pharmacology test 2 chapters 41,42,43,44,45,46,47

Question 1

1. A patient is brought to the emergency department with shortness of breath, a respiratory rate of 30 breaths per minute, intercostal retractions, and frothy, pink sputum. The nurse caring for this patient will expect to administer which drug?
   a. Furosemide [Lasix]
   b. Hydrochlorothiazide [HydroDIURIL]
   c. Mannitol [Osmitrol]
   d. Spironolactone [Aldactone]

Answer 1

ANS: A
Furosemide, a potent diuretic, is used when rapid or massive mobilization of fluids is needed. This patient shows severe signs of congestive heart failure with respiratory distress and pulmonary edema and needs immediate mobilization of fluid. Hydrochlorothiazide and spironolactone are not indicated for pulmonary edema, because their diuretic effects are less rapid. Mannitol is indicated for patients with increased intracranial pressure and must be discontinued immediately if signs of pulmonary congestion or heart failure occur.

Question 2

2. A patient who is taking digoxin is admitted to the hospital for treatment of congestive heart failure. The prescriber has ordered furosemide [Lasix]. The nurse notes an irregular heart rate of 86 beats per minute, a respiratory rate of 22 breaths per minute, and a blood pressure of 130/82 mm Hg. The nurse auscultates crackles in both lungs. Which laboratory value causes the nurse the most concern?
   a. Blood glucose level of 120 mg/dL
   b. Oxygen saturation of 90%
   c. Potassium level of 3.5 mEq/L
   d. Sodium level of 140 mEq/L

Answer 2

ANS: C
This patient has an irregular, rapid heartbeat that might be caused by a dysrhythmia. This patient’s serum potassium level is low, which can trigger fatal dysrhythmias, especially in patients taking digoxin. Furosemide contributes to loss of potassium through its effects on the distal nephron. Potassium-sparing diuretics often are used in conjunction with furosemide to prevent this complication. This patient’s serum glucose and sodium levels are normal and of no concern at this point, although they can be affected by furosemide. The oxygen saturation is somewhat low and needs to be monitored, although it may improve with diuresis.

Question 3

3. A patient has 2+ pitting edema of the lower extremities bilaterally. Auscultation of the lungs reveals crackles bilaterally, and the serum potassium level is 6 mEq/L. Which diuretic agent ordered by the prescriber should the nurse question?
   a. Bumetanide [Bumex]
   b. Furosemide [Lasix]
   c. Spironolactone [Aldactone]
   d. Hydrochlorothiazide [HydroDIURIL]

Answer 3

ANS: C
Spironolactone is a non–potassium-wasting diuretic; therefore, if the patient has a serum potassium level of 6 mEq/L, indicating hyperkalemia, an order for this drug should be questioned. Bumetanide, furosemide, and hydrochlorothiazide are potassium-wasting diuretics and would be appropriate to administer in a patient with hyperkalemia.

Question 4

4. A nurse preparing to administer morning medications notes that a patient with a history of hypertension has been prescribed spironolactone [Aldactone]. The nurse assesses the patient and notes dyspnea, bilateral crackles, and pitting edema in both feet. Which intervention is appropriate?
   a. Administer the medications as ordered.
   b. Ask the patient about the use of salt substitutes.
   c. Contact the provider to request an order for serum electrolytes.
   d. Request an order for furosemide [Lasix].

Answer 4

ANS: D
Spironolactone takes up to 48 hours for its effects to develop, so it should not be used when the patient needs immediate diuresis. This patient has shortness of breath, crackles, and edema and needs a short-acting diuretic, such as furosemide. Asking the patient about the use of salt substitutes is not indicated. The patient does not need assessment of serum electrolytes.

Question 5

5. A patient with hypertension is taking furosemide [Lasix] for congestive heart failure. The prescriber orders digoxin to help increase cardiac output. What other medication will the nurse expect to be ordered for this patient?
   a. Bumetanide [Bumex]
   b. Chlorothiazide [Diuril]
   c. Hydrochlorothiazide [HydroDIURIL]
   d. Spironolactone [Aldactone]

Answer 5

ANS: D
Spironolactone is used in conjunction with furosemide because of its potassium-sparing effects. Furosemide can contribute to hypokalemia, which can increase the risk of fatal dysrhythmias, especially with digoxin administration. The other diuretics listed are all potassium-wasting diuretics.

Question 6

6. A patient who was in a motor vehicle accident sustained a severe head injury and is brought into the emergency department. The provider orders intravenous mannitol [Osmitrol]. The nurse knows that this is given to:
   a. reduce intracranial pressure.
   b. reduce renal perfusion.
   c. reduce peripheral edema.
   d. restore extracellular fluid.

Answer 6

ANS: A
Mannitol is an osmotic diuretic that is used to reduce intracranial pressure by relieving cerebral edema. The presence of mannitol in blood vessels in the brain creates an osmotic force that draws edematous fluid from the brain into the blood. Mannitol can also be used to increase renal perfusion. It can cause peripheral edema and is not used to restore extracellular fluid.

Question 7

. A patient is taking gentamicin [Garamycin] and furosemide [Lasix]. The nurse should counsel this patient to report which symptom?

a. Frequent nocturia
b. Headaches
c. Ringing in the ears
d. Urinary retention

Answer 7

ANS: C
Patients taking furosemide should be advised that the risk of furosemide-induced hearing loss can be increased when other ototoxic drugs, such as gentamicin, are also taken. Patients should be told to report tinnitus, dizziness, or hearing loss. Nocturia may be an expected effect of furosemide. Headaches are not likely to occur with concomitant use of gentamicin and furosemide. Urinary retention is not an expected side effect.

Question 8

8. An older adult patient with congestive heart failure develops crackles in both lungs and pitting edema of all extremities. The physician orders hydrochlorothiazide [HydroDIURIL]. Before administering this medication, the nurse reviews the patient’s chart. Which laboratory value causes the nurse the most concern?
   a. Elevated creatinine clearance
   b. Elevated serum potassium level
   c. Normal blood glucose level
   d. Low levels of low-density lipoprotein (LDL) cholesterol

Answer 8

ANS: A
Hydrochlorothiazide should not be given to patients with severe renal impairment; therefore, an elevated creatinine clearance would cause the most concern. Thiazide diuretics are potassium-wasting drugs and thus may actually improve the patient’s potassium level. Thiazides may elevate the serum glucose level in diabetic patients. Thiazides increase LDL cholesterol; however, this patient’s levels are low, so this is not a risk.

Question 9

9. A patient with chronic congestive heart failure has repeated hospitalizations in spite of ongoing treatment with hydrochlorothiazide [HydroDIURIL] and digoxin. The prescriber has ordered spironolactone [Aldactone] to be added to this patient’s drug regimen, and the nurse provides education about this medication. Which statement by the patient indicates understanding of the teaching?
   a. “I can expect improvement within a few hours after taking this drug.”
   b. “I need to stop taking potassium supplements.”
   c. “I should use salt substitutes to prevent toxic side effects.”
   d. “I should watch closely for dehydration.”

Answer 9

ANS: B
Spironolactone is a potassium-sparing diuretic used to counter the potassium-wasting effects of hydrochlorothiazides. Patients taking potassium supplements are at risk for hyperkalemia when taking this medication, so they should be advised to stop the supplements. Spironolactone takes up to 48 hours to have effects. Salt substitutes contain high levels of potassium and are contraindicated. Spironolactone is a weak diuretic, so the risk of dehydration is not increased.

