EXAM 2 - Lehne NCLEX Chapter Questions

Which phrase should the nurse use to best describe activation of a receptor?

A. An effect that causes the physiologic process to speed up

B. An effect that mimics the natural neurotransmitter for that receptor

C. An effect that improves the function of the receptor

D. An effect that causes the receptor to be more sensitive

B

The nurse is administering isoproterenol, a beta1 and beta2 agonist. The nurse understands activation of these two receptors will result in which expected drug effects?

Select all that apply.

A. Increased heart rate

B. Excessive drowsiness

C. Increased force of heart contraction

D. Decreased cardiac output

E. Bronchial dilation

F. Decreased glucose levels

A, C, E

The nurse knows that the advantage of patients having multiple types of receptors to regulate bodily functions is what?

A. Improved maximal efficacy

B. Reduction of side effects and toxicity

C. Higher degree of selectivity

D. Lower therapeutic index

C

Which organs are controlled primarily by the parasympathetic system?

Select all that apply.

A. Gastrointestinal tract

B. Respiratory tract

C. Cardiovascular system

D. Skin

E. Salivary glands

A, B, D, E

Which receptors below are considered adrenergic receptors?

Select all that apply

A. Alpha1

B. Beta2

C. Dopamine

D. Muscarinic

E. Beta1

F. Alpha2

A, B, C, E, F

The nurse is preparing to give a drug that stimulates the parasympathetic nervous system. Which patient response is an expected outcome of this drug?

A. Wheezing decreases due to bronchodilation.

B. Heart rate decreases to 60 beats per minute.

C. Diarrhea stool count decreases.

D. Oxygenation improves because of bronchodilation.

B

The nurse knows that which neurotransmitter is most commonly found at the synapses of the peripheral nervous system?

A. Norepinephrine

B. Epinephrine

C. Dopamine

D. Acetylcholine

D

A nurse gives a medication that inhibits acetylcholinesterase. How would this drug affect autonomic activity?

A. Parasympathetic activity would increase.

B. Parasympathetic signals would be depressed.

C. Sympathetic activity would increase.

D. Respiratory centers would be depressed.

A

A patient is experiencing symptoms of the fight-or-flight response. Which autonomic process stimulates this response?

A. Sympathetic system

B. Predominant tone of the organs

C. Baroreceptor reflex

D. Parasympathetic system

A

The nurse is preparing to give a drug to stimulate activation of adrenergic receptors. Which effects indicate sympathetic stimulation?

A. Increase in heart rate

B. Constriction of pupils

C. Atrioventricular block

D. Sinus bradycardia

A

Which receptors mediate responses to the neurotransmitter acetylcholine?

Select all that apply.

A. Alpha1

B. Beta2

C. Dopamine

D. Nicotinic

E. Muscarinic

D, E

The nurse is caring for a group of patients who are all receiving anticholinergic drugs. In which patient is an anticholinergic drug contraindicated?

A. A 60-year-old woman with an overactive bladder (OAB)

B. A 72-year-old man with glaucoma

C. A 45-year-old woman with peptic ulcer disease (PUD)

D. A 26-year-old man being prepared for surgery today

B

A nurse is preparing to give bethanechol [Urecholine]. What is an expected outcome of this drug?

A. Nondistended bladder

B. Increased heart rate and blood pressure

C. Improved pulse oximetry reading

D. Relief of cardiac rhythm problems

A

Antimuscarinic poisoning can result from overdose of antihistamines, phenothiazines, and tricyclic antidepressants. Differential diagnosis is important, because antimuscarinic poisoning resembles which other condition?

A. Epilepsy

B. Diabetic coma

C. Meningitis

D. Psychosis

D

Which label most aptly describes the drug atropine [Sal-Tropine]?

A. Cholinergic

B. Parasympatholytic

C. Muscarinic agonist

D. Parasympathomimetic

B

A nurse prepares to administer a new prescription for bethanechol [Urecholine]. Which information in the patient's history should prompt the nurse to consult with the prescriber before giving the drug?

A. Constipation

B. Hypertension

C. Psoriasis

D. Asthma

D

The nurse is caring for a patient receiving atropine. Which is a therapeutic indication for giving this drug?

A. Use as a preanesthesia medication

B. Treatment of tachycardias

C. Prevention of urinary retention

D. Reduction of intraocular pressure in glaucoma

A

Which symptom is the most indicative of muscarinic poisoning?

A. Constipation

B. Heart rate of 140 beats per minute

C. Blood pressure of 180/110 mm Hg

D. Blurred vision

D

Antimuscarinic adverse effects include which of the following?

Select all that apply.

A. Xerostomia

B. Blurred vision

C. Diarrhea

D. Decrease in intraocular pressure

E. Anhidrosis

A, B, E

The nurse is teaching a patient with a history of anaphylaxis how to use an EpiPen. Which statement made by the patient indicates that he understands the proper use of this drug?

A. "I will keep my medication in the refrigerator when I'm not using it."

B. "I should take this medication within 30 minutes of the onset of symptoms."

C. "I must remove my pants before injecting the medication into the leg."

D. "I will jab this medication firmly into my outer thigh if needed."

D

The nurse is preparing to give epinephrine by the IV push route. Which actions are essential before giving this drug?

Select all that apply.

A. Check the blood urea nitrogen (BUN) and creatinine levels.

B. Obtain insulin from the medication cart.

C. Assess the patency of the IV line.

D. Review the allergy history.

E. Assess the vital signs.

C, D, E

The nurse in the cardiac care unit is caring for a patient receiving epinephrine. Which assessment criterion takes priority in the monitoring for adverse effects of this drug?

