Pharmacology Exam 2 Material
A patient is prescribed spironolactone [Aldactone] for treatment of hypertension. Which foods should the nurse teach the patient to avoid? A Baked fish B Low-fat milk C Salt substitutes D Green beans
Answer: C Rationale: Spironolactone is a potassium-sparing diuretic. Medications that are potassium sparing, potassium supplements, and salt substitutes should be avoided. High-potassium foods should also be avoided.
what is postural hypotension?
a fall in blood pressure brought on by moving from supine or seated position to an upright position
What is Adenosine made from?
its a naturally occurring nucleotide
What is the treatment of choice for left side heart failure that would quickly treat a patient's heart failure symptoms?
o Diuretics are the first line drug for all patients with signs of volume overload or a history of volume overload.
Nicotinic acid (Niaspan) side effects (select all that apply)
(flushing, itching) GI tract (gastric upset, nausea, vomiting, diarrhea). response. hepatotoxicity Niacin can elevate blood levels of uric acid. Use with caution with patients with gout or hyperuricemia. Hyperglycemia and gouty arthritis are additional adverse effects.
therapeutic uses for furosemide (lasix)
(reserved for rapid/massive fluid mobilization) Pulmonary edema Edema of hepatic, cardiac or renal origin that is unresponsive to other diuretics Hypertension Patient that need a diuretic that have low renal blood flow
What medications would require close monitoring for digoxin toxicity if taken along with digoxin
* Diuretics (Thiazide and Loop Diuretics they increase potassium loss). * ACE Inhibitors and ARBS (drugs increase potassium levels). * Sympathomimetics (Dobutamine and Dopamine which increase contractile force of heart). * Quinidine (can cause Digoxin levels to rise) * Verapamil ( increases plasma digoxin levels).
education for discharging a patient with nitroglycerin tablets
* Patient should be informed on how to take sublingual drugs (under tongue) , and not chewed * Tablets should be stored in moisture free environment , in original container , closed tightly after
What is the purpose of administering a Thrombolytic drug following the onset of an MI?
1. Used to dissolve existing thrombi which are blood clots formed within a blood vessel or within the heart. Thrombosis (thrombus formation) reflects pathologic functioning of hemostatic mechanisms 2. Most useful when started early (for acute MI, within 4-6 hours or sooner) 3. Thrombolytics cause significant risk of bleeding with ICH (Intracranial Hemorrhage) being the greatest
how many doses of nitro can you give to a pt?
3, one every 5 minutes. check for bp and hr in between
Normal range for potassium level?
3.5-5 mEq/L
What symptoms should a patient be instructed when taking nitroglycerin that is an expected finding
> Initial therapy can cause headache > Orthostatic hypotension may develop due to decreased venous return, reducing cardiac output causing BP to fall > Reflex tachycardia may occur due to decreased venous return, which can cause sympathetic stimulation of the heart > All mentioned symptoms are due to vasodilation
education needed to provide to a patient regarding nitroglycerin for chest pain (How much, how often, when to contact 911, etc.)
> Nitroglycerin is given as 3 doses sublingually every 5 minutes (tablet or spray) and follow with IV therapy in the event of persistent ischemia or hypertension. If pain does not improve after third nitro, then it is an emergency situation. > Preparations of nitroglycerin that are rapid onset are used to stop an ongoing angina attack, also prophylactically to protect against acute angina (taken before exertion). > Long acting preparations are used to provide sustained protection against angina attack, they are administered on a fixed schedule (but one that permits at least 8 drug free hours each day ) > A patient should call 911 if pain is not relieved in 5 minutes, while awaiting emergency care , they can take 1 more tablet , and then a third 5 minutes later. > Transdermal patches should be applied to clean hairless area of skin using a new patch, and different site everyday . Patients should remove after 12 - 14 hrs allowing 10 to 12 "patch free" hrs each day , to prevent tolerance.
How does a thiazide diuretic impact a type 2 diabetic?
A thiazide may elevate the glucose levels of a type 2 diabetic. They should be diligent to monitor and maintain glucose levels by using larger insulin doses or hypoglycemic (antihyperglycemic) drugs.
A patient with stage 2 hypertension has been prescribed a thiazide diuretic and an angiotensin-converting enzyme inhibitor. It is most appropriate for the nurse to do what? A Contact the health care provider. B Administer both drugs to the patient. C Administer the thiazide diuretic at bedtime. D Hold the medications if the blood pressure is normal.
