Practice Exam Flashcards
A 50 year old female patient with no previous medical history comes to you with complaints of overactive bladders. What treatment recommendations would you begin with?
A) behavior therapy
B) Oxybutynin 5 mg once daily
C) Vesicare 10 mg once daily
D) Enablex 7.5mg once daily
A) behavior therapy
Reasoning: page 93/94
You begin a patient on an M3 Muscarinic selective blocker for overactive bladder. Which of the following side effects would you NOT tell the patient about?
A) constipation
B) blurred vision
C) dry mouth
D) tachycardia
D) tachycardia
Reasoning: page 95
When prescribing a Oxybutin for overactive bladder what other type drugs would you tell the patient to avoid?
A) ACEI
B) Antihistamines
C) Aspirin
D) Tylenol
B) Antihistamines
Reasoning: page 96
All the following are signs of antimuscarinic toxicity EXCEPT:
A) hyperthermia
B) flushed face
C) delirium
D) vomiting
D) vomiting
Reasoning: p. 97
The following are properties of catecholamine Adrenergic Agonists EXCEPT:
A) they cannot be used orally
B) they cannot cross the blood brain barrier
C) their half life can be up to 24 hours
D) they are short acting
C) their half life can be up to 24 hours
Reasoning: p 100
What is one if the clinic effects epinephrine has on alpha 1 receptor
A) increased cranial pressure
B) elevation of blood pressure
C) decreased blood pressure
D) decreased edema
B) elevation of blood pressure
Reasoning: p. 102
What is a therapeutic application of adrenergic agonists on Beta 1 receptors? In other words, which scenario below would you use a adrenergic agonist on Beta 1 receptors?
A) dysrhythmias
B) headache
C) cardiac arrest
D) diarrhea
C) cardiac arrest
Reasoning: p 103
What is a side effect of Adrenergic Agonists on Beta 2 receptors
A) Hyperglycemia in diabetic patients only
B) Hyperglycemia in any patient
C) preterm labor
D) exacerbation of asthma
A) Hyperglycemia in diabetic patients only
Reasoning: p 103
Question: Albuterol is preferred in patients over isoproterenol because
A) isoproterenol tasts bad
B) Albuterol is more selective for Beta 2 receptors so it has fewer side effects
C) Albuterol is more available
D) Isoproterenol is more selective for Beta 2 receptors so it is not able to cause bronchodilation
B) Albuterol is more selective for Beta 2 receptors so it has fewer side effects
Reasoning: p 103
Epinephrine has specificity to all of the following adrenergic receptors EXCEPT:
A) Alpha 1
B) Alpha 2
C) Beta 1
D) Dopamine
D) Dopamine
Reasoning: p. 104
Mr. Prince was recently diagnosed with heart failure. He arrives to his follow up appointment after starting his new medication regimen. What statement would alarm the APRN?
a. “I have been taking Aleve twice a day for my arthritis in my knee”
b. “I haven’t gotten a good night’s rest because I have been urinating so often”.
c. “I take my blood pressure and heart rate every day after taking my medications and I have noticed my heart rate around 60 bpm”.
d. “I am still short of breath when walking to my mailbox, but it seems it is getting better every day”.
a. “I have been taking Aleve twice a day for my arthritis in my knee”
NSAIDS should be avoided in heart failure patients as it has the potential to increase fluid retention.
Increased urine output is normal after starting some new heart failure medications, especially diuretics. Patient should be instructed to take those medications in the morning to avoid nocturia. Side effects of some heart failure medications are lowered heart rate and blood pressure. Patient should be education on side effects and also to start taking blood pressure and heart rate prior to taking medications that would affect his vitals. Continued shortness of breath may indicate the need for adjustments of some medications, which can be addressed at the current appointment.
Ms. Smith presents to her primary care physician office with complaints of shortness of breath while ambulating and general fatigue. She has recently had to increase her daily oxygen demand to 2L/NC from her usual 1 L. Upon exam, she has 4+ pitting edema to bilateral lower extremities, BP 156/98, and heart rate 90. What new medication orders would alarm the nurse?
a. Increase Lasix from 20mg to 40mg daily
b. Give loading dose of Digoxin, then start 0.125mg daily.
c. Begin Lisinopril (Zestril) 2.5mg daily.
d. Increase Metoprolol from 12.5mg to 25mg
d. Increase Metoprolol from 12.5mg to 25mg
Start of new or change of dose of a beta blocker shouldn’t be given to heart failure patients in exacerbation or showing signs of fluid overload. This may worsen the patient’s current condition. Depending on what stage of heart failure she may be classified, adding ACE-I (Lisinopril) and a cardiac glycoside (Digoxin) is appropriate treatment of heart failure. Increasing Lasix during is exacerbation is appropriate.
The major underlying causes of heart failure are
a. diabetes and chronic hypertension
b. chronic hypertension and myocardial infarction
c. myocardial infarction and hyperlipidemia
d. CAD and uncontrolled hypercholesteremia
b. chronic hypertension and myocardial infarction
pg. 325/HF Medication Video
Major underlying cause of heart failure are chronic hypertension and myocardial infarction. Other causes include Valvular Heart Disease, CAD, Congenital Heart Disease, dysrhythmias, and aging of the myocardium.
