Homework Cardiology Pharmacology PDF

Dig “Heart” -oxin: digoxin x 56 1) Which nursing intervention is important when caring for clients receiving intravenous (IV) digoxin? Select all that apply. One, some, or all responses may be correct. A. Monitor the heart rate closely. B. Check the blood levels of digoxin. C. Administer...

Dig “Heart” -oxin: digoxin x 56 1) Which nursing intervention is important when caring for clients receiving intravenous (IV) digoxin? Select all that apply. One, some, or all responses may be correct. A. Monitor the heart rate closely. B. Check the blood levels of digoxin. C. Administer the dose over 1 minute. D. Monitor the serum potassium level. E. Give the medication with other infusing medications. Rationale Bradycardia or other dysrhythmias may occur; therefore the heart rate and rhythm should be monitored. Electrocardiogram (ECG) monitoring should be continuous. The digoxin level is checked before administration to avoid toxicity. A low serum potassium level when digoxin is administered can contribute to toxicity. Digoxin should be given over a 5-minute period through a Y-tube or three-way stopcock. There are many syringe, Y-site, and additive incompatibilities; the manufacturer recommends that digoxin not be administered with other medications. 2) An infant with congenital heart disease is prescribed digoxin and furosemide upon discharge. Which sign would the nurse instruct the parents to be alert for? A. Difficulty feeding with vomiting B. Cyanosis during periods of crying C. Daily naps lasting more than 3 hours D. A pulse rate faster than 100 beats/min Rationale Vomiting and feeding issues are early signs of digoxin toxicity. Cyanosis is expected in a crying infant with heart disease because the energy expenditure exceeds the body’s ability to meet the oxygen demand. Long naps are expected; infants routinely require several naps, and an infant with heart disease requires long rest periods. The pulse rate of an infant receiving digoxin should remain faster than 100 beats/min. 3) According to developmental norms for a 5-year-old child, the nurse would hold digoxin if an apical heart rate falls below which number? A. 70 beats/min B. 80 beats/min C. 90 beats/min D. 100 beats/min Rationale The purpose of digoxin is to slow and strengthen the apical rate. The apical rate for a healthy child of 5 years is 70 to 110 beats/min. If the apical rate is slow, administration of the medication may lower the apical rate to an unsafe level. 4) The clinic nurse receives a call from the mother of an infant prescribed digoxin. The mother reports she forgot whether she gave the morning dose of digoxin. Which response by the nurse is most appropriate? A. 'Give the next dose immediately.' B. 'Wait 2 hours before giving the medication.' C. 'Skip this dose and give it at the next prescribed time.' D. 'Take the baby’s pulse and give the medication if it’s more than 90 beats/min.' Rationale An additional dose may cause overdosage, leading to toxicity; it is better to skip the dose. Giving the dose without waiting may cause an overdose, which could result in toxicity. Even waiting 2 hours may cause an overdose, leading to toxicity. Taking the pulse is not a reliable method for determining a missed dose; 90 to 110 beats/min is within the expected range for this age. 5) The nurse is monitoring a 6-year-old child for toxicity precipitated by digoxin. Which sign of digoxin toxicity would the nurse monitor for? A. Oliguria B. Vomiting C. Tachypnea D. Splenomegaly Rationale Vomiting is a sign of digoxin toxicity in children. Oliguria is associated with renal failure, not toxicity. Tachypnea is associated with heart failure, not toxicity. Splenomegaly is associated with heart failure, specifically right ventricular failure. 6) Which lifestyle advice does the nurse give to a client when oral digoxin therapy is initiated? Select all that apply. One, some, or all responses may be correct. A. Bran can decrease digoxin absorption. B. Digoxin should not be taken with hawthorn supplements. C. Ginseng may cause a dangerous increase in digoxin levels in the blood. D. St. John’s Wort can increase digoxin levels in the blood. E. Medications that lower serum potassium or magnesium can cause digoxin toxicity. Rationale Consuming large amounts of bran can decrease the absorption of digoxin. Hawthorn may potentiate the effects of digoxin and should be avoided. Ginseng might increase levels of digoxin. St. John’s Wort can reduce levels of digoxin in the blood. 7) The client with hypokalemia reports nausea, vomiting, and seeing a yellow light around objects. Which of the client’s medications is the likely cause of the client’s symptoms? A. Digoxin B. Furosemide C. Propranolol D. Spironolactone Rationale These are signs of digitalis toxicity, which is more likely to occur in the presence of hypokalemia. Although furosemide most likely contributed to the hypokalemia, the client’s symptoms are consistent with digitalis toxicity. Although propranolol can cause nausea, vomiting, and blurred vision, the presence of hypokalemia and yellow vision are more suggestive of digitalis toxicity. A side effect of spironolactone is hyperkalemia, not hypokalemia. 8) When teaching a client about digoxin, which symptom will the nurse include as a reason to withhold the digoxin? A. Fatigue B. Yellow vision C. Persistent hiccups D. Increased urinary output Rationale Digoxin toxicity is a common and dangerous effect. Visual disturbances, most notably yellow vision, may be evidence of digoxin toxicity. Fatigue is not a toxic effect of digoxin. Persistent hiccups are not related to digoxin toxicity. An increased urinary output is not a sign of digoxin toxicity; it may be a sign of a therapeutic response to the medication and an improved cardiac output. 9) Which clinical finding indicates that a client taking digoxin may have developed digoxin toxicity? A. Constipation B. Decreased urination C. Cardiac dysrhythmias D. Metallic taste in the mouth Rationale The development of cardiac dysrhythmias is often a sign of digoxin toxicity. Constipation is not a sign of toxicity; gastrointestinal signs and symptoms of toxicity include anorexia, nausea, vomiting, and diarrhea. Decreased urination is not a sign of toxicity. Digoxin does not cause a metallic taste in the mouth. 10) A client who takes multiple medications complains of severe nausea, and the client’s heartbeat is irregular and slow. The nurse determines that these signs and symptoms are toxic effects of which medication? A. Digoxin B. Captopril C. Furosemide D. Morphine sulfate Rationale Signs of digoxin toxicity include cardiac dysrhythmias, anorexia, nausea, vomiting, and visual disturbances. Although nausea and heart block may occur with captopril, these symptoms rarely are seen; drowsiness and central nervous system disturbances are more common. Toxic effects of morphine are slow, deep respirations, stupor, and constricted pupils; nausea is a side effect, not a toxic effect. Toxic effects of furosemide are renal failure, blood dyscrasias, and loss of hearing. 11) A health care provider prescribes digoxin for a client. The nurse teaches the client to be alert for which common early indication of acute digoxin toxicity? A. Vomiting B. Urticaria C. Photophobia D. Respiratory distress Rationale Nausea, vomiting, anorexia, and abdominal pain are early indications of acute toxicity in approximately 50% of clients who take a cardiac glycoside, such as digoxin. Urticaria is a rare, not common, manifestation of digoxin toxicity. Photophobia is a later, not early, manifestation of digoxin toxicity. Respiratory distress is not directly associated with digoxin toxicity. 12) One week after being hospitalized for an acute myocardial infarction, a client reports nausea and loss of appetite. Which of the client’s prescribed medications would be withheld and the health care provider notified? A. Digoxin B. Propranolol C. Furosemide D. Spironolactone Rationale Toxic levels of digoxin stimulate the medullary chemoreceptor trigger zone, resulting in anorexia, nausea, and vomiting. Although anorexia, nausea, and vomiting may be side effects of furosemide, propranolol, and spironolactone, they do not indicate toxicity. 13) A client has been given a prescription for furosemide 40 mg every day in conjunction with digoxin. Which concern would prompt the nurse to ask the health care provider about potassium supplements? A. Digoxin causes significant potassium depletion. B. The liver destroys potassium as digoxin is detoxified. C. Lasix requires adequate serum potassium to promote diuresis. D. Digoxin toxicity occurs rapidly in the presence of hypokalemia. Rationale Furosemide promotes potassium excretion, and low potassium (hypokalemia) increases cardiac excitability. Digoxin is more likely to cause dysrhythmias when potassium is low. Digoxin does not affect potassium excretion. Furosemide causes potassium excretion. Potassium is excreted by the kidneys, not destroyed by the liver. Furosemide causes diuresis and consequent potassium loss regardless of the serum potassium level. 14) A client has been receiving digoxin. The client calls the clinic and complains of 'yellow vision.' Which response would the nurse provide? A. 'This is related to your illness rather than to your medication.' B. 'This is an expected side effect; you will become accustomed to it over time.' C. 'This side effect is only temporary. You should continue the medication.' D. 'The medication may need to be discontinued. Come to the clinic this afternoon.' Rationale Yellow vision indicates digoxin toxicity; the medication should be withheld until the health care provider can assess the client and check the digoxin blood level. Yellow vision is related to digoxin therapy, not the client’s underlying medical condition. Yellow vision is a sign of digoxin toxicity; taking more digoxin will escalate the digoxin toxicity. 15) Digoxin is prescribed for a client. Which therapeutic effect of digoxin would the nurse expect? A. Decreased cardiac output B. Decreased stroke volume of the heart C. Increased contractile force of the myocardium D. Increased electrical conduction through the atrioventricular (AV) node Rationale Digoxin produces a positive inotropic effect that increases the strength of myocardial contractions and thus cardiac output. The positive inotropic effect of digoxin increases, not decreases, cardiac output. Digoxin increases the strength of myocardial contractions (positive inotropic effect) and slows the heart rate (negative chronotropic effect); these effects increase the stroke volume of the heart. Digoxin decreases the refractory period of the AV node and decreases conduction through the sinoatrial (SA) and AV nodes. 16) A client takes furosemide and digoxin for heart failure. Why would the nurse advise the client to drink a glass of orange juice every day? A. Maintaining potassium levels B. Preventing increased sodium levels C. Limiting the medications’ synergistic effects D. Correcting the associated dehydration Rationale Orange juice is an excellent source of potassium. Furosemide promotes excretion of potassium, which can result in hypokalemia. Digoxin toxicity can occur in the presence of hypokalemia. Neither medication increases sodium levels. Digoxin does not potentiate the action of furosemide; therefore the client should not experience dehydration. Orange juice will not prevent an interaction between digoxin and furosemide. 17) The nurse is providing discharge medication teaching to a client who will be taking furosemide and digoxin after discharge from the hospital. Which information is important for the nurse to include in the teaching plan? A. Maintenance of a low-potassium diet B. Avoidance of foods high in cholesterol C. Signs and symptoms of digoxin toxicity D. Importance of monitoring output Rationale The risk of digoxin toxicity increases when the client is receiving digoxin and furosemide, a loop diuretic; loop diuretics can cause hypokalemia, which potentiates the effects of digoxin, leading to toxicity. Digoxin toxicity can result in dysrhythmias and death. When a client is receiving a loop diuretic, the diet should be high in potassium. Although teaching the need to avoid foods high in cholesterol may be included in the teaching plan, it is not the priority. It is not necessary to monitor output. 