Exam 3 - NSG 318 Questions.docx

The nurse is teaching a nursing student about the minimal effective concentration (MEC) of antibiotics. Which statement by the nursing student indicates an understanding of this concept? “A serum drug level greater than the MEC ensures the drug is bacteriostatic.” “A serum drug level greater than th...

The nurse is teaching a nursing student about the minimal effective concentration (MEC) of antibiotics. Which statement by the nursing student indicates an understanding of this concept? “A serum drug level greater than the MEC ensures the drug is bacteriostatic.” “A serum drug level greater than the MEC broadens the spectrum of the drug.” “A serum drug level greater than the MEC is sufficient to halt the growth of the microorganism.” “A serum drug level greater than the MEC increases the therapeutic index.” ANS: C The nurse cares for a patient with recurrent urinary tract infections. The patient’s current infection is not responding to an antibiotic that has been used successfully several times. The nurse understands that this is most likely due to acquired bacterial resistance. Cross-resistance. Inherent bacterial resistance. Transferred resistance. ANS: A The nurse prepares to administer amoxicillin to a patient and learns that the patient previously experienced a severe rash when taking penicillin. Which action will the nurse take? Administer the amoxicillin and have epinephrine available. Ask the provider to order an antihistamine. Contact the provider to discuss using a different antibiotic. Request an order for a beta-lactamase-resistant drug. ANS: C The nurse is preparing to administer an antibiotic to a patient who has been receiving the antibiotic for 2 days after a culture was obtained. The nurse notes increased erythema and swelling, and the patient has a persistent high fever of 102 F. What is the nurse’s next best action? Administer the antibiotic as ordered. Contact the provider to request another culture. Discuss the need to add a second antibiotic with the provider. Review the sensitivity results from the patient’s culture. ANS: D The nurse is preparing to administer the first dose of an antibiotic to a patient admitted for a urinary tract infection. Which action is most important before administering the antibiotic? Administering a small test dose to determine whether hypersensitivity exists. Having epinephrine available in the event of a severe hypersensitivity reaction Monitoring baseline vital signs, including temperature and blood pressure. Obtaining a urine specimen for culture and sensitivity ANS: D The specimen should be obtained before antibiotic therapy begins to obtain the most accurate culture. It is important to obtain cultures when possible to correctly identify the organism and help determine which antibiotic will be most effective. Test doses to determine hypersensitivity are sometimes administered when there is a strong suspicion of allergy, and a particular antibiotic is needed. Epinephrine is kept closed when there is a strong suspicion of allergy. A patient is admitted to the hospital for treatment of pneumonia after complaining of high fever and shortness of breath. The patient was not able to produce sputum for a culture. Which of the following will the nurse expect the patient’s provider to order? A broad-spectrum antibiotic A narrow-spectrum antibiotic Multiple antibiotics The pneumococcal vaccine ANS: A Broad-spectrum antibiotics are frequently used to treat infections when the offending organism is not identified by culture and sensitivity (C&S). Narrow-spectrum antibiotics are usually effective against one type of organism and are used when the C&S indicates sensitivity to that antibiotic. Multiple antibiotics, unless indicated by C&S, can increase resistance. The pneumococcal vaccine is used to prevent, not treat, an infection. The nurse is teaching a patient who will be discharged home from the hospital to take amoxicillin twice daily for ten days. Which statement by the nurse is correct? “Discontinue the antibiotic when your temperature returns to normal and your symptoms have improved.” “If diarrhea occurs, stop taking the drug immediately and contact your provider.” “Stop taking the drug and notify your provider if you develop a rash while taking this drug.” “You may save any unused antibiotic if your symptoms recur.” ANS: C The nurse is preparing to administer the first dose of intravenous ceftriaxone to a patient. When reviewing the patient’s chart, the nurse notes that the patient previously experienced a rash when taking amoxicillin. What is the nurse’s next action? Administer the drug and observe closely for hypersensitivity reactions. Ask the provider whether a cephalosporin from a different generation may be used. Contact the provider to report drug hypersensitivity. Notify the provider and suggest an oral cephalosporin. ANS: A The nurse is preparing to give a dose of cephalosporin medication to a patient who has received the antibiotic for two weeks. The nurse notes ulcers on the patient’s tongue and buccal mucosa. Which action will the nurse take? Hold the drug and notify the provider. Obtain an order to culture the oral lesions. Gather emergency equipment to prepare for anaphylaxis. Report a possible side effect of the cephalosporin, such as superinfection. ANS: D The nurse is providing teaching to a patient who will begin taking cephalosporin to treat an infection. Which statement by the patient indicates a need for further teaching? “I may stop taking the medication if my symptoms clear up.” “I should eat yogurt while taking this medication.” “I should stop taking the drug and call my provider if I develop a rash.” “I can take this medication with food if it irritates my stomach.” ANS: A Patients should take all an antibiotic regimen even after symptoms clear to ensure complete infection treatment. Patients are often advised to eat yogurt or drink buttermilk to prevent superinfection. A rash is a sign of hypersensitivity, and patients should be counseled to stop taking the drug and notify the provider if this occurs. Oral cephalosporins can be taken with food if gastric irritation occurs. A patient will begin taking amoxicillin. The nurse should instruct the patient to avoid which foods? Green leafy vegetables Beef and other red meat Coffee, tea, and colas Acidic fruits and juices ANS: D Acidic fruits and juices should be avoided while the client is treated with amoxicillin. Amoxicillin may be less effective when taken with acidic fruit or juice. The patient will begin taking penicillin G procaine. The nurse notes that the solution is milky in color. What action will the nurse take? Call the pharmacist and report the milky color. Add normal saline to dilute the medication. Call the physician and report the milky appearance. Administer the medication as ordered by the physician. ANS: D Penicillin G procaine has a milky appearance; therefore, the appearance should not concern the nurse. Which actions can contribute to bacterial resistance to antibiotics? (Select all that apply.) Frequent use of antibiotics Giving large doses of antibiotics Skipping doses Taking a full course of antibiotics Treating viral infections with antibiotics ANS: A, C, E Frequent use of antibiotics increases bacteria's exposure to an antibiotic and results in acquired resistance. Skipping doses of an antibiotic can lead to incomplete treatment of an infection, and the remaining bacteria may develop acquired resistance. Treating viral infections with antibiotics is unnecessary and may cause acquired resistance to develop from unneeded exposure to a drug. Infections adequately treated with an antibiotic do not result in resistance. The nurse is caring for a patient prescribed azithromycin for an exacerbation of chronic bronchitis. The patient also takes digoxin and warfarin. Which of the following will the nurse expect? Decreased effectiveness of digoxin Increased effectiveness of digoxin Decreased effectiveness of warfarin Increased effectiveness of azithromycin ANS: B Azithromycin can interact with digoxin and warfarin to increase their effects. If azithromycin is added to treat bronchitis, monitoring for increased effects of these medications would be appropriate. The nurse caring for a patient who will receive penicillin to treat an infection asks the patient about previous drug reactions. The patient reports having had a rash when taking penicillin. The nurse will contact the provider to discuss giving a smaller dose of penicillin. discuss using erythromycin instead of penicillin. request an order for diphenhydramine. discuss giving a larger dose of penicillin. ANS: B When penicillin is not an option, erythromycin is the drug of choice. Giving smaller or larger doses of penicillin does not prevent hypersensitivity reactions. Diphenhydramine is useful when a hypersensitivity reaction has occurred. The nurse is caring for a patient receiving a high dose of intravenous azithromycin to