Final Flashcards
An 18 y/o male presents to clinic concerned he got ringworm from his goats. On exam he had a quarter sized ring-shaped lesion with a scaly border and central clearing. It is itchy, and the patient has been using a topical corticosteroid cream to help with symptoms. You decide he has tinea corporis. What should you do next?
a. ) Order him a prescription topical antifungal to add to his current regimen.
b. ) Tell him to stop using topical corticosteroids as they can often times make the ringworm worse or reoccur with long-term use.
c. ) Prescribe some nystatin powder.
d. ) Nothing, it will resolve on its own.
ANS B. Tell him to stop using topical corticosteroids as they can often times make the ringworm worse or reoccur with long-term use.
An 80-year-old patient has a diagnosis of glaucoma, and the ophthalmologist has prescribed timolol (Timoptic) and pilocarpine eye drops. The primary care NP should counsel this patient:
a. That systemic side effects of these medications may be severe
b. That the combination of these two drugs may cause drowsiness
c. To begin an exercise program to improve cardiovascular health
d. That a higher dose of one or both of these medications may be needed
ANS A. that systemic side effects of these medications may be severe. Older patients are susceptible to systemic effects of topical eye drops. Timolol can cause cerebrovascular, central nervous system, and respiratory side effects, and pilocarpine can cause systemic β-blocker effects. The combination does not cause drowsiness. Although there is some correlation between cardiovascular health and glaucoma, beginning a new exercise program is not indicated. A higher dose of the medications would increase systemic side effects.
An 18-month-old child who attends day care has head lice and has been treated with permethrin 1% (Nix). The parent brings the child to the clinic 1 week later, and the primary care NP notes live bugs on the child's scalp. The NP should order: A. Lindane B. Malathion C. Ivermectin D. Permethrin 5%
ANS D permethrin 5%. Permethrin is the first-line drug of choice for treating head lice and is usually effective in one application. Significant resistance to permethrin 1% has developed, and permethrin 5% is more effective. In pediculosis, if live lice can be found after 1 week, reapply treatment. This child may have been reinfected at day care and so should be treated again. Malathion is a second-line drug and is not recommended in children younger than age 2. Lindane is a third-line drug. Ivermectin is a fourth-line drug.
An NP student asks her instructor about guidelines for using topical steroids. The Nurse Educator tell the student that:
A. evidence-based guidelines are available for each product.
B. standardized guidelines may be found for disease-specific conditions.
C. evidence-based studies support limited corticosteroid use in pregnancy.
D. standardized guidelines have been developed for use in children.
ANS B standardized guidelines may be found for disease-specific conditions.
The advance practice registered nurse examines an adolescent who complains of severe right ear pain for the past 3 days. When retracting the pinna of the right ear to examine the ear, the APRN notes erythema, edema, and pain and a large amount of white exudate in the ear canal. The APRN should prescribe:
A. benzocaine otic drops tid.
B. ciprofloxacin otic drops qid.
C. glycerin oil drops weekly.
D. acetic acid, boric acid, and isopropyl alcohol solution.
ANS B ciprofloxacin otic drops qid. This patient has otitis externa. Ciprofloxacin otic drops instilled onto a wick in the ear canal are indicated to treat this condition. Benzocaine is a local anesthetic and would not treat the infection. Glycerin oil drops are used to soften cerumen. An acetic acid, boric acid, and isopropyl alcohol solution is used to prevent, not treat, otitis externa.
A primary care NP is performing a well-child checkup on an adolescent patient and notes approximately 20 papules and comedones and 10 pustules on the patient’s face, chest, and back. The patient has not tried any over-the-counter products to treat these lesions. The NP should begin treatment with:
A. salicylic acid.
B. oral antibiotics.
C. topical tretinoin.
D. benzoyl peroxide and topical clindamycin.
AND D benzoyl peroxide and topical clindamycin.
To anesthetize the thumb for sutures, the NP should use:
a. lidocaine hydrochloride
b. lidocaine w epinephrine
c. bupivacaine hydrochloride
d. bupivacaine w epinephrine
ANS A lidocaine hydrochloride
A parent brings in a 2-month-old infant with a 5-day history of a white coating on the
tongue and decreased oral intake. The primary care NP should prescribe:
a. Clotrimazole, one troche tid
b. Chlorhexidine, 15 mL oral rinse bid
c. Carbamide peroxide, 2-3 drops tid
d. Nystatin oral suspension, 200,000 units qid
ANS D. Nystatin oral
A patient who has scabies has been treated by the primary care NP with permethrin (Elimite). The patient returns to the clinic with mild pruritus and erythema. The NP does not observe new burrows on the skin. The NP should: A. order malathion. B. order lindane. C. re-treat with permethrin. D. prescribe triamcinolone 0.1%.
ANS D prescribe triamcinolone 0.1%.
The primary care NP teaches a patient how to instill eye drops for a prescription that requires two drops twice daily. Which statement by the patient indicates understanding of the teaching?
A. “I should put in one drop and wait 5 minutes before putting in the other one.”
B. “I should gently massage my eyes for 3 to 5 minutes after instilling the drops.”
C. “To make sure the medicine is evenly distributed, I should blink several times.”
D. “I may continue wearing my soft contact lenses while I am using this medication.”
ANS A “I should put in one drop and wait 5 minutes before putting in the other one.”
A patient is seen by a primary care NP to evaluate a rash. The NP notes three ring-shaped lesions with elevated, erythematous borders and two smaller, scaly patches on the patient's abdomen. The patient has not used any over-the-counter medications on the rash. The NP diagnoses tinea corporis and should prescribe: A. ketoconazole (Nizoral). B. miconazole (Lotrimin AF). C. oral terbinafine. D. oral itraconazole.
ANS B miconazole (Lotrimin AF).
A primary care nurse practitioner (NP) prescribes a topical cream medication. Which statement by the patient indicates understanding of proper application of this medication?
A. “I should apply this medication after bathing.”
B. “I will apply this medication using circular strokes to ensure absorption.”
C. “I need to use a tongue blade to apply this medication.”
D. “I should apply this medication liberally to all affected areas.”
ANS A “I should apply this medication after bathing.”
A primary care NP is considering using a topical immunosuppressive agent for a patient who has atopic dermatitis that is refractory to treatment with topical corticosteroids. The NP should:
A. tell the patient that these agents may be used long-term.
B. tell the patient that laboratory monitoring for hypothalamic-pituitary-adrenal (HPA) suppression will be necessary.
C. begin therapy with pimecrolimus (Elidel).
D. counsel the patient that these agents are more likely to cause skin atrophy.
ANS C begin therapy with pimecrolimus
A patient has been treated for severe contact dermatitis on both arms with clobetasol propionate cream. At a follow-up visit, the primary care NP notes that the condition has cleared. The NP should:
A. prescribe triamcinolone cream for 2 weeks.
B. recommend continuing treatment for 2 more weeks.
C. discontinue the clobetasol and schedule a follow-up visit in 2 weeks.
D. discontinue the clobetasol and recommend prn use for occasional flare-ups.
ANS A prescribe triamcinolone cream for 2 weeks. treatment should be discontinued when the skin condition has resolved. Tapering the corticosteroid will prevent recurrence of the skin condition. Tapering is best done by gradually reducing the potency and dosing frequency at 2-week intervals. This patient was on a very high potency steroid, so changing to a medium frequency with follow-up in 2 weeks is an appropriate action. Discontinuing the steroid abruptly can lead to recurrence.
A 5-year-old child has atopic dermatitis that is refractory to treatment with hydrocortisone acetone 2.5% cream. The prescriber should prescribe:
A. desonide cream 0.01%.
B. triamcinolone acetonide.
C. fluocinolone cream 0.2%.
D. betamethasone dipropionate ointment 0.05%.
ANS B triamcinolone acetonide. An over-the-counter steroid has failed to treat this child’s dermatitis, so the NP should prescribe something in a higher strength. Triamcinolone is a medium-strength steroid and should be used. The other three are in groups I and II, which are high-strength steroids and are not recommended in children.
A FNP sees a child who has honey-crusted lesions with areas of erythema around the nose and mouth. The child's parent has been applying Polysporin ointment for 5 days and reports no improvement in the rash. The FNP should prescribe: A. mupirocin. B. neomycin. C. a systemic antibiotic. D. Polysporin with a corticosteroid.
ANS A. mupirocin. Treatment with a topical antiinfective agent should be reevaluated in 3 to 5 days if there is no improvement. Polysporin ointment is bacteriostatic, not bacteriocidal. Mupirocin is indicated for impetigo caused by Staphylococcus aureus, which is most common in children. Neomycin is an aminoglycoside and is not effective against S. aureus. A systemic antibiotic is not indicated unless the mupirocin fails to treat the infection. Adding a corticosteroid would increase the likelihood that the infection will worsen.
A patient tells a nurse practitioner (NP) that several coworkers have upper respiratory infections and asks about the best way to avoid getting sick. The NP should recommend which of the following?
a. Zinc gluconate supplements
b. Frequent hand washing
c. Echinacea
d. Normal saline nasal irrigation
B. Frequent hand washing.- Hand washing is the most effective way to prevent the spread of viral upper respiratory illness (VURI). Echinacea has not been shown to be effective in preventing VURI. Zinc gluconate may decrease the duration of a VURI if taken within 24 hours of onset, but it does not prevent infection. Normal saline irrigation is helpful for symptomatic relief after a VURI has begun.
A patient comes to the clinic with a 2-day history of cough and wheezing. The patient has no previous history of asthma. The patient reports having heartburn for several months, which has worsened considerably. The primary care NP makes a diagnosis of asthma and orders oral steroids and inhaled albuterol. The patients condition worsens, and a chest radiograph obstained 2 days later shows bilateral infiltrates. The NP failed to:
a. Confirm the diagnosis
b. Prescribe an adequate dose of medications
c. Allow the drugs adequate time to work
d. Determine the aggressiveness of therapy
ANS A- the patient had symptoms that could occur with both asthma and aspiration pneumonia. The NP failed to confirm the diagnosis and prescribed the wrong treatment.
A patient comes to the clinic with a 3-day history of fever and a severe cough that interferes with sleep. The patient asks the NP about using a cough suppressant to help with sleep. The NP should:
a. suggest that the patient try a guaifenesin-only over-the-counter product.
b. prescribe an antibiotic to treat the underlying cause of the patient’s cough.
c. order a narcotic antitussive to suppress cough.
d. obtain a thorough history of the patient’s symptoms.
D. obtain a thorough history of the patient’s symptoms.- It is important to determine the underlying disorder that is causing the cough to rule out serious causes of cough. The NP should obtain a thorough history before prescribing any treatment. A narcotic antitussive may be used after serious causes are ruled out. Guaifenesin may be used to make nonproductive coughs more productive. Antibiotics are indicated only for a proven bacterial infection.
An NP prescribes azelastine for a patient who has allergic rhinitis. The NP will teach the patient that this drug:
a. will cause rebound congestion if withdrawn suddenly.
b. can cause many systemic side effects such as drowsiness.
c. will not provide maximum relief for a few weeks.
d. may cause a bitter aftertaste.
d. may cause a bitter aftertaste- Azelastine is a topical antihistamine with few adverse systemic side effects. Patients may experience relief from symptoms within 30 minutes. Decongestants can cause rebound congestion if withdrawn suddenly. Topical antihistamines rarely cause systemic side effects.
A parent asks an NP which over-the-counter medication would be best to give to a 5-year-old child who has a viral respiratory illness with nasal congestion and a cough. The NP should recommend which of the following?
a. Increased fluids with a teaspoon of honey
b. An antitussive/expectorant combination such as Robitussin DM
c. Diphenhydramine (Benadryl)
d. Over-the-counter pseudoephedrine with guaifenesin (Sudafed)
a. Increased fluids with a teaspoon of honey- Nonpharmacologic treatments are recommended for children younger than 6 years. Adequate hydration can decrease cough, thin secretions, and hydrate tissues. A teaspoon of honey has been shown to be effective in reducing cough in small children. Diphenhydramine is an antihistamine that dries nasal secretions but does not aid in decongestion. Sudafed and Robitussin are not recommended in children younger than 6 years.
A child with chronic allergic symptoms uses an intranasal steroid for control of symptoms. At this child’s annual well-child checkup, the NP should carefully review this child’s:
a. height and weight.
b. blood pressure.
c. liver function tests.
d. urinalysis.
a. height and weight.- Intranasal corticosteroids can cause growth suppression in children. When using intranasal steroids in children, the lowest dosage should be used for the shortest period of time necessary, and growth should be routinely monitored. It is not necessary to evaluate urine, blood pressure, or liver function because of intranasal steroid use.
An NP sees a patient who reports persistent seasonal symptoms of rhinorrhea, sneezing, and nasal itching every spring unrelieved with diphenhydramine (Benadryl). The NP should prescribe:
a. triamcinolone (Nasacort AQ).
b. cromolyn sodium (Nasalcrom).
c. azelastine (Astelin).
d. phenylephrine (Neo-Synephrine)
a. triamcinolone (Nasacort AQ)- According to randomized controlled trials in patients with allergic rhinitis, oral antihistamines are used first to help control itching, sneezing, rhinorrhea, and stuffiness in most patients. Intranasal corticosteroids are indicated for patients who do not respond to antihistamines. Azelastine is a topical antihistamine. Phenylephrine is a decongestant, and this patient does not have congestion. Cromolyn sodium is less effective than intranasal corticosteroids.