A. Cardiac rhythm

B. Blood urea nitrogen

C. Central nervous system (CNS) tremor

D. Lung sounds

A

The nurse is reviewing drugs on the emergency cart with regard to their therapeutic action. Which medications can help initiate heart contraction during a cardiac arrest?

A. Topical phenylephrine

B. Subcutaneous terbutaline

C. Intravenous epinephrine

D. Inhaled albuterol

C

The nurse is caring for a patient receiving propranolol [Inderal]. Which clinical finding is most indicative of an adverse effect of this drug?

A. A heart rate of 100 beats per minute

B. Wheezing

C. A glucose level of 180 mg/dL

D. Urinary urgency

B

A patient is to be discharged home with a new prescription for prazosin [Minipress]. Which statement is most important for the nurse to include in the teaching plan?

A. "You should increase your intake of fresh fruits and vegetables."

B. "You should move slowly from a sitting to a standing position."

C. "Be sure to wear a Medic Alert bracelet while taking this medication."

D. "Take your first dose of this medication first thing in the morning."

B

The nurse is preparing to administer diltiazem and atenolol. What is the priority nursing intervention before administering these two medications to the patient?

A. Obtain blood glucose

B. Observe for lower leg edema

C. Assess the heart rate

D. Apply a pulse oximeter

C

The nurse notices significant edema surrounding and proximal to the peripheral intravenous (IV) site where epinephrine is being infused. Which action would the nurse anticipate first?

A. Prepare to administer phentolamine [Regitine].

B. Ensure that naloxone [Narcan] is available.

C. Institute the protocol for congestive heart failure (CHF).

D. Monitor the blood urea nitrogen (BUN), creatinine, and potassium levels.

A

Why does the nurse anticipate administering metoprolol [Lopressor] rather than propranolol [Inderal] for diabetic patients who need a beta-blocking agent?

A. Metoprolol is less likely to cause diabetic nephropathy.

B. Propranolol causes both beta1 and beta2 blockade.

C. Metoprolol helps prevent retinopathy in individuals with diabetes.

D. Propranolol is associated with a higher incidence of foot ulcers.

B

The nurse is caring for several patients prescribed propranolol [Inderal]. In which patient condition is propranolol [Inderal] contraindicated?

A. Cardiac dysrhythmias

B. Hypertension

C. Diabetes

D. Angina

C

A patient who abuses cocaine, opioids, and other drugs frequently abuses which drug?

A. Guanfacine

B. Reserpine

C. Methyldopa

D. Clonidine

D

The nurse is evaluating the teaching done with a patient who has a new prescription for transdermal clonidine [Catapres-TTS]. Which statement by the patient indicates understanding of the nurse's teaching?

A. "I will apply the patch to a hairless, intact skin area on my upper arm."

B. "I need to apply the patch before my evening meal."

C. "The patch will not cause any skin reaction."

D. "I will need to apply a new patch once every 3 to 4 days."

A

The nurse is preparing to administer a dose of clonidine [Catapres]. Which is the best description of the action of this drug?

A. It selectively activates alpha2 receptors in the central nervous system (CNS).

B. It causes peripheral activation of alpha1 and alpha2 receptors.

C. It depletes sympathetic neurons of norepinephrine.

D. It directly blocks alpha and beta receptors in the periphery.

A

Clonidine is an alpha2-adrenergic agonist that causes selective activation of alpha2 receptors in the CNS. This in turn reduces sympathetic outflow to the blood vessels and the heart. Although the body's responses are similar to those from a peripheral adrenergic blocker, clonidine's action occurs in the CNS.

Which statement is most appropriate for the nurse to include in the discharge teaching plan for a 30-year-old woman beginning a new prescription of clonidine [Catapres]?

A. "If you stop taking this drug abruptly, your blood pressure might go up very high."

B. "You will need to have your blood drawn regularly to check for anemia."

C. "Take this medication first thing in the morning to reduce nighttime wakefulness."

D. "This medication often is used to manage hypertension during pregnancy."

A

The nurse is assessing a patient in a clinic who has been taking clonidine [Catapres] for hypertension. Which clinical findings are most indicative of an adverse effect of this drug?

A. Cough and wheezing

B. Epigastric pain and diarrhea

C. Drowsiness and dry mouth

D. Positive Coombs' test result and anemia

C

The nurse should monitor for which adverse effect after administering hydrochlorothiazide [HydroDIURIL] and digoxin [Lanoxin] to a patient?

A. Digoxin toxicity

B. Decreased diuretic effect

C. Dehydration

D. Heart failure

A

The nurse is caring for a patient with heart failure who needs a diuretic. Which agent is likely to be chosen, because it has been shown to greatly reduce mortality in patients with heart failure?

A. Furosemide [Lasix]

B. Hydrochlorothiazide [HydroDIURIL]

C. Spironolactone [Aldactone]

D. Mannitol [Osmitrol]

C

The nurse is reviewing the home medication list with the patient. The nurse recognizes that hydrochlorothiazide is used primarily for which condition?

A. Hypertension

B. Edema

C. Diabetes insipidus

D. Protection against postmenopausal osteoporosis

A

The nurse is teaching a patient who has a new prescription for spironolactone [Aldactone]. Which statement by the patient indicates that the teaching was effective?

A. "I will use salt substitutes to lower my sodium intake."

B. "I will increase my intake of foods that are high in potassium."

C. "I will call my doctor if I begin having menstrual irregularities."

D. "I will take this medication at bedtime each evening."

C

Spironolactone is a potassium-sparing, aldosterone-blocking diuretic. As such, it can cause endocrine effects, such as gynecomastia, menstrual irregularities, impotence, hirsutism, and deepening of the voice. Patients taking spironolactone should avoid salt substitutes because they contain potassium, and high-potassium foods should be avoided with this drug. Ideally, all diuretics should be taken in the morning to prevent nocturia.