treat an infection. The patient is also taking acetaminophen for pain. The nurse should expect to review which lab values when monitoring for this drug’s side effects. Complete blood counts Electrolytes Liver enzymes Urinalysis ANS: C Liver function tests should be monitored in patients taking high doses of macrolides. Because this patient is also taking acetaminophen, he or she may be at increased risk for hepatotoxicity. The nurse provides home-care instructions for a patient who will take a high dose of azithromycin after discharge from the hospital. Which statement by the patient indicates an understanding of the teaching? “I may take antacids 2 hours before taking this drug.” “I should take this medication with food.” “I don’t need to worry about reporting watery diarrhea if it occurs, as this is common.” “I should avoid dairy products while taking this drug.” ANS: A Antacids taken at the same time may reduce azithromycin peak levels, so patients should be cautioned to take them 2 hours before or 2 hours after taking the drug. Azithromycin is poorly absorbed when taken with food, so it should be administered 1 hour before or 2 hours after meals. Diarrhea may indicate pseudomembranous colitis and should be reported. There is no restriction for dairy products when taking azithromycin. The nurse prepares to administer clarithromycin to a patient. When performing a medication history, the nurse learns that the patient takes warfarin to treat atrial fibrillation. The nurse will perform which action? Ask the provider if azithromycin may be used instead of clarithromycin. Obtain an order for continuous cardiovascular monitoring. Request an order for INR testing. Withhold the clarithromycin and notify the provider. ANS: C Macrolides can increase serum levels of other drugs, such as warfarin. If these drugs are used with macrolides, INR testing is warranted. All macrolides have this drug interaction. Cardiovascular monitoring is not indicated. The drug may be given as long as serum drug levels are monitored. A female patient allergic to penicillin will begin taking an antibiotic to treat a lower respiratory tract infection. The patient tells the nurse that she almost always develops a vaginal yeast infection when she takes antibiotics and that she will take fluconazole with the antibiotic being prescribed. Which macrolide order would the nurse question for this patient? Azithromycin Clarithromycin Erythromycin Fidaxomicin ANS: C When erythromycin is given concurrently with fluconazole, erythromycin blood concentration and the risk of sudden cardiac death increase. The nurse is caring for a patient receiving an intravenous antibiotic. The nurse notes that the provider has ordered serum drug peak and trough levels. The nurse understands that these tests are necessary for which type of drug? Drugs with a broad spectrum Drugs with a narrow spectrum Drugs with a broad therapeutic index Drugs with a narrow therapeutic index ANS: D Medications with a narrow therapeutic index have a limited range between therapeutic and toxic doses. It is important to monitor these medications closely by evaluating regular serum peak and trough levels. The nurse is caring for a patient receiving an intravenous antibiotic. The patient's serum drug trough is 1.5 mcg/mL, whereas the normal trough for this drug is 1.7 to 2.2 mcg/mL. What will the nurse expect the patient to experience? Inadequate therapeutic effects Increased risk for superinfection Excessive adverse effects Signs of drug toxicity ANS: A A trough level below the normal trough range indicates that the medication is below the therapeutic level. This finding would not indicate an altered risk for superinfection. Because drug levels are lower than indicated, it would not be expected to see excessive adverse effects or signs of drug toxicity. The nurse cares for a patient who will begin taking doxycycline to treat an infection. The nurse should plan to give this medication. 1 hour before or 2 hours after a meal. with an antacid to minimize GI irritation. with food to improve absorption. with small sips of water. ANS: C Doxycycline is a tetracycline that is better absorbed when taken with food. Antacids impair the absorption of tetracyclines. Small sips of water are not necessarily indicated. The nurse cares for a patient receiving a high tetracycline dose. Which laboratory values will the nurse expect to monitor while caring for this patient? Blood urea nitrogen (BUN) and creatinine levels Complete blood counts Electrolytes Prothrombin time ANS: A High doses of tetracycline can lead to nephrotoxicity, especially when given along with other nephrotoxic drugs. Renal function tests should be performed to monitor for nephrotoxicity. A female patient will receive doxycycline to treat a sexually transmitted infection (STI). What information will the nurse include when teaching this patient about this medication? Nausea and vomiting are uncommon adverse effects. The drug is a preferred antibiotic in pregnancy. Increase intake of dairy products with each dose of this medication. Use a backup method of contraception if taking oral contraceptives. ANS: D The desired action of oral contraceptives can be lessened when taken with tetracyclines, so patients taking oral contraceptives should be advised to use a backup contraception method while taking tetracyclines. Nausea and vomiting are common adverse effects. Doxycycline should not be taken with dairy products. Tetracycline should be used with caution in pregnancy. The nurse is preparing to administer an infant a maintenance dose of intravenous gentamicin through an intermittent needle. The nurse notes that the infant has not had a wet diaper for several hours. The nurse will perform which action? Administer the medication and give the infant extra oral fluids. Contact the provider to request that intravenous fluids be added when giving themedication. Give the medication and obtain a serum peak drug level 45 minutes after the dose. Hold the dose and contact the provider to request a serum trough drug level. ANS: D Gentamicin can cause nephrotoxicity. When changes in urine output occur, the provider should be notified, and serum trough levels should be obtained to ensure the drug is not toxic. If the drug level is determined to be safe, extra fluids, either orally or intravenously, may be indicated. Serum peak levels give information about therapeutic levels but are not a substitute for avoiding nephrotoxicity in the face of possible oliguria. The nurse cares for a 70-kg patient receiving gentamicin 85 mg 4 times daily. The patient reports experiencing ringing in the ears. Which of the following will the nurse contact the provider to discuss? Decreasing the dose to 50 mg QID Giving the dose three times daily Obtaining a serum drug level Ordering a hearing test ANS: C Aminoglycosides can cause ototoxicity. Any changes in hearing should be reported to the provider so that serum drug levels can be monitored. The dose is correct for this patient’s weight (5 mg/kg/day in 4 divided doses). A hearing test is not indicated unless changes in hearing persist. The nurse is preparing to begin a medication regimen for a patient receiving intravenous ampicillin and gentamicin. Which is an important nursing action? Administer each antibiotic to infuse over 15 to 20 minutes. Order serum peak and trough levels of ampicillin. Prepare the schedule so that the drugs are given simultaneously. Set up separate tubing sets for each drug labeled with the drug name and date. ANS: D Intravenous aminoglycosides can be given with penicillins and cephalosporins but should not be mixed in the same container. The IV line should be flushed between antibiotics, or separate tubing sets may be set up. Gentamicin must be infused over 30 to 60 minutes. It is not necessary to measure ampicillin peak and trough levels. Giving the drugs at the same time increases the risk of mixing them. The nurse reviews a patient’s chart before administering gentamicin and notes that the last serum peak drug level was 9 mcg/mL and the last trough level was two mcg/mL. What action will the nurse take? Administer the next dose as ordered. Obtain repeat peak and trough levels before giving the next dose. Report possible drug toxicity to the patient’s provider. Report a decreased drug therapeutic level to the patient’s provider. ANS: C Gentamicin peak values should be 5 to 8 mcg/mL, and trough levels should be <1 to 2 mcg/mL. Peak levels indicate whether a drug reaches potentially toxic levels, while trough levels indicate whether a therapeutic level is maintained. This drug is at a toxic level, and the next dose should not be given. The nurse provides discharge teaching for a patient receiving oral levofloxacin to treat pneumonia. The patient takes an oral hypoglycemic medication and uses over-the-counter (OTC)antacids to treat occasional heartburn. The patient reports frequent arthritis pain and takes acetaminophen when needed. Which