NUR 2474 NUR2474 Pharm Exam 2 NCLEX Questions

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) a.Furosemide (Lasix) 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. 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 c.Potassium level of 3.5 mEq/L 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. 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) c.Spironolactone (Aldactone) 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. A nurse preparing to administer morning medications notes that a patient with a history of hypertension has been prescribed the angiotensin-converting enzyme (ACE) inhibitor captopril (Capoten) concurrently with spironolactone (Aldactone). Morning laboratory results reveal a serum sodium level of 144 mg/dL, a serum potassium level of 5.1 mEq/L, and a blood glucose level of 128 mg/dL. 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 report the laboratory values. d.Request an order for furosemide (Lasix). c.Contact the provider to report the laboratory values. Spironolactone should not be administered with ACE inhibitors, which can also elevate potassium levels. Because the potassium level is elevated, the nurse should not administer the medication and should obtain clarification of the order. There is no need to repeat the potassium level test that was just done this morning. Requesting an order for furosemide is appropriate only after the provider has been notified of the laboratory values. 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) d.Spironolactone (Aldactone) 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. 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 c.Ringing in the ears 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 or 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. 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 a.Elevated creatinine clearance 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. 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." b."I need to stop taking potassium supplements." 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. 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 d.Renal artery stenosis ACE inhibitors can cause severe renal insufficiency in patients with bilateral renal artery stenosis or stenosis in the artery to a single remaining kidney. Bronchial asthma, coronary artery disease, and diabetes mellitus are not comorbidities that are contraindications to treatment with an ACE inhibitor. A nurse administers an ACE inhibitor to a patient who is taking the drug for the first time. What will the nurse do? a.Instruct the patient not to get up without assistance. b.Make sure the patient takes a potassium supplement. c.Report the presence of a dry cough to the prescriber. d.Request an order for a diuretic to counter the side effects of the ACE inhibitor. a.Instruct the patient not to get up without assistance. Severe hypotension can result with the first dose of an ACE inhibitor. The patient should be discouraged from getting up without assistance. Potassium supplements are contraindicated. A dry cough is an expected side effect that eventually may cause a patient to discontinue the drug; however, it is not a contraindication to treatment. Diuretics can exacerbate hypotension and should be discontinued temporarily when a patient starts an ACE inhibitor. A patient who has been taking an antihypertensive medication for several years is recovering from a myocardial infarction. The prescriber changes the patient's medication to an ACE inhibitor. The patient asks the nurse why a new drug is necessary. What is the nurse's response? a."ACE inhibitors can prevent or reverse pathologic changes in the heart's structure." b."ACE inhibitors help lower LDL cholesterol and raise HDL cholesterol." c."ACE inhibitors increase venous return to the heart, improving cardiac output." d."ACE inhibitors regulate electrolytes that affect the cardiac rhythm." a."ACE inhibitors can prevent or reverse pathologic changes in the heart's structure." ACE inhibitors have many advantages over other antihypertensive medications, the most important of which is their ability to prevent or reverse pathologic changes in the heart and reduce the risk of cardiac mortality caused by hypertension. They are useful in patients with high low-density lipoprotein (LDL) or low high-density lipoprotein (HDL) cholesterol, but they do not directly affect this comorbidity. They reduce venous return to the heart, thereby reducing right heart size. They do not alter serum electrolyte levels A prescriber orders ramipril (Altace) for an obese patient with type 2 diabetes mellitus who has developed hypertension. The nurse provides teaching before dismissing the patient home. Which statement by the patient indicates understanding of the teaching? a."I am less likely to develop diabetic nephropathy when taking this medication." b."I should check my blood sugar more often, because hyperglycemia is a side effect of this drug." c."Taking this medication helps reduce my risk of stroke and heart attack." d."This medication will probably