The nurse knows that diuretics mostly affect which function of the kidneys?

A. Cleansing and maintenance of extracellular fluid volume

B. Maintenance of acid-base balance

C. Excretion of metabolic waste

D. Elimination of foreign substances

A

Most diuretics block sodium and chloride reabsorption, thus affecting the maintenance of extracellular fluid volume.

The nurse plans to closely monitor for which clinical manifestation after administering furosemide [Lasix]?

A. Decreased pulse

B. Decreased temperature

C. Decreased blood pressure

D. Decreased respiratory rate

C

High-ceiling loop diuretics, such as furosemide, are the most effective diuretic agents. They produce more loss of fluid and electrolytes than any others. A sudden loss of fluid can result in decreased blood pressure. When blood pressure drops, the pulse probably will increase rather than decrease. Lasix should not affect respirations or temperature. The nurse should also closely monitor the patient's potassium level.

The nurse caring for a patient taking furosemide [Lasix] is reviewing the patient's most recent laboratory results, which are: sodium, 136 mEq/L; potassium, 3.2 mEq/L; chloride, 100 mEq/L; blood urea nitrogen, 15 mg/dL. What is the nurse's best action?

A. Administer Lasix as ordered.

B. Place the patient on a cardiac monitor.

C. Begin a 24-hour urine collection.

D. Hold the Lasix and notify the physician.

D

The nurse's best action is to hold the Lasix and notify the physician. Loop diuretics, such as furosemide, can cause significant potassium loss. The normal potassium level is 3.5 to 5 mEq/L. The remaining electrolyte levels are normal. Administering the Lasix could result in a critically low potassium level. Effects of low potassium include cardiac dysrhythmias. Placing a patient on a cardiac monitor requires a physician's order and would warrant further assessment first, such as taking vital signs and asking the patient whether he or she is having any cardiac-related symptoms. Collecting a 24-hour urine specimen is not appropriate in this case.

The nurse is preparing to administer IV potassium to a patient with hypokalemia. Which prescription is the most appropriate?

A. Potassium chloride 30 mEq in 100 mL IV over 1 hour

B. Potassium chloride 10 mEq in 100 mL IV over 30 minutes

C. Potassium chloride 10 mEq in 100 mL IV over 1 hour

D. Potassium chloride 10 mEq IV push over 1 minute

C

The nurse knows that which organ is primarily responsible for maintaining fluid volume and osmolality?

A. Liver

B. Kidneys

C. Blood vessels

D. Heart

B

The nurse is caring for a patient receiving IV therapy with a 3% sodium chloride infusion at 75 mL/hr. The nurse should closely monitor for which adverse effect of treatment?

A. Blood urea nitrogen of 22 mg/dL

B. Tenting of the skin and dry mucous membranes

C. Distended neck veins and ankle edema

D. Sodium level of 140 mEq/L

C

Complete the equation: Cardiac output = Volume of blood ejected at each heartbeat × __.

A. Stroke volume

B. Preload

C. Afterload

D. Heart rate

D

Which hemodynamic system serves as a reservoir for circulating blood?

A. Heart

B. Lungs

C. Arteries

D. Veins

D

What are the primary regulatory systems of arterial pressure?

Select all that apply.

A. Autonomic nervous system

B. Renin-angiotensin-aldosterone system

C. Renal system

D. Pulmonary system

E. P450 enzyme system

A, B, C

The nurse is caring for a patient prescribed aliskiren [Tekturna]. How does this medication lower blood pressure?

A. It blocks the conversion of angiotensin I to angiotensin II.

B. It prevents angiotensin II from binding to its receptors.

C. It inhibits the conversion of angiotensinogen into angiotensin I.

D. It selectively blocks aldosterone receptors in the kidneys.

C

Aliskiren is the first direct renin inhibitor on the market. It binds with renin and thus inhibits the conversion of angiotensinogen to angiotensin I. The other items describe ACE inhibitors, ARBs, and selective aldosterone receptor blockers.

The renin-angiotensin-aldosterone system plays an important role in maintaining blood pressure. Which compound in this system is most powerful at raising the blood pressure?

A. Angiotensin I

B. Angiotensin II

C. Angiotensin III

D. Renin

B

Angiotensin II is a potent vasoconstrictor. It participates in all the pathways regulated by the renin-angiotensin-aldosterone system. Angiotensin I is a precursor to angiotensin II; angiotensin III is formed by degradation of angiotensin II and is less potent. Renin catalyzes the conversion of angiotensinogen to angiotensin I.

The nurse has just administered the initial dose of enalapril [Vasotec] to a newly admitted patient with hypertension. What is the priority nursing intervention over the next several hours?

A. Monitor blood pressure.

B. Check the heart rate.

C. Auscultate lung sounds.

D. Draw a potassium level.

A

First-dose hypotension is a serious potential adverse effect of ACE inhibitors, such as enalapril. Monitoring the blood pressure is the priority nursing intervention. If hypotension develops, the nurse will place the patient in the supine position and possibly increase intravenous fluids. The other interventions may be appropriate for this patient; however, in the hours immediately after the first dose of an ACE inhibitor, monitoring of the blood pressure is most important.

Which medication is most likely to cause the side effect of constipation?

A. Nifedipine [Adalat]

B. Amlodipine [Norvasc]

C. Isradipine [DynaCirc]

D. Diltiazem [Cardizem]

D

Nifedipine, amlodipine, and isradipine, which are dihydropyridine calcium channel blockers, cause less risk of constipation than diltiazem and verapamil.

Calcium channel blockers work by reducing calcium influx into the cells of the heart and blood vessels. Calcium channels are coupled to which type of autonomic nervous system receptors?