Question 10

. Besides having diuretic effects for patients with congestive heart failure, thiazides are also used to treat what? (Select all that apply.)

a. Diabetes insipidus
b. Hepatic failure
c. Increased intracranial pressure
d. Intraocular pressure
e. Postmenopausal osteoporosis

Answer 10

ANS: A, B, E
Thiazide diuretics have the paradoxical effect of reducing urine output in patients with diabetes insipidus. They can also be used to mobilize edema associated with liver disease. They promote tubular reabsorption of calcium, which may reduce the risk of osteoporosis in postmenopausal women. Mannitol is used to treat edema that causes increased intracranial pressure and intraocular pressure.

Question 11

. A patient who is a chronic alcoholic is admitted to the hospital. Admission laboratory work reveals a magnesium level of 1.2 mEq/L. The prescriber orders intravenous magnesium sulfate in a 10% solution at a rate of 10 mL/min. What will the nurse do?

a. Administer the IV dose as ordered and have calcium gluconate on hand.
b. Administer the IV dose and make preparations for mechanical ventilation.
c. Hold the IV dose until the infusion rate has been clarified with the provider.
d. Request an order for renal function tests before administering the IV dose.

Answer 11

ANS: C
This patient has hypomagnesemia and should be given magnesium sulfate intravenously. The percent of magnesium in solution is correct; however, magnesium should not be infused faster than 1.5 mL/min, so the nurse is correct to question the rate of infusion. Calcium gluconate should be available when magnesium is given, but the nurse needs to clarify the rate of infusion first. Mechanical ventilation is necessary with excessive magnesium. Renal function tests are not indicated.

Question 12

2. A patient who was injured at home is brought to the emergency department. The nurse caring for this patient notes a respiratory rate of 32 breaths per minute and a heart rate of 90 beats per minute. The injuries are minor, but the patient is inconsolable and hysterical. The nurse expects that initial management will include:
   a. administering a gas mixture of 5% carbon dioxide (CO2).
   b. providing 100% oxygen via nasal cannula.
   c. giving sodium bicarbonate IV.
   d. providing sedatives to calm the patient.

Answer 12

ANS: A
The patient is at risk for respiratory alkalosis as a result of hyperventilation, and giving the patient a gas mixture containing CO2 will help correct the alkalosis. Administering oxygen would worsen the problem. Sodium bicarbonate is given to correct metabolic acidosis. Sedatives may be necessary if initial measures fail.

Question 13

3. A child who ingested a handful of aspirin tablets from a medicine cabinet at home is brought to the emergency department. The nurse caring for the child notes a respiratory rate of 48 breaths per minute. The nurse understands that this child’s respiratory rate is the result of the body’s attempt to compensate for:
   a. metabolic acidosis.
   b. metabolic alkalosis.
   c. respiratory acidosis.
   d. respiratory alkalosis.

Answer 13

ANS: A
Metabolic acidosis can result from the ingestion of aspirin. The body responds by hyperventilating to reduce CO2, which represents volatile carbonic acid, and raise pH. This child has a rapid respiratory rate in response to metabolic acidosis. In patients with metabolic alkalosis, the body responds with hypoventilation in an effort to increase the CO2 level. Patients with respiratory acidosis usually have retention of CO2 secondary to hypoventilation, and compensation is the result of retention of bicarbonate by the kidneys, which is a slow process. Respiratory alkalosis is caused by hyperventilation; treatment involves having the patient rebreathe CO2 or administering sedatives.

Question 14

4. A patient with congestive heart failure is admitted to the hospital. During the admission assessment, the nurse learns that the patient is taking a thiazide diuretic. The nurse notes that the admission electrolyte levels include a sodium level of 142 mEq/L, a chloride level of 95 mEq/L, and a potassium level of 3 mEq/L. The prescriber has ordered digoxin to be given immediately. What will the nurse do initially?
   a. Give the digoxin and maintain close cardiac monitoring.
   b. Hold the digoxin and report the laboratory values to the provider.
   c. Hold the thiazide diuretic and give the digoxin.
   d. Request an order for an electrocardiogram (ECG).

Answer 14

ANS: B
Potassium depletion is common with thiazide diuretics, and hypokalemia is especially dangerous for patients receiving digoxin, because the drug can precipitate a fatal dysrhythmia and digoxin toxicity. The provider should be notified of the serum potassium level so that it can be corrected before the digoxin is administered. Giving the digoxin could produce a fatal adverse effect, so this is not an appropriate course of action. Holding the thiazide diuretic will not correct the potassium deficiency. An ECG is not the initial priority.

Question 15

5. A patient collapses after running a marathon on a hot day and is brought to the emergency department to be treated for dehydration. The nurse will expect to provide which therapy?
   a. Intravenous hypertonic fluids given slowly over several hours
   b. Intravenous hypotonic fluids administered in stages
   c. Intravenous isotonic fluids given as a rapid bolus
   d. Oral electrolyte replacement fluids with potassium

Answer 15

ANS: B
Because this patient is experiencing fluid volume loss as the result of excessive sweating, this is most likely hypertonic dehydration, in which loss of water exceeds loss of electrolytes. This should be treated with a hypotonic solution or with fluids that contain no solutes at all. Initial treatment may consist of having the patient drink water. When intravenous therapy is provided, volume replenishment should occur in stages. Hypertonic fluids are used to treat hypotonic contraction, usually caused by excessive sodium loss through the kidneys as the result of diuretic therapy. Isotonic fluids are used to treat isotonic contraction, which is generally caused by vomiting and diarrhea. An oral electrolyte solution would only increase the hypertonicity; if oral rehydration is used in this case, the patient should drink plain water.

Question 16

6. A nurse is caring for a child whose respirations are shallow and marked by a prolonged expiratory phase. The nurse auscultates wheezes and poor air movement bilaterally. The child’s respiratory rate is 26 breaths per minute, and the oxygen saturation is 89%. What does the nurse suspect?
   a. Metabolic acidosis
   b. Metabolic alkalosis
   c. Respiratory acidosis
   d. Respiratory alkalosis

Answer 16

ANS: C
Respiratory acidosis results from retention of CO2 secondary to hypoventilation caused either by depression of the medullary respiratory center in the central nervous system (CNS) or by a pathologic lung condition, such as asthma. This child has shallow respirations with evidence of airway obstruction and poor ventilation. Metabolic acidosis occurs in chronic renal failure, loss of bicarbonate with severe diarrhea, metabolic disorders, and ingestion of acids such as salicylates; hyperventilation is a compensatory mechanism. Metabolic alkalosis is usually caused by excessive loss of gastric acid or by ingestion of alkalinizing salts; hypoventilation is a compensatory mechanism. Respiratory alkalosis is produced by hyperventila

Question 17

7. A nurse is caring for a postoperative patient who has a nasogastric tube with continuous suction. The nurse notes that the patient has shallow respirations and suspects that this patient has developed:
   a. metabolic acidosis.
   b. metabolic alkalosis.
   c. respiratory acidosis.
   d. respiratory alkalosis.

Answer 17

ANS: B
Metabolic alkalosis occurs with excessive loss of acid, such as gastric acid, or an excessive increase in alkalinizing salts. The body compensates for metabolic alkalosis by hypoventilating in an attempt to retain CO2. Metabolic acidosis is usually caused by ingestion of acids or excessive loss of bicarbonate and is compensated by hyperventilation. Respiratory acidosis results from hypoventilation. Respiratory alkalosis is the result of hyperventilation.

Question 18

8. While performing an admission assessment on a patient, the nurse learns that the patient is taking furosemide [Lasix], digoxin, and spironolactone [Aldactone]. A diet history reveals the use of salt substitutes. The patient is confused and dyspneic and complains of hand and foot tingling. Which is an appropriate nursing action for this patient?
   a. Contact the provider to request orders for an electrocardiogram and serum electrolyte levels.
   b. Evaluate the patient’s urine output and request an order for intravenous potassium.
   c. Hold the next dose of furosemide and request an order for intravenous magnesium sulfate.
   d. Request an order for intravenous insulin to help this patient regulate extracellular potassium.