A patient asks an NP about using an oral over-the-counter decongestant medication for nasal congestion associated with a viral upper respiratory illness. The NP learns that this patient uses loratadine (Claritin), a b-adrenergic blocker, and an intranasal corticosteroid. The NP would be concerned about which adverse effects?
a. Rebound congestion
b. Liver toxicity
c. Excessive drowsiness
d. Tremor, restlessness, and insomnia
d. Tremor, restlessness, and insomnia- b-Adrenergic blockers and monoamine oxidase inhibitors may potentiate the effects of decongestants, such as tremor, restlessness, and insomnia. Liver toxicity, excessive drowsiness, and rebound congestion are not known adverse effects of drug interactions
A primary care NP sees an adolescent patient for a hospitalization follow-up after an asthma exacerbation. The patient reports having daily symptoms with nighttime awakening 4 or 5 nights per week and misses school several days each month. The patient currently uses a salmeterol/fluticasone LABA twice daily and albuterol as needed. The patient requires a refill of the albuterol prescription once a month. The patient does not have any known allergies. The NP should:
a. order a high-dose ICS plus a LABA twice daily.
b. consider adding theophylline to this patient’s regimen.
c. order a combination product with ipratropium and albuterol.
d. continue the current regimen and add omalizumab daily.
a. order a high-dose ICS plus a LABA twice daily.- The patient has moderate persistent asthma not well controlled with the current regimen. The next step is to prescribe a high-dose ICS to be taken along with the LABA and to refer to an asthma specialist. Theophylline is recommended in the 5- to 11-year age group. Omalizumab is indicated if the patient has allergies. Ipratropium is used during acute exacerbations.
A 50-year-old patient who recently quit smoking reports a frequent morning cough productive of yellow sputum. A chest x-ray is clear, and the patient’s FEV1 is 80% of predicted. Pulse oximetry reveals an oxygen saturation of 97%. The primary care NP auscultates clear breath sounds. The NP should:
a. order a long-acting anticholinergic with albuterol twice daily.
b. prescribe a moderate-dose ICS twice daily.
c. prescribe an albuterol metered-dose-inhaler, 2 puffs every 4 hours as needed.
d. reassure the patient that these symptoms will subside.
c. prescribe an albuterol metered-dose-inhaler, 2 puffs every 4 hours as needed.- For patients with stable COPD having respiratory symptoms with FEV1 between 60% and 80% of predicted, inhaled bronchodilators may be used. COPD is not reversible, and the symptoms will not subside. ICS therapy or long-acting anticholinergics are recommended when FEV1 is less than 60%.
A patient who was recently diagnosed with COPD comes to the clinic for a follow-up evaluation after beginning therapy with a SABA as needed for dyspnea. The patient reports occasional mild exertional dyspnea but is able to sleep well. The patient’s FEV1 in the clinic is 85% of predicted, and oxygen saturation is 96%. The primary care NP should recommend:
a. a combination LABA/ICS twice daily.
b. home oxygen therapy as needed for dyspnea.
c. influenza and pneumococcal vaccines.
d. ipratropium bromide (Atrovent) twice daily.
c. influenza and pneumococcal vaccines. Influenza and pneumococcal immunizations are recommended to help reduce comorbidity that will affect respiratory status. This patient is stable with the prescribed medications, so no additional medications are needed at this time. Home oxygen therapy is used for patients with severe resting hypoxemia.
A 70-year-old patient who has COPD takes theophylline daily and uses a SABA for exacerbation of symptoms. The patient reports using the SABA three or four times each week when short of breath. The patient reports feeling jittery and nauseated and having trouble sleeping. The primary care NP should:
a. obtain a serum theophylline level.
b. prescribe a leukotriene modifier instead of theophylline.
c. order a creatinine clearance level.
d. discontinue the SABA and change to ipratropium bromide.
a. obtain a serum theophylline level.- Nausea, vomiting, insomnia, jitteriness, and other symptoms may indicate theophylline toxicity. Serum concentration monitoring should be done whenever signs of toxicity are suspected. A serum creatinine clearance level is not indicated. Leukotriene modifiers are not used for COPD. Ipratropium is used as an adjunct to the SABA during acute exacerbations.
A 75-year-old patient requires frequent use of corticosteroids to control COPD exacerbations. To monitor adverse drug effects in this patient, the primary care NP should:
a. order an electrocardiogram to assess for arrhythmias.
b. order routine chest radiographs to watch for pneumonia.
c. order a bone density study.
d. monitor the patient’s renal function at every visit.
c. order a bone density study.- High-dose ICSs and oral corticosteroids that are often used in COPD may cause or worsen osteoporosis in an older adult. The NP should order a bone density study.
A NP sees a patient who needs to be treated for the management of allergic rhinitis. Which of the following are preferred antihistamines that the NP can recommend? (SELECT ALL THAT APPLY):
a. Loratadine
b. Chlorpheniramine
c. Cetirizine
d. Fexofenadine
ANS: A & C & D
A NP prescribes to a patient an antitussive syrup medication containing guaifenesin with codeine. Which common side effects may this patient experience? (SELECT ALL THAT APPLY):
a. Drowsiness
b. Diarrhea
c. Dizziness
d. Nausea/vomiting
ANS: A C D
According to the CDC, National Center for Health Statistics, COPD is the third leading cause of death in the United States. True or False?
TRUE
According to the CDC video, when using a metered-dose inhaler (in mouth), you should do the following (SELECT ALL THAT APPLY):
a. Press down on inhaler one time, breathe in QUICKLY, and then hold breath for 5 - 10 seconds
b. Put inhaler in your mouth, above your tongue, and between your teeth.
c. Hold inhaler upright
d. Shake inhaler 10 - 15 times
ANS: B C D
Mr. Smith is a 53 year old patient that has been diagnosed with COPD using Spirometry. Further assessment results show his FEV1 is 28% of predicted, CAT score of 12, and he had 1 exacerbation in the past year leading to hospital admission. Based on your knowledge of the refined ABCD assessment tool (GOLD 2017), the NP should labelled this patient as follow: A. GOLD grade 4, group B B. GOLD grade 4, group D C. GOLD grade 2, group B D. GOLD grade 3, group D
B. GOLD grade 4, group D
Mrs. Gomez is a 45 year old female diagnosed with COPD using Spirometry. She has been a smoker for over 20 years. Her FEV1 is 48% of predicted, she has a CAT score of 8, and she had more than 3 exacerbations in the past year. Based on the GOLD 2017 guidelines and Mrs. Gomez COPD assessment results, the NP should initiate treatment with:
A. Spiriva (tiotropium bromide)
B. Serevent Diskus (salmeterol xinafoate)
C. Ventolin (albuterol)
D. Flovent (fluticasone)
ANS: Spiriva
According to GOLD 2017 guidelines, ICS-containing regimens are NOT recommended as initial maintenance treatment for COPD of any severity.
TRUE
Based on the Gold 2017 guidelines and COPD assessment results, Mr. Scott was prescribed a LAMA medication to treat his COPD symptoms. However, a few months later, Mr. Scott's symptoms continue to be persistent and he has further exacerbations. Which of the following drugs is the next preferred treatment the NP should initiate: A. ANORO ELLIPTA B. FLOVENT DISKUS C. SYMBICORT AEROSOL D. BREO ELLIPTA
ANS: A Anoro ellipta
Which of the following drugs is a LABA/ICS combination and would be most appropriate for a patient who is having compliance issues?
a. Breo Ellipta
b. Spiriva
c. Anoro Ellipta
d. Symbicort Aerosol
ANS A Breo Ellipta
A MSN-prepared nurse is caring for a 70-year-old patient who reports having seasonal allergies with severe rhinorrhea. Using the Beers criteria, which of the following medications should the MSN-prepared nurse recommend for this patient?
a. Loratadine (Claritin)
b. Hydroxyzine (Vistaril)
c. Diphenhydramine (Benadryl)
d. Chlorpheniramine maleate (Chlorphen 12)
ANS A- Loratadine (Claritin)- Loratadine is the only nonsedating antihistamine on this list. Older patients are especially susceptible to sedation side effects and should not use these medications if possible.
A FNP is evaluating a patient who has COPD. The patient uses a LABA twice daily. The patient reports having increased exertional dyspnea, a frequent cough, and poor sleep. The patient also uses a short-acting β-adrenergic agonist (SABA) five or six times each day. Pulse oximetry reveals an oxygen saturation of 92%. The patient’s FEV1/forced vital capacity is 65, and FEV1 is 55% of predicted. The NP should prescribe a(n):
a. combination ICS/LABA inhaler.
b. oral corticosteroid.
c. long-acting anticholinergic.
d. long-acting oral theophylline.
ANS A combination ICS/LABA inhaler.- Providers should administer combination inhaled therapies for symptomatic patients with stable COPD and FEV1 less than 60%. Oral corticosteroids have not been shown to be effective, even in severe cases of COPD. Long-acting anticholinergic medications may be used as monotherapy in early stages of COPD. Long-acting theophylline is poorly tolerated because of side effects.
A FNP sees a child with asthma to evaluate the child’s response to the prescribed therapy. The child uses an ICS twice daily and an albuterol metered-dose inhaler as needed. The child’s symptoms are well controlled. The FNP notes slowing of the child’s linear growth on a standardized growth chart. The FNP should change this child’s medication regimen to a:
a. SABA as needed plus a leukotriene modifier once daily.
b. combination ICS/LABA inhaler twice daily.
c. short-acting β2-agonist (SABA) with oral corticosteroids when symptomatic.
d. combination ipratropium/albuterol inhaler twice daily.
ANS A - SABA as needed plus a leukotriene modifier once daily.- A leukotriene modifier may be used as an alternative to ICS for children who experience systemic side effects of the ICS. This child’s symptoms are well controlled, so there is no need to step up therapy to include a LABA. Oral corticosteroids should be used only for severe exacerbations. Ipratropium and albuterol are used for severe exacerbations.
A patient who has type 2 diabetes mellitus will begin taking a bile acid sequestrant. Which bile acid sequestrant should the primary care NP order?
a. Colesevelam (Welchol)
b. Colestipol (Colestid)
c. Cholestyramine (Questran Light)
d. Cholestyramine (Questran)
a. Colesevelam (Welchol) - All bile acid sequestrants are equally effective. Colesevelam has an additional indication to improve glycemic control in adults with type 2 diabetes and so should be selected when prescribing a bile acid sequestrant for this patient.
A patient with primary hypercholesterolemia is taking an HMG-CoA reductase inhibitor. All of the patient’s baseline LFTs were normal. At a 6-month follow-up visit, the patient reports occasional headache. A lipid profile reveals a decrease of 20% in the patient’s LDL cholesterol. The NP should:
a. reassure the patient that this side effect is common.
b. order CK-MM tests.
c. order LFTs.
d. consider decreasing the dose of the medication.
a. reassure the patient that this side effect is common. - LFTs should be performed at baseline, 12 weeks after initiation of therapy, and only periodically thereafter. Headaches are common side effects, but do not raise concern about hepatotoxicity. CK-MM tests are indicated if patients report muscle pain or weakness. It is not necessary to decrease the medication.
The primary care nurse practitioner (NP) sees a patient for a physical examination and orders laboratory tests that reveal low-density lipoprotein (LDL) of 100 mg/dL, high-density lipoprotein (HDL) of 30 mg/dL, and triglycerides of 350 mg/dL. The patient has no previous history of coronary heart disease. The NP should consider prescribing:
a. ezetimibe (Zetia).
b. simvastatin (Zocor).
c. nicotinic acid (Niaspan).
d. gemfibrozil (Lopid).
AND D. gemfibrozil (Lopid).
Fibric acid derivatives, such as gemfibrozil, are indicated for reducing the risk that coronary heart disease may develop in patients without a history of coronary heart disease who have low HDL cholesterol levels and elevated triglyceride levels. This patient’s LDL is within normal limits, so a 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitor, such as simvastatin, is not indicated. Ezetimibe is a selective cholesterol absorption inhibitor, used to reduce total and LDL cholesterol. Nicotinic acid is used to treat hyperlipidemia in patients who have failed dietary therapy.
A patient who has atrial fibrillation (AF) has been taking warfarin (Coumadin). The prescriber plans to change the patient’s medication to dabigatran (Pradaxa). To do this safely, the prescriber should:
A. initiate dabigatran when the patient’s international normalized ratio (INR) is less than 2.
B. start dabigatran 7 to 14 days after discontinuing warfarin.
C. begin giving dabigatran 1 week before discontinuing warfarin.
D. order frequent monitoring of the patient’s INR after dabigatran therapy begins.
ANS A. initiate dabigatran when the patient’s international normalized ratio (INR) is less than 2.
