Drugs affecting the Cardiac System ( Chap 43-53) Flashcards
A patient is taking a beta1-adrenergic drug to improve the stroke volume of the heart. The nurse caring for this patient knows that this drug acts by increasing:
a. cardiac afterload.
b. cardiac preload.
c. myocardial contractility.
d. venous return.
ANS: C
Beta1-adrenergic agents help increase the heart’s stroke volume by increasing myocardial contractility. Cardiac afterload is determined primarily by the degree of peripheral resistance caused by constriction of arterioles; increasing afterload would decrease stroke volume. Beta1-adrenergic agents do not affect afterload. Cardiac preload is the amount of stretch applied to the cardiac muscle before contraction and is determined by the amount of venous return. Beta1-adrenergic agents do not affect cardiac preload. Venous return is determined by the systemic filling pressure and auxiliary muscle pumps and is not affected by beta1-adrenergic agents.
A nurse is caring for a patient who is receiving a drug that causes constriction of arterioles. The nurse expects to observe which effect from this drug?
a. Decreased stroke volume
b. Increased stroke volume
c. Decreased myocardial contractility
d. Increased myocardial contractility
ANS: A
Constriction of arterioles increases the load against which the heart must pump to eject blood. Increased constriction of arterioles would decrease, not increase, the stroke volume of the heart. Myocardial contractility is determined by the sympathetic nervous system, acting through beta1-adrenergic receptors in the myocardium.
A patient with a history of hypertension is admitted for a procedure. If the patient’s arterial pressure decreases, which clinical manifestation would the nurse expect to see?
a. Decreased heart rate
b. Increased heart rate
c. Decreased blood pressure
d. Syncope
ANS: B
When arterial pressure decreases, the vasoconstrictor center causes constriction of nearly all arterioles, leading to an increase in peripheral resistance, constriction of veins, increasing venous return, and subsequent acceleration of the heart rate. A decrease in arterial pressure would not cause a decrease in the heart rate or blood pressure, nor would it cause syncope.
A nurse is teaching a nursing student how blood can return to the heart when pressure in the venous capillary beds is very low. Which statement by the student indicates a need for further teaching?
a. “Constriction of small muscles in the venous wall increases venous pressure.”
b. “Negative pressure in the left atrium draws blood toward the heart.”
c. “Skeletal muscles relax to allow the free flow of blood.”
d. “Venous valves help prevent the backflow of blood.”
ANS: C
Skeletal muscle contraction, along with one-way venous valves, help create an “auxiliary” venous pump that helps drive blood toward the heart. Constriction of small muscles in venous walls helps increase venous pressure. Negative pressure in the left atrium sucks blood toward the heart. Valves, which are one-way, work with the contraction of skeletal muscles to create a venous pump.
A nurse is assessing a patient with heart failure. The patient complains of shortness of breath, and the nurse auscultates crackles in both lungs. The nurse understands that these symptoms are the result of:
a. decreased force of ventricular contraction.
b. increased force of ventricular contraction.
c. decreased ventricular filling.
d. increased ventricular filling.
ANS: A
In the failing heart Starling’s law breaks down, and the force of contraction no longer increases in proportion to the amount of ventricular filling. The result is the backup of blood into the lungs and the symptoms of shortness of breath and crackles caused by fluid. Increased ventricular contraction would not result in a backup of blood into the lungs. Changes in ventricular filling are not the direct cause of this symptom.
A patient with hypertension is admitted to the hospital. On admission the patient’s heart rate is 72 beats per minute, and the blood pressure is 140/95 mm Hg. After administering an antihypertensive medication, the nurse notes a heart rate of 85 beats per minute and a blood pressure of 130/80 mm Hg. What does the nurse expect to occur?
a. A decrease in the heart rate back to baseline in 1 to 2 days
b. An increase in the blood pressure within a few days
c. An increase in potassium retention in 1 to 2 days
d. A decrease in fluid retention within a week
ANS: A
When blood pressure drops, the baroreceptors in the aortic arch and carotid sinus sense this and relay information to the vasoconstrictor center of the medulla; this causes constriction of arterioles and veins and increased sympathetic impulses to the heart, resulting in an increased heart rate. After 1 to 2 days, this system resets to the new pressure, and the heart rate returns to normal. The blood pressure will not increase when this system resets. Increased potassium retention will not occur. Over time, the body will retain more fluid to increase the blood pressure.
A patient is taking a drug that interferes with venous constriction. The nurse will tell the patient to:
a. ask for assistance when getting out of bed.
b. expect bradycardia for a few days.
c. notify the provider if headache occurs.
d. report shortness of breath.
ANS: A
A drop in venous pressure reduces venous return to the heart, and as blood pools in the extremities, orthostatic hypotension can occur. Patients taking drugs that reduce venous constriction should be cautioned to ask for assistance when getting out of bed. Bradycardia, headache, and shortness of breath are not expected effects.
A patient with hypertension is prescribed an angiotensin-converting enzyme (ACE) inhibitor. The nurse reviewing this patient’s chart before administering the medication will be most concerned about which other disease process?
a. Bronchial asthma
b. Coronary artery disease
c. Diabetes mellitus
d. Renal artery stenosis
ANS: D
ACE inhibitors can cause severe renal insufficiency in patients with bilateral renal artery stenosis or stenosis in the artery to a single remaining kidney. Bronchial asthma, coronary artery disease, and diabetes mellitus are not comorbidities that are contraindications to treatment with an ACE inhibitor.
A nurse administers an ACE inhibitor to a patient who is taking the drug for the first time. What will the nurse do?
a. Instruct the patient not to get up without assistance.
b. Make sure the patient takes a potassium supplement.
c. Report the presence of a dry cough to the prescriber.
d. Request an order for a diuretic to counter the side effects of the ACE inhibitor.
ANS: A
Severe hypotension can result with the first dose of an ACE inhibitor. The patient should be discouraged from getting up without assistance. Potassium supplements are contraindicated. A dry cough is an expected side effect that eventually may cause a patient to discontinue the drug; however, it is not a contraindication to treatment. Diuretics can exacerbate hypotension and should be discontinued temporarily when a patient starts an ACE inhibitor.
A patient who has been taking an antihypertensive medication for several years is recovering from a myocardial infarction. The prescriber changes the patient’s medication to an ACE inhibitor. The patient asks the nurse why a new drug is necessary. What is the nurse’s response?
a. “ACE inhibitors can prevent or reverse pathologic changes in the heart’s structure.”
b. “ACE inhibitors help lower LDL cholesterol and raise HDL cholesterol.”
c. “ACE inhibitors increase venous return to the heart, improving cardiac output.”
d. “ACE inhibitors regulate electrolytes that affect the cardiac rhythm.”
ANS: A
ACE inhibitors have many advantages over other antihypertensive medications, the most important of which is their ability to prevent or reverse pathologic changes in the heart and reduce the risk of cardiac mortality caused by hypertension. They are useful in patients with high low-density lipoprotein (LDL) or low high-density lipoprotein (HDL) cholesterol, but they do not directly affect this comorbidity. They reduce venous return to the heart, thereby reducing right heart size. They do not alter serum electrolyte levels.
A prescriber orders ramipril (Altace) for an obese patient with type 2 diabetes mellitus who has developed hypertension. The nurse provides teaching before dismissing the patient home. Which statement by the patient indicates understanding of the teaching?
a. “I am less likely to develop diabetic nephropathy when taking this medication.”
b. “I should check my blood sugar more often, because hyperglycemia is a side effect of this drug.”
c. “Taking this medication helps reduce my risk of stroke and heart attack.”
d. “This medication will probably prevent the development of diabetic retinopathy.”
ANS: C
Ramipril (Altace) is approved for reducing the risk of stroke and myocardial infarction (MI) in patients at high risk for a major cardiovascular event because they have hypertension in conjunction with a history of stroke or MI or because they have diabetes. ACE inhibitors cannot be used for primary prevention of diabetic nephropathy, but they can delay the onset of overt nephropathy in patients who already have less advanced nephropathy. ACE inhibitors do not affect serum electrolytes or glucose. One ACE inhibitor, enalapril, can reduce the risk of diabetic retinopathy in some patients with type 1 diabetes mellitus.
A patient begins taking an ACE inhibitor and complains of a dry cough. What does the nurse correctly tell the patient about this symptom?
a. It indicates that a serious side effect has occurred.
b. It is a common side effect that occurs in almost all patients taking the drug.
c. It may be uncomfortable enough that the drug will need to be discontinued.
d. It occurs frequently in patients taking the drug but will subside over time.
ANS: C
A cough occurs in about 10% of patients taking ACE inhibitors and is the most common reason for discontinuing therapy. It does not indicate a serious condition. It occurs in about 10% of all patients and is more common in women, older adults, and those of Asian ancestry. It does not subside until the medication is discontinued.
A patient with hypertension who has been taking captopril (Capoten) for several months is admitted to the hospital. The patient reports that food “tastes funny.” What will the nurse do?
a. Compare the patient’s admission weight to a previous weight.
b. Notify the provider to request a different antihypertensive medication.
c. Reassure the patient that this is a temporary side effect of the drug.
d. Request an order for a white blood cell count (WBC) with differential.
ANS: A
Dysgeusia is a relatively common side effect of ACE inhibitors. It is not necessary to withdraw the medication unless anorexia or weight loss occurs, so assessing the patient’s weight is an appropriate nursing action. Unless the condition is interfering with the patient’s weight, there is no need to withdraw the drug. Dysgeusia is not temporary. A WBC with differential is indicated if neutropenia, a rare side effect, is suspected.
A nurse is reviewing a patient’s medications before administration. Which drug-to-drug interactions should most concern the nurse in a patient with a history of heart failure and a potassium level of 5.5 mEq/L?
a. Furosemide (Lasix) and enalapril (Vasotec)
b. Amlodipine (Norvasc) and spironolactone (Aldactone)
c. Eplerenone (Inspra) and spironolactone (Aldactone)
d. Metoprolol (Lopressor) and furosemide (Lasix)
ANS: C
The greatest risk with eplerenone is hyperkalemia, and combining this drug with a potassium-sparing diuretic creates a significant risk of hyperkalemia. Furosemide and enalapril, an ACE inhibitor, would not be contraindicated in this patient. Amlodipine and spironolactone would not cause hyperkalemia. The combination of metoprolol, a beta blocker, and furosemide would not be contraindicated in this patient.
A patient who is taking furosemide (Lasix) and digoxin will begin taking captopril (Capoten). The nurse is providing information about the drug. Which statement by the patient indicates a need for further teaching?
a. “I can use acetaminophen for analgesia if needed.”
b. “I should stop taking the Lasix about a week before starting the Capoten.”
c. “I should take this medication on a full stomach.”
d. “I will need to have blood tests done every 2 weeks for a few months.”
ANS: C
Most oral formulations of ACE inhibitors may be given without regard for meals; captopril and moexipril, however, should be given 1 hour before meals. Nonsteroidal anti-inflammatory medications should be avoided; acetaminophen is not contraindicated. Patients taking diuretics should stop taking them 1 week before starting an ACE inhibitor to minimize the risk of hypotension. A WBC with differential should be evaluated at baseline and, after treatment starts, every 2 weeks for several months to monitor for neutropenia.
A patient who stops taking an ACE inhibitor because of its side effects will begin taking an angiotensin II receptor blocker (ARB) medication. Which side effect of ACE inhibitors will not occur with an ARB medication?
a. Angioedema
b. Cancer
c. Cough
d. Renal failure
ANS: C
ARBs do not promote the accumulation of bradykinin in the lungs and do not induce cough. Angioedema may occur with ARBs, but the incidence is lower than with ACE inhibitors. An increased risk of cancer may be a concern with ARBs but is not a concern with ACE inhibitors. As with ACE inhibitors, renal failure can occur in patients with bilateral renal artery stenosis or stenosis in the artery to a single remaining kidney.
A female patient who is not taking any other medications is prescribed aliskiren (Tekturna), a direct renin inhibitor (DRI). The nurse reviews medication information with the patient. Which statement by the patient indicates understanding of the teaching?
a. “If I get pregnant, I should stop taking this drug by the second trimester.”
b. “If I take this drug with a high-fat meal, it will be more effective.”
c. “I should restrict my potassium intake while taking this drug.”
d. “I should take this medication 1 hour before sitting down to a meal.”
ANS: D
DRIs should be taken on an empty stomach to improve their bioavailability. Patients should not take this drug when pregnant and should stop immediately upon finding out they are pregnant. Dosing with a high-fat meal reduces the drug’s bioavailability. DRIs rarely cause hyperkalemia when taken alone.
A female patient who begins taking spironolactone (Aldactone) as an adjunct to furosemide (Lasix) complains that her voice is deepening. What will the nurse do?
a. Contact the provider to obtain an order for a complete blood count (CBC) and liver function tests.
b. Explain that this drug binds with receptors for steroid hormones, causing this effect.
c. Report this side effect to the provider and request another medication for this patient.
d. Teach the patient to report any associated cough, which may indicate a more severe side effect.
ANS: B
Spironolactone binds with receptors for aldosterone and with other steroid hormones, causing side effects such as gynecomastia, menstrual irregularities, impotence, hirsutism, and deepening of the voice. There is no indication for a CBC or for liver function tests in this patient with this side effect. Deepening of the voice is not an indication for withdrawal of the drug. This side effect is not associated with cough.
A female patient taking an ACE inhibitor learns that she is pregnant. What will the nurse tell this patient?
a. The fetus most likely will have serious congenital defects.
b. The fetus must be monitored closely while the patient is taking this drug.
c. The patient’s prescriber probably will change her medication to an ARB.
d. The patient should stop taking the medication and contact her provider immediately.