prevent the development of diabetic retinopathy." c."Taking this medication helps reduce my risk of stroke and heart attack." Ramipril (Altace) is approved for reducing the risk of stroke and myocardial infarction (MI) in patients at high risk for a major cardiovascular event because they have hypertension in conjunction with a history of stroke or MI or because they have diabetes. ACE inhibitors cannot be used for primary prevention of diabetic nephropathy, but they can delay the onset of overt nephropathy in patients who already have less advanced nephropathy. ACE inhibitors do not affect serum electrolytes or glucose. One ACE inhibitor, enalapril, can reduce the risk of diabetic retinopathy in some patients with type 1 diabetes mellitus. A patient begins taking an ACE inhibitor and complains of a dry cough. What does the nurse correctly tell the patient about this symptom? a.It indicates that a serious side effect has occurred. b.It is a common side effect that occurs in almost all patients taking the drug. c.It may be uncomfortable enough that the drug will need to be discontinued. d.It occurs frequently in patients taking the drug but will subside over time. c.It may be uncomfortable enough that the drug will need to be discontinued. A cough occurs in about 10% of patients taking ACE inhibitors and is the most common reason for discontinuing therapy. It does not indicate a serious condition. It occurs in about 10% of all patients and is more common in women, older adults, and those of Asian ancestry. It does not subside until the medication is discontinued. A nurse is reviewing a patient's medications before administration. Which drug-to-drug interactions should most concern the nurse in a patient with a history of heart failure and a potassium level of 5.5 mEq/L? a.Furosemide (Lasix) and enalapril (Vasotec) b.Amlodipine (Norvasc) and spironolactone (Aldactone) c.Eplerenone (Inspra) and spironolactone (Aldactone) d.Metoprolol (Lopressor) and furosemide (Lasix) c.Eplerenone (Inspra) and spironolactone (Aldactone) The greatest risk with eplerenone is hyperkalemia, and combining this drug with a potassium-sparing diuretic creates a significant risk of hyperkalemia. Furosemide and enalapril, an ACE inhibitor, would not be contraindicated in this patient. Amlodipine and spironolactone would not cause hyperkalemia. The combination of metoprolol, a beta blocker, and furosemide would not be contraindicated in this patient. A patient who stops taking an ACE inhibitor because of its side effects will begin taking an angiotensin II receptor blocker (ARB) medication. Which side effect of ACE inhibitors will not occur with an ARB medication? a.Angioedema b.Cancer c.Cough d.Renal failure c.Cough ARBs do not promote the accumulation of bradykinin in the lungs and do not induce cough. Angioedema may occur with ARBs, but the incidence is lower than with ACE inhibitors. An increased risk of cancer may be a concern with ARBs but is not a concern with ACE inhibitors. As with ACE inhibitors, renal failure can occur in patients with bilateral renal artery stenosis or stenosis in the artery to a single remaining kidney. A female patient 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. d.The patient should stop taking the medication and contact her provider immediately. ACE inhibitors are known to cause serious fetal injury during the second and third trimesters of pregnancy. Whether injury occurs earlier in pregnancy is unknown, and the incidence probably is low. However, women should be counseled to stop taking the drug if they become pregnant, and they should not take it if they are contemplating becoming pregnant. Women who take ACE inhibitors in the first trimester should be counseled that the risk to the fetus is probably low. Women should stop taking the drug when pregnant. ARBs carry the same risk as ACE inhibitors. A nurse is caring for a patient who is receiving verapamil (Calan) for hypertension and digoxin (Lanoxin) for heart failure. The nurse will observe this patient for: a.AV blockade. val hyperplasia. ine headaches. x tachycardia. a.AV blockade. Verapamil and digoxin both suppress impulse conduction through the AV node; when the two drugs are used concurrently, the risk of AV blockade is increased. Gingival hyperplasia can occur in rare cases with verapamil, but it is not an acute symptom. Verapamil can be used to prevent migraine, and its use for this purpose is under investigation. Verapamil and digoxin both suppress the heart rate. Nifedipine causes reflex tachycardia. A patient begins taking nifedipine (Procardia), along with a beta blocker, to treat hypertension. The nurse understands that the beta blocker is used to: e flushing. ize gingival hyperplasia. nt constipation. nt reflex tachycardia. nt reflex tachycardia. Beta blockers are combined with nifedipine to prevent reflex tachycardia. Beta blockers do not reduce flushing, minimize gingival hyperplasia, or prevent constipation. Beta blockers can reduce the adverse cardiac effects of nifedipine. A nurse is teaching a patient who will begin taking