18) When a client with type 1 diabetes develops heart failure, digoxin is prescribed. Which nursing action is important to include when planning care? A. Administer the digoxin 1 hour after the client’s morning insulin. B. Monitor the client for cardiac dysrhythmias. C. Monitor for increased risk of hyperglycemia. D. Increase digoxin dosage if insulin requirements are increased. Rationale The speed of conduction is decreased when digoxin is given, and this can result in a variety of cardiac dysrhythmias. The risk for hyperglycemia is not increased. Administration times for insulin and digoxin do not have to be coordinated. Dosage of digoxin is not dependent on insulin dosage. 19) A client with left ventricular heart failure and supraventricular tachycardia is prescribed digoxin 0.25 mg daily. Which changes would the nurse expect to find if this medication is therapeutically effective? Select all that apply. One, some, or all responses may be correct. A. Diuresis B. Tachycardia C. Decreased edema D. Decreased pulse rate E. Reduced heart murmur F. Jugular vein distention Rationale Digoxin increases kidney perfusion, which results in urine formation and diuresis. The urine output increases because of improved cardiac output and kidney perfusion, resulting in a reduction in edema. Because of digoxin’s inotropic and chronotropic effects, the heart rate will decrease. Digoxin increases the force of contractions (inotropic effect) and decreases the heart rate (chronotropic effect). Digoxin does not affect a heart murmur. Jugular vein distention is a specific sign of right ventricular heart failure; it is treated with diuretics to reduce the intravascular volume and venous pressure. 20) A client with hypertensive heart disease who had an acute episode of heart failure is to be discharged on a regimen of metoprolol and digoxin. Which outcome would the nurse anticipate when metoprolol is administered with digoxin? A. Headaches B. Bradycardia C. Hypertension D. Junctional tachycardia Rationale Metoprolol and digoxin both exert a negative chronotropic effect, resulting in a decreased heart rate. Metoprolol reduces, not produces, headaches. These medications may cause hypotension, not hypertension. These medications may depress nodal conduction; therefore junctional tachycardia would be less likely to occur. 21) A client is given a loading dose of digoxin and placed on a maintenance dose of digoxin 0.25 mg by mouth daily. Which responses would the nurse expect the client to exhibit when a therapeutic effect of digoxin is achieved? A. Resolution of heart failure B. Decreased anginal episodes C. Conversion of atrial fibrillation D. Decreased blood pressure Rationale Digoxin improves cardiac output to improve heart failure. Digoxin is not an antianginal medication; if it decreases angina as a result of controlling heart failure, it is a secondary effect. Digoxin may be given to control a rapid ventricular response to atrial fibrillation, but it does not convert the rhythm. Digoxin has a negligible effect on blood pressure; therefore it is not an antihypertensive medication. 22) The nurse provides medication discharge instructions to a client who received a prescription for digoxin. Which statement by the client leads the nurse to conclude that the teaching was effective? A. 'I will avoid foods high in potassium.' B. 'I must increase my intake of vitamin K.' C. 'I should adjust the dosage according to my activities.' D. 'It will be important to check my pulse rate daily.' Rationale Checking the pulse rate daily is necessary for monitoring cardiac function; digoxin slows and strengthens the heart rate. Digoxin should be withheld, and the health care provider notified, if the pulse rate falls below a predetermined rate (e.g., 60 beats per minute). Hypokalemia increases the potential for digoxin toxicity; potassium intake may need to be increased, not decreased. An increase in the intake of foods rich in vitamin K is unnecessary; digoxin does not affect vitamin K or vitamin K clotting factors. Adjusting the dosage according to activities is not an appropriate decision for the client; the health care provider should make this decision. 23) Which advice will the nurse include when teaching a client about digoxin for left ventricular failure? A. Sleep flat in bed. B. Follow a low-potassium diet. C. Take the pulse three times a day. D. Report increasing fatigue. Rationale Treatment with digoxin should improve fatigue associated with heart failure; if fatigue increases, it may reflect complications of therapy. Sleeping with the head slightly elevated facilitates respiration. The client needs potassium. A low-potassium diet when the client is taking digoxin predisposes the client to toxicity and dangerous dysrhythmias. To avoid becoming obsessed with the pulse rate, the client should take the pulse less often; once daily is adequate. 24) A client with heart failure is to receive digoxin. Which therapeutic effect is associated with this medication? A. Reduces edema B. Increases cardiac conduction C. Increases rate of ventricular contractions D. Slows and strengthens cardiac contractions Rationale Digoxin improves cardiac function by increasing the strength of myocardial contractions (positive inotropic effect) and, by altering the electrophysiological properties of the heart, slows the heart rate (negative chronotropic effect). Digoxin increases the strength of the contractions but decreases the heart rate. Although a reduction in edema may result from the increased blood supply to the kidneys, it is not the reason for administering digoxin. Digoxin decreases, not increases, cardiac impulses through the conduction system of the heart. 25) A client with heart failure is to receive digoxin. Which therapeutic effect is associated with this medication? A. Reduces edema B. Increases cardiac conduction C. Increases rate of ventricular contractions D. Slows and strengthens cardiac contractions Rationale Digoxin improves cardiac function by increasing the strength of myocardial contractions (positive inotropic effect) and, by altering the electrophysiological properties of the heart, slows the heart rate (negative chronotropic effect). Digoxin increases the strength of the contractions but decreases the heart rate. Although a reduction in edema may result from the increased blood supply to the kidneys, it is not the reason for administering digoxin. Digoxin decreases, not increases, cardiac impulses through the conduction system of the heart. 26) Which assessment will the nurse conduct before administering digoxin to a client? A. Apical heart rate B. Radial pulse C. Difference between carotid and radial pulses D. Difference between apical and radial pulses Rationale Because digoxin slows the heart rate, the apical pulse should be counted for 1 minute before administration. If the apical rate is below a preset parameter (usually 60 beats/minute), digoxin should be withheld because its administration may further decrease the heart rate. Some protocols permit waiting for 1 hour and retaking the apical rate; the result determines if it is administered or if the health care provider is notified. Obtaining the radial pulse on the left side is not as accurate as an apical pulse; the client also may have an atrial dysrhythmia, which cannot be detected through a radial rate alone. Obtaining the radial pulse in both right and left arms is not as accurate as an apical pulse; the client also may have an atrial dysrhythmia, which cannot be detected through a radial rate alone. Obtaining the difference between apical and radial pulses is a pulse deficit, not a pulse rate. 27) Digoxin is prescribed for a client with heart failure. The nurse will assess for which signs and symptoms that indicate digoxin toxicity? Select all that apply. One, some, or all responses may be correct. A. Nausea B. Yellow vision C. Irregular pulse Increased urine output Heart rate of 64 beats/minute Rationale Signs and symptoms of digoxin toxicity include bradycardia, headache, dizziness, confusion, nausea, and visual disturbances (blurred vision or yellow vision). In addition, electrocardiogram (ECG) findings may include heart block, atrial tachycardia with block, or ventricular dysrhythmias, all causing an irregular pulse. Increased urine output is an expected effect of improved cardiac output; a pulse rate of 64 beats/minute is an acceptable rate when a client is receiving digoxin. 28) A client who takes furosemide and digoxin reports to the nurse that everything looks yellow. Which response by the nurse is most appropriate? A. 'This is related to your heart problems, not to the medication.' B. 'I will hold the medication until I consult with your health care provider.' C. 'It is a medication that is necessary, and that side effect is only temporary.' D. 'Take this dose, and when I see your health care provider, I will ask about it.' Rationale The response 'I will hold the medication until I consult with your health care provider' is a safe practice because yellow vision indicates digitalis toxicity. The response 'This is related to your heart problems, not to the medication' is incorrect; yellow vision is not a symptom of heart disease. The response 'It is a medication that is necessary, and that side effect is only temporary' is incorrect; yellow vision is not a temporary side effect. The response 'Take this dose, and when I see your health care provider, I will ask about it' is unsafe. 29) The nurse is reviewing medication instructions with parents of an infant receiving digoxin and spironolactone. Which parental response indicates instructions have been understood? A. Activity should be restricted. B. Orange juice should be given daily. C. Vomiting should be reported to the health care provider. D. Anti-inflammatory medications should be avoided. Rationale Vomiting is a classic sign of digoxin toxicity, and the health care provider must be notified. Infants regulate their own activity according to their energy level. Orange juice is rarely needed because spironolactone spares potassium. There is no restriction on anti-inflammatory medications with spironolactone. 30) A child being treated with cardiac medications developed vomiting, bradycardia, anorexia, and dysrhythmias. The nurse understands which medication toxicity is responsible for these symptoms? A. Digoxin B. Nesiritide C. Dobutamine D. Spironolactone Rationale Digoxin helps improve pumping efficacy of the heart, but an overdose can cause toxicity leading to nausea, vomiting, bradycardia, anorexia, and dysrhythmias. The side effects of nesiritide may include effects such as headache, insomnia, and hypotension. Dobutamine does not cause nausea or vomiting but may cause hypertension and hypotension. Spironolactone may cause edema. 31) A client is admitted to the hospital for a new onset of supraventricular tachycardia (SVT) and is prescribed digoxin. For which laboratory finding should the nurse notify the healthcare provider immediately? A. Potassium level of 3.1 mEq/L. B. Sodium level of 132 mEq/L. C. Calcium level of 8.6 mg/dL. D. Magnesium level of 1.2 mEq/L. Hypokalemia affects myocardial contractility and places this client at greatest risk for dysrhythmias that may be unresponsive to drug therapy. Although an imbalance of serum sodium, calcium, and magnesium can effect cardiac rhythm, the greatest risk for a client receiving digoxin is low potassium. 32) A client with coronary artery disease who is taking digoxin (Lanoxin) receives a new prescription for atorvastatin (Lipitor). Two weeks after initiation of the Lipitor prescription, the nurse assesses the client. Which finding requires the most immediate intervention? A. Heartburn. B. Headache. C. Constipation. D. Vomiting. Vomiting, anorexia, and abdominal pain are early indications of digitalis toxicity. Since Lipitor increases the risk for digitalis toxicity, this finding requires the most immediate intervention by the nurse. 