Answer: A Rationale: A combination of drugs is used to treat stage 2 hypertension; each drug has a different mechanism of action. The nurse should administer antihypertensive medications even if the blood pressure is normal. Thiazide diuretics should be given in the morning because of diuresis
A patient with stage 2 hypertension has been prescribed a thiazide diuretic and an angiotensin-converting enzyme inhibitor. It is most appropriate for the nurse to do what? A Contact the health care provider. B Administer both drugs to the patient. C Administer the thiazide diuretic at bedtime. D Hold the medications if the blood pressure is normal.
Answer: A Rationale: A combination of drugs is used to treat stage 2 hypertension; each drug has a different mechanism of action. The nurse should administer antihypertensive medications even if the blood pressure is normal. Thiazide diuretics should be given in the morning because of diuresis.
The nurse teaches a patient about benazepril [Lotensin]. Which statement by the patient requires an intervention by the nurse? A "I use NoSalt instead of salt to season foods." B "I eat sweet potatoes once or twice a week." C "I drink 4 ounces of prune juice each morning." D "I like asparagus because it's high in vitamin K."
Answer: A Rationale: An adverse effect of angiotensin-converting enzyme (ACE) inhibitors (for example, benazepril) is hyperkalemia. Significant potassium accumulation is usually limited to patients taking potassium supplements, salt substitutes (which contain potassium), or a potassium-sparing diuretic. Patients should be instructed to avoid potassium supplements and potassium-containing salt substitutes unless they are prescribed. Sweet potatoes and prune juice are foods high in potassium; asparagus is high in vitamin K. Foods high in vitamin K are restricted for patients who are prescribed warfarin [Coumadin].
Cholestyramine has been prescribed for a patient. Which instruction should the nurse include in patient teaching? A Cholestyramine can impair absorption of fat-soluble vitamins. B Stop taking the drug if you develop constipation. C Take cholestyramine with other drugs you are prescribed to enhance absorption. D Do not take the medication if the formula is cloudy after mixing with water.
Answer: A Rationale: Cholestyramine is a bile acid sequestrant. Cholestyramine can impair absorption of fat-soluble vitamins (A, D, E, and K); vitamin supplements may be required. Cholestyramine causes constipation; patients should be informed that constipation can be minimized by increasing dietary fiber and fluids. A mild laxative may be used if needed. Instruct patients taking cholestyramine or colestipol to notify the prescriber if constipation becomes bothersome, in which case a switch to colesevelam should be considered. Cholestyramine can bind with other drugs and prevent their absorption. Advise patients to administer other medications 1 hour before or 4 hours after cholestyramine. Cholestyramine powder should be mixed with water, fruit juice, soup, or pulpy fruit (for example, applesauce, crushed pineapple) to reduce the risk of esophageal irritation and impaction. Inform patients that the sequestrants are not water soluble, therefore the mixtures will be cloudy suspensions, not clear solutions.
The health care provider prescribes sustained-release verapamil [Calan SR] to an 82-year-old patient who takes digoxin [Lanoxin] daily. Which action is most appropriate for the nurse to take? A Monitor the patient's cardiac rhythm continuously. B Assess the patient for tachycardia and hypertension. C Maintain the patient on bed rest for 8 to 10 hours. D Reduce dietary fiber to prevent loose, watery diarrhea.
Answer: A Rationale: Digoxin and verapamil suppress impulse conduction through the atrioventricular (AV) node. When these drugs are used concurrently, the risk of AV block is increased. The cardiac rhythm of patients receiving both medications should be monitored closely. The patient should be monitored for bradycardia and hypotension. Bed rest is not indicated. Constipation may occur; increased dietary fiber and fluids are indicated to prevent constipation.
When providing discharge teaching for a patient who has been prescribed furosemide [Lasix], it is most important for the nurse to include which dietary items to prevent adverse effects of furosemide [Lasix] therapy? A Oranges, spinach, and potatoes B Baked fish, chicken, and cauliflower C Tomato juice, skim milk, and cottage cheese D Oatmeal, cabbage, and bran flakes
Answer: A Rationale: Furosemide may have the adverse effect of hypokalemia. Hypokalemia can be reduced by consuming foods that are high in potassium, such as nuts, dried fruits, spinach, citrus fruits, potatoes, and bananas.
