Pharm Ex 3 Review Q's

The nurse is caring for a patient who is being treated pharmacologically for the symptoms of heart failure. What would be included in the nurse's role of pharmacologic management of this patient? Select all that apply. 1. Teaching the patient how to space medications to decrease adverse effects 2. Teaching the patient the long-term benefits of beta blockers 3. Continually monitoring the patient during IV infusions 4. Decreasing medication dosages when the patient complains of adverse effects 5. Changing a medication that is no longer working to decrease the patient's symptoms

1. Teaching the patient how to space medications to decrease adverse effects 2. Teaching the patient the long-term benefits of beta blockers 3. Continually monitoring the patient during IV infusions

The patient receives enalapril (Vasotec) as treatment for heart failure. What is the best nursing assessment following the initial administration of this drug? 1. Assess the patient for ototoxicity. 2. Assess the patient's blood pressure. 3. Assess the patient for an irregular pulse. 4. Assess the patient for a serious rash.

2. Assess the patient's blood pressure

Lisinopril (Prinivil) is often used to treat heart failure because it lowers blood volume. Which of the following best explains how lisinopril lowers blood volume? 1. It has an antagonistic effect on angiotensin-converting enzyme. 2. It lowers aldosterone secretion, a hormone that increases sodium reabsorption. 3. It causes hypernatremia and increased renal tubule permeability, resulting in a diuretic effect. 4. It causes a diuretic effect by lowering the amount of sodium lost in the urine.

2. It lowers aldosterone secretion, a hormone that increases sodium reabsorption.

The patient will receive an IV infusion of milrinone (Primacor) as treatment for acute heart failure. What is the priority plan by the nurse? 1. Plan to monitor for atrial fibrillation. 2. Plan to monitor the ECG continuously. 3. Plan to take vital signs every 15 minutes. 4. Plan to monitor for hypertension.

2. Plan to monitor the ECG continuously.

The patient receives digoxin (Lanoxin). Which assessment findings would indicate adverse effects to this medication? 1. Tachycardia and hypotension 2. Blurred vision and tachycardia 3. Anorexia and nausea 4. Anorexia and constipation

3. Anorexia and nausea

The physician orders metoprolol (Toprol-XL) for several patients. The nurse will hold the medication and contact the physician for which patient? 1. The patient with an apical pulse rate of 100 2. The patient with compensated heart failure 3. The patient with chronic bronchitis 4. The patient with a history of migraines

3. The patient with chronic bronchitis

The nurse teaches the patient about lisinopril (Prinivil) and evaluates that additional teaching is required when the patient makes which statement? 1. "I will monitor my blood pressure until my next appointment." 2. "I will avoid using salt substitutes for seasoning." 3. "It takes a while for this medication to take effect." 4. "I don't need to worry about having blood tests done."

4. "I don't need to worry about having blood tests done."

8. In assessing a patient before administration of a cardiac glycoside, the nurse knows that which lab result can increase the toxicity of the drug? a. Potassium level 2.8 mEq/L b. Potassium level 4.9 mEq/L c. Sodium level 140 mEq/L d. Calcium level 10 mg/dL

ANS: A Hypokalemia increases the chance of digitalis toxicity. The other levels listed are incorrect. DIF: COGNITIVE LEVEL: Analyzing (Analysis) REF: p. 384 TOP: NURSING PROCESS: Assessment

11. When administering digoxin immune Fab (Digibind) to a patient with severe digoxin toxicity, the nurse knows that each vial can bind with how much digoxin? a. 0.5 mg b. 5 mg c. 5.5 mg d. 15 mg

ANS: A One vial of digoxin immune Fab binds 0.5 mg of digoxin. The other options are incorrect. DIF: COGNITIVE LEVEL: Remembering (Knowledge) REF: p. 383 TOP: NURSING PROCESS: Assessment

3. While assessing a patient who is receiving intravenous digitalis, the nurse recognizes that the drug has a negative chronotropic effect. How would this drug effect be evident in the patient? a. Decreased blood pressure b. Decreased heart rate c. Decreased conduction d. Decreased ectopic beats

ANS: B A negative chronotropic effect results in a decreased heart rate; this is one effect of cardiac glycosides. The other options are incorrect. DIF: COGNITIVE LEVEL: Applying (Application) REF: p. 381 TOP: NURSING PROCESS: Evaluation

8. The nurse notes in the patient's medication orders that the patient will be starting anticoagulant therapy. What is the primary goal of anticoagulant therapy? a. Stabilizing an existing thrombus b. Dissolving an existing thrombus c. Preventing thrombus formation d. Dilating the vessel around a clot

ANS: C Anticoagulants prevent thrombus formation but do not dissolve or stabilize an existing thrombus, nor do they dilate vessels around a clot. DIF: COGNITIVE LEVEL: Understanding (Comprehension) REF: p. 414 TOP: NURSING PROCESS: Implementation

6. The nurse is screening a patient who will be taking a nonspecific/nonselective beta blocker. Which condition, if present, may cause serious problems if the patient takes this medication? a. Angina b. Hypertension c. Glaucoma d. Asthma

ANS: D Nonspecific/nonselective beta-blocking drugs may precipitate bradycardia, hypotension, heart block, heart failure, bronchoconstriction, and/or increased airway resistance. Therefore, any pre-existing respiratory conditions such as asthma might be worsened by the concurrent use of any of these medications. DIF: COGNITIVE LEVEL: Applying (Application) REF: p. 317 TOP: NURSING PROCESS: Implementation

29.13 The client will be receiving dopamine (Dopastat). What equipment will the nurse plan to obtain prior to infusion of this drug? 1. Pulse oximeter 2. Oxygen cannula 3. Sequential compression devices 4. Intravenous (IV) pump

Answer: 4 Intravenous (IV) pump Rationale: Inotropic medications are administered as a continuous infusion based on micrograms per kilograms per minute. Always infuse these medications via an intravenous (IV) pump. A pulse oximeter is an important piece of equipment, but not as important as an intravenous (IV) pump. An oxygen cannula is an important piece of equipment, but not as important as an intravenous (IV) pump. Sequential compression devices are important pieces of equipment, but not as important as an intravenous (IV) pump.

29. 21 The mechanism of action of norepinephrine is to: a. Produce vasoconstriction. b. Cause increased blood flow. c. Decrease cardiac output. d. Increase heart rate.

Answer: A Produce vasoconstriction.

29.17 A client with cardiogenic shock would exhibit which of the following symptoms? a. Restlessness and anxiety b. Bradycardia c. Tachycardia and low blood pressure d. Low temperature

Answer: C Tachycardia and low blood pressure

The patient has hypertension and asks the nurse how this can lead to heart failure. What is the best response by the nurse? 1. "Hypertension causes resistance in your blood vessels, or afterload; your heart works harder, and weakens." 2. "Hypertension limits the ability of your heart to stretch before emptying, or afterload; your heart works harder, and weakens." 3. "Hypertension causes resistance in your aorta, or afterload; your heart works harder and weakens." 4. "Hypertension limits the amount of blood entering your left ventricle, or afterload; your heart works harder, and weakens."

1. "Hypertension causes resistance in your blood vessels, or afterload; your heart works harder, and weakens."

The nurse is educating a patient diagnosed with heart failure (HF). The nurse knows that instruction regarding compensatory mechanisms has been effective when the patient states, Select all that apply. 1. "My heart enlarged in order to compensate for the effects of heart failure." 2. "My nervous system kicks in to compensate for the effects of heart failure." 3. "My body will decrease blood flow to other organs in order to compensate for heart failure." 4. "My body will increase urine output in order to compensate for the effects of heart failure." 5. "My body will produce anti-inflammatory agents to compensate for heart failure."

1. "My heart enlarged in order to compensate for the effects of heart failure." 2. "My nervous system kicks in to compensate for the effects of heart failure." 3. "My body will decrease blood flow to other organs in order to compensate for heart failure."

The patient has heart failure and receives digoxin (Lanoxin). Prior to discharge, what will the best teaching plan by the nurse include? 1. "Report a weight gain of 2 or more pounds per day." 2. "Report mental changes such as euphoria." 3. "Stop the medication if your pulse is 56." 4. "If you miss a dose, take two doses."

1. "Report a weight gain of 2 or more pounds per day."