A. Alpha 1

B. Alpha 2

C. Beta 1

D. Beta 2

C

Calcium channels are coupled to beta1-adrenergic receptors in the heart. For that reason, calcium channel blockers affect the heart in ways similar to the beta blockers. Both types of drugs cause a decrease in the force of contraction, heart rate, and cardiac impulse conduction.

The healthcare provider prescribes an intravenous dose of diltiazem [Cardizem] for treatment of a patient with atrial fibrillation. What is the priority nursing intervention?

A. Assist with cardioversion.

B. Monitor electrocardiogram.

C. Obtain baseline coagulation studies.

D. Assess for increased urinary output.

B

Monitor the electrocardiogram (ECG) continuously during IV administration of diltiazem for AV block, sudden reduction in heart rate, and prolongation of the PR or QT interval. Cardioversion is not necessary; however, have equipment for cardioversion available. Baseline laboratory studies are needed for liver and kidney function. Increased urinary output is not an adverse effect of diltiazem.

A patient with angina pectoris has been prescribed nifedipine [Procardia].Which possible adverse effects should the nurse expect with this medication?

Select all that apply.

A. Headache

B. Constipation

C. Nausea and vomiting

D. Edema of ankles and feet

E. Overgrowth of gum tissue

A, D, E

What is the most appropriate nursing consideration for a patient who is prescribed verapamil [Calan] and digoxin [Lanoxin]?

A. Restrict intake of oral fluids and high-fiber food.

B. Take an apical pulse for 30 seconds before administration.

C. Notify the healthcare provider of nausea, vomiting, and visual changes.

D. Hold the medications if the heart rate is greater than 110 beats per minute.

C

The nurse is caring for several patients. For which patient diagnosis would a prescription for nifedipine [Adalat] be least appropriate?

A. Angina pectoris

B. Essential hypertension

C. Atrial fibrillation

D. Vasospastic angina

C

Nifedipine produces very little blockade of the calcium channels of the heart; therefore, it is ineffective for treating dysrhythmias, such as atrial fibrillation. Therapeutic uses for nifedipine include the treatment of angina pectoris, essential hypertension, and vasospastic angina.

Which instructions should the nurse include when developing a teaching plan for a patient prescribed diltiazem [Cardizem] for atrial fibrillation?

Select all that apply.

A. Weigh yourself daily at the same time each day.

B. The medication will not cause dizziness or headache.

C. Notify the healthcare provider if a skin rash develops.

D. Do not take daily oral calcium supplements.

E. Rise slowly from a lying to a sitting position.

A, C, E

The nurse is teaching a patient who has just been prescribed a vasodilator. Which statement by the patient indicates that the teaching was effective?

A. "I can take this medication in the morning to reduce nighttime urination."

B. "I will rise slowly when changing from a sitting to a standing position."

C. "My heart rate may slow down with this drug. I will call if my pulse is below 60."

D. "I need to increase my intake of fluids and foods that are high in fiber."

B

Vasodilators may cause postural hypotension and reflex tachycardia. Patients should be taught to move slowly when changing positions to prevent dizziness.

The nurse is caring for a patient receiving hydralazine [Apresoline]. The healthcare provider prescribes propranolol [Inderal]. The nurse knows that a drug such as propranolol often is combined with hydralazine for what purpose?

A. To reduce the risk of headache

B. To improve hypotensive effects

C. To prevent heart failure

D. To protect against reflex tachycardia

B

The nurse is caring for a patient receiving a nitroprusside [Nipride] intravenous infusion. The patient's wife asks why furosemide [Lasix] is being prescribed along with this drug. The nurse's response is based on which concept?

A. Furosemide will help reduce reflex tachycardia.

B. Many vasodilators cause retention of sodium and water.

C. Thiocyanate may accumulate in patients receiving nitroprusside.

D. Vasodilators can cause serious orthostatic hypotension.

B

Which laboratory result may be a consequence of therapy with a thiazide diuretic?

A. Serum glucose level of 58 mg/dL

B. Serum potassium level of 5.3 mEq/L

C. Serum sodium level of 135 mEq/L

D. Serum uric acid level of 10.4 mg/dL

D

Hyperuricemia is a side effect of thiazide diuretics. Normal uric acid levels typically range from 3.6 to 8.5 mg/dL. Hyperglycemia, not hypoglycemia, and hypokalemia, not hyperkalemia, are side effects of thiazides. A serum sodium of 135 mEq/L is a normal value.

An adult male patient is taking medication for blood pressure management. The patient states to the nurse, "I'm not going to take these drugs anymore, because they are interfering with my sex life." What is the most appropriate response by the nurse?

A. "It is unfortunate these drugs can cause erectile dysfunction but managing your blood pressure is more important than your sexual performance."

B. "I understand how discouraging it must be to live with this adverse effect, but you could have a stroke if you do not take your blood pressure medications."

C. "Let's discuss this effect with your prescriber. There are other drugs available to manage your blood pressure that may not have the same adverse effect."

D. "I am glad you told me about your experience with this common side effect. Sexual performance can be a difficult subject to discuss."

C

Many antihypertensive medications can produce adverse sexual side effects, including impotence. It is important for the nurse to listen to the patient's concerns and to avoid making value judgments. Other antihypertensive medications may manage this patient's blood pressure without causing adverse sexual effects. Reducing the undesired effects of antihypertensive medication will improve the patient's adherence.

The nurse is caring for a patient who has diabetes and hypertension. Which medication is most likely to be prescribed to treat this patient's hypertension?