33) The healthcare provider prescribes digitalis (Digoxin) for a client diagnosed with heart failure. Which intervention should the nurse implement prior to administering the digoxin? A. Observe respiratory rate and depth. B. Assess the serum potassium level. C. Obtain the client's blood pressure. D. Monitor the serum glucose level. Hypokalemia (decreased serum potassium) will precipitate digitalis toxicity in persons receiving digoxin. The nurse should monitor the client's serum potassium levels. Blood pressure and respiratory rate will not inform the nurse about potential safety issues with digitalis. 34) The nurse is preparing to administer prescribed digoxin to client with atrial fibrillation. The nurse notes the packaging for the medication is provided in a different route than prescribed. Which action should the nurse take? A. Administer the medication as ordered B. Consult the pharmacist regarding the error C. Alert the charge nurse to the medication error D. Alert the charge nurse to the medication error DContact the health care provider Contact the health care provider Rationale: Careful consultation with a pharmacist regarding the error is the most appropriate action for the nurse to take if an error occurs when the pharmacy dispenses the medication. The medication as provided by the pharmacy is incorrect and cannot be administered. The charge nurse may be alerted, but the pharmacy can correct the error. 35) A charge nurse is observing a staff nurse prepare 1 ml of intravenous digoxin for a client with heart failure. After the staff nurse prepares the medication, the nurse notices precipitate in the syringe. Which action by the staff nurse likely caused this reaction? A. D5W was used as the diluent. B. The medication was not allowed to reach room temperature. C. The medication was added to 1 mL of diluent. D. Air was not inserted into the vial. Rationale: When administering digoxin, 1 milliliter of digoxin should be mixed into at least 4 milliliters of diluent. Using a smaller amount of diluent will cause precipitation of the medication. Dextrose 5% in water (D5W) is compatible with digoxin and can be used to dilute the medication. Digoxin is not a temperature-controlled medication. Precipitation occurs as a result of incompatibilities or improper mixing. The insertion of air into a vial facilitates the withdrawal of the medication. Omission of this does not cause medication precipitation. 36) The nurse is caring for a client prescribed furosemide and digoxin for the treatment of heart failure. The client reports seeing halos and bright lights. Which laboratory result would be anticipated? A. Low sodium level B. Low digitalis level C. Low potassium level D. Low serum osmolality Rationale: Digitalis toxicity is an accumulation of digitalis (digoxin) in the body that leads to nausea, vomiting, visual disturbances, atrial or ventricular tachydysrhythmias, ventricular fibrillation, sinoatrial block, and atrioventricular block. Clients with heart failure who take digoxin are commonly given diuretics. Hypokalemia can increase the risk of digitalis toxicity. Digitalis toxicity may also develop in the presence of hypomagnesemia. Clients with dig toxicity would have elevated digoxin levels. Sodium would likely be normal. The serum osmolality would likely be normal or high in a client on a diuretic. 37) The nurse is caring for a client who received digoxin-specific immune fab. Which finding indicates the treatment is having the intended effect? A. Increased heart rate B. Decreased potassium levels C. Decreased blood pressure D. Increased serum digoxin levels Rationale: Digoxin-specific immune fab is an antidote that binds molecules of digoxin, making them unavailable for binding at their usual sites of action in the body. After administration of the medication, serum digoxin levels may be misleading, as they will be elevated until the drug is excreted by the kidneys. The goal of treatment is to lower digoxin levels and treat symptomatic digoxin toxicity, specifically cardiac dysrhythmias including bradycardia. Potassium levels may be low, triggering digoxin toxicity, and then elevated due to shifts caused by digoxin toxicity, so fluctuating levels are not a sign of effective treatment. Effective treatment of dysrhythmia should raise blood pressure. 38) A nurse is providing care to an older adult client with newly diagnosed heart failure. The nurse receives a prescription for digoxin PO 1.5 mg daily. Which action does the nurse perform next? A. Instruct the client to take the heart rate before administration B. Educate the client on the purpose of digoxin C. Administer the medication to the client D. Clarify the prescription with the healthcare provider Rationale: Older adult clients (geriatric) have a high sensitivity to the toxic effects of digoxin. A dose of 1.5 mg daily is above the recommended range for adults. The initial daily dose for a geriatric client should not exceed 0.125 mg. Educating the client on the purpose of digoxin and performing related assessments are expected interventions. However, the nurse should clarify the dose first. Administering the prescribed medication dose to the client may result in significant side effects. 39) A nurse is preparing to administer prescribed maintenance dose of digoxin to a client who has heart failure. Which action should the nurse to take? A. Withhold the medication if the heart rate is above 100/min B. Instruct the client to eat foods that are low in potassium C. Measure apical pulse rate for 30 seconds before administration D. Evaluate the client for nausea, vomiting, and anorexia Rationale: A client with heart failure who is prescribed digoxin should be assessed for digoxin toxicity. Manifestations of digoxin toxicity include nausea, vomiting, and anorexia. Digoxin is used to decrease heart rate and should be held if the heart rate is less than 60 beats per minute. Digoxin toxicity can occur when the client has low potassium. When administering digoxin, the nurse should measure the client’s apical pulse for a full minute. 40) A client is prescribed furosemide and digoxin for heart failure. The nurse should monitor the client for which potential adverse drug effect? A. Pulmonary hypertension B. Acute arterial occlusion C. Acute kidney injury D. Cardiac dysrhythmias Rationale: Digoxin is a cardiac glycoside, or positive inotrope that increases myocardial contractility. By increasing contractile force, digoxin can increase cardiac output in clients with heart failure (HF). Furosemide is a potassium-wasting (loop) diuretic, prescribed to prevent fluid overload in clients with HF. Clients who take furosemide are at risk for developing hypokalemia. Potassium ions compete with digoxin and a low potassium level can cause digoxin toxicity, leading to lethal cardiac dysrhythmias. Therefore, it is imperative that potassium levels be kept within normal range (3.5 to 5 mEq/L) while taking digoxin. 41) The client diagnosed with heart failure is prescribed oral digoxin. What is the priority nursing assessment for this medication? A. Monitor serum electrolytes and creatinine B. Measure apical pulse prior to administration C. Maintain accurate intake and output ratios D. Monitor blood pressure every 4 hours Rationale: Digoxin is an antiarrhythmic and an inotropic drug. It works to increase cardiac output and slow the heart rate. The priority assessment is to measure the apical pulse for one minute prior to administering the drug. The nurse will withhold the dose and notify the healthcare provider if the apical rate is less than 60 beats per minute. Intake and output ratios and daily weights should be monitored for a client in heart failure, but this is not the priority assessment. Impaired renal function may contribute to drug toxicity, which is why the nurse will monitor serum electrolytes, creatinine and BUN; the nurse should also monitor serum digoxin levels. 42. The nurse is reviewing medication instructions with a client who is taking digoxin. The nurse should reinforce to the client to report which of the following side effects? A. Rash, dyspnea, edema B. Nausea, vomiting, fatigue C. Hunger, dizziness, diaphoresis D. Polyuria, thirst, dry skin Rationale: Digoxin is considered an antidysrhythmic and inotrope, that is used to treat atrial dysrhythmias and congestive heart failure. The medication produces a positive inotropic effect, prolongs the refractory period and slows conduction through the sinoatrial (SA) and atrioventricular (AV) nodes. Overall, digoxin increases cardiac output and slows the heart rate. The effects of digoxin produce many side effects and clients who take digoxin are at risk for digoxin toxicity. Because digoxin improves cardiac output, side effects of the medication would not include dyspnea or edema. Rashes are also not considered a side effect of digoxin. Common manifestations of digoxin toxicity include nausea, vomiting and fatigue. Hunger, dizziness and diaphoresis, together, are not considered side effects of digoxin. Although dizziness could occur with another side effect of digoxin, such as bradycardia. Polyuria, thirst and dry skin are not considered side effects of digoxin. 43) The nurse is monitoring a 4-month-old infant who is prescribed digoxin. The infant's blood pressure is 92/78 mm Hg; resting pulse is 78 beats per minute; respirations are 28 breaths per minute; and serum potassium level is 4.8 mEq/L. The infant is irritable and has vomited twice since receiving the morning dose of digoxin. Which finding is most indicative of digoxin toxicity? A. Irritability B. Vomiting C. Bradycardia D. Dyspnea Rationale: The most common sign of digoxin toxicity in children is bradycardia which is a heart rate below 100 beats per minute in an infant. Normal resting heart rate for infants 1-11 months-old is 100-160 beats per minute. 44) The nurse is providing care for a client admitted to the hospital with a diagnosis of digoxin toxicity. The client reports more than usual urine output over the previous 48 hours, because of the prescribed diuretic. Which assessment finding does the nurse anticipate? A. Muscle weakness or cramping B. Blood in the urine C. Hypertension D. Tinnitus Rationale: The client with heart failure on digoxin and a diuretic is at risk for hypokalemia. The digoxin binds to the potassium receptor of the sodium/potassium ATPase pump. The increased urine output makes hypokalemia likely and thus it is more likely for digoxin toxicity to occur. Symptoms of hypokalemia include muscle weakness and cramping. The digoxin toxicity will not cause blood in the urine, or tinnitus or hypertension. 45) A hospitalized 8-month-old infant is receiving digoxin to treat Tetralogy of Fallot. Prior to administering the next dose of the medication, the parent reports that the baby vomited one time, just after breakfast. The infant's heart rate is 92 bpm. What action should the nurse take? A. Give the scheduled dose after the client is done eating lunch. B. Hold the medication and notify the primary health care provider. C. Reduce the next dose by half and then resume the normal medication schedule. D. Double the next dose to make up for the medication lost from vomiting. Rationale: Toxic side effects of digoxin include bradycardia, dysrhythmia, nausea, vomiting, anorexia, dizziness, headache, weakness and fatigue. It isn't typically necessary to hold the medication for infants and children if there is only one episode of vomiting. However, it is appropriate to hold the medication and notify the primary health care provider (HCP) of the vomiting episode and the lower than normal heart rate. A digoxin level may need to be drawn. The normal resting heart rate for infants 1 to 11 months old is 100 to 160 bpm. 46) The home care nurse is reviewing the medical record of a new client with a history of chronic obstructive pulmonary disease, atrial fibrillation and gout. After reviewing the client's medication list, for which medications should the nurse arrange to monitor blood levels? Select all that apply. A. Beclomethasone B. Digoxin C. Theophylline D. Allopurinol E. Montelukast Rationale: It is necessary to monitor blood levels for theophylline and digoxin to prevent toxicity. Both of those drugs can accumulate in the blood and reach toxic levels. The other medications are not known to accumulate and cause toxicity if taken as prescribed. 