A patient is diagnosed with heart failure at his primary care physician’s office. The nurse anticipates which meds to be routinely prescribed for heart failure? Select all.
a. A drug that inhibits the RAAS
b. cardiac glycoside
c. diuretic
d. beta blocker
Correct: a, c, d,
pg.327
For routine therapy, heart failure is treatment of drugs that inhibit RAAS, diuretic, and a beta blockers. Cardiac glycoside, such as digoxin, is not considered first line treatment.
Mrs. Johnson arrives to clinic with the complaint of a new onset, non-productive cough. She was recently diagnosed with heart failure and started on furosemide (Lasix), Enalapril (Vasotec), and Metoprolol (Toprol). The APRN would make which adjustments to the patient’s medication regimen?
a. Discontinue Lasix and start Spironolactone
b. Add Digoxin loading dose, with 0.125mg daily thereafter
c. Discontinue Enalapril and start Losartan (Cozaar)
d. Increase Lasix dosage, check labs, consider adding potassium supplement
c. Discontinue Enalapril and start Losartan (Cozaar)
pg. 32
An adverse effect of ACE-I is intractable cough. ACE-I are preferred drug compared to ARB, but ARBs are considered if patient cannot tolerate ACE-I.
The nurse should expect initial and follow up labs after patient starts Spironolactone to monitor for:
a. Hypernatremia
b. Hyperkalemia
c. Hyperglycemia
d. Hyponatremia
b. Hyperkalemia
pg. 329
Aldosterone antagonist’s major adverse effect is hyperkalemia with underlying case from renal retention of potassium. Potassium levels and renal function should be measured at baseline and periodically there after.
Mr. Jones is on a treatment regimen for heart failure after recently suffering a MI. His regimen includes Quinapril (Accupril), Lasix (furosemide), and KlorCon, and bisoprolol (Zebeta). Mr. Jones symptoms continues to persist despite adequate treatment and multiple dosage changes. The APRN would expect to
a. Discontinue Lasix and add Spironolactone
b. Add Spironolactone and discontinue KlorCon
c. Discontinue Quinapril (Accupril) and add Ramipril (Altace)
d. Add Losartan (Cozaar) after confirming potassium is within normal limits
b. Add Spironolactone and discontinue KlorCon
pg. 329- An aldosterone antagonist is recommended for addition to standard heart failure therapy, but only if symptoms persist. The major effect of an aldosterone antagonist if hyperkalemia, so potassium supplements should be discontinued.
pg. 335-336- Adding an aldosterone antagonist (spironolactone or eplerenone) to standard therapy (i.e. diuretic, ACEI or ARB, and a beta blocker) is reasonable in patients with moderately severe symptoms of heart failure after a heart attack. However, aldosterone antagonist must not be used if kidney function is impaired or serum potassium is elevated. Monitor renal function and potassium levels with treatment regimen.
Ms. Simpson lives alone in an apartment complex. She complains that lately when she walks to the mailbox, approximately 1 block away, she becomes short of breath and needs to rest to catch her breath upon returning. According the New York Heart Association (NYHA) Heart Failure Classification, Ms. Simpson would be classified as
a. Class I
b. Class II
c. Class III
d. Class IV
c. Class III
HF Medication Video
Class III is when patient starts to become symptomatic upon minimal exertion, such as walking two blocks with shortness of breath and fatigue.
Mr. Broussard is a 70-year-old male who has been recently diagnosed with heart failure. What statement made by the patient should warrant further education by the APRN?
a. “I will see you soon for my lab recheck”.
b. “I have decreased my smoking to three cigarettes a day and I should be completely off of them by next week”.
c. “I limit my wine intake to four glasses daily”.
d. “I have an appointment soon with my endocrinologist to check my thyroid and adjust my medications”.
c. “I limit my wine intake to four glasses daily”.
HF Medication Video
Alcohol should be limited to one drink per day for women and two drinks per day in men.
A patient is diagnosed with heart failure classified as Class III in the NYHA Classification. The patient is prescribed Digoxin in addition to standard medication for heart failure. What finding would alarm the APRN? Select all.
A. Digoxin level of 1.2 ng/mL on follow up labs
B. Complaints of GI upset, occasional diarrhea, and mild nausea
C. Patient reports they cannot tell the difference between the red/yellow/green lights when driving.
D. Complaints of muscle cramps at nighttime
Correct: ALL, P.332-334
Digoxin treatment for heart failure labs should be kept between 0.5-0.8ng/mL. Symptoms of digoxin toxicity is visual disturbance, GI upset, nausea, and diarrhea. Muscle cramps are a sign of hypokalemia. Loss of potassium increases the risk of digoxin-induced dysrhythmias. Digoxin is excreted primarily by renal excretion.
NP students may take what type of drug to alleviate symptoms of test anxiety?