A. Hydrochlorothiazide [HCTZ]

B. Enalapril [Vasotec]

C. Propranolol [Inderal]

D. Methyldopa [Aldomet]

B

Preferred antihypertensives for patients with diabetes include ACE inhibitors (enalapril), ARBs, and calcium channel blockers. ACE inhibitors are particularly useful, because they slow the progression of diabetic nephropathy in addition to lowering blood pressure. Thiazide diuretics promote hyperglycemia and are used with caution.

Which medications should be used with caution in a hypertensive diabetic patient?

Select all that apply.

A. Furosemide [Lasix]

B. Metoprolol [Lopressor]

C. Diltiazem [Cardizem]

D. Hydrochlorothiazide [HCTZ]

E. Enalapril [Vasotec]

A, B, D

Hydrochlorothiazide and furosemide promote hyperglycemia, and metoprolol suppresses glycogenolysis and can mask signs of hypoglycemia. Therefore, these medications should be administered with caution to patients with diabetes. Diltiazem and enalapril do not cause either of these effects.

Which classes of medications are prescribed as initial therapy for hypertension after a myocardial infarction (MI)?

A. Diuretic and beta blocker

B. Beta blocker and ACE inhibitor

C. ACE inhibitor and calcium channel blocker

D. Diuretic and calcium channel blocker

B

Beta blockers and ACE inhibitors, as well as aldosterone antagonists, are the drug classes recommended for initial therapy of hypertension after an MI. Diuretics and calcium channel blockers are not part of initial therapy for hypertension after an MI.

The nurse reviews the medication treatment regimen for a patient with chronic hypertension. To promote optimal medication adherence, which frequency of drug dosing should the nurse advocate for this patient?

A. Once a day

B. Three times a day

C. Four times a day

D. Every 8 hours

A

The nurse understands that cholesterol is carried through the blood by lipoproteins. Which lipoprotein is most closely associated with coronary atherosclerosis?

A. Very-low-density lipoprotein (VLDL)

B. Apolipoprotein B-100

C. Low-density lipoprotein (LDL)

D. High-density lipoprotein (HDL)

C

Cholesterol is the primary core lipid of LDLs, which are responsible for carrying cholesterol to tissues outside the liver. Of all the lipoproteins, LDLs are the most significant contributors to coronary atherosclerosis. When pharmacologic agents are used to lower cholesterol, the primary goal is to reduce elevated LDL levels.

The nurse is teaching a group of patients about dietary approaches to reduce cholesterol levels. Which statement is most important to include in the teaching?

A. "Lower your cholesterol to 300 mg/day."

B. "Eliminate red meat and pork from your diet."

C. "Read food labels and reduce your intake of saturated fats."

D. "Reduce salt consumption to keep your sodium intake to 2400 mg/day."

C

An increase in dietary cholesterol intake does not produce a large increase in blood cholesterol because of the body's feedback system. When cholesterol intake increases, endogenous production decreases. However, because the body uses dietary saturated fats to make cholesterol, an increase in saturated fat intake can produce a significant increase in blood cholesterol levels. To lower blood cholesterol, it is most important to lower saturated fat intake. Although red meat and pork should be limited, it is not necessary to eliminate them from the diet. Sodium intake is not directly related to lowering cholesterol levels.

Which drug is the most effective for lowering LDL cholesterol?

A. Atorvastatin [Lipitor]

B. Cholestyramine [Questran]

C. Gemfibrozil [Lopid]

D. Ezetimibe [Zetia]

A

The statin drugs, such as atorvastatin, are the most effective drugs for lowering LDL cholesterol. They are better tolerated, have fewer adverse effects, and produce better clinical outcomes than any other agents available for lowering LDL.

The nurse is providing discharge teaching for a patient with a new prescription for a nitroglycerin transdermal patch. Which statement by the patient indicates a need for further teaching?

A. "I will remove my patch at bedtime each evening."

B. "I will limit my alcohol to one drink per day."

C. "I will not use Viagra as long as I am on nitroglycerin."

D. "I will move slowly when changing positions."

B

Alcohol can intensify the hypotensive effects of nitrates, so the patient should avoid alcohol. Patients develop tolerance to nitrates rather quickly. Patients receiving transdermal nitrates are recommended to have 10 to 12 hours of patch-free time each evening. Sildenafil [Viagra] and other drugs for erectile dysfunction also can cause significant hypotension with nitroglycerin and are contraindicated. Nitroglycerin causes orthostatic hypotension; therefore, patients should change positions slowly.

The home health nurse observes the patient for proper use of topical nitroglycerin ointment. Which action by the patient indicates the need for further teaching?

A. Rotates the application sites to minimize skin irritation

B. Uses the applicator paper to measure the prescribed dose

C. Removes ointment from a previous dose before applying the next dose

D. Applies the prescribed ribbon of ointment to the applicator paper and places it on the chest

D

The nurse is caring for a patient receiving nitrates for relief of angina. What pharmacodynamic action is responsible for the relief of anginal pain with nitrates?

A. Vasoconstriction leads to improved cardiac output.

B. Decreased force of contraction leads to decreased oxygen demand.

C. Vasodilation leads to decreased preload, which decreases oxygen demand.

D. Influx of calcium ions leads to relaxation of vascular smooth muscle.

C

The primary action of nitroglycerin is vasodilation, which leads to decreased venous return, decreased ventricular filling, and decreased preload, thus reducing oxygen demand on the heart.

Which are the main types of drugs used to prevent or relieve anginal pain?

Select all that apply.

A. Platelet inhibitors

B. Beta blockers

C. Nitrates

D. Calcium channel blockers

E. Statins

B, C, D

The three main types of antianginal drugs are organic nitrates, beta blockers, and calcium channel blockers. Platelet inhibitors and statins (unless contraindicated) are incorporated into the treatment plan to reduce the risk of myocardial infarction.

