Question 1

An elderly client with depression, diabetes mellitus, and heart failure has received a new digoxin prescription for daily use.  Which client assessment indicates that the nurse should follow up on serum digoxin levels frequently?

Accepted Answer

Digoxin (Lanoxin) is a cardiac glycoside that increases cardiac contractility but slows the heart rate and conduction. It is used in heart failure (to increase cardiac output) and atrial fibrillation (to reduce the heart rate). The drug is excreted almost exclusively by the kidney. BUN and creatinine levels are measurements of kidney function. The normal range for creatinine is 0.6-1.3 mg/dL (53-115 µmol/L). Elderly clients tend to develop age-related decrease in glomerular filtration rate (GFR). These clients and those with obvious kidney injury (possibly due to diabetes in this client) can accumulate digoxin. The early symptoms of toxicity are nausea and vomiting. Later signs of toxicity are arrhythmias, including heart blocks. Therefore, clients at risk for digoxin toxicity require frequent drug level monitoring and dose adjustment. (Option A) An apical heart rate is taken for a full minute prior to administration. It is safe to administer the drug when the apical heart rate is ≥60/min. (Option B) An elevated blood sugar level requires attention but is unrelated to digoxin toxicity. However, hypokalemia can increase the risk of digoxin toxicity. (Option C) Fluoxetine (Prozac) is an antidepressant drug that is a selective serotonin reuptake inhibitor. It does not usually interact with digoxin and its use is unaltered by cardiac disease. This is a normal dose. Educational objective: Digoxin (Lanoxin) is excreted almost exclusively by the kidneys. Decreased kidney function usually requires decreased digoxin dosage and frequent drug level monitoring. BUN and creatinine are measurements of kidney function.

Question 2

A client with long-term hypertension and hypercholesterolemia comes to the clinic for an annual checkup.  The client takes nifedipine, simvastatin, and spironolactone and reports some occasional dizziness.  Which statement by the client would warrant intervention by the nurse?

Accepted Answer

The nurse should intervene when the client talks about eating grapefruit. Grapefruit inhibits enzyme CYP3A4. The drugs that are metabolized by the same pathway would not be metabolized, resulting in higher drug levels and serious side effects. Calcium channel blocker (eg, nifedipine) use with grapefruit juice can cause severe hypotension; some statins (eg, simvastatin) may result in myopathy. (Option A) The nurse should praise and encourage the client to continue exercising and possibly increase the amount. This is a positive lifestyle change. The client should engage in moderate-intensity aerobic exercise for at least 30 minutes most days of the week or vigorous-intensity aerobic exercise for 20 minutes 3 days a week. (Option C) It is thought that red wine in moderation has some beneficial effects on the heart. The nurse would not encourage a client to start drinking red wine if the client didn't already. Excessive alcohol consumption is strongly associated with hypertension. The nurse should encourage the client to discuss alcohol consumption with the health care provider (HCP). (Option D) Sodium restriction is important in the management of hypertension. This teaching should be reinforced and the client should be encouraged to restrict the use of salt. Educational objective: The nurse should tell the client not to eat grapefruit or drink grapefruit juice while taking calcium channel blockers due to the possible development of severe hypotension. The nurse should report this client's statement to the HCP.

Question 3

The nurse is providing discharge teaching to a client with a new prescription for warfarin. The nurse should instruct the client to avoid excess or inconsistent intake of which foods? Select all that apply.