The nurse will teach a patient who is prescribed niacin [Niacor] to prevent flushing of the face by doing what? A Drinking a full glass of water after taking the medication B Taking 325 mg of aspirin 30 minutes before each dose C Ingesting a meal before taking the medication D Increasing dietary fiber before and after each dose
Answer: B Rationale: Aspirin reduces flushing by preventing the synthesis of prostaglandins, which mediate the flushing response.
A patient is prescribed lovastatin [Mevacor]. The nurse will teach the patient to take the medication at which time? A With any meal B With the evening meal C 1 hour before breakfast D 2 hours after a meal
Answer: B Rationale: Lovastatin should be taken with the evening meal to increase absorption. Cholesterol synthesis normally increases during the night; statins are most effective when given in the evening.
The nurse instructs a patient about taking nifedipine [Procardia XL]. Which statement made by the patient indicates an understanding of medication teaching? A "I'll stop taking my beta blocker." B "The pill should be swallowed whole." C "The drug will cause constipation." D "This drug treats heart rhythm problems."
Answer: B Rationale: Patients should swallow sustained-release tablets whole, without crushing or chewing. Nifedipine may cause reflex tachycardia; beta blockers are prescribed to prevent reflex tachycardia. Nifedipine causes very little constipation. Nifedipine cannot be used to treat dysrhythmias.
A patient is prescribed a medication that causes venous dilation. It is most important for the nurse to teach the patient about what? A B-natriuretic peptide B Postural hypotension C Increased urination D Intermittent claudication
Answer: B Rationale: Postural hypotension may occur with drugs that promote the dilation of veins or that prevent the veins from constricting.
A patient diagnosed with heart failure has stage 1 hypertension. Which medication, if ordered by the health care provider, should the nurse question? A Angiotensin-converting enzyme inhibitor B Calcium channel blocker C Thiazide diuretic D Beta blocker
Answer: B Rationale: The patient with heart failure should not receive a calcium channel blocker (for example, verapamil, diltiazem); calcium channel blockers may act on the heart to decrease myocardial contractility, thereby further reducing cardiac output.
A patient diagnosed with heart failure has stage 1 hypertension. Which medication, if ordered by the health care provider, should the nurse question? A Angiotensin-converting enzyme inhibitor BCalcium channel blocker C Thiazide diuretic D Beta blocker
Answer: B Rationale: The patient with heart failure should not receive a calcium channel blocker (for example, verapamil, diltiazem); calcium channel blockers may act on the heart to decrease myocardial contractility, thereby further reducing cardiac output.
A patient is prescribed a medication that lowers the arterial blood pressure. The nurse should assess for which response by the body to restore the blood pressure? A Orthostatic hypotension B Fluid retention C Reflex tachycardia D Increased natriuresis
Answer: C Rationale: Drugs that lower the arterial pressure will trigger the baroreceptor reflex with the response of reflex tachycardia.
A patient is prescribed verapamil [Calan]. The nurse should assess the patient for which common adverse effects? A Atrial fibrillation, photosensitivity, and blurred vision B Tachycardia, stomatitis, and inflammation of the joints C Constipation, headache, and edema of the ankles and feet D Dry mouth, lymphadenopathy, and decreased appetite
Answer: C Rationale: The adverse effects of verapamil occur secondary to vasodilation. Common adverse effects include constipation, dizziness, facial flushing, headache, and edema of the ankles and feet.
A patient who is taking spironolactone [Aldactone] is prescribed losartan [Cozaar]. The nurse should take which action? A Assess for symptoms of hyperkalemia. B Observe for a hypertensive crisis. C Administer the medications as scheduled. D Evaluate for first-dose hypotension.
Answer: C Rationale: These medications may be administered together without serious drug interactions. Spironolactone is a potassium-sparing diuretic, and losartan is an angiotensin II receptor blocker (ARB). The hypotensive effects of ARBs are additive with those of other antihypertensive drugs. When an ARB is added to an antihypertensive regimen, dosages of the other drugs may require reduction. The patient would be observed for hypotension (not first-dose hypotension).
A patient is to receive a scheduled dose of diltiazem [Cardizem]. The nurse should hold the medication and contact the prescriber if which of the following is noted? A The patient's blood pressure is 112/64 mm Hg. B The patient's cardiac rhythm is atrial fibrillation. C The patient is complaining of chest pain. D The patient is in second-degree heart block.