A. B Adrenergic Antagonists
B. A Adrenergic Antagonists
C. Muscarinic Antagonist
D. B Adrenergic Agonist
Answer A:
B Adrenergic Antagonists
Pg. 113
Therapeutic uses for B Adrenergic Antagonists are hypertension, angina pectoris, cardiac dysrhythmias, prophylaxis of migraines, treatment of MI, and symptom suppression of situational anxiety. B Adrenergic Antagonists blocks B1 mediated tachycardia.
A patient abruptly quits taking their B Blocker medications. He begins to experience chest pain and ventricular dysrhythmias. What might be the cause?
A. Myocardial Infarction
B. Rebound Excitation
C. Heart Failure
D. Cardiac Ischemia
Answer B: Rebound Excitation
Pg. 113
Increased cardiac activity is a phenomenon that develops with abrupt cessation of B Blockers. The patient may experience chest pain and/or ventricular dysrhythmias. If this occurs dosing should be temporarily resumed. Patient education should include warning to not abruptly stop B Blocker therapy, and to make sure to have a sufficient amount of medications when traveling. To minimize this phenomenon patient’s dosage should be slowly tapered for 1-2 weeks.
What B Blockers is recommended for the treatment of hypertension in pregnant women?
A. Labetalol
B. Nadolol
C. Metoprolol
D. Bisoprolol
Answer A: Labetalol
pg. 114-115
Labetalol is a third generation B Blocker. It acts on blood vessels to cause dilation, but may produce nonselective B Blockade. It is one of three medications recommended by the American College of Obstetricians and Gynecologists for the treatment of hypertension in pregnant women. It has low lipid solubility, is metabolized in the liver, and excreted through the urine. Peak time is 2-4 minutes PO and half-life of 6-8 hours
A patient is being prescribed propranolol. How would the NP establish an effective dosage for the patient?
A. Draw blood levels to determine therapeutic levels
B. Adjust dosage by monitoring the patient’s response
C. Rely on dosing information
D. Start at a high dose
Answer B: Adjust dosage by monitoring the patient’s response
Page 115
Propranolol must be adjusted in response due to patients varying requirements and poor correlation between blood levels and therapeutic response. SNS activity is responsible for the responses to propranolol. Those with high sympathetic activity the dose will need to be high to reduce receptor activation. If sympathetic activity is low, a lower dose is needed.
A patient presents to the clinic with uncontrolled hypertension. You are considering starting the patient on a B Blocker. Reviewing the patient’s h/x you see the patient is diabetic and has asthma. What B Blocker would be safe to use?
A. Propranolol
B. Labetalol
C. Metoprolol
D. Nebivolol
Answer C: Metoprolol
Pg. 115
Metoprolol is a selective B Blocker that blocks B1 receptors in the heart when using therapeutic dosing. Higher doses may block B2 receptors as well. Because it is selective to B1 receptors it is preferred to use in patients with diabetes and asthma. It reduces secretion of renin in the kidney and does not block bronchial B2 receptors when taking usual doses. Contraindications include patients with sinus bradycardia and AV block greater than 1st degree. Patients still need to have teaching medication can mask normal signs of hypoglycemia. Black Box ma cause exacerbation of angina and increased risk of MI with abrupt cessation of drug.
The NP is considering restarting a patient on sotalol for cardiac dysrhythmia. What precautions need to be taken with this drug?
A. None, the drug is safe
B. Do a baseline ECG, CBC, and creatine clearance
C. The patient’s liver enzymes need to be checked prior to restarting this medication
D. The patient needs to be in a facility that has continuous ECG monitoring and CPR capabilities for a minimum of 3 days. Obtain a creatine clearance before start.
Answer D: The patient needs to be in a facility that has continuous ECG monitoring and CPR capabilities for a minimum of 3 days. Obtain a creatine clearance before start.
pg. 116
Sotalol has a black box warning for starting and restarting this medication. Creatine clearance needs to be checked and the patient needs to be in a facility with continuous monitoring to minimize problems associated with induced arrhythmia. Betapace cannot be substituted for Betapace AF when treating a-fib. This drug is approved for ventricular dysrhythmias and maintenance of sinus rhythm in patients that previously experienced A-fib or A-flutter.
What receptor blockade should the NP be aware of when choosing a B Blocker for a patient with diabetes?
A. A1 blockade
B. A2 blockade
C. B1 blockade
D. B2 Blockade
Answer D: B2 Blockade
pg. 119
B2 blockade can prevent glycogenolysis. Patients need to reduce their use of insulin. Cardioselective agents are more preferred. Diabetic patients on B Blockers need to be taught to monitor for other indicators of hypoglycemia such as hunger and poor concentration.
The NP is planning to start a patient on methyldopa for hypertension. The NP should order what lab tests before starting the medication?