Answer 18

ANS: A
This patient is taking a potassium-sparing diuretic and is ingesting dietary potassium in salt substitutes. The patient shows signs of hyperkalemia: confusion, shortness of breath, and tingling of the hands and feet. The cardiac effects can be fatal, especially if a patient also is taking digoxin. The most appropriate first action would be to obtain an ECG and serum electrolyte levels to evaluate the extent of the patient’s hyperkalemia. The patient does not need increased potassium. Furosemide is a potassium-wasting diuretic and would be helpful. Magnesium sulfate is not indicated. Until the patient’s status has been assessed further, intravenous insulin is not indicated.

Question 19

9. A patient arrives in the emergency department complaining of muscle weakness and drowsiness. The nurse notes a heart rate of 80 beats per minute, a respiratory rate of 18 breaths per minute, and a blood pressure of 90/50 mm Hg. The electrocardiogram reveals an abnormal rhythm. The nurse will question the patient about which over-the-counter medication?
   a. Antacids
   b. Aspirin
   c. Laxatives
   d. Potassium supplements

Answer 19

ANS: A
Hypermagnesemia can occur when patients are taking magnesium-containing antacids. Symptoms include muscle weakness, sedation, hypotension, and ECG changes. Aspirin would cause metabolic acidosis. Laxatives can contribute to hypokalemia. Potassium supplements would cause hyperkalemia.

Question 20

10. A patient arrives in the emergency department after becoming dehydrated. Based on the patient’s history, the provider determines that isotonic dehydration has occurred. Which solution will the nurse expect to infuse to treat this patient?
    a. 0.45% sodium chloride in sterile water
    b. 0.9% sodium chloride in sterile water
    c. 3% sodium chloride in sterile water
    d. 5% dextrose solution

Answer 20

ANS: B
Isotonic dehydration should be treated with an isotonic solution of 0.9% NaCl in sterile water. A 0.45% solution or 5% dextrose is used to treat hypertonic dehydration. A 3% NaCl solution is used to treat hypotonic dehydration.

Question 21

1. A patient is admitted to the hospital after several days of vomiting and diarrhea. After an initial bolus of isotonic (0.9%) sodium chloride solution, the prescriber orders dextrose 5% in normal saline (D5NS) with 20 mEq potassium chloride to infuse at a maintenance rate. What should the nurse review before implementing this order? (Select all that apply.)
   a. Electrocardiogram
   b. Arterial blood gas levels
   c. Serum electrolyte levels
   d. Serum glucose level
   e. Urine output

Answer 21

ANS: A, C, E
Patients receiving potassium should be monitored for cardiovascular toxicity; an ECG before and during administration can help monitor for this adverse effect. Serum electrolyte levels should be reviewed to make sure the patient is not already hyperkalemic. Because potassium is excreted via the kidneys, it is important to determine that renal function is intact. Intravenous potassium should never be given if the patient has not voided. Patients who are hyperkalemic can be treated with sodium bicarbonate to increase pH and insulin to promote uptake of potassium by cells, but it is not necessary to evaluate the blood gas or glucose levels before administering potassium.

Question 22

2. Which order for potassium (KCl) would the nurse question? (Select all that apply.)
   a. NS with 20 mEq KCl to start after patient voids
   b. NS with 60 mEq KCl for a patient with a serum potassium of 3.2 mEq/L
   c. K-Dur, 1 tablet daily for a patient in diabetic ketoacidosis
   d. K-Dur, 1 tablet with a full glass of water
   e. Potassium chloride, 10 mEq rapid IV push

Answer 22

ANS: B, C, E
Patients receiving potassium should not receive potassium in solution diluted at more than 40 mEq/L. Diabetic ketoacidosis causes decreased cellular uptake of potassium, and patients in whom acidosis is present should also receive sodium bicarbonate if they need potassium. IV potassium should not be infused faster than 10 mEq/hr. NS with 20 mEq KCl is an appropriate solution for a patient with intact renal function. Oral potassium should be given with a full glass of water to minimize gastrointestinal (GI) effects.

Question 23

1. A patient is taking a beta1-adrenergic drug to improve the stroke volume of the heart. The nurse caring for this patient knows that this drug acts by increasing:
   a. cardiac afterload.
   b. cardiac preload.
   c. myocardial contractility.
   d. venous return.

Answer 23

ANS: C
Beta1-adrenergic agents help increase the heart’s stroke volume by increasing myocardial contractility. Cardiac afterload is determined primarily by the degree of peripheral resistance caused by constriction of arterioles; increasing afterload would decrease stroke volume. Beta1-adrenergic agents do not affect afterload. Cardiac preload is the amount of stretch applied to the cardiac muscle before contraction and is determined by the amount of venous return. Beta1-adrenergic agents do not affect cardiac preload. Venous return is determined by the systemic filling pressure and auxiliary muscle pumps and is not affected by beta1-adrenergic agents.

Question 24

2. A nurse is caring for a patient who is receiving a drug that causes constriction of arterioles. The nurse expects to observe which effect from this drug?
   a. Decreased stroke volume
   b. Increased stroke volume
   c. Decreased myocardial contractility
   d. Increased myocardial contractility

Answer 24

ANS: A
Constriction of arterioles increases the load against which the heart must pump to eject blood. Increased constriction of arterioles would decrease, not increase, the stroke volume of the heart. Myocardial contractility is determined by the sympathetic nervous system, acting through beta1-adrenergic receptors in the myocardium.

Question 25

3. A patient with a history of hypertension is admitted for a procedure. If the patient’s arterial pressure decreases, which clinical manifestation would the nurse expect to see?
   a. Decreased heart rate
   b. Increased heart rate
   c. Decreased blood pressure
   d. Syncope

Answer 25

ANS: B
When arterial pressure decreases, the vasoconstrictor center causes constriction of nearly all arterioles, leading to an increase in peripheral resistance, constriction of veins, increasing venous return, and subsequent acceleration of the heart rate. A decrease in arterial pressure would not cause a decrease in the heart rate or blood pressure, nor would it cause syncope

Question 26

4. A nurse is teaching a nursing student how blood can return to the heart when pressure in the venous capillary beds is very low. Which statement by the student indicates a need for further teaching?
   a. “Constriction of small muscles in the venous wall increases venous pressure.”
   b. “Negative pressure in the left atrium draws blood toward the heart.”
   c. “Skeletal muscles relax to allow the free flow of blood.”
   d. “Venous valves help prevent the backflow of blood.”

Answer 26

ANS: C
Skeletal muscle contraction, along with one-way venous valves, helps create an “auxiliary” venous pump that helps drive blood toward the heart. Constriction of small muscles in venous walls helps increase venous pressure. Negative pressure in the left atrium sucks blood toward the heart. Valves, which are one-way, work with the contraction of skeletal muscles to create a venous pump.

Question 27

5. A nurse is assessing a patient who has heart failure. The patient complains of shortness of breath, and the nurse auscultates crackles in both lungs. The nurse understands that these symptoms are the result of:
   a. decreased force of ventricular contraction.
   b. increased force of ventricular contraction.
   c. decreased ventricular filling.
   d. increased ventricular filling.

Answer 27

ANS: A
In the failing heart Starling’s law breaks down, and the force of contraction no longer increases in proportion to the amount of ventricular filling. The result is the backup of blood into the lungs and the symptoms of shortness of breath and crackles caused by fluid. Increased ventricular contraction would not result in a backup of blood into the lungs. Changes in ventricular filling are not the direct cause of this symptom.