47) An 80-year-old client who is taking digoxin reports nausea, vomiting, abdominal cramps and halo vision. Which laboratory result should the nurse evaluate first? A. Potassium levels B. Blood pH C. Magnesium levels D. Blood urea nitrogen Rationale: Nausea, vomiting, abdominal cramps and halo vision are classic signs of digitalis toxicity. The most common cause of digitalis toxicity is a low potassium level. Clients are to be taught that it is important to have adequate potassium intake, especially if taking loop or thiazide diuretics that enhance the loss of potassium. 48) A nurse is preparing to administer morning medications to a client with heart failure. The morning lab values are: sodium 142 mEq/L (142 mmol/L), potassium 2.9 mEq/L (2.9 mmol/L), digoxin level 1.4 ng/mL. Which of the following medications should the nurse not administer until after speaking with the health care provider? A. Spironolactone B. Carvedilol (Coreg) C. Digoxin (Lanoxin) D. Ferrous sulfate Rationale: Because the potassium levels are low (normal is 3.5 to 5 mEq/L or 3.5 to 5 mmol/L), the nurse should not give the digoxin; hypokalemia can predispose a person to digoxin toxicity. The other medications can be administered. Although carvedilol can increase plasma digoxin concentration, the digoxin level is normal. Spironolactone is a potassium-sparing diuretic and because the potassium level is low, this too can be given. Ferrous sulfate does not affect the given lab values. 49) A client is prescribed digoxin 0.25 mg by mouth daily. The health care provider has written a new order to give metoprolol tartrate 25 mg twice a day by mouth. In assessing the client prior to administering the medications, which finding should the nurse report to the health care provider? A. Urine output of 50 mL/hour B. Respiratory rate of 16 C. Blood pressure of 94/60 D. Heart rate of 76 BPM Rationale: Both medications decrease the heart rate. Metoprolol (Lopressor)affects blood pressure. Therefore, the heart rate and blood pressure must be within normal range (HR 60 to 100 BPM and systolic BP greater than 100 mm Hg) in order to safely administer both medications. 50) The nurse is preparing to administer digoxin to a client with recurring atrial fibrillation. Which laboratory value should be of highest concern for the nurse? A. Hemoglobin 9.4 g/dL B. Serum potassium 3.1 mEq/L C. Serum creatinine 1.9 mg/dL D. B-type natriuretic peptide 140 pg/mL Rationale: Digoxin is a cardiac glycoside used to treat atrial dysrhythmias and heart failure. Because digoxin competes with potassium ions, digoxin should not be given when the client's potassium level is below normal range. Giving digoxin to a client with hypokalemia can cause digoxin toxicity and life-threatening cardiac dysrhythmias. Although all of the lab values are outside of normal range, the low potassium level (normal range 3.5-5.0 mEq/L) should be of highest concern for the client at this time. The nurse should hold the digoxin and notify the health care provider. 51) A client recently diagnosed with heart failure has been prescribed digoxin and furosemide. Which of the following foods should the nurse teach the client to eat at least one serving a day? A. Blueberries B. Wheat cereal C. Tomato juice D. Pear nectar Rationale: Digoxin, an antiarrhythmic, and furosemide, a diuretic, are commonly prescribed for clients with heart failure. A common side effect for furosemide is depletion of potassium. Of the food choices, tomato juice is the highest in potassium. To reduce the risk of potassium depletion, the client should be encouraged to drink at least 1/2 cup of tomato juice every day which is about 400 mg of potassium. The other choices are low in potassium which would be recommended for clients diagnosed with chronic renal failure. 52) The nurse is caring for a client diagnosed with heart failure who will begin treatment with digoxin. Which therapeutic effect would the nurse expect to find after administering this medication? A. Decreased chest pain with decreased blood pressure B. Increased heart rate with increased respirations C. Improved respiratory status with increased urinary output D. Diaphoresis with decreased urinary output Rationale: Digoxin (Lanoxin), a cardiac glycoside, is used in clients with heart failure to slow and strengthen the heartbeat. As cardiac output is improved, renal perfusion is improved and urinary output increases. The other findings are related to adverse, not therapeutic, effects related to digoxin or are not typically seen at all with digoxin. 53) The nurse is preparing to administer digoxin to a client admitted for acute decompensated heart failure. Which action is the priority before giving this drug? A. Monitor oxygen saturation on room air B. Assess the client's weight and compare to the baseline C. Auscultate the lungs for crackles in the bases D. Assess the apical pulse for a full minute Rationale: Digoxin, a cardiac glycoside, is used to slow the heart rate and increase the force of contraction. The priority for the nurse is to count the client's apical pulse for one full minute, even if the heart rhythm is regular. Typically, when the pulse is less than 60, digoxin should not be given. The other actions are also appropriate assessments for a client with heart failure. However, they are not the priority when administering digoxin. 54) Which response would a nurse give to a client who takes furosemide and digoxin and reports that everything looks yellow? A. "This is related to your heart problems, not to the medication." B. "I will hold the medication until I consult with your health care provider." C. "It is a medication that is necessary, and that side effect is only temporary." D. "Take this dose, and when I see your health care provider, I will ask about it." Rationale The response "I will hold the medication until I consult with your health care provider" is a safe practice because yellow vision indicates digitalis toxicity. The response "This is related to your heart problems, not to the medication" is incorrect; yellow vision is not a symptom of heart disease. The response "It is a medication that is necessary, and that side effect is only temporary" is incorrect; yellow vision is not a temporary side effect. The response "Take this dose, and when I see your health care provider, I will ask about it" is unsafe. 55) According to developmental norms for a 5-year-old child, the nurse would hold digoxin if an apical heart rate falls below which number? A. 70 beats/min B. 80 beats/min C. 90 beats/min D. 100 beats/min Rationale The purpose of digoxin is to slow and strengthen the apical rate. The apical rate for a healthy child of 5 years is 70 to 110 beats/min. If the apical rate is slow, administration of the medication may lower the apical rate to an unsafe level. 56) A client receives a cardiac glycoside, a diuretic, an angiotensin-converting enzyme (ACE) inhibitor, and a vasodilator. The client’s apical pulse rate is 44 beats/minute. The nurse concludes that the decreased heart rate is caused by which medication? A. Diuretic/furosemide B. Vasodilator/nitroglycerin C. ACE inhibitor/ “ace” to -pril D. Cardiac glycoside/digoxin Rationale A cardiac glycoside such as digoxin decreases the conduction speed within the myocardium and slows the heart rate. The primary effect of a diuretic is on the kidneys, not the heart; it may reduce the blood pressure, not the heart rate. A vasodilator can cause tachycardia, not bradycardia, which is an adverse effect. ACE inhibitors act on the renin-angiotensin system and are not associated with decreased heart rates. “painful” Potassium x 17 1) Which medications may be used to correct severe hyperkalemia resulting from intravenous (IV) administration? Select all that apply. One, some, or all responses may be correct. A. Calcium chloride B. Sodium chloride C. Calcium gluconate D. Sodium bicarbonate E. Dextrose solution with insulin Rationale Hyperkalemia resulting from IV administration might be treated with calcium chloride, calcium gluconate, sodium bicarbonate, and dextrose solution with insulin. These substances lead to the rapid shifting of intracellular potassium ions, thereby reducing potassium concentration. Sodium chloride is primarily used to prevent or treat sodium losses. 2) The nurse administers a parenteral preparation of potassium slowly to avoid which complication? A. Metabolic acidosis B. Cardiac arrest C. Seizure activity D. Respiratory depression Rationale Too rapid an administration can cause hyperkalemia, which contributes to a long refractory period in the cardiac cycle, resulting in cardiac dysrhythmias and arrest. Although acidosis can cause hyperkalemia, hyperkalemia will not lead to acidosis. Hyperkalemia causes muscle flaccidity and weakness, not seizures. Respiratory depression can occur with too rapid intravenous (IV) magnesium administration, not potassium administration. 3) Which assessment would be brought to the health care provider’s attention before administration of intravenous potassium chloride? A. Progressively worsening muscle weakness B. Poor tissue turgor with tenting C. Urinary output of 200 mL during the previous 8 hours D. Oral fluid intake of 300 mL during the previous 12 hours Rationale Decreased urinary output may result in the retention of potassium, causing hyperkalemia. Progressively worsening muscle weakness is a manifestation of hypokalemia, which is the reason for prescribing the potassium. Reporting poor tissue turgor with tenting is unnecessary; this may indicate dehydration, which is probably the rationale for the fluid prescribed. Reporting an oral fluid intake of 300 mL during the previous 12 hours is unnecessary; this can precipitate dehydration or can compound an existing dehydration, which can be treated with appropriate hydration. 4) Intravenous (IV) potassium is prescribed for a client with a diagnosis of hypokalemia. Which statement about administration of IV potassium is accurate? A. Oliguria is an indication for withholding IV potassium. B. Rapid infusion of potassium prevents burning at the IV site. C. Clients with severe deficits should be given IV push potassium. D. Average IV dosage of potassium should not exceed 60 mEq in 1 hour. Rationale Potassium chloride should not be given unless renal flow is adequate; otherwise, the potassium chloride will accumulate in the body, causing hyperkalemia. Rapid infusion may cause severe pain at the infusion site and precipitate cardiac arrest. Potassium chloride must be well diluted or it will precipitate cardiac arrest. A dose of 60 mEq per hour of potassium chloride is too high. 5) Which medication is unsafe to administer as an intravenous (IV) bolus? A. Saline flush B. Potassium chloride C. Naloxone D. Adenosine Rationale Potassium chloride given as an IV bolus can cause cardiac arrest. It must be diluted and infused slowly through an IV infusion pump. Saline flush, naloxone, and adenosine are appropriate to be given as an IV bolus undiluted. 