unit 6 & 7 exam

A patient with diabetes develops hypertension. The nurse will anticipate administering which type of medication to treat hypertension in this patient? a. ACE inhibitors b. Beta blockers c. Direct-acting vasodilators d. Thiazide diuretics

ANS: A ACE inhibitors slow the progression of kidney injury in diabetic patients with renal damage. Beta blockers can mask signs of hypoglycemia and must be used with caution in diabetics. Direct-acting vasodilators are third-line drugs for chronic hypertension. Thiazide diuretics promote hyperglycemia.

A patient who was in a motor vehicle accident sustained a severe head injury and is brought into the emergency department. The provider orders intravenous mannitol [Osmitrol]. The nurse knows that this is given to: a. reduce intracranial pressure. b. reduce renal perfusion. c. reduce peripheral edema. d. restore extracellular fluid.

ANS: A Mannitol is an osmotic diuretic that is used to reduce intracranial pressure by relieving cerebral edema. The presence of mannitol in blood vessels in the brain creates an osmotic force that draws edematous fluid from the brain into the blood. Mannitol can also be used to increase renal perfusion. It can cause peripheral edema and is not used to restore extracellular fluid.

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

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

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

A 5-year-old patient seen in an outpatient clinic is noted to have hypertension on three separate visits. Ambulatory blood pressure monitoring confirms that the child has hypertension. As an initial intervention with the child's parents, the nurse will expect to: a. perform a detailed health history on the child. b. provide teaching about antihypertensive medications. c. reassure the parents that their child may outgrow this condition. d. teach the parents about lifestyle changes and a special diet.

ANS: A Because the incidence of secondary hypertension is much higher in children than adults, it is important to obtain an accurate health history to help uncover primary causes. Once the type of hypertension is established, the teaching interventions may be useful. Hypertension must be treated, and it is incorrect to reassure parents that their child may just outgrow the condition.

A nurse is caring for a patient who is receiving a drug that causes constriction of arterioles. The nurse expects to observe which effect from this drug? a. Decreased stroke volume b. Increased stroke volume c. Decreased myocardial contractility d. Increased myocardial contractility

ANS: A Constriction of arterioles increases the load against which the heart must pump to eject blood. Increased constriction of arterioles would decrease, not increase, the stroke volume of the heart. Myocardial contractility is determined by the sympathetic nervous system, acting through beta1- adrenergic receptors in the myocardium

A patient arrives in the emergency department complaining of muscle weakness and drowsiness. The nurse notes a heart rate of 80 beats/min, a respiratory rate of 18 breaths per minute, and a blood pressure of 90/50 mm Hg. The electrocardiogram reveals an abnormal rhythm. The nurse will question the patient about which over-the-counter medication? a. Antacids b. Aspirin c. Laxatives d. Potassium supplements

ANS: A Hypermagnesemia can occur when patients are taking magnesium-containing antacids. Symptoms include muscle weakness, sedation, hypotension, and ECG changes. Aspirin would cause metabolic acidosis. Laxatives can contribute to hypokalemia. Potassium supplements would cause hyperkalemia

A nurse is assessing a patient who has heart failure. The patient complains of shortness of breath, and the nurse auscultates crackles in both lungs. The nurse understands that these symptoms are the result of: a. decreased force of ventricular contraction. b. increased force of ventricular contraction. c. decreased ventricular filling. d. increased ventricular filling.

ANS: A In the failing heart, Starling's law breaks down, and the force of contraction no longer increases in proportion to the amount of ventricular filling. The result is the backup of blood into the lungs and the symptoms of shortness of breath and crackles caused by fluid. Increased ventricular contraction would not result in a backup of blood into the lungs. Changes in ventricular filling are not the direct cause of this symptom.

Which patients may receive hydralazine to treat hypertension? (Select all that apply.) a. A 1-month-old infant b. A 5-year-old child c. A pregnant woman d. A mother breast-feeding a newborn e. An older adult

ANS: A, B, E Hydralazine may be used in infants as young as 1 month of age, in children, and in older adults. Hydralazine is labeled pregnancy category C and data is lacking regarding transmission of hydralazine in breast-feeding women, so benefits should outweigh risks.

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 who took an overdose of verapamil has been treated with gastric lavage and a cathartic. The emergency department nurse assesses the patient and notes a heart rate of 50 beats/min and a blood pressure of 90/50 mm Hg. The nurse will anticipate: a. administering intravenous norepinephrine (NE) and atropine and glucagon. b. assisting with direct-current (DC) cardioversion. c. placing the patient in an upright position. d. preparing to administer a beta blocker.

ANS: A Verapamil toxicity can cause bradycardia and hypotension. Atropine and glucagon should be given to treat bradycardia and NE for hypotension. DC cardioversion is indicated for ventricular tachydysrhythmias, which this patient does not have. Patients with hypotension should be placed in Trendelenburg's position. Beta blockers will only exacerbate these effects.

A patient is taking a drug that interferes with venous constriction. The nurse will tell the patient to: a. ask for assistance when getting out of bed. b. expect bradycardia for a few days. c. notify the provider if headache occurs. d. report shortness of breath.

ANS: A A drop in venous pressure reduces venous return to the heart, and as blood pools in the extremities, orthostatic hypotension can occur. Patients taking drugs that reduce venous constriction should be cautioned to ask for assistance when getting out of bed. Bradycardia, headache, and shortness of breath are not expected effects

A patient who has been taking an antihypertensive medication for several years is recovering from a myocardial infarction. The prescriber changes the patient's medication to an ACE inhibitor. The patient asks the nurse why a new drug is necessary. What is the nurse's response? a. "ACE inhibitors can prevent or reverse pathologic changes in the heart's structure." b. "ACE inhibitors help lower LDL cholesterol and raise HDL cholesterol." c. "ACE inhibitors increase venous return to the heart, improving cardiac output." d. "ACE inhibitors regulate electrolytes that affect the cardiac rhythm."

ANS: A ACE inhibitors have many advantages over other antihypertensive medications, the most important of which is their ability to prevent or reverse pathologic changes in the heart and reduce the risk of cardiac mortality caused by hypertension. They are useful in patients with high low-density lipoprotein (LDL) or low high-density lipoprotein (HDL) cholesterol, but they do not directly affect this comorbidity. They reduce venous return to the heart, thereby reducing right heart size. They do not alter serum electrolyte levels.

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. Thirdgeneration 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

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 antidysrhythmic 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) revent fibrotic changes. DRIs are not widely used.

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 p

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."

ANS: 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.

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/min. 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/min, 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 additional medication 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/min. 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 nurse is reviewing a patient's most recent blood count and notes that the patient has a hemoglobin of 9.6 gm/dL and a hematocrit of 33%. The nurse will notify the provider and will expect initial treatment to include: a. determining the cause of the anemia. b. giving intravenous iron dextran. c. giving oral carbonyl iron [Feosol]. d. teaching about dietary iron.

ANS: A Before therapy for iron deficiency anemia is started, the cause must be determined so that the appropriate treatment is given. Oral iron is safer and, most of the time, as effective as parenteral iron, so IV iron is not an initial choice. Oral iron will be given once the cause of the deficiency has been determined. Patients who are iron deficient should be taught about dietary iron, but this is not part of the initial treatment when a deficiency is detected.

A patient with hypertension with a blood pressure of 168/110 mm Hg begins taking hydrochlorothiazide and verapamil. The patient returns to the clinic after 2 weeks of drug therapy, and the nurse notes a blood pressure of 140/85 mm Hg and a heart rate of 98 beats/min. What will the nurse do? a. Notify the provider and ask about adding a beta-blocker medication. b. Reassure the patient that the medications are working. c. Remind the patient to move slowly from sitting to standing. d. Request an order for an electrocardiogram.

ANS: A Beta blockers are often added to drug regimens to treat reflex tachycardia, which is a common side effect of lowering blood pressure, caused by the baroreceptor reflex. The patient's blood pressure is responding to the medications, but the tachycardia warrants treatment. Reminding the patient to move slowly from sitting to standing is appropriate with any blood pressure medication, but this patient has reflex tachycardia, which must be treated. An electrocardiogram is not indicated.

A nurse is discussing how beta blockers work to decrease blood pressure with a nursing student. Which statement by the student indicates a need for further teaching? a. "Beta blockers block the actions of angiotensin II." b. "Beta blockers decrease heart rate and contractility." c. "Beta blockers decrease peripheral vascular resistance." d. "Beta blockers decrease the release of renin."

ANS: A Beta blockers reduce the release of renin by blockade of beta1 receptors on juxtaglomerular cells in the kidney, which reduce angiotensin II-mediated vasoconstriction, but do not block the actions of angiotensin II directly. Beta blockers decrease heart rate and cardiac contractility, decrease peripheral vascular resistance, and decrease the release of renin.

A patient with lung cancer receives filgrastim [Neupogen] after chemotherapy to reduce neutropenia. The patient reports a moderate degree of bone pain. What will the nurse do? a. Obtain an order to administer acetaminophen. b. Request an order for a complete blood count (CBC). c. Request an order to reduce the dose of filgrastim. d. Suspect metastasis of the cancer to the bone.

ANS: A Bone pain occurs in about 25% of patients receiving filgrastim. It can be treated with a nonopioid analgesic and, if necessary, an opioid analgesic. Leukocytosis can occur, but bone pain is not a symptom of this, so a CBC is not indicated. Bone pain is not an indication for reducing the dose of filgrastim. Because moderate bone pain is a common adverse effect, metastasis to the bone is less likely.

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.

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.

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.

