discharge instructions on the medication with the client. Which statement by the client indicates that teaching has been effective? 1. "I can continue to take my prescription of sildenafil." 2. "I should take the patch off when I shower." 3. "I will remove the patch if I develop a headache." 4. "I will rotate the site where I apply the patch."

4. "I will rotate the site where I apply the patch." Nitroglycerin patches are transdermal patches used to prevent angina in clients with coronary artery disease. They are usually applied once a day (not as needed) and worn for 12-14 hours and then removed. Continuous use of patches without removal can result in tolerance. No more than one patch at a time should be worn. The patch should be applied to the upper body or upper arms. Clean, dry, hairless skin that is not irritated, scarred, burned, broken, or calloused should be used. A different location should be chosen each day to prevent skin irritation. Nursing education about transdermal nitroglycerin includes application of the patch to the upper arms or body, rotating the sites daily, removing the patch at night, taking no erectile dysfunction medications, and informing clients that headaches are common. Patches do not need to be removed for bathing.

A client with coronary artery disease was discharged home with a prescription for sublingual nitroglycerin (NTG) to treat angina. Which statement by the client indicates that further teaching is required? 1. "I may experience flushing but will continue to take the medication as prescribed." 2. "I should lie down before taking the medication." 3. "I should not swallow the tablet." 4. "I will wait to call 911 if I don't experience relief after the third tablet."

4. "I will wait to call 911 if I don't experience relief after the third tablet." Current evidence indicates that up to 50% of clients lack knowledge about administration procedures, storage, and side effects of NTG. Proper teaching can prevent many hospital visits for chest pain from stable angina. The client should be instructed to take 1 pill (or 1 spray) every 5 minutes for up to 3 doses, but emergency medical services (EMS) should be called if pain is unimproved or worsening 5 minutes after the first tablet. Previously, clients were taught to call EMS after the third dose, but newer studies suggest that this causes a significant delay in treatment (Option 4). NTG should cause a slight tingling sensation under the tongue if it is potent; otherwise, the medication is likely outdated. The oral mucosa needs to be moist for adequate absorption of NTG, and clients should be instructed to take a drink of water before administration if needed for dry mouth. Sublingual tablets should never be swallowed (Option 3). If using a spray, the client should not inhale it but direct it onto/under the tongue instead. Educational objective:The nurse should instruct clients taking sublingual NTG that they should call EMS if their chest pain is unrelieved or worsening 5 minutes after the first tablet. The tablet should be allowed to dissolve under the tongue to allow for adequate absorption and should never be swallowed.

The nurse has just completed discharge teaching about sublingual nitroglycerin (NTG) tablets to a client with stable angina. Which statement by the client indicates the need for further teaching? 1. "I will call 911 if my chest pain isn't relieved by NTG." 2. "If I have chest pain, I can take up to 3 pills 5 minutes apart." 3. "I'll call my doctor if I start having chest pain at night." 4. "I'll keep one bottle in the house and one in the car."

4. "I'll keep one bottle in the house and one in the car." NTG is a vasodilator used to treat stable angina. It is a sublingual tablet or spray that is placed under the client's tongue. It usually relieves pain in about 3 minutes and lasts 30-40 minutes. The recommended dose is 1 tablet or 1 spray taken sublingually for angina every 5 minutes for a maximum of 3 doses. If symptoms are unchanged or worse 5 minutes after the first dose, emergency medical services (EMS) should be contacted. Previously, clients were taught to call EMS after the third dose was taken, but newer studies suggest that this leads to a significant delay in treatment. The NTG should be easily accessible at all times. Tablets are packaged in a light-resistant bottle with a metal cap. They should be stored away from light and heat sources, including body heat, to protect from degradation. Clients should be instructed to keep the tablets in the original container. Once opened, the tablets lose potency and should be replaced every 6 months. The car is not a good place to store NTG due to heat Education about sublingual NTG should include placing the tablet or spray under the tongue; repeating the dose every 5 minutes, with up to 3 total doses if angina is not relieved; notifying EMS if the first dose does not improve the symptoms; keeping the tablets in the original container away from light and heat; and replacing the bottle every 6 months once opened.