There are no requirements for monitoring the INR or other measures for patients taking dabigatran. When changing from warfarin, it is recommended that dabigatran be initiated when the INR is less than 2.
A patient who is at risk for DVT tells the primary care NP she has just learned she is pregnant. The NP should expect that this patient will use which of the following anticoagulant medications?
a. Warfarin
b. Heparin
c. Aspirin
d. Dabigatran
b. Heparin
Heparin does not cross the placental barrier and is the drug of choice for anticoagulation therapy during pregnancy, despite its category C classification. Aspirin is not recommended during the last 3 months of pregnancy. Dabigatran is not recommended. Warfarin crosses the placental barrier.
An 80-year-old patient who has persistent AF takes warfarin (Coumadin) for anticoagulation therapy. The patient has an INR of 3.5. The primary care NP should consider:
a. rechecking the INR in 1 week.
b. omitting a dose and administering 1 mg of vitamin K.
c. omitting a dose and resuming at a lower dose.
d. lowering the dose of warfarin.
a. rechecking the INR in 1 week.
This patient’s INR is only minimally prolonged, so no dose reduction is required. The NP should recheck the INR periodically. If the INR becomes more prolonged, lowering the dose of warfarin is recommended. If the INR approaches 5, omitting a dose and resuming at a lower dose is recommended. Vitamin K is used for an INR of 9 or greater.
A patient who has had a new onset of AF the day prior will undergo cardioversion that day. The primary care NP will expect the cardiologist to:
a. give low-dose aspirin before administering cardioversion.
b. give clopidogrel after administering cardioversion.
c. administer cardioversion without using anticoagulants.
d. give warfarin and aspirin before attempting cardioversion
c. administer cardioversion without using anticoagulants. If the onset of AF has occurred within 48 hours, cardioversion can be done without anticoagulation. Clopidogrel is used in other cases for patients who cannot take aspirin. For patients with rheumatic mitral valve disease and AF or a history of systemic embolism, cardioversion plus aspirin is used. Warfarin is used in patients with one or more risk factors for stroke.
A patient who has disabling intermittent claudication is not a candidate for surgery. Which of the following medications should the primary care NP prescribe to treat this patient?
a. Warfarin (Coumadin)
b. Cilostazol (Pletal)
c. Pentoxifylline (Trental)
d. Low-dose, short-term aspirin
b. Cilostazol (Pletal) - Patients with disabling intermittent claudication who are not candidates for surgery or catheter-based intervention should be treated with cilostazol rather than pentoxifylline. Warfarin is not indicated. Patients with chronic limb ischemia are treated with lifelong aspirin therapy.
A patient who is taking an oral anticoagulant is in the clinic in the late afternoon and reports having missed the morning dose of the medication because the prescription was not refilled. The primary care NP should counsel this patient to:
a. take a double dose of the medication the next morning.
b. avoid foods that are high in vitamin K for several days.
c. skip today’s dose and resume a regular dosing schedule in the morning.
d. refill the prescription and take today’s dose immediately.
c. skip today’s dose and resume a regular dosing schedule in the morning.
Consistency is the key to successful warfarin treatment, and the patient should take the medication at the same time every day. For missed doses, the patient should take the medication as soon as possible after the missed dose or not at all that day. Because it is late afternoon, the patient should skip the dose and resume normal scheduling the next day. It is not necessary to avoid foods high in vitamin K. Patients should not double up the next day.
A patient who is obese is preparing to have surgery. To help prevent venous thromboembolism (VTE), the primary care NP should prescribe:
a. low-dose aspirin once daily.
b. clopidogrel (Plavix) 75 mg once daily
c. warfarin (Coumadin) titrated to achieve an INR of 3.5.
d. enoxaparin (Lovenox) 30 mg twice daily.
ANS D. enoxaparin (Lovenox) 30 mg twice daily.
The American College of Clinical Pharmacy recommends against the use of aspirin alone for prophylaxis of VTE. Patients undergoing surgery who are at moderate to high risk for VTE should receive unfractionated heparin or low-molecular-weight heparin, such as enoxaparin. Aspirin may be part of the prophylaxis regimen. Clopidogrel and warfarin are not recommended.
A patient in the clinic develops sudden shortness of breath and tachycardia. The primary care NP notes thready pulses, poor peripheral perfusion, and a decreased level of consciousness. The NP activates the emergency medical system and should anticipate that this patient will receive:
a. low-dose aspirin and warfarin
b. intravenous alteplase.
c. low-molecular-weight heparin (LMWH).
d. unfractionated heparin (UFH) and warfarin
ANS D. Unfractionated heparin (UFH) and warfarin
This patient has unstable pulmonary embolism (PE) and should receive thrombolytic therapy. Intravenous alteplase is the preferred agent. UFH and warfarin are recommended for stable PE. LMWH is beneficial in submassive PE and deep vein thrombosis (DVT) but is controversial for treatment of massive PE.
A patient with primary hypercholesterolemia is taking an HMG-CoA reductase inhibitor. All of the patient’s baseline LFTs were normal. At a 6-month follow-up visit, the patient reports occasional headache. A lipid profile reveals a decrease of 20% in the patient’s LDL cholesterol. The NP should:
a. order LFTs.
b. reassure the patient that this side effect is common.
c. order CK-MM tests.
d. consider decreasing the dose of the medication.
b. reassure the patient that this side effect is common.
LFTs should be performed at baseline, 12 weeks after initiation of therapy, and only periodically thereafter. Headaches are common side effects, but do not raise concern about hepatotoxicity. CK-MM tests are indicated if patients report muscle pain or weakness. It is not necessary to decrease the medication.
A patient who will undergo surgery in implant a biosynthetic heart valve asks the primary care NP whether any medications will be necessary postoperatively. The NP should tell the patient that it will be necessary to take:
a. daily low-dose aspirin for 1 year.
b. warfarin for 3 months postoperatively plus long-term aspirin.
c. lifelong warfarin combined with enoxaparin as needed.
d. heparin injections as needed based on activated partial thromboplastin time levels.
ANS b. warfarin for 3 months postoperatively plus long-term aspirin.
Patients with biosynthetic valves should receive anticoagulation for 3 months with long-term aspirin prophylaxis. Patients with biosynthetic valves should receive anticoagulation for 3 months (INR goal, 2 to 3). Long-term prophylaxis for these patients should include aminosalicylic acid (75 to 100 mg daily), unless AF is present.
A patient comes to the clinic with a complaint of gradual onset of left-sided weakness. The primary care NP notes slurring of the patient’s speech. A family member accompanying the patient tells the NP that these symptoms began 4 or 5 hours ago. The NP will activate the emergency medical system and expect to administer:
a. 325 mg of chewable aspirin.
b. LMWH.
c. warfarin (Coumadin) and aspirin.
d. intravenous alteplase and aspirin.
ANS a. 325 mg of chewable aspirin.
Alteplase is used to treat ischemic stroke but is contraindicated if onset of symptoms occurred 3 hours previously. The administration of anticoagulation or antiplatelet agents during the first 24 hours is not recommended. The oral administration of aspirin within 24 to 48 hours after stroke onset is recommended.
A patient who has diabetes is taking simvastatin (Zocor) 80 mg daily to treat LDL cholesterol level of 170 mg/dL. The patient has a body mass index of 29. At a follow-up visit, the patient’s LDL level is 120 mg/dL. The primary care NP should consider:
a. referring the patient to a dietitian for assistance with weight reduction.
b. increasing the simvastatin to 80 mg twice daily.
c. changing the medication to ezetimibe/simvastatin (Vytorin).
d. adding nicotinic acid to the patient’s drug regimen.
ANS c. changing the medication to ezetimibe/simvastatin (Vytorin).
Patients with diabetes have a goal LDL of less than 100 mg/dL. If maximum-dose statin is unable to achieve the goal LDL, a combination product such as a statin plus ezetimibe is recommended. The maximum recommended dose is 80 mg daily, so increasing the dose to 80 mg twice daily is incorrect.
A patient who has primary hyperlipidemia and who takes atorvastatin (Lipitor) continues to have LDL cholesterol of 140 mg/dL after 3 months of therapy. The primary care NP increases the dose from 10 mg daily to 20 mg daily. The patient reports headache and dizziness a few weeks after the dose increase. The NP should:
a. recommend supplements of omega-3 along with the atorvastatin.
b. change the patient’s medication to cholestyramine (Questran).
c. change the atorvastatin dose to 15 mg twice daily.
d. add ezetimibe (Zetia) and lower the atorvastatin to 10 mg daily.
d. add ezetimibe (Zetia) and lower the atorvastatin to 10 mg daily.
When used in combination with a low-dose statin, ezetimibe has been noted to produce an additional 18% reduction in LDL. Because this patient continues to have elevated LDL along with side effects of the statin, the NP should resume the lower dose of the statin and add ezetimibe. Atorvastatin is given once daily. Cholestyramine and omega-3 supplements are not indicated.
A patient who has hyperlipidemia has been taking atorvastatin (Lipitor) 60 mg daily for 6 months. The patient’s initial lipid profile showed LDL of 180 mg/dL, HDL of 45 mg/dL, and triglycerides of 160 mg/dL. The primary care NP orders a lipid profile today that shows LDL of 105 mg/dL, HDL of 50 mg/dL, and triglycerides of 120 mg/dL. The patient reports muscle pain and weakness. The NP should:
a. order liver function tests (LFTs).
b. add gemfibrozil (Lopid) to the patient’s medication regimen.
c. change atorvastatin to twice-daily dosing.
d. order a creatine kinase-MM (CK-MM) level.
d. order a creatine kinase-MM (CK-MM) level.
Hepatotoxicity and muscle toxicity are the two primary adverse effects of greatest concern with statin use. Patients who report muscle discomfort or weakness should have a CK-MM level drawn. LFTs are indicated with signs of hepatotoxicity. It is not correct to change the dosing schedule. Gemfibrozil is not indicated.
Which of the following statements is true regarding unfractioned heparin (UFH) and low molecular weight heparin (LMWH): (SELECT ALL THAT APPLY)
a. LMWH may be administered IV or SC
b. LMWH has a longer half-life and increased bioavailability compared to UFH
c. No effect on existing clots
d. The anticoagulant effect of heparin starts with its binding to antithrombin III
ANS: BCD
TRUE/FALSE: The mechanism of action of clopidogrel is by inhibiting the binding of ADP to its receptors on platelets and subsequent ADP-mediated activation of IIb/IIIa complex.
TRUE
Which of the following statements is true regarding the Rx product Vascepa (icosapent ethyl)? SELECT ALL THAT APPLY
a. It is used for lowering triglyceride levels
b. It contains only EPA
c. It increases LDL levels
d. It contains both EPA and DHA
Ans: A,B
TRUE/FALSE: There is a boxed warning about stopping DOAC agents in AF patients because DOAC agents are short-acting, and if stopped can quickly return patients to their risk of stroke before starting therapy.
True
A male patient was released from the hospital after the placing of a coronary stent. The patient needs to be treated with an antiplatelet medication. After reviewing the drugs available with the NP, the patient shares with the NP that he has no insurance and that he recently lost his job. Based on the patients needs and current drugs available, which medication with the NP most likely prescribe?
a. Warfarin (coumadin)
b. Clopidogrel (Plavix)
c. Prasugrel (effient)
d. Dabigatran (Pradaxa)
ANS: B. clopidogrel (Plavix)
Which of the following statements are true regarding the new oral anticoagulants Eliquis, Pradaxa, and Xarelto? (SELECT ALL THAT APPLY)
a. Pradaxa is the only one given once per day
b. Eliquis leads to MORE bleeds when compared to warfarin
c. Xarelto is the only one given once per day
d. Eliquis leads to FEWER bleeds when compared to warfarin.
ANS: CD
A 55-year-old woman has a history of myocardial infarction (MI). A lipid profile reveals LDL of 130 mg/dL, HDL of 35 mg/dL, and triglycerides 150 mg/dL. The woman is sedentary with a body mass index of 26. The woman asks the prescriber about using a statin medication. The prescriber should:
A. recommend dietary and lifestyle changes first.
B. begin therapy with atorvastatin 10 mg per day.
C. discuss quality-of-life issues as part of the decision to begin medication.
D. tell her there is no clinical evidence regarding efficacy of statin medication in her case.
B. begin therapy with atorvastatin 10 mg per day.
This woman would be using a statin medication for secondary prevention because she already has a history of MI, so a statin should be prescribed. Dietary and lifestyle changes should be a part of therapy, but not the only therapy. She is relatively young, and quality-of-life issues are not a concern. There is no clinical evidence to support use of statins as primary prevention in women.
Persistent atrial fibrillation (AF) is diagnosed in a patient who has valvular disease, and the cardiologist has prescribed warfarin (Coumadin). The patient is scheduled for electrical cardioversion in 3 weeks. The patient asks the family care nurse practitioner (FNP) why the procedure is necessary. The FNP should tell the patient:
A. this medication prevents clots but does not alter rhythm.
B. if the medication proves effective, the procedure may be canceled.
C. there are no medications that alter the arrhythmia causing AF.
D. to ask the cardiologist if verapamil may be ordered instead of cardioversion.
ANS A. this medication prevents clots but does not alter rhythm.