A patient is receiving oral iron for iron deficiency anemia. Which antibiotic drug, taken concurrently with iron, would most concern the nurse? a. Tetracycline b. Cephalosporin c. Metronidazole [Flagyl] d. Penicillin

ANS: A Coadministration of tetracycline and iron reduces absorption of both iron and tetracycline. Cephalosporin, metronidazole, and penicillin have no significant drug-to-drug interaction with iron.

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.

ANS: 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 nurse is teaching a patient who will begin taking verapamil [Calan] for hypertension about the drug's side effects. Which statement by the patient indicates understanding of the teaching? a. "I may become constipated, so I should increase fluids and fiber." b. "I may experience a rapid heart rate as a result of taking this drug." c. "I may have swelling of my hands and feet, but this will subside." d. "I may need to increase my digoxin dose while taking this drug."

ANS: A Constipation is common with verapamil and can be minimized by increasing dietary fiber and fluids. Verapamil lowers the heart rate. Peripheral edema may occur secondary to vasodilation, and patients should notify their prescriber if this occurs, because the prescriber may use diuretics to treat the condition. Verapamil and digoxin have similar cardiac effects; also, verapamil may increase plasma levels of digoxin by as much as 60%, so digoxin doses may need to be reduced.

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.

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

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

A patient is about to undergo a procedure to harvest hematopoietic stem cells from the bone marrow. Which medication will the nurse anticipate giving before this procedure? a. Filgrastim [Neupogen] b. Pegfilgrastim [Neulasta] c. Oprelvekin [Neumega] d. Sargramostim [Leukine]

ANS: A Filgrastim is given before harvesting of hematopoietic stem cells (HSCs), because it increases the number of circulating HSCs. Pegfilgrastim is used only to reduce the incidence of infection in patients undergoing chemotherapy of nonmyeloid malignancies. Oprelvekin is used to minimize thrombocytopenia and to reduce the need for platelet transfusion. Sargramostim is used to accelerate myeloid recovery in patients who have undergone autologous bone marrow transplantation.

A patient is brought to the emergency department with shortness of breath, a respiratory rate of 30 breaths per minute, intercostal retractions, and frothy, pink sputum. The nurse caring for this patient will expect to administer which drug? a. Furosemide [Lasix] b. Hydrochlorothiazide [HydroDIURIL] c. Mannitol [Osmitrol] d. Spironolactone [Aldactone]

ANS: A Furosemide, a potent diuretic, is used when rapid or massive mobilization of fluids is needed. This patient shows severe signs of congestive heart failure with respiratory distress and pulmonary edema and needs immediate mobilization of fluid. Hydrochlorothiazide and spironolactone are not indicated for pulmonary edema, because their diuretic effects are less rapid. Mannitol is indicated for patients with increased intracranial pressure and must be discontinued immediately if signs of pulmonary congestion or heart failure occur.

An older adult patient with congestive heart failure develops crackles in both lungs and pitting edema of all extremities. The physician orders hydrochlorothiazide [HydroDIURIL]. Before administering this medication, the nurse reviews the patient's chart. Which laboratory value causes the nurse the most concern? a. Elevated creatinine clearance b. Elevated serum potassium level c. Normal blood glucose level d. Low levels of low-density lipoprotein (LDL) cholesterol

ANS: A Hydrochlorothiazide should not be given to patients with severe renal impairment; therefore, an elevated creatinine clearance would cause the most concern. Thiazide diuretics are potassiumwasting drugs and thus may actually improve the patient's potassium level. Thiazides may elevate the serum glucose level in diabetic patients. Thiazides increase LDL cholesterol; however, this patient's levels are low, so this is not a risk.

A patient has three separate blood pressure (BP) readings of 120/100, 138/92, and 126/96 mm Hg. Which category describes this patient's BP? a. Hypertension b. Isolated systolic hypertension c. Normal d. Prehypertension

ANS: A Hypertension is defined as systolic BP over 140 mm Hg or diastolic BP over 90 mm Hg. When systolic and diastolic BP fall into different categories, classification is based on the higher category. This patient has a hypertensive diastolic BP. Isolated systolic hypertension occurs if the systolic BP is greater than 140 mm Hg with a diastolic BP less than 90 mm Hg. Because this patient has an elevated diastolic BP, it is not considered normal. Prehypertension occurs with a systolic BP of 120 to 139 mm Hg or a diastolic BP of 80 to 89 mm Hg.

A patient who has recently immigrated to the United States from an impoverished country appears malnourished. The patient's folic acid levels are low, and the vitamin B12 levels are normal. The nurse expects this patient's treatment to include: a. a diet high in folic acid. b. intramuscular folic acid. c. oral folic acid and vitamin B12. d. oral folic acid supplements.

ANS: A If a folic acid deficiency is caused by poor diet, it should be corrected with dietary measures, not supplements. IM or oral supplements of folic acid are not indicated. Vitamin B12 is not recommended

A patient with a recent onset of nephrosclerosis has been taking an ACE inhibitor and a thiazide diuretic. The patient's initial blood pressure was 148/100 mm Hg. After 1 month of drug therapy, the patient's blood pressure is 130/90 mm Hg. The nurse will contact the provider to discuss: a. adding a calcium channel blocker to this patient's drug regimen. b. lowering doses of the antihypertensive medications. c. ordering a high-potassium diet. d. adding spironolactone to the drug regimen.

ANS: A In patients with renal disease, the goal of antihypertensive therapy is to lower the blood pressure to 130/80 mm Hg or less. Adding a third medication is often indicated. Lowering the dose of the medications is not indicated because the patient's blood pressure is not in the target range. Adding potassium to the diet and using a potassium-sparing diuretic are contraindicated.

A hospitalized patient has a blood pressure of 145/96 mm Hg. The nurse caring for this patient notes that the blood pressure the day before was 132/98 mm Hg. The patient reports ambulatory blood pressure readings of 136/98 and 138/92 mm Hg. The patient has a history of a previous myocardial infarction and has adopted a lifestyle that includes use of the DASH diet and regular exercise. What will the nurse do? a. Notify the provider and discuss ordering a beta blocker for this patient. b. Notify the provider and suggest a thiazide diuretic as initial therapy. c. Order a diet low in sodium and high in potassium for this patient. d. Recheck the patient's blood pressure in 4 hours to verify the result.

ANS: A Initial drug selection is determined by the presence or absence of a compelling indication or comorbid condition. This patient has a history of MI; beta blockers are indicated for patients with pre-existing heart disease. Thiazide diuretics are first-line drugs of choice in patients without compelling indications. The patient is already consuming a DASH diet; closer monitoring of sodium or potassium will not help lower blood pressure. The patient has a record of hypertension, so it is unnecessary to recheck the blood pressure to verify the condition.

A child who ingested a handful of aspirin tablets from a medicine cabinet at home is brought to the emergency department. The nurse caring for the child notes a respiratory rate of 48 breaths per minute. The nurse understands that this child's respiratory rate is the result of the body's attempt to compensate for: a. metabolic acidosis. b. metabolic alkalosis. c. respiratory acidosis. d. respiratory alkalosis.

ANS: A Metabolic acidosis can result from the ingestion of aspirin. The body responds by hyperventilating to reduce CO2, which represents volatile carbonic acid, and raise pH. This child has a rapid respiratory rate in response to metabolic acidosis. In patients with metabolic alkalosis, the body responds with hypoventilation in an effort to increase the CO2 level. Patients with respiratory acidosis usually have retention of CO2 secondary to hypoventilation, and compensation is the result of retention of bicarbonate by the kidneys, which is a slow process. Respiratory alkalosis is caused by hyperventilation; treatment involves having the patient rebreathe CO2 or administering sedatives

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."

ANS: 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 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: A 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 is taking a vasodilator that relaxes smooth muscles in veins. To help minimize drug side effects, the nurse caring for this patient will: a. caution the patient not to get up abruptly. b. encourage the patient to increase fluid intake. c. tell the patient to report shortness of breath. d. warn the patient about the possibility of bradycardia.

ANS: A Postural hypotension occurs when moving from a supine or seated position to an upright position. It is caused by relaxation of smooth muscle in veins, which allows blood to pool in veins and decreases venous return of blood to the heart. Patients taking such drugs should avoid abrupt transitions to prevent falls. Prolonged use of vasodilators can lead to expansion of blood volume and fluid overload, so increasing fluid intake is not appropriate. Shortness of breath is a symptom associated with heart failure. Tachycardia can occur when the blood pressure drops as a result of the baroreceptor reflex.

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 betaadrenergic 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 renal failure is undergoing chronic hemodialysis. The patient's hemoglobin is 10.6 gm/dL. The provider orders sodium-ferric gluconate complex (SFGC [Ferrlecit]). What will the nurse expect to do? a. Administer the drug intravenously with erythropoietin. b. Give a test dose before each administration of the drug. c. Have epinephrine on hand to treat anaphylaxis if needed. d. Infuse the drug rapidly to achieve maximum effects quickly. .

ANS: A SFGC is given parenterally for iron deficiency anemia in patients undergoing chronic hemodialysis. It is always used in conjunction with erythropoietin to stimulate production of red blood cells (RBCs). A test dose is given only with the initial dose and is not necessary with subsequent doses. Anaphylaxis is not a common side effect. The drug should be infused slowly

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 causes 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.