ANS: D
ACE inhibitors are known to cause serious fetal injury during the second and third trimesters of pregnancy. Whether injury occurs earlier in pregnancy is unknown, and the incidence probably is low. However, women should be counseled to stop taking the drug if they become pregnant, and they should not take it if they are contemplating becoming pregnant. Women who take ACE inhibitors in the first trimester should be counseled that the risk to the fetus is probably low. Women should stop taking the drug when pregnant. ARBs carry the same risk as ACE inhibitors.
A nurse is caring for a patient who is receiving verapamil (Calan) for hypertension and digoxin (Lanoxin) for heart failure. The nurse will observe this patient for:
a. AV blockade.
b. gingival hyperplasia.
c. migraine headaches.
d. reflex tachycardia.
ANS: A
Verapamil and digoxin both suppress impulse conduction through the AV node; when the two drugs are used concurrently, the risk of AV blockade is increased. Gingival hyperplasia can occur in rare cases with verapamil, but it is not an acute symptom. Verapamil can be used to prevent migraine, and its use for this purpose is under investigation. Verapamil and digoxin both suppress the heart rate. Nifedipine causes reflex tachycardia.
A patient begins taking nifedipine (Procardia), along with a beta blocker, to treat hypertension. The nurse understands that the beta blocker is used to:
a. reduce flushing.
b. minimize gingival hyperplasia.
c. prevent constipation.
d. prevent reflex tachycardia.
ANS: D
Beta blockers are combined with nifedipine to prevent reflex tachycardia. Beta blockers do not reduce flushing, minimize gingival hyperplasia, or prevent constipation. Beta blockers can reduce the adverse cardiac effects of nifedipine.
A nurse is teaching a patient who will begin taking verapamil (Calan) for hypertension about the drug’s side effects. Which statement by the patient indicates understanding of the teaching?
a. “I may become constipated, so I should increase fluids and fiber.”
b. “I may experience a rapid heart rate as a result of taking this drug.”
c. “I may have swelling of my hands and feet, but this will subside.”
d. “I may need to increase my digoxin dose while taking this drug.”
ANS: A
Constipation is common with verapamil and can be minimized by increasing dietary fiber and fluids. Verapamil lowers the heart rate. Peripheral edema may occur secondary to vasodilation, and patients should notify their prescriber if this occurs, because the prescriber may use diuretics to treat the condition. Verapamil and digoxin have similar cardiac effects; also, verapamil may increase plasma levels of digoxin by as much as 60%, so digoxin doses may need to be reduced.
A nurse is preparing to assist a nursing student in administering intravenous verapamil to a patient who also receives a beta blocker. The nurse asks the nursing student to discuss the plan of care for this patient. Which statement by the student indicates a need for further teaching?
a. “I will check to see when the last dose of the beta blocker was given.”
b. “I will monitor vital signs closely to assess for hypotension.”
c. “I will monitor the heart rate frequently to assess for reflex tachycardia.”
d. “I will prepare to administer intravenous norepinephrine if necessary.”
ANS: C
Reflex tachycardia is not an expected effect; the greater risk is cardiosuppression and bradycardia. Because beta blockers and verapamil have the same effects on the heart, there is a risk of excessive cardiosuppression. To minimize this risk, the two drugs should be given several hours apart. Hypotension may occur and should be treated with IV norepinephrine.
A patient who took an overdose of verapamil has been treated with gastric lavage and a cathartic. The emergency department nurse assesses the patient and notes a heart rate of 50 beats per minute and a blood pressure of 90/50 mm Hg. The nurse will anticipate:
a. administering intravenous norepinephrine (NE) and isoproterenol.
b. assisting with direct-current (DC) cardioversion.
c. placing the patient in an upright position.
d. preparing to administer a beta blocker.
ANS: A
Verapamil toxicity can cause bradycardia and hypotension. Isoproterenol should be given to treat bradycardia and NE for hypotension. DC cardioversion is indicated for ventricular tachydysrhythmias, which this patient does not have. Patients with hypotension should be placed in Trendelenburg’s position. Beta blockers will only exacerbate these effects.
A patient who has been taking verapamil (Calan) for hypertension complains of constipation. The patient will begin taking amlodipine (Norvasc) to prevent this side effect. The nurse provides teaching about the difference between the two drugs. Which statement by the patient indicates that further teaching is needed?
a. “I can expect dizziness and facial flushing with nifedipine.”
b. “I should notify the provider if I have swelling of my hands and feet.”
c. “I will need to take a beta blocker to prevent reflex tachycardia.”
d. “I will need to take this drug once a day.”
ANS: C
Amlodipine produces selective blockade of calcium channels in blood vessels with minimal effects on the heart. Reflex tachycardia is not common, so a beta blocker is not indicated to prevent this effect. Dizziness and facial flushing may occur. Peripheral edema may occur and should be reported to the provider. Amlodipine is given once daily.
Which are therapeutic uses for verapamil? (Select all that apply.)
a. Angina of effort
b. Cardiac dysrhythmias
c. Essential hypertension
d. Sick sinus syndrome
e. Suppression of preterm labor
ANS: A, B, C
Verapamil is used to treat both vasospastic angina and angina of effort. It slows the ventricular rate in patients with atrial flutter, atrial fibrillation, and paroxysmal supraventricular tachycardia. It is a first-line drug for the treatment of essential hypertension. It is contraindicated in patients with sick sinus syndrome. Nifedipine has investigational uses in suppressing preterm labor.
A nurse is administering a vasodilator that dilates resistance vessels. The nurse understands that this drug will have which effect on the patient?
a. Decreased cardiac preload
b. Decreased cardiac output
c. Increased tissue perfusion
d. Increased ventricular contraction
ANS: C
Vasodilators that dilate resistance vessels, or arterioles, cause a decrease in afterload, which allows cardiac output and tissue perfusion to increase. A decrease in preload would be the result of dilation of capacitance vessels, or veins. Dilation of arterioles increases cardiac output. Ventricular contraction results when preload is increased.
A patient is taking a vasodilator that relaxes smooth muscles in veins. To help minimize drug side effects, the nurse caring for this patient will:
a. caution the patient not to get up without assistance.
b. encourage the patient to increase fluid intake.
c. tell the patient to report shortness of breath.
d. warn the patient about the possibility of bradycardia.
ANS: A
Postural hypotension occurs when moving from a supine or seated position to an upright position. It is caused by relaxation of smooth muscle in veins, which allows blood to pool in veins and decreases venous return of blood to the heart. Patients taking such drugs should ask for assistance when getting up to prevent falls. Prolonged use of vasodilators can lead to expansion of blood volume and fluid overload, so increasing fluid intake is not appropriate. Shortness of breath is a symptom associated with heart failure. Tachycardia can occur when the blood pressure drops as a result of the baroreceptor reflex.
A nurse is caring for a patient with hypertension and diabetes. The patient’s prescriber recently ordered an angiotensin-converting enzyme (ACE) inhibitor. Which statement by the patient indicates understanding of the nurse’s teaching about this drug?
a. “ACE inhibitors only dilate veins, so I may have more edema in my ankles.”
b. “ACE inhibitors prevent the nervous system from causing increased blood pressure.”
c. “This drug can also cause shortness of breath because of bronchoconstriction.”
d. “This drug will help lower my blood pressure and will benefit my kidneys.”
ANS: D
ACE inhibitors reduce blood pressure and help preserve renal function in people with diabetes. ACE inhibitors dilate both veins and arterioles. ACE inhibitors work on the renin-angiotensin-aldosterone system, not the nervous system. ACE inhibitors do not have effects on the bronchioles of the lungs.
The nurse is caring for a patient who is taking a vasodilator that dilates capacitance vessels. The nurse will expect which effect in this patient?
a. Decrease in cardiac work
b. Increase in cardiac output
c. Increase in tissue perfusion
d. Increase in venous return
ANS: A
Vasodilators that dilate capacitance vessels, or veins, lead to a decrease in venous return to the heart, which reduces preload and the force of ventricular contraction. The resultant effect is a decrease in cardiac work. With a decrease in ventricular contraction, cardiac output is reduced, as is tissue perfusion. Dilation of veins causes a decrease in venous return.
A nurse is reviewing the phenomenon of reflex tachycardia with a group of nursing students. Which statement by a student indicates understanding of this phenomenon?
a. “Baroreceptors in the aortic arch stimulate the heart to beat faster.”
b. “Reflex tachycardia can negate the desired effects of vasodilators.”
c. “Reflex tachycardia is more likely to occur when beta blockers are given.”
d. “Venous dilation must occur for reflex tachycardia to occur.”
ANS: B
Reflex tachycardia, which is a compensatory mechanism in response to decreased blood pressure, can negate the desired effect of a vasodilator by eventually increasing blood pressure. Baroreceptors relay information to the vasomotor center of the medulla; the medulla sends impulses to the heart. Beta blockers are given to counter reflex tachycardia. Reflex tachycardia can be produced by dilation of both arterioles and veins.
A female patient with essential hypertension is being treated with hydralazine (Apresoline) 25 mg twice daily. The nurse assesses the patient and notes a heart rate of 96 beats per minute and a blood pressure of 110/72 mm Hg. The nurse will request an order to:
a. administer a beta blocker.
b. administer a drug that dilates veins.
c. reduce the dose of hydralazine.
d. give the patient a diuretic.
ANS: A
This patient is showing signs of reflex tachycardia, so a beta blocker is indicated to slow the heart rate. Patients with heart failure who take hydralazine often require the addition of isosorbide dinitrate, which also dilates veins. There is no indication for reducing the dose of hydralazine. A diuretic can be given with hydralazine if sodium and water retention is present.
A nurse is obtaining a medication history on a newly admitted patient, who reports taking minoxidil for hypertension. Admission vital signs reveal a heart rate of 78 beats per minute and a blood pressure of 120/80 mm Hg. What is an important part of the initial assessment for this patient?
a. Evaluating ankle edema
b. Monitoring for nausea and vomiting
c. Noting the presence of hypertrichosis
d. Obtaining a blood glucose
ANS: A
Fluid retention is a common and serious adverse effect of minoxidil, because it can lead to cardiac decompensation. If present, a diuretic is indicated. Nausea and vomiting may occur with this drug but is not a serious side effect. Hypertrichosis occurs in about 80% of patients taking the drug, but its effects are cosmetic and not life threatening. It may be important to monitor the blood glucose level in some patients, because the drug can alter glucose tolerance, but this effect is not as serious as fluid retention.
A patient is admitted with severe hypertensive crisis. The nurse will anticipate administering which medication?
a. Captopril PO
b. Hydralazine (Apresoline) 25 mg PO
c. Minoxidil 20 mg PO
d. Sodium nitroprusside (Nitropress) IV
ANS: D
Sodium nitroprusside is the drug of choice for hypertensive emergencies and is given intravenously. ACE inhibitors, such as captopril, are not used. Hydralazine may be used but should be given IV. Minoxidil is effective, but its severe side effects make it a second-line drug.
A nursing student asks a nurse why a patient in hypertensive crisis is receiving both intravenous sodium nitroprusside (Nitropress) and oral hydralazine (Apresoline). The nurse will explain that this is done to prevent:
a. cyanide poisoning.
b. fluid retention.
c. rebound hypertension.
d. reflex tachycardia.
ANS: C
Sodium nitroprusside acts rapidly and is given only intravenously. Rebound hypertension occurs immediately when the IV is stopped, so an oral antihypertensive should be given simultaneously. Cyanide poisoning can occur with sodium nitroprusside, but giving hydralazine does not counter this adverse effect. Hydralazine does not prevent fluid retention or reflex tachycardia.
Which medications are most likely to cause postural hypotension? (Select all that apply.)
a. Minoxidil
b. Diltiazem (Cardizem)
c. Prazosin (Minipress)
d. Captopril (Capoten)
e. Losartan (Cozaar)
ANS: C, D, E
Postural, or orthostatic, hypotension is defined as a fall in blood pressure related to a change in position. Minoxidil and diltiazem dilate arterioles; therefore, they are not likely to cause postural hypotension. Prazosin, captopril, and losartan all reportedly can cause orthostatic hypotension.
A patient has had blood pressures of 150/95 mm Hg and 148/90 mm Hg on two separate office visits. The patient reports a blood pressure of 145/92 mm Hg taken in an ambulatory setting. The patient’s diagnostic tests are all normal. The nurse will expect this patient’s provider to order:
a. a beta blocker.
b. a loop diuretic and spironolactone.
c. a thiazide diuretic.
d. counseling on lifestyle changes.
ANS: C
This patient has primary, or essential, hypertension as evidenced by systolic pressure greater than 140 and diastolic pressure greater than 90, along with normal tests ruling out another primary cause. Thiazide diuretics are first-line drugs for hypertension. Beta blockers are effective, but are most often used to counter reflex tachycardia associated with reduced blood pressure caused by therapeutic agents. Loop diuretics cause greater diuresis than is usually needed and so are not first-line drugs. This patient should be counseled on lifestyle changes as an adjunct to drug therapy, but should also begin drug therapy because hypertension already exists.
A patient with diabetes develops hypertension. The nurse will anticipate administering which type of medication to treat hypertension in this patient?
a. ACE inhibitors
b. Beta blockers
c. Direct-acting vasodilators
d. Thiazide diuretics
ANS: A
ACE inhibitors slow the progression of kidney injury in diabetic patients with renal damage. Beta blockers can mask signs of hypoglycemia and must be used with caution in diabetics. Direct-acting vasodilators are third-line drugs for chronic hypertension. Thiazide diuretics promote hyperglycemia.