A patient with angina is being discharged with a prescription for nitroglycerin sublingual tablets. Which instruction should the nurse include?

A. "Store the tablets in the original container and tightly close it after use."

B. "The tablets are only good for 1 month after the container is opened."

C. "Sublingual nitroglycerin tablets are also effective when swallowed whole."

D. "Effects of sublingual nitroglycerin begin in 5 to 10 minutes."

A

The nurse understands patients receiving nitroglycerin are at risk for which adverse effects?

Select all that apply.

A. Headache

B. Wheezing

C. Dizziness

D. Tachycardia

E. Bradycardia

A, C, D

The primary adverse effects of nitroglycerin are headache; orthostatic hypotension, which can lead to dizziness; and reflex tachycardia.

Which medication combination is useful in the treatment of variant angina?

A. Metoprolol [Lopressor] and ranolazine [Ranexa]

B. Isosorbide dinitrate [Isordil] and metoprolol [Lopressor]

C. Diltiazem [Cardizem] and isosorbide mononitrate [Imdur]

D. Propranolol [Inderal] and diltiazem [Cardizem]

C

Variant angina, also known as Prinzmetal's or vasospastic angina, is a result of coronary artery vasospasm. Drug combinations used to prevent and/or relax the coronary artery are calcium channel blockers (eg, diltiazem) and organic nitrates (eg, isosorbide mononitrate). Beta blockers (metoprolol and propranolol) and ranolazine, although effective in stable angina, are ineffective for treating variant angina.

The heart undergoes cardiac remodeling during the initial phase of heart failure. Which cardiac geometric change occurs during heart failure?

A. Ventricular constriction

B. Ventricular wall thickening

C. Ventricular atrophy

D. Ventricles become more cylindric

B

may not need this card because one of these drugs is not on the test

The nurse is caring for a patient who takes spironolactone [Aldactone] and quinapril [Accupril] for treatment of heart failure. What finding indicates a potential interaction between these two drugs?

A. Elevated serum quinapril level

B. Heart rate of 58 bpm

C. Potassium level of 5.7 mEq/L

D. Glucose level of 180 mg/dL

C

Explanation: Both spironolactone, a potassium-sparing diuretic, and quinapril, an angiotensin-converting enzyme (ACE) inhibitor, can increase potassium levels. These agents together do not increase quinapril levels, lower the heart rate, or raise the blood glucose level.

About which patient should the nurse notify the healthcare provider immediately?

A. A patient who takes digoxin [Lanoxin] 0.125 mg orally daily with a serum digoxin level of 0.8 ng/mL

B. A patient who takes oral spironolactone [Aldactone] 25 mg daily and enalapril [Vasotec] 5 mg daily with a serum potassium level of 5.5 mEq/L

C. A patient who takes digoxin [Lanoxin] 0.25 mg orally daily with a serum potassium level of 4.0 mEq/L

D. A patient who takes oral lisinopril [Zestril] 5 mg daily and digoxin 0.125 mg daily with a serum digoxin level of 0.5 ng/mL

B

Explanation: Patients who take an aldosterone antagonist (spironolactone) are at risk for developing hyperkalemia. The risk is increased if an aldosterone antagonist and an ACE inhibitor (enalapril) are used together. The normal serum potassium level ranges from 3.5 to 5.0 mEq/mL. This patient is hyperkalemic, which increases the risk for electrocardiographic changes. The optimal range for the serum digoxin level is 0.5 to 0.8 ng/mL. The risk of digoxin toxicity increases when hypokalemia is present (potassium level below 3.5 mEq/L).

The nurse is preparing to administer an oral dose of digoxin [Lanoxin]. The apical pulse rate is 64. What nursing action is most appropriate?

A. Give the medication

B. Obtain a serum digoxin level

C. Notify the healthcare provider

D. Assess for signs of digoxin toxicity

A

Explanation: Determine heart rate and rhythm prior to administration. If heart rate is less than 60 beats/min or if a change in rhythm is detected, withhold digoxin and notify the healthcare provider.

What is the primary benefit of spironolactone [Aldactone] in patients with heart failure?

A. Increase in diuresis and fluid loss

B. Blockage of aldosterone receptors

C. Inhibition of beta activation by norepinephrine

D. Stimulation of the RAAS

B

Explanation: Spironolactone is a potassium-sparing diuretic that has been shown to prolong survival in patients with heart failure. It has only weak diuretic properties. The primary benefit of this drug is blockage of aldosterone receptors. It does not inhibit beta receptors, nor does it stimulate the renin-angiotensin-aldosterone system.

In the failing heart, arterial pressure falls, stimulating the baroreceptor reflex to increase sympathetic nervous system activity. The nurse understands increased sympathetic activity will produce which response?

A. Tachycardia

B. Bradypnea

C. Hypotension

D. Hypoglycemia

A

Explanation: Increased sympathetic activity results in an increased heart rate (tachycardia), increased contractility, increased venous tone, and increased arteriolar tone (elevated blood pressure). Sympathetic stimulation also causes bronchodilation (not bradypnea) and possibly hyperglycemia.

The nurse is caring for a patient prescribed digoxin [Lanoxin] for heart failure. Which finding would require immediate attention by the nurse?

A. Potassium level of 3.7 mEq/L

B. Digoxin level of 0.7 ng/mL

C. Vomiting and diarrhea

D. Heart rate of 68 bpm

C

Explanation: Vomiting and diarrhea can lead to hypokalemia, which increases the risk of digoxin toxicity. These symptoms, along with nausea, fatigue, and visual disturbances, also may precede digoxin toxicity and warrant further attention. The heart rate, potassium level, and digoxin level are within the normal range.

The nurse is preparing to administer a daily dose of digoxin [Lanoxin]. What is the priority nursing intervention?