A postmenopausal woman will begin taking atorvastatin [Lipitor] to treat hypercholesterolemia. The woman reports a history of osteopenia with a family risk of osteoporosis. What will the nurse include when teaching this patient? a. The need to discuss taking a bisphosphonate medication with her provider b. That statins are known to reduce the risk of osteoporosis c. That she should avoid foods high in calcium d. To discuss vitamin D supplements with her provider since statins deplete calcium

ANS: A Studies demonstrating a protective effect of statins in reducing the risk of osteoporosis have been inconclusive. Women at risk should discuss taking a bisphosphonate medication with their providers. Statins are not known to reduce the risk of osteoporosis. She should consume foods containing calcium. Vitamin D supplements are not indicated

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 who was injured at home is brought to the emergency department. The nurse caring for this patient notes a respiratory rate of 32 breaths per minute, and a heart rate of 90 beats/min. The injuries are minor, but the patient is inconsolable and hysterical. The nurse expects that initial management will include: a. administering a gas mixture of 5% carbon dioxide (CO2). b. providing 100% oxygen via nasal cannula. c. giving sodium bicarbonate IV. d. providing sedatives to calm the patient.

ANS: A The patient is at risk for respiratory alkalosis as a result of hyperventilation, and giving the patient a gas mixture containing CO2 will help correct the alkalosis. Administering oxygen would worsen the problem. Sodium bicarbonate is given to correct metabolic acidosis. Sedatives may be necessary if initial measures fail

The patient with which of the following is most at risk for folic acid deficiency? a. Alcoholism b. Sprue c. Gastrectomy d. Peptic ulcer disease

ANS: A The patient most at risk for folic acid deficiency secondary to a poor diet is a patient with a history of alcoholism. Malabsorption secondary to intestinal disease is another indication for folic acid therapy, but these patients are not most at risk

A patient with a hemoglobin of 7.2 gm/dL begins therapy with an ESA. Two weeks later the patient's hemoglobin is 8.3 gm/dL. The nurse anticipates that the provider will: a. reduce the ESA dose. b. discontinue the ESA. c. order a blood transfusion. d. order heparin.

ANS: A The patient's hemoglobin has risen just over 1 gm/dL in 2 weeks, so the dose of ESA should be reduced. The ESA should be discontinued when the hemoglobin is greater than 13 gm/dL. A blood transfusion is not indicated. Heparin is used when patients are undergoing dialysis.

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 with vitamin B12 deficiency is admitted with symptoms of hypoxia, anemia, numbness of hands and feet, and oral stomatitis. The nurse expects the prescriber to order which of the following therapies? a. IM cyanocobalamin and folic acid b. IM cyanocobalamin and antibiotics c. PO cyanocobalamin and folic acid d. PO cyanocobalamin and blood transfusions

ANS: A This patient is showing signs of more severe vitamin B12 deficiency with neurologic symptoms; therefore, cyanocobalamin should be given parenterally along with folic acid. Antibiotics are indicated only when signs of infection are present. Oral cyanocobalamin is not recommended.

A female patient with essential hypertension is being treated with hydralazine 25 mg twice daily. The nurse assesses the patient and notes a heart rate of 96 beats/min and a blood pressure of 110/72 mm Hg. The nurse will request an order to: a. administer a beta blocker. b. administer a drug that dilates veins. c. reduce the dose of hydralazine. d. give the patient a diuretic.

ANS: A This patient is showing signs of reflex tachycardia, so a beta blocker is indicated to slow the heart rate. Patients with heart failure who take hydralazine often require the addition of isosorbide dinitrate, which also dilates veins. There is no indication for reducing the dose of hydralazine. A diuretic can be given with hydralazine if sodium and water retention is present.

While performing an admission assessment on a patient, the nurse learns that the patient is taking furosemide [Lasix], digoxin, and spironolactone [Aldactone]. A diet history reveals the use of salt substitutes. The patient is confused and dyspneic and complains of hand and foot tingling. Which is an appropriate nursing action for this patient? a. Contact the provider to request orders for an electrocardiogram and serum electrolyte levels. b. Evaluate the patient's urine output and request an order for intravenous potassium. c. Hold the next dose of furosemide and request an order for intravenous magnesium sulfate. d. Request an order for intravenous insulin to help this patient regulate extracellular potassium.

ANS: A This patient is taking a potassium-sparing diuretic and is ingesting dietary potassium in salt substitutes. The patient shows signs of hyperkalemia: confusion, shortness of breath, and tingling of the hands and feet. The cardiac effects can be fatal, especially if a patient also is taking digoxin. The most appropriate first action would be to obtain an ECG and serum electrolyte levels to evaluate the extent of the patient's hyperkalemia. The patient does not need increased potassium. Furosemide is a potassium-wasting diuretic and would be helpful. Magnesium sulfate is not indicated. Until the patient's status has been assessed further, intravenous insulin is not indicated.

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.

The nurse is caring for a patient who is taking a vasodilator that dilates capacitance vessels. The nurse will expect which effect in this patient? a. Decrease in cardiac work b. Increase in cardiac output c. Increase in tissue perfusion d. Increase in venous return

ANS: A Vasodilators that dilate capacitance vessels, or veins, lead to a decrease in venous return to the heart, which reduces preload and the force of ventricular contraction. The resultant effect is a decrease in cardiac work. With a decrease in ventricular contraction, cardiac output is reduced, as is tissue perfusion. Dilation of veins causes a decrease in venous return.

A nurse is caring for a patient who is receiving verapamil [Calan] for hypertension and digoxin [Lanoxin] for heart failure. The nurse will observe this patient for: a. AV blockade. b. gingival hyperplasia. c. migraine headaches. d. reflex tachycardia.

ANS: A Verapamil and digoxin both suppress impulse conduction through the AV node; when the two drugs are used concurrently, the risk of AV blockade is increased. Gingival hyperplasia can occur in rare cases with verapamil, but it is not an acute symptom. Verapamil can be used to prevent migraine, and its use for this purpose is under investigation. Verapamil and digoxin both suppress the heart rate. Nifedipine causes reflex tachycardia.

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 laboratory 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/min. 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/min. 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/min is a desired effect. There is no indication of a need to change medications for this patient.

A patient with hypertension is admitted to the hospital. On admission the patient's heart rate is 72 beats/min, and the blood pressure is 140/95 mm Hg. After administering an antihypertensive medication, the nurse notes a heart rate of 85 beats/ min and a blood pressure of 130/80 mm Hg. What does the nurse expect to occur? a. A decrease in the heart rate back to baseline in 1 to 2 days b. An increase in the blood pressure within a few days c. An increase in potassium retention in 1 to 2 days d. A decrease in fluid retention within a week

ANS: A When blood pressure drops, the baroreceptors in the aortic arch and carotid sinus sense this and relay information to the vasoconstrictor center of the medulla; this causes constriction of arterioles and veins and increased sympathetic impulses to the heart, resulting in an increased heart rate. After 1 to 2 days, this system resets to the new pressure, and the heart rate returns to normal. The blood pressure will not increase when this system resets. Increased potassium retention will not occur. Over time, the body will retain more fluid to increase the blood pressure.

Which two-drug regimen would be appropriate for a patient with hypertension who does not have other compelling conditions? a. Hydrochlorothiazide and nadolol b. Hydralazine and minoxidil c. Spironolactone and amiloride d. Trichlormethiazide and hydrochlorothiazide

ANS: A When two or more drugs are used to treat hypertension, each drug should come from a different class. Hydrochlorothiazide is a diuretic and nadolol is a beta blocker, so this choice is appropriate. Hydralazine and minoxidil are vasodilators. Spironolactone and amiloride are potassium-sparing diuretics. Trichlormethiazide and hydrochlorothiazide are both thiazide diuretics.

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.

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

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

A nurse is obtaining a medication history on a newly admitted patient, who reports taking minoxidil for hypertension. Admission vital signs reveal a heart rate of 78 beats/min and a blood pressure of 120/80 mm Hg. What is an important part of the initial assessment for this patient? a. Evaluating ankle edema b. Monitoring for nausea and vomiting c. Noting the presence of hypertrichosis d. Obtaining a blood glucose

ANS: A Fluid retention is a common and serious adverse effect of minoxidil, because it can lead to cardiac decompensation. If present, a diuretic is indicated. Nausea and vomiting may occur with this drug but is not a serious side effect. Hypertrichosis occurs in about 80% of patients taking the drug, but its effects are cosmetic and not life threatening. It may be important to monitor the blood glucose level in some patients, because the drug can alter glucose tolerance, but this effect is not as serious as fluid retention.

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 T ransdermal 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

Which are therapeutic uses of verapamil? (Select all that apply.) a. Angina of effort b. Cardiac dysrhythmias c. Essential hypertension d. Sick sinus syndrome e. Suppression of preterm labor

ANS: A, B, C Verapamil is used to treat both vasospastic angina and angina of effort. It slows the ventricular rate in patients with atrial flutter, atrial fibrillation, and paroxysmal supraventricular tachycardia. It is a first-line drug for the treatment of essential hypertension. It is contraindicated in patients with sick sinus syndrome. Nifedipine has investigational uses in suppressing preterm labor.

What are the indications for administration of a parenteral iron preparation? (Select all that apply.) a. Blood loss of 750 mL/week b. Celiac disease with anemia c. History of alcoholism d. Intestinal disease impairing absorption e. Megaloblastic anemia

ANS: A, B, D Patients who have lost 750 mL/week of iron cannot absorb enough oral iron, so parenteral iron is indicated for these patients. Patients with celiac disease or other diseases that impair iron absorption must receive parenteral iron. Patients with a history of alcoholism are generally deficient in folic acid. Megaloblastic anemia is a symptom of vitamin B12 and/or folic acid deficiency.

Which patients are eligible to receive erythropoiesis stimulating agents? (Select all that apply.) a. All patients with nonmyeloid malignancies who require transfusions b. All patients with nonmyeloid malignancies whose chemotherapy is palliative c. All patients whose goal of therapy is curative d. All patients with nonmyeloid malignancies and chemotherapy-induced anemia e. All patients with leukemias or myeloid malignancies

ANS: A, B, D Patients who have nonmyeloid malignancies who require transfusions, whose therapy is considered palliative, and who have chemotherapy-induced anemia are eligible for ESAs. Because ESAs are potentially lethal drugs, giving them to patients who expect a cure is not recommended. ESAs also are not given to patients with leukemias or myeloid malignancies, because the drugs can stimulate proliferation of these cancers.