Question 28

6. A patient with hypertension is admitted to the hospital. On admission the patient’s heart rate is 72 beats per minute, and the blood pressure is 140/95 mm Hg. After administering an antihypertensive medication, the nurse notes a heart rate of 85 beats per minute and a blood pressure of 130/80 mm Hg. What does the nurse expect to occur?
   a. A decrease in the heart rate back to baseline in 1 to 2 days
   b. An increase in the blood pressure within a few days
   c. An increase in potassium retention in 1 to 2 days
   d. A decrease in fluid retention within a week

Answer 28

ANS: A
When blood pressure drops, the baroreceptors in the aortic arch and carotid sinus sense this and relay information to the vasoconstrictor center of the medulla; this causes constriction of arterioles and veins and increased sympathetic impulses to the heart, resulting in an increased heart rate. After 1 to 2 days, this system resets to the new pressure, and the heart rate returns to normal. The blood pressure will not increase when this system resets. Increased potassium retention will not occur. Over time, the body will retain more fluid to increase the blood pressure.

Question 29

7. A patient is taking a drug that interferes with venous constriction. The nurse will tell the patient to:
   a. ask for assistance when getting out of bed.
   b. expect bradycardia for a few days.
   c. notify the provider if headache occurs.
   d. report shortness of breath.

Answer 29

ANS: A
A drop in venous pressure reduces venous return to the heart, and as blood pools in the extremities, orthostatic hypotension can occur. Patients taking drugs that reduce venous constriction should be cautioned to ask for assistance when getting out of bed. Bradycardia, headache, and shortness of breath are not expected effects.

Question 30

1. A patient with hypertension is prescribed an angiotensin-converting enzyme (ACE) inhibitor. The nurse reviewing this patient’s chart before administering the medication will be most concerned about which other disease process?
   a. Bronchial asthma
   b. Coronary artery disease
   c. Diabetes mellitus
   d. Renal artery stenosis

Answer 30

ANS: D
ACE inhibitors can cause severe renal insufficiency in patients with bilateral renal artery stenosis or stenosis in the artery to a single remaining kidney. Bronchial asthma, coronary artery disease, and diabetes mellitus are not comorbidities that are contraindications to treatment with an ACE inhibitor.

Question 31

2. A nurse administers an ACE inhibitor to a patient who is taking the drug for the first time. What will the nurse do?
   a. Instruct the patient not to get up without assistance.
   b. Make sure the patient takes a potassium supplement.
   c. Report the presence of a dry cough to the prescriber.
   d. Request an order for a diuretic to counter the side effects of the ACE inhibitor.

Answer 31

ANS: A
Severe hypotension can result with the first dose of an ACE inhibitor. The patient should be discouraged from getting up without assistance. Potassium supplements are contraindicated. A dry cough is an expected side effect that eventually may cause a patient to discontinue the drug; however, it is not a contraindication to treatment. Diuretics can exacerbate hypotension and should be discontinued temporarily when a patient starts an ACE inhibitor.

Question 32

3. A patient who has been taking an antihypertensive medication for several years is recovering from a myocardial infarction. The prescriber changes the patient’s medication to an ACE inhibitor. The patient asks the nurse why a new drug is necessary. What is the nurse’s response?
   a. “ACE inhibitors can prevent or reverse pathologic changes in the heart’s structure.”
   b. “ACE inhibitors help lower LDL cholesterol and raise HDL cholesterol.”
   c. “ACE inhibitors increase venous return to the heart, improving cardiac output.”
   d. “ACE inhibitors regulate electrolytes that affect the cardiac rhythm.”

Answer 32

ANS: A
ACE inhibitors have many advantages over other antihypertensive medications, the most important of which is their ability to prevent or reverse pathologic changes in the heart and reduce the risk of cardiac mortality caused by hypertension. They are useful in patients with high low-density lipoprotein (LDL) or low high-density lipoprotein (HDL) cholesterol, but they do not directly affect this comorbidity. They reduce venous return to the heart, thereby reducing right heart size. They do not alter serum electrolyte levels.

Question 33

4. A prescriber orders ramipril [Altace] for an obese patient with type 2 diabetes mellitus who has developed hypertension. The nurse provides teaching before dismissing the patient home. Which statement by the patient indicates understanding of the teaching?
   a. “I am less likely to develop diabetic nephropathy when taking this medication.”
   b. “I should check my blood sugar more often, because hyperglycemia is a side effect of this drug.”
   c. “Taking this medication helps reduce my risk of stroke and heart attack.”
   d. “This medication will probably prevent the development of diabetic retinopathy.”

Answer 33

ANS: C
Ramipril [Altace] is approved for reducing the risk of stroke and myocardial infarction (MI) in patients at high risk for a major cardiovascular event because they have hypertension in conjunction with a history of stroke or MI or because they have diabetes. ACE inhibitors cannot be used for primary prevention of diabetic nephropathy, but they can delay the onset of overt nephropathy in patients who already have less advanced nephropathy. ACE inhibitors do not affect serum electrolytes or glucose. One ACE inhibitor, enalapril, can reduce the risk of diabetic retinopathy in some patients with type 1 diabetes mellitus.

Question 34

5. A patient begins taking an ACE inhibitor and complains of a dry cough. What does the nurse correctly tell the patient about this symptom?
   a. It indicates that a serious side effect has occurred.
   b. It is a common side effect that occurs in almost all patients taking the drug.
   c. It may be uncomfortable enough that the drug will need to be discontinued.
   d. It occurs frequently in patients taking the drug but will subside over time.

Answer 34

ANS: C
A cough occurs in about 10% of patients taking ACE inhibitors and is the most common reason for discontinuing therapy. It does not indicate a serious condition. It occurs in about 10% of all patients and is more common in women, older adults, and those of Asian ancestry. It does not subside until the medication is discontinued.

Question 35

6. A provider has ordered captopril [Capoten] for a patient who has hypertension. The patient reports a history of swelling of the tongue and lips after taking enalapril [Vasotec] in the past. Which action by the nurse is correct?
   a. Administer the captopril and monitor for adverse effects.
   b. Hold the dose and notify the provider.
   c. Request an order to administer fosinopril instead of captopril.
   d. Reassure the patient that this is not a serious side effect.

Answer 35

ANS: B
Angioedema is a potentially life-threatening reaction to ACE inhibitors. If a patient has exhibited this reaction with any ACE inhibitor, he or she should not receive ACE inhibitors again. The nurse should hold the medication and notify the provider. Fosinopril is an ACE inhibitor and should not be given.

Question 36

7. A nurse is reviewing a patient’s medications before administration. Which drug-to-drug interactions will most concern the nurse in a patient with a history of heart failure and a potassium level of 5.5 mEq/L?
   a. Furosemide [Lasix] and enalapril [Vasotec]
   b. Amlodipine [Norvasc] and spironolactone [Aldactone]
   c. Captopril [Capoten] and spironolactone [Aldactone]
   d. Metoprolol [Lopressor] and furosemide [Lasix]

Answer 36

ANS: C
ACE inhibitors increase the risk of hyperkalemia, and combining this drug with a potassium-sparing diuretic creates a significant risk of hyperkalemia. Furosemide and enalapril, an ACE inhibitor, would not be contraindicated in this patient. Amlodipine and spironolactone would not cause hyperkalemia. The combination of metoprolol, a beta blocker, and furosemide would not be contraindicated in this patient.

Question 37

8. A patient who is taking furosemide [Lasix] and digoxin will begin taking captopril [Capoten]. The nurse is providing information about the drug. Which statement by the patient indicates a need for further teaching?
   a. “I can use acetaminophen for analgesia if needed.”
   b. “I should stop taking the Lasix about a week before starting the Capoten.”
   c. “I should take this medication on a full stomach.”
   d. “I will need to have blood tests done every 2 weeks for a few months.”