Persistent AF lasts longer than 7 days and episodes fail to terminate on their own, but episodes can be terminated by electrical cardioversion after therapeutic warfarin therapy for 3 weeks. Warfarin does not alter AF. β-Blockers, calcium channel blockers, and digoxin are sometimes given to alter the rate. Verapamil is not an alternative to cardioversion for patients with persistent AF.
A primary care NP sees a 46-year-old male patient and orders a fasting lipoprotein profile that reveals LDL of 190 mg/dL, HDL of 40 mg/dL, and triglycerides of 200 mg/dL. The patient has no previous history of coronary heart disease, but the patient’s father developed coronary heart disease at age 55 years. The NP should prescribe:
a. cholestyramine (Questran).
b. lovastatin/niacin (Advicor).
c. gemfibrozil (Lopid).
d. atorvastatin (Lipitor).
AND D. atorvastatin (Lipitor).
HMG-CoA reductase inhibitors are used to treat hyperlipidemia when the LDL is the primary lipid elevation. This patient has risk factors of being a man older than 45 years, with a positive family history of coronary heart disease before age 55 in a male first-degree relative. Gemfibrozil is used for patients with elevated triglycerides and low HDL. Bile acid sequestrants are used as adjunctive and not first-line therapy for reducing LDL. A combination product is not indicated for first-line therapy.
A primary care NP is preparing to order digoxin for an 80-year-old patient who has systolic heart failure. The NP obtains renal function tests, which are normal. The NP should:
a. administer a digoxin 0.6 mg capsule once and then 0.3 mg every 8 hours x3.
b. prescribe a digoxin 0.125 mg tablet once daily.
c. administer a loading dose of intravenous digoxin in the clinic and then give 0.125 mg once daily.
d. give an initial dose of 0.5 mg digoxin tablet and then 0.125 mg every 6 hours x4.
ANS b. prescribe a digoxin 0.125 mg tablet once daily. In primary care settings, slow digitalization rather than a loading dose is generally recommended because of the risk of toxicity. Digitalization may be achieved within 1 week with the use of small daily maintenance doses.
A patient who has been taking digoxin 0.25 mg daily for 6 months reports that it is not working as well as it did initially. The primary care NP should:
a. contact the patient’s pharmacy to ask if generic digoxin was dispensed.
b. recommend a reduced potassium intake.
c. hold the next dose of digoxin and obtain a serum digoxin level.
d. increase the dose of digoxin to 0.5 mg daily.
ANS A. contact the patient’s pharmacy to ask if generic digoxin was dispensed Clinicians should be aware that generic digoxin marketed by different companies may not be bioequivalent to the branded digoxin (Lanoxin). Patients with hyperkalemia would show intensified effects, not diminished effects of digoxin. Patients with diminished effects may have received a generic brand. It is not correct to increase the dose of digoxin without first obtaining a digoxin level. Because this patient is reporting decreased effects, it is unnecessary to suspect toxicity.
A patient undergoes a routine electrocardiogram (ECG), which reveals occasional premature ventricular contractions that are present when the patient is resting and disappear with exercise. The patient has no previous history of cardiovascular disease, and the cardiovascular examination is normal. The primary care NP should:
a. prescribe quinidine (Quinidex Extentabs).
b. consider using amiodarone if the patient develops other symptoms.
c. refer the patient to a cardiologist for further evaluation.
d. tell the patient that treatment is not indicated
ANS d. tell the patient that treatment is not indicated. The most important factor in determining whether to treat premature ventricular contractions is the presence of underlying heart disease, such as myocardial ischemia, previous myocardial infarction, cardiac scarring or hypertrophy, or left ventricular dysfunction. Because of the risks associated with antiarrhythmic therapy, patients should not be treated unless clear indications are present. Premature ventricular contractions are not treated if the patient is asymptomatic, if the patient has a normal heart, if the premature ventricular contractions are simple, and if they disappear with exercise. Amiodarone is not used to treat acute premature ventricular contractions but is used for long-term prophylaxis.
A patient comes to the clinic with a history of syncope and weakness for 2 to 3 days. The primary care NP notes thready, rapid pulses and 3-second capillary refill. An ECG reveals a heart rate of 198 beats per minute with a regular rhythm. The NP should:
a. order digoxin and verapamil and ask the patient to return for a follow-up examination in 1 week.
b. administer intravenous fluids and obtain serum electrolytes.
c. send the patient to an emergency department for evaluation and treatment.
d. administer amiodarone in the clinic and observe closely for response.
ANS c. send the patient to an emergency department for evaluation and treatment. Paroxysmal supraventricular tachycardia (PSVT) is a very fast regular rate and rhythm. This patient is becoming decompensated and should be referred to the emergency department for evaluation and treatment. The primary care NP should not treat this in the clinic or as an outpatient until the patient is stable.
A patient has heart failure. A recent echocardiogram reveals decreased compliance of the left ventricle and poor ventricular filling. The patient takes low-dose furosemide and an ACE inhibitor. The primary care NP sees the patient for a routine physical examination and notes a heart rate of 92 beats per minute and a blood pressure of 100/60 mm Hg. The NP should:
a. consider prescribing a b-blocker.
b. obtain renal function tests.
c. order serum electrolytes.
d. call the patient’s cardiologist to discuss adding digoxin to the patient’s regimen.
ANS c. order serum electrolytes. Patients with diastolic heart failure are sensitive to fluid depletion, which can cause decreased preload and stroke volume. This patient has a rapid heart rate and a low blood pressure, which can indicate dehydration, so serum electrolytes should be obtained. Renal function tests are not indicated. b-Blockers are used in patients who are stable. Digoxin should not be used in patients with diastolic failure.
A patient who is taking trimethoprim-sulfamethoxazole for prophylaxis of urinary tract infections tells the primary care NP that a sibling recently died from a sudden cardiac arrest, determined to be from long QT syndrome. The NP should:
a. order genetic testing for this patient.
b. refer the patient to a cardiologist for further evaluation.
c. schedule a treadmill stress test.
d. discontinue the trimethoprim-sulfamethoxazole
ANS a. order genetic testing for this patient. When a family member’s death is found to be from long QT syndrome, the entire family must undergo testing. Treadmill testing may be normal in many cases. Trimethoprim-sulfamethoxazole can prolong the QT interval and should not be used in patients at risk, but genetic testing should be performed to determine this.
The primary care NP is seeing a patient for a hospital follow up after the patient has had a first myocardial infarction. The patient has a list of the prescribed medications and tells the NP that “no one explained anything about them”. The NP’s initial response should be to:
A. ask the patient to describe the medication regimen
B. ask the patient to make a list of questions about the medications
C. determine what the patient understands about coronary artery disease
D. give the patient information about drug effects and any adverse reactions
ANS C. determine what the patient understands about coronary artery disease
A 55-year-old African American patient has three consecutive blood pressure readings of 140/95 mm Hg. The patients body mass index is 24. A fasting plasma glucose is 100 mg/dL. Creatinine clearance and cholesterol tests are normal. The primary care NP should order:
a. An angiotensin-converting enzyme inhibitor.
b. A thiazide diuretic
c. Dietary and lifestyle changes only
d. A beta-blocker
ANS B thiazide diuretic. the patient has stage I hypertension. Because there are no compelling indications for other treatment, a thiazide diuretic should be used initially to treat the hypertension. Dietary and lifestyle changes should also be recommended but are not sufficient for patients with stage I hypertension. Other drugs may be added later if thiazide diuretic therapy fails.
The primary care nurse practitioner (NP) sees a patient in the clinic who has a blood pressure of 130/85 mm Hg. The patient’s laboratory tests reveal high-density lipoprotein, 35 mg/dL; triglycerides, 120 mg/dL; and fasting plasma glucose, 100 mg/dL. The NP calculates a body mass index of 29. The patient has a positive family history for cardiovascular disease. The NP should:
a. counsel the patient about dietary and lifestyle changes.
b. prescribe a thiazide diuretic.
c. consider treatment with an angiotensin-converting enzyme inhibitor.
d. reassure the patient that these findings are normal.
ANS a. counsel the patient about dietary and lifestyle changes. The patient’s blood pressure indicates prehypertension, but the patient does not have cardiovascular risk factors such as hyperlipidemia or hyperinsulinemia. The body mass index indicates that the patient is overweight but not obese. Pharmacologic treatment is not recommended for prehypertension unless compelling reasons are present. The findings are not normal, so it is appropriate to counsel the patient about diet and exercise.
A 55-year-old patient with no prior history of hypertension has a blood pressure greater than 140/90 on three separate occasions. The patient does not smoke, has a body mass index of 24, and exercises regularly. The patient has no known risk factors for cardiovascular disease. The primary care NP should:
a. prescribe a thiazide diuretic and an angiotensin-converting enzyme inhibitor.
b. order a urinalysis and creatinine clearance and begin therapy with a b-blocker.
c. counsel the patient about dietary and lifestyle changes.
d. perform a careful cardiovascular physical assessment.
d. perform a careful cardiovascular physical assessment. if the patient is younger than 20 or older than 50 years old at the onset of elevated blood pressure, the NP should look for causes of secondary hypertension. The physical examination should include a careful cardiovascular assessment. This patient will need pharmacologic treatment, but not until the underlying cause of hypertension is determined.
The primary care NP sees a new patient who has diabetes and hypertension and has been taking a thiazide diuretic for 6 months. The patient’s blood pressure at the beginning of treatment was 150/95 mm Hg. The blood pressure today is 138/85 mm Hg. The NP should:
a. continue the current drug regimen.
b. add an angiotensin-converting enzyme inhibitor.
c. order a b-blocker.
d. change to an aldosterone antagonist medication.
b. add an angiotensin-converting enzyme inhibitor.- evidence-based guidelines suggest that optimal control of hypertension to less than 130/80 mm Hg could prevent 37% of cardiovascular disease in men and 56% in women, so this patient, although showing improvement, could benefit from the addition of another medication. An angiotensin-converting enzyme inhibitor is an appropriate drug for patients who also have diabetes. b-Blockers and aldosterone antagonist medications are not recommended for patients with diabetes.
A patient who has had a previous myocardial infarction has a blood pressure of 135/82 mm Hg. The patient’s body mass index is 28, and the patient has a fasting plasma glucose of 105 mg/dL. The primary care NP should prescribe:
a. a calcium-channel blocker.
b. an angiotensin-converting enzyme inhibitor.
c. lifestyle modifications.
d. a thiazide diuretic.
b. an angiotensin-converting enzyme inhibitor. this patient has prehypertension but has a compelling reason for treatment. Patients who have had a myocardial infarction should be treated with a b-blocker and angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker (ARB).
The primary care NP sees a new African-American patient who has blood pressure readings of 140/90 mm Hg, 130/85 mm Hg, and 142/80 mm Hg on three separate occasions. The NP learns that the patient has a family history of hypertension. The NP should:
a. initiate monotherapy with a thiazide diuretic.
b. begin combination therapy with an ARB and a calcium-channel blocker.
c. prescribe a thiazide diuretic and an angiotensin-converting enzyme inhibitor.
d. discuss dietary and lifestyle modifications with the patient.
a. initiate monotherapy with a thiazide diuretic. african Americans tend to respond better than whites to diuretic monotherapy, so this is an appropriate starting therapy. Calcium-channel blockers and ARBs are preferred as adjunct medications in African Americans.
An 80-year-old male patient will begin taking an a-antiadrenergic medication. The primary care NP should teach this patient to:
a. be aware that priapism is a common side effect.
b. ask for assistance while bathing.
c. take the medication in the morning with food.
d. restrict fluids to aid with diuresis.
b. ask for assistance while bathing. all antihypertensives can cause orthostatic hypotension, so patients should be cautioned to avoid sudden changes in position and to use caution when bathing because a hot bath or shower may aggravate dizziness. Older patients are at increased risk for falls and should be cautioned to ask for assistance. Patients taking a-antiadrenergics should consume extra fluids because dehydration can increase the risk of orthostatic hypotension. Patients should take the medication at bedtime because drowsiness is a common side effect. Priapism is not a side effect of these drugs.
A patient is in the clinic for an annual physical examination. The primary care NP obtains a medication history and learns that the patient is taking a b-blocker and nitroglycerin. The NP orders laboratory tests, performs a physical examination, and performs a review of systems. Which finding may warrant discontinuation of the b-blocker in this patient?
a. Wheezing, dyspnea, and cough
b. Decreased exercise tolerance
c. Increased triglycerides
d. Nausea, vomiting, and anorexia
a. Wheezing, dyspnea, and cough. b-Blockers may cause bronchospasm in susceptible patients, and discontinuation of the b-blocker may be required. b-Blockers may cause an insignificant increase in serum triglycerides. Exercise intolerance, fatigue, and gastrointestinal side effects are common.