A. CBC, CMP, Magnesium
B. Liver enzymes, CMP
C. WBC, Electrolytes,
D. CBC, Coombs test, liver enzymes
Answer D: CBC, Coombs test, liver enzymes
pg. 123
Methyldopa inhibits sympathetic outflow from CNS causing A2 activation in the brain It is not an A2 agonist and must be converted to methyl norepinephrine in order to activate A2 receptors. It does not decrease the heart rate or cardiac output. It is safe to administer to pregnant women. Coombs test should be administered before therapy and 6-12 months after initiation of drug therapy. Patients with a positive coombs test need to be monitored for hemolytic anemia. If hemolytic anemia develops the medication should be discontinued immediately
A student asks the NP how an indirect-acting antiadrenergic agent works. Which statement best describes how these drugs work?
A. Central acting A2 agonists act within the CNS to reduce outflow impulses along sympathetic neurons acting as an antiadrenergic agent. These drugs decrease activation of A- and B- adrenergic receptors in the periphery.
B. Indirect-acting antiadrenergic agents produce a blockade of adrenergic receptors
C. These agents work by binding directly to the receptor. They promote norepinephrine release, blockade of NE reuptake, or inhibit NE reactivation
D. These agents act directly at cholinergic receptors blocking the actions of acetylcholine.
Answer A: Central acting A2 agonists act within the CNS to reduce outflow impulses along sympathetic neurons acting as an antiadrenergic agent. These drugs decrease activation of A- and B- adrenergic receptors in the periphery.
Pg. 120
Adrenergic antagonists produce blockades of adrenergic receptors. Adrenergic agonist binds to receptors and promote NE release, blockade of NE reuptake or inhibit NE reactivation. Muscarinic Antagonists block actions of acetylcholine and act directly on cholinergic receptors.
A 32 year old female presents to the clinic to speak about family planning. When reviewing the patient’s current medications, you notice one medication that is of some concern. What medication would you change?
A. Methyldopa
B. Labetalol
C. Clonidine
D. Nifedipine
Answer C: Clonidine
Pg. 121
Clonidine is not recommended for pregnant women because of possible fetal harm. It is known to be embryotoxic in animals. Other adverse effects include CNS depression patients should be advised to take daily dose at night to minimize daytime sedation. Do not discontinue abruptly. There is a potential for rebound hypertension. This drug also has potential for abuse due to subjective effects of euphoria, sedation, and hallucinations.
- A provider knows that the medication administered when a patient is experiencing toxic effects from a muscarinic agonist is:
a. Neostigmine
b. Bethanechol
c. Atropine
d. Scopolamine
Answer: C-Atropine
pg 85. By blocking access of muscarinic agonist to their receptors, atropine can reverse most signs of toxicity.
- Cholinesterase inhibitors are the primary therapy for patients with Myasthenia Gravis. The NP knows that cholinesterase inhibitors work by:
a. Increasing the reuptake of acetylcholine
b. Preventing acetylcholine inactivation
c. Deactivating muscarinic receptors
d. Releasing epinephrine from the adrenal medulla
Answer: B- Preventing acetylcholine inactivation
pg 89. By preventing acetylcholine inactivation, cholinesterase inhibitors can intensify the effects of acetylcholine released from motor neurons, increasing muscle strength.
- The drug most appropriate for the use in a patient with glaucoma is:
a. Bethanechol
b. Atropine
c. Pilocarpine
d. Pyridostgmine
Answer: C. Pilocarpine
pg. 85.
- Adverse effects seen with cholinergic agonists are directly related to:
a. The activation of the sympathetic nervous system
b. The increase of acetylcholinesterase
c. The overstimulation of cholinergic receptors
d. The activation of Beta 2 receptors
Answer: C. The overstimulation of cholinergic receptors
Pg. 85- see Box 13.1 on Muscarinic/Cholinergic Toxicity
- What symptom would you not expect from a patient experiencing muscarinic toxicity?
a. Urination
b. Bradycardia
c. Diarrhea
d. Mydriasis
Answer: D. Mydriasis
Pg. 85 see box 13.1
- Atropine works by:
a. Deactivating acetylcholine
b. Inhibiting acetylcholinesterase
c. Preventing receptor activation by acetylcholine
d. Blocking all nicotinic receptors
Answer: C pg. 91
- A therapeutic goal of atropine is:
a. Treatment of bradycardia or AV block
b. Treatment of tachydysrhythmia
c. Treatment of elevated IOP
d. Severe constipation
Answer: A. Treatment of bradycardia or AV block
See pg. 93 Summary of Key Prescribing Considerations
- Scopolamine is similar to atropine in all the following EXCEPT:
a. Adverse effect of xerostomia
b. Produces sedation
c. Can be used as preanesthetic sedation
d. Can cause urinary retention
b. Produces sedation
Answer: Pg. 93
- True/False: The first line treatment for OAB is behavioral therapy?
Answer: True. Pg. 94
- To minimize the side effects of medications used to treat OAB, the provider should prescribe a medication that is:
a. Short-acting
b. Non-selective
c. Acts on the M3 receptor subtype
d. Is a topical gel
Answer: C. Acts on the M3 receptor subtype
Pg. 95.