statement by the nurse is correct when teaching this patient? “You may take antacids with levofloxacin to decrease gastrointestinal upset.” “You may take nonsteroidal anti-inflammatory medications (NSAIDs) for arthritis pain.” “You should monitor your serum glucose more closely while taking levofloxacin.” “You should take levofloxacin on an empty stomach to improve absorption.” ANS: C Levofloxacin may increase the effects of oral hypoglycemic medications, so patients should be advised to monitor their glucose levels closely. Antacids decrease the absorption of levofloxacin and should be given 2 hours before or after the antibiotic. NSAIDs taken with levofloxacin can cause central nervous system reactions, including seizures. The drug can be taken with food. A female patient who is taking trimethoprim–sulfamethoxazole (TMP–SMZ) to treat a urinary tract infection reports vaginal itching and discharge. The nurse will perform which action? Ask the patient if she might be pregnant. Reassure the patient that this is a normal side effect. Report a possible superinfection to the provider. Suspect that the patient is having a hematologic reaction. ANS: C Superinfection can occur with a secondary infection. Vaginal itching and discharge is a sign of superinfection. This is not symptomatic of pregnancy. These are not common side effects and do not indicate a hematologic reaction. A patient who will begin taking trimethoprim–sulfamethoxazole (TMP–SMX) asks the nurse why the combination drug is necessary. The nurse will explain that the combination is used to broaden the antibacterial spectrum. produce a synergistic effect. improve the taste. minimize toxic effects. ANS: B The combination drug produces a synergistic effect that increases the desired drug response. It does not broaden the spectrum, improve the taste, or decrease toxicity. The nurse is preparing to administer trimethoprim–sulfamethoxazole (TMP–SMX) to a patient who is being treated for a urinary tract infection. The nurse learns that the patient has type 2 diabetes mellitus and takes a sulfonylurea oral antidiabetic drug. The nurse will monitor this patient closely for which effect? Headaches Hypertension Hypoglycemia Superinfection ANS: C Combining oral antidiabetic agents (sulfonylurea) with sulfonamides increases the hypoglycemic effect. However, sulfonylureas do not increase the incidence of headaches, hypertension, or superinfection when taken with sulfonamides. Antidiabetic sulfonylurea medications include glipizide, glimepiride, glyburide, tolazamide, and tolbutamide. The nurse prepares to give a trimethoprim–sulfamethoxazole (TMP–SMX) dose and learns that the patient takes warfarin. The nurse will request an order for a decreased dose of TMP–SMX. a different antibiotic. an increased dose of warfarin. coagulation studies. ANS: D Sulfonamides can increase warfarin's anticoagulant effects. The nurse should request INR levels. An increased dose of warfarin would likely lead to toxicity and undesirable anticoagulation. A patient taking trimethoprim–sulfamethoxazole (TMP–SMX) calls to report developing an all-over rash. Which action will the nurse instruct the patient to perform? Increase fluid intake. Take diphenhydramine. Stop taking TMP–SMX immediately. Continue taking the medication. ANS: C A rash can indicate a serious drug reaction. Patients should stop taking the drug immediately and notify the provider. A patient taking trimethoprim–sulfamethoxazole (TMP–SMX) to treat a urinary tract infection complains of a sore throat. The nurse will contact the provider to request an order for which laboratory test(s)? Complete blood count with differential Throat culture Urinalysis Coagulation studies ANS: A A sore throat can indicate life-threatening anemia, so a complete blood count with differentials should be ordered. The nurse is caring for a patient ordered to receive trimethoprim– sulfamethoxazole 160/800 PO QID to treat a urinary tract infection caused by E. coli. The nurse will contact the provider to clarify the correct dose. drug. frequency. route. ANS: C TMP–SMX is taken twice daily. This is the correct dose, drug, and route to treat this condition. The nurse is preparing to give a second dose of trimethoprim–sulfamethoxazole (TMP– SMX) to the patient and notes a petechial rash on the patient’s extremities. The nurse will perform which action? Hold the dose and notify the provider. Request an order for a blood glucose level. Request an order for a BUN and creatinine level. Request an order for diphenhydramine (Benadryl). ANS: A A petechial rash can indicate a severe adverse reaction and should be reported before administering the dose. The nurse cares for a patient taking trimethoprim–sulfamethoxazole (TMP–SMX). The nurse learns the patient takes an angiotensin-converting enzyme (ACE) inhibitor. To monitor drug interactions, the nurse will request an order for which laboratory test(s)? A complete blood count BUN and creatinine Electrolytes Glucose ANS: C TMP–SMX can result in hyperkalemia when taken with an ACE inhibitor. Monitoring of electrolytes and symptoms of hyperkalemia would be indicated. A 10-kg child will begin taking oral trimethoprim–sulfamethoxazole (TMP—SMX). The liquid preparation contains 40 mg of TMP and 200 mg of SMX per 5 mL. The nurse determines that the child’s dose should be 8 mg of TMP and 40 mg of SMX/kg/day divided into two doses. Which order for this child is correct? 5 mL PO BID 5 mL PO daily 10 mL PO BID 10 mL PO daily ANS: A This child should receive (10 kg × 8 mg) 80 mg of TMP and (10 kg × 40 mg) 400 mL of SMX daily. When divided into two doses, the correct dose is 40 mg TMP and 200 mg SMX, or 5 mL per dose. In the initial phase of treatment for tuberculosis, a patient is being treated with isoniazid (INH), rifampin, and pyrazinamide. The organism develops resistance to isoniazid. Which drug will the nurse anticipate the provider will order to replace the isoniazid? Ciprofloxacin Ethambutol Kanamycin Streptomycin sulfate ANS: B If bacterial resistance to isoniazid develops, the first phase may be changed to ethambutol, rifampin, and pyrazinamide. Ciprofloxacin, kanamycin, and streptomycin are not generally first-line antitubercular drugs. The nurse is caring for a patient diagnosed with active tuberculosis. The patient tells the nurse that the provider plans to order a prophylactic antitubercular drug for family members and asks which drug will be ordered. Which drug will the nurse expect the provider to order? Isoniazid Pyrazinamide Rifampin Streptomycin ANS: A INH is the drug of choice for the prophylactic treatment of TB. A patient is receiving antitubercular treatment for latent TB. The patient develops symptoms of peripheral neuropathy and is started on pyridoxine (vitamin B6). The nurse suspects this was caused by which of the following medications? Ethambutol Isoniazid Rifampin Kanamycin ANS: B Peripheral neuropathy can be a problem in patients taking isoniazid, especially for those who are malnourished, have diabetes mellitus, or are alcoholics. This condition can be prevented if pyridoxine (vitamin B6) is administered. A patient taking isoniazid (INH) as part of a two-drug tuberculosis treatment regimen reports tingling in the fingers and toes. The nurse will recommend discussing which treatment with the provider. Adding pyrazinamide Changing to ethambutol Increasing oral fluid intake Taking pyridoxine (B6) ANS: D Peripheral neuropathy is an adverse reaction to INH, so pyridoxine is usually given to prevent this. It is not necessary to change medications. Increasing fluids will not help with this. A patient with oral candidiasis will begin using nystatin suspension to treat the infection. What information will the nurse include when teaching this patient? “Coat the buccal mucosa with the drug and then rinse your mouth.” “Put the pill under the tongue and let it dissolve.” “Mix the suspension with 4 ounces of water and then drink it.” “Swish the liquid in your mouth and then swallow after a few minutes.” ANS: D Patients should be taught to swish the suspension in the mouth to coat the tongue and buccal mucosa and then either dispose of or swallow the medication. It should not be diluted or swallowed with water. Oral suspension is the preferred route for treating oral thrush. A patient taking oral sulfonylurea medication will begin taking fluconazole. Which of the following will the nurse expect to monitor this patient? Blood urea nitrogen (BUN) and creatinine Electrolytes Fluconazole levels Glucose ANS: D Fluconazole can increase the risk of hypoglycemia when taken with oral sulfonylureas. The patient’s blood glucose should be monitored during treatment. The nurse receives an order to administer a purine nucleoside antiviral medication. The nurse understands that this medication treats which type of virus? Hepatitis virus Herpes virus HIV Influenza virus ANS: B Purine nucleosides, such as acyclovir, treat herpes simplex viruses (HSV- 1, HSV-2)and