The nurse is concerned that a patient is developing right heart failure. What did the nurse assess in this patient? Select all that apply. 1. Ankle edema 2. Enlarged liver 3. Displaced apical heart rate 4. Shortness of breath 5. Cough

1. Ankle edema 2. Enlarged liver 3. Displaced apical heart rate

Which of the following medications would be of most help to increase myocardial contractility in a patient with heart failure? 1. Digoxin (Lanoxin) 2. Lisinopril (Prinivil) 3. Carvedilol (Coreg) 4. Furosemide (Lasix)

1. Digoxin (Lanoxin)

The nurse is caring for a patient with heart failure. Which assessment findings indicate the patient is currently experiencing class 2 heart failure? Select all that apply. 1. Fatigue with physical activity 2. Palpitations with physical activity 3. No symptoms with physical activity 4. Dyspnea with physical activity 5. Angina at rest

1. Fatigue with physical activity 2. Palpitations with physical activit 4. Dyspnea with physical activity

Which vital sign is of greatest concern to the nurse prior to administering digoxin (Lanoxin)? 1. Heart rate 2. Temperature 3. Blood pressure 4. Respiratory rate

1. Heart rate

The nurse is caring for a patient being treated pharmacologically for heart failure. Which laboratory values is the nurse careful to monitor during treatment? Select all that apply. 1. Potassium levels 2. BUN 3. Creatinine 4. Liver function tests 5. Serum drug levels

1. Potassium levels 2. BUN 3. Creatinine 5. Serum drug levels

The patient receives captopril (Capoten) as treatment for heart failure. Which adverse effect will the nurse plan to report to the physician? 1. The patient develops a cough. 2. The patient develops diarrhea. 3. The patient develops dehydration. 4. The patient develops facial flushing

1. The patient develops a cough.

The nurse is caring for a patient who has been diagnosed with heart failure. The nurse knows that which conditions may have contributed to the development of heart failure in this patient? Select all that apply. 1. Uncontrolled hypertension 2. Coronary artery disease 3. Diabetes 4. HIV 5. Mitral stenosis

1. Uncontrolled hypertension 2. Coronary artery disease 3. Diabetes 5. Mitral stenosis

Which of the following is the most serious adverse effect associated with milrinone (Primacor)? 1. Ventricular dysrhythmia 2. Nausea 3. Headache 4. Atrial dysrhythmia

1. Ventricular dysrhythmia

The patient has a history of cardiac disease and receives digoxin (Lanoxin). The nurse determines that education about dietary needs with this medication has been effective when the patient makes which selection for lunch? 1. Cottage cheese, peach salad, and blueberry pie 2. Baked fish, sweet potatoes, and banana pudding 3. Green bean soup, whole-wheat bread, and an apple 4. Hamburger, French fries, and chocolate chip cookies

2. Baked fish, sweet potatoes, and banana pudding

The patient takes insulin for diabetes mellitus. The physician orders metoprolol (Lopressor) for hypertension. After medication teaching, the nurse determines that learning has occurred when the patient makes which statement? 1. "I might not need to check my blood sugars as often with metoprolol (Lopressor)." 2. "I might be able to change from insulin to a pill with metoprolol (Lopressor)." 3. "I might need less insulin when I take metoprolol (Lopressor)." 4. "I might need more insulin when I take metoprolol (Lopressor)."

3. "I might need less insulin when I take metoprolol (Lopressor)."

The nurse teaches the patient about digoxin (Lanoxin) toxicity and determines that learning has occurred when the patient makes which statement(s)? Select all that apply. 1. "I should limit my fluids while taking this medication." 2. "It is okay to keep taking my ginseng." 3. "If I have nausea, it means I must stop the medication." 4. "I can drink orange juice every morning." 5. "I must check my pulse and not take the medication if it is less than 60."

3. "If I have nausea, it means I must stop the medication." 4. "I can drink orange juice every morning." 5. "I must check my pulse and not take the medication if it is less than 60."

The patient comes to the emergency department complaining of coughing and difficulty breathing. The patient's diagnosis is heart failure. He asks the nurse how difficulty breathing could be a heart problem. What is the best response by the nurse? Select all that apply. 1. "The right side of your heart has weakened and blood has entered your lungs." 2. "The right side of your heart has enlarged and cannot effectively pump blood." 3. "What you have is called congestive heart failure." 4. "The left side of your heart is weak and pumps blood too quickly." 5. "The left side of your heart has weakened and blood has entered your lungs."

3. "What you have is called congestive heart failure." 5. "The left side of your heart has weakened and blood has entered your lungs."

The nurse volunteers at a senior citizen center. The nurse assesses which senior citizen as having the greatest risk of developing heart failure? 1. A 50-year-old black female who smokes 2. A 75-year-old white male who is overweight 3. A 69-year-old black male with hypertension 4. A 52-year-old white female with asthma

3. A 69-year-old black male with hypertension

Which statement is accurate regarding the physiological changes associated with heart failure? 1. Blood backs up into the lungs due to right ventricular hypertrophy. 2. The walls of the heart shrink, leading to lower cardiac output. 3. Cardiac remodeling occurs after prolonged ventricular hypertrophy. 4. Blood pressure increases, resulting in lowered afterload.

3. Cardiac remodeling occurs after prolonged ventricular hypertrophy

Which individual listed below would be at the greatest risk for developing heart disease? 1. 35-year-old with diabetes mellitus and prehypertension 2. 75-year-old with Parkinson's disease and normal blood pressure 3. 52-year-old with osteoporosis and stage 1 hypertension 4. 68-year-old with stage 2 hypertension and recent myocardial infarction

4. 68-year-old with stage 2 hypertension and recent myocardial infarction

The patient receives furosemide (Lasix) and digoxin (Lanoxin) together. Which laboratory findings will the nurse assess as increasing the patient's risk for digoxin (Lanoxin) toxicity? 1. Hyponatremia and hyperkalemia 2. Hypermagnesemia and hyponatremia 3. Hypercalcemia and hyperkalemia 4. Hypokalemia and hypocalcemia

4. Hypokalemia and hypocalcemia

Which of the following would lead to an increase in cardiac output? 1. Reduced cardiac contractility 2. Hypovolemia 3. Peripheral vascular resistance 4. Increase in preload

4. Increase in preload

Which statement is accurate regarding the use of beta-adrenergic blockers for use in patients with heart failure? 1. Higher doses are used initially until optimal vital signs are achieved. 2. Dosage changes are done on a daily basis for the first 2 weeks. 3. This drug class does not have an effect on the bronchioles of the lungs. 4. They are generally used in combination with other heart-failure drugs.

4. They are generally used in combination with other heart-failure drugs.

2. An elderly patient has had hip surgery and will be receiving heparin, 4000 units subcutaneously every 12 hours. The heparin is available in vials of 5000 units/mL. Calculate how much heparin the nurse will administer for this dose. _______

ANS: DIF: COGNITIVE LEVEL: Applying (Application) REF: N/A TOP: NURSING PROCESS: Implementation

1. The medication order for a 4-year-old child reads, "Give digoxin elixir, 15 mcg/kg, PO now." Convert the micrograms to milligrams. _______

ANS: 0.015 mg DIF: COGNITIVE LEVEL: Applying (Application) REF: N/A TOP: NURSING PROCESS: Implementation

1. The nurse is to administer epinephrine 0.3 mg subcutaneously. The ampule contains 1 mL of medication and is labeled "Epinephrine 1:1000." Identify how many milliliters of epinephrine will the nurse give. _______

ANS: 0.3 mL Note that 1:1000 indicates 1 gram per 1000 mL or 1000 mg per 1000 mL, which is a concentration of 1 mg/mL. DIF: COGNITIVE LEVEL: Applying (Application) REF: N/A TOP: NURSING PROCESS: Implementation

1. A patient has an order for carvedilol (Coreg) 6.25 mg twice a day PO. The tablets are 3.125 mg. Identify how many tablets will the nurse administer per dose. _______

ANS: 2 tablets DIF: COGNITIVE LEVEL: Applying (Application) REF: N/A TOP: NURSING PROCESS: Implementation

1. A patient will be receiving metoprolol (Lopressor) 5 mg IV push for angina. The medication is available in a strength of 1 mg/mL. Identify how much medication will the nurse draw up for each dose. _______

ANS: 5 mL DIF: COGNITIVE LEVEL: Applying (Application) REF: N/A TOP: NURSING PROCESS: Implementation

1. A patient has received an overdose of enoxaparin (Lovenox). The order was for 30 mg, but the patient received 90 mg. The nurse notes that the patient is showing signs of bleeding (oozing blood from the intravenous sites, increased bruising) and notifies the physician, who prescribes protamine sulfate to cover the excess amount of enoxaparin that the patient received. Calculate how much protamine sulfate the patient will receive. _______

ANS: 60 mg Protamine sulfate is used to reverse the effects of low-molecular-weight heparins (LMWHs). A 1-mg dose of protamine is administered for each milligram of the LMWH. This patient received 60 mg of enoxaparin more than the ordered dose of 30 mg; therefore, 60 mg of protamine sulfate will be used as an antidote. DIF: COGNITIVE LEVEL: Applying (Application) REF: p. 416 TOP: NURSING PROCESS: Implementation

2. When an adrenergic drug stimulates beta1-adrenergic receptors, the result is an increased force of contraction, which is known as what type of effect? a. Positive inotropic b. Anti-adrenergic c. Negative dromotropic d. Positive chronotropic

ANS: A An increased force of contraction is known as a positive inotropic effect. DIF: COGNITIVE LEVEL: Understanding (Comprehension) REF: p. 299 TOP: NURSING PROCESS: General

7. When applying transdermal nitroglycerin patches, which instruction by the nurse is correct? a. "Rotate application sites with each dose." b. "Use only the chest area for application sites." c. "Temporarily remove the patch if you go swimming." d. "Apply the patch to the same site each time."