Answer: D Rationale: Diltiazem is contraindicated in patients with second-degree or third-degree heart block; diltiazem can exacerbate cardiac dysfunction.
Which patient would most likely be prescribed sodium nitroprusside [Nitropress]? A A patient with a recent diagnosis of essential hypertension B A patient with heart failure who receives weekly home visits C A patient who is hypotensive after a myocardial infarction D A patient with a hypertensive crisis in the intensive care unit
Answer: D Rationale: Sodium nitroprusside is used to treat hypertensive emergencies. The medication is administered intravenously, with continuous monitoring of blood pressure.
The nurse cares for a patient who is prescribed oral bumetanide twice daily. It is most important for the nurse to take which action? A Monitor the patient for signs and symptoms of hyperkalemia. 2 Insert a urinary catheter and assess the hourly urine output. 3 Weigh the patient before administering each dose. 4 Schedule the medication to be given at 0800 and 1400.
Answer: D Rationale: The nurse should administer oral bumetanide with twice-a-day dosing at 0800 and 1400 to minimize nocturia. Daily weights should be obtained in the morning before eating. Patients receiving IV bumetanide are more likely to need hourly monitoring of urine output with a urinary catheter. Bumetanide may cause hypokalemia; signs and symptoms of hypokalemia include irregular heartbeat, muscle weakness, cramping, flaccid paralysis, leg discomfort, extreme thirst, and confusion.
verapamil 5 direct effects
By blocking calcium channels in the heart and blood vessels, verapamil has five direct effects: Blockade at peripheral arterioles causes dilation, thereby reducing the arterial pressure. Blockade at the arteries and arterioles of the heart increases coronary perfusion. Blockade at the SA node reduces the heart rate. Blockade at the AV node reduces AV node conduction. Blockade in the myocardium reduces the force of contraction
what are the causes of isotonic contraction
Causes: vomiting, diarrhea, kidney disease, and misuse of diuretics
Why do HMG-CoA Reductase Inhibitors (Statins) work better if taken at bedtime or with evening meal?
Dosing is done once daily. Evening meal or bedtime is more beneficial because endogenous (made inside the body) cholesterol synthesis increases during the night. Therefore, statins have the greatest impact when given at night.
adverse effects of furosemide (lasix)
Hyponatremia Hypochloremia Dehydration can cause thrombus and embolism Hypotension Hypokalemia (below 3.5 mEq/L) can result in dysrhythmia Ototoxicity hyperglycemia hyperuricemia increased LDL decreased HDL
treatment for hypertonic contraction
Hypotonic fluids or fluids that contain no solutes at all (D5W) Initial therapy - drink water
What medication is generally administered for pain relating to MI?
IV morphine
When would a patient be instructed to take atorvastatin (Lipitor)
Lipitor and all other statins should be taken in the evening.
lab values to monitor for warfarin (coumadin)
Prothrombin time - normal value 12 seconds INR (preferred) normal ratio is 2-3
pharmokinetics of furosemide (lasix)
Rapid onset oral: onset-60 min, last-8 hours IV onset-5 min, last-2 hours
adverse effects of nifedipine
Reflex tachycardia, peripheral edema, increases pain in patients with angina because of increased cardiac oxygen demand, flushing, dizziness, headache, gingival hyperplasia, and chronic eczematous rash in older patients
difference between nifedipine and verapamil
SEE TABLE**** 45-2 p489 Both have direct effects on heart and arterioles Nifedipine/ Verapamil Arterial dilation no / yes Effects on the heart lowers automaticity yes / yes lowers av conduction yes / yes lowers force of contraction yes/ yes
Education necessary for a patient taking a potassium-sparing diuretic
Take drugs with or after a meal (bc of GI effects) take in morning to decrease nocturia restrict potassium rich foods inform pt about possible menstrual irregularities and impotence Teach s/s of hypokalemia and importance of K monitoring (irregular heartbeat, muscle weakness, cramping, flaccid paralysis, leg discomfort, extreme thirst, confusion)
what is the treatment for isotonic contraction
Treatment: Lost volume should be replaced with fluids that are isotonic to plasma. This can be accomplished by infusing isotonic (0.9%) sodium chloride in sterile water (a solution containing both sodium and chloride)
lab values to monitor for Heparin
aPTT - normal value is 40 seconds (this is your blood clotting)
What would occur if a patient suddenly stopped taking a beta-adrenergic blocker prescribed for angina?