An African American client comes to the clinic for a follow-up visit 2 months after starting enalapril for hypertension. Which client statement should be reported to the health care provider immediately? 1. "Is there anything I can take for my dry, hacking cough?" 2. "My blood pressure this morning was 158/84 mm Hg." 3. "Sometimes I feel somewhat dizzy when I stand up." 4. "Will you look at my tongue? It feels thicker than normal."

4. "Will you look at my tongue? It feels thicker than normal." Angioedema is swelling that usually affects areas of the face (lips, tongue), larynx, extremities, gastrointestinal tract, and genitalia. The swelling often starts in the face and can quickly become life-threatening as it progresses to the airways. Angioedema is an adverse effect of ACE inhibitors (eg, enalapril, lisinopril, captopril) and occurs more commonly in African American clients. Unlike other typical drug allergies, this side effect can occur any time after starting the medication. The nurse should immediately report angioedema to the health care provider and carefully monitor the client. Swelling of the tongue can be a sign of angioedema in clients taking ACE inhibitors; this can be potentially life-threatening if the airway becomes compromised. The nurse should report this immediately to the health care provider. Angioedema occurs more commonly in African American clients.

The clinic nurse is reviewing telephone messages from four clients. Which client's call should the nurse return first? 1. Client who has just taken albuterol and reports a heart rate of 108/min and a coarse tremor in both arms 2. Client who is prescribed azithromycin and reports frequent, foul-smelling, liquid stools and abdominal cramping 3. Client who is prescribed metformin and reports a blood glucose of 284 mg/dL (15.76 mmol/L) and frequent urination 4. Client who takes amiodarone and reports a dry cough and increased dyspnea when walking around the house

4. Client who takes amiodarone and reports a dry cough and increased dyspnea when walking around the house Amiodarone is an antiarrhythmic medication used to treat life-threatening arrhythmias that cannot be controlled with other medications. Amiodarone therapy is used only if other treatments have failed, as it has many toxic, adverse effects that may be severe. Pulmonary toxicity is a life-threatening adverse effect of amiodarone, which is believed to cause direct cellular damage and activation of an immune response in the lungs. Clients who develop pulmonary toxicity may report respiratory symptoms such as dry cough, pleuritic chest pain, and dyspnea. Clients with clinical manifestations of pulmonary toxicity require immediate intervention to prevent fatal, irreversible lung damage . Amiodarone is an antiarrhythmic medication used to treat life-threatening arrhythmias. Pulmonary toxicity is a life-threatening complication that may cause symptoms such as dry cough, pleuritic chest pain, and dyspnea. Clients taking amiodarone with signs of pulmonary toxicity require immediate follow-up.

Which prescriptions for these clients does the nurse question? Select all that apply. 1. Client with Clostridium difficile colitis, prescribed vancomycin 125 mg PO 2. Client with diabetes and elevated mealtime glucose, prescribed lispro insulin scale 6 units subcutaneously 3. Client with gastrointestinal bleed and nasogastric tube, prescribed pantoprazole 40 mg intravenous 4. Client with hypertension and blood pressure (BP) 94/40 mm Hg, prescribed metoprolol succinate SR 50 mg PO 5. Client with otitis media and penicillin allergy, prescribed ampicillin 500 mg PO

4. Client with hypertension and blood pressure (BP) 94/40 mm Hg, prescribed metoprolol succinate SR 50 mg PO 5. Client with otitis media and penicillin allergy, prescribed ampicillin 500 mg PO The nurse would question the prescriptions for the following clients: Client with hypertension and BP 94/40 mm Hg, prescribed metoprolol succinate SR (Toprol-XL) 50 mg PO: This client's mean arterial pressure (MAP) is only 58 mm Hg ({[2x diastolic] + systolic} ÷ 3). A MAP >60-65 mm Hg is necessary to perfuse the vital organs (eg, brain, coronary arteries, kidneys). Toprol-XL is a long-acting beta blocker and will continue to drop the client's BP over a 24-hour period. Client with otitis media and penicillin allergy prescribed ampicillin 500 mg PO: Ampicillin is classified as a penicillin antibiotic and is contraindicated in clients with a penicillin allergy. IV proton pump inhibitors are used for gastric ulcer bleeding. Oral vancomycin can be used for C difficile colitis. Ampicillin or amoxicillin are contraindicated in clients with a penicillin allergy. Antihypertensives are held if the client has borderline low BP.