Why are drugs that act via synaptic transmission preferred to drugs that act via axonal conduction?
a. They work faster
b. They are highly selective
c. They have less drug-drug interactions
d. They are cost-effective
Answer (B) They are highly selective
(pg 68): “drugs that alter synaptic transmission can produce effects that are highly selective. This selectivity can occur because synapses, unlike axons, differ from one another”
Choose the option that is NOT one of the effects that drugs can have on transmitter synthesis.
a. Increase transmitter synthesis
b. Decrease transmitter synthesis
c. Dissolve transmitters in the synaptic cleft
d. Cause the synthesis of transmitter molecules that are more effective than the natural transmitter itself (aka super transmitters)
Answer (C) Dissolve transmitters in the synaptic cleft
(pg 69) please read rationale in the heading “transmitter synthesis”
Select all that apply. Which are the transmitters that bind with adrenergic receptors
a. Epinephrine
b. Norepinephrine
c. Acetylcholine
d. Dopamine
Answers (A, B, D)
(pg 75): acetylcholine is the neurotransmitter that binds with cholinergic receptors
Select all that apply: Which of the following is/are subtypes of cholinergic receptors?
a. Alpha 1
b. Muscarinic
c. Nicotinic
d. Beta 2
Answers (B, C) (pg 76):
alpha and beta are subtypes of adrenergic receptors
Which of the following is a function of the parasympathetic nervous system (cholinergic receptors)?
a. Increased heart rate
b. Increased gastric secretion
c. Dilation of pupils
d. Dilation of bronchi
Answer: (B) (pg 72): Increased gastric secretion
read heading “functions of the parasympathetic nervous system” for rationale
Which of the following is a function of the sympathetic nervous system (adrenergic receptors)?
a. Pupil constriction
b. Increased secretions
c. Decreased blood pressure
d. Glucose production by the liver
Answer: (D) (pg 72): Decreased blood pressure
read heading “functions of the parasympathetic nervous system” for rationale
How can drugs increase the activation of receptors? (select two)
a. Blockade of transmitter reuptake
b. Increased transmitter production
c. Inhibition of transmitter degradation
d. Increased enzyme production
Answers: (A, C)
(pg 69): drugs that act by blockade of transmitter reuptake or inhibition of transmitter degradation will increase transmitter availability, thereby causing receptor activation to increase
If a drug directly activates a receptor, it is called a:
a. Substrate
b. Catalyst
c. Agonist
d. Antagonist
Answer: (C) Agonist
pg 69
If a drug prevents a receptor from being activated, it is called a:
a. Antagonist
b. Prodrug
c. Inactive compound
d. Agonist
Answer: (A)Antagonist
(pg 69)
When blood pressure falls, the baroreceptor reflex signals for the body to compensate via what mechanism?
a. Vasoconstrict
b. Vasodilate
c. Release bradykinin
d. Dilate bronchi
Answer: (A) (pg 73): Vasoconstrict
when BP falls, baroreceptors cause vasoconstriction and increase cardiac output. Conversely, when BP rises, baroreceptors cause vasodilation and reduces cardiac output.
A patient with HTN is admitted to the hospital. On admission the patient’s HR is 72 bpm and b/p 140/95. After administering a antihypertensive medication the patient’s HR is 85 and b/p 130/80. Which does the nurse expect to occur?
a) a decrease in the HR back to baseline in 1-2 days.
b) an increase in the blood pressure within a few days
c) an increase in potassium retention in 1-2 days
d) a decrease in fluid retention within a week
Answer: a. a decrease in the HR back to baseline in 1-2 days.
When blood pressure drops the baroreceptors in the aortic arch and carotid sinuses sense this and relay information to the vasoconstriction area of the medulla; this causes constriction of the arterioles and veins and increased sympathetic impulses to the heart resulting in increased HR. After 1-2 days the system resets itself to adjust to the new pressure and the heart rate will return to normal. Blood pressure will not reset, no effect on potassium (depends on med) and fluid retention may increase over time but no decrease. From Lehne’s pharmacotherapeutics test bank, 1st edition
- 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 headaches
d) Report SOB
Answer: a. Ask for assistance when getting out of bed
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 warned for ask for assistance when getting out of bed. Bradycardia, headache, and SOB are not expected effects in venous constriction. From Lehne’s pharmacotherapeutics test bank, 1st edition
- A patient is taking a beta-1 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: c. Myocardial contractility
Beta 1 receptors increase heart rate, contractility, and velocity of AV conduction. Preload- stretch or volume of heart at diastole. Afterload= SVR. Venous return not affected.