Accepted Answer

11ecbb05_cc68_bed7_b433_eb63f5d8eea4_MD0009_00 Warfarin (Coumadin) is a vitamin K antagonist used to prevent blood clots in clients with atrial fibrillation, artificial heart valves, or a history of thrombosis. Excessive intake of vitamin K-rich foods (eg, broccoli, spinach, liver) can decrease the anticoagulant effects of warfarin therapy (Options B, C, and E). Clients should be consistent with intake of foods high in vitamin K after initiation of warfarin because dosing is individualized to the client and dietary changes may require dose adjustment. (Options A and D) Bananas and oranges are rich in potassium, not vitamin K, and are not known to interact with warfarin. The chemical symbol for potassium (K⁺) should not be confused with vitamin K because they are two different micronutrients; potassium (K⁺) is an element involved in muscle contraction, whereas vitamin K is a fat-soluble vitamin involved in blood clotting. Educational objective: Clients receiving warfarin therapy should maintain consistent intake of foods high in vitamin K; it is not necessary to remove vitamin K-rich foods completely. Clients should avoid excess or inconsistent intake of green vegetables (eg, broccoli, spinach) and liver to promote steady warfarin efficacy.

Question 4

The home health nurse visits a client with hypertension whose blood pressure has been well controlled on oral valsartan 320 mg daily. The client's blood pressure is 190/88 mm Hg, significantly higher than it was 2 weeks ago. The client reports a cold, a stuffy nose, and sneezing for 3 days. Which question is most appropriate for the nurse to ask?

Accepted Answer

Clients with hypertension should be instructed not to take potentially high-risk over-the-counter (OTC) medications such as high-sodium antacids, appetite suppressants, and cold and sinus preparations. It is appropriate to ask a client with hypertension about taking OTC cold medications as many cold and sinus medications contain phenylephrine or pseudoephedrine. These sympathomimetic decongestants activate alpha-1 adrenergic receptors, producing vasoconstriction. The resulting decreased nasal blood flow relieves nasal congestion. These agents have both oral and topical forms. With systemic absorption, these agents can cause dangerous hypertensive crisis. (Option B) Taking extra vitamin C may offer some protection for the immune system, but it does not cause an increase in blood pressure. (Option C) Exposure to young children increases the risk for contracting a contagious respiratory illness, but it does not directly increase blood pressure. (Option D) A flu shot would not offer protection against the flu within a week and does not cause an increase in blood pressure. Educational objective: Clients with hypertension should be instructed not to take potentially high-risk over-the-counter medications, including high-sodium antacids, appetite suppressants, and cold and sinus preparations, as they can increase blood pressure.

Question 5

The nurse is assessing a client with hypertension and essential tremor 2 hours after receiving a first dose of propranolol. Which assessment is most concerning to the nurse?

Accepted Answer

Propranolol is a nonselective beta-blocker that inhibits beta₁ (heart) and beta₂ (bronchial) receptors. It is used for many indications (eg, essential tremor) in addition to blood pressure control. Blood pressure decreases secondary to a decrease in heart rate. Bronchoconstriction may occur due to the effect on the beta₂ receptors. The presence of wheezing in a client taking propranolol may indicate that bronchoconstriction or bronchospasm is occurring. The nurse should assess for any history of asthma or respiratory problems with this client and notify the health care provider (HCP). (Option A) A headache is a common occurrence with hypertension. The nurse may administer an analgesic as needed. (Option B) This is the first dose of propranolol that the client has received. It may take several days of treatment for the blood pressure to reduce to a more normal reading. (Option C) A reduction in heart rate is expected with a beta-blocker. The nurse should continue to monitor it for further reduction. Educational objective: The nurse should be concerned about the presence of wheezing in a client taking a nonselective beta-blocker like propranolol. Wheezing may indicate bronchoconstriction or bronchospasm. The nurse should assess for any history of asthma or other respiratory problems and report to the HCP.

Question 6

What intervention is essential prior to starting a client on atorvastatin therapy?

Accepted Answer

Prior to starting therapy with statin medications (eg, rosuvastatin, simvastatin, pravastatin, atorvastatin), the client's liver function tests should be assessed. The drug is metabolized by the hepatic enzyme system and could cause drug-induced hepatitis and increased liver enzymes. Liver function tests should be assessed prior to the start of therapy. (Option A) Statins can also cause muscle aches and, rarely, severe muscle injury (rhabdomyolysis). Clients should be educated to report the development of muscle pains while on therapy. Assessment of muscle strength is not necessary prior to starting therapy. (Option B) Assessment of dietary intake prior to therapy is not essential. Dietary teaching would have been performed prior to determining that medication therapy was necessary. (Option C) Atorvastatin may slightly increase serum digoxin levels; however, it is not essential to determine if the client is on this medication prior to starting therapy. Educational objective: Statin medications (eg, rosuvastatin, atorvastatin) can cause hepatotoxicity and muscle aches. Liver function tests should be assessed prior to the start of therapy.