adrenergic administration can increase the incidence and intensity of angina attacks, and may precipitate MI
When assessing a patient's pulse where would you assess to determine patient's rhythm to determine if it is safe to administer digoxin?
apical pulse or Erb's point for a full minute
mechanism of furosemide (lasix)
blocks the sodium, chloride and potassium transporter in the ascending loop of Henle (potassium wasting)
adverse effects of verapamil
bradycardia, AV block, heart failure, peripheral edema, constipation, flushing, dizziness, headache, gingival hyperplasia, and chronic eczematous rash in older patients
What adverse effect would indicate a patient is not able to handle a beta-adrenergic blocker due to potential asthma in which the medication would not be the best medication for the patient?
bronchoconstriction- don't give to patients with asthma
Action of class III antidysrhythmic potassium channel blocker
delays repolarization of fast potentials
baseline assessment for verapamil and nifedipine
determine blood pressure and pulse rate and obtain lab evaluations of liver and kidney function. For patients with angina pectoris, obtain baseline data on the frequency and severity of angina attacks.
side effects of quinidine - what are the symptoms a patient should be aware of with cinchonism
diarrhea - to reduce this, take with meals cinchonism - Tinnitus, HA, nausea, vertigo, disturbed vision *** instruct pts to NOTIFY PRESCRIBER if s/s develop
drug interactions of furosemide (lasix)
digoxin ototoxic drugs potassium sparing diuretics lithium antihypertensives
What labs/values do you have to monitor a patient for while taking loop and thiazide diuretics?
electrolytes- sodium/ chlorine/ potassium/ magnesium glucose uric acid lipids weight (fluid imbalance)
Prototype diuretic
furosemide (lasix)
metabolic acidosis
headache decreased bp hyperkalemia muscle twitching changes in loc kussmaul respirations warm flushed skin n/v/d
determinants of cardiac output
heart rate stroke volume cardiac preload
Compare and contrast Heparin and warfarin (Coumadin) in regards what they are used for and why would one be given over the other?
heparin is the preferred anticoagulant for use during pregnancy and in situations that require rapid onset of anticoagulant effects including pulmonary embolism and massive DVT. Warfarin is well suited for lng term prophylaxis
Which diuretic produces the greatest degree of diuresis?
high ceiling (loop) diuretics - furosemide
What education concerning GI side effects of Niacin could the patient do to alleviate nausea?
niacin should be taken with meals to reduce GI upset
how long should the pts blood pressure be monitored following the first dose of ACE inhbitor?
o A patient's blood pressure should be monitored for several hours following first dose. o Also withdraw any diuretic 2-3 days before an ACE inhibitor first dose is given to reduce risk of first dose hypotension.
Hypokalemia is one of the most common causes of dysrhythmias in patients receiving digoxin, therefore there are times when MD's will place the patient on a potassium sparing diuretic. What education would then be necessary to discuss with the patient regarding their new medication in an effort to prevent hyperkalemia?
o Avoid foods high in potassium such as oranges, bananas, leafy greens. Avoid salt substitutes as they can contain Potassium. o Stress importance of patient to making sure they get their Digoxin serum levels checked frequently as this reduces the risks of cardiac dysrhythmias. o Teach patients to report S/S of hypokalemia also such as muscle weakness.
to avoid hyperkalemia what should a patient be instructed to avoid?
o Avoid salt substitutes, potassium supplements, potassium sparing diuretics, and possible aliskiren. o Avoid foods high in potassium like bananas, oranges, leafy greens, avocado, fish.
medications a patient should expect to be on indefinitely post and MI? (select all that apply)
o Beta blocker o ACE inhibitor or ARB o Anti platelet (Aspirin, Clopidrogrel, ticagrelor, or prasugrel) and Anticoagulant (Warfarin). o Statin
What signs are going to be seen with digoxin toxicity?
o Cardiac Signs and Symptoms: dysrhythmias, hypokalemia (s/s muscle weakness, as well as vomiting and diarrhea as they indicate a loss of potassium) o Non Cardiac Signs and Symptoms: Nausea, Vomiting, Anorexia, Fatigue, and Visual Disturbance (Halo effect).
reversal for severe toxicity of digoxin
o Fab antibody fragments such as Digibind, Digifab, reverse Digoxin severe toxicity but are very expensive. * Activated Charcoal and Cholestyramine are other agents that can be used to bind Digoxin and administered orally to suppress absorption in GI.