verapamil (Calan) for hypertension about the drug's side effects. Which statement by the patient indicates understanding of the teaching? a."I may become constipated, so I should increase fluids and fiber." b."I may experience a rapid heart rate as a result of taking this drug." c."I may have swelling of my hands and feet, but this will subside." d."I may need to increase my digoxin dose while taking this drug." a."I may become constipated, so I should increase fluids and fiber." Constipation is common with verapamil and can be minimized by increasing dietary fiber and fluids. Verapamil lowers the heart rate. Peripheral edema may occur secondary to vasodilation, and patients should notify their prescriber if this occurs, because the prescriber may use diuretics to treat the condition. Verapamil and digoxin have similar cardiac effects; also, verapamil may increase plasma levels of digoxin by as much as 60%, so digoxin doses may need to be reduced. A nurse is preparing to assist a nursing student in administering intravenous verapamil to a patient who also receives a beta blocker. The nurse asks the nursing student to discuss the plan of care for this patient. Which statement by the student indicates a need for further teaching? a."I will check to see when the last dose of the beta blocker was given." b."I will monitor vital signs closely to assess for hypotension." c."I will monitor the heart rate frequently to assess for reflex tachycardia." d."I will prepare to administer intravenous norepinephrine if necessary." c."I will monitor the heart rate frequently to assess for reflex tachycardia." Reflex tachycardia is not an expected effect; the greater risk is cardiosuppression and bradycardia. Because beta blockers and verapamil have the same effects on the heart, there is a risk of excessive cardiosuppression. To minimize this risk, the two drugs should be given several hours apart. Hypotension may occur and should be treated with IV norepinephrine. A patient who has been taking verapamil (Calan) for hypertension complains of constipation. The patient will begin taking amlodipine (Norvasc) to prevent this side effect. The nurse provides teaching about the difference between the two drugs. Which statement by the patient indicates that further teaching is needed? a."I can expect dizziness and facial flushing with nifedipine." b."I should notify the provider if I have swelling of my hands and feet." c."I will need to take a beta blocker to prevent reflex tachycardia." d."I will need to take this drug once a day." c."I will need to take a beta blocker to prevent reflex tachycardia." Amlodipine produces selective blockade of calcium channels in blood vessels with minimal effects on the heart. Reflex tachycardia is not common, so a beta blocker is not indicated to prevent this effect. Dizziness and facial flushing may occur. Peripheral edema may occur and should be reported to the provider. Amlodipine is given once daily. Which are therapeutic uses for verapamil? (Select all that apply.) a.Angina of effort b.Cardiac dysrhythmias c.Essential hypertension d.Sick sinus syndrome e.Suppression of preterm labor a.Angina of effort b.Cardiac dysrhythmias c.Essential hypertension Verapamil is used to treat both vasospastic angina and angina of effort. It slows the ventricular rate in patients with atrial flutter, atrial fibrillation, and paroxysmal supraventricular tachycardia. It is a first-line drug for the treatment of essential hypertension. It is contraindicated in patients with sick sinus syndrome. Nifedipine has investigational uses in suppressing preterm labor. A 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. eling on lifestyle changes. c.a thiazide diuretic. This patient has primary, or essential, hypertension as evidenced by systolic pressure greater than 140 and diastolic pressure greater than 90, along with normal tests ruling out another primary cause. Thiazide diuretics are first-line drugs for hypertension. Beta blockers are effective, but are most often used to counter reflex tachycardia associated with reduced blood pressure caused by therapeutic agents. Loop diuretics cause greater diuresis than is usually needed and so are not first-line drugs. This patient should be counseled on lifestyle changes as an adjunct to drug therapy, but should also begin drug therapy because hypertension already exists. A patient with diabetes develops hypertension. The nurse will anticipate administering which type of medication to treat hypertension in this patient? a.ACE inhibitors b.Beta blockers c.Direct-acting vasodilators d.Thiazide diuretics a.ACE inhibitors ACE inhibitors slow the progression of kidney injury in diabetic patients with renal damage. Beta blockers can mask signs of hypoglycemia and must be used with caution in diabetics. Direct-acting vasodilators are third-line drugs for chronic hypertension. Thiazide diuretics promote hyperglycemia. A patient 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. DASH diet, sodium restriction, and exercise. ased calcium and potassium supplements. ide diuretics and