varicella-zoster viruses (chickenpox and shingles). The nurse receives the following order for an immunocompetent patient who has been diagnosed with herpes zoster virus: PO acyclovir 400 mg TID for 7 to 10 days. The nurse will contact the provider to clarify which part of the order. Dose and frequency. Frequency and duration Drug and dose. Drug and duration. ANS: A Acyclovir is used for herpes zoster, but the dose should be 800 mg 5 times daily for 7 to 10 days. The nurse should clarify the dose and frequency. The nurse teaches a patient who will receive acyclovir for a herpes virus infection. What information will the nurse include when teaching this patient? Herpes cannot be spread to your partner while taking this medication. Dizziness and confusion are harmless side effects. Increase fluid intake while taking this medication. Side effects are rare with this medication. ANS: C Patients taking acyclovir should increase fluid intake to maintain hydration. Patients should be instructed to avoid spreading the infection by practicing sexual abstinence or using condoms correctly and consistently. Dizziness and confusion should be reported to the provider. Antiviral medications have many side effects. Which diseases are caused by herpes viruses? (Select all that apply.) Chicken pox Hepatitis Influenza Mononucleosis Shingles ANS: A, D, E Herpes viruses cause chicken pox, mononucleosis, and shingles. A young adult female is prescribed metronidazole to treat trichomoniasis. Which of the following is FALSE regarding metronidazole? Metronidazole is inappropriate for this patient because it is only indicated for bacterial infections. Alcohol use is contraindicated. Metronidazole is available in multiple dosage forms, including oral, topical, intravaginal, and IV products. Metronidazole can be used for both bacterial and protozoal infections. ANS: A Metronidazole can treat bacterial and protozoal infections and would be an appropriate therapy for treating trichomoniasis. A patient is prescribed ivermectin to treat onchocerciasis. The patient is currently taking warfarin and atorvastatin. Which of the following will the nurse recommend monitoring in this patient? Increase in INR Decrease in INR Increase in LDL cholesterol Decrease in LDL cholesterol ANS: A Ivermectin can interact with warfarin, increasing INR. There are no major concerns about ivermectin and LDL levels. A patient who has atrial fibrillation is taking digoxin. Nurses expect which medication to be given concurrently to treat this condition. Hydrochlorothiazide Digoxin-immune Fab Milrinone Warfarin ANS: D Digoxin is given for atrial fibrillation to restore a normal heart rhythm. Warfarin is given concurrently to prevent thromboemboli. Hydrochlorothiazide is a diuretic medication. Milrinone is an inotropic agent used in decompensated heart failure. Digoxin-immune Fab is an antidote for digitalis toxicity. A patient is diagnosed with heart failure (HF), and the prescriber has ordered digoxin. The patient asked what lifestyle changes would help manage this condition. The nurse will recommend which changes? Vigorous aerobic exercise and weightlifting 2 or 3 times weekly. Changing from cigarette smoking to pipe smoking Consuming three teaspoons or less of salt every day Having no more than one alcoholic beverage per day ANS: D Alcohol should either be completely avoided or restricted to no more than one per day. Mild exercise, such as walking, is recommended. All methods of smoking can deprive the heart of oxygen. Salt should be limited to no more than one teaspoon per day. The nurse is preparing to administer digoxin to an HF patient. The patient reports nausea, vomiting, and visual halos around objects. The nurse notes a respiratory rate of 18 breaths per minute, a heart rate of 58 beats per minute, and a blood pressure of 120/78 mm Hg. What will the nurse do next? Administer the next dose as ordered since these are mild side effects. Hold the dose and notify the provider of possible digoxin toxicity. Reassure the patient that these are common, self-limiting side effects. Request an order for an antiemetic and analgesic medication. ANS: B Nausea, vomiting, and headache are common signs of digoxin toxicity, as is a heart rate of less than 60 beats per minute. Patients sometimes present with visual illusions, such as colored halos around objectives. Then, the nurse should hold the dose and notify the provider. The nurse cares for a patient taking digoxin to treat HF. The patient’s ECG shows ventricular dysrhythmia. The nurse will notify the provider and anticipate an order for which medication to treat a digoxin-induced ventricular dysrhythmia? Digoxin immune Fab Furosemide Phenytoin Potassium ANS: C The antidysrhythmics phenytoin and lidocaine are effective in treating digoxin-induced ventricular dysrhythmias. Digoxin immune Fab is used to treat severe digitalis toxicity, characterized by bradycardia, nausea, and vomiting. Unless a potassium deficit is present, giving potassium could worsen the dysrhythmia. A patient who takes digoxin to treat HF will begin taking a vasodilator. The patient asks the nurse why this new drug has been ordered. The nurse will explain that the vasodilator is used to decrease ventricular stretching. improve renal perfusion. increase cardiac output. promote peripheral fluid loss. ANS: A Vasodilators are given to decrease venous blood return to the heart, resulting in decreased cardiac filling and decreased ventricular stretching, reducing the heart's preload, contractility, and oxygen demand. The nurse performs a medication history and learns that the patient takes a loop diuretic and digoxin. The nurse will question the patient to ensure that the patient is also taking which medication? Cortisone Lidocaine Nitroglycerin Potassium ANS: D Suppose a patient takes digoxin and a potassium-wasting diuretic, such as a loop diuretic. In that case, the patient should also take a potassium supplement to prevent hypokalemia that could result in digoxin toxicity. Cortisone, lidocaine, or nitroglycerin are not necessary unless the patient has symptoms that warrant these drugs. The nurse administers a dose of digoxin to a patient who has HF and returns to the room later to reassess the patient. Which finding indicates that the medication is effective? Decreased dyspnea Decreased urine output. Increased blood pressure Increased heart rate ANS: A The patient should show improvement in breathing and oxygenation. Urine output should increase. Blood pressure and heart rate will decrease. A patient with HF receives digoxin and an angiotensin-converting enzyme (ACE) inhibitor. The patient will then begin taking spironolactone. The patient asks why the new drug is necessary. The nurse tells the patient that spironolactone will be given for which reason? To enhance potassium excretion To increase cardiac contractility To minimize fluid losses To provide cardioprotective effects ANS: D Spironolactone is a potassium-sparing diuretic that blocks the production of aldosterone, causing improved heart rate variability and decreased myocardial fibrosis. It is given in congestive HF for its cardioprotective effects. Spironolactone does not directly alter cardiac contractility but may slightly decrease contractility if fluid volume is decreased. It is a mild diuretic but is not given to minimize fluid losses. A stable angina pectoris patient is given sublingual nitroglycerin to use as needed. In addition to pharmacotherapy, which instruction will the nurse give the patient? Avoid extremes in weather. Begin a rigorous exercise program. Drink red wine daily. Call 911 at the first sign of pain. ANS: A To help prevent anginal attacks, it is important to avoid extreme weather conditions. Patients should be instructed to avoid strenuous exercise and alcohol, which can enhance the hypotensive effects of nitrates, and to use nitroglycerin at the first sign of pain. If the pain does not resolve after the use of a single dose of sublingual nitroglycerin, the patient should call 911. The nurse teaches a patient about using a transdermal nitroglycerin patch. Which statement by the patient indicates an understanding of the teaching? “I will apply the patch when I experience anginal pain.” “I will remove the old patch and replace it with a new one at bedtime each day.” “I should rotate sites when changing the patch to prevent skin irritation.” “When I am symptom-free, I may stop using the patch regularly.” ANS: C Patients should be taught to rotate application sites when using the transdermal nitroglycerin. Transdermal nitroglycerin is not used as needed. Patients should remove the patch at bedtime to provide an 8- to 12-hour nitrate-free interval. Patients should use the patch even when symptom-free unless otherwise instructed by the provider. The nurse is teaching a patient about sublingual nitroglycerin administration. What information will the nurse include when teaching this patient? Call 911 if pain does not improve