Question 7

Which prescriptions for these clients does the nurse question? Select all that apply.

Accepted Answer

The nurse would question the prescriptions for the following clients: Client with hypertension and BP 94/40 mm Hg, prescribed metoprolol succinate SR (Toprol-XL) 50 mg PO: This client's mean arterial pressure (MAP) is only 58 mm Hg ({[2x diastolic] + systolic} ÷ 3). A MAP >60-65 mm Hg is necessary to perfuse the vital organs (eg, brain, coronary arteries, kidneys). Toprol-XL is a long-acting beta blocker and will continue to drop the client's BP over a 24-hour period.Client with otitis media and penicillin allergy prescribed ampicillin 500 mg PO: Ampicillin is classified as a penicillin antibiotic and is contraindicated in clients with a penicillin allergy. Client with hypertension and BP 94/40 mm Hg, prescribed metoprolol succinate SR (Toprol-XL) 50 mg PO: This client's mean arterial pressure (MAP) is only 58 mm Hg ({[2x diastolic] + systolic} ÷ 3). A MAP >60-65 mm Hg is necessary to perfuse the vital organs (eg, brain, coronary arteries, kidneys). Toprol-XL is a long-acting beta blocker and will continue to drop the client's BP over a 24-hour period. Client with hypertension and BP 94/40 mm Hg, prescribed metoprolol succinate SR (Toprol-XL) 50 mg PO: This client's mean arterial pressure (MAP) is only 58 mm Hg ({[2x diastolic] + systolic} ÷ 3). A MAP >60-65 mm Hg is necessary to perfuse the vital organs (eg, brain, coronary arteries, kidneys). Toprol-XL is a long-acting beta blocker and will continue to drop the client's BP over a 24-hour period. Client with otitis media and penicillin allergy prescribed ampicillin 500 mg PO: Ampicillin is classified as a penicillin antibiotic and is contraindicated in clients with a penicillin allergy. Client with otitis media and penicillin allergy prescribed ampicillin 500 mg PO: Ampicillin is classified as a penicillin antibiotic and is contraindicated in clients with a penicillin allergy. (Option A) C difficile colitis is treated with metronidazole or vancomycin, depending on severity and number of relapses. Vancomycin is typically given orally in this situation, unlike other nonintestinal infections in which IV is the standard route. There is no reason to question this prescription. (Option B) A sliding insulin (correction) scale is used to prescribe rapid-acting lispro (Humalog) to control postprandial hyperglycemia. The nurse would not question this prescription. (Option C) Proton pump inhibitors (eg, pantoprazole, omeprazole) are prescribed for gastroesophageal reflux disease, and ulcer treatment and prophylaxis. The IV preparation is administered when the oral route is contraindicated. The nurse would not question this prescription. Educational objective: IV proton pump inhibitors are used for gastric ulcer bleeding. Oral vancomycin can be used for C difficile colitis. Ampicillin or amoxicillin are contraindicated in clients with a penicillin allergy. Antihypertensives are held if the client has borderline low BP.

Question 8

A client in the emergency department has an acute myocardial infarction. The health care provider (HCP) has prescribed thrombolytic therapy. Which assessment data should the nurse report immediately to the HCP?