6) A nurse is assessing a client receiving intravenous potassium chloride. The client verbalizes pain to the IV site. The site appears swollen and is warm to touch. Which action does the nurse perform? A. Decrease the rate of the infusion B. Apply ice to the IV access site C. Inform the client that this is an expected finding D. Discontinue the IV catheter Rationale: The nurse should discontinue the IV catheter. The client’s symptoms are indicative of phlebitis, inflammation of the vein. Decreasing the rate of the infusion will not treat the swelling or injury to the vein. Applying ice to the access site does not address the possible vein injury caused by the medication. Pain, swelling, and warmth are not expected findings for a patent IV access site. 7) The inpatient hospital nurse is caring for a client with hypokalemia. The health care provider prescribed a potassium intravenous (IV) infusion of 40 mEq potassium chloride in 250 mL normal saline to be infused over 4 hours. The nurse receives the infusion from the pharmacy. Which action should the nurse take next? A. Confirm patency of the peripheral venous access device and start the infusion Confirm patency of the peripheral venous access device and start the infusion B. Notify the health care provider of the inappropriate dose of the prescribed IV potassium Notify the health care provider of the inappropriate dose of the prescribed IV potassium C. Ask another nurse to verify the prescription, IV solution and serum potassium level D. Ask another nurse to witness the addition of the prescribed potassium to the IV solution Rationale: Since potassium chloride is considered a high alert medication, especially when given IV, having two nurses verify the order and IV bag is recommended. The nurses should compare the supplied IV bag to the prescriber's order. If potassium IV is infused too rapidly or in too high a dose, it can cause dysrhythmias and cardiac arrest. In addition, the second nurse should also verify the client's most recent serum potassium level to ensure that the prescription is appropriate. The prescribed dose and amount of IV solution is within normal range for IV potassium replacement therapy. Potassium should never be added by a nurse to an IV bag. 8) Which information will the nurse include when teaching a client about potassium chloride effervescent tablets? A. Chew the tablet completely. B. Take the medication with food. C. Take the medication at bedtime. D. Use warm water to dissolve the tablet. Rationale Eating food when taking the medication will decrease gastrointestinal irritation. Side effects of this medication include abdominal cramps, diarrhea, and ulceration of the small intestine. Chewing the tablet completely will cause oral mucosal irritation and is not the way the medication should be administered. Taking the medication at bedtime increases the possibility of mucosal irritation because the gastrointestinal tract is empty during the night. The tablet should be dissolved in cold water or juice to make it more palatable. 9) Which nursing assessment would performed by a nurse before administering intravenous (IV) infusion of potassium chloride (KCl) 40 mEq in 100 mL of 5% dextrose and water to be infused over 2 hours? Select all that apply. One, some, or all responses may be correct. A. Urinary output B. Deep tendon reflexes C. Last bowel movement D. Arterial blood gas results E. Last serum potassium level F. Patency of the intravenous access Rationale Before administering IV potassium, the urinary output must be normal. If the urine output is low, a potassium infusion may damage renal cells. The last serum potassium level should also be checked to ensure potassium replacement is appropriate. A patent IV access is essential because potassium is very irritating and painful to subcutaneous tissue. The infusion of KCL 40 mEq in 100 mL of 5% dextrose and water has no direct effect on bowel movement patterns, arterial blood gases, or deep tendon reflexes. These items are not required to be assessed before the administration of this medication. 10) Which reason would an intravenous infusion of 5% dextrose with 0.45% sodium chloride and 20 mEq of potassium be prescribed for a client with a nasogastric (NG) tube set to low intermittent suction? A. Prevent constipation B. Prevent dehydration C. Prevent vomiting D. Prevent electrolyte imbalance Rationale When clients do not receive nutrients or fluids by mouth and have a loss of electrolytes through the removal of gastric secretions via an NG tube, electrolyte imbalance is a primary concern. Constipation is usually not a concern in this situation. Although dehydration is a possible effect of an NG tube that removes gastric secretions and fluid, electrolyte balance is still the priority. An NG tube set to low intermittent suction usually relieves nausea and vomiting. 11) Which teaching would a nurse give to a client with a prescription for potassium supplements? A. To report any abdominal distress B. To use salt substitutes to season food C. To take the medication on an empty stomach D. To increase the dosage if muscle cramps occur Rationale Potassium supplements can cause gastrointestinal ulceration and bleeding. Most salt substitutes contain potassium, and their use with potassium supplements can cause hyperkalemia. Because they can be irritating to the stomach, potassium supplements should not be taken on an empty stomach. Although muscle cramps may indicate hypokalemia, clients should not adjust their own dosage. 12) Potassium supplements are prescribed for a client receiving diuretic therapy. Which client statement indicates that the teaching about potassium supplements is understood? A. 'I will report any abdominal distress.' B. 'I should use salt substitutes with my food.' C. 'The medication must be taken on an empty stomach.' D. 'The dosage is correct if my urine output increases.' Rationale Potassium supplements can cause gastrointestinal ulceration and bleeding. Most salt substitutes contain potassium, and their use with potassium supplements can cause hyperkalemia. Because they can be irritating to the stomach, potassium supplements should not be taken on an empty stomach. An increase in urine output is the therapeutic effect of diuretic therapy, not potassium supplements. An adverse effect of potassium supplements is oliguria. 13) A client with an intravenous (IV) infusion containing 40 mEq of potassium reports a stinging pain at the IV site. Which actions will the nurse take? Select all that apply. One, some, or all responses may be correct. A. Restart the IV in a different vein. B. Assist the client through guided imagery. C. Assess the IV site. D. Ask the health care provider for pain medication. E. Verify that the potassium is adequately diluted and not infusing too rapidly. Rationale It is important to first make sure that the IV catheter is patent and that there is no infiltration. The potassium dosage is large and can be very irritating to veins if it isn’t sufficient diluted or if it infuses too rapidly. A 40-mEq dose should be diluted in at least 1 L of IV solution. Although imagery may help distract the client from discomfort, this response provides no information as to why the stinging sensation is occurring. Asking the provider for an analgesic doesn’t address the underlying problem. 14) The nurse is discharging a client on oral potassium replacement. Which of the following statements requires further teaching by the nurse? A. "I can still take my nonsteroidal anti-inflammatory medications occasionally for my arthritis pain." B. "I will continue to use salt substitutes to flavor my food." C. "I will take my furosemide first thing in the morning." D. "I will read the food labels for added potassium." Rationale: Salt substitutes are made using potassium. As the client is taking potassium supplements, they should avoid salt substitutes to prevent hyperkalemia from occurring. NSAIDS can be used occasionally. The furosemide should be taken in the morning. Some low-sodium prepared foods may contain potassium, so reading the labels is important. 15) Which food would the nurse encourage a client to eat while receiving treatment to prevent hypokalemia? A. Broccoli B. Oatmeal C. Fried rice D. Canned carrots Rationale Potassium is plentiful in green leafy vegetables; broccoli provides 207 mg of potassium per half cup. Oatmeal provides 73 mg of potassium per half cup. Rice provides 29 mg of potassium per half cup. Cooked fresh carrots provide 172 mg of potassium per half cup; canned carrots provide only 93 mg of potassium per half cup. 16) When the nurse is administering intravenous potassium to a client with hypokalemia, which finding is most important to communicate to the health care provider? A. U waves on cardiac monitor B. QRS duration of 0.28 seconds C. Decreased bowel sounds D. Weakened grip strength Rationale When administering intravenous potassium supplements, it is important to evaluate for clinical manifestations of hyperkalemia. Widening of the Q waves is a potentially fatal manifestation of hyperkalemia (because it may lead to cardiac arrest) and would be communicated rapidly to the health care provider so that the infusion can be stopped and the potassium level can be rechecked. The other findings would be reported to the health care provider but are expected with hypokalemia and are not an indication for a change in treatment. U waves are an expected manifestation of hypokalemia because of changes in ventricular repolarization. Decreased bowel sounds may occur because of decreased peristalsis caused by low potassium levels but should improve with potassium administration. Weakened grips may occur with hypokalemia because normal extracellular potassium levels are needed for skeletal muscle contraction. 17) The nurse administers sodium polystyrene sulfonate to a client with chronic renal failure. Which finding provides evidence that the intervention is effective? A. Pruritus decreases. B. Mental status improves. C. Sodium decreases to 137 mEq/L (137 mmol/L). D. Potassium decreases to 4.2 mEq/L (4.2 mmol/L). Rationale This resin exchanges sodium ions for potassium in the large intestine to lower the serum potassium level; 4.2 mEq/L (4.2 mmol/L) is in the expected range for potassium. Mental status improvement and relief of pruritus are not therapeutic effects of the medication. Sodium retention is an adverse effect; 137 mEq/L (137 mmol/L) is in the expected range for sodium. Nitro/Nitrate “TNT” glycerin: nitroglycerin, nitroprusside, dinitrate x 37 1) Which pain characteristic would the nurse expect to observe when a client is experiencing anginal pain? A. Unchanged by rest B. Precipitated by light activity C. Described as a knifelike sharpness D. Relieved by sublingual nitroglycerin Rationale Relief by sublingual nitroglycerin is a classic reaction because it causes vasodilation of peripheral veins and arteries, thereby decreasing oxygen demand by decreasing preload. To a lesser extent, sublingual nitroglycerin dilates coronary arteries, which increases oxygen to the myocardium, thereby decreasing pain. Immediate rest frequently relieves anginal pain. Angina usually is precipitated by exertion, emotion, or a heavy meal. Angina usually is described as tightness, indigestion, or heaviness. 2) Which instructions about the use of nitroglycerin to prevent angina will the nurse provide to a client? A. 'At the point when pain first occurs, place two tablets under the tongue.' B. 'Place one tablet under the tongue before activity, and swallow another if pain occurs.' C. 'Before physical activity, place one tablet under the tongue, and repeat the dose in 5 minutes if pain occurs.' D. 'Place one tablet under the tongue when pain occurs and use an additional tablet after the attack to prevent recurrence.' Rationale Anginal pain, which can be anticipated during certain activities, may be prevented by dilating the coronary arteries immediately before engaging in the activity. Generally, one tablet is administered at a time; doubling the dosage may produce severe hypotension and headache. The sublingual form of nitroglycerin is absorbed directly through the mucous membranes and should not be swallowed. When the pain is relieved, rest generally will prevent its recurrence by reducing oxygen consumption of the myocardium. 3) A client who had a myocardial infarction receives a prescription for a nitroglycerin patch. Which statement would the nurse identify as the purpose of the nitroglycerin patch? A. Decreased heart rate lowers cardiac output. B. Increased cardiac output increases oxygen demand. C. Decreased cardiac preload reduces cardiac workload. D. Peripheral venous and arterial constriction increases peripheral resistance. Rationale Nitroglycerin reduces cardiac workload by decreasing the preload of the heart by its vasodilating effect. It decreases blood pressure, not heart rate (which may increase to compensate for the decreased blood pressure). It decreases, not increases, oxygen demand. Nitroglycerin dilates, not constricts, peripheral veins and arteries. 4) The health care provider prescribes isosorbide dinitrate 10 mg for a client with chronic angina pectoris. The client asks the nurse why the isosorbide dinitrate is prescribed. How will the nurse respond? A. 'It prevents excessive blood clotting.' B. 'It suppresses irritability in the ventricles.' C. 'It decreases cardiac oxygen demand.' D. 