From Lehne’s pharmacotherapeutics test bank, 1st edition
- A patient with HTN is admitted for a procedure. If the patients arterial pressure decreases what else would the nurse expect to see?
a) Decreased HR
b) Increased HR
c) Decreased B/P
d) Syncope
Answer: b. Increased HR
When arterial pressure decreases, the vasoconstriction center causes vasoconstriction of nearly all arterioles. This causes peripheral resistance, constriction of veins increasing venous return, and subsequent increase in HR. Would not cause decrease in B/p or HR. No syncope. From Lehne’s pharmacotherapeutics test bank, 1st edition
- A patient is brought to the ER with SOB, RR 30, intercostal retractions and frothy, pink sputum. The nurse caring for this patient would expect to administer which drug?
a) Furosemide (Lasix)
b) HCTZ (Hydrodiuril)
c) Mannitol (Osmitrol)
d) Spironolactone (Aldactone)
Answer: a. Furosemide (Lasix)
Lasix, a potent diuretic is used when rapid or massive mobilization of fluids is needed. This patient shows severe CHF with respiratory distress and pulmonary edema needing immediate mobilization of fluids. HCTZ and spironolactone are not indicated for CHF because their diuretic effects are less rapid. Mannitol is indicated for increased ICP and must be d/c’d immediately if signs of HF or pulmonary congestion occur. From Lehne’s pharmacotherapeutics test bank, 1st edition
- An older patient with CHF develops crackles in both lungs and pitting edema in all extremities. The physician orders HCTZ. Before administering, the nurse reviews the chart. Which finding would be concerning in giving this medication?
a) Elevated creatine clearance
b) Elevated serum potassium
c) Normal blood glucose
d) Low LDL
Answer: a. Elevated creatine clearance
HCTZ should not be given to patient with severe renal impairment. Therefore, an elevated CC would be of concern. Thiazide diuretics are potassium sparing. Thiazides can increase BG in diabetics. And can increase LDL but this patient’s is low. From Lehne’s pharmacotherapeutics test bank, 1st edition
- A patient is taking gentamycin and Lasix. The nurse should counsel the patient to report which symptom?
a) Nocturia
b) Headaches
c) Ringing in the ears
d) Urinary retention
Answer: c. Ringing in the ears
Patients taking Lasix should be advised that the risk of furosemide induced hearing loss can be increased when other ototoxic drugs like gentamycin are taken. Patient should report tinnitus, dizziness, or hearing loss. Nocturia may be expected on a diuretic. Urinary retention and headaches are not likely a side effect of Lasix. From Lehne’s pharmacotherapeutics test bank, 1st edition
- A patient with chronic CHF has repeated hospitalizations in spite of ongoing treatment with HCTZ and Digoxin. The provider adds spironolactone, and the nurse provides education. Which statement by the patient confirms they understand teaching?
a) I will feel better a few hours after taking this drug
b) I need to stop my potassium supplements
c) I should use salt substitutes form now on
d) I should watch for signs of dehydration
Answer: b. I need to stop my potassium supplements
spironolactone is an adjunct therapy that is potassium sparing in comparison to thiazides and loop diuretics. Continuing potassium supplements would put a patient at risk for hyperkalemia- even more concerning because they are taking digoxin. Spironolactone takes up to 48 hours to take effect. Salt substitutes are high in potassium. Spironolactone is a weak diuretic; risk of dehydration is minimal. From Lehne’s pharmacotherapeutics test bank, 1st edition
- A patient has a new diagnosis of hypertension and the provider wants to start a daily thiazide diuretic. Which of these conditions would not be a contraindication for thiazide treatment?
a) Sulfa allergy
b) Gout
c) Pregnancy
d) Renal insufficiency with a GFR of 20
Answer: c. Pregnancy
Thiazides are a Pregnancy Category B drug meaning they are used routinely. Gout, sulfa and GFR < 30 are contraindications of thiazide diuretic therapy. In renal insufficiency use a loop. Tara Hillard ppt presentation, slide 11
- Aterial Pressure is regulated by:
a) The autonomic nervous system
b) RAAS
c) The kidneys
d) All of the above
Answer: d. All of the above
The ANS responds in seconds or minutes through baroreceptors (pressure sensors) in the carotid sinus and aortic arch and send messages to the brain the respond. The RAAS responds more slowly- hours (vasoconstriction) to days (water retention because of increased sodium reabsorption), through angiotensin 2, a powerful vasoconstrictor. This is where ACE I, ARBs and Renin antagonists work. When AP remains low for a long time (weeks, etc.) the kidneys retain water, release renin and activate the RAAS. Lehne pg. 288
Which medications are most likely to cause postural hypotension? Select all that apply.
A. Minoxidil B. Diltiazem (Cardizem) C. Prazosin (Minipres) D. Captopril (Capoten) E. Losartan (Cozaar)
ANS: C, D, E
C. Prazosin (Minipres)
D. Captopril (Capoten)
E. Losartan (Cozaar)
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. (pg. 314)
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/min and a BP of 120/80. What is an important part of the initial assessment for this patient?
A. evaluating ankle edema
B. monitoring for nausea and vomiting
C. noting the presence of hypertrichosis
D. obtaining a blood glucose
ANS: A -evaluating ankle edema
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 it is not a serious side effect. Hypertrichosis occurs in about 80% of patients taking this 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. (pg. 314)
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”
ANS: B
“I will also take a beta blocker medication with this drug to prevent rapid heart rate”
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 joing pain, which indicates and SLE syndrome and requires discontinuation of the drug. Minoxidil can cause excessive hair growth, no hydralazine. (pg. 313)
A hospitalized patient has a blood pressure of 145/96. The nurse caring for this patient notes that the BP the day before was 132/98. The patient reports ambulatory blood pressure readings of 136/98 and 138/92. The patient has a history of a myocardial infarction and has adopted a lifestyle that includes a DASH diet and regular exercise. What will the nurse do?