An 80-year-old patient has begun taking propranolol (Inderal) and reports feeling tired all of the time. The primary care NP should:
a. contact the patient’s cardiologist to discuss decreasing the dose of propranolol.
b. tell the patient to stop taking the medication immediately.
c. recommend that the patient take the medication at bedtime.
d. tell the patient that tolerance to this side effect will occur over time.
a. contact the patient’s cardiologist to discuss decreasing the dose of propranolol. elderly patients have described sedation and sleep disturbances with b-blockers. Elderly patients often need lower doses of these drugs. Patients should not be advised to discontinue the medication abruptly.
A patient will begin treatment with a beta-blocker. The patient wants to know about the most common side effects. The NP should educate the patient and discuss the following: (SELECT ALL THAT APPLY)
a. Sexual dysfunction
b. Fatigue
c. Insomnia
d. Tachycardia
ANS: ABC sexual dysfunction, fatigue, insomnia
A patient who has stable angina pectoris and a history of previous myocardial infarction takes nitroglycerin and verapamil. The patient asks the primary care nurse practitioner (NP) why it is necessary to take verapamil. The NP should tell the patient that verapamil:
a. increases the rate of contraction of the cardiac muscle.
b. has a positive inotropic effect to increase cardiac output.
c. increases the force of contraction of the cardiac muscle.
d. improves blood flow and oxygen delivery to the heart.
d. improves blood flow and oxygen delivery to the heart. Verapamil decreases the force of smooth muscle contraction in the smooth muscle of the coronary and peripheral vessels; this results in coronary artery dilation, which lowers coronary resistance and improves blood flow through collateral vessels as well as oxygen delivery to ischemic areas of the heart. Calcium channel blockers do not increase the rate or force of contraction of the heart.
A patient who is taking nifedipine develops mild edema of both feet. The primary care NP should contact the patient’s cardiologist to discuss:
a. increasing the dose of nifedipine.
b. ordering renal function tests.
c. evaluation of left ventricular function.
d. changing to amlodipine
d. changing to amlodipine. mild to moderate peripheral edema occurs in the lower extremities in about 10% of patients; this is caused by arterial dilation, not by left ventricular dysfunction. Amlodipine is less likely to have this effect. Renal function tests are not indicated. Increasing the nifedipine dose would worsen the symptoms
Which of the following adverse effects are associated with calcium channel blockers? (SELECT ALL THAT APPLY)
a. Dizziness
b. Headache
c. Hyperlipidemia
d. Sedation
ANS: AB dizziness, headache
Clinical studies have found that ACEIs are clinically proven to reduce total mortality by preventing deaths from progressive heart failure. ACEIs should be given to all patients with symptomatic or asymptomatic heart failure because ACEIs: (SELECT ALL THAT APPLY)
a. Restore the heart to its normal elliptical shape
b. Reverse ventricular remodeling
c. Decrease renal blood flow
d. Reduce ventricular dilation
ANS: A, B, D (increases renal blood flow)
A patient who is taking an ACE inhibitor sees the primary care NP for a follow-up visit. The patient reports having a persistent cough. The NP should:
a. ask whether the patient has had any associated facial swelling with this cough.
b. reassure the patient that tolerance to this adverse effect will develop over time.
c. consider changing the medication to an ARB.
d. order a bronchodilator to counter the bronchospasm caused by this drug.
c. consider changing the medication to an ARB. A persistent cough may occur with ACE inhibitors and may warrant discontinuation of the drug. An ARB would be the next drug of choice because it does not have this side effect. The cough is not related to bronchospasm. Angioedema is not related to ACE inhibitor-induced cough. Patients do not develop tolerance to this side effect.
A patient who takes a thiazide diuretic will begin taking an ACE inhibitor. The primary care NP should counsel the patient to:
a. take care when getting out of bed or a chair after the first dose of the ACE inhibitor.
b. minimize fluid intake for several days when beginning therapy with the ACE inhibitor.
c. discuss taking an increased dose of the thiazide diuretic with the cardiologist.
d. report wheezing and shortness of breath, which may occur with these drugs.
a. take care when getting out of bed or a chair after the first dose of the ACE inhibitor. ACE inhibitors have a first-dose effect that may cause a precipitous symptomatic fall in blood pressure, particularly in patients receiving diuretics. The patient should be counseled about rising quickly from sitting or lying down. Wheezing and shortness of breath are unlikely. An increased dose of diuretic and a reduction in fluid intake are not indicated and may add to hypotension.
Which of the following statements is true regarding the use of loop diuretics? (SELECT ALL THAT APPLY)
a. Loop diuretics relieve the congestive symptoms of pulmonary and peripheral edema
b. It is a potent diuretic that, if given in excessive amounts, may lead to profound losses of water and electrolyte depletion
c. May cause hyperkalemia
d. May cause ototoxicity
ANS ABD
The primary care NP is preparing to prescribe a diuretic for a patient who has heart failure. The patient reports having had an allergic reaction to sulfamethoxazole-trimethoprim (Bactrim) previously. The NP should prescribe: A. ethacrynic acid. B. furosemide (Lasix). C. acetazolamide (Diamox). D. hydrochlorothiazide (HydroDIURIL).
ANS A ethacrynic acid (a different kind of loop diuretic). Patients who are allergic to sulfa drugs should avoid diuretics that are sulfonamide derivatives. Ethacrynic acid is the only choice that is not a sulfonamide derivative.
A patient with congestive heart failure will begin therapy with a diuretic medication. The primary care NP orders lab tests, which reveal a GFR of 25ml/min. The initial drug the NP should prescribe is: A. metolazone B. furosemide (Lasix) C. spironolactonce (Aldactone) D. hydrochlorothiazine (hydrodiuril
ANS: A metolazone. In patients with GFR less than 30, thiazides are relatively ineffective with the exception of metolazone. Potassium-sparing diuretics should be used with great caution or acoided altogether in patients with renal insufficiency
Mrs. Smith is a 43-year-old Caucasian female patient who presents to the clinic for a follow up appointment. She has diabetes and hypertension and has been taking a thiazide diuretic for 6 months. Her blood pressure at the beginning of treatment was 155/95 mmHg. the blood pressure today is 144/90 mmHg. The NP should:
a. Change to an aldosterone antagonist medication
b. Order a beta blocker
c. Continue the current drug regimen
d. Add an angiotensin-converting enzyme inhibitor
ANS D Add an angiotensin-converting enzyme inhibitor
A patient is in the clinic for a follow-up examination after a myocardial infarction (MI). The patient has a history of left ventricular systolic dysfunction. The primary care NP should expect this patient to be taking:
a. carvedilol (Coreg).
b. propranolol (Inderal).
c. nadolol (Corgard).
d. timolol (Blocadren).
a. carvedilol (Coreg). The 2012 guides for prevention of cardiovascular disease recommend that b-blocker therapy should be used in all patients with left ventricular systolic dysfunction with heart failure or prior MI. Use should be limited to carvedilol, metoprolol succinate, or bisoprolol.
A patient who takes a calcium channel blocker is in the clinic for an annual physical examination. The cardiovascular examination is normal. As part of routine monitoring for this patient, the primary care NP should evaluate:
a. complete blood count and electrolytes.
b. liver function tests (LFTs) and renal function.
c. thyroid and insulin levels.
d. serum calcium channel blocker level.
b. liver function tests (LFTs) and renal function. Patients who take calcium channel blockers should have periodic renal and LFTs.
A patient who has stable angina is taking nitroglycerin and a b-blocker. The patient tells the primary care NP that the cardiologist is considering adding a calcium channel blocker. The NP should anticipate that the cardiologist will prescribe:
a. verapamil HCl (Calan).
b. isradipine (DynaCirc).
c. nicardipine (Cardene).
d. nifedipine (Procardia XL).
a. verapamil HCl (Calan). Nitrates and b-blockers are first-line therapy for stable angina. Calcium channel blockers should be reserved for patients who cannot take these agents or patients whose symptoms are not controlled with these agents. Verapamil is one of the calcium channel blockers that should be used. The other calcium channel blockers are not recommended for this purpose.
A patient has been taking furosemide 80 mg once daily for 4 weeks and returns for a follow-up visit. The primary care NP notes a blood pressure of 100/60 mmHg. The patients lungs are clear, and there is no peripheral edema. The patients seeum potassium is 3.4 mEq/L. The NP should:
a. continue furosemide at the current dose.
b. decrease furosemide to 60 mg once daily.
c. increase furosemide to 80 mg twice daily.
d. change furosemide dose the 40 mg twice daily.
ANS: B The major toxicities related to loop diuretics result from fluid and electrolyte imbalances. This patient has a low potassium level just under the lower limit, so a reduction in dose is indicated.
A patient is taking spironolactone and comes to the clinic complaining of weakness and tingling of the hands and feet. The primary care NP notes a heart rate of 62 beats per minute and a blood pressure of 100/58 mm Hg. The NP should:
a. obtain a serum drug level.
b. order an electrocardiogram (ECG) and serum electrolytes.
c. change the medication to a thiazide diuretic.
d. question the patient about potassium intake.
ANS: B The patient is showing signs of hyperkalemia, so the NP should order an ECG and serum electrolytes. This should be done before changing the medication. Because hyperkalemia can cause fatal arrhythmias, an ECG is necessary.
A patient who has congestive heart failure and arthritis has been taking chlorthalidone(Zaroxolyn) 25 mg daily for 6 months. The primary care NP notes a persistent blood pressure of 145/90 mm Hg. The NP should:
a. ask the patient which medications are used for pain.
b. add furosemide (Lasix) to the patient’s drug regimen.
c. increase the dose of chlorthalidone to 100 mg daily
d. recommend that the patient use salt substitutes to season
Answer A. for diuretic resistance, the NP should evaluate factors such as patient nonadherence, physiologic causes, and drugs that may increase resistance, including nonsteroidal antiinflammatory drugs (NSAIDs). This patient has arthritis, and it is likely that NSAID use may be causing diuretic resistance. A second drug, such as furosemide, should be added after the cause of diuretic resistance is determined. The maximum daily dose of chlorthalidone is100 mg per day, but increasing the dose is not recommended to treat diuretic resistance. Recommending salt substitutes is not indicated.
The primary care NP sees a patient several months after a myocardial infarction (MI). The patient has been taking furosemide to treat heart failure. The NP notes that the patient has edema of the hands, feet, and ankles. The NP should add which drug to this patient’s regimen?
a. Ethacrynic acid
b. Chlorothiazide (Lozol)
c. Triamterene (Dyrenium)
d. Spironolactone (Aldactone)
ANS: B. The addition of a thiazide to a loop diuretic along with sodium restriction may be useful in the treatment of refractory edema in patients with congestive heart failure. Ethacrynic acid is a loop diuretic. The other two options are potassium-sparing diuretics.
The primary care NP sees a patient who has a history of hypertension and alcoholism. The patient is not taking any medications. The NP auscultates crackles in both lungs and palpates the liver 2 cm below the costal margin. Laboratory tests show an elevated creatinine level. The NP will refer this patient to a cardiologist and should prescribe:
a. albuterol metered-dose inhaler.
b. furosemide (Lasix).
c. spironolactone (Aldactone).
d. chlorthalidone (Zaroxolyn).
ANS: B furosemide (Lasix). In the treatment of heart failure, loop diuretics relieve the congestive symptoms of pulmonary and congestive edema. Loop diuretics are also useful to treat states of volume excess in cirrhosis and renal insufficiency. Because this patient has a history of alcoholism and has an enlarged liver on examination, furosemide is a good first choice to relieve this patient’s congestive symptoms. Spironolactone and chlorthalidone are not loop diuretics. Albuterol might be used for symptomatic treatment only.
The primary care NP sees a patient who has heart failure following an MI 6 months before this visit. The patient has been taking an ACE inhibitor, nitroglycerin, furosemide, and hydrochlorothiazide. The NP auscultates crackles in both lungs and notes pitting edema of both feet. The NP should prescribe:
a. mannitol.
b. metolazone.
c. acetazolamide (Diamox).
d. spironolactone (Aldactone).
ANS: D Spironolactone has been shown to be of particular benefit in the treatment of severe congestive heart failure when added to an ACE inhibitor and a loop diuretic.
A 45-year-old patient who has a positive family history but no personal history of coronary artery disease is seen by the primary care NP for a physical examination. The patient has a body mass index of 27 and a blood pressure of 130/78 mm Hg. Laboratory tests reveal low-density lipoprotein, 110 mg/dL; high-density lipoprotein, 70 mg/dL; and triglycerides, 120 mg/dL. The patient does not smoke but has a sedentary lifestyle. The NP should recommend:
a. 30 minutes of aerobic exercise daily.
b. beginning therapy with a statin medication.
c. taking 81 to 325 mg of aspirin daily.
d. starting a thiazide diuretic to treat hypertension.
a. 30 minutes of aerobic exercise daily. this patient is overweight but not obese, and blood lipids are within normal limits. Blood pressure is not elevated. Exercise is recommended as an initial risk reduction strategy because of its positive effects on blood pressure and blood lipids. Aspirin is generally given to patients older than 55 to 65 who are at risk. Statin medications and thiazide diuretics are not indicated.