A patient has three separate blood pressure (BP) readings of 120/100 mm Hg, 138/92 mm Hg, and 126/96 mm Hg. Which category describes this patient’s BP?
a. Hypertension
b. Isolated systolic hypertension
c. Normal
d. Prehypertension
ANS: A
Hypertension is defined as systolic BP over 140 mm Hg or diastolic BP over 90 mm Hg. When systolic and diastolic BP fall into different categories, classification is based on the higher category. This patient has a hypertensive diastolic BP. Isolated systolic hypertension occurs if the systolic BP is greater than 140 mm Hg with a diastolic BP less than 90 mm Hg. Because this patient has an elevated diastolic BP, it is not considered normal. Prehypertension occurs with a systolic BP of 120 to 139 mm Hg or a diastolic BP of 80 to 89 mm Hg.
A nurse checks a patient’s vital signs in the hospital and notes a blood pressure of 146/98 mm Hg. What will the nurse do?
a. Instruct the patient to consume a low-sodium diet.
b. Prepare the patient for an electrocardiogram and blood tests.
c. Recheck the patient’s blood pressure in the other arm.
d. Request an order for a thiazide diuretic.
ANS: C
Diagnosis of hypertension should be based on several blood pressure readings, not just one. High readings should be confirmed in the contralateral arm. Low-sodium diets are indicated for patients with confirmed hypertension. An electrocardiogram and blood tests are indicated for patients with confirmed hypertension to rule out primary causes. Thiazide diuretics are first-line drugs for confirmed hypertension.
A patient who does not consume alcohol or nicotine products reports a strong family history of hypertension and cardiovascular disease. The patient has a blood pressure of 126/82 and a normal weight and body mass index for height and age. The nurse will expect to teach this patient about:
a. ACE inhibitors and calcium channel blocker medications.
b. the DASH diet, sodium restriction, and exercise.
c. increased calcium and potassium supplements.
d. thiazide diuretics and lifestyle changes.
ANS: B
This patient has prehypertension without other risk factors. Lifestyle changes are indicated at this point. If blood pressure rises to hypertension levels, other measures, including drug therapy, will be initiated. Calcium and potassium supplements are not indicated.
A patient with hypertension with a blood pressure of 168/110 mm Hg begins taking hydrochlorothiazide and verapamil. The patient returns to the clinic after 2 weeks of drug therapy, and the nurse notes a blood pressure of 140/85 mm Hg and a heart rate of 98 beats per minute. What will the nurse do?
a. Notify the provider and ask about adding a beta blocker medication.
b. Reassure the patient that the medications are working.
c. Remind the patient to move slowly from sitting to standing.
d. Request an order for an electrocardiogram.
ANS: A
Beta blockers are often added to drug regimens to treat reflex tachycardia, which is a common side effect of lowering blood pressure, caused by the baroreceptor reflex. The patient’s blood pressure is responding to the medications, but the tachycardia warrants treatment. Reminding the patient to move slowly from sitting to standing is appropriate with any blood pressure medication, but this patient has reflex tachycardia, which must be treated. An electrocardiogram is not indicated.
A patient has been taking chlorthalidone to treat hypertension. The patient’s prescriber has just ordered the addition of spironolactone to the patient’s drug regimen. Which statement by the patient indicates a need for further teaching?
a. “I should continue following the DASH diet when adding this drug.”
b. “I should not take an ACE inhibitor when adding this drug.”
c. “I will need to take potassium supplements when adding this drug.”
d. “I will not experience a significant increase in diuresis when adding this drug.”
ANS: C
Spironolactone is given in addition to thiazide diuretics to balance potassium loss caused by the thiazide diuretic. Patients should be advised against taking potassium supplements with spironolactone, because hyperkalemia can result. The DASH diet may be continued. ACE inhibitors are contraindicated because they promote hyperkalemia. Spironolactone does not significantly increase diuresis.
A nurse is discussing how beta blockers work to decrease blood pressure with a nursing student. Which statement by the student indicates a need for further teaching?
a. “Beta blockers block the actions of angiotensin II.”
b. “Beta blockers decrease heart rate and contractility.”
c. “Beta blockers decrease peripheral vascular resistance.”
d. “Beta blockers decrease the release of renin.”
ANS: A
Beta blockers reduce the release of renin by blockade of beta1 receptors on juxtaglomerular cells in the kidney, which reduces angiotensin II-mediated vasoconstriction, but do not block the actions of angiotensin II directly. Beta blockers decrease heart rate and cardiac contractility, decrease peripheral vascular resistance, and decrease the release of renin.
A patient with hypertension will begin taking an alpha1 blocker. What will the nurse teach this patient?
a. A persistent cough is a known side effect of this drug.
b. Eat foods rich in potassium while taking this drug.
c. Move slowly from sitting to standing when taking this drug.
d. Report shortness of breath while taking this drug.
ANS: C
The most disturbing side effect of alpha blockers is orthostatic hypotension. Patients taking these drugs should be cautioned to stand up slowly to avoid lightheadedness or falls. A persistent cough is a common side effect of ACE inhibitors. It is not necessary to increase dietary potassium intake when taking this drug. Shortness of breath may occur in individuals with asthma who are taking beta blockers.
A patient is taking clonidine for hypertension and reports having dry mouth and drowsiness. What will the nurse tell the patient?
a. Beta blockers can reverse these side effects.
b. Discontinue the medication immediately and notify the provider.
c. Drink extra fluids and avoid driving when drowsy.
d. Notify the provider if symptoms persist after several weeks.
ANS: C
Clonidine can cause dry mouth and sedation; patients should be warned to drink extra fluids and avoid driving. Beta blockers do not reverse these drug side effects. Discontinuing clonidine abruptly can cause severe rebound hypertension. These are common side effects that do not abate over time.
A patient takes an ACE inhibitor to treat hypertension and tells the nurse that she wants to become pregnant. She asks whether she should continue taking the medication while she is pregnant. What will the nurse tell her?
a. Controlling her blood pressure will decrease her risk of preeclampsia.
b. Ask the provider about changing to an ARB during pregnancy.
c. Continue taking the ACE inhibitor during her pregnancy.
d. Discuss using methyldopa instead while she is pregnant.
ANS: D
Methyldopa has limited effects on uteroplacental and fetal hemodynamics and does not adversely affect the fetus or neonate. Controlling blood pressure does not lower the risk of preeclampsia. ACE inhibitors and ARBs are specifically contraindicated during pregnancy
A hospitalized patient has a blood pressure of 145/96 mm Hg. The nurse caring for this patient notes that the blood pressure the day before was 132/98 mm Hg. The patient reports ambulatory blood pressure readings of 136/98 and 138/92 mm Hg. The patient has a history of a previous myocardial infarction and has adopted a lifestyle that includes use of the DASH diet and regular exercise. What will the nurse do?
a. Notify the provider and discuss ordering a beta blocker for this patient.
b. Notify the provider and suggest a thiazide diuretic as initial therapy.
c. Order a diet low in sodium and high in potassium for this patient.
d. Recheck the patient’s blood pressure in 4 hours to verify the result.
ANS: A
Initial drug selection is determined by the presence or absence of a compelling indication or comorbid condition. This patient has a history of MI; beta blockers are indicated for patients with pre-existing heart disease. Thiazide diuretics are first-line drugs of choice in patients without compelling indications. The patient is already consuming a DASH diet; closer monitoring of sodium or potassium will not help lower blood pressure. The patient has a record of hypertension, so it is unnecessary to recheck the blood pressure to verify the condition.
Which two-drug regimen would be appropriate for a patient with hypertension who does not have other compelling conditions?
a. Hydrochlorothiazide and nadolol
b. Hydralazine and minoxidil
c. Spironolactone and amiloride
d. Trichlormethiazide and hydrochlorothiazide
ANS: A
When using two or more drugs to treat hypertension, each drug should come from a different class. Hydrochlorothiazide is a diuretic and nadolol is a beta blocker, so this choice is appropriate. Hydralazine and minoxidil are both vasodilators. Spironolactone and amiloride are both potassium-sparing diuretics. Trichlormethiazide and hydrochlorothiazide are both thiazide diuretics.
A nursing student asks the nurse why multi-drug therapy is often used to treat hypertension. Which statement by the student indicates a need for further teaching?
a. “Multi-drug therapy often means that drugs may be given in lower doses.”
b. “Some agents are used to offset adverse effects of other agents.”
c. “Treatment of hypertension via different mechanisms increases success.”
d. “Two or more drugs will lower blood pressure more quickly.”
ANS: D
Multi-drug therapy does not lower blood pressure more quickly. Using more than one drug often means that doses can be decreased. Some agents can offset adverse effects of other agents. Treatment via different mechanisms increases the likelihood of success.
A patient with a recent onset of nephrosclerosis has been taking an ACE inhibitor and a thiazide diuretic. The patient’s initial blood pressure was 148/100 mm Hg. After 1 month of drug therapy, the patient’s blood pressure is 130/90 mm Hg. The nurse will contact the provider to discuss:
a. adding a calcium channel blocker to this patient’s drug regimen.
b. lowering doses of the antihypertensive medications.
c. ordering a high potassium diet.
d. adding spironolactone to the drug regimen.
ANS: A
In patients with renal disease, the goal of antihypertensive therapy is to lower the blood pressure to 130/80 mm Hg or less. Adding a third medication is often indicated. Lowering the dose of the medications is not indicated because the patient’s blood pressure is not in the target range. Adding potassium to the diet and using a potassium-sparing diuretic are contraindicated.
A 5-year-old patient seen in an outpatient clinic is noted to have hypertension on three separate visits. Ambulatory blood pressure monitoring confirms that the child has hypertension. As an initial intervention with the child’s parents, the nurse will expect to:
a. perform a detailed health history on the child.
b. provide teaching about antihypertensive medications.
c. reassure the parents that their child may outgrow this condition.
d. teach the parents about lifestyle changes and a special diet.
ANS: A
Because the incidence of secondary hypertension is much higher in children than adults, it is important to obtain an accurate health history to help uncover primary causes. Once the type of hypertension is established, the teaching interventions may be useful. Hypertension must be treated, and it is incorrect to reassure parents that their child may just outgrow the condition.
The nurse is caring for a pregnant patient who is in labor. The woman reports having had mild preeclampsia with a previous pregnancy. The nurse notes that the woman has a blood pressure of 168/102 mm Hg. The nurse will contact the provider to request an order for which drug?
a. Angiotensin-converting enzyme (ACE) inhibitor
b. Hydralazine (Apresoline)
c. Magnesium sulfate
d. Sodium nitroprusside
ANS: B
The drug of choice for lowering blood pressure in a patient with severe preeclampsia is hydralazine. Sodium nitroprusside is not indicated. Magnesium sulfate is given as prophylaxis against seizures but does not treat hypertension. ACE inhibitors are contraindicated because of their potential for fetal harm.
A nurse has provided education for a patient newly diagnosed with hypertension who is just beginning therapy with antihypertensive medications. Which statement by the patient indicates a need for further teaching?
a. “I may experience serious long-term problems even if I am not having symptoms.”
b. “I should report side effects to the provider since other drugs may be substituted.”
c. “I will need to take medications on a long-term basis.”
d. “When my symptoms subside, I may discontinue the medications.”
ANS: D
Patients should be taught that hypertension treatment is lifelong and that medications must be continued even when symptoms subside. Long-term problems may still occur without symptoms. Reporting drug side effects is necessary so that other drugs may be tried if needed.
A patient is taking enalapril (Vasotec). The nurse understands that patients taking this type of drug for heart failure need to be monitored carefully for:
a. hypernatremia.
b. hypertension.
c. hyperkalemia.
d. hypokalemia.
ANS: C
One of the principal effects of angiotensin-converting enzyme (ACE) inhibitors is hyperkalemia, which is due to decreased aldosterone release arising from blockage of angiotensin II. There is no indication that careful monitoring of sodium for increased levels is indicated. Vasotec is indicated for heart failure, not hypertension. The drug therapy should be monitored to ascertain its effectiveness, but hyperkalemia is the main concern. Hyperkalemia, not hypokalemia, is a concern because of the decreased aldosterone release that occurs with blockage of angiotensin II.
A nurse is discussing heart failure with a group of nursing students. Which statement by a student reflects an understanding of how compensatory mechanisms can compound existing problems in patients with heart failure?
a. “An increase in arteriolar tone to improve tissue perfusion can decrease resistance.”
b. “An increase in contractility to increase cardiac output can cause pulmonary edema.”
c. “When the heart rate increases to increase cardiac output, it can prevent adequate filling of the ventricles.”
d. “When venous tone increases to increase ventricular filling, an increase in arterial pressure occurs.”
ANS: C
The heart rate increases to improve cardiac output, but it may prevent adequate ventricular filling. An increase in arteriole tone improves tissue perfusion but also increases both the resistance to the pumping of the heart and the cardiac workload. Increased contractility helps improve cardiac output but is detrimental because it increases the oxygen demand of the heart. An increase in venous tone improves ventricular filling but, as the ventricles fail, blood can back up and cause pulmonary edema.
A patient with chronic hypertension is admitted to the hospital. During the admission assessment, the nurse notes a heart rate of 96 beats per minute, a blood pressure of 150/90 mm Hg, bibasilar crackles, 2+ pitting edema of the ankles, and distension of the jugular veins. The nurse will contact the provider to request an order for which medication?
a. ACE inhibitor
b. Digoxin (Lanoxin)
c. Furosemide (Lasix)
d. Spironolactone (Aldactone)
ANS: C
This patient shows signs of fluid volume overload and needs a diuretic. Furosemide is a high-ceiling (loop) diuretic, which can produce profound diuresis very quickly even when the glomerular filtration rate (GFR) is low. An ACE inhibitor will not reduce fluid volume overload. Digoxin has a positive inotropic effect on the heart, which may improve renal perfusion, but this is not its primary effect. Spironolactone is a potassium-sparing diuretic with weak diuresis effects; it is used in conjunction with other diuretics to improve electrolyte balance.