A nurse in the cardiac intermediate care unit is caring for a client with acute decompensated heart failure (ADHF). The client also has a history of coronary artery disease and peripheral vascular disease. The nurse is preparing to administer medications. Based on the assessment data, the nurse should question which medication? Click on the exhibit button for additional information. 1. Aspirin 2. Atorvastatin 3. Furosemide 4. Metoprolol

4. Metoprolol Beta blockers, or "lols" (metoprolol, carvedilol, bisoprolol, atenolol), are the mainstay of therapy for clients with chronic heart failure as these improve survival rates for both systolic and diastolic heart failure. However, in certain situations beta blockers can worsen heart failure symptoms by decreasing normal compensatory sympathetic nervous system responses and myocardial contractility. In this client with acute decompensated heart failure (ADHF), marginally low blood pressure (BP), crackles in the lungs, low oxygen saturation, jugular venous distension (JVD), and peripheral edema, the administration of beta blockers can cause the client to further deteriorate. Beta blockers at low doses may be able to be restarted after this client has stabilized and exacerbation of ADHF has resolved with diuresis. Educational objective:The nurse should question administration of beta blockers in a client with symptoms of acute ADHF due to the possibility of further clinical deterioration. Beta blockers are most useful for chronic heart failure.

A home health nurse visits a client 2 weeks after the client is discharged from treatment for an acute myocardial infarction and heart failure. After a review of the home medications, which symptom reported by the client is most concerning to the nurse? Home medications Aspirin: 81 mg PO, daily Clopidogrel: 75 mg PO, daily Metoprolol XL: 50 mg PO, daily Furosemide: 40 mg PO, twice daily Fish oil: 4 g PO, daily. 1. Bruising easily, especially on the arms 2. Fatigue 3. Feeling depressed 4. Muscle cramps in the legs

4. Muscle cramps in the legs Hypokalemia (<3.5 mEq/L [<3.5 mmol/L]) is a common, adverse effect of potassium-wasting diuretics (eg, furosemide, bumetanide) that may cause muscle cramps, weakness, or paresthesia. Unmanaged hypokalemia can lead to lethal cardiac dysrhythmias and paralysis. Therefore, the nurse should immediately notify the health care provider of symptoms of hypokalemia Educational objective: Nurses caring for clients receiving potassium-wasting diuretics (eg, furosemide) should monitor for and report signs of hypokalemia (eg, muscle cramps), as unmanaged hypokalemia may result in lethal complications. Bruising, a side effect of antiplatelet medications, and fatigue, a side effect of beta blockers, should be monitored, but are not lethal.

A client is being discharged after having a stent placed in the left anterior descending coronary artery. The client is prescribed clopidogrel. Which client data obtained by the nurse would be concerning in relation to this new medication? Select all that apply. 1. Blood pressure of 140/84 mm Hg 2. Heart rate of 98/min 3. Platelet count of 200,000/mm3 (200 x 109/L) 4. Report of Ginkgo biloba use 5. Report of peptic ulcer disease

4. Report of Ginkgo biloba use 5. Report of peptic ulcer disease Antiplatelet agents (eg, clopidogrel, ticagrelor, prasugrel, aspirin) prevent platelet aggregation and are given to clients to prevent stent re-occlusion. They prolong bleeding time and should not be taken by clients with a bleeding peptic ulcer, active bleeding, or intracranial hemorrhage. Ginkgo biloba also interferes with platelet aggregation and can cause increased bleeding time. Antiplatelet agents and Ginkgo biloba should not be taken together. If this were to occur, this client would be at an increased risk for bleeding. This information should be reported to the prescribing health care provider before the client is discharged. . Educational objective:If a client is prescribed clopidogrel, the nurse should be concerned about a history of peptic ulcer disease and Ginkgo biloba use. In this situation, the client would be at increased risk for bleeding. This data should be reported to the prescribing health care provider before the client is discharged.