ANS: A Application sites for transdermal nitroglycerin patches need to be rotated. Apply the transdermal patch to any nonhairy area of the body; the old patch should first be removed. The patch may be worn while swimming, but if it does come off, it should be replaced after the old site is cleansed. DIF: COGNITIVE LEVEL: Applying (Application) REF: p. 374 TOP: NURSING PROCESS: Implementation

8. During a teaching session about self-monitoring while taking a beta blocker at home, the nurse has taught the patient to take his apical pulse daily for 1 minute. If the pulse rate decreases to less than 60 beats/min, the nurse will instruct the patient to: a. notify his prescriber. b. reduce the dose of his beta blocker by half. c. continue the medication because this is an expected effect. d. skip the medication dose that day, and check his pulse again the next day.

ANS: A Cardiac depression can occur with beta blockers; instruct the patient to contact his prescriber if his pulse rate decreases to less than 60 per minute. The medication dose may need to be changed, but it is not appropriate for the nurse to change the dosage. The other options are incorrect. DIF: COGNITIVE LEVEL: Applying (Application) REF: p. 317 TOP: NURSING PROCESS: Implementation

4. A 74-year-old professional golfer has chest pain that occurs toward the end of his golfing games. He says the pain usually goes away after one or two sublingual nitroglycerin tablets and rest. What type of angina is he experiencing? a. Classic b. Variant c. Unstable d. Prinzmetal's

ANS: A Classic, or chronic stable, angina is triggered by either exertion or stress and usually subsides within 15 minutes with either rest or drug therapy. DIF: COGNITIVE LEVEL: Understanding (Comprehension) REF: p. 363 TOP: NURSING PROCESS: Assessment

5. A patient arrives in the emergency department with severe chest pain. The patient reports that the pain has been occurring off and on for a week now. Which assessment finding would indicate the need for cautious use of nitrates and nitrites? a. Blood pressure of 88/62 mm Hg b. Apical pulse rate of 110 beats/min c. History of renal disease d. History of a myocardial infarction 2 years ago

ANS: A Hypotension is a possible contraindication to the use of nitrates because the medications may cause the blood pressure to decrease. The other options are incorrect. DIF: COGNITIVE LEVEL: Analyzing (Analysis) REF: p. 364 TOP: NURSING PROCESS: Assessment

3. When a patient is taking an adrenergic drug, the nurse expects to observe which effect? a. Increased heart rate b. Bronchial constriction c. Constricted pupils d. Increased intestinal peristalsis

ANS: A Increased heart rate is one of the effects of adrenergic drugs. Sympathetic nervous system stimulation also results in bronchodilation, dilated pupils, and decreased gastrointestinal mobility, depending upon which receptors are stimulated. DIF: COGNITIVE LEVEL: Understanding (Comprehension) REF: p. 297 TOP: NURSING PROCESS: Assessment

11. A patient is taking an alpha blocker as treatment for benign prostatic hyperplasia. The nurse will monitor for which potential drug effect? a. Orthostatic hypotension b. Increased blood pressure c. Decreased urine flow d. Discolored urine

ANS: A Orthostatic hypotension can occur with any dose of an alpha blocker, and patients must be warned to get up slowly from a supine position. The other responses are not drug effects of alpha blockers. DIF: COGNITIVE LEVEL: Applying (Application) REF: p. 311 TOP: NURSING PROCESS: Evaluation

2. A patient is going home with a new prescription for the beta-blocker atenolol (Tenormin). The nurse will include which content when teaching the patient about this drug? a. Never stop taking this medication abruptly. b. The medication will be stopped once symptoms subside. c. If adverse effects occur, stop taking the drug for 24 hours, and then resume. d. Be watchful for first-dose hypotension.

ANS: A Patients need to be weaned off these medications slowly because rebound hypertension and chest pain are possible with abrupt withdrawal. The drugs should never be stopped abruptly nor doses skipped. First-dose hypotension occurs with alpha blockers. DIF: COGNITIVE LEVEL: Applying (Application) REF: p. 318 TOP: NURSING PROCESS: Implementation

2. A patient is taking digoxin (Lanoxin) and a loop diuretic daily. When the nurse enters the room with the morning medications, the patient states, "I am seeing a funny yellow color around the lights." What is the nurse's next action? a. Assess the patient for symptoms of digoxin toxicity. b. Withhold the next dose of the diuretic. c. Administer the digoxin and diuretic together as ordered. d. Document this finding, and reassess in 1 hour.

ANS: A Seeing colors around lights is one potential indication of developing digoxin toxicity. If a patient complains of this, the nurse needs to assess for other signs and symptoms of digoxin toxicity including bradycardia, headache, dizziness, confusion, nausea, and blurred vision, and then notify the prescriber. Administering the drug or withholding the diuretic are incorrect options. DIF: COGNITIVE LEVEL: Analyzing (Analysis) REF: p. 382 TOP: NURSING PROCESS: Assessment

2. Which drug classes are considered first-line treatment for heart failure? (Select all that apply.) a. Angiotensin-converting enzyme (ACE) inhibitors b. Angiotensin II receptor blockers (ARBs) c. Digoxin (cardiac glycoside) d. Beta blockers e. Nesiritide (Natrecor), the B-type natriuretic peptide

ANS: A, B, D ACE inhibitors, ARBs, and beta blockers are now considered the first-line treatments for heart failure. Digoxin is used when the first-line treatments are not successful; nesiritide is considered a last-resort treatment. DIF: COGNITIVE LEVEL: Applying (Application) REF: p. 378 TOP: NURSING PROCESS: Planning

1. A beta blocker is prescribed for a patient with angina. The nurse reviews the orders for other drugs that may interact with the beta blocker. Which drugs or drug classes are known to have an interaction with a beta blocker? (Select all that apply.) a. Diuretics b. Anticholinergics c. Penicillins d. Oral hypoglycemics e. Alcohol f. Anticoagulants

ANS: A, B, D, E When taken with beta blockers, diuretics and alcohol may cause additive hypotensive effects; oral hypoglycemic medications may cause the blood glucose to decrease; and anticholinergics may cause decreased beta-blocker effects. Penicillins and anticoagulants are not known to interact with beta blockers. DIF: COGNITIVE LEVEL: Applying (Application) REF: p. 314 TOP: NURSING PROCESS: Assessment

1. A patient will be taking dabigatran (Pradaxa) as part of treatment for chronic atrial fibrillation. Which statements about dabigatran are true? (Select all that apply.) a. The dose of dabigatran is reduced in patients with decreased renal function. b. Bleeding is the most common adverse effect. c. Potassium chloride is given as an antidote in cases of overdose. d. Dabigatran levels are monitored by measuring prothrombin time/international normalized ratio (PT/INR) results. e. This drug is a prodrug and becomes activated in the liver.

ANS: A, B, E Dabigatran is excreted extensively in the kidneys, and the dose is dependent upon renal function. The normal dose is 150 mg twice daily, but it must be reduced to 75 mg twice daily if creatinine clearance is less than 30 mL/min. The most common and serious side effect is bleeding. Dabigatran is a prodrug that becomes activated in the liver. There is no antidote to dabigatran. The other options are incorrect. DIF: COGNITIVE LEVEL: Applying (Application) REF: p. 417 TOP: NURSING PROCESS: Implementation

1. The nurse is providing education about the use of sublingual nitroglycerin tablets. She asks the patient, "What would you do if you experienced chest pain while mowing your yard? You have your bottle of sublingual nitroglycerin with you." Which actions by the patient are appropriate in this situation? (Select all that apply.) a. Stop the activity, and lie down or sit down. b. Call 911 immediately. c. Call 911 if the pain is not relieved after taking one sublingual tablet. d. Call 911 if the pain is not relieved after taking three sublingual tablets in 15 minutes. e. Place a tablet under the tongue. f. Place a tablet in the space between the gum and cheek. g. Take another sublingual tablet if chest pain is not relieved after 5 minutes, up to three total.