A. Analyze heart rate and rhythm.

B. Asses for Homans' sign

C. Check BP

D. Palpate pedal pulses

A

Explanation: Before giving digoxin, the nurse will assess the heart rate and rhythm. The dosage will be held and the prescriber notified if the heart rate is below 60 beats per minute or if the cardiac rhythm has changed. Digoxin can cause bradycardia and electrical changes in the heart.

Which patient symptoms should cause the nurse to be concerned about digoxin [Lanoxin] toxicity? (select all that apply)

A. Fatigue

B. Vomiting

C. Dizziness

D. Blurred vision

E. Muscle weakness

A, B, D

Explanation: Dizziness is not a symptom of Digoxin, and muscle weakness is an early sign of hypokalemia.

The laboratory calls to report a drop in the platelet count to 90,000/mm3 for a patient receiving heparin for the treatment of postoperative deep vein thrombosis. Which action by the nurse is the most appropriate?

A. Notify the healthcare provider to discuss the reduction or withdrawal of heparin.

B. Call the healthcare provider to discuss increasing the heparin dose to achieve a therapeutic level.

C. Obtain vitamin K and prepare to administer it by intramuscular (IM) injection.

D. Observe the patient and monitor the activated partial thromboplastin time (aPTT) as indicated.

A

Heparin-induced thrombocytopenia (HIT) is a potential immune-mediated adverse effect of heparin infusions that can prove fatal. HIT is suspected when the platelet counts fall significantly. A platelet count below 100,000/mm3 would warrant discontinuation of the heparin.

Which instruction about clopidogrel [Plavix] should the nurse include in the discharge teaching for a patient who has received a drug-eluting coronary stent?

A. "Constipation is a common side effect of clopidogrel, so take a stool softener daily."

B. "If you see blood in your urine or black stools, stop the clopidogrel immediately."

C. "Check with your healthcare provider before taking any over-the-counter medications for gastric acidity."

D. "Keep the amounts of foods containing vitamin K, such as mayonnaise, canola and soybean oil, and green, leafy vegetables, consistent in your diet."

C

Proton pump inhibitors (PPIs), such as omeprazole [Prilosec], and CYP2C1 inhibitors, such as cimetidine [Tagamet], can be purchased over the counter to treat heartburn. However, patients taking clopidogrel should consult their healthcare provider before using them. PPIs and CYP2C1 inhibitors can reduce the antiplatelet effects of clopidogrel. Diarrhea (5% incidence), not constipation, is a side effect of clopidogrel. Patients should immediately contact their healthcare provider if signs of bleeding occur, such as bloody urine, stool, or emesis. The drug should not be stopped until the prescriber advises it, because this could lead to coronary stent restenosis. Consistency of vitamin K intake is indicated while taking warfarin [Coumadin].

The nurse is ready to begin a heparin infusion for a patient with evolving stroke. The baseline activated partial thromboplastin time (aPTT) is 40 seconds. Which aPTT value indicates that a therapeutic dose has been achieved?

A. 50

B. 70

C. 90

D. 110

B

The therapeutic level of heparin is achieved when the aPTT reaches 1.5 to 2 times normal. Thus, a range of 60 to 80 seconds would be appropriate for this patient.

A patient with nonvalvular atrial fibrillation is to be discharged on dabigatran etexilate [Pradaxa]. Which statement should the nurse include in the discharge teaching?

A. "The medication must be stored in the manufacturer-supplied bottle."

B. "Once a new bottle is opened, the capsules maintain efficacy for 90 days."

C. "If you have difficulty swallowing the capsule, you can open it and mix it with food."

D. "You will need to learn how to give yourself a subcutaneous injection in your abdomen."

A

Dabigatran is unstable, especially when exposed to moisture, and should be stored in the manufacturer-supplied bottle, which has a desiccant cap. Current labeling of the pill bottle indicates that once the bottle is opened, the pills should be used within 30 days. However, recent evidence indicates that they maintain efficacy for 60 days, provided they have been stored in the original container. Capsules should be swallowed intact, because chewing, crushing, or opening enhances absorption by 75% and increases the risk of bleeding. The medication is administered orally, not subcutaneously.

A patient with a deep vein thrombosis receiving an intravenous (IV) heparin infusion asks the nurse how this medication works. What is the nurse's best response?

A. Heparin prevents the activation of vitamin K and thus blocks synthesis of some clotting factors.

B. Heparin suppresses coagulation by helping antithrombin perform its natural functions.

C. Heparin works by converting plasminogen to plasmin, which in turn dissolves the clot matrix.

D. Heparin inhibits the enzyme responsible for platelet activation and aggregation within vessels.

B

Heparin is an anticoagulant that works by helping antithrombin inactivate thrombin and factor Xa, reducing the production of fibrin and thus decreasing the formation of clots.

A patient is being discharged from the hospital on warfarin [Coumadin] for deep vein thrombosis prevention. Which instructions should the nurse include in the patient's discharge teaching plan?

Select all that apply.

A. Wear a medical alert bracelet.

B. Check all urine and stool for discoloration.

C. Do not start any new medication without first talking to your healthcare provider.

D. Enteric-coated aspirin and any aspirin products can be used unless they cause a gastrointestinal ulcer.

E. No laboratory or home monitoring of international normalized ratio (INR) is required after the first 6 months.

A, B, C,

Advise the patient to wear some form of identification (eg, Medic Alert bracelet) to alert emergency personnel to warfarin use. Bleeding is a major complication of warfarin therapy. Inform patients about the signs of bleeding, which include discolored urine or stools. Inform patients that warfarin is subject to a large number of potentially dangerous drug interactions. Instruct them to avoid all prescription and nonprescription drugs that have not been specifically approved by the prescriber. Aspirin and aspirin products should be avoided because aspirin can increase the effects of warfarin to promote bleeding and on the gastrointestinal tract to cause ulcers, thereby initiating bleeding. The INR should be determined frequently: daily during the first 5 days, twice a week for the next 1 to 2 weeks, once a week for the next 1 to 2 months, and every 2 to 4 weeks thereafter.