A patient newly diagnosed with heart failure is admitted to the hospital. The nurse notes a pulse of 90 beats per minute. The nurse will observe this patient closely for:
a. decreased urine output.
b. increased blood pressure.
c. jugular vein distension.
d. shortness of breath.
ANS: A
As the heart rate increases, ventricular filling decreases, and cardiac output and renal perfusion decrease. Tachycardia does not elevate blood pressure. Jugular vein distension and shortness of breath occur with fluid volume overload.
A diabetic patient is recovering from a myocardial infarction but does not have symptoms of heart failure. The nurse will expect to teach this patient about:
a. ACE inhibitors and beta blockers.
b. biventricular pacemakers.
c. dietary supplements and exercise.
d. diuretics and digoxin.
ANS: A
This patient is classified as having Stage B heart failure with no current symptoms but with structural heart disease strongly associated with the development of heart failure. Treatment at this stage includes an ACE inhibitor and a beta blocker to help prevent the progression of symptoms. Biventricular pacemakers are used for patients in Stage C heart failure and have more advanced structural disease and symptoms. Dietary supplements and exercise have not been proven to prevent structural heart disease. Diuretics and digoxin are used for patients with Stage C heart failure.
A patient with moderate heart failure begins taking a thiazide diuretic. The nurse will tell the patient to expect which outcome when taking this drug?
a. Improved exercise tolerance
b. Increased cardiac output
c. Prevention of cardiac remodeling
d. Prolonged survival
ANS: A
Diuretics help reduce fluid volume overload which, by reducing pulmonary edema, can improve exercise tolerance. Diuretics do not improve cardiac output. ACE inhibitors are used to prevent cardiac remodeling and to improve long-term survival.
A patient with heart failure who has been taking an ACE inhibitor, a thiazide diuretic, and a beta blocker for several months comes to the clinic for evaluation. As part of the ongoing assessment of this patient, the nurse will expect the provider to evaluate:
a. complete blood count.
b. ejection fraction.
c. maximal exercise capacity.
d. serum electrolyte levels.
ANS: D
Patients taking thiazide diuretics can develop hypokalemia, which can increase the risk for dysrhythmias; therefore, the serum electrolyte levels should be monitored closely. A complete blood count is not recommended. This patient is taking the drugs recommended for patients with Stage C heart failure; although the patient’s quality of life and ability to participate in activities should be monitored, routine measurement of the ejection fraction and maximal exercise capacity is not recommended.
A patient with Stage C heart failure (HF) who has been taking an ACE inhibitor, a beta blocker, and a diuretic begins to have increased dyspnea, weight gain, and decreased urine output. The provider orders spironolactone (Aldactone). The nurse will make sure that the patient:
a. does not take potassium supplements.
b. monitors for a decreased heart rate.
c. takes extra fluids.
d. uses a salt substitute instead of salt.
ANS: A
Spironolactone is added to therapy for patients with worsening symptoms of HF. Because spironolactone is a potassium-sparing diuretic, patients should not take supplemental potassium. Patients taking digoxin need to monitor their heart rate. Extra fluids are not indicated. Salt substitutes contain potassium.
A patient has heart failure and is taking an ACE inhibitor. The patient has developed fibrotic changes in the heart and vessels. The nurse expects the provider to order which medication to counter this development?
a. Aldosterone antagonist
b. Angiotensin II receptor blocker (ARB)
c. Beta blocker
d. Direct renin inhibitor (DRI)
ANS: A
Aldosterone antagonists are added to therapy for patients with worsening symptoms of HF. Aldosterone promotes myocardial remodeling and myocardial fibrosis, so aldosterone antagonists can help with this symptom. ARBs are given for patients who do not tolerate ACE inhibitors. Beta blockers do not prevent fibrotic changes. DRIs are not widely used.
The potassium-sparing diuretic spironolactone (Aldactone) prolongs survival and improves heart failure symptoms by which mechanism?
a. Blocking aldosterone receptors
b. Increasing diuresis
c. Reducing venous pressure
d. Reducing afterload
ANS: A
Spironolactone prolongs survival in patients with HF primarily by blocking receptors for aldosterone. Spironolactone cause only minimal diuresis. Spironolactone does not reduce afterload, and it does not reduce venous pressure enough to prolong survival, because it causes only minimal diuresis.
A nurse prepares to administer a scheduled dose of digoxin. The nurse finds a new laboratory report showing a plasma digoxin level of 0.7 ng/mL. What action should the nurse take?
a. Withhold the drug for an hour and reassess the level.
b. Withhold the drug and notify the prescriber immediately.
c. Administer Digibind to counteract the toxicity.
d. Check the patient’s apical pulse, and if it is within a safe range, administer the digoxin.
ANS: D
The optimum plasma digoxin range is 0.5 to 0.8 ng/mL. The patient’s pulse should be checked before administration, as always, and the digoxin should be administered. The digoxin does not have to be withheld, nor does the prescriber need to be notified. If the digoxin level is demonstrating a trend of increasing, the issue should be discussed in rounds. Digibind is not indicated, because the digoxin level is therapeutic.
A man asks a nurse why he cannot use digoxin (Lanoxin) for his heart failure, because both of his parents used it for HF. The nurse will explain that digoxin is not first-line therapy for which reason?
a. It causes tachycardia and increases the cardiac workload.
b. It does not correct the underlying pathology of heart failure.
c. It has a wide therapeutic range that makes dosing difficult.
d. It may actually shorten the patient’s life expectancy.
ANS: B
Digoxin improves cardiac output, alters electrical effects, and helps to decrease sympathetic outflow from the central nervous system (CNS) through its neurohormonal effects; however, it does not alter the underlying pathology of heart failure or prevent cardiac remodeling. Digoxin causes bradycardia and increases the cardiac workload by increasing contractility. It has a narrow therapeutic range and many adverse effects. Digoxin does not improve life expectancy; in women it may actually shorten life expectancy.
A nurse is preparing to administer digoxin (Lanoxin) to a patient. The patient’s heart rate is 62 beats per minute, and the blood pressure is 120/60 mm Hg. The last serum electrolyte value showed a potassium level of 5.2 mEq/L. What will the nurse do?
a. Contact the provider to request an increased dose of digoxin.
b. Give the dose of digoxin and notify the provider of the potassium level.
c. Request an order for a diuretic.
d. Withhold the dose and notify the provider of the heart rate.
ANS: B
The patient’s serum potassium level is above normal limits, but only slightly. An elevated potassium level can reduce the effects of digoxin, so there is no risk of toxicity. There is no indication that an increased dose of digoxin is needed. There is no indication for a diuretic. The heart rate is acceptable; doses should be withheld if the heart rate is less than 60 beats per minute.
A patient with heart failure who has been given digoxin (Lanoxin) daily for a week complains of nausea. Before giving the next dose, the nurse will:
a. assess the heart rate (HR) and give the dose if the HR is greater than 60 beats per minute.
b. contact the provider to report digoxin toxicity.
c. request an order for a decreased dose of digoxin.
d. review the serum electrolyte values and withhold the dose if the potassium level is greater than 3.5 mEq/L.
ANS: A
Anorexia, nausea, and vomiting are the most common adverse effects of digoxin and should cause nurses to evaluate for more serious signs of toxicity. If the HR is greater than 60 beats per minute, the dose may be given. Nausea by itself is not a sign of toxicity. A decreased dose is not indicated. A serum potassium level less than 3.5 mEq/L is an indication for withholding the dose.
A patient is taking a thiazide diuretic for hypertension and quinidine to treat a dysrhythmia. The prescriber orders digoxin 0.125 mg to improve this patient’s cardiac output. The nurse should contact the provider to request:
a. adding spironolactone (Aldactone).
b. reducing the dose of digoxin.
c. discontinuing the quinidine.
d. giving potassium supplements.
ANS: C
Quinidine can cause plasma levels of digoxin to rise; concurrent use of quinidine and digoxin is contraindicated. There is no indication for adding spironolactone unless this patient’s potassium level is elevated. The dose of digoxin ordered is a low dose. Potassium supplements are contraindicated with digoxin.
A patient with heart failure who takes a thiazide diuretic and digoxin (Lanoxin) is admitted for shortness of breath. The patient’s heart rate is 66 beats per minute, and the blood pressure is 130/88 mm Hg. The serum potassium level is 3.8 mEq/L, and the digoxin level is 0.8 ng/mL. The nurse admitting this patient understands that the patient:
a. has digoxin toxicity.
b. is showing signs of renal failure.
c. is experiencing worsening of the disease.
d. needs a potassium-sparing diuretic.
ANS: C
This patient has a normal serum potassium level, and the digoxin level is normal. The patient is showing signs of pulmonary edema, which indicates progression of heart failure. The digoxin level is within normal limits, and the heart rate is above 60 beats per minute, so digoxin toxicity is not likely. There is no sign of renal failure. A potassium-sparing diuretic is not indicated.
An 88-year-old patient with heart failure has progressed to Stage D and is hospitalized for the third time in a month. The nurse will expect to discuss which topic with the patient’s family?
a. Antidysrhythmic medications
b. End-of-life care
c. Heart transplantation
d. Implantable mechanical assist devices
ANS: B
Patients in Stage D heart failure have advanced structural heart disease. For eligible patients, the best long-term solution is heart transplantation, but this patient probably is not eligible, given his advanced age. End-of-life care should be discussed. Antidysrhythmic medications are not indicated and may make symptoms worse. An implantable mechanical assist device is used in patients awaiting heart transplantation.
A patient has been taking digoxin (Lanoxin) 0.25 mg, and furosemide (Lasix) 40 mg, daily. Upon routine assessment by the nurse, the patient states, “I see yellow halos around the lights.” The nurse should perform which action based on this assessment?
a. Check the patient for other symptoms of digitalis toxicity.
b. Withhold the next dose of furosemide.
c. Continue to monitor the patient for heart failure.
d. Document the findings and reassess in 1 hour.
ANS: A
Yellow halos around lights indicate digoxin toxicity. The use of furosemide increases the risk of hypokalemia, which in turn potentiates digoxin toxicity. The patient should also be assessed for headache, nausea, and vomiting, and blood should be drawn for measurement of the serum digoxin level. The nurse should not withhold the dose of furosemide until further assessment is done, including measurement of a serum digoxin level. No evidence indicates that the patient is in worsening heart failure. Documentation of findings is secondary to further assessment and prevention of digoxin toxicity.
Which medications are included in first-line therapy for heart failure? (Select all that apply.)
a. Agents that inhibit the renin-angiotensin-aldosterone system (RAAS)
b. Aldosterone antagonists
c. Beta blockers
d. Cardiac glycosides
e. Diuretics
ANS: A, C, E
For routine therapy, heart failure is treated with agents that inhibit the RAAS, beta blockers, and diuretics. Aldosterone antagonists and cardiac glycosides are not first-line drugs for HF.
Which are expected effects of cardiac glycosides? (Select all that apply.)
a. Decreased cardiac output
b. Decreased force of contraction
c. Decreased heart rate
d. Modulation of neurohormonal systems
e. Positive inotropic effects
ANS: C, D, E
Digoxin slows the heart rate, modulates the activity of neurohormonal systems, and increases the force of contraction. It does not decrease cardiac output or reduce the force of contraction.
Which two classes of antidysrhythmic drugs have nearly identical cardiac effects?
a. Beta blockers and calcium channel blockers
b. Beta blockers and potassium channel blockers
c. Calcium channel blockers and sodium channel blockers
d. Sodium channel blockers and potassium channel blockers
ANS: A
Calcium channel blockade has the same impact on cardiac action potentials as does beta blockade, so these agents have nearly identical effects on cardiac function; that is, they reduce automaticity in the SA node, delay conduction through the AV node, and reduce myocardial contractility. Potassium channel blockers act by delaying repolarization of fast potentials. Sodium channel blockers block sodium channels to slow impulse conduction in the atria, ventricles, and His-Purkinje system.
A patient with atrial fibrillation is taking verapamil (Calan). The patient has read about the drug on the Internet and wants to know why a drug that affects the rate of ventricular contraction is used to treat an abnormal atrial contraction. What will the nurse tell the patient?
a. “Drugs that treat ventricular dysrhythmias help to restore normal sinus rhythm.”
b. “Atrial dysrhythmias can have life-threatening effects on ventricular function.”
c. “Treating ventricular dysrhythmias helps prevent the likelihood of stroke.”
d. “When ventricular contraction slows, atrial contraction is also slowed.”
ANS: B
Dysrhythmic activity in the atria does not significantly reduce cardiac output but can be dangerous when dysrhythmic impulses cross the AV node, causing ventricular dysrhythmias, which can be life threatening. Treating ventricular dysrhythmia helps improve ventricular pumping. These drugs do not restore normal sinus rhythm. To prevent stroke, an anticoagulant, such as warfarin, is used. Slowing ventricular contraction does not affect the rate of atrial contraction. Restoring normal sinus rhythm requires cardioversion, short-term treatment with amiodarone or sotalol, or RF ablation of the dysrhythmia source.
A nurse is teaching a patient who is about to undergo direct-current (DC) cardioversion to treat atrial flutter. The patient has been taking verapamil and warfarin for 6 months. Which statement by the patient indicates understanding of the teaching?
a. “I may need long-term therapy with another cardiac medication after the procedure.”
b. “I should stop taking warfarin a few days before the procedure.”
c. “I will need to take a beta blocker after the procedure to prevent recurrence of atrial flutter.”
d. “I will not have to take antidysrhythmia medications after the procedure.”
ANS: A After cardioversion for atrial flutter, patients may continue to need long-term therapy with either a class IC agent or a class III agent to prevent recurrence. Patients undergoing DC cardioversion need to take warfarin 3 to 4 weeks before the procedure and for several weeks afterward. Beta blockers are not indicated for postprocedural prophylaxis. Class IC and class III agents are antidysrhythmic drugs.