after three doses. A second dose of nitroglycerin should be given regardless of symptom resolution. Swallow the tablet with small sips of water. Take the first tablet while sitting or lying down. ANS: D Because nitroglycerin can cause hypotension, patients should be cautioned to take it while sitting or lying down. If pain is not better or has worsened 5 minutes after the first dose, patients should call 911. A second dose should be administered only if symptoms are not resolved after taking the first dose. The tablets must dissolve under the tongue and should not be swallowed. A patient who just started using transdermal nitroglycerin reports having headaches. Which action will the nurse counsel the patient to perform? Call 911 when this occurs. Notify the provider. Reapply the patch three times daily. Take acetaminophen as needed. ANS: D Headaches are one of the most common side effects of nitroglycerin, but they may become less frequent; acetaminophen is generally recommended for pain. If the headaches do not resolve after continued use, discussing alternatives with the provider would be appropriate. Headaches are not an emergency; the patient does not need to call 911. The patch is applied once daily. A patient asks the nurse why nitroglycerin is given sublingually. The nurse will explain why this route administers nitroglycerin? To avoid hypotension To increase the rate of absorption To minimize gastrointestinal upset To prevent hepatotoxicity ANS: B Nitroglycerin is given sublingually to avoid first-pass metabolism by the liver, which would occur if the drug is swallowed, and to increase the absorption rate. It does not prevent hypotension. Gastrointestinal upset and hepatotoxicity usually do not occur. A patient who has been taking nitroglycerin for angina has developed variant angina, and the provider has added verapamil to the patient’s regimen. The nurse will explain that verapamil is given for which purpose? To facilitate oxygen use by the heart. To improve renal perfusion To increase cardiac contractility To relax coronary arteries ANS: D Verapamil is a calcium channel blocker used to relax coronary artery spasms in patients with variant angina. It does not facilitate coronary muscle oxygen use, improve renal function, or increase cardiac contractility. A patient who has begun taking nifedipine to treat variant angina has had a recurrent blood pressure of 90/60 mm Hg or less. Which of the following will the nurse anticipate that the provider will do? Add digoxin to the drug regimen. Change to a beta blocker. Order serum liver enzymes. Switch to diltiazem. ANS: D Hypotension is a common effect of calcium channel blockers, and it is more common with nifedipine. It is less common with diltiazem, so the provider may order that drug. Adding digoxin, changing to a beta blocker, or ordering serum liver enzymes is not indicated. The nurse prepares to administer digoxin to a patient with a serum digoxin level of 2.5ng/mL. The patient takes 0.25 mg of digoxin per day. What action will the nurse take? Administer the next dose as ordered. Do not administer the digoxin and notify the provider of toxic digoxin levels. Request an order to decrease the digoxin dose. Suggest that the patient may need an increased digoxin dose. ANS: B The therapeutic range of digoxin is between 0.8 and 2 ng/mL. This patient’s level is high, indicating toxic blood levels. The nurse should not give the next dose or request a change in dose. A patient has HF and has been taking digoxin for 9 years. The patient is admitted with signs and symptoms of digoxin toxicity. Which signs and symptoms are associated with digoxin toxicity? (Select all that apply.) Dysuria Vomiting Tachycardia Yellow haloes in the visual field Diarrhea Insomnia ANS: B, D, E Vomiting, yellow haloes in the visual field, and diarrhea are classic signs of digoxin toxicity. Bradycardia, not tachycardia, will likely be noted. The nurse is preparing to administer the first dose of hydrochlorothiazide 50 mg to a patient who has a blood pressure of 160/95 mm Hg. The nurse notes that the patient had a urine output of 200 mL in the past 12 hours. The nurse will perform which action? Administer the medication as ordered. Encourage the patient to drink more fluids. Hold the medication and request an order for serum BUN (blood urea nitrogen) and creatinine. Request an order for serum electrolytes and administer the medication. ANS: C Thiazide diuretics are contraindicated in renal failure. This patient has oliguria and should be evaluated for renal failure before administration of the diuretic—especially in the absence of known renal failure for this patient. Drinking more fluids will not increase urine output in patients with renal failure. The nurse is preparing to administer hydrochlorothiazide and digoxin doses to a heart failure patient. The patient reports blurred vision. The nurse notes a heart rate of 60 beats per minute and a 140/78 mm Hg blood pressure. Which action will the nurse take? Administer the medications and request an order for serum electrolytes. Give both medications and evaluate serum blood glucose frequently. Hold the digoxin and notify the provider. Hold the hydrochlorothiazide and notify the provider. ANS: C When thiazide diuretics are taken with digoxin, patients are at risk of digoxin toxicity because thiazides can cause hypokalemia. The patient has bradycardia and blurred vision, which are both signs of digoxin toxicity. The nurse should hold the digoxin and notify the provider. Serum electrolytes may be ordered, but digoxin should not be given. The nurse is teaching a patient about taking hydrochlorothiazide. Which statement by the patient indicates a need for further teaching? “I may need extra sodium and calcium while taking this drug.” “I should eat plenty of fruits and vegetables while taking this medication.” “I should take care when rising from a bed or chair when I’m starting this medication.” “I will take the medication in the morning to minimize certain side effects.” ANS: A Patients do not need extra sodium or calcium while taking thiazide diuretics. However, thiazide diuretics can lead to hypokalemia, so patients should be counseled to eat fruits and vegetables that are high in potassium. Patients can develop orthostatic hypotension and should be counseled to rise slowly from sitting or lying down. Taking the medication in the morning helps to prevent nocturia-induced insomnia. The nurse is caring for a patient who is to begin receiving a thiazide diuretic to help manage heart failure. When performing a health history on this patient, the nurse will be concerned about the history of which condition? Asthma Glaucoma Gout Hypertension ANS: C Thiazides block uric acid secretion, and elevated levels can contribute to gout. Patients with a history of gout should take thiazide diuretics with caution; they may need behavioral and/or pharmacologic changes to their gout treatment. The nurse is caring for a patient who develops marked edema and a low urine output due to heart failure. Which medication will the nurse expect the provider to order for this patient? Digoxin Furosemide Hydrochlorothiazide Spironolactone ANS: B Furosemide is a loop diuretic given when the patient’s condition warrants immediate removal of body fluid, as can occur in heart failure. Digoxin improves cardiac function but does not remove fluid quickly. Other diuretics may be used when immediate fluid removal is not necessary. The nurse cares for a patient receiving furosemide and an aminoglycoside antibiotic. The nurse will be most concerned if the patient reports which symptom? Dizziness Dysuria Nausea Tinnitus ANS: D The interaction of furosemide and an aminoglycoside can produce ototoxicity in the patient. Tinnitus is a sign of ototoxicity. Dizziness can occur because of diuretic therapy but not necessarily because of this combination. Dysuria and nausea are not common signs of these drugs interact. The nurse is teaching a patient who will begin taking furosemide. The nurse learns that the patient has just begun a 2-week course of steroid medication. What will the nurse recommend? Consume licorice to prevent excess potassium loss. Report a urine output greater than 600 mL/24 hours. Obtain an order for a potassium supplement. Take the furosemide at bedtime. ANS: C The interaction of furosemide and a steroid drug can result in an increased loss of potassium. Patients should take a potassium supplement. Patients should avoid licorice while taking furosemide, partially due to the hypokalemic effects of both substances. Urine output greater than 600 mL/24 hours is normal. Patients should take furosemide in the morning to avoid nocturia. A patient has begun taking spironolactone in addition to a thiazide diuretic. With the addition of the spironolactone, the nurse will counsel this patient on which of the following? Continue taking a potassium supplement daily. Recognize that abdominal cramping is a transient side