lifestyle changes. DASH diet, sodium restriction, and exercise. This patient has prehypertension without other risk factors. Lifestyle changes are indicated at this point. If blood pressure rises to hypertension levels, other measures, including drug therapy, will be initiated. Calcium and potassium supplements are not indicated. A patient with hypertension with a blood pressure of 168/110 mm Hg begins taking hydrochlorothiazide and verapamil. The patient returns to the clinic after 2 weeks of drug therapy, and the nurse notes a blood pressure of 140/85 mm Hg and a heart rate of 98 beats per minute. What will the nurse do? a.Notify the provider and ask about adding a beta blocker medication. b.Reassure the patient that the medications are working. c.Remind the patient to move slowly from sitting to standing. d.Request an order for an electrocardiogram. a.Notify the provider and ask about adding a beta blocker medication. Beta blockers are often added to drug regimens to treat reflex tachycardia, which is a common side effect of lowering blood pressure, caused by the baroreceptor reflex. The patient's blood pressure is responding to the medications, but the tachycardia warrants treatment. Reminding the patient to move slowly from sitting to standing is appropriate with any blood pressure medication, but this patient has reflex tachycardia, which must be treated. An electrocardiogram is not indicated. A 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." a."Beta blockers block the actions of angiotensin II." Beta blockers reduce the release of renin by blockade of beta1 receptors on juxtaglomerular cells in the kidney, which reduces angiotensin II-mediated vasoconstriction, but do not block the actions of angiotensin II directly. Beta blockers decrease heart rate and cardiac contractility, decrease peripheral vascular resistance, and decrease the release of renin. A patient is taking enalapril (Vasotec). The nurse understands that patients taking this type of drug for heart failure need to be monitored carefully for: natremia. tension. kalemia. alemia. kalemia. One of the principal effects of angiotensin-converting enzyme (ACE) inhibitors is hyperkalemia, which is due to decreased aldosterone release arising from blockage of angiotensin II. There is no indication that careful monitoring of sodium for increased levels is indicated. Vasotec is indicated for heart failure, not hypertension. The drug therapy should be monitored to ascertain its effectiveness, but hyperkalemia is the main concern. Hyperkalemia, not hypokalemia, is a concern because of the decreased aldosterone release that occurs with blockage of angiotensin II. A patient with chronic hypertension is admitted to the hospital. During the admission assessment, the nurse notes a heart rate of 96 beats per minute, a blood pressure of 150/90 mm Hg, bibasilar crackles, 2+ pitting edema of the ankles, and distension of the jugular veins. The nurse will contact the provider to request an order for which medication? a.ACE inhibitor b.Digoxin (Lanoxin) c.Furosemide (Lasix) d.Spironolactone (Aldactone) c.Furosemide (Lasix) This patient shows signs of fluid volume overload and needs a diuretic. Furosemide is a high-ceiling (loop) diuretic, which can produce profound diuresis very quickly even when the glomerular filtration rate (GFR) is low. An ACE inhibitor will not reduce fluid volume overload. Digoxin has a positive inotropic effect on the heart, which may improve renal perfusion, but this is not its primary effect. Spironolactone is a potassium-sparing diuretic with weak diuresis effects; it is used in conjunction with other diuretics to improve electrolyte balance. A diabetic patient is recovering from a myocardial infarction but does not have symptoms of heart failure. The nurse will expect to teach this patient about: a.ACE inhibitors and beta blockers. tricular pacemakers. ry supplements and exercise. tics and digoxin. a.ACE inhibitors and beta blockers. This patient is classified as having Stage B heart failure with no current symptoms but with structural heart disease strongly associated with the development of heart failure. Treatment at this stage includes an ACE inhibitor and a beta blocker to help prevent the progression of symptoms. Biventricular pacemakers are used for patients in Stage C heart failure and have more advanced structural disease and symptoms. Dietary supplements and exercise have not been proven to prevent structural heart disease. Diuretics and digoxin are used for patients with Stage C heart failure. A patient with heart failure who has been taking an ACE inhibitor, a thiazide diuretic, and a beta blocker for several months comes to the clinic for evaluation. As part of the ongoing assessment of this patient, the nurse will expect the provider to evaluate: ete blood count. ion fraction. al exercise capacity. electrolyte levels. electrolyte levels. Patients taking thiazide diuretics can develop hypokalemia, which can increase the risk for dysrhythmias; therefore, the serum electrolyte levels should be monitored closely. A complete