Answer 37

ANS: C
Most oral formulations of ACE inhibitors may be given without regard for meals; captopril and moexipril, however, should be given 1 hour before meals. Nonsteroidal anti-inflammatory medications should be avoided; acetaminophen is not contraindicated. Patients taking diuretics should stop taking them 1 week before starting an ACE inhibitor to minimize the risk of hypotension. A WBC with differential should be evaluated at baseline and, after treatment starts, every 2 weeks for several months to monitor for neutropenia.

Question 38

9. A patient who stops taking an ACE inhibitor because of its side effects will begin taking an angiotensin II receptor blocker (ARB) medication. Which side effect of ACE inhibitors will not occur with an ARB medication?
   a. Angioedema
   b. Cough
   c. Hyperkalemia
   d. Renal failure

Answer 38

ANS: C
ARBs do not produce clinically significant hyperkalemia. Angioedema may occur with ARBs, but the incidence is lower than with ACE inhibitors. They do not promote the accumulation of bradykinin in the lungs and produce a lower incidence of cough. An increased risk of cancer may be a concern with ARBs but is not a concern with ACE inhibitors. As with ACE inhibitors, renal failure can occur in patients with bilateral renal artery stenosis or stenosis in the artery to a single remaining kidney.

Question 39

10. A female patient who is not taking any other medications is prescribed aliskiren [Tekturna], a direct renin inhibitor (DRI). The nurse reviews medication information with the patient. Which statement by the patient indicates understanding of the teaching?
    a. “If I get pregnant, I should stop taking this drug by the second trimester.”
    b. “If I take this drug with a high-fat meal, it will be more effective.”
    c. “I should restrict my potassium intake while taking this drug.”
    d. “I should take this medication 1 hour before sitting down to a meal.”

Answer 39

ANS: D
DRIs should be taken on an empty stomach to improve their bioavailability. Patients should not take this drug when pregnant and should stop immediately upon finding out they are pregnant. Dosing with a high-fat meal reduces the drug’s bioavailability. DRIs rarely cause hyperkalemia when taken alone.

Question 40

11. A female patient who begins taking spironolactone [Aldactone] as an adjunct to furosemide [Lasix] complains that her voice is deepening. What will the nurse do?
    a. Contact the provider to obtain an order for a complete blood count (CBC) and liver function tests.
    b. Explain that this drug binds with receptors for steroid hormones, causing this effect.
    c. Report this side effect to the provider and request another medication for this patient.
    d. Teach the patient to report any associated cough, which may indicate a more severe side effect.

Answer 40

ANS: B
Spironolactone binds with receptors for aldosterone and with other steroid hormones, causing side effects such as gynecomastia, menstrual irregularities, impotence, hirsutism, and deepening of the voice. There is no indication for a CBC or for liver function tests in this patient with this side effect. Deepening of the voice is not an indication for withdrawal of the drug. This side effect is not associated with cough.

Question 41

12. A female patient taking an ACE inhibitor learns that she is pregnant. What will the nurse tell this patient?
    a. The fetus most likely will have serious congenital defects.
    b. The fetus must be monitored closely while the patient is taking this drug.
    c. The patient’s prescriber probably will change her medication to an ARB.
    d. The patient should stop taking the medication and contact her provider immediately.

Answer 41

ANS: D
ACE inhibitors are known to cause serious fetal injury during the second and third trimesters of pregnancy. Whether injury occurs earlier in pregnancy is unknown, and the incidence probably is low. However, women should be counseled to stop taking the drug if they become pregnant, and they should not take it if they are contemplating becoming pregnant. Women who take ACE inhibitors in the first trimester should be counseled that the risk to the fetus is probably low. Women should stop taking the drug when pregnant. ARBs carry the same risk as ACE inhibitors.

Question 42

1. A nurse is caring for a patient who is receiving verapamil [Calan] for hypertension and digoxin [Lanoxin] for heart failure. The nurse will observe this patient for:
   a. AV blockade.
   b. gingival hyperplasia.
   c. migraine headaches.
   d. reflex tachycardia.

Answer 42

ANS: A
Verapamil and digoxin both suppress impulse conduction through the AV node; when the two drugs are used concurrently, the risk of AV blockade is increased. Gingival hyperplasia can occur in rare cases with verapamil, but it is not an acute symptom. Verapamil can be used to prevent migraine, and its use for this purpose is under investigation. Verapamil and digoxin both suppress the heart rate. Nifedipine causes reflex tachycardia.

Question 43

2. A patient begins taking nifedipine [Procardia], along with metoprolol, to treat hypertension. The nurse understands that metoprolol is used to:
   a. reduce flushing.
   b. minimize gingival hyperplasia.
   c. prevent constipation.
   d. prevent reflex tachycardia.

Answer 43

ANS: D
Beta blockers are combined with nifedipine to prevent reflex tachycardia. Beta blockers do not reduce flushing, minimize gingival hyperplasia, or prevent constipation. Beta blockers can reduce the adverse cardiac effects of nifedipine.

Question 44

3. A nurse is teaching a patient who will begin taking verapamil [Calan] for hypertension about the drug’s side effects. Which statement by the patient indicates understanding of the teaching?
   a. “I may become constipated, so I should increase fluids and fiber.”
   b. “I may experience a rapid heart rate as a result of taking this drug.”
   c. “I may have swelling of my hands and feet, but this will subside.”
   d. “I may need to increase my digoxin dose while taking this drug.”

Answer 44

ANS: A
Constipation is common with verapamil and can be minimized by increasing dietary fiber and fluids. Verapamil lowers the heart rate. Peripheral edema may occur secondary to vasodilation, and patients should notify their prescriber if this occurs, because the prescriber may use diuretics to treat the condition. Verapamil and digoxin have similar cardiac effects; also, verapamil may increase plasma levels of digoxin by as much as 60%, so digoxin doses may need to be reduced.

Question 45

. A nurse is preparing to assist a nursing student to administer intravenous verapamil to a patient who also receives a beta blocker. The nurse asks the nursing student to discuss the plan of care for this patient. Which statement by the student indicates a need for further teaching?

a. “I will check to see when the last dose of the beta blocker was given.”
b. “I will monitor vital signs closely to assess for hypotension.”
c. “I will monitor the heart rate frequently to assess for reflex tachycardia.”
d. “I will prepare to administer intravenous norepinephrine if necessary.”

Answer 45

ANS: C
Reflex tachycardia is not an expected effect; the greater risks are cardiosuppression and bradycardia. Because beta blockers and verapamil have the same effects on the heart, there is a risk of excessive cardiosuppression. To minimize this risk, the two drugs should be given several hours apart. Hypotension may occur and should be treated with IV norepinephrine.

Question 46

5. A patient who took an overdose of verapamil has been treated with gastric lavage and a cathartic. The emergency department nurse assesses the patient and notes a heart rate of 50 beats per minute and a blood pressure of 90/50 mm Hg. The nurse will anticipate:
   a. administering intravenous norepinephrine (NE) and atropine and glucagon.
   b. assisting with direct-current (DC) cardioversion.
   c. placing the patient in an upright position.
   d. preparing to administer a beta blocker.

Answer 46

ANS: A
Verapamil toxicity can cause bradycardia and hypotension. Atropine and glucagon should be given to treat bradycardia and NE for hypotension. DC cardioversion is indicated for ventricular tachydysrhythmias, which this patient does not have. Patients with hypotension should be placed in Trendelenburg’s position. Beta blockers will only exacerbate these effects.

Question 47

6. A patient who has been taking verapamil [Calan] for hypertension complains of constipation. The patient will begin taking amlodipine [Norvasc] to avoid this side effect. The nurse provides teaching about the difference between the two drugs. Which statement by the patient indicates that further teaching is needed?
   a. “I can expect dizziness and facial flushing with nifedipine.”
   b. “I should notify the provider if I have swelling of my hands and feet.”
   c. “I will need to take a beta blocker to prevent reflex tachycardia.”
   d. “I will need to take this drug once a day.”