effect. Report decreased urine output to the provider. Take these medications at bedtime. ANS: C Caution must be used when giving potassium-sparing diuretics to patients with poor renal function, so patients should be taught to report a decrease in urine output. Patients taking potassium-sparing diuretics are at risk for hyperkalemia, so they should not take potassium supplements. Abdominal cramping should be reported to the provider. The medications should be taken in the morning for patients who sleep during the night. The nurse is caring for a patient who is taking hydrochlorothiazide and digoxin. Which potential electrolyte imbalance will the nurse monitor for in this patient? Hypermagnesemia Hypernatremia Hypocalcemia Hypokalemia ANS: D Thiazide diuretics can cause hypokalemia, which enhances the effects of digoxin and can lead todigoxin toxicity. Thiazides can cause hypercalcemia. A patient has been taking spironolactone to treat heart failure. The nurse will monitor for which of the following electrolyte abnormalities? Hyperkalemia Hypermagnesemia Hypocalcemia Hypoglycemia ANS: A Spironolactone is a potassium-sparing diuretic and can induce hyperkalemia. Which of the following calcium channel blockers can be used to treat dysrhythmias in addition to hypertension? Amlodipine Nicardipine Diltiazem Felodipine ANS: C Diltiazem and verapamil are non-dihydropyridine calcium channel blockers that can be used for the treatment of hypertension in addition to managing cardiac dysrhythmias. Dihydropyridine calcium channel blockers like amlodipine, nicardipine, and felodipine are not used to treat dysrhythmias. The nurse is caring for an African American patient who has been taking a beta blocker to treat hypertension for several weeks with only a slight improvement in blood pressure. Which of the following will the nurse contact the provider to discuss? Adding a diuretic medication Changing to an angiotensin-converting enzyme (ACE) inhibitor Decreasing the beta blocker dose Doubling the beta blocker dose ANS: A African Americans do not respond well to beta blockers and ACE inhibitors but do tend to respond to diuretics and calcium channel blockers. Changing to an ACE inhibitor or altering the beta blocker dose is not indicated. Hypertension in African American patients can be controlled by combining beta blockers with diuretics. The nurse is caring for an 80-year-old patient who has just started a thiazide diuretic to treat hypertension. What is an important aspect of care for this patient? Encouraging increased fluid intake Increasing activity and exercise Initiating a fall risk protocol Providing a low potassium diet ANS: C Older patients experience a higher risk of orthostatic hypotension when taking antihypertensive medications. Fall risk also increases with a need for increased trips to the bathroom. A fall risk protocol should be implemented. Increasing fluids and activity and limiting potassium are not indicated. The nurse assesses each patient who will begin taking propranolol to treat hypertension. The nurse learns that the patient has a history of asthma and diabetes. The nurse will take which action? Administer the medication and monitor the patient’s serum glucose. Contact the provider to discuss another type of antihypertensive medication. Request an order for renal function tests before administering this drug. Teach the patient about the risks of combining herbal medications with this drug. ANS: B Patients with chronic lung disease are at risk for bronchospasm with beta-blockers, especially those like propranolol, which are nonselective. Beta-blockers, except carvedilol, also decrease the efficacy of many oral antidiabetic medications. Non-cardio-selective beta-blockers may also impair recovery from hypoglycemia by inhibiting the conversion of glycogen to glucose in the liver. The nurse should discuss changing medications to ones that do not carry these risks. The nurse is admitting a patient who has been taking minoxidil to treat resistant hypertension. Before beginning therapy with this medication, the patient had a blood pressure of 170/95 mm Hg and a heart rate of 72 beats per minute. The nurse assesses the patient and notes a blood pressure of 130/72 mm Hg, a heart rate of 78 beats per minute, and a 2.2-kg weight gain since the previous hospitalization and edema of the hands and feet. The nurse will contact the provider to discuss which intervention? Adding hydrochlorothiazide to help increase urine output. Adding metoprolol (Lopressor) to help decrease the heart rate. Increasing the dose of minoxidil to lower blood pressure. Restricting fluids to help with weight reduction. ANS: A Minoxidil is a direct-acting vasodilator that can cause sodium and water retention. Combining this drug with a diuretic can help reduce edema by increasing urine output. If the patient were tachycardic, a beta blocker might be added. It is not necessary to increase the minoxidil dose or to restrict fluids. The nurse is teaching a patient with hypertension about long-term disease management with alpha-blocker therapy. The patient reports consuming 1 to 2 glasses of wine each evening with meals. How will the nurse respond? “Alpha-blockers and wine cause a reflex hypertension.” “Four to 6 ounces of wine is considered safe with these medications.” “Wine in moderation helps you relax and get better blood pressure control.” “Wine can increase the hypotensive effects of alpha-blockers.” ANS: D Patients who take alpha-blockers should be aware that the hypotensive effects of alpha-blockers, like prazosin, can be intensified when taken in combination with alcohol. A patient who has recently begun taking Captopril to treat hypertension calls a clinic to report a persistent cough that started right after starting the Captopril. The nurse will perform which action? Instruct the patient to go to an emergency department because this is a hypersensitivity reaction. Reassure the patient that this side effect is nothing to worry about and will diminish over time. Schedule an appointment with the provider to evaluate the cough and discuss changing to an angiotensin II receptor blocker (ARB). Tell the patient to stop taking the drug immediately since this is a serious side effect of this drug. ANS: C An ACE inhibitor, such as captopril, can cause a constant, irritated cough. The cough will stop with discontinuation of the drug, and many patients can switch to an ARB medication that will not contribute to the cough. It does not indicate a hypersensitivity reaction. The cough will not diminish while still taking the drug. The patient does not need to stop taking the drug immediately. The nurse is preparing to administer an ACE inhibitor to a patient who has hypertension. The patient started the ACE inhibitor the day prior. The nurse notes peripheral edema and swelling of the patient’s lips. The patient has a blood pressure of 160/80 mm Hg and a heart rate of 76 beats per minute. What is the nurse’s next action? Administer the dose and observe carefully for hypotension. Hold the dose and notify the provider of a hypersensitivity reaction. Notify the provider and request an order for a diuretic medication. Request an order for serum electrolytes and renal function tests. ANS: B The patient has signs of angioedema, which indicates a hypersensitivity reaction. The nurse should hold the dose and notify the provider. Giving the dose will make the reaction more serious. These are not signs of edema, so a diuretic is not indicated. Electrolytes and renal function tests are not indicated. The nurse cares for a patient who will begin taking lisinopril for hypertension. The nurse reviews the patient’s laboratory test results, and notes increased BUN and creatinine. Which action will the nurse take? Administer the captopril and monitor vital signs. Contact the provider to discuss changing to fosinopril. Obtain an order for intravenous fluids to improve urine output. Request an order to add hydrochlorothiazide. ANS: B Patients who have renal insufficiency will not require a decrease in dose with fosinopril, as they would with other ACE inhibitors. If lisinopril is given, it should be given at a dose appropriate for the patient’s current kidney function. Increased IV fluids are not indicated. The nurse teaches a patient about their antihypertensive medication. Which statements by the patient indicate understanding of the teaching? (Select all that apply.) “I should be careful when I stand up from a chair when I start this medication.” “I should not add extra salt to my foods.” “If I have side effects, I should stop taking the drug immediately.” “If my blood pressure returns to normal, I can stop taking this drug.” “I may need to take a combination of drugs, including diuretics.” “I will not need to make lifestyle changes since I am taking a medication.” ANS: A, B, E The patient receiving antihypertensive medication should be warned to rise slowly to avoid orthostatic hypotension. Patients should