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.

Besides having diuretic effects for patients with congestive heart failure, thiazides are also used to treat what? (Select all that apply.) a. Diabetes insipidus b. Hepatic failure c. Increased intracranial pressure d. Intraocular pressure e. Postmenopausal osteoporosis

ANS: A, B, E Thiazide diuretics have the paradoxical effect of reducing urine output in patients with diabetes insipidus. They can also be used to mobilize edema associated with liver disease. They promote tubular reabsorption of calcium, which may reduce the risk of osteoporosis in postmenopausal women. Mannitol is used to treat edema that causes increased intracranial pressure and intraocular pressure

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.

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 hospital after several days of vomiting and diarrhea. After an initial bolus of isotonic (0.9%) sodium chloride solution, the prescriber orders dextrose 5% in 1/2 normal saline (D5NS) with 20 mEq potassium chloride to infuse at a maintenance rate. What should the nurse review before implementing this order? (Select all that apply.) a. Electrocardiogram b. Arterial blood gas levels c. Serum electrolyte levels d. Serum glucose level e. Urine output

ANS: A, C, E Patients receiving potassium should be monitored for cardiovascular toxicity; an ECG before and during administration can help monitor for this adverse effect. Serum electrolyte levels should be reviewed to make sure the patient is not already hyperkalemic. Because potassium is excreted via the kidneys, it is important to determine that renal function is intact. Intravenous potassium should never be given if the patient has not voided. Patients who are hyperkalemic can be treated with sodium bicarbonate to increase pH and insulin to promote uptake of potassium by cells, but it is not necessary to evaluate the blood gas or glucose levels before administering potassium.

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

ANS: 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 provider has ordered captopril [Capoten] for a patient who has hypertension. The patient reports a history of swelling of the tongue and lips after taking enalapril [Vasotec] in the past. Which action by the nurse is correct? a. Administer the captopril and monitor for adverse effects. b. Hold the dose and notify the provider. c. Request an order to administer fosinopril instead of captopril. d. Reassure the patient that this is not a serious side effect.

ANS: B Angioedema is a potentially life-threatening reaction to ACE inhibitors. If a patient has exhibited this reaction with any ACE inhibitor, he or she should not receive ACE inhibitors again. The nurse should hold the medication and notify the provider. Fosinopril is an ACE inhibitor and should not be given.

A nurse is caring for a postoperative patient who has a nasogastric tube with continuous suction. The nurse notes that the patient has shallow respirations and suspects that this patient has developed: a. metabolic acidosis. b. metabolic alkalosis. c. respiratory acidosis. d. respiratory alkalosis.

ANS: B Metabolic alkalosis occurs with excessive loss of acid, such as gastric acid, or an excessive increase in alkalinizing salts. The body compensates for metabolic alkalosis by hypoventilating in an attempt to retain CO2. Metabolic acidosis is usually caused by ingestion of acids or excessive loss of bicarbonate and is compensated by hyperventilation. Respiratory acidosis results from hypoventilation. Respiratory alkalosis is the result of hyperventilation.

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/min 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.

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 WolffParkinson-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/min, 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 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 morbidity from influenza." 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."

ANS: 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. A recent study demonstrated protection against influenza morbidity in patients because of a decrease in proinflammatory cytokine release. 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 collapses after running a marathon on a hot day and is brought to the emergency department to be treated for dehydration. The nurse will expect to provide which therapy? a. Intravenous hypertonic fluids given slowly over several hours b. Intravenous hypotonic fluids administered in stages c. Intravenous isotonic fluids given as a rapid bolus d. Oral electrolyte replacement fluids with potassium

ANS: B Because this patient is experiencing fluid volume loss as the result of excessive sweating, this is most likely hypertonic dehydration, in which loss of water exceeds loss of electrolytes. This should be treated with a hypotonic solution or with fluids that contain no solutes at all. Initial treatment may consist of having the patient drink water. When intravenous therapy is provided, volume replenishment should occur in stages. Hypertonic fluids are used to treat hypotonic contraction, usually caused by excessive sodium loss through the kidneys as the result of diuretic therapy. Isotonic fluids are used to treat isotonic contraction, which is generally caused by vomiting and diarrhea. An oral electrolyte solution would only increase the hypertonicity; if oral rehydration is used in this case, the patient should drink plain water.

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.

A nurse provides teaching for a patient who will begin taking procainamide [Procanbid] for longterm 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.

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 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

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.

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.

A nurse is teaching a patient who has chronic renal failure and will begin receiving epoetin alfa [Epogen] about this drug therapy. Which statement by the patient indicates understanding of the teaching? a. "If I have to start dialysis, I will have to stop taking this drug." b. "Taking this drug will not eliminate my need for blood transfusions." c. "Taking this medication will prevent the need for dialysis in the future." d. "When I take this, my serum ferritin levels will increase."

ANS: B Epoetin alfa virtually reduces, but does not eliminate, the need for blood transfusions in patients with CRF. Dialysis is not a contraindication for taking this drug. Epoetin alfa does not prevent the need for dialysis. Epoetin alfa does not raise the serum ferritin level.

The nurse is taking a medication history on a newly admitted patient. The patient reports taking folic acid and vitamin B12. The nurse notifies the provider because of the concern that folic acid can: a. cause fetal malformation. b. mask the signs of vitamin B12 deficiency. c. negatively affect potassium levels. d. worsen megaloblastic anemia.

ANS: B Folic acid can reverse the hematologic effects of vitamin B12 deficiency, but it does not reverse the neurologic effects, so it is important to determine the degree of B12 deficiency to treat it. Folic acid does not cause fetal malformation; in fact, it can help prevent neural tube defects. Folic acid does not worsen megaloblastic anemia. Folic acid does not affect potassium levels.

A nurse is caring for a patient who will begin taking hydralazine to treat hypertension. Which statement by the patient indicates understanding of the nurse's teaching about this drug? a. "I will need to ask for assistance when getting up out of a chair." b. "I will also take a beta blocker medication with this drug to prevent rapid heart rate." c. "I may develop joint pain, but this side effect will decrease over time." d. "This drug may cause excessive hair growth on my face, arms, and back."

ANS: B Hydralazine can cause severe reflex tachycardia; a beta blocker is usually given to counter this effect. Postural hypotension is minimal with hydralazine. Patients should be taught to report joint pain, which indicates an SLE syndrome and requires discontinuation of the drug. Minoxidil can cause excessive hair growth, not hydralazine.

A patient with CRF who will begin receiving an erythropoiesis stimulating agent (ESA) is admitted to the hospital. The nurse notes that the patient's heart rate is 82 beats/min, and the blood pressure is 140/100 mm Hg. A complete blood count reveals a hemoglobin of 8 gm/dL and a hematocrit of 29%. What will the nurse do? a. Administer the ESA and request an order for a blood transfusion. b. Withhold the ESA and request an order for an antihypertensive medication. c. Request an order to increase the dose of ESA to raise the hemoglobin more quickly. d. Suggest initiating dialysis while giving the ESA.

ANS: B In patients with CRF, treatment with epoetin alfa is often associated with an increase in blood pressure, so patients with hypertension should be treated before beginning treatment with epoetin alfa. There is no indication for a blood transfusion, an increased dose of ESA, or dialysis.

A patient arrives in the emergency department after becoming dehydrated. Based on the patient's history, the provider determines that isotonic dehydration has occurred. Which solution will the nurse expect to infuse to treat this patient? a. 0.45% sodium chloride in sterile water b. 0.9% sodium chloride in sterile water c. 3% sodium chloride in sterile water d. 5% dextrose solution

ANS: B Isotonic dehydration should be treated with an isotonic solution of 0.9% NaCl in sterile water. A 0.45% solution or 5% dextrose is used to treat hypertonic dehydration. A 3% NaCl solution is used to treat hypotonic dehydration.

A patient tells a nurse that she is thinking about getting pregnant and asks about nutritional supplements. What will the nurse recommend? a. A balanced diet high in green vegetables and grains b. 400 to 800 mg of folic acid per day c. A multivitamin with iron d. Vitamin B12 supplements

ANS: B The current recommendation is that all women of child-bearing age receive folic acid supplementation to prevent the development of neural tube defects that can occur early in pregnancy. Dietary folic acid is not sufficient to provide this amount. Iron supplements are given when pregnancy occurs and are not necessary before becoming pregnant. Vitamin B12 supplements are not recommended.

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 atorvastatin [Lipitor] to treat elevated LDL levels. The patient asks the nurse what to do to minimize the risk of myositis associated with taking this drug. What will the nurse counsel this patient? a. "Consume an increased amount of citrus fruits while taking this drug." b. "Take vitamin D and coenzyme Q supplements." c. "Ask your provider about adding a fibrate medication to your regimen." d. "Have your creatine kinase levels checked every 4 weeks."

ANS: B Patients taking a statin medication may take vitamin D and coenzyme Q supplements to reduce their risk of developing myositis. Citrus fruits can elevate statin levels and increase the risk of myositis. Fibrates also cause myositis in some patients, and adding a fibrate will increase the risk. Creatine kinase levels should be determined at baseline and as needed if symptoms occur but do not need to be monitored every 4 weeks.

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 1 year and the aspirin will be given indefinitely. c. The aspirin will be discontinued in 1 year and the clopidogrel will be given indefinitely. d. Both drugs will be discontinued in 1 year.