A nurse is teaching a group of nursing students about antidysrhythmic medications. Which statement by a student indicates understanding of the teaching?
a. “Antidysrhythmic drugs can cause new dysrhythmias or worsen existing ones.”
b. “Adverse effects of these drugs are mainly noncardiac in nature.”
c. “For most antidysrhythmic drugs, there is evidence of reduced mortality.”
d. “Use of these drugs may be necessary even if the benefits are unknown.”
ANS: A
Because antidysrhythmic drugs have prodysrhythmic actions, they can exacerbate existing dysrhythmias or generate new ones. Most adverse effects are cardiac related. There is evidence of increased mortality with many of these drugs. Use of these drugs should be limited to situations in which there is a clear benefit and only if that benefit outweighs any risks.
A patient is taking digoxin (Lanoxin) and quinidine to treat sustained ventricular tachycardia. Before giving medications, the nurse reviews the patient’s electrocardiogram (ECG) and notes a QRS complex that has widened by 50% from the baseline ECG. What will the nurse do?
a. Administer the medications as ordered, because this indicates improvement.
b. Contact the provider to discuss reducing the digoxin dose.
c. Contact the provider to request an increase in the quinidine dose.
d. Withhold the quinidine and contact the provider to report the ECG finding.
ANS: D
Quinidine widens the QRS complex by slowing depolarization of the ventricles. As cardiotoxicity develops as a result of quinidine toxicity, the QRS complex widens excessively. Any widening of the QRS complex of 50% or more warrants notifying the provider, so the nurse should withhold the medication and contact the provider. Widening of the QRS complex by more than 50% of baseline indicates cardiotoxicity. Quinidine can double digoxin levels, so it is not likely that the digoxin dose would need to be increased, and an increase in the QRS complex does not indicate a need for more digoxin. The quinidine dose should not be increased, because the findings indicate cardiotoxicity from the quinidine.
A nurse provides teaching for a patient who will begin taking procainamide (Procanbid) for long-term suppression of a dysrhythmia. Which statement by the patient indicates a need for further teaching?
a. “I need to take this drug at evenly spaced intervals around the clock.”
b. “I may have increased bruising, but this is a temporary side effect.”
c. “I should report pain and swelling in my joints when taking this drug.”
d. “I will need to have blood tests at regular intervals while taking this drug.”
ANS: B
Blood dyscrasias are a rare but potentially fatal side effect of procainamide and are an indication for withdrawing the drug. Procainamide should be taken around the clock at evenly spaced intervals. Lupuslike symptoms may occur; inflammation of the joints is one manifestation and should be reported so that antinuclear antibody (ANA) titers can be monitored. Because of the risk of lupuslike symptoms and blood dyscrasias, blood tests need to be done weekly at first and then periodically thereafter.
A nurse is caring for a patient in the intensive care unit who is receiving intravenous lidocaine. The patient is drowsy and confused and reports numbness of the fingers and toes. Which standing order will the nurse initiate at this time?
a. Administer diazepam.
b. Reduce the rate of infusion.
c. Discontinue the infusion.
d. Prepare for mechanical ventilation.
ANS: B
This patient is showing signs that are common with high therapeutic levels of lidocaine. Because lidocaine is rapidly degraded, slowing the rate of infusion can help remove excess drug from the circulation. Seizures are possible with toxic doses; diazepam should be used to control seizures. It is not necessary to discontinue the infusion, because this patient is showing signs common to high therapeutic doses. Respiratory arrest is possible with toxic doses; mechanical ventilation may be needed.
A patient with diabetes develops ventricular tachycardia and is in the hospital for evaluation of this condition. The nurse reviews the history and learns that the patient takes mexiletine (Mexitil) for pain caused by peripheral neuropathy. What does the nurse do?
a. Discuss common side effects associated with taking mexiletine with cardiac agents.
b. Understand that this drug will help with both peripheral neuropathy and dysrhythmias.
c. Notify the provider to request that another drug be used for peripheral neuropathy pain.
d. Request an order for renal function and hepatic function tests.
ANS: C
Mexiletine is an antidysrhythmic medication that can also cause dysrhythmias. It is used to treat the pain associated with peripheral neuropathy in diabetic patients, but it is contraindicated in diabetic patients with heart disease and so should be stopped now that this patient has developed a heart disorder. Because it is contraindicated, the nurse will not teach the patient about side effects with other agents. It can exacerbate cardiac symptoms, so it should not be used to treat dysrhythmias in diabetic patients. There is no indication for tests of renal and hepatic function.
A prescriber has ordered propranolol (Inderal) for a patient with recurrent ventricular tachycardia. The nurse preparing to administer this drug will be concerned about what in the patient’s history?
a. Asthma
b. Exercise-induced tachyarrhythmias
c. Hypertension
d. Paroxysmal atrial tachycardia associated with emotion
ANS: A
Propranolol is contraindicated in patients with asthma, because it is a nonselective beta-adrenergic antagonist and can cause bronchoconstriction and exacerbate asthma. It is used to treat tachyarrhythmias and paroxysmal atrial tachycardia evoked by emotion, so it is not contraindicated for patients with these conditions. It lowers blood pressure, so it would be helpful in patients with hypertension.
A nurse is providing teaching to a patient who is admitted to the hospital for initiation of treatment with amiodarone (Cordarone) for atrial fibrillation that has been refractory to other medications. Which statement by the patient indicates a need for further teaching?
a. “I may have itching, malaise, and jaundice, but these symptoms will subside.”
b. “I need to use sun block to help keep my skin from turning bluish gray.”
c. “I should not drink grapefruit juice while taking this medication.”
d. “I should report shortness of breath and cough and stop taking the drug immediately.”
ANS: A
Amiodarone has many toxic effects. Liver toxicity is rare but serious and should be reported and the drug discontinued. Dermatologic toxicity can occur, and sun block helps protect the skin, which, with prolonged exposure to the sun, can turn bluish gray. Drinking grapefruit juice can increase amiodarone levels. Pulmonary toxicity is the greatest concern, and patients with pulmonary symptoms should report these to the provider.
A patient is in the intensive care unit after a myocardial infarction. The nurse notes that the QT interval on this patient’s electrocardiogram has been elongating. The nurse is concerned that which cardiac dysrhythmia may occur?
a. AV block
b. Bradycardia
c. Supraventricular tachycardia
d. Torsades de pointes
ANS: D
Torsades de pointes is a dysrhythmia that can occur with prolongation of the QT interval and can progress to fatal ventricular fibrillation. A prolonged QT interval does not signal the development of AV block, bradycardia, or SVT.
A prescriber is considering prescribing the amiodarone derivative dronedarone (Multaq) for a patient with atrial flutter. The nurse should be concerned about which of the following?
a. History of asthma
b. History of hypothyroidism
c. PR interval of 260 msec
d. QT interval of 520 msec
ANS: D
Because dronedarone prolongs the QT interval by about 10 msec, it should not be used in patients with a QT interval of more than 500 msec. It does not have significant pulmonary or thyroid toxicity. It should not be used in patients with a PR interval of more than 280 msec.
A prescriber orders verapamil (Covera HS) for a patient who is taking digoxin (Lanoxin) and warfarin. The nurse will expect the prescriber to _____ the dose of _____.
a. lower; digoxin
b. increase; digoxin
c. lower; warfarin
d. increase; warfarin
ANS: A
Calcium channel blockers, such as verapamil, can increase levels of digoxin, so patients taking these drugs may need to have their digoxin dose reduced. Increasing the dose of digoxin can result in digoxin toxicity. Verapamil does not affect warfarin levels.
A nurse is discussing adenosine with a nursing student. Which statement by the student indicates a need for further teaching?
a. “Adenosine acts by suppressing action potentials in the SA and AV nodes.”
b. “Adenosine can be used to prevent paroxysmal supraventricular tachycardia and Wolff-Parkinson-White syndrome.”
c. “Adenosine has a half-life that lasts only a few seconds and must be given intravenously.”
d. “Adenosine is not effective for treating atrial fibrillation, atrial flutter, or ventricular dysrhythmias.”
ANS: B
Adenosine is used to terminate paroxysmal supraventricular tachycardia (SVT) and Wolff-Parkinson-White (WPW) syndrome, not to prevent symptoms. Adenosine suppresses action potentials in the SA and AV nodes. Because it has a very short half-life of 1.5 to 10 seconds, it must be given IV bolus, as close to the heart as possible. Adenosine is not active against atrial fibrillation, atrial flutter, or ventricular dysrhythmias.
A nursing student asks a nurse how digoxin causes dysrhythmias. The nurse correctly states that digoxin:
a. reduces automaticity in the AV node.
b. increases automaticity in the Purkinje fibers.
c. increases automaticity in the SA node.
d. speeds up AV conduction.
ANS: B
Digoxin increases automaticity in the Purkinje fibers, which contributes to dysrhythmias caused by digoxin. Decreased automaticity in the AV node is a desired effect of digoxin. Digoxin does not increase automaticity in the SA node. It does not increase AV node conduction.
The nurse is teaching a class on dysrhythmias and associated therapy. The nurse asks the class, “Which cardiac dysrhythmia would result in the lowest cardiac output, and what treatment would be effective?” The class best demonstrates understanding by responding that _____ results in the lowest cardiac output, and treatment includes _____.
a. atrial flutter; lidocaine
b. tachycardia; atropine
c. first-degree heart block; verapamil (Calan)
d. ventricular fibrillation; defibrillation
ANS: D
With ventricular fibrillation there is no cardiac output, because the pumping action of the heart stops. Treatment with electrical countershock is indicated to restore cardiac function. Atrial flutter, tachycardia, and first-degree heart block do not result in the lowest cardiac output.
The nurse educator is providing patient education about the Cardiac Arrhythmia Suppression Trial (CAST). The nurse correctly explains that the trial demonstrated what effect from the pharmacologic suppression of dysrhythmias?
a. It reduced mortality by 50% but increased morbidity.
b. It significantly reduced the risk of a second myocardial infarction (MI).
c. It doubled the risk of a second MI.
d. It should be used in all patients who have had an MI, regardless of rhythm.
ANS: C In the CAST, class IC dysrhythmic drugs were used to prevent dysrhythmias after MI. These drugs were found to actually double the rate of mortality. The antidysrhythmic drugs did not reduce mortality or the risk of a second MI. They should not be used for any MI patients with associated dysrhythmias unless the dysrhythmias are life threatening.
A patient is taking digoxin (Lanoxin) and develops a dysrhythmia. The nurse reports this finding to the prescriber, who will most likely order what? (Select all that apply.)
a. Amiodarone
b. Diltiazem
c. Phenytoin (Dilantin)
d. Quinidine
e. Serum electrolytes
ANS: C, E
Phenytoin is an antiseizure medication used to treat digoxin-induced dysrhythmias. Because digoxin-induced dysrhythmias can be caused by hypokalemia, it is appropriate to evaluate the serum electrolyte levels. Amiodarone, diltiazem, and quinidine increase digoxin levels.
A patient will be taking amiodarone (Cordarone). Which baseline tests are necessary before this medication is started? (Select all that apply.)
a. Chest radiograph and pulmonary function tests
b. Complete blood count with differential
c. Ophthalmologic examination
d. Renal function tests
e. Thyroid function tests
ANS: A, C, E
Amiodarone has many potential toxic side effects, including pulmonary toxicity, ophthalmic effects, and thyroid toxicity, so these systems should be evaluated at baseline and periodically while the patient is taking the drug. A complete blood count is not indicated. Renal function tests are not indicated.
A patient with a history of angina and hypertension is being started on nicotinic acid (Niacin). The nurse is providing patient education. What statement made by the patient demonstrates a need for further teaching?
a. “I will take Tylenol with my medication to reduce the inflammatory effects.”
b. “I will be cautious taking this medication, because I have mild liver damage.”
c. “I will take an aspirin 30 minutes before my niacin to reduce flushing.”
d. “This medication will lower my triglyceride levels.”
ANS: A
Intense flushing of the face, neck, and ears occurs in practically all patients taking nicotinic acid in pharmacologic doses. Tylenol will not reduce the flushing or inflammatory effects of the medication; further patient teaching is required. The flushing reaction diminishes in several weeks and can be attenuated by taking 325 mg of aspirin 30 minutes before each dose. Nicotinic acid is hepatotoxic; therefore, the patient should be taught to have the liver enzymes checked and to self-monitor for signs and symptoms. Nicotinic acid reduces low-density lipoprotein (LDL) cholesterol and triglyceride (TG) levels.
A prescriber has ordered rosuvastatin (Crestor) for a patient with non–alcoholic-related cirrhosis. Which intervention would be most appropriate for the nurse before administration of this drug?
a. Question the order, because rosuvastatin is contraindicated in patients with liver disease.
b. No intervention is necessary; just administer the drug as ordered.
c. Review the baseline liver function test results.
d. Assess the patient for liver disease.
ANS: C
Before administering rosuvastatin, the nurse should review the results of the baseline liver function tests (LFTs). Statins can be used by patients with liver disease but not by those with alcoholic or viral hepatitis. Administering the drug before obtaining baseline LFT results would not allow for an accurate baseline. The patient clearly already has liver disease.
A patient with malaise has been taking daptomycin (Cubicin) for an infection and is concurrently taking simvastatin (Zocor). The nurse should be concerned if the patient complains of:
a. nausea.
b. tiredness.
c. muscle pain.
d. headache.