ANS: A, C, E, G With sublingual forms, the medication is taken at the first sign of chest pain, not delayed until the pain is severe. The patient needs to sit down or lie down and take one sublingual tablet. According to current guidelines, if the chest pain or discomfort is not relieved in 5 minutes, after 1 dose, the patient (or family member) must call 911 immediately. The patient can take one more tablet while awaiting emergency care and may take a third tablet 5 minutes later, but no more than a total of three tablets. These guidelines reflect the fact that angina pain that does not respond to nitroglycerin may indicate a myocardial infarction. The sublingual dose is placed under the tongue, and the patient needs to avoid swallowing until the tablet has dissolved. Placing a tablet between the gum and cheek is the buccal route. DIF: COGNITIVE LEVEL: Analyzing (Analysis) REF: p. 372 TOP: NURSING PROCESS: Implementation

1. The nurse is presenting information to a class of students about adrenergic drugs. Which are the effects of drugs that stimulate the sympathetic nervous system? (Select all that apply.) a. Dilation of bronchioles b. Constriction of bronchioles c. Decreased heart rate d. Increased heart rate e. Dilated pupils f. Constricted pupils g. Glycogenolysis

ANS: A, D, E, G Stimulation of the sympathetic nervous system causes bronchodilation, increased heart rate, pupil dilation, and glycogenolysis as well as many other effects (see Table 18-1). The other responses are effects that occur as a result of the stimulation of the parasympathetic nervous system. DIF: COGNITIVE LEVEL: Applying (Application) REF: p. 297 TOP: NURSING PROCESS: Assessment

10. A patient has had recent mechanical heart valve surgery and is receiving anticoagulant therapy. While monitoring the patient's laboratory work, the nurse interprets that the patient's international normalized ratio (INR) level of 3 indicates that: a. the patient is not receiving enough warfarin to have a therapeutic effect. b. the patient's warfarin dose is at therapeutic levels. c. the patient's intravenous heparin dose is dangerously high. d. the patient's intravenous heparin dose is at therapeutic levels.

ANS: B A normal INR (without warfarin) is 1.0. A therapeutic INR for patients who have had mechanical heart valve surgery ranges from 2.5 to 3.5, with a middle value of 3. DIF: COGNITIVE LEVEL: Applying (Application) REF: p. 419 TOP: NURSING PROCESS: Implementation

9. A patient is being discharged on anticoagulant therapy. The nurse will include in the patient-education conversation that it is important to avoid herbal products that contain which substance? a. Valerian b. Ginkgo c. Soy d. Saw palmetto

ANS: B Capsicum pepper, feverfew, garlic, ginger, ginkgo, St. John's wort, and ginseng are some herbals that have potential interactions with anticoagulants, especially with warfarin. DIF: COGNITIVE LEVEL: Understanding (Comprehension) REF: p. 417 TOP: NURSING PROCESS: Assessment

10. A patient has a new prescription for tamsulosin (Flomax) as treatment for benign prostatic hyperplasia. The nurse is checking his current medication list and will contact the prescriber regarding a potential interaction if the patient is also taking which drug? a. Levothyroxine (Synthroid) for hypothyroidism b. Sildenafil (Viagra), an erectile dysfunction medication c. Omeprazole (Prilosec), a proton pump inhibitor d. Low-dose aspirin for stroke prevention

ANS: B Drugs that interact with alpha blockers such as tamsulosin include erectile dysfunction drugs; additive hypotensive effects may occur. The other drugs do not interact with tamsulosin. DIF: COGNITIVE LEVEL: Applying (Application) REF: p. 313 TOP: NURSING PROCESS: Implementation

8. A hospitalized patient is experiencing a severe anaphylactic reaction to a dose of intravenous penicillin. Which drug will the nurse expect to use to treat this condition? a. Ephedra b. Epinephrine c. Phenylephrine d. Pseudoephedrine

ANS: B Epinephrine is the drug of choice for the treatment of anaphylaxis. The other drugs listed are incorrect choices. DIF: COGNITIVE LEVEL: Understanding (Comprehension) REF: p. 301 TOP: NURSING PROCESS: Planning

1. During therapy with a beta blocker, the patient notices that she has swollen feet, has gained 3 pounds within 2 days, feels short of breath even when walking around the house, and has been dizzy. The nurse suspects that which of these is occurring? a. The patient is experiencing an allergic reaction. b. The patient may be developing heart failure. c. More time is needed for the patient to see a therapeutic response to the drug. d. The patient is experiencing expected adverse effects of the drug.

ANS: B Even though some beta blockers may be used for the treatment of some types of heart failure, the patient needs to be assessed often for the development of heart failure, a potential adverse effect of the drugs. These symptoms do not indicate expected adverse effects, an allergic reaction, or a therapeutic response. DIF: COGNITIVE LEVEL: Applying (Application) REF: p. 318 TOP: NURSING PROCESS: Evaluation

4. An adrenergic agonist is ordered for a patient in shock. The nurse will note that this drug has had its primary intended effect if which expected outcome occurs? a. Volume restoration b. Increased cardiac output c. Decreased urine output d. Reduced anxiety

ANS: B For a patient in shock, a primary benefit of an adrenergic agonist drug is to increase cardiac output. A drug in this category should not be used in place of volume restoration, nor does it provide volume restoration (IV fluids do this). Adrenergic agonists may enhance urine output if cardiac output and perfusion to the kidneys increase. These drugs do not reduce anxiety. DIF: COGNITIVE LEVEL: Applying (Application) REF: p. 302 TOP: NURSING PROCESS: Evaluation

10. The nurse notes in a patient's medical record that nesiritide (Natrecor) has been ordered. Based on this order, the nurse interprets that the patient has which disorder? a. Atrial fibrillation b. Acutely decompensated heart failure with dyspnea at rest c. Systolic heart failure d. Chronic, stable heart failure

ANS: B Nesiritide is indicated for the treatment of acutely decompensated heart failure with dyspnea at rest. Digoxin is used for the treatment of atrial fibrillation and systolic heart failure. Nesiritide is not indicated for chronic, stable heart failure. DIF: COGNITIVE LEVEL: Understanding (Comprehension) REF: p. 380 TOP: NURSING PROCESS: Assessment

7. A patient is experiencing diastolic heart failure. The nurse expects which beta blocker to be ordered for this patient? a. Atenolol (Tenormin) b. Carvedilol (Coreg) c. Acebutolol (Sectral) d. Esmolol (Brevibloc)

ANS: B Not all beta blockers are used for the treatment of heart failure. Carvedilol and metoprolol are currently used in the treatment of heart failure. The other options are not indicated for the treatment of heart failure. DIF: COGNITIVE LEVEL: Understanding (Comprehension) REF: p. 315 TOP: NURSING PROCESS: Planning

7. A patient is receiving heparin therapy as part of the treatment for a pulmonary embolism. The nurse monitors the results of which laboratory test to check the drug's effectiveness? a. Bleeding times b. Activated partial thromboplastin time (aPTT) c. Prothrombin time/international normalized ratio (PT/INR) d. Vitamin K levels

ANS: B Ongoing aPTT values are used to monitor heparin therapy. PT/INR is used to monitor warfarin therapy. The other two options are not used to monitor anticoagulant therapy. DIF: COGNITIVE LEVEL: Understanding (Comprehension) REF: p. 432 TOP: NURSING PROCESS: Evaluation

6. A patient has a digoxin level of 1.1 ng/mL. Which interpretation by the nurse is correct? a. It is below the therapeutic level. b. It is within the therapeutic range. c. It is above the therapeutic level. d. It is at a toxic level.

ANS: B The normal therapeutic drug level of digoxin is between 0.5 and 2 ng/mL. The other options are incorrect. DIF: COGNITIVE LEVEL: Analyzing (Analysis) REF: p. 383 TOP: NURSING PROCESS: Evaluation

3. A patient who has been anticoagulated with warfarin (Coumadin) has been admitted for gastrointestinal bleeding. The history and physical examination indicates that the patient may have taken too much warfarin. The nurse anticipates that the patient will receive which antidote? a. Vitamin E b. Vitamin K c. Protamine sulfate d. Potassium chloride

ANS: B Vitamin K is given to reverse the anticoagulation effects of warfarin toxicity. Protamine sulfate is the antidote for heparin overdose. The other options are incorrect. DIF: COGNITIVE LEVEL: Understanding (Comprehension) REF: p. 416 TOP: NURSING PROCESS: Implementation

1. When a patient is experiencing digoxin toxicity, which clinical situation would necessitate the use of digoxin immune Fab (Digifab)? (Select all that apply.) a. The patient reports seeing colorful halos around lights. b. The patient's serum potassium level is above 5 mEq/L. c. The patient is experiencing nausea and anorexia. d. The patient is experiencing severe sinus bradycardia that does not respond to cardiac pacing. e. The patient has received an overdose of greater than 10 mg of digoxin. f. The patient reports fatigue and headaches.