Answer 47

ANS: C
Amlodipine produces selective blockade of calcium channels in blood vessels with minimal effects on the heart. Reflex tachycardia is not common, so a beta blocker is not indicated to prevent this effect. Dizziness and facial flushing may occur. Peripheral edema may occur and should be reported to the provider. Amlodipine is given once daily.

Question 48

1. Which are therapeutic uses for verapamil? (Select all that apply.)
   a. Angina of effort
   b. Cardiac dysrhythmias
   c. Essential hypertension
   d. Sick sinus syndrome
   e. Suppression of preterm labor

Answer 48

ANS: A, B, C
Verapamil is used to treat both vasospastic angina and angina of effort. It slows the ventricular rate in patients with atrial flutter, atrial fibrillation, and paroxysmal supraventricular tachycardia. It is a first-line drug for the treatment of essential hypertension. It is contraindicated in patients with sick sinus syndrome. Nifedipine has investigational uses in suppressing preterm labor.

Question 49

1. A nurse is administering a vasodilator that dilates resistance vessels. The nurse understands that this drug will have which effect on the patient?
   a. Decreased cardiac preload
   b. Decreased cardiac output
   c. Increased tissue perfusion
   d. Increased ventricular contraction

Answer 49

ANS: C
Vasodilators that dilate resistance vessels, or arterioles, cause a decrease in afterload, which allows cardiac output and tissue perfusion to increase. A decrease in preload would be the result of dilation of capacitance vessels, or veins. Dilation of arterioles increases cardiac output. Ventricular contraction results when preload is increased.

Question 50

2. A patient is taking a vasodilator that relaxes smooth muscles in veins. To help minimize drug side effects, the nurse caring for this patient will:
   a. caution the patient not to get up abruptly.
   b. encourage the patient to increase fluid intake.
   c. tell the patient to report shortness of breath.
   d. warn the patient about the possibility of bradycardia.

Answer 50

ANS: A
Postural hypotension occurs when moving from a supine or seated position to an upright position. It is caused by relaxation of smooth muscle in veins, which allows blood to pool in veins and decreases venous return of blood to the heart. Patients taking such drugs should avoid abrupt transitions to prevent falls. Prolonged use of vasodilators can lead to expansion of blood volume and fluid overload, so increasing fluid intake is not appropriate. Shortness of breath is a symptom associated with heart failure. Tachycardia can occur when the blood pressure drops as a result of the baroreceptor reflex.

Question 51

3. A nurse is caring for a patient who will begin taking hydralazine to treat hypertension. Which statement by the patient indicates understanding of the nurse’s teaching about this drug?
   a. “I will need to ask for assistance when getting up out of a chair.”
   b. “I will also take a beta blocker medication with this drug to prevent rapid heart rate.”
   c. “I may develop joint pain, but this side effect will decrease over time.”
   d. “This drug may cause excessive hair growth on my face, arms, and back.”

Answer 51

ANS: B
Hydralazine can cause severe reflex tachycardia; a beta blocker is usually given to counter this effect. Postural hypotension is minimal with hydralazine. Patients should be taught to report joint pain, which indicates an SLE syndrome and requires discontinuation of the drug. Minoxidil can cause excessive hair growth, not hydralazine.

Question 52

4. The nurse is caring for a patient who is taking a vasodilator that dilates capacitance vessels. The nurse will expect which effect in this patient?
   a. Decrease in cardiac work
   b. Increase in cardiac output
   c. Increase in tissue perfusion
   d. Increase in venous return

Answer 52

ANS: A
Vasodilators that dilate capacitance vessels, or veins, lead to a decrease in venous return to the heart, which reduces preload and the force of ventricular contraction. The resultant effect is a decrease in cardiac work. With a decrease in ventricular contraction, cardiac output is reduced, as is tissue perfusion. Dilation of veins causes a decrease in venous return.

Question 53

5. A nurse is reviewing the phenomenon of reflex tachycardia with a group of nursing students. Which statement by a student indicates understanding of this phenomenon?
   a. “Baroreceptors in the aortic arch stimulate the heart to beat faster.”
   b. “Reflex tachycardia can negate the desired effects of vasodilators.”
   c. “Reflex tachycardia is more likely to occur when beta blockers are given.”
   d. “Venous dilation must occur for reflex tachycardia to occur.”

Answer 53

ANS: B
Reflex tachycardia, which is a compensatory mechanism in response to decreased blood pressure, can negate the desired effect of a vasodilator by eventually increasing blood pressure. Baroreceptors relay information to the vasomotor center of the medulla; the medulla sends impulses to the heart. Beta blockers are given to counter reflex tachycardia. Reflex tachycardia can be produced by dilation of both arterioles and veins.

Question 54

6. A female patient with essential hypertension is being treated with hydralazine 25 mg twice daily. The nurse assesses the patient and notes a heart rate of 96 beats per minute and a blood pressure of 110/72 mm Hg. The nurse will request an order to:
   a. administer a beta blocker.
   b. administer a drug that dilates veins.
   c. reduce the dose of hydralazine.
   d. give the patient a diuretic.

Answer 54

ANS: A
This patient is showing signs of reflex tachycardia, so a beta blocker is indicated to slow the heart rate. Patients with heart failure who take hydralazine often require the addition of isosorbide dinitrate, which also dilates veins. There is no indication for reducing the dose of hydralazine. A diuretic can be given with hydralazine if sodium and water retention is present

Question 55

7. A nurse is obtaining a medication history on a newly admitted patient, who reports taking minoxidil for hypertension. Admission vital signs reveal a heart rate of 78 beats per minute and a blood pressure of 120/80 mm Hg. What is an important part of the initial assessment for this patient?
   a. Evaluating ankle edema
   b. Monitoring for nausea and vomiting
   c. Noting the presence of hypertrichosis
   d. Obtaining a blood glucose

Answer 55

ANS: A
Fluid retention is a common and serious adverse effect of minoxidil, because it can lead to cardiac decompensation. If present, a diuretic is indicated. Nausea and vomiting may occur with this drug but is not a serious side effect. Hypertrichosis occurs in about 80% of patients taking the drug, but its effects are cosmetic and not life threatening. It may be important to monitor the blood glucose level in some patients, because the drug can alter glucose tolerance, but this effect is not as serious as fluid retention.

Question 56

8. A patient is admitted with severe hypertensive crisis. The nurse will anticipate administering which medication?
   a. Captopril PO
   b. Hydralazine [Apresoline] 25 mg PO
   c. Minoxidil 20 mg PO
   d. Sodium nitroprusside [Nitropress] IV

Answer 56

ANS: D
Sodium nitroprusside is the drug of choice for hypertensive emergencies and is given intravenously. ACE inhibitors, such as captopril, are not used. Hydralazine may be used but should be given IV. Minoxidil is effective, but its severe side effects make it a second-line drug.

Question 57

9. A nursing student asks a nurse why a patient in hypertensive crisis is receiving both intravenous sodium nitroprusside [Nitropress] and oral hydralazine. The nurse will explain that this is done to prevent:
   a. cyanide poisoning.
   b. fluid retention.
   c. rebound hypertension.
   d. reflex tachycardia.

Answer 57

ANS: C
Sodium nitroprusside acts rapidly and is given only intravenously. Rebound hypertension occurs immediately when the IV is stopped, so an oral antihypertensive should be given simultaneously. Cyanide poisoning can occur with sodium nitroprusside, but giving hydralazine does not counter this adverse effect. Hydralazine does not prevent fluid retention or reflex tachycardia.