Accepted Answer

11ecbb05_cc64_03e5_b433_031943cc3939_MD0009_00 Thrombolytic therapy aims to stop the infarction process, dissolve the thrombus in the coronary artery, and reperfuse the myocardium. This treatment is used when facilities do not have an interventional cardiac catheterization laboratory or when such a facility is too far away to transfer the client safely. Client selection is important because all thrombolytics lyse the pathologic clot but may also lyse other clots (eg, at a postoperative site). Minor or major bleeding can be a complication. Inclusion criteria for thrombolytic therapy in clients with acute myocardial infarction include chest pain lasting ≤12 hours, 12-lead ECG findings indicating acute ST-elevation myocardial infarction, and no absolute contraindications (eg, history of cerebral arteriovenous malformation) (Option A). (Option B) Active menstruation is not a contraindication for thrombolytic therapy. Research shows that the risk of increased menstrual bleeding due to thrombolytic administration is low and not life-threatening. Physiologic menstrual bleeding is also not a contraindication for anticoagulation therapy. (Option C) Chest pain is one of the inclusion criteria for thrombolytic therapy. (Option D) Uncontrolled blood pressure of >180 mm Hg systolic or >110 mm Hg diastolic is a relative contraindication for thrombolytic therapy. This client's blood pressure (170/92 mm Hg) is elevated but not uncontrolled, which does not rule out this therapy. Educational objective: The candidate for thrombolytic therapy should be screened for absolute and relative contraindications. The nurse should immediately notify the health care provider if the client has history of arteriovenous malformation, which is an absolute contraindication to the use of thrombolytics.

Question 9

A client with unstable angina and chronic kidney disease is receiving a continuous infusion of unfractionated heparin.  Which value for activated partial thromboplastin time (aPTT) would indicate to the nurse that the heparin therapy is at an optimal therapeutic level?

Accepted Answer

Unfractionated heparin is used as an anticoagulant in unstable angina. It prevents the conversion of fibrinogen to fibrin and prothrombin to thrombin, both components of clot formation. The aPTT is a laboratory test that characterizes blood coagulation. It is used to monitor treatment effects of clients receiving heparin. The normal aPTT is 25-35 seconds. Heparin infusions are titrated to obtain a therapeutic value of aPTT, typically 1.5-2 times the normal value. Therapeutic value for aPTT is 46-70 seconds. The nurse would evaluate the aPTT for a therapeutic value and make adjustments in the rate of infusion of the heparin as needed. (Options A and B) These are normal aPTT levels for clients not being anticoagulated. (Option D) This aPTT is too high. This client is at risk for bleeding. The heparin should be titrated down based on the heparin drip protocol. Educational objective: The nurse caring for a client receiving a heparin infusion should monitor the aPTT and follow the heparin infusion protocol for titration. A therapeutic level is 1.5-2 times normal, or an aPTT of 46-70 seconds.

Question 10

A client with deep vein thrombosis (DVT) is receiving a continuous infusion of unfractionated heparin.  The client asks the nurse what the heparin is for.  How should the nurse respond?

Accepted Answer

Venous thrombosis involves the formation of a thrombus (clot) and the inflammation of the vein. Anticoagulant therapy such as heparin does not dissolve the clot. The clot will be broken down by the body's intrinsic fibrinolytic system over time. The heparin slows the time it takes blood to clot, thereby keeping the current clot from growing bigger and preventing new clots from forming. (Option A) Anticoagulants do not dissolve clots. Thrombolytic agents (fibrinolytics), such as tissue plasminogen activator (tPA), are used to break the clots, but they also carry the risk of serious intracranial hemorrhage and are used only for acute life-/organ-threatening conditions. The body will break down the clot over a period of time. (Option B) Heparin does not prevent the clot from breaking off but will deter the clot from growing larger. (Option D) The nurse should be able to answer client questions regarding medications being administered. The HCP can answer any further questions the client may have. Educational objective: The nurse should teach the client that the purpose of unfractionated heparin infusion in the treatment of DVT is to slow the time it takes blood to clot, thereby keeping the current clot from getting bigger and preventing new clots from forming.

Question 11

The nurse is caring for a client with chronic, stable angina.  The client takes the long-acting nitrate isosorbide mononitrate.  Which client outcome indicates that the drug is effective?