ANS: B Patients who have undergone PCI with a stent will take ASA indefinitely along with an antiplatelet drug for 1 year. The clopidogrel will be discontinued in 1 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 patient with congestive heart failure is admitted to the hospital. During the admission assessment, the nurse learns that the patient is taking a thiazide diuretic. The nurse notes that the admission electrolyte levels include a sodium level of 142 mEq/L, a chloride level of 95 mEq/L, and a potassium level of 3 mEq/L. The prescriber has ordered digoxin to be given immediately. What will the nurse do initially? a. Give the digoxin and maintain close cardiac monitoring. b. Hold the digoxin and report the laboratory values to the provider. c. Hold the thiazide diuretic and give the digoxin. d. Request an order for an electrocardiogram (ECG).

ANS: B Potassium depletion is common with thiazide diuretics, and hypokalemia is especially dangerous for patients receiving digoxin, because the drug can precipitate a fatal dysrhythmia and digoxin toxicity. The provider should be notified of the serum potassium level so that it can be corrected before the digoxin is administered. Giving the digoxin could produce a fatal adverse effect, so this is not an appropriate course of action. Holding the thiazide diuretic will not correct the potassium deficiency. An ECG is not the initial priority.

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. "It will take 6 months 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."

ANS: B Reductions in LDL cholesterol are significant within 2 weeks and maximal within 4 to 6 weeks. It does not take 6 months to 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 nurse is reviewing the phenomenon of reflex tachycardia with a group of nursing students. Which statement by a student indicates understanding of this phenomenon? a. "Baroreceptors in the aortic arch stimulate the heart to beat faster." b. "Reflex tachycardia can negate the desired effects of vasodilators." c. "Reflex tachycardia is more likely to occur when beta blockers are given." d. "Venous dilation must occur for reflex tachycardia to occur."

ANS: B Reflex tachycardia, which is a compensatory mechanism in response to decreased blood pressure, can negate the desired effect of a vasodilator by eventually increasing blood pressure. Baroreceptors relay information to the vasomotor center of the medulla; the medulla sends impulses to the heart. Beta blockers are given to counter reflex tachycardia. Reflex tachycardia can be produced by dilation of both arterioles and veins

A female patient who begins taking spironolactone [Aldactone] as an adjunct to furosemide [Lasix] complains that her voice is deepening. What will the nurse do? a. Contact the provider to obtain an order for a complete blood count (CBC) and liver function tests. b. Explain that this drug binds with receptors for steroid hormones, causing this effect. c. Report this side effect to the provider and request another medication for this patient. d. Teach the patient to report any associated cough, which may indicate a more severe side effect.

ANS: B Spironolactone binds with receptors for aldosterone and with other steroid hormones, causing side effects such as gynecomastia, menstrual irregularities, impotence, hirsutism, and deepening of the voice. There is no indication for a CBC or for liver function tests in this patient with this side effect. Deepening of the voice is not an indication for withdrawal of the drug. This side effect is not associated with cough.

The nurse is caring for a pregnant patient who is in labor. The woman reports having had mild preeclampsia with a previous pregnancy. The nurse notes that the woman has a blood pressure of 168/102 mm Hg. The nurse will contact the provider to request an order for which drug? a. Angiotensin-converting enzyme (ACE) inhibitor b. Hydralazine (Apresoline) c. Magnesium sulfate d. Sodium nitroprusside

ANS: B The drug of choice for lowering blood pressure in a patient with severe preeclampsia is hydralazine. Sodium nitroprusside is not indicated. Magnesium sulfate is given as prophylaxis against seizures but does not treat hypertension. ACE inhibitors are contraindicated because of their potential for fetal harm.

A 12-year-old female patient is admitted to the hospital before sinus surgery. The nurse preparing to care for this patient notes that the admission hemoglobin is 10.2 gm/dL, and the hematocrit is 32%. The nurse will ask the child's parents which question about their daughter? a. "Does she eat green, leafy vegetables?" b. "Has she begun menstruating?" c. "Is she a vegetarian?" d. "Is there a chance she might be pregnant?"

ANS: B The most common cause of iron deficiency anemia in adolescent females is heavy periods, so asking about menses is an appropriate first question when evaluating the cause of low iron in young females. Iron deficiency only rarely occurs because of poor dietary intake. Although pregnancy is not unheard of in 12-year-old girls, a question about possible pregnancy should not be the first question asked.

A nurse is preparing to administer digoxin [Lanoxin] to a patient. The patient's heart rate is 62 beats/min, 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/min.

A patient who does not consume alcohol or nicotine products reports a strong family history of hypertension and cardiovascular disease. The patient has a blood pressure of 126/82 and a normal weight and body mass index for height and age. The nurse will expect to teach this patient about: a. ACE inhibitors and calcium channel blocker medications. b. the DASH diet, sodium restriction, and exercise. c. increased calcium and potassium supplements. d. thiazide diuretics and lifestyle changes.

ANS: B This patient has prehypertension without other risk factors. Lifestyle changes are indicated at this point. If blood pressure rises to hypertension levels, other measures, including drug therapy, will be initiated. Calcium and potassium supplements are not indicated

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/min 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/min 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.

A nurse is caring for a patient after hip replacement surgery. The patient has been receiving iron replacement therapy for 2 days. The nurse notes that the patient's stools appear black. The patient is pale and complains of fatigue. The patient's heart rate is 98 beats/min, respirations are 20 breaths per minute, and the blood pressure is 100/50 mm Hg. The nurse will contact the provider to: a. report possible gastrointestinal hemorrhage. b. request a hemoglobin and hematocrit (H&H). c. request an order for a stool guaiac. d. suggest giving a hypertonic fluid bolus.

ANS: B This patient is showing signs of iron deficiency anemia, as manifested by tachycardia and pallor. Because this patient's blood pressure is low, the anemia probably has occurred secondary to blood loss, a common occurrence with hip replacement surgery. The first response should be to obtain an H&H to assess the anemia. GI hemorrhage is not a concern in this patient; black stools are an expected effect of oral iron administration. A stool guaiac is not indicated. If the patient has blood loss that is causing hypotension, an isotonic fluid bolus and packed red blood cells (PRBCs) are indicated to treat this.

A nurse is caring for a patient in the intensive care unit who is receiving intravenous lidocaine. The patient is drowsy, 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 with a history of hypertension is admitted for a procedure. If the patient's arterial pressure decreases, which clinical manifestation would the nurse expect to see? a. Decreased heart rate b. Increased heart rate c. Decreased blood pressure d. Syncope

ANS: B When arterial pressure decreases, the vasoconstrictor center causes constriction of nearly all arterioles, leading to an increase in peripheral resistance, constriction of veins, increasing venous return, and subsequent acceleration of the heart rate. A decrease in arterial pressure would not cause a decrease in the heart rate or blood pressure, nor would it cause syncope.

A patient with chronic congestive heart failure has repeated hospitalizations in spite of ongoing treatment with hydrochlorothiazide [HydroDIURIL] and digoxin. The prescriber has ordered spironolactone [Aldactone] to be added to this patient's drug regimen, and the nurse provides education about this medication. Which statement by the patient indicates understanding of the teaching? a. "I can expect improvement within a few hours after taking this drug." b. "I need to stop taking potassium supplements." c. "I should use salt substitutes to prevent toxic side effects." d. "I should watch closely for dehydration."

ANS: B Spironolactone is a potassium-sparing diuretic used to counter the potassium-wasting effects of hydrochlorothiazide. Patients taking potassium supplements are at risk for hyperkalemia when taking this medication, so they should be advised to stop the supplements. Spironolactone takes up to 48 hours to have effects. Salt substitutes contain high levels of potassium and are contraindicated. Spironolactone is a weak diuretic, so the risk of dehydration is not increased.

Which order for potassium (KCl) would the nurse question? (Select all that apply.) a. D5 NS with 20 mEq KCl to start after patient voids b. D5 NS with 60 mEq KCl for a patient with a serum potassium of 3.2 mEq/L c. K-Dur, 1 tablet daily for a patient with diabetic ketoacidosis d. K-Dur, 1 tablet with a full glass of water e. Potassium chloride, 10 mEq rapid IV push

ANS: B, C, E Patients receiving potassium should not receive potassium in solution diluted at more than 40 mEq/L. Diabetic ketoacidosis causes decreased cellular uptake of potassium, and patients in whom acidosis is present should also receive sodium bicarbonate if they need potassium. IV potassium should not be infused faster than 10 mEq/hr. D5 NS with 20 mEq KCl is an appropriate solution for a patient with intact renal function. Oral potassium should be given with a full glass of water to minimize gastrointestinal (GI) effects.

A patient is taking clonidine for hypertension and reports having dry mouth and drowsiness. What will the nurse tell the patient? a. Beta blockers can reverse these side effects. b. Discontinue the medication immediately and notify the provider. c. Drink extra fluids and avoid driving when drowsy. d. Notify the provider if symptoms persist after several weeks.

ANS: C Clonidine can cause dry mouth and sedation; patients should be warned to drink extra fluids and avoid driving. Beta blockers do not reverse these drug side effects. Discontinuing clonidine abruptly can cause severe rebound hypertension. These are common side effects that do not abate over time.

A 60-year-old African American patient has a blood pressure of 120/80 mm Hg and reports a family history of hypertension. The patient has a body mass index of 22.3. The patient reports consuming alcohol occasionally. Which therapeutic lifestyle change will the nurse expect to teach this patient? a. Alcohol cessation b. Potassium supplementation c. Sodium restriction d. Weight loss

ANS: C Current recommendations for African Americans to prevent hypertension include sodium restriction of less than 1500 mg/day, although this is under investigation. The patient has a normal BMI and does not consume alcohol excessively, so weight loss and alcohol cessation are not necessary. Potassium supplements are not indicated; patients should be advised to consume foods high in potassium.