be counseled to continue to make lifestyle changes, including decreasing sodium. Often, more than one medication is required. Patients should not stop taking the drug abruptly to avoid rebound hypertension and will not stop taking it when blood pressure returns to normal. The nurse is caring for a postoperative patient. The nurse will anticipate administering whichmedication to this patient to help prevent thrombus formation caused by slow venous blood flow? Alteplase Aspirin Clopidogrel Low-molecular-weight heparin ANS: D Low-molecular-weight heparins are anticoagulants that inhibit clot formation. They are used clinically as prophylactic agents to prevent postoperative deep vein thrombosis. Alteplase is a thrombolytic that breaks down clots after they form; alteplase is contraindicated in any patient with recent surgery. Aspirin and clopidogrel are antiplatelet drugs that prevent arterial thrombosis. A nursing student asks why the anticoagulant heparin is given to patients with disseminated intravascular coagulation (DIC) at risk for excessive bleeding. Will the nurse explain why heparin is used in this case? To decrease the risk of venous thrombosis To dissolve blood clots as they form To enhance the formation of fibrous clots To preserve platelet function ANS: A Heparin is used primarily to prevent venous thrombosis in patients with DIC, which can lead to pulmonary embolism or stroke. Heparin does not break down blood clots, enhance the formation of fibrous clots, or preserve platelet function. A patient has been receiving intravenous heparin. When laboratory tests are drawn, the nurse has difficulty stopping bleeding at the puncture site. The patient has bloody stools and is reporting abdominal pain. The nurse notes elevated partial thromboplastin time (PTT) and activated PPT (aPTT). Which action will the nurse perform? Ask for an order for oral warfarin (Coumadin). Obtain an order for protamine sulfate. Request an order for vitamin K. Suggest that the patient receives subcutaneous heparin. ANS: B Protamine sulfate is an antidote to heparin when a patient’s clotting times are elevated. Oral warfarin will not stop the anticoagulant effects of heparin. Vitamin K is used as an antidote for warfarin. Administering heparin by another route is not indicated when the effects of heparin need to be reversed. A patient who has received heparin after previous surgeries will be given enoxaparin sodium after knee-replacement surgery. The patient asks how this drug is different from heparin. The nurse will explain that the benefit of enoxaparin over heparin is that it decreases the need for laboratory tests. has a shorter half-life than heparin. increases the risk of hemorrhage. may be taken orally instead of subcutaneously. ANS: A Enoxaparin is a low-molecular-weight heparin that produces more stable responses at lower doses, thus reducing the need for frequent lab monitoring. It has a longer half-life than heparin. Because it is more stable at lower doses, it decreases the risk of hemorrhage. It is given subcutaneously. The nurse cares for a patient receiving warfarin and notes bruising and petechiae on the patient’s extremities. Which laboratory test will the nurse request an order for? International normalized ratio (INR) Platelet level PTT and aPTT Vitamin K level ANS: A The INR is the test used most frequently to report prothrombin time results in patients taking warfarin. Warfarin is not an antiplatelet drug, so platelet levels are not indicated. PTT and aPTT are used to monitor heparin therapy. Vitamin K is an antidote for warfarin; levels are not routinely checked. A warfarin patient has an international normalized ratio (INR) of 5.5. Which of the following will the nurse anticipate giving? Fresh frozen plasma Intravenous iron Oral vitamin K Protamine sulfate ANS: C Vitamin K antagonizes the effects of warfarin, an oral anticoagulant. Patients with an INR of 5.5 should be given a low dose of oral vitamin K. Too much vitamin K may reduce the effectiveness of warfarin for up to 2 weeks. Fresh frozen plasma and intravenous iron are given for anemia caused by blood loss. Protamine sulfate is given for heparin overdose. The nurse is teaching a patient who will begin taking warfarin for atrial fibrillation. Which statement by the patient indicates understanding of the teaching? “I should eat plenty of green, leafy vegetables while taking this drug.” “I should take a nonsteroidal anti-inflammatory drug (NSAID) instead of acetaminophen for pain or fever.” “I will take cimetidine to prevent gastric irritation and bleeding.” “I will tell my dentist that I am taking this medication.” ANS: D Patients taking warfarin should tell their dentists that they are taking the medication because of the increased risk for bleeding. Patients should avoid foods high in vitamin K, which can decrease the effects of warfarin. Patients should not take NSAIDs or cimetidine because they can displace warfarin from protein-binding sites. The nurse is assessing a patient who takes warfarin. The nurse notes a heart rate of 92 beats per minute and a blood pressure of 88/78 mm Hg. To evaluate the reason for these vital signs, the nurse will assess which of the following? Gums, nose, and skin Lung sounds and respiratory effort Skin turgor and oral mucous membranes Urine output and level of consciousness ANS: A An increased heart rate followed by a decreased systolic pressure can indicate a fluid volume deficit caused by internal or external bleeding. The nurse should examine the patient’s mouth, nose, and skin for signs of bleeding. These vital signs do not indicate a pulmonary problem. Skin turgor and mucous membranes, as well as urine output and level of consciousness, may be assessed to determine the level of fluid deficit, but finding the source of blood loss is more important. Signs of gastrointestinal bleeding should also be assessed. A patient who has recently had a myocardial infarction (MI) will begin taking clopidogrel to prevent a second MI. Which medication will the nurse expect the provider to order as adjunctive therapy for this patient? Aspirin Enoxaparin sodium Ticagrelor Warfarin ANS: A To increase the effectiveness of clopidogrel, aspirin is often used with it to inhibit platelet aggregation (dual antiplatelet therapy). Enoxaparin is used to prevent venous thrombosis. Ticagrelor is like clopidogrel and is not used along with clopidogrel. Warfarin is used to prevent thrombosis. A patient is taking clopidogrel. When teaching this patient about dietary restrictions while taking this medication, the nurse will instruct the patient to avoid excessive consumption of which food? Garlic Grapefruit Green, leafy vegetables Red meats ANS: A Patients taking this drug may experience increased bleeding when taken with garlic. Grapefruit is not restricted, as is the case with many other medications. However, green, leafy vegetables should be restricted in patients taking warfarin. Red meats are not contraindicated. A patient experiences a blood clot in one leg, and the provider has ordered a thrombolytic medication. The patient learns that the medication is expensive and asks the nurse if it is necessary. Which response by the nurse is correct? “The drug will decrease the likelihood of permanent tissue damage.” “This medication also prevents future blood clots from forming.” “You could take aspirin instead of this drug to achieve the same effect.” “Your body will break down the clot, so the drug is not necessary.” ANS: A Thrombolytic medications are given primarily to prevent permanent tissue damage caused by compromised blood flow to the affected area. Thrombolytics do not prevent clots from forming. Aspirin prevents, but does not dissolve, clots. Although the body will break down the clot, the drug is needed to prevent tissue damage due to active ischemia. Which of the following would be considered a contraindication to thrombolytic therapy? Traumatic head injury High blood pressure Use of aspirin for secondary cardiovascular protection A previous history of gastric ulcer ANS: A Thrombolytics are contraindicated for patients with a recent history of traumatic injury, especially head injury due to bleeding risk. High blood pressure, use of aspirin for CV prevention, and history of a gastric ulcer would not be considered contraindications tothrombolytic therapy. The nurse is caring for a postoperative patient who is receiving alteplase after developing a bloodclot. The nurse notes a heart rate of 110 beats per minute and a blood pressure of 90/60 mm Hg. The nurse will perform which action? Ask the patient about itching or shortness of breath. Assess the surgical dressing for bleeding. Evaluate the patient’s urine output and fluid intake. Recheck the patient’s vital signs in 15 minutes. ANS: B Tachycardia and hypotension indicate bleeding. The nurse should check the patient’s surgical dressing to assess for bleeding. These signs do not indicate anaphylaxis. They may indicate dehydration, but