A client is receiving a continuous heparin infusion and the most recent aPTT is 140 seconds. The nurse notices blood oozing at the surgical incision and IV insertion sites. What interventions should the nurse implement? Select all that apply. 1. Continue heparin infusion and recheck aPTT in 6 hours 2. Prepare to administer vitamin K 3. Redraw blood for laboratory tests 4. Review guidelines for administration of protamine 5. Stop infusion of heparin and notify the health care provider (HCP)

4. Review guidelines for administration of protamine 5. Stop infusion of heparin and notify the health care provider (HCP) Depending on the institution and HCP, a therapeutic aPTT level for a client being heparinized is somewhere between 46-70 seconds (1.5-2.0 times the baseline value). An aPTT of 140 seconds is too long and this client is showing signs of bleeding. The nurse should stop the heparin infusion, notify the HCP, and review administration guidelines for possible administration of protamine (reversal agent for heparin). Educational objective:The nurse should stop the infusion of heparin when there is evidence of bleeding. The HCP should be notified immediately and the nurse should be prepared to give protamine if ordered.

An elderly client with depression, diabetes mellitus, and heart failure has received a new digoxin prescription for daily use. Which client assessment indicates that the nurse should follow up on serum digoxin levels frequently? 1. Apical heart rate is 62/min 2. Blood sugar level is 240 mg/dL (13.3 mmol/L) 3. Client is taking 20 mg fluoxetine daily 4. Serum creatinine is 2.3 mg/dL (203 µmol/L)

4. Serum creatinine is 2.3 mg/dL (203 µmol/L) Digoxin (Lanoxin) is a cardiac glycoside that increases cardiac contractility but slows the heart rate and conduction. It is used in heart failure (to increase cardiac output) and atrial fibrillation (to reduce the heart rate). The drug is excreted almost exclusively by the kidney. BUN and creatinine levels are measurements of kidney function. The normal range for creatinine is 0.6-1.3 mg/dL (53-115 µmol/L). Elderly clients tend to develop age-related decrease in glomerular filtration rate (GFR). These clients and those with obvious kidney injury (possibly due to diabetes in this client) can accumulate digoxin. The early symptoms of toxicity are nausea and vomiting. Later signs of toxicity are arrhythmias, including heart blocks. Therefore, clients at risk for digoxin toxicity require frequent drug level monitoring and dose adjustment. Educational objective:Digoxin (Lanoxin) is excreted almost exclusively by the kidneys. Decreased kidney function usually requires decreased digoxin dosage and frequent drug level monitoring. BUN and creatinine are measurements of kidney function.

The nurse is assessing a client with hypertension and essential tremor 2 hours after receiving a first dose of propranolol. Which assessment is most concerning to the nurse? 1. Client reports a headache 2. Current blood pressure is 160/88 mm Hg 3. Heart rate has dropped from 70/min to 60/min 4. Slight wheezes auscultated during inspiration

4. Slight wheezes auscultated during inspiration Propranolol is a nonselective beta-blocker that inhibits beta1 (heart) and beta2 (bronchial) receptors. It is used for many indications (eg, essential tremor) in addition to blood pressure control. Blood pressure decreases secondary to a decrease in heart rate. Bronchoconstriction may occur due to the effect on the beta2 receptors. The presence of wheezing in a client taking propranolol may indicate that bronchoconstriction or bronchospasm is occurring. The nurse should assess for any history of asthma or respiratory problems with this client and notify the health care provider (HCP). Educational objective:The nurse should be concerned about the presence of wheezing in a client taking a nonselective beta-blocker like propranolol. Wheezing may indicate bronchoconstriction or bronchospasm. The nurse should assess for any history of asthma or other respiratory problems and report to the HCP.