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

ANS: C Patients taking furosemide should be advised that the risk of furosemide-induced hearing loss can be increased when other ototoxic drugs, such as gentamicin, are also taken. Patients should be told to report tinnitus, dizziness, or hearing loss. Nocturia may be an expected effect of furosemide. Headaches are not likely to occur with concomitant use of gentamicin and furosemide. Urinary retention is not an expected side effect.

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

A patient has been taking chlorthalidone to treat hypertension. The patient's prescriber has just ordered the addition of spironolactone to the patient's drug regimen. Which statement by the patient indicates a need for further teaching? a. "I should continue following the DASH diet when adding this drug." b. "I should not take an ACE inhibitor when adding this drug." c. "I will need to take potassium supplements when adding this drug." d. "I will not experience a significant increase in diuresis when adding this drug."

ANS: C Spironolactone is given in addition to thiazide diuretics to balance potassium loss caused by the thiazide diuretic. Patients should be advised against taking potassium supplements with spironolactone, because hyperkalemia can result. The DASH diet may be continued. ACE inhibitors are contraindicated because they promote hyperkalemia. Spironolactone does not significantly increase diuresis.

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 not only 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 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 antiangina 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 patient begins taking an ACE inhibitor and complains of a dry cough. What does the nurse correctly tell the patient about this symptom? a. It indicates that a serious side effect has occurred. b. It is a common side effect that occurs in almost all patients taking the drug. c. It may be uncomfortable enough that the drug will need to be discontinued. d. It occurs frequently in patients taking the drug but will subside over time.

ANS: C A cough occurs in about 10% of patients taking ACE inhibitors and is the most common reason for discontinuing therapy. It does not indicate a serious condition. It occurs in about 10% of all patients and is more common in women, older adults, and those of Asian ancestry. It does not subside until the medication is discontinued.

A nurse is reviewing a patient's medications before administration. Which drug-to-drug interactions will most concern the nurse in a patient with a history of heart failure and a potassium level of 5.5 mEq/L? a. Furosemide [Lasix] and enalapril [Vasotec] b. Amlodipine [Norvasc] and spironolactone [Aldactone] c. Captopril [Capoten] and spironolactone [Aldactone] d. Metoprolol [Lopressor] and furosemide [Lasix]

ANS: C ACE inhibitors increase the risk of hyperkalemia, and combining this drug with a potassiumsparing diuretic creates a significant risk of hyperkalemia. Furosemide and enalapril, an ACE inhibitor, would not be contraindicated in this patient. Amlodipine and spironolactone would not cause hyperkalemia. The combination of metoprolol, a beta blocker, and furosemide would not be contraindicated in this patient.

A patient who stops taking an ACE inhibitor because of its side effects will begin taking an angiotensin II receptor blocker (ARB) medication. Which side effect of ACE inhibitors will not occur with an ARB medication? a. Angioedema b. Cough c. Hyperkalemia d. Renal failure

ANS: C ARBs do not produce clinically significant hyperkalemia. Angioedema may occur with ARBs, but the incidence is lower than with ACE inhibitors. They do not promote the accumulation of bradykinin in the lungs and produce a lower incidence of cough. An increased risk of cancer may be a concern with ARBs but is not a concern with ACE inhibitors. As with ACE inhibitors, renal failure can occur in patients with bilateral renal artery stenosis or stenosis in the artery to a single remaining kidney.

A patient who has been taking verapamil [Calan] for hypertension complains of constipation. The patient will begin taking amlodipine [Norvasc] to avoid this side effect. The nurse provides teaching about the difference between the two drugs. Which statement by the patient indicates that further teaching is needed? a. "I can expect dizziness and facial flushing with nifedipine." b. "I should notify the provider if I have swelling of my hands and feet." c. "I will need to take a beta blocker to prevent reflex tachycardia." d. "I will need to take this drug once a day."

ANS: C Amlodipine produces selective blockade of calcium channels in blood vessels with minimal effects on the heart. Reflex tachycardia is not common, so a beta blocker is not indicated to prevent this effect. Dizziness and facial flushing may occur. Peripheral edema may occur and should be reported to the provider. Amlodipine is given once daily.

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 is taking a beta1-adrenergic drug to improve the stroke volume of the heart. The nurse caring for this patient knows that this drug acts by increasing: a. cardiac afterload. b. cardiac preload. c. myocardial contractility. d. venous return.

ANS: C Beta1-adrenergic agents help increase the heart's stroke volume by increasing myocardial contractility. Cardiac afterload is determined primarily by the degree of peripheral resistance caused by constriction of arterioles; increasing afterload would decrease stroke volume. Beta1- adrenergic agents do not affect afterload. Cardiac preload is the amount of stretch applied to the cardiac muscle before contraction and is determined by the amount of venous return. Beta1- adrenergic agents do not affect cardiac preload. Venous return is determined by the systemic filling pressure and auxiliary muscle pumps and is not affected by beta1-adrenergic agents.

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

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 nurse checks a patient's vital signs in the hospital and notes a blood pressure of 146/98 mm Hg. What will the nurse do? a. Instruct the patient to consume a low-sodium diet. b. Prepare the patient for an electrocardiogram and blood tests. c. Recheck the patient's blood pressure in the other arm. d. Request an order for a thiazide diuretic.

ANS: C Diagnosis of hypertension should be based on several blood pressure readings, not just one. High readings should be confirmed in the contralateral arm. Low-sodium diets are indicated for patients with confirmed hypertension. An electrocardiogram and blood tests are indicated for patients with confirmed hypertension to rule out primary causes. Thiazide diuretics are first-line drugs for confirmed hypertension.

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."

ANS: 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.

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."

ANS: 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.

Which plasma lipoprotein level is most concerning when considering the risk of coronary atherosclerosis? a. Elevated cholesterol b. Elevated high-density lipoprotein c. Elevated low-density lipoprotein d. Elevated very-low-density lipoprotein

ANS: C Elevated LDL levels make the greatest contribution to coronary atherosclerosis with the probability of developing coronary heart disease (CHD) directly related to the LDL level in the blood. Total cholesterol levels do not have the same direct link. HDL levels cause increased risk when they are low. The relation between elevated very-low-density lipoprotein levels and CHD is not clear.

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 nursing student asks a nurse why patients with chronic renal failure (CRF) have low erythrocyte counts. Which response by the nurse is correct? a. "Damage to the renal tubules increases serum blood loss." b. "Dialysis accelerates the breakdown of red blood cells." c. "Erythropoietin is no longer produced by cells in the kidneys." d. "Patients with CRF are deficient in iron, folic acid, and vitamin B12."

ANS: C Erythropoietin is normally produced by peritubular cells in the proximal tubules of the kidneys, but it is not produced in patients with CRF. Erythropoietin stimulates red blood cell (RBC) production; therefore, when it is absent, RBC production is compromised. Blood loss in damaged renal tubules does not cause low blood counts in patients with CRF. Dialysis does not contribute to low blood counts. Patients with CRF are not more likely to be deficient in iron, folic acid, and vitamin B12.

A patient who is receiving a factor VIII concentrate to treat hemophilia A develops hives, a lowgrade 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

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

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

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.

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 functions.

A patient who is taking furosemide [Lasix] and digoxin will begin taking captopril [Capoten]. The nurse is providing information about the drug. Which statement by the patient indicates a need for further teaching? a. "I can use acetaminophen for analgesia if needed." b. "I should stop taking the Lasix about a week before starting the Capoten." c. "I should take this medication on a full stomach." d. "I will need to have blood tests done every 2 weeks for a few months."

ANS: C Most oral formulations of ACE inhibitors may be given without regard for meals; captopril and moexipril, however, should be given 1 hour before meals. Nonsteroidal anti-inflammatory medications should be avoided; acetaminophen is not contraindicated. Patients taking diuretics should stop taking them 1 week before starting an ACE inhibitor to minimize the risk of hypotension. A WBC with differential should be evaluated at baseline and, after treatment starts, every 2 weeks for several months to monitor for neutropenia.

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.

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

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

While giving discharge instructions to a patient who will be taking cholestyramine [Questran], the nurse wants to assess the patient's understanding of the treatment. 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."

ANS: 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 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 patient with chronic renal failure who is on dialysis receives an ESA. The nurse caring for this patient during dialysis notes that the patient's hemoglobin is 10.9 gm/dL, up from the 10.2 gm/dL recorded 2 weeks ago. The patient's blood pressure is 120/80 mm Hg. The nurse will contact the provider to suggest: a. adding an antihypertensive drug. b. discontinuing the ESA. c. giving heparin. d. increasing the dose of the ESA.

ANS: C Patients with CRF on dialysis can benefit from heparin to prevent clotting in the dialysis machine. The risk of clotting is greatest when the hemoglobin level exceeds 11 gm/dL. There is no indication for an antihypertensive drug, because the patient's blood pressure is normal. The patient's hemoglobin is less than 12 gm/dL and has risen less than 1 gm/dL in 2 weeks; therefore, neither reducing the ESA dose nor stopping the ESA is indicated.

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 patient is diagnosed with moderate vitamin B12 deficiency. The nurse reviews the laboratory work and notes that the plasma B12 is low; also, a Schilling test reveals B12 malabsorption. The provider orders oral cyanocobalamin 500 mcg/day. The nurse will contact the provider to: a. discuss IM dosing. b. request an order for folic acid. c. suggest an increased dose. d. suggest platelet transfusion therapy.