A. Notify the provider and suggest a thiazide diuretic as initial therapy.
B. Order a diet low in sodium and high in potassium for this patient.
C. Recheck the patients BP in 4 hrs to verify the result.
D. Notify the provider and discuss ordering a beta blocker for this patient
ANS: D: Notify the provider and discuss ordering a beta blocker for this patient
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 so 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 BP to verify the condition. (pg. 320)
Which two-drug regimen would be appropriate for a patient with hypertension who does not have other compelling conditions?
A. hydralazine and minoxidil
B. hydrochlorothiazide and nadolol
C. spironolactone and amiloride
D. trichlormethiazide and hydrochlorothiazide
ANS: B hydrochlorothiazide and nadolol
When two or more drugs are used to treat hypertension, each drug should come from a different class. (og. 321) HCTZ 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.
A nurse is discussing how beta blockers work to decrease blood pressure with a nursing student. Which statement by the student indicates a need for further teaching?
A. “Beta blockers block the actions of angiotensin II”
B. “Beta blockers decrease heart rate and contractility”
C. “Beta blockers decrease peripheral vascular resistance”
D. “Beta blockers decrease the release of renin”
ANS: A “Beta blockers block the actions of angiotensin II”
Beta blockers reduce the release of rennin by blockade of b-1 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 resitance, and decrease the release of rennin. (pg. 318)
A 5-year old patient seen in an outpatient clinic is noted to have hypertension on three separate visits. Ambulatory blood pressure monitoring confirms that the child has hypertension. As an initial intervention with the child’s parents, the nurse will expect to:
A. perform a detailed health history on the child
B. provide teaching about antihypertensive medications
C. reassure the parents that their child may outgrow this condition
D. teach the parents about lifestyle changes and a special diet
ANS: A: perform a detailed health history on the child
Because the incidence of secondary hypertension is much higher in children than in 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 the parents that their child may just outgrow the condition. (pg. 323)
A 60 year old African-American patient has a BP of 120/80 and reports a family history of HTN. 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
ANS: C - sodium restriction
Current recommendations for African-Americans to prevent HTN include sodium due to an increased sensitivity to salt. 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. (pg. 322).
A patient is taking clonidine for HTN and reports having dry mouth and drowsiness. What will the nurse tell the patient?
A. Beta blockers can reverse these side effects
B. Discontinue the medication immediately and notify the provider
C. Drink extra fluids and avoid driving when drowsy
D. Notify the provider if symptoms persist after several weeks
ANS: C - Drink extra fluids and avoid driving when drowsy
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. D/C clonidine abruptly can cause severe rebound HTN. These are common side effects that do not abate over time.
A patient who does not consume alcohol or nicotininc products reports a strong family history of HTN and cardiovascular disease. The patient has a blood pressure of 126/82 and a normal weight and body mass index for height and age. The nurse will expect to teach this patient about:
A. ACE inhibitors and calcium-channel blocker medications
B. the DASH diet, sodium restriction and exercise
C. increased calcium and potassium supplements
D. thiazide diuretics and lifestyle changes
ANS: B- the DASH diet, sodium restriction and exercise
This patient has prehypertension without other risk factors. Lifestyle changes are indicated at this point. If BP rises to HTN levels , other measures, including drug therapy, will be initiated. Calcium and potassium supplements are not indicated. (pg. 317).
In which of the following should you not take a ACE Inhibitor ? Select all that apply
A. Patient with renal artery stenosis
B. Pregnant women
C. Patients with Diabetic Nephropathy and hypertension
D. Patients that exhibit a cough as a side effect to ACE Inhibitors
The answers are A,B&D
A. Patient with renal artery stenosis
B. Pregnant women
D. Patients that exhibit a cough as a side effect to ACE Inhibitors
It is contraindicated to take ACE Inhibitors for patients with renal artery stenosis, in pregnant women it is a teratogen, and for patients that exhibit a cough they should stop talking an ACE Inhibitor. ACE Inhibitors help delay renal progression in diabetic patients with renal disease. They do NOT prevent renal disease.
P.303
How does an ARB work?
A. They catalyze the formation of angiotensin 1 from angiotensinogen
B. They reduce the risk for cardiovascular mortality caused by HTN
C. They inhibit the block production of Angiotensin II
D. They block the actions of Angiotensin II.
The answer is D. They block the actions of Angiotensin II.
ARB block the actions of Angiostensin II.
A. Is the model of action of a DRI
B.&C. is true for ACE Inhibitors
P. 304
Which of the following ARBs are approved for Heart Failure (HF)?