When would alteplase (Activase) need to be administered following an MI to be most effective?
o Fibrinolytic drugs (alteplase, reteplase, and tenecteplase) dissolve clots (via plasminogen to plasmin). Most effective when given early. Target 30 mins or less.
adverse effects of ACE inhibitors (safety alert)
o First-dose hypotension o Cough o Hyperkalemia (potassium retention) o Avoid the use of salt substitutes (contain potassium) o Angioedema- safety alert, can be life threatening, if patient reports edema of tongue, eye, or lips they must go to ED and never take and ACE inhibitor again. o Dysgeusia (distorted sense of taste) and rash o Renal failure o Neutropenia (mainly with captopril)
Assessment prior to administering digoxin?
o Gather baseline data on signs and symptoms of HF such as fatigue, weakness,JVD, edema. Determine baseline data for maximum activity without symptoms. o Laboratory tests such as serum electrolytes (especially potassium), and EKG, Ejection Fraction, and Kidney Function test.
What would you do if the HR was less than 60 beats per min when administering digoxin?
o IF HR is less than 60 beats per minute or if a change in rhythm is detected, withhold Digoxin and contact prescriber.
routine drug therapy following signs and symptoms of an acute MI.
o Oxygen, Aspirin, NSAID, Morphine, Beta Blockers, and Nitroglycerin.
What is the most effective way to preserve myocardial function following an MI?
o Reperfusion therapy- it restores blood flow to myocardium reducing myocardial 02 demand using finbrinolytic or PCI(percutaneous coronary intervention).
What medications would a nurse need to educate a patient with Stage B (they have no signs of symptoms but structural damage (like from and MI)?
o Stage B goal of treatment of HF is to stop the patient from having symptomatic HR. ACE inhibitors ARBs Beta blockers * ACE and ARBS can elevate potassium levels so you need to tell the patient to avoid foods high in potassium and salt substitutes.
What should the patients be instructed to do or be done if the patient is in the hospital to monitor if heart failure is being managed (What happens with fluid retention)?
o They need to monitor their weight daily as well as serum electrolyte levels. Monitor patient for third spacing if there is fluid retention. o Patients should be assessed for crackles in lungs to see if there is fluid on the lungs.
how to educate pt about postural hypotension to minimize effects?
o To avoid, avoid abrupt transition from a supine or seated position to an upright position, take transitions slow to give your blood a chance to react. Sit or lay down is lightheadedness or dizziness occur.
What supplements may be necessary for a patient to take while on loop and thiazide diuretics?
potassium, magnesium, fish oil
Therapeutic goal for Mannitol
prophylaxis of renal failure (by promoting diuresis) reduction of intracranial pressure reduction of intraocular pressure
Education for a patient on warfarin (Coumadin) (select all that apply)
provide purpose of treatment provide dosage size and timing stress importance of adherence provide pt with a chart to keep a record of warfarin use advise pt to avoid prolonged immobility advise to elevate legs when sitting avoid garments that constrict blood flow in legs exercise wear support hose teach pts how to monitor PT and INR at home
signs and symptoms of metabolic alkalosis
restlessness followed by lethargy tachycardia compensatory hypoventilation Confusion n/v/d tremors, muscle cramps tingling of fingers and toes hypokalemia
reversal agent and signs and symptoms for heparin toxicity
s/s: hemorrhaging reversal agent: protamine sulfate
reversal agent and signs and symptoms for warfarin toxicity
s/s: hemorrhaging reversal agent: Vitamin K
signs and symptoms of respiratory alkalosis
siezures deep rapid breathing hyperventilation tachycardia low or normal bp hypokalemia numbness and tingling of extremities lethargy and confusion light headedness N/V
why are beta blockers prescribed along with nifedipine?
to prevent reflex tachycardia that is caused by increased oxygen demand
digoxin levels
usage dose 0.125 mg per day therapeutic levels 0.5-0.8 ng/mL
What should a patient do to avoid developing a tolerance to nitroglycerin?
use lowest effective dose long acting variants should be used on set schedule which allows 8 drug free hours a day pain can be managed with nitrates for transdermal patch a 10 to 12 hr patch free interval should be used
what lung sound is indicative of bronchoconstriction
wheezing sounds