A patient comes to the clinic with a recent onset of nocturnal and exertional dyspnea. The primary care nurse practitioner (NP) auscultates S3 heart sounds but does not palpate hepatomegaly. The patient has mild peripheral edema of the ankles. The NP should consult a cardiologist to discuss prescribing a(n):
a. loop diuretic.
b. angiotensin-converting enzyme (ACE) inhibitor.
c. b-blocker.
d. angiotensin receptor blocker (ARB).
a. loop diuretic. This patient shows signs of systolic heart failure. Treatment for heart failure should begin with a loop diuretic, with an ACE inhibitor added after the diuretic has been taken. b-Blockers are used in patients with minimal fluid retention and would be added later. ARBs are used if ACE inhibitors are not tolerated or are ineffective
A patient who has heart failure has been treated with furosemide and an ACE inhibitor. The patient’s cardiologist has added digoxin to the patient’s medication regimen. The primary care NP who cares for this patient should expect to monitor:
a. serum electrolytes.
b. blood glucose levels.
c. complete blood counts (CBCs).
d. serum thyroid levels
a. serum electrolytes. hypokalemia makes the myocardium more sensitive to digoxin. These levels should be monitored closely in patients taking furosemide, which can deplete potassium. Serum glucose, thyroid levels, and a CBC should be monitored if indicated by other conditions.
A patient who takes spironolactone for heart failure has begun taking digoxin (Lanoxin) for atrial fibrillation. The primary care NP provides teaching for this patient and asks the patient to repeat back what has been learned. Which statement by the patient indicates understanding of the teaching?
a. “I should eat foods high in potassium.”
b. “I should use a salt substitute while taking these medications.”
c. “I need to take a calcium supplement every day.”
d. “I should avoid high-sodium foods.”
d. “I should avoid high-sodium foods.” patients should be taught to reduce their overall sodium intake by avoiding salty foods and not adding salt while cooking. Spironolactone is a potassium-sparing diuretic and carries a risk of hyperkalemia, which can make the myocardium more sensitive to the effects of digoxin. Hypercalcemia can predispose the patient to digoxin toxicity. Salt substitutes are high in potassium.
A patient has heart failure. A recent echocardiogram reveals decreased compliance of the left ventricle and poor ventricular filling. The patient takes low-dose furosemide and an ACE inhibitor. The primary care NP sees the patient for a routine physical examination and notes a heart rate of 92 beats per minute and a blood pressure of 100/60 mm Hg. The NP should:
a. consider prescribing a b-blocker.
b. obtain renal function tests.
c. order serum electrolytes.
d. call the patient’s cardiologist to discuss adding digoxin to the patient’s regimen.
c. order serum electrolytes. patients with diastolic heart failure are sensitive to fluid depletion, which can cause decreased preload and stroke volume. This patient has a rapid heart rate and a low blood pressure, which can indicate dehydration, so serum electrolytes should be obtained. Renal function tests are not indicated. b-Blockers are used in patients who are stable. Digoxin should not be used in patients with diastolic failure.
A primary care NP sees a patient who is being treated for heart failure with digoxin, a loop diuretic, and an ACE inhibitor. The patient reports having nausea. The NP notes a heart rate of 60 beats per minute and a blood pressure of 100/60 mm Hg. The NP should:
a. obtain a serum potassium level to assess for hyperkalemia.
b. decrease the dose of the diuretic to prevent further dehydration.
c. obtain a digoxin level before the patient takes the next dose of digoxin.
d. hold the ACE inhibitor until the patient’s blood pressure stabilizes.
c. obtain a digoxin level before the patient takes the next dose of digoxin. to monitor for toxicity, the health care provider must be alert to early signs of toxicity and must obtain a serum level. Nausea is an early sign of toxicity.
An 80-year-old patient with chronic stable angina has begun taking nadolol (Corgard) 20 mg once daily in addition to taking nitroglycerin as needed. After 1 week, the patient reports no change in frequency of nitroglycerin use. The primary care nurse practitioner (NP) should change the dose of nadolol to _____ mg _____ daily.
a. 20; twice
b. 40; twice
c. 40; once
d. 80; once
c. 40; once. b-Blockers are the treatment of choice for chronic stable and unstable angina. Their therapeutic effect is dose dependent, and drug titration should be based on frequency of angina symptoms and nitroglycerin use. Nadolol should be started at 20 mg daily for elderly patients when treating angina and should be increased by 20 mg every 3 to 7 days if symptoms do not improve. Nadolol is given once daily.
A patient with a history of coronary heart disease develops atrial fibrillation. The primary care NP refers the patient to a cardiologist who performs direct current cardioversion. The NP should expect the patient to begin taking which b-blocker medication?
a. Sotalol (Betapace)
b. Nadolol (Corgard)
c. Timolol (Blocadren)
d. Propranolol (Inderal)
a. Sotalol (Betapace). Sotalol is classified as a class II and III antiarrhythmic and is a preferred agent in patients with a history of coronary heart disease.
A patient who has migraine headaches has begun taking timolol and 2 months after beginning this therapy reports no change in frequency of migraines. The patient’s current dose is 30 mg once daily. The primary care NP should:
a. obtain serum drug levels to see if the dose is therapeutic.
b. tell the patient to continue taking the timolol and return in 1 month.
c. change the medication to propranolol.
d. increase the dose to 40 mg once daily.
b. tell the patient to continue taking the timolol and return in 1 month. When giving timolol for migraine prophylaxis, the provider should inform the patient that it may take several weeks for therapy to be effective. The dose should be titrated and maintained for a minimum of 3 months before the treatment is deemed a failure. It may be necessary to change to propranolol if the therapy is not effective in 1 month. The maximum dose of timolol for migraine prophylaxis is 30 mg. Drug effectiveness is determined by patient response, not serum drug levels.
A patient who has been taking propranolol for 6 months reports having nocturnal cough and shortness of breath. The primary care NP should:
a. obtain serum drug levels to monitor for toxicity of this medication.
b. contact the patient’s cardiologist to discuss changing to a selective b-blocker.
c. instruct the patient to increase activity and exercise to counter these side effects.
d. tell the patient to stop taking the medication.
b. contact the patient’s cardiologist to discuss changing to a selective b-blocker. nocturnal cough and shortness of breath may be a side effect of propranolol, which can cause bronchospasm because it is a nonselective â-blocker. The NP should discuss a selective b-blocker with the patient’s cardiologist. â-Blockers should never be stopped abruptly. Bradycardia and hypotension are signs of toxicity. Increasing activity would not counter these side effects if bronchospasm is the cause.
A primary care NP provides teaching for a patient who will begin taking propranolol (Inderal). Which statement by the patient indicates understanding of the teaching?
a. “I should take this medication on an empty stomach.”
b. “I should use caution while driving while taking this medication.”
c. “I should not take the medication if my pulse is less than 60 beats per minute.”
d. “If I have shortness of breath, I should discontinue the medication immediately.”
b. “I should use caution while driving while taking this medication.” because the medication can cause fatigue and drowsiness, patients should be advised to use caution when driving. The medication should be taken with food. Patients should not take a dose if the heart rate is less than 50 beats per minute. Patients should be advised to report shortness of breath but should not abruptly stop taking the medication.
A patient who takes nitroglycerin for stable angina pectoris develops hypertension. The primary care NP should contact the patient’s cardiologist to discuss adding:
a. verapamil HCl (Calan).
b. diltiazem (Cardizem).
c. nifedipine (Procardia XL).
d. amlodipine (Norvasc).
c. nifedipine (Procardia XL). Nifedipine and related drugs are potent vasodilators, which makes them more effective for hypertension than verapamil and diltiazem. Amlodipine is not a first-line drug.
A patient who has angina is taking nitroglycerin and long-acting nifedipine. The primary care NP notes a persistent blood pressure of 90/60 mm Hg at several follow-up visits. The patient reports lightheadedness associated with standing up. The NP should consult with the patient’s cardiologist about changing the medication to:
a. amlodipine (Norvasc).
b. verapamil HCl (Calan).
c. short-acting nifedipine (Procardia).
d. isradipine (DynaCirc).
b. verapamil HCl (Calan). Verapamil and diltiazem are less likely to cause hypotension than nifedipine and related drugs, such as isradipine and amlodipine.
An African-American patient who is obese has persistent blood pressure readings greater than 150/95 mm Hg despite treatment with a thiazide diuretic. The primary care NP should consider prescribing a(n):
a. b-blocker.
b. ACE inhibitor.
c. calcium channel blocker.
d. angiotensin receptor blocker.
c. calcium channel blocker. African-American patients are considered good candidates for calcium channel blockers to treat hypertension. Treatment with calcium channel blockers as monotherapy in African-American patients has proved to be more effective than some other classes of antihypertensive agents.
Which of the following agents used in class II and class III heart failures is known to have alpha as well as non-selective beta blocking action?
a. Carvedilol (coreg)
b. Amlodipine (Norvasc)
c. Lisinopril (Zestril)
d. Captopril (capoten)
ANS. A. Carvedilol
A patient takes hydrochlorothiazide to treat hypertension and asks the primary care NP why it is necessary to reduce sodium intake while taking this medication. The NP should explain that decreasing sodium is necessary to:
a. prevent renal insufficiency
b. minimize the incidence of hypokalemia
c. decrease the length of time the patient needs to be on the diuretic
d. prevent post diuretic sodium retention
ANS D. If dietary salt intake is high, the amount of sodium lost in response to the diuretic may be partially or completely offset by postdiuretic sodium retention. Sodium restriction does not prevent renal insufficiency or minimize the incidence of hypokalemia. Sodium restriction is necessary to maintain the drugs effectiveness but does not increase the chance of discontinuing the medication.
A patient develops hypertension. The primary care nurse practitioner (NP) plans to begin diuretic therapy for this patient. The NP notes clear breath sounds, no organomegaly, and no peripheral edema. The patient’s serum electrolytes are normal. The NP should prescribe:
a. furosemide (Lasix)
b. triamterene (Dyrenium)
c. acetazolamide (Diamox)
d. hydrochlorothiazide (hydrodiuril)
ANS D. Hydrochlorothiazide. Thiazide diuretics are first line drugs for treating hypertension. The other three drugs are not thiazide diuretics.
An African-American patient is taking captopril (Capoten) 25 mg twice daily. When performing a physical examination, the primary care nurse practitioner (NP) learns that the patient continues to have blood pressure readings of 135/90 mm Hg. The NP should:
a. recommend a low-sodium diet in addition to the medication.
b. increase the captopril dose to 50 mg twice daily.
c. change the drug to losartan (Cozaar) 50 mg once daily.
d. add a thiazide diuretic to this patient’s regimen
d. add a thiazide diuretic to this patient’s regimen. some African-American patients do not appear to respond as well as whites in terms of blood pressure reduction. The addition of a low-dose thiazide diuretic often allows for efficacy in blood pressure lowering that is comparable with that seen in white patients. Increasing the captopril dose is not indicated. Losartan is an angiotensin receptor blocker (ARB) and is not indicated in this case.
A patient with a previous history of myocardial infarction (MI) who takes nitroglycerin for angina develops hypertension. The primary care NP is considering ordering an ACE inhibitor. Preliminary laboratory tests reveal decreased renal function. The NP should:
a. order a renal perfusion study before starting treatment.
b. choose an ARB instead.
c. add a low-dose thiazide diuretic to the drug regimen.
d. begin therapy with a low-dose ACE inhibitor.
a. order a renal perfusion study before starting treatment. ACE inhibitors are contraindicated in patients with bilateral renal stenosis. Because this patient has decreased renal function, perfusion studies are indicated. If the patient does not have bilateral renal stenosis, a low-dose ACE inhibitor may be used. An ARB is indicated if perfusion studies show bilateral renal stenosis. A thiazide diuretic is not indicated
A patient who has type 2 diabetes is seen by a primary care NP for a physical examination. The NP notes a blood pressure of 140/95 mm Hg on three occasions. A urinalysis reveals macroalbuminuria. The patient’s serum creatinine is 1.9 mg/dL. Adhering to evidence-based practice, the NP should prescribe:
a. fosinopril sodium (Monopril).
b. losartan (Cozaar).
c. captopril (Capoten).
d. enalapril maleate (Vasotec
b. losartan (Cozaar). In patients with type 2 diabetes, hypertension, macroalbuminuria, and renal insufficiency (serum creatinine >1.5 mg/dL), ARBs have been shown to delay the progression of nephropathy. Losartan is an ARB. The other medications are ACE inhibitors.
A patient who takes an ACE inhibitor and a thiazide diuretic for hypertension will begin taking spironolactone. The primary care NP should counsel this patient to:
a. avoid foods that are high in potassium.
b. discuss changing the ACE inhibitor to an ARB with the cardiologist.
c. avoid taking antacids containing magnesium while taking these drugs.
d. use a salt substitute when seasoning foods
a. avoid foods that are high in potassium. Use of potassium-sparing diuretics or salt substitutes can induce hyperkalemia when taking ACE inhibitors, so this patient should be counseled to restrict potassium. Salt substitutes are high in potassium and are contraindicated. It is not necessary to change to an ARB. Antacids are not contraindicated.