ANS: B, D, E Clinical situations that would require the use of digoxin immune Fab in a patient with digoxin toxicity include serum potassium level above 5 mEq/L, severe sinus bradycardia that does not respond to cardiac pacing, or an overdose of more than 10 mg of digoxin. Seeing colorful halos around lights and experiencing nausea, anorexia, fatigue, and headaches are potential adverse effects of digoxin therapy but are not necessarily reasons for digoxin immune Fab treatment. DIF: COGNITIVE LEVEL: Analyzing (Analysis) REF: p. 382 TOP: NURSING PROCESS: Assessment

2. A patient with a history of angina will be started on ranolazine (Ranexa). The nurse is reviewing the patient's history and will note potential contraindications to this drug therapy if which condition is present? (Select all that apply.) a. Type 2 diabetes mellitus b. Prolonged QT interval on the electrocardiogram c. Heart failure d. Closed-angle glaucoma e. Decreased liver function

ANS: B, E Ranolazine is contraindicated in patients with pre-existing QT prolongation or hepatic impairment. The other options are not contraindications. DIF: COGNITIVE LEVEL: Applying (Application) REF: p. 370 TOP: NURSING PROCESS: Assessment

3. A patient has been diagnosed with angina and will be given a prescription for sublingual nitroglycerin tablets. When teaching the patient how to use sublingual nitroglycerin, the nurse will include which instruction? a. Take up to 5 doses at 15-minute intervals for an angina attack. b. If the tablet does not dissolve quickly, chew the tablet for maximal effect. c. If the chest pain is not relieved after one tablet, call 911 immediately. d. Wait 1 minute between doses of sublingual tablets, up to 3 doses.

ANS: C According to current guidelines, if the chest pain or discomfort is not relieved in 5 minutes, after 1 dose, the patient (or family member) must call 911 immediately. The patient may take one more tablet while awaiting emergency care and may take a third tablet 5 minutes later, but no more than a total of three tablets. The sublingual dose is placed under the tongue, and the patient needs to avoid swallowing until the tablet has dissolved. DIF: COGNITIVE LEVEL: Applying (Application) REF: p. 373 TOP: NURSING PROCESS: Implementation

1. The nurse is aware that adrenergic drugs produce effects similar to which of these nervous systems? a. Central nervous system b. Somatic nervous system c. Sympathetic nervous system d. Parasympathetic nervous system

ANS: C Adrenergic drugs mimic the effects of the sympathetic nervous system. DIF: COGNITIVE LEVEL: Remembering (Knowledge) REF: p. 297 TOP: NURSING PROCESS: General

10. While assessing a patient who is taking a beta blocker for angina, the nurse knows to monitor for which adverse effect? a. Nervousness b. Hypertension c. Bradycardia d. Dry cough

ANS: C Adverse effects of beta blockers include bradycardia, hypotension, dizziness, lethargy, impotence, and several other effects, but not dry cough or nervousness. DIF: COGNITIVE LEVEL: Understanding (Comprehension) REF: p. 367 TOP: NURSING PROCESS: Evaluation

6. A patient is on a low-dose dobutamine drip for heart failure. She had been feeling better but now has a sense of tightness in her chest, palpitations, and a bit of anxiety. Her heart rate is up to 110 per minute, and her blood pressure is 150/98 mm Hg (increased from previous readings of 86 per minute and 120/80 mm Hg). What is the nurse's immediate concern for this patient? a. She is experiencing normal adverse effects of dobutamine therapy. b. She may be experiencing an allergic reaction to the dobutamine. c. The medication may be causing a worsening of a pre-existing cardiac disorder. d. The dosage of the dobutamine needs to be increased to control the symptoms better.

ANS: C Because dobutamine is a vasoactive adrenergic, it works by increasing the cardiac output in heart failure patients by increasing myocardial contractility and stroke volume. However, adrenergic drugs may worsen a pre-existing cardiac disorder, such as causing a myocardial infarction in a patient with coronary artery disease. The other options are incorrect. DIF: COGNITIVE LEVEL: Analyzing (Analysis) REF: p. 300 TOP: NURSING PROCESS: Implementation

5. A patient has been instructed to take one enteric-coated low-dose aspirin a day as part of therapy to prevent strokes. The nurse will provide which instruction when providing patient teaching about this medication? a. Aspirin needs to be taken on an empty stomach to ensure maximal absorption. b. Low-dose aspirin therapy rarely causes problems with bleeding. c. Take the medication with 6 to 8 ounces of water and with food. d. Coated tablets may be crushed if necessary for easier swallowing.

ANS: C Enteric-coated aspirin is best taken with 6 to 8 ounces of water and with food to help decrease gastrointestinal upset. Enteric-coated tablets should not be crushed. Risk for bleeding increases with aspirin therapy, even at low doses. DIF: COGNITIVE LEVEL: Applying (Application) REF: p. 431 TOP: NURSING PROCESS: Implementation

12. A patient is in the intensive care unit and receiving an infusion of milrinone (Primacor) for severe heart failure. The prescriber has written an order for an intravenous dose of furosemide (Lasix). How will the nurse give this drug? a. Infuse the drug into the same intravenous line as the milrinone. b. Stop the milrinone, flush the line, and then administer the furosemide. c. Administer the furosemide in a separate intravenous line. d. Notify the prescriber that the furosemide cannot be given at this time.

ANS: C Furosemide must not be injected into an intravenous line with milrinone because it will precipitate immediately. The infusion must not be stopped because of the patient's condition. A separate line will be needed. The other options are incorrect. DIF: COGNITIVE LEVEL: Applying (Application) REF: p. 381 TOP: NURSING PROCESS: Planning

9. The nurse administering the phosphodiesterase inhibitor milrinone (Primacor) recognizes that this drug will have a positive inotropic effect. Which result reflects this effect? a. Increased heart rate b. Increased blood vessel dilation c. Increased force of cardiac contractions d. Increased conduction of electrical impulses across the heart

ANS: C Positive inotropic drugs increase myocardial contractility, thus increasing the force of cardiac conduction. Positive chronotropic drugs increase the heart rate. Positive dromotropic drugs increase the conduction of electrical impulses across the heart. Blood vessel dilation is not affected. DIF: COGNITIVE LEVEL: Applying (Application) REF: p. 377 TOP: NURSING PROCESS: Assessment

11. A patient has received an overdose of intravenous heparin, and is showing signs of excessive bleeding. Which substance is the antidote for heparin overdose? a. Vitamin E b. Vitamin K c. Protamine sulfate d. Potassium chloride

ANS: C Protamine sulfate is a specific heparin antidote and forms a complex with heparin, completely reversing its anticoagulant properties. Vitamin K is the antidote for warfarin (Coumadin) overdose. The other options are incorrect. DIF: COGNITIVE LEVEL: Applying (Application) REF: p. 416 TOP: NURSING PROCESS: Implementation

9. The nurse recognizes that adrenergic drugs cause relaxation of the bronchi and bronchodilation by stimulating which type of receptors? a. Dopaminergic b. Beta1 adrenergic c. Beta2 adrenergic d. Alpha1 adrenergic

ANS: C Stimulation of beta2-adrenergic receptors results in bronchodilation. The other choices are incorrect. DIF: COGNITIVE LEVEL: Understanding (Comprehension) REF: p. 303 TOP: NURSING PROCESS: Implementation

1. When the nurse is administering topical nitroglycerin ointment, which technique is correct? a. Apply the ointment on the skin on the forearm. b. Apply the ointment only in the case of a mild angina episode. c. Remove the old ointment before new ointment is applied. d. Massage the ointment gently into the skin, and then cover the area with plastic wrap.

ANS: C The old ointment should be removed before a new dose is applied. The ointment should be applied to clean, dry, hairless skin of the upper arms or body, not below the elbows or below the knees. The ointment is not massaged or spread on the skin, and it is not indicated for the treatment of acute angina. DIF: COGNITIVE LEVEL: Applying (Application) REF: p. 372 TOP: NURSING PROCESS: Implementation

5. The teaching for a patient who is taking tamsulosin (Flomax) to reduce urinary obstruction due to benign prostatic hyperplasia will include which of these? a. Fluids need to be restricted while on this medication. b. Take the medication with breakfast to promote the maximum effects of the drug. c. Get up slowly from a sitting or lying position. d. Blood pressure must be monitored because the medication may cause hypertension.