bleeding is the most likely cause of fluid volume deficit. The nurse should continue to evaluate vital signs, but the nurse must assess the patient to explore the potential cause. A patient is receiving thrombolytic medication. The patient calls the nurse to report having bloody diarrhea. The nurse will anticipate administering which medication? Aminocaproic acid Enoxaparin sodium Protamine sulfate Vitamin K ANS: A The antithrombotic drug aminocaproic acid is used to treat hemorrhage. Nurses giving thrombolytic drugs should monitor patients for bleeding from the mouth and rectum. Enoxaparin is a low-molecular-weight heparin and would not be indicated. Protamine sulfate is an antidote for heparin. Vitamin K is an antidote for warfarin. The nurse is assessing a patient before administering thrombolytic therapy. Which assessment is important for this patient? Determining whether the patient has a history of diabetes. Finding out about a history of renal disease Assessing which medications are taken for discomfort/pain. Assessing whether the patient eats green, leafy vegetables. ANS: C Patients who take aspirin or NSAIDs should be monitored closely for excessive bleeding when given thrombolytics. There are no contraindications or precautions for patients with diabetes or renal disease. Foods rich in vitamin K are of concern for patients taking warfarin. The nurse is preparing to administer a first dose of clopidogrel to a patient. As part of the history, the nurse learns that the patient has a previous history of peptic ulcers, diabetes, hyperlipidemia, and hypertension. The nurse understands that which of these conditions warrants caution with clopidogrel treatment? Peptic ulcer disease Diabetes Hyperlipidemia Hypertension ANS: A Patients with a previous history of peptic ulcer are at increased risk for gastric bleeding and clopidogrel should be used with caution. The patient should be counseled about signs and symptoms of GI bleeding if it is decided to use the medication. There are no contraindications or precautions for clopidogrel use in patients with diabetes, high cholesterol, or high blood pressure. A patient who is taking clopidogrel and aspirin is preparing for orthopedic surgery. The nurse will consult with the surgeon and provide which instruction to the patient? Continue taking aspirin and stop taking clopidogrel 2 weeks prior to surgery. Continue taking clopidogrel and stop taking aspirin 5 days prior to surgery. Continue both medications to prevent thromboembolic events during surgery. Stop taking both medications 7 days prior to surgery. ANS: D Because both drugs can prolong bleeding time, patients should discontinue the drugs 7 days priorto surgery. Which of the following is NOT considered a potential life-threatening adverse reaction to clopidogrel use? Hepatic failure Ischemic stroke Thrombocytopenia Stevens-Johnson syndrome ANS: B Antiplatelet agents like clopidogrel are not associated with clot formation and ischemia. Clopidogrel has been associated with life threatening adverse reactions such as hepatic failure, thrombocytopenia, and Stevens-Johnson syndrome. A female patient has a serum lipid panel performed, which reveals total cholesterol of 285 mg/dL, triglycerides of 188 mg/dL, low-density lipoprotein (LDL) of 175 mg/dL, and high-density lipoprotein (HDL) of 40 mg/dL. The patient’s blood pressure is 138/72 mm Hg. The patient is currently not receiving any prescription medications. Which of the following would be the most appropriate medication to be started at this time? Ezetimibe Colestipol Fenofibrate Atorvastatin ANS: D Statins have actions in decreasing serum cholesterol, LDL, VLDL, and triglycerides, and they slightly elevate HDL. Because the patient has elevated cholesterol levels, starting a statin at this time would be appropriate and considered an appropriate first- line antihyperlipidemic therapy. A patient is admitted to the hospital, and the provider orders gemfibrozil 600 mg twice daily, 30 minutes prior to meals. The nurse learns that the patient takes warfarin once daily. The nurse will contact the provider to discuss decreasing the dose of gemfibrozil. giving the warfarin at noon. increasing the dose of warfarin. ordering frequent INR levels. ANS: D Gemfibrozil is highly protein-bound and competes for receptor sites with drugs such as warfarin. The anticoagulant dose should be decreased, and the international normalized ratio (INR) should be closely monitored. Decreasing the dose of gemfibrozil is not recommended. Giving warfarin at a different time of day does not change this drug interaction. The warfarin dose should be decreased, not increased. A patient has been taking atorvastatin for several months to treat hyperlipidemia. The patient reports severe muscle weakness and tenderness. The nurse will counsel the patient to do which of the following? Ask the provider about switching to simvastatin. Contact the provider to report these symptoms. Start taking ibuprofen to combat these effects. Stop taking the medication immediately. ANS: B Patients taking statins should immediately report any muscle aches or weakness. These can lead to rhabdomyolysis, a fatal muscle disintegration. All statins carry this risk, so changing to another statin is not indicated. Ibuprofen may be useful, but notifying the provider is essential. Patients should not abruptly discontinue statins without discussing this with the provider. A patient, who has intermittent claudication, has been taking 100 mg of cilostazol twice daily with meals for 2 weeks. The patient calls the clinic and reports continued pain in both legs during exercise. How will the nurse advise the patient? “It can take from 2-12 weeks for the medication to help with your claudicationsymptoms.” “Notify the provider of the continued pain and request increasing the dose.” “You should stop the medication immediately since it is not working.” “Take the medication right before you exercise for best effects.” ANS: A Patients should be counseled that the desired therapeutic effects may take up to 3 months. The patient is currently taking the maximum recommended daily dose of cilostazol, so an increased in dose would not be recommended. The medication should be taken 30 minutes before or 2 hours after the morning and evening meals. Taking it immediately before bouts of exercise will not increase effectiveness. A patient will begin taking simvastatin to decrease serum cholesterol. When teaching the patient about this medication, the nurse will counsel the patient to take which action? Return to the clinic annually for laboratory testing. Take care when rising from a sitting to standing position. Take the medication in the evening for best effect. Use ibuprofen as needed for severe muscle aches and pain. ANS: C Simvastatin is given in the evening. Laboratory tests are performed every 3 to 6 months, not annually. Statins do not cause postural hypotension. Patients taking statins should report severe muscle aches and weakness immediately. A patient will begin taking rosuvastatin to treat hyperlipidemia. The patient asks the nurse how to take the medication for best effect. Which statement by the nurse is correct? “Increase your fluid intake while taking this medication.” “Stop taking the medication immediately if you develop muscle aches.” “Take the medication with food to improve absorption.” “You may increase dietary fat while taking this medication.” ANS: A Patients taking antihyperlipidemic should be advised to increase fluid intake. It is not necessary to take food. Patients should never stop taking a statin without consulting the provider. Patients should continue a low-fat diet while taking statins. A patient has been prescribed cilostazol. Which statement by the client indicates the need for further teaching? “I can take the medication with food if it causes nausea.” “This medication is used to improve blood flow.” “I can continue to take ginkgo biloba to improve my memory.” “I should be cautious when standing.” ANS: C Cilostazol should not be taken with ginkgo biloba because bleeding time can be prolonged. It can cause nausea so the nurse should recommend taking the medication with food. Cilostazol does cause vasodilation and improves blood flow which can also cause peripheral edema. Caution should be taken when standing for long periods. A patient with high cholesterol is ordered to take atorvastatin. What information will be included in the patient teaching? (Select all that apply.) Dietary management is not a priority with this medication. The medication should be taken on an empty stomach. The medicine should be taken with a full glass of water. The patient should watch for body aches or gastrointestinal upset as side effects. The patient should have renal function tests frequently. The patient should have periodic liver function testing. ANS: C, D, F This medication is most effective with careful monitoring of diet. Atorvastatin does not affectrenal function.