ANS: C
Statins can injure muscle tissue, causing muscle aches and pain known as myopathy/rhabdomyolysis. Daptomycin also can cause myopathy and therefore should be used with caution in patients concurrently taking simvastatin. Nausea, tiredness, and headache would not cause the nurse as much concern as the likelihood of myopathy
A patient who recently started therapy with an HMG-COA reductase inhibitor asks the nurse, “How long will it take until I see an effect on my LDL cholesterol?” The nurse gives which correct answer?
a. “At least 6 months is required to see a change.”
b. “A reduction usually is seen within 2 weeks.”
c. “Blood levels normalize immediately after the drug is started.”
d. “Cholesterol will not be affected, but triglycerides will fall within the first week.”
ANS: B
Reductions in LDL cholesterol are significant within 2 weeks and maximal within 4 to 6 weeks. It does not take 6 months too see a change. The blood level of LDL cholesterol is not reduced immediately upon starting the drug; a reduction is seen within 2 weeks. Blood cholesterol is affected, specifically LDL cholesterol, not triglycerides.
A patient taking gemfibrozil (Lopid) and rosuvastatin (Crestor) concurrently begins to complain of muscle aches, fatigue, and weakness. What should the nurse monitor?
a. For tendon tenderness
b. For a lupuslike syndrome
c. The patient’s LFT results
d. The patient’s creatinine kinase levels
ANS: D
Creatinine kinase levels are the best laboratory indicator of myopathy and/or rhabdomyolysis, which may lead to renal failure. As can the statins, gemfibrozil and other fibrates can cause myopathy. Fibrates must be used with caution in patients taking statins. Concurrent use of gemfibrozil and rosuvastatin does not cause tendon tenderness or a lupuslike syndrome. Liver function levels should be determined at the start of statin therapy and every 6 months thereafter in patients who do not have liver disease.
A patient presents to the clinic with complaints of muscle aches, muscle pain, and weakness. Upon review of the individual’s medications, the nurse notes that the patient is concurrently taking gemfibrozil (Lopid) and atorvastatin (Lipitor). The nurse should assess the patient for the development of:
a. migraines.
b. hypothyroidism.
c. myopathy.
d. heart failure.
ANS: C
When gemfibrozil and a statin are taken concurrently, the risk of myopathy is increased more than with either agent alone. Migraines, hypothyroidism, and heart failure are not drug-to-drug interactions.
A patient has begun taking an HMG-COA reductase inhibitor. Which statement about this class of drugs made by the nurse during patient education would be inappropriate?
a. “Statins reduce the risk of stroke.”
b. “You should come into the clinic for liver enzymes in 1 month.”
c. “Statins reduce the risk of coronary events in people with normal LDL levels.”
d. “You should maintain a healthy lifestyle and avoid high-fat foods.”
ANS: B
Baseline liver enzyme tests should be done before a patient starts taking an HMG-COA reductase inhibitor. They should be measured again in 6 to 12 months unless the patient has poor liver function, in which case the tests are indicated every 3 months. Statins do reduce the risk of stroke and coronary events in people with normal LDL levels. Maintaining a healthy lifestyle is important, as is avoiding high-fat foods.
A nurse is instructing a patient receiving a cholesterol-lowering agent. Which information should the nurse include in the patient education?
a. “This medication will replace other interventions you have been trying.”
b. “It is important for you to double your dose if you miss one to maintain therapeutic blood levels.”
c. “Stop taking the medication if you experience constipation.”
d. “You should continue your exercise program to increase your HDL serum levels.”
ANS: D
Regular exercise can reduce LDL cholesterol and elevate high-density lipoprotein (HDL) cholesterol, thereby reducing the risk of coronary heart disease (CHD). The patient should consider the cholesterol-lowering drug an adjunct to a proper diet and exercise. Drug therapy cannot replace other important interventions, such as diet and exercise. The patient should never be instructed to double the dose. Constipation is a side effect of most cholesterol-lowering agents. The patient should be encouraged to eat a high-fiber diet and increase fluids if not contraindicated.
An Asian patient comes to the clinic. Upon assessment, the nurse notes a slight yellow tint to the skin and sclera, edema, and hepatomegaly. The drug history reveals that the patient has been taking rosuvastatin (Crestor) for 6 months. The nurse is concerned, because rosuvastatin (Crestor) has been shown to do what?
a. Cause renal and pancreatic toxicity specifically in Asian patients
b. Cause renal failure
c. Create myoglobin in the urine
d. Reach levels twice as high in Asians as in Caucasians, resulting in a greater chance of hepatotoxicity
ANS: D
Rosuvastatin reaches abnormally high levels in people of Asian heritage. Consequently, hepatotoxicity may occur more often in Asian patients because of the high level of the drug in the blood. Rosuvastatin does not cause renal or pancreatic toxicity. Rosuvastatin does not cause renal failure. Rosuvastatin does not create myoglobin in the urine.
Lovastatin (Mevacor) is prescribed for a patient for the first time. The nurse should provide the patient with which instruction?
a. “Take lovastatin with your evening meal.”
b. “Take this medicine before breakfast.”
c. “You may take lovastatin without regard to meals.”
d. “Take this medicine on an empty stomach.”
ANS: A
Patients should be instructed to take lovastatin with the evening meal. Statins should be taken with the evening meal, not before breakfast. Statins should not be administered without regard to meals and should not be taken on an empty stomach.
A nurse is providing discharge teaching instructions for a patient taking cholestyramine (Questran). Which statement made by the patient demonstrates a need for further teaching?
a. “I will take warfarin (Coumadin) 1 hour before my medicine.”
b. “I will increase the fluids and fiber in my diet.”
c. “I can take cholestyramine with my hydrochlorothiazide.”
d. “I will take digoxin 4 hours after taking the cholestyramine.”
ANS: C
Drugs known to form complexes with the sequestrants include thiazide diuretics, such as hydrochlorothiazide, digoxin, warfarin, and some antibiotics. To reduce the formation of sequestrant-drug complexes, oral medication should be administered either 1 hour before the sequestrant or 4 hours after. Further teaching is needed. Warfarin should be taken 1 hour before or 4 hours after cholestyramine. Adverse effects of Questran are limited to the gastrointestinal (GI) tract. Constipation, the principal complaint, can be minimized by increasing dietary fiber and fluids. Digoxin should be taken 1 hour before or 4 hours after cholestyramine.
A nurse is providing patient education about colesevelam (Welchol), a bile acid sequestrant. Which statement made by the patient demonstrates a need for further teaching?
a. “Colesevelam will reduce my levels of low-density lipoprotein.”
b. “Colesevelam will augment my statin drug therapy.”
c. “I will not have to worry about having as many drug interactions as I did when I took cholestyramine.”
d. “I cannot take digoxin while on this medication.”
ANS: D
Digoxin can be taken 1 hour before or 4 hours after taking a bile acid sequestrant. Colesevelam reduces the LDL cholesterol level, which is one of its therapeutic uses. Colesevelam augments statin therapy. Colesevelam does not significantly interact with or reduce the absorption of statins, digoxin, warfarin, or most other drugs.
A nurse is reviewing the medications of a patient with diabetes before discharge. The nurse realizes that the patient will be going home on colesevelam, a bile acid sequestrant, and insulin. What patient education should the nurse provide in the discharge teaching for this patient?
a. The patient needs to monitor the blood sugar carefully, because colesevelam can cause hypoglycemia.
b. The patient needs to monitor the blood sugar carefully, because colesevelam can cause hyperglycemia.
c. The patient needs to take the insulin at least 3 hours before the colesevelam.
d. The patient needs to use an oral antidiabetic agent or agents, not insulin, with colesevelam.
ANS: A
Colesevelam can help control hyperglycemia in patients with diabetes; therefore, hypoglycemia is a possible risk. Hyperglycemia is not a risk for patients with diabetes who take colesevelam. Insulin and colesevelam do not interact; therefore, the insulin can be taken at the patient’s preferred time or times. Either insulin or oral antidiabetic agents can be taken with colesevelam.
A nurse is reviewing a patient’s medications and realizes that gemfibrozil (Lopid) and warfarin (Coumadin) are to be administered concomitantly. This finding concerns the nurse, who is aware that the _____ will be _____.
a. level of gemfibrozil; increased
b. level of gemfibrozil; reduced
c. anticoagulant effects; increased
d. anticoagulant effects; reduced
ANS: C
Gemfibrozil displaces warfarin from the plasma albumin, thereby increasing anticoagulant effects. The level of gemfibrozil will not be increased or decreased. The anticoagulation effects will not be reduced, because free-floating drug is present in the system; the dosage of warfarin may need to be reduced.
During discharge instruction, a nurse wants to assess a patient’s understanding of treatment with cholestyramine (Questran). Which statement made by the patient best demonstrates a need for additional teaching?
a. “I will take cholestyramine (Questran) 1 hour before my other medications.”
b. “I will increase fluids and fiber in my diet.”
c. “I will weigh myself weekly.”
d. “I will have my blood pressure checked weekly.”
ANS: C
Patients need not weigh themselves weekly when taking cholestyramine. Cholestyramine should be taken at least 1 hour before other medications. When taken with other medications, cholestyramine can inhibit the absorption of the other drugs. Constipation is the principal complaint with cholestyramine. It can be minimized by increasing dietary fiber and fluids. Regular blood pressure checks are a good idea. The patient is taking cholestyramine because of high cholesterol, which contributes to hypertension.
A patient is being started on nicotinic acid (Niaspan) to reduce triglyceride levels. The nurse is providing patient education and should include which adverse effects? (Select all that apply.)
a. Facial flushing
b. Constipation
c. Hypoglycemia
d. Gastric upset
e. Itching
ANS: A, D, E
Adverse effects of nicotinic acid include intense flushing of the face, neck, and ears; itching; and GI upset (nausea, vomiting, and diarrhea). Constipation and hypoglycemia are not adverse effects of niacin therapy
A nurse is providing teaching for a patient with stable angina who will begin taking nitroglycerin. Which statement by the patient indicates understanding of the teaching?
a. “I should not participate in aerobic exercise while taking this drug.”
b. “I should take aspirin daily to reduce my need for nitroglycerin.”
c. “If I take nitroglycerin before exertion, I can reduce the chance of an anginal attack.”
d. “I take nitroglycerin to increase the amount of oxygen to my heart.”
ANS: C
Nitroglycerin can be taken before stressful events or exertion to reduce the chance of an attack of angina. Aerobic exercise is an important part of nondrug therapy to reduce the risk of heart attack. Aspirin therapy is an important adjunct to treatment to prevent coronary thrombus formation, but it does not reduce the need for nitroglycerin. Nitroglycerin reduces cardiac oxygen demand, but it does not increase the amount of oxygen available to the heart.
A nurse is discussing the difference between stable and variant angina with a group of nursing students. Which statement by a student indicates the need for further teaching?
a. “Beta blockers are effective in stable angina but not in variant angina.”
b. “In both types of angina, prophylactic treatment is possible.”
c. “Variant angina is primarily treated with vasodilators to increase oxygen supply.”
d. “Variant angina is the result of increased oxygen demand by the heart.”
ANS: D
Variant angina is caused by coronary artery spasm, which reduces the oxygen supply to the heart. Beta blockers are not effective in variant angina but are useful with stable angina. Medications may be given to prevent anginal attacks in both types of angina. Vasodilators are used in variant angina to relieve coronary artery spasm and increase the oxygen supply to the heart.
A patient with new-onset exertional angina takes a nitroglycerin sublingual tablet, but the pain intensifies. The nurse notes that the patient has a heart rate of 76 beats per minute and a blood pressure of 120/82 mm Hg. The electrocardiogram is normal. The patient’s lips and nail beds are pink, and there is no respiratory distress. The nurse will anticipate providing:
a. an angiotensin-converting enzyme (ACE) inhibitor.
b. intravenous nitroglycerin and a beta blocker.
c. ranolazine (Ranexa) and quinidine.
d. supplemental oxygen and intravenous morphine.
ANS: B
This patient has unstable angina, and the next step, when pain is unrelieved by sublingual nitroglycerin, is to give intravenous nitroglycerin and a beta blocker. ACE inhibitors should be given to patients with persistent hypertension if they have left ventricular dysfunction or congestive heart failure (CHF). Ranolazine is a first-line angina drug, but it should not be given with quinidine because of the risk of increasing the QT interval. Supplemental oxygen is indicated if cyanosis or respiratory distress is present. IV morphine may be given if the pain is unrelieved by nitroglycerin.
A patient asks a nurse how nitroglycerin works to relieve anginal pain. The nurse correctly states, “Nitroglycerin:
a. dilates coronary arteries to increase blood flow to the heart.”
b. increases the oxygen supply to the cardiac muscle.”
c. increases ventricular filling to improve cardiac output.”
d. promotes vasodilation, which reduces preload and oxygen demand.”
ANS: D
Nitroglycerin dilates the veins, which reduces venous return to the heart, which in turn decreases ventricular filling. The resulting decrease in preload reduces the oxygen requirements of the heart. Nitroglycerin does not increase the blood flow or oxygen supply to the heart. An increase in ventricular filling would increase oxygen demand and result in increased anginal pain.
A hospitalized patient complains of acute chest pain. The nurse administers a 0.3 mg sublingual nitroglycerin tablet, but the patient continues to complain of pain. Vital signs remain stable. What is the nurse’s next step?
a. Apply a nitroglycerin transdermal patch.
b. Continue dosing at 10-minute intervals.
c. Give a second dose of nitroglycerin in 5 minutes.
d. Request an order for intravenous nitroglycerin.
ANS: C
An initial dose of sublingual nitroglycerin is taken, and if the chest pain persists, as in this case, the patient should take another dose in 5 minutes. Transdermal delivery systems are not useful for terminating an ongoing attack. Dosing at 10-minute intervals is incorrect. If the patient fails to respond or if the pain intensifies, intravenous nitroglycerin may be indicated.