ANS: C This medication is used to relieve impaired urinary flow in men with benign prostatic hyperplasia, but it also can cause orthostatic hypotension when changing positions from sitting or lying positions. Because of these effects, the blood pressure may become dramatically lowered, and lightheadedness may occur, increasing the risk of falling. DIF: COGNITIVE LEVEL: Applying (Application) REF: p. 317 TOP: NURSING PROCESS: Implementation

6. A patient will be receiving a thrombolytic drug as part of the treatment for acute myocardial infarction. The nurse explains to the patient that this drug is used for which purpose? a. To relieve chest pain b. To prevent further clot formation c. To dissolve the clot in the coronary artery d. To control bleeding in the coronary vessels

ANS: C Thrombolytic drugs lyse, or dissolve, thrombi. They are not used to prevent further clot formation or to control bleeding. As a result of dissolving of the thrombi, chest pain may be relieved, but that is not the primary purpose of thrombolytic therapy. DIF: COGNITIVE LEVEL: Understanding (Comprehension) REF: p. 414 TOP: NURSING PROCESS: Implementation

11. When teaching a patient who has a new prescription for transdermal nitroglycerin patches, the nurse tells the patient that these patches are most appropriately used for which situation? a. To prevent low blood pressure b. To relieve shortness of breath c. To prevent the occurrence of angina d. To keep the heart rate from rising too high during exercise

ANS: C Transdermal dosage formulations of nitroglycerin are used for the long-term prophylactic management (prevention) of angina pectoris. Transdermal nitroglycerin patches are not appropriate for the relief of shortness of breath, to prevent palpitations, or to control the heart rate during exercise. DIF: COGNITIVE LEVEL: Applying (Application) REF: p. 366 TOP: NURSING PROCESS: Implementation

5. The nurse is administering a stat dose of epinephrine. Epinephrine is appropriate for which situation? a. Severe hypertension b. Angina c. Cardiac arrest d. Tachycardia

ANS: C Treatment of cardiac arrest is an indication for the use of epinephrine. The other options are not indications for epinephrine. DIF: COGNITIVE LEVEL: Understanding (Comprehension) REF: p. 302 TOP: NURSING PROCESS: Assessment

4. When administering heparin subcutaneously, the nurse will follow which procedure? a. Aspirating the syringe before injecting the medication b. Massaging the site after injection c. Applying heat to the injection site d. Using a - to -inch 25- to 28-gauge needle

ANS: D A - to -inch 25- to 28-gauge needle is the correct needle to use for a subcutaneous heparin injection. The other options would encourage hematoma formation at the injection site. DIF: COGNITIVE LEVEL: Applying (Application) REF: p. 429 TOP: NURSING PROCESS: Implementation

4. A 58-year-old man has had a myocardial infarction (MI), has begun rehabilitation, and is ready for discharge. He is given a prescription for metoprolol (Lopressor) and becomes upset after reading the patient education pamphlet. "I don't have high blood pressure—why did my doctor give me this medicine?" Which explanation by the nurse is correct? a. "This medication will prevent blood clots that may lead to another heart attack." b. "Beta blockers will improve blood flow to the kidneys." c. "This drug is prescribed to prevent the high blood pressure that often occurs after a heart attack." d. "Studies have shown that this medication has greatly increased survival rates in patients who have had a heart attack."

ANS: D Beta blockers are frequently given to patients after they have suffered an MI because of their cardioprotective properties. The other responses are incorrect. DIF: COGNITIVE LEVEL: Analyzing (Analysis) REF: p. 313 TOP: NURSING PROCESS: Implementation

8. A patient has been taking a beta blocker for 4 weeks as part of his antianginal therapy. He also has type II diabetes and hyperthyroidism. When discussing possible adverse effects, the nurse will include which information? a. "Watch for unusual weight loss." b. "Monitor your pulse for increased heart rate." c. "Use the hot tub and sauna at the gym as long as time is limited to 15 minutes." d. "Monitor your blood glucose levels for possible hypoglycemia or hyperglycemia."

ANS: D Beta blockers can cause both hypoglycemia and hyperglycemia. They may also cause weight gain if heart failure is developing, and decreased pulse rate. The use of hot tubs and saunas is not recommended because of the possibility of hypotensive episodes. DIF: COGNITIVE LEVEL: Understanding (Comprehension) REF: p. 367 TOP: NURSING PROCESS: Implementation

2. A patient is receiving thrombolytic therapy, and the nurse monitors the patient for adverse effects. What is the most common undesirable effect of thrombolytic therapy? a. Dysrhythmias b. Nausea and vomiting c. Anaphylactic reactions d. Internal and superficial bleeding

ANS: D Bleeding, both internal and superficial, as well as intracranial, is the most common undesirable effect of thrombolytic therapy. The other options list possible adverse effects of thrombolytic drugs, but they are not the most common effects. DIF: COGNITIVE LEVEL: Remembering (Knowledge) REF: p. 424 TOP: NURSING PROCESS: Evaluation

7. The nurse is reviewing discharge teaching for a patient who will be taking digoxin (Lanoxin) therapy. The nurse will teach the patient to avoid which foods when taking the digoxin? a. Leafy green vegetables b. Dairy products c. Grapefruit juice d. Bran muffins

ANS: D Bran, in large amounts, may decrease the absorption of oral digitalis drugs. The other foods do not affect digoxin levels. DIF: COGNITIVE LEVEL: Understanding (Comprehension) REF: p. 385 TOP: NURSING PROCESS: Implementation

6. A calcium channel blocker (CCB) is prescribed for a patient, and the nurse provides instructions to the patient about the medication. Which instruction is correct? a. Chew the tablet for faster release of the medication. b. To increase the effect of the drug, take it with grapefruit juice. c. If the adverse effects of chest pain, fainting, or dyspnea occur, discontinue the medication immediately. d. A high-fiber diet with plenty of fluids will help prevent the constipation that may occur.

ANS: D Constipation is a common effect of CCBs, and a high-fiber diet and plenty of fluids will help to prevent it. Grapefruit juice decreases the metabolism of CCBs. Extended-release tablets must never be chewed or crushed. These medications should never be discontinued abruptly because of the risk for rebound hypertension. DIF: COGNITIVE LEVEL: Applying (Application) REF: p. 373 TOP: NURSING PROCESS: Implementation

1. A patient about to receive a morning dose of digoxin has an apical pulse of 53 beats/min. What will the nurse do next? a. Administer the dose. b. Administer the dose, and notify the prescriber. c. Check the radial pulse for 1 full minute. d. Withhold the dose, and notify the prescriber.

ANS: D Digoxin doses are held and the prescriber notified if the apical pulse is 60 beats/min or lower or is higher than 100 beats/min. The other options are incorrect. DIF: COGNITIVE LEVEL: Applying (Application) REF: p. 385 TOP: NURSING PROCESS: Implementation

4. A patient has been taking digoxin at home but took an accidental overdose and has developed toxicity. The patient has been admitted to the telemetry unit, where the physician has ordered digoxin immune Fab (Digifab). The patient asks the nurse why the medication is ordered. What is the nurse's best response? a. "It will increase your heart rate." b. "This drug helps to lower your potassium levels." c. "It helps to convert the irregular heart rhythm to a more normal rhythm." d. "This drug is an antidote to digoxin and will help to lower the blood levels."

ANS: D Digoxin immune Fab (Digifab) is the antidote for a severe digoxin overdose. It is given intravenously. The other options are incorrect. DIF: COGNITIVE LEVEL: Applying (Application) REF: p. 383 TOP: NURSING PROCESS: Implementation

10. The nurse is preparing to administer dopamine. Which is the correct technique for administering dopamine? a. Orally b. Intravenous (IV) push injection c. Intermittent IV infusions (IV piggyback) d. Continuous IV infusion with an infusion pump

ANS: D Dopamine is available only as an IV injectable drug and is given by continuous infusion, using an infusion pump. The other options are incorrect. DIF: COGNITIVE LEVEL: Applying (Application) REF: pp. 301-302 TOP: NURSING PROCESS: Implementation

9. A 49-year-old patient is in the clinic for a follow-up visit 6 months after starting a beta blocker for treatment of hypertension. During this visit, his blood pressure is 169/98 mm Hg, and he eventually confesses that he stopped taking this medicine 2 months ago because of an "embarrassing problem." What problem did the patient most likely experience with this medication that caused him to stop taking it? a. Urge incontinence b. Dizziness when standing up c. Excessive flatus d. Impotence

ANS: D Impotence is a potential adverse effect of beta blockers and may cause patients to stop taking the medication. The other options are not adverse effects of beta blockers. DIF: COGNITIVE LEVEL: Applying (Application) REF: p. 314 TOP: NURSING PROCESS: Implementation

12. The nurse is reviewing new medication orders for a patient who has an epidural catheter for pain relief. One of the orders is for enoxaparin (Lovenox), a low-molecular-weight heparin (LMWH). What is the nurse's priority action? a. Give the LMWH as ordered. b. Double-check the LMWH order with another nurse, and then administer as ordered. c. Stop the epidural pain medication, and then administer the LMWH. d. Contact the prescriber because the LMWH cannot be given if the patient has an epidural catheter.