Accepted Answer

Long-acting nitrates are used to reduce the incidence of anginal attacks. Nitrates are effective if the client is able to do activities without the incidence of chest pain. The client should be taught to report any increase in chest pain and how to manage headaches, a common side effect of nitrates. (Options B and C) A reduction in stress level and anxiety, and being able to sleep through the night are positive outcomes for any client with cardiovascular disease. However, these outcomes are not directly related to long-acting nitrate use. (Option D) Nitrates are vasodilators and may decrease the client's blood pressure, which is a positive outcome but not the primary reason for taking the medication. This client is taking the medication for angina. Educational objective: The ability to perform activities without chest pain is a desirable client outcome of long-acting nitrate use. The nurse would want to assess for this outcome in clients taking these medications.

Question 12

The nurse has just completed discharge teaching about sublingual nitroglycerin (NTG) tablets to a client with stable angina. Which statement by the client indicates the need for further teaching?

Accepted Answer

11ecbb05_cc63_8eb4_b433_fd4d51ec0b0b_MD0009_00 NTG is a vasodilator used to treat stable angina. It is a sublingual tablet or spray that is placed under the client's tongue. It usually relieves pain in about 3 minutes and lasts 30-40 minutes. The recommended dose is 1 tablet or 1 spray taken sublingually for angina every 5 minutes for a maximum of 3 doses (Option B). If symptoms are unchanged or worse 5 minutes after the first dose, emergency medical services (EMS) should be contacted (Option A). Previously, clients were taught to call EMS after the third dose was taken, but newer studies suggest that this leads to a significant delay in treatment. The NTG should be easily accessible at all times. Tablets are packaged in a light-resistant bottle with a metal cap. They should be stored away from light and heat sources, including body heat, to protect from degradation. Clients should be instructed to keep the tablets in the original container. Once opened, the tablets lose potency and should be replaced every 6 months. The car is not a good place to store NTG due to heat (Option D). (Option C) Waking up at night with chest pain can signify that angina is occurring at rest and is no longer considered stable angina. This should be reported to the health care provider. Educational objective: Education about sublingual NTG should include placing the tablet or spray under the tongue; repeating the dose every 5 minutes, with up to 3 total doses if angina is not relieved; notifying EMS if the first dose does not improve the symptoms; keeping the tablets in the original container away from light and heat; and replacing the bottle every 6 months once opened.

Question 13

A client is started on lisinopril therapy. Which assessment finding requires immediate action?

Accepted Answer

The dosage of angiotensin-converting enzyme (ACE) inhibitors (eg, lisinopril, enalapril, ramipril) should be adjusted for clients with renal impairment. A serum creatinine of 2.5 mg/dL (221 µmol/L ) indicates renal impairment (normal 0.6-1.3 mg/dL [53-115 µmol/L]). The nurse should notify the health care provider so that the dosage can be decreased or held. (Options A, B, and D) The client's blood pressure, heart rate, and serum potassium (normal 3.5-5.0 mEq/L [3.5-5.0 mmol/L]) are within normal limits. They do not require immediate action. Hyperkalemia and hypotension are contraindications for giving ACE inhibitors. Educational objective: Evaluation of kidney function is essential for clients taking medications that are excreted renally or can worsen renal injury. These include ACE inhibitors (eg, lisinopril, enalapril), aminoglycosides (eg, gentamicin), and digoxin.

Question 14

A client with stable angina is being discharged home with a prescription for a transdermal nitroglycerin patch.  The nurse has reviewed discharge instructions on the medication with the client.  Which statement by the client indicates that teaching has been effective?