A client with hypertension is prescribed lisinopril. The nurse instructs the client to notify the health care provider immediately if which adverse effect occurs when taking this medication? 1. Cough 2. Dizziness 3. Rapid-onset confusion 4. Swelling of the lips and tongue

4. Swelling of the lips and tongue Lisinopril (Prinivil, Zestril) is an angiotensin-converting enzyme (ACE) inhibitor prescribed to treat hypertension and slow the progression of heart failure. Lisinopril has a low incidence of serious adverse effects except angioedema (rapid swelling of lips, tongue, throat, face, and larynx). Angioedema can lead to airway obstruction and possible death. ACE inhibitors are the most frequent medications causing drug-induced angioedema. The risk is 5 times greater for African Americans than for Caucasians. If clients experience symptoms of angioedema, they are instructed to discontinue the drug and notify the HCP immediately. Educational objective:ACE inhibitors (eg, captopril, enalapril, lisinopril, ramipril) have a low incidence of serious adverse effects except angioedema (rapid swelling of lips, tongue, throat, face, and larynx). More common adverse effects of ACE inhibitors include dry cough, orthostatic hypotension, and hyperkalemia.

A client recently diagnosed with heart failure is being discharged with a prescription for lisinopril. Which client teaching related to this new medication is important to review at discharge? 1. Instruct client to report for monthly blood work to monitor drug levels 2. Review foods high in potassium that client should include in diet 3. Teach client to count own pulse for 1 minute; hold medication if pulse <60/min 4. Teach client to rise slowly and sit on side of bed for several minutes before rising

4. Teach client to rise slowly and sit on side of bed for several minutes before rising ion Explanation: Angiotensin converting enzyme (ACE) inhibitors (eg, captopril, enalapril, lisinopril, ramipril) prevent the pathological enlargement of the left ventricle of the heart. They work by blocking a crucial step in the renin-angiotensin-aldosterone system, the main hormonal mechanism involved in blood pressure regulation. Interrupting this step of the renin-angiotensin-aldosterone system has following effects: A shortage of angiotensin II results in an absence of the vasoconstrictive responses (orthostatic reflex, renal blood flow regulation) causing orthostatic hypotension. Clients may be more prone to experiencing orthostatic hypotension early in treatment with ACE inhibitors and should be taught ways to prevent it. A shortage of aldosterone causes hyperkalemia. Aldosterone Saves Sodium and Pushes Potassium out of the body. ACE inhibitors are contraindicated in pregnancy due to teratogenic effects on the fetus (eg, oligohydramnios, fetal kidney injury). The other important side effects of ACE inhibitors, cough and angioedema, are thought to be due to the accumulation of bradykinin. Educational objective:Client education after initiation of an angiotensin converting enzyme inhibitor (eg captopril, lisinopril) includes a discussion on development of a dry cough, taking several minutes to get out of bed, possible allergic reactions (rash, angioedema), and the teratogenic effects of the drug.

The nurse admits a client with newly diagnosed unstable angina. Which information obtained during the admission health history is most important for the nurse to report to the health care provider (HCP) immediately? 1. Drinks 6 cans of beers on the weekend 2. Gets up 4 times during the night to void 3. Smokes 1 pack of cigarettes daily 4. Uses sildenafil occasionally

4. Uses sildenafil occasionally Sildenafil (Viagra) is a phosphodiesterase inhibitor used to treat erectile dysfunction. The use of sildenafil is most important for the nurse to report to the HCP. This must be communicated immediately as concurrent use of nitrate drugs (commonly prescribed to treat unstable angina) is contraindicated as it can cause life-threatening hypotension. Before any nitrate drugs can be administered, further action is necessary to determine when sildenafil was taken last (ie, half-life is about 4 hours). Educational objective:Nitrate drugs are prescribed to treat angina. The concurrent use sildenafil (Viagra) and nitrates is contraindicated as it can cause life-threatening hypotension.