A. Losartan and Irbesartan
B. Varsartan and Candesartan
C. Losartan only
D. Telimisartan
The answer is B. Varsartan and Candesartan are the only ARBs approved for HF
A. Losartan and Irbesartan are approved for diabetic nephropathy
C. Losartan is also approved for stroke prevention and diabetic retinopathy
D. Telimisartan is approved for reducing risk for MI , stroke, death from cardiovascular causes in patients 55 years and older only if they are intolerant to an ACE.
p.305
What are the adverse effects of a ARB? select all that apply
A.hypokalemia
B. Hyperkalemia
C.Cough
D. Angioedema
The answers are B and D,
B. Hyperkalemia
D. Angioedema
ARBs cause hyperkalemia and in some cases angioedema although angioedema is less common in ARBS than in ACE Inhibitors In addition, the cough is seen in patients taking ACE Inhibitors the cough comes from increased bradykinnin.
P.305
What is the black box warming in spironlactone?
A. Pose a risk for major congenital malformation and fetal death
B. Use of spironlactone is a tumorigenic in chronic toxicity studies in rats.
C. Can injure the developing fetus in the second and third trimester.
D. There is no black box warning for spironlactone.
The answer is B. Use of spironlactone is a tumorigenic in chronic toxicity studies in rats.
A. is a black box warning for Alisken which is a DRI
C. Is a black box warning for ACE/ARB
D. there is a black box warning.
p.307
What are the adverse effects of spironlactone? Select all that apply?
A, Hypokalemia B. Hyperkalemia C. gynemastia D. menstrual irregularites E. Anguiedema
The answers are B,C,& D
The Adverse effects of spironlactone are hyperkalemia, (it is a potassium sparring diuretic, and aldosterone antagonist). Spironlactone can cause gynemastia and menstrual irregularities.
Angioedema think ACE and ARB
p.307
Which class of Calcium channel blockers affect the heart and the lungs?
A. Dihydropyridine
B. NonDihyropyridine
C. Both dihydropyridine and nondihydropydine
D. lisinopril
the answer is B NonDihyropyridine
It is important to know which type of calcium channel blacker affects the conduction system. Non-Dihydropyridine affect both the heart and the blood vessels.Medications in this class include Verapamil and Diltiazem. p.308
What are the indications for Verapamil and Diltiazem? Select all that apply
A. Angina Pectoris B. AV block C.essential HTN D.Cardiac dysrhymias E. Heart failure
The answer is A, C & D.
Verapamil and Diltiazem are used for angina pectoris, HTN and cardiac dysrhythmias.
They are contraindicated in patients with 2nd and 3rd atrioventricular block.
p.310
Which blood pressure medication causes reflexive tachycardia?
A. lisinopril
B. Diltiazem
C. nifedipine
D. Verapamil
The answer is C.
Nifedipine causes reflexive tachycardia. Important to note beta blockers can be used to prevent reflexive tachycardia in dihydropyidines like (nifedipine) but they can INTENSIFY adverse effects of nondihyopyidines like verapamil and diltiazem causing CARDIO SUPPRESSION.
p. 312
Vasodilators are used for essential HTN, HTN crisis , angina pectoris , Heart failure and MI. What are some important key points to teach patients in regardless to Vasodilators? Select all that apply
A. They increase the risk of falls
B. Patients should be taught S/S of hypotension such as light head and dizzy
C. Avoid Grapefruit
D. Postural HTN
The answer is A,B & D.
patients should be taught s/s of hypotension. Vasodilators placed patients at increase risk for falls and postural hypotension.
Grapefruit is not an issue for vasodilators but they do pose a risk of toxicity for verapamil which is a calcium channel blacker.
p.313.
Which combination of drugs increases the risk for gallstones?
a. Gemifibrozil plus Ezetimibe
b. Alirocumab plus Atrovastatin
c. Simavstatin plus Ezetimibe
d. Colesevalam plus Evolocumab
Answer: A Gemifibrozil plus Ezetimibe
Explanation: pg. 361 under Drug interactions.
Both ezetimibe and fibrates can increase the cholesterol content of bile and can thereby increase the risk of gallstone.
Which drug should be carefully monitored and even reduced in patients of Asian backgrounds?
a. Atrovastatin
b. Pravastatin
c. Rosuvastatin
d. Simvastatin
Answer: C - Rosuvastatin
Explanation: pg. 358
Rouvastatin reaches abnormally high levels in people of Asian heritage. Accordingly, if rosuvastatin is used by Asians, dosage should be reduced.
Which of the following is not a group that would benefit from Statins?
a. Individuals with primary elevations of LDL cholesterol of greater than 190mg/dL
b. Individuals 40-75 years of age with diabetes and LDL cholesterol of greater than 150mg/dL
c. Individuals with clinical ASCVD
d. Individuals with an estimated 10-year ASCVD risk of 7.3%
Answer: D Individuals with an estimated 10-year ASCVD risk of 7.3%
Explanation: pg. 353
Box 44.1 lists the statin benefit groups as defined by the 2018 American College of Cardiology/American Heart Association Blood Cholesterol Guidelines
Which drug is no longer used for the treatment of hypertriglyceridemia?
a. Fenofibrate
b. Nicotinic Acid
c. Pitavastatin
d. Colestipol
Answer: B - Nicotinic Acid
Explanation: pg. 359. Panel of experts recommended that niacin be removed from the guidelines for use in hypertriglyceridemia and in lowering LDL cholesterol