The primary care NP is considering prescribing captopril (Capoten) for a patient. The NP learns that the patient has decreased renal function and has renal artery stenosis in the right kidney. The NP should:
a. initiate ACE inhibitor therapy at a low dose.
b. give the captopril with a thiazide diuretic to improve renal function.
c. order lisinopril (Zestril) instead of captopril to avoid increased nephropathy.
d. consider a different drug class to treat this patient’s symptoms.
a. initiate ACE inhibitor therapy at a low dose. patients with impaired renal function should use low-dose ACE inhibitors. It is not necessary to avoid ACE inhibitors with unilateral renal stenosis.
A patient who has angina uses 0.4 mg of sublingual nitroglycerin for angina episodes. The patient brings a log of angina episodes to an annual physical examination. The primary care NP notes that the patient has experienced an increase in frequency of episodes in the past month but no increase in duration or severity of pain. The NP should:
a. change from a sublingual to a transdermal patch nitroglycerin.
b. contact the patient’s cardiologist to discuss admission to the hospital.
c. discontinue the nitroglycerin and order ranolazine (Ranexa ER).
d. increase the nitroglycerin dose to 0.6 mg per dose.
ANS b. contact the patient’s cardiologist to discuss admission to the hospital. Unstable angina is a change in pattern or pain, such as an increase in frequency, severity, or duration of pain and fewer precipitating factors. Patients with unstable angina should be admitted to a coronary care unit. The primary care NP should not change any medications without consultation with the patient’s cardiologist.
A patient who has stable angina and uses sublingual nitroglycerin tablets is in the clinic and begins having chest pain. The primary care NP administers a nitroglycerin tablet and instructs the patient to lie down. The NP’s next action should be to:
a. give 325 mg of chewable aspirin.
b. administer oxygen at 2 L/minute.
c. call EMS.
d. obtain an electrocardiogram.
ANS b. administer oxygen at 2 L/minute. When a patient experiences an acute attack of angina in the clinic, the primary care NP should be prepared to treat the condition. After giving nitroglycerin, oxygen should be administered. An electrocardiogram is not immediately indicated. Chewable aspirin is given if the angina is unrelieved and when the patient is being transported to the hospital. EMS should be activated if there is no pain relief 5 minutes after the first dose of nitroglycerin.
A patient who has a history of angina has sublingual nitroglycerin tablets to use as needed. The primary care nurse practitioner (NP) reviews this medication with the patient at the patient’s annual physical examination. Which statement by the patient indicates understanding of the medication?
a. “I should take aspirin along with the nitroglycerin when I have chest pain.”
b. “I should take nitroglycerin and then rest for 15 minutes before taking the next dose.”
c. “I should take 3 nitroglycerin tablets 5 minutes apart and then call 9-1-1.”
d. “I should call 9-1-1 if chest pain persists 5 minutes after the first dose.”
ANS d. “I should call 9-1-1 if chest pain persists 5 minutes after the first dose.” Although the traditional recommendation is for patients to take up to 3 nitroglycerin doses over 15 minutes before accessing emergency medical services (EMS), more recent guidelines suggest an alternative strategy to reduce delays in emergency care. These include instructions to call 9-1-1 immediately if pain persists for 5 minutes after the first dose. Aspirin is recommended when the patient is being transported to emergency care and is not recommended as an adjunct to nitroglycerin with each episode of chest pain. The three doses of nitroglycerin are given 5 minutes apart over 15 minutes.
A primary care NP prescribes a nitroglycerin transdermal patch, 0.4 mg/hour release, for a patient with chronic stable angina. The NP should teach the patient to:
a. use the patch as needed for angina pain.
b. change the patch four times daily.
c. apply one patch daily in the morning and remove in 12 hours.
d. use two patches daily and change them every 12 hours.
ANS c. apply one patch daily in the morning and remove in 12 hours. To avoid tolerance, the patient should remove the patch after 12 hours. The transdermal patch is not changed four times daily or used on a prn basis. The patch is applied once daily.
A patient who has been taking quinidine for several years reports lightheadedness, fatigue, and weakness. The primary care NP notes a heart rate of 110 beats per minute. The serum quinidine level is 6 mg/mL. The NP should:
a. reassure the patient that this is a therapeutic drug level.
b. admit the patient to the hospital and obtain a cardiology consultation.
c. discontinue the medication immediately.
d. order an ECG, CBC, liver function tests (LFTs), and renal function tests.
ANS d. order an ECG, CBC, liver function tests (LFTs), and renal function tests. The therapeutic level for quinidine is 2 to 5 ìg/mL. Some patients have therapeutic responses at up to 6 mg/mL. The NP should order ECG, CBC, LFT, and renal function tests.
The primary care NP refers a patient to a cardiologist who diagnoses long QT syndrome. The cardiologist has prescribed propranolol (Inderal). The patient exercises regularly and is not obese. The patient asks the NP what else can be done to minimize risk of sudden cardiac arrest. The NP should counsel the patient to:
a. drink extra fluids when exercising.
b. reduce stress with yoga and hot baths.
c. ask the cardiologist about an implantable defibrillator.
d. ask the cardiologist about adding procainamide to the drug regimen.
a. drink extra fluids when exercising. patients with long QT syndrome should avoid situations in which they might overheat or get dehydrated. This patient should be encouraged to drink plenty of fluids while exercising and should avoid activities such as yoga and hot baths. Implantable cardioverter-defibrillators are used for high-risk patients. Procainamide can cause long QT syndrome.
Which of the following statements is true regarding the mechanism of action of digoxin in the treatment of HF? (SELECT ALL THAT APPLY)
a. has an inotropic effect on cardiac cells
b. produces a decreased force of contraction of the cardiac muscle
c. increases CO and produces mild diuresis, helping to relieve symptoms
d. it is most effective in HF causes by decreased left ventricular function and other low-output syndromes
ANS ACD
Which of the following drugs can exacerbate HF and should be avoided, when possible? (SELECT ALL THAT APPLY)
a. ibuprofen
b. lisinopril
c. pioglitazone
d. furosemide
ANS AC
Which of the following statements is true regarding the use of organic nitrates?
a. Ensure a nitrate-free interval to prevent tolerance
b. Produce vascular smooth muscle relaxation
c. Are contraindicated with PDE5 inhibitors (sildenafil and others)
d. Only first and second statements are correct
e. All of the above statements are correct
ANS. E all of the above
Match the following antiarrhythmic class of drugs with their corresponding mechanism of action: Class I ------------------- Class II ------------------ Class III ---------------- Class IV ----------------
Sodium Channel Blockers
Beta-adrenergic blockers
Potassium channel blockers
Calcium channel blockers
A patient will begin treatment with amiodarone. To monitor for toxicity the NP should do the following (SELECT ALL THAT APPLY):
a. Perform baseline chest radiographs and pulmonary function tests
b. Thyroid function test at baseline and periodically during therapy
c. Obtain annual ophthalmic examination
d. Obtain ECG, serum creatinine, magnesium, and potassium levels every 3 months
ANS ABC
A primary care NP sees a patient who is being treated for heart failure with digoxin, a loop diuretic, and an ACE inhibitor. The patient reports having nausea. The NP notes a heart rate of 60 beats per minute and a blood pressure of 100/60 mm Hg. The NP should:
a. decrease the dose of the diuretic to prevent further dehydration.
b. obtain a serum potassium level to assess for hyperkalemia.
c. obtain a digoxin level before the patient takes the next dose of digoxin.
d. hold the ACE inhibitor until the patient’s blood pressure stabilizes.
ANS c. obtain a digoxin level before the patient takes the next dose of digoxin. To monitor for toxicity, the health care provider must be alert to early signs of toxicity and must obtain a serum level. Nausea is an early sign of toxicity
TRUE/FALSE: The most common cause of death from digoxin toxicity is ventricular fibrillation.
True
The primary care NP sees a new patient for a routine physical examination. When auscultating the heart, the NP notes a heart rate of 78 beats per minute with occasional extra beats followed by a pause. History reveals no past cardiovascular disease, but the patient reports occasional syncope and shortness of breath. The NP should:
a. order a complete blood count (CBC) and electrolytes and consider a trial of procainamide.
b. prescribe a b-blocker and anticoagulant and order 24-hour Holter monitoring.
c. schedule a cardiac stress test and a graded exercise test.
d. order an ECG and refer to a cardiologist.
ANS d. order an ECG and refer to a cardiologist. Premature ventricular contractions are premature ventricular beats with a compensatory pause. This patient has no prior history, but does have syncope and shortness of breath. The NP should order an ECG and refer the patient to a cardiologist for further evaluation. If there were no other symptoms, the NP could order stress testing. Medications are not indicated without further testing and without consultation with a cardiologist.
The primary care NP is preparing to prescribe isosorbide dinitrate sustained release (Dilatrate SR) for a patient who has chronic, stable angina. The NP should recommend initial dosing of:
a. 60 mg on awakening and 40 mg 7 hours later.
b. 40 mg twice daily 30 minutes before meals.
c. 60 mg four times daily at 6-hour intervals.
d. 80 mg three times daily at 8:00 AM, 1:00 PM, and 6:00 PM.
ANS b. 40 mg twice daily 30 minutes before meals. Long-acting nitrates should be considered to treat chronic, stable angina. The main limitation is tolerance, which can be limited by providing a nitrate-free period of 6 to 10 hours each day. The medication should be taken on an empty stomach, 30 to 60 minutes before a meal. An appropriate initial dose of isosorbide dinitrate is 40 mg every 12 hours. This dose can be increased as needed. Isosorbide mononitrate is given on awakening and again 7 hours later. The medication is not given four times daily. Dosing may be increased to 80 mg tid, and the dosing schedule of 8:00 AM, 1:00 PM, and 6:00 PM. would be appropriate at that point.
A patient in the clinic reports heartburn 30 minutes after meals, a feeling of fullness, frequent belching, and a constant sour taste. The patient has a normal weight and reports having a high-stress job. The primary care NP should recommend:
a. changes in diet to avoid acidic foods.
b. daily treatment with a PPI.
c. antacid therapy as needed.
d. consultation with a gastroenterologist for endoscopy
ANS: B daily treatment with PPI. This patient has symptoms of GERD. PPIs are first-line medications for treating GERD and may be started empirically. Antacids are not first-line medications. Changes in diet are not recommended as treatment but may help with symptoms. Patients with symptoms unrelieved by PPIs should be referred for possible endoscopy.
Which of the following statements is true regarding the use of antacids? (SELECT ALL THAT APPLY)
a. Antacids are weak bases that neutralize gastric hydrochloric acid
b. Antacids also have a number of cytoprotective effects
c. Antacids protect the stomach by coating the mucosal lining
d. Antacids with high ANC usually are more effective than others
ANS: ABD
An 80-year-old patient asks a primary care NP about OTC antacids for occasional heartburn. The NP notes that the patient has a normal complete blood count and normal electrolytes and a slight elevation in creatinine levels. The NP should recommend:
a. magnesium hydroxide (Milk of Magnesia).
b. aluminum hydroxide (Amphojel).
c. sodium bicarbonate (Alka-Seltzer).
d. calcium carbonate (Tums).
d. calcium carbonate (Tums). Elderly patients with renal failure should not take antacids containing magnesium because of the risk of hypermagnesemia. Sodium-containing antacids may cause fluid retention in elderly patients. Aluminum hydroxide is not as effective as calcium carbonate.
A patient has NSAID-induced ulcer and has started taking ranitidine (Zantac). At a follow-up appointment 3 days later, the patient reports no alleviation of symptoms. The primary care NP should:
a. change from ranitidine to omeprazole (Prilosec).
b. reassure the patient that drug effects take several weeks.
c. order cimetidine (Tagamet).
d. add metronidazole to the drug regimen.
a. change from ranitidine to omeprazole (Prilosec). If the patient does not start to see improvement within a few days after initiation of treatment with a histamine-2 blocker, the provider either should increase the dose of the medication or should change to a PPI. Cimetidine is a histamine-2 blocker and has many serious side effects. Metronidazole is used only when H. pylori is known to be present. Patients should start to get relief within a few days.
A postmenopausal woman develops NSAID-induced ulcer. The primary care NP should prescribe:
a. pantoprazole (Protonix).
b. omeprazole (Prilosec).
c. esomeprazole (Nexium).
d. ranitidine (Zantac).
d. ranitidine (Zantac). PPIs carry a possible increased risk of fractures in postmenopausal women. The NP should begin therapy with a histamine-2 blocker, such as ranitidine.
A patient who has severe arthritis and who takes nonsteroidal antiinflammatory drugs (NSAIDs) daily develops a duodenal ulcer. The patient has tried a cyclooxygenase-2 selective NSAID in the past and states that it is not as effective as the current NSAID. The primary care nurse practitioner (NP) should:
a. change the NSAID to a corticosteroid.
b. prescribe omeprazole (Prilosec).
c. teach the patient about a bland diet.
d. prescribe cimetidine (Tagamet)
b. prescribe omeprazole (Prilosec). Patients with NSAID-induced ulcer should discontinue the NSAID if possible and use an acid suppressant. This patient has severe arthritis and so cannot discontinue the NSAID. In a situation such as this, a PPI is indicated. Cimetidine is a histamine-2 blocker, which would be a second-line choice, but cimetidine has many serious side effects. Bland diets are not effective in treating ulcers. Corticosteroids are not indicated.