The healthcare provider prescribes heparin 900 units/hr. The label on the IV bag reads Heparin 10,000 units in 500 mL D5W. How many mL/hr will deliver the correct dose?

45 mL

The patient's heparin is infusing at 28 mL/hr. The bag of fluid is mixed 20,000 units of heparin in 500 mL D5W. What hourly dose is the patient receiving?

1120 units/hr

The nurse is caring for a patient who takes warfarin [Coumadin] for prevention of deep vein thrombosis. The patient has an international normalized ratio (INR) of 1.2. Which action by the nurse is most appropriate?

A. Administer intravenous (IV) push protamine sulfate.

B. Continue with the current prescription.

C. Prepare to administer vitamin K.

D. Call the healthcare provider to increase the dose.

D

An INR in the range of 2 to 3 is considered the level for warfarin therapy. For a level of 1.2, the nurse should contact the healthcare provider to discuss an order for an increased dose.

A patient is receiving a continuous heparin infusion for venous thromboembolism treatment. Which laboratory results should the nurse monitor?

Select all that apply.

A. Platelets

B. Vitamin K

C. Prothrombin time (PT)

D. International normalized ratio (INR)

E. Activated partial thromboplastin time (aPTT)

A, E

To reduce the risk of heparin-induced thrombocytopenia (HIT), platelet counts should be monitored. Heparin therapy is monitored by measuring the laboratory test activated partial thromboplastin time (aPTT). Warfarin therapy is monitored by measuring prothrombin time (PT) and results are expressed as an international normalized ratio (INR). Vitamin K is not monitored for a heparin infusion.

A patient diagnosed with a pulmonary embolism is receiving a continuous heparin infusion at 1000 units/hr. Of which findings should the nurse immediately notify the healthcare provider?

Select all that apply.

A. aPTT of 65 seconds

B. aPTT of 40 seconds

C. Nosebleeds

D. aPTT of 100 seconds

E. Platelet count of 300,000/mcL

B, C, D

Measurement of the aPTT is essential to determine whether the heparin infusion is having the desired effect. If the normal value of the aPTT is 40 seconds, the goal is to achieve a therapeutic range of a factor of 1.5 to 2 (60 to 80 seconds). Because 40 seconds is too short (increases the risk for clotting) and 100 seconds is too long (increases the risk for bleeding), the physician requires notification for adjustment of the infusion rate. Evidence of bleeding, such as nosebleeds, hematuria, and red or tarry stools, warrant a call to the physician. An aPTT of 65 seconds indicates that a therapeutic effect has been achieved, and a platelet count of 300,000/mcL is within normal limits, indicating no evidence of thrombocytopenia.

A patient presents to the emergency department with symptoms of acute myocardial infarction. After a diagnostic workup, the healthcare provider prescribes a 15-mg IV bolus of alteplase (tPA), followed by 50 mg infused over 30 minutes. In monitoring this patient, which finding by the nurse most likely indicates an adverse reaction to this drug?

A. Urticaria, itching, and flushing

B. Blood pressure of 90/50 mm Hg

C. Decreasing level of consciousness

D. Potassium level of 5.5 mEq/L

C

The greatest risk with this drug is bleeding, with intracranial bleeding being the greatest concern. A decreasing level of consciousness indicates intracranial bleeding. Alteplase does not cause an allergic reaction or hypotension. Thrombolytic agents, such as alteplase, do not typically cause an elevated potassium level.

The nurse is caring for a group of patients taking warfarin [Coumadin]. Which patients are at moderate to high risk for harm as a result of warfarin therapy?

Select all that apply.

A. A patient with variant genes that code for VKORC1 and CYP2CP

B. A patient with a current INR of 2.2 treated for deep vein thrombosis

C. A woman with a new onset of symptoms of a pulmonary embolus

D. A patient on day 4 after hip replacement with a new order for warfarin

E. A patient with a prosthetic heart valve, for whom an interacting drug is being deleted from the regimen

A, C, E

Patients with genetic alterations in VKORC1 and CYP2CP are at increased risk of warfarin-induced bleeding. An INR of 2.2 indicates a therapeutic warfarin level. Warfarin can cause fetal hemorrhage and is listed as Pregnancy Risk Category X. Warfarin could be prescribed for the prevention of deep vein thrombosis after hip replacement surgery. The day of prescription would not likely be a day to expect a dangerous adverse effect from warfarin, because its half-life is 1.5 to 2 days. Warfarin interacts with many other agents. The greatest risk for harm is when an interacting drug is being added to or deleted from the regimen.

The healthcare provider prescribes heparin 2500 units subcutaneous daily. The drug is available in 10,000 units per mL. How many milliliters will the nurse give? (Fill in the blank and record your answer using one decimal place.)

0.25 mL

The nurse is monitoring a patient receiving a heparin infusion for the treatment of pulmonary embolism. Which assessment finding most likely relates to an adverse effect of heparin?

A. Heart rate of 60 beats per minute

B. Blood pressure of 160/88 mm Hg

C. Discolored urine

D. Inspiratory wheezing

C

The primary and most serious adverse effect of heparin is bleeding. Bleeding can occur from any site and may be manifested in various ways, including reduced blood pressure, increased heart rate, bruises, petechiae, hematomas, red or black stools, cloudy or discolored urine, pelvic pain, headache, and lumbar pain.