ANS: C Patients with vitamin B12 deficiency associated with B12 malabsorption need increased doses of oral cyanocobalamin of 1000 to 10,000 mcg/day. It is not necessary to give this drug intramuscularly. Folic acid is indicated when B12 deficiency is severe. Platelets are given when B12 deficiency is severe.

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 prescriber orders ramipril [Altace] for an obese patient with type 2 diabetes mellitus who has developed hypertension. The nurse provides teaching before dismissing the patient home. Which statement by the patient indicates understanding of the teaching? a. "I am less likely to develop diabetic nephropathy when taking this medication." b. "I should check my blood sugar more often, because hyperglycemia is a side effect of this drug." c. "Taking this medication helps reduce my risk of stroke and heart attack." d. "This medication will probably prevent the development of diabetic retinopathy."

ANS: C Ramipril [Altace] is approved for reducing the risk of stroke and myocardial infarction (MI) in patients at high risk for a major cardiovascular event because they have hypertension in conjunction with a history of stroke or MI or because they have diabetes. ACE inhibitors cannot be used for primary prevention of diabetic nephropathy, but they can delay the onset of overt nephropathy in patients who already have less advanced nephropathy. ACE inhibitors do not affect serum electrolytes or glucose. One ACE inhibitor, enalapril, can reduce the risk of diabetic retinopathy in some patients with type 1 diabetes mellitus

A nurse is preparing to assist a nursing student to administer intravenous verapamil to a patient who also receives a beta blocker. The nurse asks the nursing student to discuss the plan of care for this patient. Which statement by the student indicates a need for further teaching? a. "I will check to see when the last dose of the beta blocker was given." b. "I will monitor vital signs closely to assess for hypotension." c. "I will monitor the heart rate frequently to assess for reflex tachycardia." d. "I will prepare to administer intravenous norepinephrine if necessary."

ANS: C Reflex tachycardia is not an expected effect; the greater risks are cardiosuppression and bradycardia. Because beta blockers and verapamil have the same effects on the heart, there is a risk of excessive cardiosuppression. To minimize this risk, the two drugs should be given several hours apart. Hypotension may occur and should be treated with IV norepinephrine.

A nurse is caring for a child whose respirations are shallow and marked by a prolonged expiratory phase. The nurse auscultates wheezes and poor air movement bilaterally. The child's respiratory rate is 26 breaths per minute, and the oxygen saturation is 89%. What does the nurse suspect? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis

ANS: C Respiratory acidosis results from retention of CO2 secondary to hypoventilation caused either by depression of the medullary respiratory center in the central nervous system (CNS) or by a pathologic lung condition, such as asthma. This child has shallow respirations with evidence of airway obstruction and poor ventilation. Metabolic acidosis occurs in chronic renal failure, loss of bicarbonate with severe diarrhea, metabolic disorders, and ingestion of acids such as salicylates; hyperventilation is a compensatory mechanism. Metabolic alkalosis is usually caused by excessive loss of gastric acid or by ingestion of alkalinizing salts; hypoventilation is a compensatory mechanism. Respiratory alkalosis is produced by hyperventilation and can occur in any condition that increases the respiratory rate and depth.

An Asian patient will begin taking rosuvastatin [Crestor] to treat hypercholesterolemia. What will the nurse include when teaching this patient about this medication? a. Higher than usual doses may be necessary for this patient. b. Renal toxicity is a common adverse effect among Asian patients. c. Serum drug levels must be monitored more frequently than with other patients. d. Yellow skin and sclera are more common side effects with Asian patients but are not concerning.

ANS: C Rosuvastatin reaches abnormally high levels in people of Asian heritage. Consequently, serum drug levels must be monitored closely. Asian patients may require lower than usual doses. Renal toxicity does not occur. Yellow skin and sclera occur with hepatotoxicity and are a cause for concern.

A nurse is teaching a nursing student how blood can return to the heart when pressure in the venous capillary beds is very low. Which statement by the student indicates a need for further teaching? a. "Constriction of small muscles in the venous wall increases venous pressure." b. "Negative pressure in the left atrium draws blood toward the heart." c. "Skeletal muscles relax to allow the free flow of blood." d. "Venous valves help prevent the backflow of blood."

ANS: C Skeletal muscle contraction, along with one-way venous valves, helps create an "auxiliary" venous pump that helps drive blood toward the heart. Constriction of small muscles in venous walls helps increase venous pressure. Negative pressure in the left atrium sucks blood toward the heart. Valves, which are one way, work with the contraction of skeletal muscles to create a venous pump.

A nursing student asks a nurse why a patient in hypertensive crisis is receiving both intravenous sodium nitroprusside [Nitropress] and oral hydralazine. The nurse will explain that this is done to prevent: a. cyanide poisoning. b. fluid retention. c. rebound hypertension. d. reflex tachycardia.

ANS: C Sodium nitroprusside acts rapidly and is given only intravenously. Rebound hypertension occurs immediately when the IV is stopped, so an oral antihypertensive should be given simultaneously. Cyanide poisoning can occur with sodium nitroprusside, but giving hydralazine does not counter this adverse effect. Hydralazine does not prevent fluid retention or reflex tachycardia.

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

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

A patient with hypertension will begin taking an alpha1 blocker. What will the nurse teach this patient? a. A persistent cough is a known side effect of this drug. b. Eat foods rich in potassium while taking this drug. c. Move slowly from sitting to standing when taking this drug. d. Report shortness of breath while taking this drug.

ANS: C The most disturbing side effect of alpha blockers is orthostatic hypotension. Patients taking these drugs should be cautioned to stand up slowly to avoid lightheadedness or falls. A persistent cough is a common side effect of ACE inhibitors. It is not necessary to increase dietary potassium intake when taking this drug. Shortness of breath may occur in individuals with asthma who are taking beta blockers.

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/min, 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/min, so digoxin toxicity is not likely. There is no sign of renal failure. A potassium-sparing diuretic is not indicated.

A patient who is taking digoxin is admitted to the hospital for treatment of congestive heart failure. The prescriber has ordered furosemide [Lasix]. The nurse notes an irregular heart rate of 86 beats/min, a respiratory rate of 22 breaths per minute, and a blood pressure of 130/82 mm Hg. The nurse auscultates crackles in both lungs. Which laboratory value causes the nurse the most concern? a. Blood glucose level of 120 mg/dL b. Oxygen saturation of 90% c. Potassium level of 3.2 mEq/L d. Sodium level of 140 mEq/L

ANS: C This patient has an irregular, rapid heartbeat that might be caused by a dysrhythmia. This patient's serum potassium level is low, which can trigger fatal dysrhythmias, especially in patients taking digoxin. Furosemide contributes to loss of potassium through its effects on the distal nephron. Potassium-sparing diuretics often are used in conjunction with furosemide to prevent this complication. This patient's serum glucose and sodium levels are normal and of no concern at this point, although they can be affected by furosemide. The oxygen saturation is somewhat low and needs to be monitored, although it may improve with diuresis

A patient who is a chronic alcoholic is admitted to the hospital. Admission laboratory work reveals a magnesium level of 1.2 mEq/L. The prescriber orders intravenous magnesium sulfate in a 10% solution at a rate of 10 mL/min. What will the nurse do? a. Administer the IV dose as ordered and have calcium gluconate on hand. b. Administer the IV dose and make preparations for mechanical ventilation. c. Hold the IV dose until the infusion rate has been clarified with the provider. d. Request an order for renal function tests before administering the IV dose.

ANS: C This patient has hypomagnesemia and should be given magnesium sulfate intravenously. The percent of magnesium in solution is correct; however, magnesium should not be infused faster than 1.5 mL/min, so the nurse is correct to question the rate of infusion. Calcium gluconate should be available when magnesium is given, but the nurse needs to clarify the rate of infusion first. Mechanical ventilation is necessary with excessive magnesium. Renal function tests are not indicated

A patient has had blood pressures of 150/95 and 148/90 mm Hg on two separate office visits. The patient reports a blood pressure of 145/92 mm Hg taken in an ambulatory setting. The patient's diagnostic tests are all normal. The nurse will expect this patient's provider to order: a. a beta blocker. b. a loop diuretic and spironolactone. c. a thiazide diuretic. d. counseling on lifestyle changes.

ANS: C This patient has primary, or essential, hypertension as evidenced by systolic pressure greater than 140 and diastolic pressure greater than 90, along with normal tests ruling out another primary cause. Thiazide diuretics are first-line drugs for hypertension. Beta blockers are effective but are most often used to counter reflex tachycardia associated with reduced blood pressure caused by therapeutic agents. Loop diuretics cause greater diuresis than is usually needed and so are not first-line drugs. This patient should be counseled on lifestyle changes as an adjunct to drug therapy but should also begin drug therapy because hypertension already exists.

A patient with chronic hypertension is admitted to the hospital. During the admission assessment, the nurse notes a heart rate of 96 beats/min, 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 nurse is administering a vasodilator that dilates resistance vessels. The nurse understands that this drug will have which effect on the patient? a. Decreased cardiac preload b. Decreased cardiac output c. Increased tissue perfusion d. Increased ventricular contraction

ANS: C Vasodilators that dilate resistance vessels, or arterioles, cause a decrease in afterload, which allows cardiac output and tissue perfusion to increase. A decrease in preload would be the result of dilation of capacitance vessels, or veins. Dilation of arterioles increases cardiac output. Ventricular contraction results when preload is increased.

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.