'The inotropic action increases the force of contraction of the heart.' Rationale Isosorbide dinitrate dilates peripheral veins and arteries thus decreasing preload and decreasing oxygen demand. Preventing blood from clotting is the action of anticoagulants. Suppressing irritability in the ventricles is the action of antidysrhythmics. Increasing the force of contraction of the heart is the action of cardiac glycosides. 5) Sublingual nitroglycerin has been prescribed for a client with unstable angina. Which client response indicates that nitroglycerin is effective? A. Pain subsides as a result of arteriole and venous dilation. B. Pulse rate increases because the cardiac output has been stimulated. C. Sublingual area tingles because sensory nerves are being triggered. D. Capacity for activity improves as a response to increased collateral circulation. Rationale Nitroglycerin causes vasodilation, increasing the flow of blood and oxygen to the myocardium and reducing anginal pain. An increased pulse rate does not indicate effectiveness; it is a side effect of nitroglycerin. The tingling indicates that the medication is fresh; relief of pain is the only indicator of effectiveness. Nitroglycerin does not promote the formation of new blood vessels. 6) Which client statement indicates understanding of the side effects of nitroglycerin ointment? A. 'I may experience a headache.' B. 'Confusion is a common adverse effect.' C. 'A slow pulse rate in an expected side effect.' D. 'Increased blood pressure readings may occur initially.' Rationale The most common side effect of nitroglycerin is a headache. Additional cardiovascular side effects are hypotension, not hypertension; tachycardia, not bradycardia; and dizziness, not confusion. 7) The nurse is preparing to apply nitroglycerin ointment. Before applying the ointment, which action will the nurse take? A. Assess the client’s pulse rate. B. Prepare the site with an alcohol swab. C. Shave the client’s chest in the area for application. D. Use the dose measuring application paper and spread the ointment in a thin layer to the prescribed amount. Rationale The nurse would use the dose measuring application paper supplied with the ointment and spread in a thin layer to the prescribed amount and place side down on the desired skin. The nurse would assess blood pressure reading, not pulse rate. There is no need to clean the site with alcohol before administration. Shaving is not recommended; a hairless site on the chest, back, abdomen, or anterior thigh should be selected. 8) A client presents to the emergency department with chest pain. A myocardial infarction is suspected, and 500 mL of 5% dextrose in water (D 5W) with 50 mg of nitroglycerin intravenously (IV) has been prescribed. The nurse will monitor the client for which common side effect of nitroglycerin? A. Bradycardia B. Hypotension C. Nausea and vomiting D. Leg cramps Rationale The major action of intravenous nitroglycerin is venous and then arterial dilation, leading to a decrease in blood pressure; orthostatic hypotension can occur. Bradycardia is not an anticipated response. Nausea and vomiting may occur but are not the most common side effects of IV nitroglycerin. Leg cramps are not a side effect of this medication. 9) Sublingual nitroglycerin is prescribed for a client with a history of a myocardial infarction and atrial tachycardia. The nurse instructs the client about the prophylactic use of these tablets. Which statement by the client indicates the teaching was effective? A. 'I should take the medicine three times a day.' B. 'I will be sure to take my pulse after I have exercised.' C. 'It will be important to avoid activities that can cause angina.' D. 'I should take one tablet before attempting activity that has caused angina.' Rationale The response about taking one tablet before activity that has caused angina indicates that the client understands the nurse’s teaching. Taking a nitroglycerin tablet before such an activity probably will prevent an episode of angina, which is an example of prophylactic use of a medication. Taking the medicine three times a day is an example of scheduled administration of a nitrate medication for prophylaxis, but the client is being prescribed sublingual nitrate. The statement to avoid activities that can cause angina indicates avoidance of activity rather than taking medication to prevent angina during the activity. Blood pressure, not pulse, is the parameter most affected by nitroglycerin. 10) Which criterion is an indicator that the nitroglycerin sublingual tablets have lost their potency? A. Sublingual tingling is experienced. B. The tablets are more than 3 months old. C. The headache is less severe. D. Onset of relief is delayed. Rationale Nitroglycerin tablets are affected by light, heat, and moisture. Loss of potency can occur after 3 months, reducing the medication’s effectiveness in relieving pain. A new supply should be obtained routinely. Experiencing sublingual tingling indicates the tablets have retained their potency. Headaches may decrease over time; this is not an indicator of medication potency. A delay in relief reflects the ischemia, not the medication. 11) Which instruction would the nurse include in a teaching plan for nitroglycerin patches? A. 'Apply the patch on a distal extremity.' B. 'Remove a previous patch before applying the next one.' C. 'Massage the area gently after applying the patch to the skin.' D. 'Apply a warm compress to the site before attaching the patch.' Rationale Removing the previous patch before applying the next patch ensures that the client receives just the prescribed dose. Ideally, a patch should be removed after 12 to 14 hours to avoid the development of tolerance. The patch should be rotated among hair-free and scar-free sites; acceptable sites include the chest, upper abdomen, proximal anterior thigh, or upper arm. The patch should be gently pressed against the skin to ensure adherence; it should not be massaged. Applying a warm compress to the site before attaching the patch is unnecessary and can result in excessive absorption of the medication. 12) A client has a prescription for a sublingual nitroglycerin tablet. Which technique will the nurse teach the client to use? A. Place the pill inside the cheek and let it dissolve. B. Place the pill under the tongue and let it dissolve. C. Chew the pill thoroughly and then swallow it. D. Swallow the pill with a full glass of water. Rationale Sublingual medication is placed under the tongue and is quickly absorbed through the mucous membranes into blood. The buccal route requires placing medication between the cheek and gums. Chewing the pill and then swallowing it may be done for oral administration of some large pills, but not with the sublingual route of administration. Taking the pill with water is required with the oral route of administration of medication, but not with sublingual. In addition, a full glass of water may be an excessive amount of fluid to swallow one pill. 13) The nurse is preparing a teaching plan for a client prescribed nitroglycerin sublingual. Which would the nurse include in the teaching? A. 'Place the tablet under the tongue or between the cheek and gums.' B. 'It takes 30 to 45 minutes for the nitroglycerin to achieve its effect.' C. 'If dizziness occurs, take a few deep breaths and lean the head back.' D. 'To facilitate absorption, drink a large glass of water after taking the medication.' Rationale Nitroglycerin sublingual tablets should not be chewed, crushed, or swallowed. They work much faster when absorbed through the lining of the mouth. Clients are instructed to place the tablet under the tongue or between the cheek and gums and let it dissolve. The client should not eat, drink, smoke, or use chewing tobacco while a tablet is dissolving; this will decrease the effectiveness of the medication. If taken with water, the tablet is washed away from the site of absorption or may be swallowed. Nitroglycerin sublingual tablets usually give relief in 1 to 5 minutes. If a client experiences dizziness or lightheadedness, the client is instructed to take several deep breaths and bend forward with the head between the knees. This position promotes blood flow to the head. 14) A client with acute myocardial infarction is admitted to the coronary care unit. Which medication should the nurse administer to lessen the workload of the heart by decreasing the cardiac preload and afterload? A. Nitroglycerin. B. Propranolol C. Morphine. D. Captopril Nitroglycerin is a nitrate that causes peripheral vasodilation and decreases contractility, thereby decreasing both preload and afterload. 15) Following the administration of sublingual nitroglycerin to a client experiencing an acute anginal attack, which assessment finding indicates to the nurse that the desired effect has been achieved? A. Client states chest pain is relieved. B. Client's pulse decreases from 120 to 90. C. Client's systolic blood pressure decreases from 180 to 90. D. Client's SaO2 level increases from 92% to 96%. Nitroglycerin reduces myocardial oxygen consumption which decreases ischemia and reduces chest pain. 16) A nurse has administered sublingual nitroglycerin to a client in the emergency department. Which clinical finding indicates an adverse response to the medication? A. Persistent chest pain B. Orthostatic hypotension C. Decreased heart rate D. Labored breathing Rationale: Decreased blood pressure when changing positions is an unexpected response to nitroglycerin. The nurse should instruct the client to lay down and elevate the feet to promote venous return. Persistent chest pain is not an unexpected response. Additional doses may be required to alleviate angina. A side effect of nitroglycerin is tachycardia, not a decreased heart rate. Nitroglycerin is not associated with respiratory effects. 17) The nurse is monitoring a client who is taking prescribed nitroglycerin for angina. Which finding indicates the medication has a therapeutic effect? A. The client blood pressure is 150/80 mm/Hg. B. The client heart rate is 110. C. The client reports a decrease in chest pressure. D. The client reports a headache. Rationale: Nitroglycerin acts to decrease myocardial oxygen consumption. Dilatation of the veins reduces the amount of blood returning to the heart (preload), so the chambers have a smaller volume to pump resulting in decreased oxygen needs. Decreased oxygen demand reduces pain caused by dilating coronary blood flow. While blood pressure may decrease slightly due to the vasodilatory effects of nitroglycerin, it is a secondary effect and not the desired therapeutic effect of this drug. Increased blood pressure and increased preload would mean the heart would work harder, increasing oxygen demand and thus angina. Decreased heart rate is not an effect of nitroglycerin. 18) A nurse is teaching a client with stable angina about newly prescribed SL nitroglycerin. Which statement should the nurse include in the teaching? A. "Take this medication after each meal and at bedtime." B. "Take one tablet 30 minutes before any physical activity." C. "Take one tablet immediately when you experience chest pain." D. "Take this medication with 8 ounces of water." Rationale: Nitroglycerin is a vasodilator used to treat angina or ischemic chest pain. When teaching a client about SL nitroglycerin, the nurse should instruct the client to take one tab and place it under their tongue immediately when experiencing chest pain. The client only takes this medication when experiencing chest pain. The client should not eat or drink when taking this medication. 