Accepted Answer

Nitroglycerin patches are transdermal patches used to prevent angina in clients with coronary artery disease. They are usually applied once a day (not as needed) and worn for 12-14 hours and then removed. Continuous use of patches without removal can result in tolerance. No more than one patch at a time should be worn. The patch should be applied to the upper body or upper arms. Clean, dry, hairless skin that is not irritated, scarred, burned, broken, or calloused should be used. A different location should be chosen each day to prevent skin irritation. (Option A) Phosphodiesterase inhibitors used in erectile dysfunction (eg, tadalafil, sildenafil, vardenafil) are contraindicated with the use of nitrates. Both have similar mechanisms and cause vascular smooth muscle dilation. Combined use can result in severe hypotension. (Option B) Patches may be worn in the shower. (Option C) Headaches are common with the use of nitrates. The client may need to take an analgesic. Educational objective: Nursing education about transdermal nitroglycerin includes application of the patch to the upper arms or body, rotating the sites daily, removing the patch at night, taking no erectile dysfunction medications, and informing clients that headaches are common. Patches do not need to be removed for bathing.

Question 15

A client with atrial fibrillation is being discharged home after being stabilized with medications, including digoxin. Which of the following statements regarding digoxin toxicity indicates that further teaching is needed?

Accepted Answer

Drug toxicity is common with digoxin due to its narrow therapeutic range. Many contributing factors (eg, hypokalemia) can cause toxicity. However, in the absence of other factors, potassium does not need to be increased just because a client is on digoxin. If the client also takes some other potassium-depleting medications, such as diuretics, potassium supplements may be needed. Signs and symptoms of digoxin toxicity include the following: Gastrointestinal symptoms (eg, anorexia, nausea, vomiting, abdominal pain) are frequently the earliest symptoms (Option B) Neurologic manifestations (eg, lethargy, fatigue, weakness, confusion) Visual symptoms are characteristic and include alterations in color vision, scotomas, or blindness Cardiac arrhythmias - most dangerous (Option A) Drug levels are frequently monitored until a steady state is achieved and when changes are expected, such as in clients with chronic kidney disease and electrolyte disturbances (eg, hypokalemia, hypomagnesemia). (Option C) Digoxin toxicity can result in bradycardia and heart block. Clients are instructed to check their pulse and report to the HCP if it is low or has skipped beats. Educational objective: Drug toxicity is common with digoxin due to its narrow therapeutic range. Drug levels are frequently monitored. Nonspecific gastrointestinal symptoms similar to gastroenteritis are common and can lead to serious cardiac arrhythmias if not recognized.

Question 16

A client taking a diuretic for chronic heart failure experiences constipation. What is the nurse's best recommendation?

Accepted Answer

Increased consumption of fiber is the best recommendation for a client with heart failure who has constipation. Diuretics may lead to dehydration; however, fluid intake is usually limited for clients with heart failure. This client's history of heart failure is a contraindication to increased fluid intake due to potential fluid overload and increased workload on the heart (Option A). The nurse should consult the health care provider before recommending a specific amount of fluid intake. (Options B and D) Exercise is important, but clients with heart failure may not exercise for long periods due to fatigue. Warm baths are not helpful for constipation. Educational objective: When a client taking a diuretic experiences constipation, the nurse must consider the reason for taking the diuretic before offering a recommendation. Increased fluid intake is usually contraindicated in clients with a history of heart failure.

Question 17

An African American client comes to the clinic for a follow-up visit 2 months after starting enalapril for hypertension. Which client statement should be reported to the health care provider immediately?

Accepted Answer

11ecbb05_cc67_8656_b433_f5b00e2e2ba2_MD0009_00 Angioedema is swelling that usually affects areas of the face (lips, tongue), larynx, extremities, gastrointestinal tract, and genitalia. The swelling often starts in the face and can quickly become life-threatening as it progresses to the airways. Angioedema is an adverse effect of ACE inhibitors (eg, enalapril, lisinopril, captopril) and occurs more commonly in African American clients. Unlike other typical drug allergies, this side effect can occur any time after starting the medication. The nurse should immediately report angioedema to the health care provider and carefully monitor the client (Option D). (Option A) A persistent, dry, hacking cough is a common side effect of ACE inhibitors. It is not life-threatening, but the medication should be discontinued or changed to resolve the cough. (Option B) The nurse should review the client's blood pressure readings over the past month since starting enalapril. The client may need a dosage change or an additional medication. This should be reported but is not the priority in this situation. (Option C) Occasional dizziness upon rising (ie, orthostatic hypotension) is a common side effect of most antihypertensives. The client should be taught to rise slowly and sit on the side of the bed for a few minutes before standing up. Educational objective: Swelling of the tongue can be a sign of angioedema in clients taking ACE inhibitors; this can be potentially life-threatening if the airway becomes compromised. The nurse should report this immediately to the health care provider. Angioedema occurs more commonly in African American clients.