A patient who has begun using transdermal nitroglycerin for angina reports occasional periods of tachycardia. The nurse will expect the prescriber to order:
a. digoxin (Lanoxin) to slow the heart rate.
b. immediate discontinuation of the nitroglycerin.
c. periods of rest when the heart rate increases.
d. verapamil as an adjunct to nitroglycerin therapy.
ANS: D
Nitroglycerin lowers blood pressure by reducing venous return and dilating the arterioles. The lowered blood pressure activates the baroreceptor reflex, causing reflex tachycardia, which can increase cardiac demand and negate the therapeutic effects of nitroglycerin. Treatment with a beta blocker or verapamil suppresses the heart to slow the rate. Digoxin is not recommended. Discontinuation of the nitroglycerin is not indicated. Resting does not slow the heart when the baroreceptor reflex is the cause of the tachycardia.
A patient with angina who uses sublingual nitroglycerin tells the nurse that the episodes are increasing in frequency and usually occur when the patient walks the dog. The patient reports needing almost daily doses of the nitroglycerin and states that one tablet usually provides complete relief. What will the nurse do?
a. Contact the provider to suggest ordering a transdermal patch for this patient.
b. Question the patient about consumption of grapefruit juice.
c. Suggest that the patient limit walking the dog to shorter distances less frequently.
d. Suggest that the patient take two tablets of nitroglycerin each time, because the symptoms are increasing in frequency.
ANS: A
Transdermal patches are good for sustained prophylaxis for anginal attacks and are especially useful when patients have a regular pattern of attacks. Grapefruit juice does not affect the metabolism of nitroglycerin. Patients with angina should be encouraged to increase, not decrease, exercise. Taking two tablets is not recommended when one is effective.
A nursing student asks a nurse how beta blockers increase the oxygen supply to the heart in the treatment of anginal pain. The nurse tells the student that beta blockers:
a. dilate arterioles to improve myocardial circulation.
b. improve cardiac contractility, which makes the heart more efficient.
c. increase arterial pressure to improve cardiac afterload.
d. increase the time the heart is in diastole.
ANS: D
Beta blockers increase the time the heart is in diastole, which increases the time during which blood flows through the myocardial vessels, allowing more oxygen to reach the heart. Beta blockers do not dilate arterioles. They do not increase cardiac contractility; they decrease it, which reduces the cardiac oxygen demand. They do not increase arterial pressure, which would increase the cardiac oxygen demand.
A patient with stable exertional angina has been receiving a beta blocker. Before giving the drug, the nurse notes a resting heart rate of 55 beats per minute. Which is an appropriate nursing action?
a. Administer the drug as ordered, because this is a desired effect.
b. Withhold the dose and notify the provider of the heart rate.
c. Request an order for a lower dose of the medication.
d. Request an order to change to another antianginal medication.
ANS: A
When beta blockers are used for anginal pain, the dosing goal is to reduce the resting heart rate to 50 to 60 beats per minute. Because this heart rate is a desired effect, there is no need to withhold the dose or notify the provider. The dosage does not need to be lowered, because a heart rate of 55 beats per minute is a desired effect. There is no indication of a need to change medications for this patient.
A patient is taking a calcium channel blocker (CCB) for stable angina. The patient’s spouse asks how calcium channel blockers relieve pain. The nurse will explain that CCBs:
a. help relax peripheral arterioles to reduce afterload.
b. improve coronary artery perfusion.
c. increase the heart rate to improve myocardial contractility.
d. increase the QT interval.
ANS: A
CCBs promote relaxation of peripheral arterioles, resulting in a decrease in afterload, which reduces the cardiac oxygen demand. CCBs do not improve coronary artery perfusion. CCBs reduce the heart rate and suppress contractility. CCBs do not affect the QT interval
A patient with variant angina wants to know why a beta blocker cannot be used to treat the angina. Which response by the nurse is correct?
a. “A beta1-selective beta blocker could be used for variant angina.”
b. “Beta blockers do not help relax coronary artery spasm.”
c. “Beta blockers do not help to improve the cardiac oxygen supply.”
d. “Beta blockers promote constriction of arterial smooth muscle.”
ANS: B
Variant angina occurs when coronary arteries go into spasm, thus reducing the circulation and oxygen supply to the heart. CCBs help to reduce coronary artery spasm; beta blockers do not. Beta1-selective beta blockers are used for stable angina for patients who also have asthma, because they do not activate beta2 receptors in the lungs to cause bronchoconstriction. Beta blockers help improve the oxygen supply in stable angina, but they do not relieve coronary artery spasm, so they are not useful in variant angina. Beta blockers do not constrict arterial smooth muscle.
A nursing student is helping to care for a patient who takes verapamil for stable angina. The nurse asks the student to explain the purpose of verapamil in the treatment of this patient. Which statement by the student indicates a need for further teaching?
a. “It relaxes coronary artery spasms.”
b. “It reduces peripheral resistance to reduce oxygen demands.”
c. “It reduces the heart rate, AV conduction, and contractility.”
d. “It relaxes the peripheral arterioles to reduce afterload.”
ANS: A
Verapamil does relax coronary artery spasms, but this is not useful in stable angina. Verapamil is used to relax coronary artery spasms in variant asthma. When used to treat stable angina, verapamil promotes relaxation of peripheral arterioles, which reduces peripheral resistance and decreases afterload. It also reduces the heart rate, AV conduction, and contractility
A patient with angina who is taking ranolazine (Ranexa) has developed a respiratory infection and a dysrhythmia. The provider has ordered azithromycin (Zithromax) for the infection and amlodipine for the dysrhythmia. A nursing student caring for this patient tells the nurse that the patient’s heart rate is 70 beats per minute, and the blood pressure is 128/80 mm Hg. The nurse asks the student to discuss the plan for this patient’s care. Which action is correct?
a. Observe the patient closely for signs of respiratory toxicity.
b. Question the order for azithromycin (Zithromax).
c. Report the patient’s increase in blood pressure to the provider.
d. Request an order for a different calcium channel blocker.
ANS: B
Agents that inhibit CYP3A4 can increase levels of ranolazine and also the risk of torsades de pointes. Macrolide antibiotics, such as azithromycin, are CYP3A4 inhibitors. Respiratory toxicity is not an expected effect with this patient. The patient’s blood pressure is not elevated enough to notify the provider. Amlodipine is the only CCB that should be used with ranolazine.
A nurse provides teaching to a patient with angina who also has type 2 diabetes mellitus, asthma, and hypertension. Which statement by the patient indicates a need for further teaching?
a. “An ACE inhibitor, in addition to nitroglycerin, will lower my risk of cardiovascular death.”
b. “Beta blockers can help control hypertension.”
c. “I should begin regular aerobic exercise.”
d. “Long-acting, slow-release calcium channel blockers can help with anginal pain.”
ANS: B
Beta blockers can be used for angina in most patients but are contraindicated in patients with asthma, because they cause bronchoconstriction. ACE inhibitors help reduce the risk of death in patients with hypertension. Regular aerobic exercise is recommended to control weight and improve cardiovascular function. Long-acting, slow-release CCBs are recommended for patients who have coexisting type 2 diabetes.
A patient with asthma and depression develops stable angina. In addition to organic nitrites, which other medications will be used to treat this condition? (Select all that apply.)
a. ACE inhibitors
b. Antiplatelet drugs
c. Beta blockers
d. Calcium channel blockers
e. Cholesterol-lowering drugs
ANS: A, B, D, E
ACE inhibitors have shown benefit in reducing the incidence of adverse outcomes in patients with coronary artery disease (CAD) and are recommended as part of therapy. Antiplatelet drugs are recommended to reduce the risk of thrombus formation. CCBs are used as adjuncts to nitroglycerin and are safe in patients with asthma and depression. Cholesterol-lowering drugs are recommended to help slow the progression of CAD. Beta blockers are not recommended in patients with asthma or depression.
A nursing student who is preparing to care for a postoperative patient with deep vein thrombosis asks the nurse why the patient must take heparin rather than warfarin. Which response by the nurse is correct?
a. “Heparin has a longer half-life.”
b. “Heparin has fewer adverse effects.”
c. “The onset of warfarin is delayed.”
d. “Warfarin prevents platelet aggregation.”
ANS: C
Warfarin is not useful for treating existing thromboses or for emergencies because the onset of action is delayed. Heparin has a shorter half life and has more side effects. Warfarin does not prevent platelet aggregation.
A patient is receiving heparin postoperatively to prevent deep vein thrombosis. The nurse notes that the patient has a blood pressure of 90/50 mm Hg and a heart rate of 98 beats per minute. The patient’s most recent aPTT is greater than 90 seconds. The patient reports lumbar pain. The nurse will request an order for:
a. a repeat aPTT to be drawn immediately.
b. analgesic medication.
c. changing heparin to aspirin.
d. protamine sulfate.
ANS: D
Heparin overdose may cause hemorrhage, which can be characterized by low blood pressure, tachycardia, and lumbar pain. Protamine sulfate should be given, and the heparin should be discontinued. An aPTT may be drawn later to monitor the effectiveness of protamine sulfate. Analgesics are not indicated because the lumbar pain is likely caused by adrenal hemorrhage. Aspirin will only increase the risk of hemorrhage
A patient has been receiving heparin while in the hospital to treat deep vein thromboses and will be discharged home with a prescription for enoxaparin (Lovenox). The nurse provides teaching for the nursing student who asks about the advantages of enoxaparin over heparin. Which statement by the student indicates a need for further teaching?
a. “Enoxaparin does not require coagulation monitoring.”
b. “Enoxaparin has greater bioavailability than heparin.”
c. “Enoxaparin is more cost-effective than heparin.”
d. “Enoxaparin may be given using a fixed dosage.”
ANS: C
Low-molecular-weight (LMW) heparins have higher bioavailability and longer half-lives, so routine coagulation monitoring is not necessary and fixed dosing is possible. LMW heparins are more expensive, however, so this statement indicates a need for further teaching.
A patient with atrial fibrillation is receiving warfarin (Coumadin). The nurse notes that the patient’s INR is 2.7. Before to giving the next dose of warfarin, the nurse will notify the provider and:
a. administer the dose as ordered.
b. request an order to decrease the dose.
c. request an order to give vitamin K (phytonadione).
d. request an order to increase the dose.
ANS: A
This patient has an INR in the appropriate range, so no change in warfarin dosing is necessary. It is not correct to request an order to either decrease or increase the dose of warfarin. It is not necessary to give vitamin K, which is an antidote for warfarin toxicity.
A patient who takes warfarin for atrial fibrillation undergoes hip replacement surgery. On the second postoperative day, the nurse assesses the patient and notes an oxygen saturation of 83%, pleuritic chest pain, shortness of breath, and hemoptysis. The nurse will contact the provider to report possible _____ and request an order for _____.
a. congestive heart failure; furosemide (Lasix)
b. hemorrhage; vitamin K (phytonadione)
c. myocardial infarction: tissue plasminogen activator (tPA)
d. pulmonary embolism; heparin
ANS: D
This patient is exhibiting signs of pulmonary embolism. Heparin is used when rapid onset of anticoagulants is needed, as with pulmonary embolism. The patient would have respiratory cracks and a cough with congestive heart failure. Hemorrhage involves a decrease in blood pressure, bruising, and lumbar pain. The patient has pleuritic pain, which is not consistent with the chest pain of an MI.
A patient who takes warfarin (Coumadin) is brought to the emergency department after accidentally taking too much warfarin. The patient’s heart rate is 78 beats per minute and the blood pressure is 120/80 mm Hg. A dipstick urinalysis is normal. The patient does not have any obvious hematoma or petechiae and does not complain of pain. The nurse will anticipate an order for:
a. vitamin K (phytonadione).
b. protamine sulfate.
c. a PTT.
d. a PT and an INR.
ANS: D
This patient does not exhibit any signs of bleeding from a warfarin overdose. The vital signs are stable, there are no hematomas or petechiae, and the patient does not have pain. A PT and INR should be drawn to evaluate the anticoagulant effects. Vitamin K may be given if laboratory values indicate overdose. Protamine sulfate is given for heparin overdose. PTT evaluation is used to monitor heparin therapy.
A patient who has taken warfarin (Coumadin) for a year begins taking carbamazepine. The nurse will anticipate an order to:
a. decrease the dose of carbamazepine.
b. increase the dose of warfarin.
c. perform more frequent aPTT monitoring.
d. provide extra dietary vitamin K.
ANS: B
Carbamazepine is a powerful inducer of hepatic drug-metabolizing enzymes and can accelerate warfarin degradation. The warfarin dose should be increased if the patient begins taking carbamazepine. Decreasing the dose of carbamazepine is not indicated. It is not necessary to perform more frequent aPTT monitoring or to add extra vitamin K.
A patient has been taking warfarin (Coumadin) for atrial fibrillation. The provider has ordered dabigatran etexilate (Pradaxa) to replace the warfarin. The nurse teaches the patient about the change in drug regimen. Which statement by the patient indicates understanding of the teaching?
a. “I may need to adjust the dose of dabigatran after weaning off the warfarin.”
b. “I should continue to take the warfarin after beginning the dabigatran until my INR is greater than 3.”
c. “I should stop taking the warfarin 3 days before starting the dabigatran.”
d. “I will stop taking the warfarin and will start taking the dabigatran when my INR is less than 2.”
ANS: D
When switching from warfarin to dabigatran, patients should stop taking the warfarin and begin taking the dabigatran when the INR is less than 2. It is not correct to begin taking the dabigatran before stopping the warfarin. While warfarin is stopped before beginning the dabigatran, the decision to start taking the dabigatran is based on the patient’s INR and not on the amount of time that has elapsed
A patient will begin taking dabigatran etexilate (Pradaxa) to prevent stroke. The nurse will include which statement when teaching this patient?
a. Dabigatran should be taken on an empty stomach to improve absorption.
b. It is important not to crush, chew, or open capsules of dabigatran.
c. The risk of bleeding with dabigatran is less than that with warfarin (Coumadin).
d. To remember to take dabigatran twice daily, a pill organizer can be useful.