19) The nurse is teaching a client with stable angina about their new prescription for nitroglycerin transdermal patch. Which instructions should the nurse include? Select all that apply. A. Remove the patch if ankle edema occurs B. Apply the patch to a hairless area of the body C. Notify your provider for persistent dizziness or any fainting episode D. Apply a second patch with chest pain E. Plan for patch-free time, usually overnight F. Rotate the application area Rationale: Nitroglycerin (NTG) acts directly on vascular smooth muscle to promote vasodilation. It decreases the pain of exertional angina primarily by decreasing cardiac oxygen demand. NTG comes in a variety of routes of administration. NTG patches contain a reservoir from which the drug is slowly released. Following release, the drug is absorbed through the skin and then into the blood. The rate of release is constant and, depending on the patch used, can range from 0.1 to 0.8 mg/ hr. Effects begin within 30 to 60 minutes and persist as long as the patch remains in place (up to 14 hours). Patches are applied once daily to a hairless area of skin. The site should be rotated to avoid local irritation. Tolerance develops if patches are used continuously (24 hours a day every day). Accordingly, a daily “patch-free” interval of 10 to 12 hours is recommended. This can be accomplished by applying a new patch each morning, leaving it in place for 12 to 14 hours, and then removing it in the evening. NTG can cause orthostatic hypotension and the client should let their provider know if dizziness and lightheadedness persist or the client has a fainting (syncopal) episode as these may indicate that the NTG dose needs to be adjusted/decreased. The other instructions are not appropriate for this medication. 20) The nurse working in an intensive care unit is caring for a client diagnosed with acute angina. The client is receiving an intravenous infusion of nitroglycerin. What is the priority assessment for this client? A. Heart rate B. Neurologic status C. Urine output D. Blood pressure Rationale: Nitroglycerin (NTG) is a vasodilator used to promote myocardial tissue perfusion and relieve chest pain associated with coronary artery occlusion. The systemic vasodilation that occurs as a result of this medication can cause profound hypotension. The client's blood pressure should be evaluated every 15 minutes until stable, and then every 30 minutes to every hour thereafter. Clients receiving IV nitroglycerin should also be placed on continuous ECG monitoring. NTG is not known to affect neurologic status, urine output or heart rate. 21) A client with angina has been instructed about the use of sublingual nitroglycerin. Which statement by the client indicates the need for additional teaching? A. "I'll call the health care provider if pain continues after three tablets five minutes apart." B. "I will rest briefly right after taking one tablet." C. "I understand that the medication should be kept in the dark bottle." D. "I can swallow two or three tablets at once if I have severe pain." Rationale: Clients must understand that just one sublingual tablet should be taken at a time. Clients must also understand that they should rest when experiencing angina. Two or three tablets should not be used at once, even in the setting of severe pain, as this can lead to significant hypotension. The client should notify their primary healthcare provider should they not have a relief of symptoms with nitroglycerin use. 22) The nurse is providing discharge instructions to a client with a prescription for sublingual nitroglycerin. The nurse should inform the client to prepare for this most common side effect? A. Headache B. Depression C. Dry mouth D. Anorexia Rationale: Nitroglycerin is a potent vasodilator and a headache is the most common side effect. The headache comes on suddenly and can be severe, thus the client should be prepared for this effect. The other side effects listed are common side effects of oral medications, but not specifically to nitroglycerin. 23) The nurse is teaching a client who has a new prescription for sublingual nitroglycerin. Which point should the nurse emphasize? A. Take the medication at the same time each day B. Rest in bed for an hour after taking medication C. Carry the nitroglycerine with you at all times D. Keep the medication bottle in the refrigerator Rationale: The medication should be kept in its original dark-colored glass container. Nitroglycerin should be carried by the client at all times so it can be used when anginal pain occurs. When needed, the client should sit and place tablet under his or her tongue. Sitting is safe because the drug can cause lightheadedness or dizziness, but it's not necessary to rest in bed. The client should never pack this and any other medications in a checked a bag when traveling. 24) The nurse is providing discharge education to a client diagnosed with coronary artery disease. The client is prescribed to use a nitroglycerin transdermal patch at home. Which statement by the client indicates a correct understanding of safe medication administration? A. "I will remove the old patch and cleanse the area before applying a new patch." B. "This drug can lead to hypertension. So, I will monitor my blood pressure at home." C. "I will keep a record of chest pain occurrences now that I have this patch." D. "I can place this patch on broken skin. It will absorb better." Rationale: Numerous administration errors have been reported with nitroglycerin paste and patches. The errors include improper storage and basic administration. The client should be taught to remove the previous patch before applying the new patch and to properly label the tube of nitroglycerin paste and keep it out of the reach of children. When selecting an area to place the patch, the skin should be intact and show no signs of irritation. Nitroglycerin paste has been used erroneously as lotion and caused toxic effects. Nitroglycerin causes vasodilation, which increases the blood supply through the coronary arteries. This may cause hypotension in clients. Some other common side effects include lightheadedness, nausea, dizziness, headache and redness or irritation of the skin covered by the patch. 25) The nurse on a cardiac unit is caring for a client who is receiving nitroglycerin intravenously for unstable angina. During administration of the medication, which assessment is the priority? A. Respiratory rate B. Cardiac enzymes C. Cardiac rhythm D. Blood pressure Rationale: Nitroglycerin is a drug that is used to provide relief from myocardial chest pain and treat hypertensive emergencies. Nitroglycerin causes vasodilation. Common adverse effects of nitroglycerin include hypotension, headache and dizziness; therefore, monitoring the client's blood pressure is the priority. Nitroglycerin does not affect respirations, cardiac enzyme levels or heart rhythm. 26) Which information would the nurse include when preparing a teaching plan for a client prescribed sublingual nitroglycerin? A. "Place the tablet under the tongue or between the cheek and gums." B. "It takes 30 to 45 minutes for the nitroglycerin to achieve its effect." C. "If dizziness occurs, take a few deep breaths and lean the head back." D. "To facilitate absorption, drink a large glass of water after taking the medication." Rationale Nitroglycerin sublingual tablets should not be chewed, crushed, or swallowed. They work much faster when absorbed through the lining of the mouth. Clients are instructed to place the tablet under the tongue or between the cheek and gums and let it dissolve. The client should not eat, drink, smoke, or use chewing tobacco while a tablet is dissolving; this will decrease the effectiveness of the medication. Nitroglycerin sublingual tablets usually give relief in 1 to 5 minutes. If a client experiences dizziness or lightheadedness, the client is instructed to take several deep breaths and bend forward with the head between the knees. This position promotes blood flow to the head. If taken with water, the tablet is washed away from the site of absorption or may be swallowed. 27) Nitroglycerin sublingual tablets are prescribed for a client with the diagnosis of angina. The nurse advises the client to anticipate pain relief will begin within which period of time? A. 1 to 3 minutes B. 4 to 5 seconds C. 30 to 45 seconds D. 10 to 15 minutes Rationale The onset of action of sublingual nitroglycerin tablets is rapid (1–3 minutes); duration of action is 30 to 60 minutes. If nitroglycerin is administered intravenously, the onset of action is immediate, and the duration is 3 to 5 minutes. It takes longer than 30 to 45 seconds for sublingual nitroglycerin tablets to have a therapeutic effect. Sustained-release nitroglycerin tablets start to act in 20 to 45 minutes, and the duration of action is 3 to 8 hours. 28) Which instruction would the nurse include when teaching the client about sublingual nitroglycerin? A. 'Once the tablet is dissolved, spit out the saliva.' B. 'Take tablets 3 minutes apart up to a maximum of five tablets.' C. 'Common side effects include headache and low blood pressure.' D. 'Once opened, the tablets should be refrigerated to prevent deterioration.' Rationale The primary side effects of nitroglycerin are headache and hypotension. It is not necessary to spit out saliva into which nitroglycerin has dissolved. For pain that is not relieved, additional tablets may be taken every 5 minutes up to a total of three tablets. It should be stored at room temperature. 29) A client with a myocardial infarction receives intravenous nitroglycerin to relieve pain. The nurse will assess for which medication side effect? A. Nausea B. Delirium C. Bradycardia D. Hypotension Rationale The major action of intravenous nitroglycerin is venous and then arterial dilation, leading to a decrease in blood pressure and resulting in decreased cardiac workload. Nausea is not a common side effect of intravenous nitroglycerin. Nitroglycerin does not cause delirium. Reflex tachycardia may occur with the decrease in blood pressure. 30) Which instructions will the nurse give a client for whom nitroglycerin tablets are prescribed? A. Limit the number of tablets to four per day. B. Discontinue the medication if a headache develops. C. Increase the number of tablets if dizziness is experienced. D. Ensure that the medication is stored in its original dark container. Rationale Nitroglycerin is sensitive to light and moisture, so it must be stored in a dark, airtight container. Limit the number of tablets to four per day, taken as needed. If more than three tablets are necessary in a 15-minute period, emergency medical attention should be received. A headache may be an expected side effect, and the medication should not be discontinued. Dizziness indicates the dosage may need to be decreased by the health care provider. 31) A client with midsternal pain presents to the emergency department. Vital signs are stable. Which form of nitroglycerin would the nurse anticipate giving initially? A. Oral capsule B. Sublingual spray C. Intravenous solution D. Transdermal patch Rationale Nitroglycerin spray provides prompt relief of symptoms. The nurse administers one to two sprays, up to a maximum of three sprays, onto or under the tongue every 5 minutes until pain is relieved. If unrelieved after three sprays, intravenous (IV) nitroglycerin may be considered. Both the transdermal and oral forms of nitroglycerin are used for prophylactic purposes, not management of acute pain. 32) A client is discharged with a prescription for sustained-release nitroglycerin. Which information will the nurse provide to the client? A. Swallow the capsule whole. B. Take the medication with milk. C. Place the capsule under the tongue. D. Crush the capsule and mix with soft food. Rationale The sustained-release capsule should be swallowed whole on an empty stomach. The capsule should not be chewed or crushed because the 'beads' within the capsule are activated on a time-release schedule. Taking the capsule with milk isn’t necessary; a full glass of water is sufficient. The sustained-release capsule is taken on an empty stomach. A sublingual tablet is held under the tongue, not swallowed; sustained-release nitroglycerin is a capsule that needs to be swallowed. A stinging feeling when the medication is under the tongue may occur with a sublingual nitroglycerin tablet; sustained-release nitroglycerin is a capsule that should be swallowed whole. 