Which medications are most likely to cause postural hypotension? (Select all that apply.) a. Minoxidil b. Diltiazem [Cardizem] c. Prazosin [Minipress] d. Captopril [Capoten] e. Losartan [Cozaar]

ANS: C, D, E Postural, or orthostatic, hypotension is defined as a fall in blood pressure related to a change in position. Minoxidil and diltiazem dilate arterioles; therefore, they are not likely to cause postural hypotension. Prazosin, captopril, and losartan all reportedly can cause orthostatic hypotension

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

ANS: 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 begins taking nifedipine [Procardia], along with metoprolol, to treat hypertension. The nurse understands that metoprolol is used to: a. reduce flushing. b. minimize gingival hyperplasia. c. prevent constipation. d. prevent reflex tachycardia.

ANS: D Beta blockers are combined with nifedipine to prevent reflex tachycardia. Beta blockers do not reduce flushing, minimize gingival hyperplasia, or prevent constipation. Beta blockers can reduce the adverse cardiac effects of nifedipine.

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 lupus-like syndrome c. The patient's liver function test results d. The patient's creatinine kinase levels

ANS: D Creatinine kinase levels are the best laboratory indicator of myopathy and/or rhabdomyolysis, which may lead to renal failure. As with 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 lupus-like 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 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 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/min, 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 was given a 30-day supply of Feosol and has been taking the drug for 4 weeks for iron deficiency anemia. The patient's initial hemoglobin was 8.9 gm/dL. The nurse notes that the hemoglobin has risen to 9.7 gm/dL. What will the nurse ask the patient about? a. Dietary iron intake b. Gastrointestinal (GI) upset c. Whether stools have been tarry or black d. Whether the prescription needs to be refilled

ANS: D When therapy is successful, the hemoglobin level increases by 2 gm/dL within 1 month. If the hemoglobin does not increase as expected, patients should be asked about compliance. If a patient reports that the prescription does not need to be refilled, the medication probably has not been taken as prescribed. Dietary iron intake is not a part of iron replacement therapy but is an important part of the prevention of anemia. GI upset and tarry, black stools are expected side effects of iron products.

A female patient who is not taking any other medications is prescribed aliskiren [Tekturna], a direct renin inhibitor (DRI). The nurse reviews medication information with the patient. Which statement by the patient indicates understanding of the teaching? a. "If I get pregnant, I should stop taking this drug by the second trimester." b. "If I take this drug with a high-fat meal, it will be more effective." c. "I should restrict my potassium intake while taking this drug." d. "I should take this medication 1 hour before sitting down to a meal."

ANS: D DRIs should be taken on an empty stomach to improve their bioavailability. Patients should not take this drug when pregnant and should stop immediately upon finding out they are pregnant. Dosing with a high-fat meal reduces the drug's bioavailability. DRIs rarely cause hyperkalemia when taken alone.

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

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

A patient with hypertension is prescribed an angiotensin-converting enzyme (ACE) inhibitor. The nurse reviewing this patient's chart before administering the medication will be most concerned about which other disease process? a. Bronchial asthma b. Coronary artery disease c. Diabetes mellitus d. Renal artery stenosis

ANS: D ACE inhibitors can cause severe renal insufficiency in patients with bilateral renal artery stenosis or stenosis in the artery to a single remaining kidney. Bronchial asthma, coronary artery disease, and diabetes mellitus are not comorbidities that are contraindications to treatment with an ACE inhibitor

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 of 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.

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 3 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 3 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 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 will need to take supplements of fat-soluble vitamins."

ANS: D Colesevelam [Welchol] does not reduce absorption of fat-soluble vitamins as do other bile-acid sequestrants, so supplements are not needed. 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

Which is a possible benefit of taking fish-oil supplements? a. A decrease in low-density lipoprotein and triglyceride levels b. Decreased risk of thrombotic stroke c. Prevention of heart disease in high-risk patients d. Reduced risk of dysrhythmia in patients after myocardial infarction

ANS: D Fish oil may be beneficial in prevention of heart dysrhythmias in patients who have had myocardial infarction or heart failure. It has not shown to be beneficial in decreasing cholesterol, reducing the risk of thrombotic stroke, or preventing heart disease.

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/min. 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 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 patient who has been prescribed oral ferrous sulfate reports taking extra doses for the past few months. The patient's serum iron level is 560 mcg/dL. What will the nurse expect the provider to order for this patient? a. Discontinuing the ferrous sulfate and rechecking the iron level in 1 month b. Gastric lavage and treatment for acidosis and shock c. Giving oral deferasirox [Exjade] d. Giving parenteral deferoxamine [Desferal]

ANS: D If the plasma level of iron is high (above 500 mcg/dL), it should be lowered with parenteral deferoxamine. This level is toxic and must be treated. Gastric lavage is used if unabsorbed tablets are present. Oral deferasirox is used for chronic overload caused by blood transfusions.

A patient with a history of elevated triglycerides and LDL cholesterol begins taking nicotinic acid [Niacin]. The patient reports uncomfortable flushing of the face, neck, and ears when taking the drug. What will the nurse advise the patient? a. "Ask your provider about taking an immediate-release form of the medication." b. "Ask your provider about assessing your serum uric acid levels which may be elevated." c. "You should stop taking the Niacin immediately since this is a serious adverse effect." d. "You should take 325 mg of aspirin a half hour before each dose of Niacin to prevent this effect."

ANS: D Intense flushing of the face, neck, and ears occurs in practically all patients taking nicotinic acid in pharmacologic doses. Patients should be advised to take 325 mg of ASA 30 minutes prior to each dose to minimize this effect or to use an extended-release form of the drug. Serum uric acid levels may increase with Niacin use, but flushing does not indicate elevated levels. This side effect is not serious and does not warrant discontinuation of the drug.

A patient takes an ACE inhibitor to treat hypertension and tells the nurse that she wants to become pregnant. She asks whether she should continue taking the medication while she is pregnant. What will the nurse tell her? a. Controlling her blood pressure will decrease her risk of preeclampsia. b. Ask the provider about changing to an ARB during pregnancy. c. Continue taking the ACE inhibitor during her pregnancy. d. Discuss using methyldopa instead while she is pregnant.

ANS: D Methyldopa has limited effects on uteroplacental and fetal hemodynamics and does not adversely affect the fetus or neonate. Controlling blood pressure does not lower the risk of preeclampsia. ACE inhibitors and ARBs are specifically contraindicated during pregnancy

A nursing student asks the nurse why multi-drug therapy is often used to treat hypertension. Which statement by the student indicates a need for further teaching? a. "Multi-drug therapy often means that drugs may be given in lower doses." b. "Some agents are used to offset adverse effects of other agents." c. "Treatment of hypertension via different mechanisms increases success." d. "Two or more drugs will lower blood pressure more quickly."

ANS: D Multi-drug therapy does not lower blood pressure more quickly. Using more than one drug often means that doses can be decreased. Some agents can offset adverse effects of other agents. Treatment via different mechanisms increases the likelihood of success.

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 nurse has provided education for a patient newly diagnosed with hypertension who is just beginning therapy with antihypertensive medications. Which statement by the patient indicates a need for further teaching? a. "I may experience serious long-term problems even if I am not having symptoms." b. "I should report side effects to the provider since other drugs may be substituted." c. "I will need to take medications on a long-term basis." d. "When my symptoms subside, I may discontinue the medications."

ANS: D Patients should be taught that hypertension treatment is lifelong and that medications must be continued even when symptoms subside. Long-term problems may still occur without symptoms. Reporting drug side effects is necessary so that other drugs may be tried if needed.

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.

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."

ANS: D Regular exercise can reduce LDL cholesterol and elevate 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.

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

ANS: D Sodium nitroprusside is the drug of choice for hypertensive emergencies and is given intravenously. ACE inhibitors, such as captopril, are not used. Hydralazine may be used but should be given IV. Minoxidil is effective, but its severe side effects make it a second-line drug.

A patient with hypertension is taking furosemide [Lasix] for congestive heart failure. The prescriber orders digoxin to help increase cardiac output. What other medication will the nurse expect to be ordered for this patient? a. Bumetanide [Bumex] b. Chlorothiazide [Diuril] c. Hydrochlorothiazide [HydroDIURIL] d. Spironolactone [Aldactone]

ANS: D Spironolactone is used in conjunction with furosemide because of its potassium-sparing effects. Furosemide can contribute to hypokalemia, which can increase the risk of fatal dysrhythmias, especially with digoxin administration. The other diuretics listed are all potassium-wasting diuretics.

A nurse preparing to administer morning medications notes that a patient with a history of hypertension has been prescribed spironolactone [Aldactone]. The nurse assesses the patient and notes dyspnea, bilateral crackles, and pitting edema in both feet. Which intervention is appropriate? a. Administer the medications as ordered. b. Ask the patient about the use of salt substitutes. c. Contact the provider to request an order for serum electrolytes. d. Request an order for furosemide [Lasix]

ANS: D Spironolactone takes up to 48 hours for its effects to develop, so it should not be used when the patient needs immediate diuresis. This patient has shortness of breath, crackles, and edema and needs a short-acting diuretic, such as furosemide. Asking the patient about the use of salt substitutes is not indicated. The patient does not need assessment of serum electrolytes

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

ANS: D 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

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 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.

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 for stable angina but not for 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 is admitted to the hospital. The patient's initial laboratory results reveal megaloblastic anemia. The patient complains of tingling of the hands and appears confused. The nurse suspects what in this patient? a. Celiac disease b. Folic acid deficiency c. Iron deficiency anemia d. Vitamin B12 deficiency

ANS: D When patients present with megaloblastic anemia, it is essential to distinguish between folic acid deficiency and vitamin B12 deficiency. If neurologic deficits are observed, vitamin B12 deficiency is more likely to be the cause. This patient does not have signs of celiac disease. Iron deficiency anemia would be indicated by a low hemoglobin and hematocrit

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.

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.