Which of the following statements is true regarding the use of proton pump inhibitors (PPIs)? (SELECT ALL THAT APPLY)
a. PPIs are the most potent available inhibitors of gastric secretion
b. Some adverse effects include: nausea, headache, diarrhea, GI disturbance, and bone fractures with long-term use
c. A dose adjustment is necessary when using PPIs to treat geriatric patients
d. PPIs and H2-blockers should not be used concurrently
ANS: ABD (no dose adjustment necessary)
A 5-year-old child has chronic constipation. The primary care NP plans to prescribe a laxative for long-term management. In addition to pharmacologic therapy, the NP should also recommend _____ g of fiber per day.
a. 20
b. 15
c. 10
d. 25
c. 10. Each day a child should receive 1 g of fiber per year of age plus 5 g after 2 years of age.
A patient who has a history of chronic constipation uses a bulk laxative to prevent episodes of acute constipation. The patient reports having an increased frequency of episodes. The primary care NP should recommend:
a. adding docusate sodium (Colace).
b. polyethylene glycol (MiraLAX) and bisacodyl (Dulcolax).
c. adding nonpharmacologic measures such as biofeedback.
d. lactulose (Chronulac) and polyethylene glycol (MiraLAX).
a. adding docusate sodium (Colace). Patients treated for long-term constipation should begin with a bulk laxative. If that is not effective, the addition of a second laxative may be necessary. Using two laxatives from the same category is not recommended. A stool softener, such as docusate sodium, is appropriate. Bisacodyl is not a second-line treatment. Lactulose and polyethylene glycol are from the same category.
A patient who takes digoxin reports taking psyllium (Metamucil) three or four times each month for constipation. The primary care NP should counsel this patient to:
a. change the laxative to docusate sodium (Colace).
b. take the digoxin 2 hours before taking the psyllium.
c. ask the cardiologist about taking an increased dose of digoxin.
d. decrease fluid intake to avoid cardiac overload.
b. take the digoxin 2 hours before taking the psyllium. Laxatives can affect the absorption of drugs in the intestine by decreasing transit time. Digoxin is a drug that is affected by decreased transit time. Patients should be counseled to take the drugs 2 hours apart.
A 12-year-old patient has acute diarrhea and an upper respiratory infection. Other family members have had similar symptoms, which have resolved. The primary care NP should recommend:
a. attapulgite (Kaopectate).
b. bismuth subsalicylate (Pepto-Bismol).
c. an electrolyte solution (Pedialyte).
d. diphenoxylate (Lomotil).
c. an electrolyte solution (Pedialyte). Antidiarrheals are not generally recommended in children. Bismuth is not recommended in children younger than 16 years of age with viral illnesses because it can mask symptoms of Reye’s syndrome. Oral rehydration with electrolyte solution is safe.
A woman who is 4 months pregnant comes to the clinic with acute diarrhea and nausea. Her husband is experiencing similar symptoms. The primary care nurse practitioner (NP) notes a temperature of 38.5° C, a heart rate of 92 beats per minute, and a blood pressure of 100/60 mm Hg. The NP should:
a. prescribe attapulgite to treat her diarrhea.
b. obtain a stool culture and start antibiotic therapy.
c. refer her to an emergency department for intravenous (IV) fluids.
d. instruct her to replace lost fluids by drinking Pedialyte.
c. refer her to an emergency department for intravenous (IV) fluids. Diarrhea in pregnant women can have serious consequences, and the patient may need to be referred. This woman is showing signs of dehydration and needs IV rehydration. Attapulgite is a category B drug for pregnancy and should be avoided if possible. Acute diarrhea is usually viral, and antibiotics are not given unless a stool culture is performed and is positive. Because the patient is pregnant and has nausea, oral rehydration would not be effective.
A patient has been taking antibiotics to treat recurrent pneumonia. The patient is in the clinic after having diarrhea for 5 days with six to seven liquid stools each day. The primary care NP should:
a. order testing for Clostridium difficile and consider metronidazole therapy.
b. obtain a stool specimen and order vancomycin.
c. prescribe diphenoxylate (Lomotil) to provide symptomatic relief.
d. reassure the patient that diarrhea is a common side effect of antibiotic therapy.
a. order testing for Clostridium difficile and consider metronidazole therapy. The guidelines for treatment of diarrhea emphasize comprehensive evaluation before treatment begins. Antibiotic use points to C. difficile as a possible cause, and metronidazole is often used to treat mild to moderate infection. Vancomycin is used when C. difficile is severe. Diphenoxylate can worsen the infection because it slows transit time of the bacteria in the gut. Prolonged diarrhea during antibiotic therapy should be investigated.
A woman is in her first trimester of pregnancy. She tells the primary care nurse practitioner (NP) that she continues to have severe morning sickness on a daily basis. The NP notes a weight loss of 1 pound from her previous visit 2 weeks prior. The NP should consult an obstetrician and prescribe:
a. prochlorperazine (Compazine).
b. scopolamine transdermal.
c. aprepitant (Emend).
d. ondansetron (Zofran).
d. ondansetron (Zofran). No antiemetic drugs should be used for nausea and vomiting during pregnancy unless approved by an obstetrician. Ondansetron has been shown to be safe and effective (off-label) for hyperemesis gravidum.
A primary care NP sees a patient who is about to take a cruise and reports having had motion sickness with nausea on a previous cruise. The NP prescribes the scopolamine transdermal patch and should instruct the patient to apply the patch:
a. every 3 days.
b. daily.
c. 1 hour before embarking.
d. as needed for nausea.
a. every 3 days. The transdermal system allows steady-state plasma levels of scopolamine to be reached rapidly and maintained for 3 days. The onset of action is approximately 4 hours. The patch should be changed every 3 days and left on at all times, not as needed.
A patient reports having episodes of dizziness, nausea, and lightheadedness and describes a sensation of the room spinning when these occur. The primary care NP will refer the patient to a specialist who, after diagnostic testing, is likely to prescribe:
a. ondansetron.
b. scopolamine.
c. meclizine.
d. dimenhydrinate
c. meclizine. Patients with vertigo may experience whirling or a feeling of the room spinning around. In true vertigo, the patient can identify the direction in which the room is spinning. Anticholinergics are the most effective agents in cases of motion sickness or vertigo. Meclizine has a specific indication to treat vertigo.
A patient has been diagnosed with IBS and tells the primary care NP that symptoms of diarrhea and cramping are worsening. The patient asks about possible drug therapy to treat the symptoms. The NP should prescribe:
a. dicyclomine (Bentyl).
b. simethicone (Phazyme).
c. metoclopramide (Reglan).
d. mesalamine (Asacol).
a. dicyclomine (Bentyl). Dicyclomine has indirect and direct effects on the smooth muscle of the gastrointestinal (GI) tract. Both actions help to relieve smooth muscle spasm. Mesalamine is used to treat ulcerative colitis. Simethicone acts locally to treat symptoms of trapped air and gas. Metoclopramide is used to increase motility.
A patient who has IBS has been taking dicyclomine and reports decreased pain and diarrhea but is now having occasional constipation. The primary care NP should recommend:
a. beginning therapy with a TCA.
b. beginning treatment with an SSRI.
c. increasing the amounts of raw fruits and vegetables in the diet.
d. over-the-counter (OTC) laxatives as needed when constipated.
d. over-the-counter (OTC) laxatives as needed when constipated. Patients who experience constipation may use OTC laxatives as needed. Antidepressants, such as SSRIs or TCAs, are used long-term to help with pain. Raw fruits and vegetables can increase the likelihood of bloating.
A woman with IBS has been taking antispasmodic medications and reports some relief, but she tells the primary care NP that the disease is interfering with her ability to work because of increased pain. The NP should consider prescribing:
a. alosetron (Lotronex).
b. misoprostol (Cytotec).
c. simethicone (Phazyme).
d. tricyclic antidepressants (TCAs).
d. tricyclic antidepressants (TCAs). TCAs and selective serotonin reuptake inhibitors (SSRIs) have been shown to reduce symptoms and are useful for long-term treatment. Alosetron is ordered by a GI specialist if symptoms are resistant to all other interventions and has been shown to be effective in women with diarrhea-predominant IBS. Misoprostol is used to treat NSAID-induced ulcers. Simethicone acts locally to treat symptoms of trapped air and gas.
TRUE/FALSE: A diet with adequate fiber is the cornerstone of treatment for IBS, and 25 grams per day is recommended
True
A patient who has gastroesophageal reflux disease (GERD) undergoes an endoscopy, which shows a hiatal hernia. The patient is mildly obese. The patient asks the primary care nurse practitioner (NP) about treatment options. The NP should tell this patient that:
a. a fundoplication will be necessary to correct the cause of GERD.
b. a combination of lifestyle changes, medications, and surgery may be necessary.
c. elevation of the head of the bed at night can relieve most symptoms.
d. over-the-counter (OTC) antacids can be effective and should be tried first.
b. a combination of lifestyle changes, medications, and surgery may be necessary. People with GERD often have hiatal hernia, but this is not the cause of GERD. The approach to treatment of GERD may include lifestyle changes, medications, and surgery. OTC antacids are sometimes used but are rarely used as first-line treatment.
A patient undergoes endoscopy, and a diagnosis of erosive esophagitis is made. The patient does not have health insurance and asks the primary care NP about using OTC antacids such as Tums. The NP should tell the patient that Tums:
a. neutralize stomach acid as well as proton pump inhibitors (PPIs)
b. do not help reduce symptoms of erosive esophagitis.
c. can help to heal erosions in esophageal tissue.
d. help reduce symptoms in conjunction with PPIs.
d. help reduce symptoms in conjunction with PPIs. Antacids reduce symptoms but do not have a significant effect on healing of erosions or esophagitis. If the patient has severe symptoms, has found treatment for milder symptoms to be ineffective, or has experienced erosion that is documented by endoscopy, he or she should be started on a PPI.
A patient who has GERD with erosive esophagitis has been taking a PPI for 4 weeks and reports a decrease in symptoms. The patient asks the primary care NP if the medication may be discontinued. The NP should tell the patient that:
a. the condition may eventually be cured, but therapy must continue for years.
b. antireflux surgery must be done before the PPI can be discontinued.
c. the dose may be decreased for long-term therapy.
d. once the symptoms have cleared completely, the medication may be discontinued.
c. the dose may be decreased for long-term therapy. Once PPIs have proven clinically effective for treatment of patients with esophagitis, therapy should be continued long-term and titrated down to the lowest effective dose based on symptom control. PPI therapy is considered safer than surgery and should be tried first before surgery is performed. GERD is a lifelong syndrome and is not curable
A patient who has GERD has been taking a PPI for 2 months and reports a slight decrease in symptoms. The next response of the primary care NP is to:
a. refer the patient to an endocrinologist for endoscopy and further management.
b. increase the dose of the PPI.
c. add a histamine-2-receptor agonist.
d. change to long-term, low-dose PPI therapy.
c. add a histamine-2-receptor agonist. If treatment with a PPI is inadequate by 2 months, histamine-2-receptor agonist therapy is indicated. Increasing the dose is not indicated. Long-term, lower dose therapy is used for recurrences of symptoms on a limited basis. When symptoms fail to resolve with pharmacologic treatments, patients should be referred to an endocrinologist.
A patient is taking a low-dose PPI for long-term management of GERD and reports taking sodium bicarbonate (Alka-Seltzer) to help with occasional heartburn. The primary care NP should tell the patient to:
a. take calcium carbonate (Tums) instead of sodium bicarbonate (Alka-Seltzer).
b. change to aluminum hydroxide (Amphojel).
c. use magnesium hydroxide (Milk of Magnesia) instead.
d. continue using sodium bicarbonate (Alka-Seltzer) as needed.
a. take calcium carbonate (Tums) instead of sodium bicarbonate (Alka-Seltzer). Sodium bicarbonate is not suitable for long-term use because of side effects. Calcium carbonate requires monitoring when used long-term but has the highest acid-neutralizing capacity. Antacids containing aluminum and magnesium can cause electrolyte imbalances.
A patient is given a diagnosis of peptic ulcer disease. A laboratory test confirms the presence of Helicobacter pylori. The primary care NP orders a proton pump inhibitor (PPI) before meals twice daily, clarithromycin, and amoxicillin. After 14 days of treatment, H. pylori is still present. The NP should order:
a. a PPI, amoxicillin, and metronidazole for 14 days.
b. continuation of the PPI for 4 to 8 weeks.
c. a PPI, bismuth subsalicylate, tetracycline, and metronidazole.
d. a PPI, clarithromycin, and amoxicillin for 14 more days.
a. a PPI, amoxicillin, and metronidazole for 14 days. A PPI, along with amoxicillin and metronidazole, is used as first-line treatment in macrolide-allergic patients and for re-treatment for 14 days if first-line treatment of choice failed because of occasional resistance to clarithromycin.