33) The nurse has administered sublingual nitroglycerin. Which outcome would the nurse use to determine the effectiveness of sublingual nitroglycerin? A. Relief of anginal pain B. Improved cardiac output C. Decreased blood pressure D. Ease in respiratory effort Rationale Cardiac nitrates relax smooth muscles of the coronary arteries; they dilate and deliver more blood to heart muscle, relieving ischemic pain. Although cardiac output may improve because of improved oxygenation of the myocardium, improved cardiac output is not a basis for evaluating the effectiveness of sublingual nitroglycerin. Although dilation of blood vessels and a subsequent drop in blood pressure is a reason why intravenous (IV) nitroglycerin may be administered, decreased blood pressure is not the basis for evaluating the effectiveness of sublingual nitroglycerin, which is indicated for pain relief. Although superficial vessels dilate, lowering the blood pressure and creating a flushed appearance, dilation of superficial blood vessels is not the basis for evaluating the medication’s effectiveness. 34) Which client response indicates to the nurse that a vasodilator medication is effective? A. Absence of adventitious breath sounds B. Increase in the daily amount of urine produced C. Pulse rate decreases from 110 to 75 beats/minute D. Blood pressure changes from 154/90 to 126/72 mm Hg Rationale Vasodilation will lower the blood pressure. The pulse rate is not decreased and may increase. Breath sounds are not directly affected by vasodilation, although vasodilator medications can decrease preload and afterload, which could indirectly affect breath sounds in heart failure. The urine output is not affected immediately, although control of blood pressure can help preserve renal function over time. 35) Sodium nitroprusside is prescribed for a client with a blood pressure of 260/120 mm Hg. The nurse recalls that sodium nitroprusside decreases blood pressure by which mechanism? A. Decreasing the heart rate B. Increasing cardiac output C. Increasing peripheral resistance D. Relaxing venous and arterial smooth muscles Rationale This medication decreases blood pressure by relaxing venous and arteriolar smooth muscles and is used for immediate reduction of blood pressure. This medication may increase the heart rate as a response to vasodilation. It decreases cardiac workload by decreasing preload and afterload. It decreases peripheral resistance by dilating peripheral blood vessels. 36) The nitrate isosorbide dinitrate is prescribed for a client with angina. Which instruction should the nurse include in this client's discharge teaching plan? A. Quit taking the medication if dizziness occurs. B. Do not get up quickly. Always rise slowly. C. Take the medication with food only. D. Increase your intake of potassium-rich foods. An expected side effect of nitrates is orthostatic hypotension and the nurse should instruct the client to prevent it by rising slowly. 37) A client's dose of isosorbide dinitrate (Imdur) is increased from 40 mg to 60 mg PO daily. When the client reports the onset of a headache prior to the next scheduled dose, which action should the nurse implement? A. Hold the next scheduled dose of Imdur 60 mg and administer a PRN dose of acetaminophen (Tylenol). B. Administer the 40 mg of Imdur and then contact the healthcare provider. C. Administer the 60 mg dose of Imdur and a PRN dose of acetaminophen (Tylenol). D. Do not administer the next dose of Imdur or any acetaminophen until notifying the healthcare provider. Imdur is a nitrate which causes vasodilation. This vasodilation can result in headaches, which can generally be controlled with acetaminophen until the client develops a tolerance to this adverse effect. “The Ides of Pee K+”-semide; -tanide; -thiazide: torsemide, furosemide, bumetanide, hydrochlorothiazide (HCTZ) x 33 1) A client is admitted to the hospital with a diagnosis of heart failure and acute pulmonary edema. The health care provider prescribes furosemide 40 mg intravenous (IV) stat to be repeated in 1 hour. Which nursing action will best evaluate the effectiveness of the furosemide in managing the client’s condition? A. Performing daily weights B. Auscultating breath sounds C. Monitoring intake and output D. Assessing for dependent edema Rationale Maintaining adequate gas exchange and minimizing hypoxia with pulmonary edema are critical; therefore assessing the effectiveness of furosemide therapy as it relates to the respiratory system is most important. Furosemide inhibits the reabsorption of sodium and chloride from the loop of Henle and distal renal tubule, causing diuresis; as diuresis occurs fluid moves out of the vascular compartment, thereby reducing pulmonary edema and the bilateral crackles. Although a liter of fluid weighs approximately 2.2 pounds (1 kg) and weight loss will reflect the amount of fluid lost, it will take time before a change in weight can be measured. Although identifying a greater output versus intake indicates the effectiveness of furosemide, it is the client’s pulmonary status that is most important with acute pulmonary edema. Although the lessening of a client’s dependent edema reflects effectiveness of furosemide therapy, it is the client’s improving pulmonary status that is the best indicator of how furosemide improves the client’s condition. 2) A health care provider prescribes furosemide for a client with hypervolemia. The nurse recalls that furosemide exerts its effects in which part of the renal system? A. Distal tubule B. Collecting duct C. Glomerulus of the nephron D. Loop of Henle Rationale Furosemide acts in the ascending limb of the loop of Henle in the kidney. Thiazides act in the distal tubule in the kidney. Potassium-sparing diuretics act in the collecting duct in the kidney. Plasma expanders, not diuretics, act in the glomerulus of the nephron in the kidney. 3) A client is receiving furosemide to relieve edema. The nurse will monitor the client for which responses? Select all that apply. One, some, or all responses may be correct. A. Weight loss B. Negative nitrogen balance C. Increased urine specific gravity D. Excessive loss of potassium ions E. Pronounced retention of sodium ions Rationale Each liter of fluid weighs 2.2 pounds (1 kilogram). Assessing weight loss is an objective measure of the effectiveness of the medication. Furosemide is a potent diuretic that is used to provide rapid diuresis in clients with pulmonary edema; it acts in the loop of Henle and causes depletion of electrolytes, such as potassium and sodium. A negative nitrogen balance does not affect protein metabolism. With increased fluid loss, the specific gravity is likely to be lowered. Furosemide inhibits the reabsorption of sodium. 4) The nurse is caring for a child receiving furosemide for pulmonary edema. Which nursing intervention(s) would the nurse implement? Select all that apply. One, some, or all responses may be correct. A. Checking the child’s weight every day B. Administering the medication on an empty stomach C. Calculating the dose of medication as carefully as possible D. Exposing the child to sunlight for increasing periods E. Assessing the child regularly to help prevent electrolyte loss Rationale The child’s weight should be checked and recorded daily to aid in the assessment of therapeutic and adverse effects. Pediatric doses should be calculated carefully to prevent an accidental overdose. Pediatric clients are at greater risk of electrolyte loss; therefore they require closer and more cautious assessment to help prevent hypertension and stroke. Furosemide may cause stomach upset if it is taken on an empty stomach; the child should be given the medication with food to help prevent gastric upset. A child taking diuretics should not be exposed to sunlight for long periods, because this action may precipitate fluid volume loss and heatstroke. 5) The client with congestive heart failure is receiving furosemide 80 mg once daily. Which data collection assessment would be performed to evaluate medication effectiveness? Select all that apply. One, some, or all responses may be correct. A. Daily weight B. Intake and output C. Monitor for edema D. Daily pulse oximetry E. Auscultate breath sounds Rationale Daily weight at the same time, on the same scale, and in the same clothing is important as it is an indication of fluid gains or losses. The nurse would also record daily intake and output and report intake exceeding output. The nurse would monitor for peripheral edema and document the findings. It is important to obtain and record vital signs and daily pulse oximetry as improving results relate to effectiveness of furosemide. The nurse would also auscultate breath sounds, look for jugular venous distension, and report abnormal data. 6) A nurse is assessing a client with heart failure who is taking prescribed torsemide. Which clinical finding indicates effectiveness of the medication? A. Symmetrical pulses bilaterally B. Full strength to bilateral extremities C. Intact whisper test D. Absence of peripheral edema Rationale: Torsemide is a loop diuretic used in the treatment of hypertension and fluid overload. The expected therapeutic response of torsemide is a decrease in fluid retention evidenced by the absence of peripheral edema. Symmetrical pulses bilaterally and full strength to bilateral extremities do not evaluate the effectiveness of torsemide. An intact whisper test indicates the absence of ototoxicity, an adverse effect of torsemide. However, this does not evaluate medication effectiveness. 7) The client is discharged from the hospital with a new prescription for furosemide. During a follow-up visit one week later, the nurse notes the following findings. Which finding is most important to report to the health care provider? A. Constipation B. Muscle cramps C. Occasional lightheadedness D. Increased urine production Rationale: Furosemide is a loop (potassium-wasting) diuretic. It can cause dehydration and hypokalemia, which can result in muscle cramps. This is the most important finding. Dizziness or lightheadedness may occur as the body adjusts to the medication. The nurse should reinforce to the client that they should get up slowly when rising from a sitting or lying position. The client should tell the HCP if these findings persist or become worse. Increased urine production is an expected action of the medication. Some people experience constipation when taking this medication, but it is not as important to report that finding as the possibility of hypokalemia. 8) The nurse is providing discharge instructions to an older adult client with heart failure. The client asks, "What is the purpose for taking the furosemide?" How should the nurse respond? A. It will help with decreasing fluid buildup in your lungs. B. It will help with reducing the risk for an irregular heart rhythm. C. It will protect your kidneys from chronic damage. D. It will reverse the damage to your heart muscle. Rationale: Furosemide is a loop diuretic. Diuretics are the first-line drug of choice in older adults with heart failure (HF) and fluid overload. These drugs enhance the renal excretion of sodium and water by reducing circulating blood volume, decreasing preload, and reducing systemic and pulmonary congestion, i.e., decreased fluid buildup in the lungs. The other actions do not pertain to furosemide. 9) A client received 40 mg of furosemide by mouth at 10 am. Which information is most important for the nurse to provide to the next nurse in the change-of-shift report? A. The client lost two pounds in the last 24 hours. B. The client is to receive another dose of furosemide at 10 pm. C. The client's potassium level was 4.0 mEq/L prior to administration. D. The client's urine output was 1500 mL over nine hours. Rationale: Although all of the information is important to include, a diuresis of 1,500 mL is a very large amount and could cause hypokalemia, fluid volume deficit and hypotension. Therefore, it is the most important information to provide to the nurse on the next shift. 10) The nurse is caring for a client who has been taking furosemide for the past week. Which manifestation would indicate that the client may be experiencing a negative side effect? A. Edema of the ankles B. Gastric irritability C. Weight gain of five pounds D. Decreased appetite Rationale: Furosemide (Lasix) causes a loss of potassium if a supplement is not taken. Findings of hypokalemia include anorexia, fatigue, nausea, decreased gastrointestinal motility, muscle weakness and dysrhythmias. 11) Which sign of hypokalemia will the nurse moni