Question 18

The nurse is preparing medications for a group of clients.  Which prescription should the nurse clarify with the health care provider before administering?

Accepted Answer

ACE inhibitors ("-prils") and angiotensin II receptor blockers (ARBs) ("-sartans") may potentiate hyperkalemia. ACE inhibitors decrease the excretion of aldosterone. Aldosterone promotes sodium retention and causes potassium excretion. However, when the ACE inhibitor suppresses aldosterone, potassium rises, placing clients at risk for hyperkalemia, especially in the presence of impaired renal function. The nurse should question the administration of an ACE inhibitor in a client with hyperkalemia (Option B). (Option A) Lactulose is administered to clients with cirrhosis and hepatic encephalopathy to promote excretion of ammonia via fecal elimination and not solely for the treatment of constipation. The dose is adjusted to achieve 2-3 soft stools each day. (Option C) Vancomycin should be infused over at least 60 minutes (100 minutes if infusing ≥1 gram). When the infusion is given too fast, the client may develop red man syndrome, which is characterized by facial and upper body flushing. If this occurs, the infusion should be slowed or stopped and restarted at a slower rate after 30 minutes. Facial flushing in isolation is not indicative of an allergic or anaphylactic reaction, and the nurse can independently manage this side effect. (Option D) Basal insulin glargine (Lantus) is used for glucose control in diabetic clients. Insulin glargine has no peak and should be administered even if the current blood glucose level is within normal limits. Educational objective: Clients receiving ACE inhibitors should be monitored for hyperkalemia, especially in the presence of renal insufficiency. The nurse should clarify a prescription for ACE inhibitor administration in a client with hyperkalemia.

Question 19

The nurse provides instructions to a client discharged on warfarin, after being treated for a pulmonary embolism (PE) following surgery. Which statements made by the client indicate the need for further teaching? Select all that apply.

Accepted Answer

Clients discharged on warfarin (Coumadin) are taught interventions to prevent injury, such as removing scatter rugs in the home to reduce the risk of tripping and falling (especially in elderly) (Option B). Clients are educated to avoid aspirin, drugs containing aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), and alcohol when taking warfarin due to an increased risk for bleeding (Option C). (Option A) Warfarin is usually administered for 3-6 months following PE to prevent further thrombus formation. A longer duration (lifelong) of anticoagulation is recommended in clients with recurrent PE. Prothrombin time and INR must be monitored regularly to adjust the dose and maintain a therapeutic anticoagulant level. (Option D) Clients should be taught to avoid trauma or injury to decrease the risk for bleeding. Preventive measures include gently brushing teeth with a soft-bristled toothbrush, avoiding use of alcohol-based mouthwash, avoiding contact sports or rollerblading, and using a straight razor. Flossing should also be avoided in general, but waxed dental floss may be used with care in some clients. (Option E) Clients are instructed to wear a MedicAlert tag (eg, necklace, bracelet) when taking anticoagulants (eg, warfarin, heparin). Educational objective: Clients on warfarin or heparin should avoid using aspirin or nonsteroidal anti-inflammatory drugs, wear a MedicAlert device, avoid activities that increase the risk for bleeding, and limit alcohol intake.

Question 20

The nurse admits a client with newly diagnosed unstable angina. Which information obtained during the admission health history is most important for the nurse to report to the health care provider (HCP) immediately?