ANS: D LMWHs are contraindicated in patients with an indwelling epidural catheter; they can be given 2 hours after the epidural is removed. This is very important to remember, because giving an LMWH with an epidural has been associated with epidural hematoma. DIF: COGNITIVE LEVEL: Analyzing (Analysis) REF: p. 416 TOP: NURSING PROCESS: Planning

3. During initial rounds, the nurse notes that a dobutamine infusion has extravasated into the forearm of a patient. After stopping the infusion, the nurse follows standing orders and immediately injects phentolamine (Regitine) subcutaneously in a circular fashion around the extravasation site. What is the mechanism of action of the phentolamine in this situation? a. It neutralizes the extravasated dobutamine immediately. b. It causes arterial vasoconstriction and reduced pain and swelling at the site. c. It increases peripheral vascular resistance and reduces arterial pressure at the site. d. It increases blood flow to the ischemic site by vasodilation to prevent tissue damage.

ANS: D Phentolamine is an alpha blocker that reduces peripheral vascular resistance when given systemically, but local subcutaneous injection around the site of extravasated vasoconstrictive drugs, such as dobutamine, causes an alpha-adrenergic receptor blockade and vasodilation. This allows for increased blood flow to the ischemic tissue and may prevent permanent tissue damage. DIF: COGNITIVE LEVEL: Understanding (Comprehension) REF: p. 312 TOP: NURSING PROCESS: Implementation

7. A 14-year-old patient has been treated for asthma for almost 4 months. Two weeks ago, she was given salmeterol as part of her medication regimen. However, her mother has called the clinic to report that it does not seem to work when her daughter is having an asthma attack. Which response by the nurse is appropriate? a. "It takes time for a therapeutic response to develop." b. "She is too young for this particular medication; it will be changed." c. "She needs to take up to two puffs every 4 hours to ensure adequate blood levels." d. "This medication is indicated for prevention of bronchospasms, not for relief of acute symptoms."

ANS: D Salmeterol is indicated for the prevention of bronchospasms, not treatment of acute symptoms. The dosage is usually two puffs twice daily, 12 hours apart, for maintenance effects in patients older than 12 years of age. The other options are incorrect. DIF: COGNITIVE LEVEL: Applying (Application) REF: p. 306 TOP: NURSING PROCESS: Implementation

2. The nurse is giving intravenous nitroglycerin to a patient who has just been admitted because of an acute myocardial infarction. Which statement is true regarding the administration of the intravenous form of this medication? a. The solution will be slightly colored green or blue. b. The intravenous form is given by bolus injection. c. It can be given in infusions with other medications. d. Non-polyvinylchloride (non-PVC) plastic intravenous bags and tubing must be used.

ANS: D The non-PVC infusion kits are used to avoid absorption and/or uptake of the nitrate by the intravenous tubing and bag and/or decomposition of the nitrate. The medication is given by infusion via an infusion pump and not with other medications. It is not given by bolus injection. If the parenteral solution is discolored blue or green, it should be discarded. DIF: COGNITIVE LEVEL: Applying (Application) REF: p. 372 TOP: NURSING PROCESS: Implementation

5. A patient has been placed on a milrinone (Primacor) infusion as part of the therapy for end-stage heart failure. What adverse effect of this drug will the nurse watch for when assessing this patient during the infusion? a. Hypertension b. Hyperkalemia c. Nausea and vomiting d. Cardiac dysrhythmias

ANS: D The primary adverse effects seen with milrinone are cardiac dysrhythmias, mainly ventricular. It may also cause hypotension, hypokalemia, and other effects, but not nausea and vomiting. DIF: COGNITIVE LEVEL: Applying (Application) REF: p. 381 TOP: NURSING PROCESS: Assessment

1. A patient has been prescribed warfarin (Coumadin) in addition to a heparin infusion. The patient asks the nurse why he has to be on two medications. The nurse's response is based on which rationale? a. The oral and injection forms work synergistically. b. The combination of heparin and an oral anticoagulant results in fewer adverse effects than heparin used alone. c. Oral anticoagulants are used to reach an adequate level of anticoagulation when heparin alone is unable to do so. d. Heparin is used to start anticoagulation so as to allow time for the blood levels of warfarin to reach adequate levels.

ANS: D This overlap therapy is required in patients who have been receiving heparin for anticoagulation and are to be switched to warfarin so that prevention of clotting is continuous. This overlapping is done purposefully to allow time for the blood levels of warfarin to rise, so that when the heparin is eventually discontinued, therapeutic anticoagulation levels of warfarin will have been achieved. Recommendations are to continue overlap therapy of the heparin and warfarin for at least 5 days; the heparin is stopped after day 5 when the international normalized ratio (INR) is above 2. DIF: COGNITIVE LEVEL: Applying (Application) REF: p. 417 TOP: NURSING PROCESS: Implementation

9. What action is often recommended to help reduce tolerance to transdermal nitroglycerin therapy? a. Omit a dose once a week. b. Leave the patch on for 2 days at a time. c. Cut the patch in half for 1 week until the tolerance subsides. d. Remove the patch at bedtime, and then apply a new one in the morning.

ANS: D To prevent tolerance, remove the transdermal patch at night for 8 hours, and apply a new patch in the morning. Transdermal patches must never be cut or left on for 2 days, and doses must not be omitted. DIF: COGNITIVE LEVEL: Applying (Application) REF: p. 365 TOP: NURSING PROCESS: Implementation

29.1 The young client has a history of multiple allergies, and the physician prescribed epinephrine (EpiPen) for prevention of anaphylactic shock. The client's mother says to the nurse, "I thought shock was about heart failure." What is the best response by the nurse? 1. "There are many kinds of shock that also include infection, nervous system damage, and loss of blood." 2. "Heart failure is the most serious kind of shock; others include infection, kidney failure, and loss of blood." 3. "There are many kinds of shock: heart failure, nervous system damage, loss of blood, and respiratory failure." 4. "Allergic response is the most fatal type of shock; other types involve loss of blood, heart failure, and liver failure."

Answer: 1 "There are many kinds of shock that also include infection, nervous system damage, and loss of blood." Rationale: Obvious bleeding suggests hypovolemic shock, trauma to the brain or spinal cord suggests neurogenic shock, inadequate cardiac output would suggest cardiogenic shock, a recent infection may indicate septic shock, and a history of allergies with a sudden onset of symptoms may suggest anaphylactic shock. Kidney failure is not a type of shock. Respiratory failure is not a type of shock. Liver failure is not a type of shock.

29.14 The client comes to the emergency department with a severe allergic reaction to peanuts, and is in serious respiratory distress. The client's spouse tells the nurse that the client has a known hypersensitivity to epinephrine (Adrenalin). What is the best response by the nurse? 1. "This is a life-threatening situation; a prior hypersensitivity is not an absolute contraindication." 2. "I will let the physician know about this immediately; we will need to choose an alternative medication." 3. "This is a problem; we will need to use IV diphenhydramine (Benadryl)." 4. "I'm not sure what we can use then. Do you know what has been used before with this allergic response?"

Answer: 1 "This is a life-threatening situation; a prior hypersensitivity is not an absolute contraindication." Rationale: Although epinephrine is contraindicated for known hypersensitivity to the drug, in life-threatening situations there are no absolute contraindications to its use. Diphenhydramine (Benadryl) may not be the best choice, and the nurse must speak with conviction to decrease anxiety in the patient and spouse.

29.7 A graduate nurse abruptly discontinues the intravenous (IV) norepinephrine (Levarterenol) once it has infused into the client. What is the priority action of the more experienced nurse? 1. Assess the client's blood pressure. 2. Notify the physician. 3. Administer oxygen via a rebreather mask. 4. Obtain an oxygen saturation reading with a pulse oximeter.

Answer: 1 Assess the client's blood pressure. Rationale: Discontinuation of vasopressor therapy is always gradual, due to the possibility of rebound hypotension and undesirable cardiac effects, so the nurse should immediately assess the client's blood pressure. The nurse will notify the physician, but the physician will want to know what the blood pressure is, so plan to assess blood pressure first. There is no indication to administer oxygen at this point. There is no indication to obtain an oxygen saturation percentage at this point.

29.9 The client has experienced hypovolemic shock as a result of severe burns. The physician orders a low dose of dopamine (Inotropin). What is the best evaluation by the nurse? 1. Urinary output of at least 50 mL/hour. 2. Increased cardiac output. 3. Vasoconstriction and increased blood pressure. 4. Stabilization of fluid loss.

Answer: 1 Urinary output of at least 50 mL/hour. Rationale: At low doses, dopamine (Inotropin) stimulates dopaminergic receptors, especially in the kidneys, leading to vasodilation and an increased blood flow through the kidneys. Increased cardiac output occurs with high, not low, doses of dopamine (Inotropin) when beta1-adrenergic receptors are stimulated. Vasoconstriction and increased blood pressure occurs with high, not low, doses of dopamine (Inotropin) when alpha-adrenergic receptors are stimulated. Dopamine (Inotropin) does not prevent or stabilize fluid loss.