Question 58

1. Which medications are most likely to cause postural hypotension? (Select all that apply.)
   a. Minoxidil
   b. Diltiazem [Cardizem]
   c. Prazosin [Minipress]
   d. Captopril [Capoten]
   e. Losartan [Cozaar]

Answer 58

ANS: C, D, E
Postural, or orthostatic, hypotension is defined as a fall in blood pressure related to a change in position. Minoxidil and diltiazem dilate arterioles; therefore, they are not likely to cause postural hypotension. Prazosin, captopril, and losartan all reportedly can cause orthostatic hypotension.

Question 59

2. Which patients may receive hydralazine to treat hypertension? (Select all that apply.)
   a. A 1-month-old infant
   b. A 5-year-old child
   c. A pregnant woman
   d. A mother breast-feeding a newborn
   e. An older adult

Answer 59

ANS: A, B, E
Hydralazine may be used in infants as young as one month of age, in children, and in older adults. Hydralazine is labeled pregnancy category C and data is lacking regarding transmission of hydralazine in breast-feeding women, so benefits should outweigh risks.

Question 60

1. A patient has had blood pressures of 150/95 mm Hg and 148/90 mm Hg on two separate office visits. The patient reports a blood pressure of 145/92 mm Hg taken in an ambulatory setting. The patient’s diagnostic tests are all normal. The nurse will expect this patient’s provider to order:
   a. a beta blocker.
   b. a loop diuretic and spironolactone.
   c. a thiazide diuretic.
   d. counseling on lifestyle changes.

Answer 60

ANS: C
This patient has primary, or essential, hypertension as evidenced by systolic pressure greater than 140 and diastolic pressure greater than 90, along with normal tests ruling out another primary cause. Thiazide diuretics are first-line drugs for hypertension. Beta blockers are effective but are most often used to counter reflex tachycardia associated with reduced blood pressure caused by therapeutic agents. Loop diuretics cause greater diuresis than is usually needed and so are not first-line drugs. This patient should be counseled on lifestyle changes as an adjunct to drug therapy but should also begin drug therapy because hypertension already exists.

Question 61

2. A patient with diabetes develops hypertension. The nurse will anticipate administering which type of medication to treat hypertension in this patient?
   a. ACE inhibitors
   b. Beta blockers
   c. Direct-acting vasodilators
   d. Thiazide diuretics

Answer 61

ANS: A
ACE inhibitors slow the progression of kidney injury in diabetic patients with renal damage. Beta blockers can mask signs of hypoglycemia and must be used with caution in diabetics. Direct-acting vasodilators are third-line drugs for chronic hypertension. Thiazide diuretics promote hyperglycemia.

Question 62

3. A patient has three separate blood pressure (BP) readings of 120/100 mm Hg, 138/92 mm Hg, and 126/96 mm Hg. Which category describes this patient’s BP?
   a. Hypertension
   b. Isolated systolic hypertension
   c. Normal
   d. Prehypertension

Answer 62

ANS: A
Hypertension is defined as systolic BP over 140 mm Hg or diastolic BP over 90 mm Hg. When systolic and diastolic BP fall into different categories, classification is based on the higher category. This patient has a hypertensive diastolic BP. Isolated systolic hypertension occurs if the systolic BP is greater than 140 mm Hg with a diastolic BP less than 90 mm Hg. Because this patient has an elevated diastolic BP, it is not considered normal. Prehypertension occurs with a systolic BP of 120 to 139 mm Hg or a diastolic BP of 80 to 89 mm Hg.

Question 63

4. A nurse checks a patient’s vital signs in the hospital and notes a blood pressure of 146/98 mm Hg. What will the nurse do?
   a. Instruct the patient to consume a low-sodium diet.
   b. Prepare the patient for an electrocardiogram and blood tests.
   c. Recheck the patient’s blood pressure in the other arm.
   d. Request an order for a thiazide diuretic.

Answer 63

ANS: C
Diagnosis of hypertension should be based on several blood pressure readings, not just one. High readings should be confirmed in the contralateral arm. Low-sodium diets are indicated for patients with confirmed hypertension. An electrocardiogram and blood tests are indicated for patients with confirmed hypertension to rule out primary causes. Thiazide diuretics are first-line drugs for confirmed hypertension.

Question 64

5. A patient who does not consume alcohol or nicotine products reports a strong family history of hypertension and cardiovascular disease. The patient has a blood pressure of 126/82 and a normal weight and body mass index for height and age. The nurse will expect to teach this patient about:
   a. ACE inhibitors and calcium channel blocker medications.
   b. the DASH diet, sodium restriction, and exercise.
   c. increased calcium and potassium supplements.
   d. thiazide diuretics and lifestyle changes.

Answer 64

ANS: B
This patient has prehypertension without other risk factors. Lifestyle changes are indicated at this point. If blood pressure rises to hypertension levels, other measures, including drug therapy, will be initiated. Calcium and potassium supplements are not indicated.

Question 65

6. A patient with hypertension with a blood pressure of 168/110 mm Hg begins taking hydrochlorothiazide and verapamil. The patient returns to the clinic after 2 weeks of drug therapy, and the nurse notes a blood pressure of 140/85 mm Hg and a heart rate of 98 beats per minute. What will the nurse do?
   a. Notify the provider and ask about adding a beta blocker medication.
   b. Reassure the patient that the medications are working.
   c. Remind the patient to move slowly from sitting to standing.
   d. Request an order for an electrocardiogram.

Answer 65

ANS: A
Beta blockers are often added to drug regimens to treat reflex tachycardia, which is a common side effect of lowering blood pressure, caused by the baroreceptor reflex. The patient’s blood pressure is responding to the medications, but the tachycardia warrants treatment. Reminding the patient to move slowly from sitting to standing is appropriate with any blood pressure medication, but this patient has reflex tachycardia, which must be treated. An electrocardiogram is not indicated.

Question 66

7. A patient has been taking chlorthalidone to treat hypertension. The patient’s prescriber has just ordered the addition of spironolactone to the patient’s drug regimen. Which statement by the patient indicates a need for further teaching?
   a. “I should continue following the DASH diet when adding this drug.”
   b. “I should not take an ACE inhibitor when adding this drug.”
   c. “I will need to take potassium supplements when adding this drug.”
   d. “I will not experience a significant increase in diuresis when adding this drug.”

Answer 66

ANS: C
Spironolactone is given in addition to thiazide diuretics to balance potassium loss caused by the thiazide diuretic. Patients should be advised against taking potassium supplements with spironolactone, because hyperkalemia can result. The DASH diet may be continued. ACE inhibitors are contraindicated because they promote hyperkalemia. Spironolactone does not significantly increase diuresis.

Question 67

8. A nurse is discussing how beta blockers work to decrease blood pressure with a nursing student. Which statement by the student indicates a need for further teaching?
   a. “Beta blockers block the actions of angiotensin II.”
   b. “Beta blockers decrease heart rate and contractility.”
   c. “Beta blockers decrease peripheral vascular resistance.”
   d. “Beta blockers decrease the release of renin.”

Answer 67

ANS: A
Beta blockers reduce the release of renin by blockade of beta1 receptors on juxtaglomerular cells in the kidney, which reduces angiotensin II-mediated vasoconstriction, but do not block the actions of angiotensin II directly. Beta blockers decrease heart rate and cardiac contractility, decrease peripheral vascular resistance, and decrease the release of renin.

Question 68

9. A patient with hypertension will begin taking an alpha1 blocker. What will the nurse teach this patient?
   a. A persistent cough is a known side effect of this drug.
   b. Eat foods rich in potassium while taking this drug.
   c. Move slowly from sitting to standing when taking this drug.
   d. Report shortness of breath while taking this drug.