Accepted Answer

Sildenafil (Viagra) is a phosphodiesterase inhibitor used to treat erectile dysfunction. The use of sildenafil is most important for the nurse to report to the HCP. This must be communicated immediately as concurrent use of nitrate drugs (commonly prescribed to treat unstable angina) is contraindicated as it can cause life-threatening hypotension. Before any nitrate drugs can be administered, further action is necessary to determine when sildenafil was taken last (ie, half-life is about 4 hours). (Option A) Clients do not always report the amount of alcohol they consume accurately. The nurse should monitor all clients for alcohol withdrawal syndrome as it is quite common in hospitalized clients. (Option B) Getting up 4 times during the night to void can be associated with medication, an enlarged prostate gland, or drinking fluids at bedtime. Further action may be needed to determine the cause of the nocturia, but this is not the most significant information to report to the HCP. (Option C) Smoking 1 pack of cigarettes daily needs to be addressed as tobacco causes vasoconstriction and decreased oxygen supply to the body tissues. Further action is needed regarding smoking cessation education. However, the client's tobacco history is not the most important information to report to the HCP. Educational objective: Nitrate drugs are prescribed to treat angina. The concurrent use sildenafil (Viagra) and nitrates is contraindicated as it can cause life-threatening hypotension.

Exam 8: Pharmacology

An elderly client with depression, diabetes mellitus, and heart failure has received a new digoxin prescription for daily use. Which client assessment indicates that the nurse should follow up on serum digoxin levels frequently?

A client with long-term hypertension and hypercholesterolemia comes to the clinic for an annual checkup. The client takes nifedipine, simvastatin, and spironolactone and reports some occasional dizziness. Which statement by the client would warrant intervention by the nurse?

The nurse is providing discharge teaching to a client with a new prescription for warfarin. The nurse should instruct the client to avoid excess or inconsistent intake of which foods? Select all that apply.

The nurse is assessing a client with hypertension and essential tremor 2 hours after receiving a first dose of propranolol. Which assessment is most concerning to the nurse?

What intervention is essential prior to starting a client on atorvastatin therapy?

Which prescriptions for these clients does the nurse question? Select all that apply.

A client in the emergency department has an acute myocardial infarction. The health care provider (HCP) has prescribed thrombolytic therapy. Which assessment data should the nurse report immediately to the HCP?

A client with unstable angina and chronic kidney disease is receiving a continuous infusion of unfractionated heparin. Which value for activated partial thromboplastin time (aPTT) would indicate to the nurse that the heparin therapy is at an optimal therapeutic level?

A client with deep vein thrombosis (DVT) is receiving a continuous infusion of unfractionated heparin. The client asks the nurse what the heparin is for. How should the nurse respond?

The nurse is caring for a client with chronic, stable angina. The client takes the long-acting nitrate isosorbide mononitrate. Which client outcome indicates that the drug is effective?

The nurse has just completed discharge teaching about sublingual nitroglycerin (NTG) tablets to a client with stable angina. Which statement by the client indicates the need for further teaching?

A client is started on lisinopril therapy. Which assessment finding requires immediate action?

A client with stable angina is being discharged home with a prescription for a transdermal nitroglycerin patch. The nurse has reviewed discharge instructions on the medication with the client. Which statement by the client indicates that teaching has been effective?

A client with atrial fibrillation is being discharged home after being stabilized with medications, including digoxin. Which of the following statements regarding digoxin toxicity indicates that further teaching is needed?

A client taking a diuretic for chronic heart failure experiences constipation. What is the nurse's best recommendation?

An African American client comes to the clinic for a follow-up visit 2 months after starting enalapril for hypertension. Which client statement should be reported to the health care provider immediately?

The nurse is preparing medications for a group of clients. Which prescription should the nurse clarify with the health care provider before administering?

The nurse provides instructions to a client discharged on warfarin, after being treated for a pulmonary embolism (PE) following surgery. Which statements made by the client indicate the need for further teaching? Select all that apply.

The nurse admits a client with newly diagnosed unstable angina. Which information obtained during the admission health history is most important for the nurse to report to the health care provider (HCP) immediately?