29.3 The client comes to the emergency department with a severely infected pressure ulcer on the back. The client is in septic shock. The physician orders norepinephrine (Levophed) IV. Prioritize the nursing interventions for this client. 1. Connect the client to a cardiac monitor and pulse oximeter. 2. Assess the client's blood pressure. 3. Prepare for debridement of the pressure ulcer. 4. Administer oxygen. 5. Maintain a patient airway.

Answer: 1, 2, 3, 4, 5

29.10 The nurse works in a summer camp for children. One of the children says she was bitten by several wasps. The nurse plans to inject the child with epinephrine (EpiPen) if which symptoms are present? Select all that apply. 1. The child is restless and confused. 2. The child's skin feels warm and dry. 3. The child is thirsty. 4. The child's skin feels cold and clammy. 5. The child is hyperactive and hyperverbal.

Answer: 1, 3, 4 Rationale: General symptoms of shock include behavioral changes such as restlessness, anxiety, confusion, depression, and apathy. Thirst is a common complaint in shock. The skin may feel cold and clammy in shock. In shock, the skin is cold and clammy, not warm and dry. In shock, the client will not be hyperactive or hyperverbal.

29.4 The client is recovering from hypovolemic shock. The nurse hangs a bag of normal human serum albumin (Albutein) and educates the client about this fluid. The nurse evaluates that learning has occurred when the client makes which statement? 1. "It is a liquid that has electrolytes in it to pull water into my blood vessels." 2. "It is a protein that pulls water into my blood vessels." 3. "It is a protein that causes my kidneys to conserve fluid." 4. "It is a super-concentrated salt solution that helps me conserve body fluid."

Answer: 2 "It is a protein that pulls water into my blood vessels." Rationale: Colloids are proteins or other large molecules that stay suspended in the blood for long periods because they are too large to easily cross membranes. They draw water molecules from the cells and tissues into the blood vessels through their ability to increase plasma oncotic pressure. Crystalloids are intravenous (IV) solutions that contain electrolytes, not proteins, in concentrations resembling those of plasma. They are used to replace lost fluids and promote urine output. Normal human serum albumin (Albutein) does not act on the kidneys. Normal human serum albumin is not a concentrated saline solution.

29.12 The physician has prescribed phenylephrine (Neo-Synephrine) for an elderly client. What is an important nursing assessment prior to administration of this drug? 1. A history of dizziness. 2. A history of narrow angle glaucoma. 3. A history of diabetes mellitus, type I. 4. A history of human immunodeficiency virus (HIV) infection.

Answer: 2 A history of narrow angle glaucoma. Rationale: Vasoconstrictors may increase intraocular pressure, so the nurse should assess for narrow angle glaucoma. Dizziness is a general symptom and not specific to this drug. Diabetes mellitus, type I is not adversely affected by administration of a vasoconstrictor drug. Human immunodeficiency virus (HIV) infection is not adversely affected by administration of a vasoconstrictor drug.

29.15 The client is receiving norepinephrine (Levophed). When monitoring the client's blood pressure, the nurse notes a pressure of 230/120 mm/Hg. What is the priority nursing action? 1. Notify the physician. 2. Stop the infusion. 3. Slow the rate of the infusion until the physician assesses the client. 4. Assess the client for signs/symptoms of a stroke.

Answer: 2 Stop the infusion Rationale: Discontinuing the infusion results in a reversal of adverse effects such as hypertension. The nurse would notify the physician, but this should occur after discontinuing the infusion. The infusion must be stopped, not slowed, before the client experiences the adverse effects of extreme hypertension.

29.6 The client is receiving human serum albumin (Albutein) as treatment for shock. What is a priority assessment by the nurse? 1. Auscultate for an absence of breath sounds in the lower lobes. 2. Auscultate breath sounds for hyper-resonance. 3. Auscultate breath sounds for crackles. 4. Auscultate breath sounds for inspiratory stridor.

Answer: 3 Auscultate breath sounds for crackles. Rationale: Because human serum albumin (Albutein) pulls fluid into the vascular space, circulatory overload is a serious complication. The nurse must monitor breath sounds; crackles will be heard with pulmonary congestion. An absence of breath sounds is heard with a pneumothorax, not with pulmonary edema. Hyper-resonance is assessed by percussion, not auscultation. Stridor is auscultated with airway obstruction, not pulmonary edema.

29.2 The client comes to the emergency department after suffering a bilateral traumatic amputation of his lower extremities. The physician orders normal serum albumin (Albuminar). The client goes into shock. What will the best nursing assessment of this client reveal? 1. B/P: 130/88 mm/Hg, P: 90, bounding, R: 32, and shallow. 2. B/P: 50/0 mm/Hg, P: 126, weak and thready, R: 14, and shallow. 3. B/P: 80/20 mm/Hg, P: 122, weak and thready, R: 28, and shallow. 4. B/P: 140/90 mm/Hg, P: 46, weak and irregular, R: 24, and shallow.

Answer: 3 B/P: 80/20 mm/Hg, P: 122, weak and thready, R: 28, and shallow. Rationale: The central problem with hypovolemic shock is the inability of the cardiovascular system to send sufficient blood to the vital organs, with the heart and brain being affected early in the progression of the disease. Assessing the client's cardiovascular status will result in a blood pressure that is low, a heart rate that may be rapid with a weak, thready pulse, and breathing that is rapid and shallow. A client in shock will have a low blood pressure and a rapid, weak, not bounding, pulse. A client in shock will have rapid respirations, a respiratory rate of 14 is considered normal. A client in shock will have a low blood pressure; the heart rate will be rapid, not slowed.

29.8 The physician orders dopamine (Dopastat) intravenous (IV) for the client in shock. What is a priority plan of the nurse with regard to administration of this drug? 1. Have epinephrine (Adrenalin) available in the room. 2. Have naltrexone (Revia) available in the room. 3. Have phentolamine (Regitine) available in the room. 4. Have flumazenil (Romazicon) available in the room.

Answer: 3 Have phentolamine (Regitine) available in the room. Rationale: Extravasation of dopamine (Dopastat) can cause severe, localized vasoconstriction resulting in tissue necrosis. The antidote for this is phentolamine (Regitine). Epinephrine is used for anaphylaxis. Naltrexone (Revia) is used for opiate overdose. Flumazenil (Romazicon) is used for benzodiazepine overdose.

29.5 The client is in shock with a blood pressure of 60/20 mm/Hg. The physician orders isoproterenol (Isuprel) intra-venously (IV). The family is quite anxious and asks what "that liquid" is for. What is the best response of the nurse? 1. "It is called a vasopressor and will help the kidneys increase and maintain blood pressure." 2. "This drug is a vasopressor and helps the heart beat more effectively, which will increase blood pressure." 3. "Vasopressor drugs act on the renin-angiotension system and thus increase blood pressure." 4. "This drug is a vasopressor and will help stabilize blood pressure by making the blood vessels smaller."

Answer: 4 "This drug is a vasopressor and will help stabilize blood pressure by making the blood vessels smaller." Rationale: In early shock, the body compensates for the fall in blood pressure by activating the sympathetic nervous system. The body's ability is limited, so sympathomimetic vasoconstrictors, known as vasopressors, have been used to stabilize blood pressure in shock clients. Vasopressors do not act on the kidneys. Vasopressors do not increase cardiac contractility. Vasopressors do not affect the renin-angiotension system.

29.11 The client is receiving normal serum albumin (Albuminar). What will be a priority outcome with this client? 1. The client will remain alert and oriented. 2. The client will be normotensive, not hypertensive. 3. The client will be free of a rash. 4. The client will experience adequate breathing patterns.

Answer: 4 The client will experience adequate breathing patterns. Rationale: Albumin is a natural blood product and allergic reactions are possible. A serious symptom of an allergic reaction is dyspnea or difficulty breathing. Alertness and orientation are important, but are not priority outcomes. Hypotension, not hypertension, is a possible adverse outcome with normal serum albumin (Albuminar). A rash is a possible adverse outcome, but is not as much of a priority as dyspnea.

29.20 Examples of vasoconstrictors used to treat shock include all of the following except: a. Propranolol (Inderal). b. Norepinephrine (Levophed). c. Mephentermine (Wyamine). d. Phenylephrine (Neo-synephrine).

Answer: A Propranolol (Inderal).

29.18 What would the expected first treatment of shock be? a. Start an intravenous line. b. Take the blood pressure. c. Assess level of consciousness. d. Maintain the airway.

Answer: D Maintain the airway.

29.19 Colloids differ from crystalloids in that: a. They contain electrolytes. b. They readily leave the blood and enter cells. c. They promote urine output. d. They are too large to cross membranes.

Answer: D They are too large to cross membranes.

29.16 Hypovolemic shock is different from neurogenic shock in that it relates to: a. Inadequate cardiac output. b. An infectious process. c. A brain or spinal cord trauma. d. Volume depletion.

Answer: D Volume depletion.