ANS: B
Patients should be taught to swallow capsules of dabigatran intact; absorption may be increased as much as 75%, increasing the risk of bleeding, if the capsules are crushed, chewed, or opened. Dabigatran may be taken with or without food. The risk of bleeding is not less than that of warfarin. Dabigatran is unstable when exposed to moisture, so using a pill organizer is not recommended.
A postoperative patient will begin anticoagulant therapy with rivaroxaban (Xarelta) after knee replacement surgery. The nurse performs a history and learns that the patient is taking erythromycin. The patient’s creatinine clearance is 50 mL/min. The nurse will:
a. administer the first dose of rivaroxaban as ordered.
b. notify the provider to discuss changing the patient’s antibiotic.
c. request an order for a different anticoagulant medication.
d. request an order to increase the dose of rivaroxaban.
ANS: B
Patients with impaired renal function who are taking macrolide antibiotics will experience increased levels of rivaroxaban, increasing the risk of bleeding. It is correct to discuss using a different antibiotic if possible. The nurse should not administer the dose without discussing the situation with the provider. The patient’s renal impairment is minor; if it were more severe, using a different anticoagulant might be appropriate. It is not correct to increase the dose of rivaroxaban.
A 55-year-old patient asks a nurse about taking aspirin to prevent heart disease. The patient does not have a history of myocardial infarction. Her cholesterol and blood pressure are normal, and she does not smoke. What will the nurse tell the patient?
a. Aspirin is useful only for preventing a second myocardial infarction.
b. She should ask her provider about using a P2Y12 ADP receptor antagonist.
c. She should take one 81 mg tablet per day to prevent myocardial infarction.
d. There is most likely no protective benefit for patients her age.
ANS: D
ASA is used for primary prevention of MI in men and in women older than 65 years. This patient has no previous history of MI, so the use of ASA is not indicated. ASA is useful for primary prevention, but only when indicated by cardiovascular risk, based on age, gender, cholesterol levels, blood pressure, and smoking status. A P2Y12 ADP receptor antagonist is used as secondary prevention. This patient should not begin taking ASA unless her risk factors change, or until she is 65 years old.
A patient who is taking clopidogrel (Plavix) calls the nurse to report black, tarry stools and coffee-ground emesis. The nurse will tell the patient to:
a. ask the provider about using aspirin instead of clopidogrel.
b. consume a diet high in vitamin K.
c. continue taking the clopidogrel until talking to the provider.
d. stop taking the clopidogrel immediately.
ANS: C
Patients who experience bleeding should be warned not to stop taking the clopidogrel until the prescriber says they should, since abrupt withdrawal may precipitate a thrombotic event. Taking aspirin with an active GI bleed is contraindicated. Warfarin is a vitamin K inhibitor; consuming extra vitamin K will not reverse the effects of clopidogrel.
A patient is admitted to the hospital with unstable angina and will undergo a percutaneous coronary intervention. Which drug regimen will the nurse expect to administer to prevent thrombosis in this patient?
a. Aspirin, clopidogrel, omeprazole
b. Aspirin, heparin, abciximab (ReoPro)
c. Enoxaparin (Lovenox), prasugrel (Effient), warfarin (Coumadin)
d. Heparin, alteplase, abciximab (ReoPro)
ANS: B
Abciximab, combined with ASA and heparin, is approved for IV therapy for patients undergoing PCI.
A postoperative patient reports pain in the left lower extremity. The nurse notes swelling in the lower leg, which feels warm to touch. The nurse will anticipate giving which medication?
a. Aspirin
b. Clopidogrel (Plavix)
c. Enoxaparin (Lovenox)
d. Warfarin (Coumadin)
ANS: C
Enoxaparin is a low-molecular-weight heparin and is used in situations requiring rapid onset of anticoagulant effects, such as massive DVT. Aspirin, clopidogrel, and warfarin are useful for primary prevention but are not used when rapid anticoagulation is required.
A nurse caring for a patient receiving heparin therapy notes that the patient has a heart rate of 98 beats per minute and a blood pressure of 110/72 mm Hg. The patient’s fingertips are purplish in color. A stat CBC shows a platelet count of less than 100,000 mm3. The nurse will:
a. administer oxygen and notify the provider.
b. discontinue the heparin and notify the provider.
c. request an order for protamine sulfate.
d. request an order for vitamin K (phytonadione).
ANS: B
This patient is showing signs of heparin-induced thrombocytopenia, so the heparin should be discontinued immediately and the provider should be notified. The purplish color of the fingertips is caused by thrombosis, not hypoxia, so oxygen is not indicated. This patient may need continued anticoagulation therapy, so a request for protamine sulfate is not correct. Heparin is not a vitamin K inhibitor.
A patient is admitted to the emergency department with chest pain. An electrocardiogram shows changes consistent with an evolving myocardial infarction. The patient’s cardiac enzymes are pending. The nurse caring for this patient will expect to:
a. administer aspirin when cardiac enzymes are completed.
b. give alteplase (Activase) within 2 hours.
c. give tenecteplase (TNKase) immediately.
d. obtain an order for an INR.
ANS: B
When alteplase is given within 2 hours after symptom onset, the death rate for MI has been shown to be 5.4%, compared with 9.4% if given 4 to 6 hours after symptom onset. ASA may be given at the first sign of MI; it is not necessary to wait for cardiac enzyme results. Tenecteplase may be given more than 2 hours after onset of symptoms. Obtaining an order for an INR is not indicated.
A patient who is taking warfarin (Coumadin) has just vomited blood. The nurse notifies the provider, who orders lab work revealing a PT of 42 seconds and an INR of 3.5. The nurse will expect to administer:
a. phytonadione (vitamin K1) 1 mg IV over 1 hour.
b. phytonadione (vitamin K1) 2.5 mg PO.
c. protamine sulfate 20 mg PO.
d. protamine sulfate 20 mg slow IV push.
ANS: A
Vitamin K1 is given for warfarin overdose and may be given IV in an emergency. To reduce the incidence of an anaphylactoid reaction, it should be infused slowly. In a non-emergency situation, it would be appropriate to give vitamin K1 orally. Protamine sulfate is used for heparin overdose.
The nurse has just received an order for tenecteplase (TNKase) for a patient experiencing an acute myocardial infarction. The nurse should administer this drug:
a. by bolus injection.
b. by infusion pump over 24 hours.
c. slowly over 90 minutes.
d. via monitored, prolonged infusion.
ANS: A
Tenecteplase (TNKase) is given by bolus injection. Tissue plasminogen activator (tPA) must be infused over 90 minutes. Because tenecteplase (TNKase) is given by bolus injection, an infusion pump is not required. Although the patient should be monitored, tenecteplase (TNKase) does not require a prolonged infusion time.
A patient arrives in the emergency department complaining of chest pain that has lasted longer than 1 hour and is unrelieved by nitroglycerin. The patient’s electrocardiogram reveals elevation of the ST segment. Initial cardiac troponin levels are negative. The patient is receiving oxygen via nasal cannula. Which drug should be given immediately?
a. Aspirin 325 mg chewable
b. Beta blocker given IV
c. Ibuprofen 400 mg orally
d. Morphine intravenously
ANS: A
This patient shows signs of acute ST-elevation myocardial infarction (STEMI). Because cardiac troponin levels usually are not detectable until 2 to 4 hours after the onset of symptoms, treatment should begin as symptoms evolve. Chewable aspirin (ASA) should be given immediately to suppress platelet aggregation and produce an antithrombotic effect. Beta blockers are indicated but do not have to be given immediately. Ibuprofen is contraindicated. Morphine is indicated for pain management and should be administered after aspirin has been given.
A nurse is discussing fibrinolytic therapy for the acute phase of STEMI management with a group of nursing students. Which statement by a student indicates understanding of this therapy?
a. “Fibrinolytics are effective when the first dose is given up to 24 hours after symptom onset.”
b. “Fibrinolytics should be given once cardiac troponins reveal the presence of STEMI.”
c. “Fibrinolytics should be used with caution in patients with a history of cerebrovascular accident.”
d. “Patients should receive either an anticoagulant or an antiplatelet agent with a fibrinolytic drug.”
ANS: C
Patients with a history of cerebrovascular accident (CVA) should not receive fibrinolytic agents because of the increased risk of intracranial hemorrhage. Fibrinolytics are most effective when given within 30 minutes of arrival in the emergency department. Because cardiac troponins are not detectable until 2 to 4 hours after the onset of symptoms, fibrinolytics should be administered before these laboratory values are available. Patients receiving fibrinolytics should receive both an anticoagulant and an antiplatelet drug.
A nurse is evaluating a patient admitted to the emergency department with an evolving STEMI for possible administration of thrombolytic therapy. Which information, identified during history taking, would contraindicate this type of therapy?
a. The patient just completed her last menstrual cycle.
b. The patient states that the chest pain started 1 hour ago.
c. The patient has a history of a small cerebral aneurysm.
d. The patient has hypertension that is well controlled by diuretic therapy.
ANS: C
Patients with a history of CVA should not receive fibrinolytic therapy. This patient has had a known cerebral aneurysm. Active internal bleeding is a contraindication for thrombolysis except for menses, but the patient has indicated she has completed her last cycle. Fibrinolytic therapy should be administered for chest pain that has been present for no longer than 12 hours. Poorly controlled or severe hypertension is a relative contraindication. Thrombolytics can be administered with caution.
A patient diagnosed with STEMI is about to undergo a primary percutaneous coronary intervention (PCI). Which combination of pharmacotherapeutic agents will be given to augment this procedure?
a. Beta blocker and nitroglycerin
b. Abciximab and a fibrinolytic drug
c. Angiotensin-converting enzyme (ACE) inhibitor and aspirin
d. Heparin, aspirin, and clopidogrel
ANS: D
Patients undergoing a primary PCI should receive heparin intravenously combined with aspirin and either clopidogrel or prasugrel. Abciximab and fibrinolytic drugs are not indicated. Beta blockers and nitroglycerin do not prevent thromboses. ACE inhibitors do not prevent thromboses.
A patient in the emergency department has severe chest pain. The nurse administers morphine intravenously. The patient asks the nurse why morphine is given. Which response by the nurse is correct?
a. “Morphine helps by reducing anxiety and relieving pain.”
b. “Morphine helps by reducing pain and dissolving clots.”
c. “Morphine helps by relieving pain and lowering blood pressure.”
d. “Morphine helps by relieving pain and reducing the cardiac oxygen demand.”
ANS: D
IV morphine is the treatment of choice for STEMI-associated pain. Besides relieving pain, it promotes vasodilation and reduces cardiac preload, which lowers the cardiac oxygen demand. It does not reduce anxiety, dissolve clots, or lower blood pressure.
A patient is admitted to the coronary care unit from the emergency department after initial management of STEMI. A primary percutaneous coronary intervention has been performed. The nurse notes an initial heart rate of 56 beats per minute and a blood pressure of 120/80 mm/Hg. The patient has a history of stroke and a previous myocardial infarction. Which order will the nurse question?
a. Aspirin
b. Beta blocker
c. Clopidogrel
d. Heparin
ANS: B
A beta blocker would be contraindicated in this patient, because it slows the heart, and this patient is already bradycardic. Aspirin, clopidogrel, and heparin are recommended in patients who have had a primary PCI.
A nurse is giving aspirin to a patient during acute management of STEMI. The patient asks why a chewable tablet is given. Which response by the nurse is correct?
a. “Aspirin is absorbed more quickly when it is chewed.”
b. “Chewing aspirin prevents it from being metabolized by the liver.”
c. “Chewing aspirin prevents stomach irritation.”
d. “More of the drug is absorbed when aspirin is chewed.”
ANS: A
Aspirin should be chewed to allow rapid absorption across the buccal mucosa. Chewing aspirin does not affect hepatic metabolism, stomach irritation, or the amount absorbed.
A patient has undergone a primary percutaneous coronary intervention with a sirolimus-eluting stent. The provider has ordered a daily dose of 243 mg of aspirin. What will the nurse tell this patient about the dose of aspirin?
a. It will be necessary indefinitely.
b. It will decrease to 81 mg per day in 6 months.
c. It will decrease to 162 mg per day in 3 months.
d. It will increase to 325 mg per day in 1 month.
ANS: C
Patients who have undergone PCI with a sirolimus-eluting stent take a higher dose of ASA for 3 months and then a low dose indefinitely. The high dose is not taken indefinitely with this type of stent. The dose will be reduced in 3 months, not 6 months. The dose will not increase.
A patient has undergone a PCI, and the provider orders clopidogrel to be given for 12 months, along with an ACE inhibitor and heparin. What will the nurse do?
a. Question the need for heparin.
b. Request an order for a beta blocker.
c. Request an order for aspirin.
d. Suggest ordering clopidogrel for 14 days.
ANS: C
Patients who have undergone a PCI should receive heparin, ASA, and a fibrinolytic; therefore, this patient needs ASA added to the drug regimen. Heparin should be given before, during, and for at least 48 to 72 hours after the procedure. Beta blockers are not necessarily indicated. Clopidogrel should be given at least 12 months after the procedure.
Patients with a history of myocardial infarction should take which medications indefinitely? (Select all that apply.)
a. ACE inhibitors
b. Alteplase
c. Aspirin
d. Beta blockers
e. Clopidogrel
ANS: A, C, D
Patients who have had an MI should take ACE inhibitors, ASA, and beta blockers indefinitely to prevent recurrence and to minimize continuing cardiac remodeling. Alteplase is given during acute management, and clopidogrel is used during acute management and as an adjunct to reperfusion therapy.