Answer 68

ANS: C
The most disturbing side effect of alpha blockers is orthostatic hypotension. Patients taking these drugs should be cautioned to stand up slowly to avoid lightheadedness or falls. A persistent cough is a common side effect of ACE inhibitors. It is not necessary to increase dietary potassium intake when taking this drug. Shortness of breath may occur in individuals with asthma who are taking beta blockers.

Question 69

10. A patient is taking clonidine for hypertension and reports having dry mouth and drowsiness. What will the nurse tell the patient?
    a. Beta blockers can reverse these side effects.
    b. Discontinue the medication immediately and notify the provider.
    c. Drink extra fluids and avoid driving when drowsy.
    d. Notify the provider if symptoms persist after several weeks.

Answer 69

ANS: C
Clonidine can cause dry mouth and sedation; patients should be warned to drink extra fluids and avoid driving. Beta blockers do not reverse these drug side effects. Discontinuing clonidine abruptly can cause severe rebound hypertension. These are common side effects that do not abate over time.

Question 70

11. A patient takes an ACE inhibitor to treat hypertension and tells the nurse that she wants to become pregnant. She asks whether she should continue taking the medication while she is pregnant. What will the nurse tell her?
    a. Controlling her blood pressure will decrease her risk of preeclampsia.
    b. Ask the provider about changing to an ARB during pregnancy.
    c. Continue taking the ACE inhibitor during her pregnancy.
    d. Discuss using methyldopa instead while she is pregnant.

Answer 70

ANS: D
Methyldopa has limited effects on uteroplacental and fetal hemodynamics and does not adversely affect the fetus or neonate. Controlling blood pressure does not lower the risk of preeclampsia. ACE inhibitors and ARBs are specifically contraindicated during pregnancy.

Question 71

12. A hospitalized patient has a blood pressure of 145/96 mm Hg. The nurse caring for this patient notes that the blood pressure the day before was 132/98 mm Hg. The patient reports ambulatory blood pressure readings of 136/98 and 138/92 mm Hg. The patient has a history of a previous myocardial infarction and has adopted a lifestyle that includes use of the DASH diet and regular exercise. What will the nurse do?
    a. Notify the provider and discuss ordering a beta blocker for this patient.
    b. Notify the provider and suggest a thiazide diuretic as initial therapy.
    c. Order a diet low in sodium and high in potassium for this patient.
    d. Recheck the patient’s blood pressure in 4 hours to verify the result.

Answer 71

ANS: A
Initial drug selection is determined by the presence or absence of a compelling indication or comorbid condition. This patient has a history of MI; beta blockers are indicated for patients with preexisting heart disease. Thiazide diuretics are first-line drugs of choice in patients without compelling indications. The patient is already consuming a DASH diet; closer monitoring of sodium or potassium will not help lower blood pressure. The patient has a record of hypertension, so it is unnecessary to recheck the blood pressure to verify the condition.

Question 72

13. Which two-drug regimen would be appropriate for a patient with hypertension who does not have other compelling conditions?
    a. Hydrochlorothiazide and nadolol
    b. Hydralazine and minoxidil
    c. Spironolactone and amiloride
    d. Trichlormethiazide and hydrochlorothiazide

Answer 72

ANS: A
When two or more drugs are used to treat hypertension, each drug should come from a different class. Hydrochlorothiazide is a diuretic and nadolol is a beta blocker, so this choice is appropriate. Hydralazine and minoxidil are vasodilators. Spironolactone and amiloride are potassium-sparing diuretics. Trichlormethiazide and hydrochlorothiazide are both thiazide diuretics.

Question 73

14. A nursing student asks the nurse why multi-drug therapy is often used to treat hypertension. Which statement by the student indicates a need for further teaching?
    a. “Multi-drug therapy often means that drugs may be given in lower doses.”
    b. “Some agents are used to offset adverse effects of other agents.”
    c. “Treatment of hypertension via different mechanisms increases success.”
    d. “Two or more drugs will lower blood pressure more quickly.”

Answer 73

ANS: D
Multi-drug therapy does not lower blood pressure more quickly. Using more than one drug often means that doses can be decreased. Some agents can offset adverse effects of other agents. Treatment via different mechanisms increases the likelihood of success.

Question 74

15. A patient with a recent onset of nephrosclerosis has been taking an ACE inhibitor and a thiazide diuretic. The patient’s initial blood pressure was 148/100 mm Hg. After 1 month of drug therapy, the patient’s blood pressure is 130/90 mm Hg. The nurse will contact the provider to discuss:
    a. adding a calcium channel blocker to this patient’s drug regimen.
    b. lowering doses of the antihypertensive medications.
    c. ordering a high-potassium diet.
    d. adding spironolactone to the drug regimen.

Answer 74

ANS: A
In patients with renal disease, the goal of antihypertensive therapy is to lower the blood pressure to 130/80 mm Hg or less. Adding a third medication is often indicated. Lowering the dose of the medications is not indicated because the patient’s blood pressure is not in the target range. Adding potassium to the diet and using a potassium-sparing diuretic are contraindicated.

Question 75

16. A 5-year-old patient seen in an outpatient clinic is noted to have hypertension on three separate visits. Ambulatory blood pressure monitoring confirms that the child has hypertension. As an initial intervention with the child’s parents, the nurse will expect to:
    a. perform a detailed health history on the child.
    b. provide teaching about antihypertensive medications.
    c. reassure the parents that their child may outgrow this condition.
    d. teach the parents about lifestyle changes and a special diet.

Answer 75

ANS: A
Because the incidence of secondary hypertension is much higher in children than adults, it is important to obtain an accurate health history to help uncover primary causes. Once the type of hypertension is established, the teaching interventions may be useful. Hypertension must be treated, and it is incorrect to reassure parents that their child may just outgrow the condition.

Question 76

17. The nurse is caring for a pregnant patient who is in labor. The woman reports having had mild preeclampsia with a previous pregnancy. The nurse notes that the woman has a blood pressure of 168/102 mm Hg. The nurse will contact the provider to request an order for which drug?
    a. Angiotensin-converting enzyme (ACE) inhibitor
    b. Hydralazine (Apresoline)
    c. Magnesium sulfate
    d. Sodium nitroprusside

Answer 76

ANS: B
The drug of choice for lowering blood pressure in a patient with severe preeclampsia is hydralazine. Sodium nitroprusside is not indicated. Magnesium sulfate is given as prophylaxis against seizures but does not treat hypertension. ACE inhibitors are contraindicated because of their potential for fetal harm.

Question 77

18. A nurse has provided education for a patient newly diagnosed with hypertension who is just beginning therapy with antihypertensive medications. Which statement by the patient indicates a need for further teaching?
    a. “I may experience serious long-term problems even if I am not having symptoms.”
    b. “I should report side effects to the provider since other drugs may be substituted.”
    c. “I will need to take medications on a long-term basis.”
    d. “When my symptoms subside, I may discontinue the medications.”

Answer 77

ANS: D
Patients should be taught that hypertension treatment is lifelong and that medications must be continued even when symptoms subside. Long-term problems may still occur without symptoms. Reporting drug side effects is necessary so that other drugs may be tried if needed.

Question 78

19. A 60-year-old African American patient has a blood pressure of 120/80 mm Hg and reports a family history of hypertension. The patient has a body mass index of 22.3. The patient reports consuming alcohol occasionally. Which therapeutic lifestyle change will the nurse expect to teach this patient?
    a. Alcohol cessation
    b. Potassium supplementation
    c. Sodium restriction
    d. Weight loss

Answer 78

ANS: C
Current recommendations for African Americans to prevent hypertension include sodium restriction of less than 1500 mg/day, although this is under investigation. The patient has a normal BMI and does not consume alcohol excessively, so weight loss and alcohol cessation are not necessary. Potassium supplements are not indicated; patients should be advised to consume foods high in potassium.