blood count is not recommended. This patient is taking the drugs recommended for patients with Stage C heart failure; although the patient's quality of life and ability to participate in activities should be monitored, routine measurement of the ejection fraction and maximal exercise capacity is not recommended. A patient with Stage C heart failure (HF) who has been taking an ACE inhibitor, a beta blocker, and a diuretic begins to have increased dyspnea, weight gain, and decreased urine output. The provider orders spironolactone (Aldactone). The nurse will make sure that the patient: not take potassium supplements. ors for a decreased heart rate. extra fluids. a salt substitute instead of salt. not take potassium supplements. Spironolactone is added to therapy for patients with worsening symptoms of HF. Because spironolactone is a potassium-sparing diuretic, patients should not take supplemental potassium. Patients taking digoxin need to monitor their heart rate. Extra fluids are not indicated. Salt substitutes contain potassium. The potassium-sparing diuretic spironolactone (Aldactone) prolongs survival and improves heart failure symptoms by which mechanism? a.Blocking aldosterone receptors b.Increasing diuresis c.Reducing venous pressure d.Reducing afterload a.Blocking aldosterone receptors Spironolactone prolongs survival in patients with HF primarily by blocking receptors for aldosterone. Spironolactone cause only minimal diuresis. Spironolactone does not reduce afterload, and it does not reduce venous pressure enough to prolong survival, because it causes only minimal diuresis. A nurse prepares to administer a scheduled dose of digoxin. The nurse finds a new laboratory report showing a plasma digoxin level of 0.7 ng/mL. What action should the nurse take? a.Withhold the drug for an hour and reassess the level. b.Withhold the drug and notify the prescriber immediately. c.Administer Digibind to counteract the toxicity. d.Check the patient's apical pulse, and if it is within a safe range, administer the digoxin. d.Check the patient's apical pulse, and if it is within a safe range, administer the digoxin. The optimum plasma digoxin range is 0.5 to 0.8 ng/mL. The patient's pulse should be checked before administration, as always, and the digoxin should be administered. The digoxin does not have to be withheld, nor does the prescriber need to be notified. If the digoxin level is demonstrating a trend of increasing, the issue should be discussed in rounds. Digibind is not indicated, because the digoxin level is therapeutic. A nurse is preparing to administer digoxin (Lanoxin) to a patient. The patient's heart rate is 62 beats per minute, and the blood pressure is 120/60 mm Hg. The last serum electrolyte value showed a potassium level of 5.2 mEq/L. What will the nurse do? a.Contact the provider to request an increased dose of digoxin. b.Give the dose of digoxin and notify the provider of the potassium level. c.Request an order for a diuretic. d.Withhold the dose and notify the provider of the heart rate b.Give the dose of digoxin and notify the provider of the potassium level. The patient's serum potassium level is above normal limits, but only slightly. An elevated potassium level can reduce the effects of digoxin, so there is no risk of toxicity. There is no indication that an increased dose of digoxin is needed. There is no indication for a diuretic. The heart rate is acceptable; doses should be withheld if the heart rate is less than 60 beats per minute. A patient with heart failure who has been given digoxin (Lanoxin) daily for a week complains of nausea. Before giving the next dose, the nurse will: s the heart rate (HR) and give the dose if the HR is greater than 60 beats per minute. ct the provider to report digoxin toxicity. st an order for a decreased dose of digoxin. w the serum electrolyte values and withhold the dose if the potassium level is greater than 3.5 mEq/L. s the heart rate (HR) and give the dose if the HR is greater than 60 beats per minute. Anorexia, nausea, and vomiting are the most common adverse effects of digoxin and should cause nurses to evaluate for more serious signs of toxicity. If the HR is greater than 60 beats per minute, the dose may be given. Nausea by itself is not a sign of toxicity. A decreased dose is not indicated. A serum potassium level less than 3.5 mEq/L is an indication for withholding the dose. A patient is taking a thiazide diuretic for hypertension and quinidine to treat a dysrhythmia. The prescriber orders digoxin 0.125 mg to improve this patient's cardiac output. The nurse should contact the provider to request: g spironolactone (Aldactone). ing the dose of digoxin. ntinuing the quinidine. g potassium supplements. ntinuing the quinidine. Quinidine can cause plasma levels of digoxin to rise; concurrent use of quinidine and digoxin is contraindicated. There is no indication for adding spironolactone unless this patient's potassium level is elevated. The dose of digoxin ordered is a low dose. Potassium supplements are contraindicated with digoxin. A patient with heart failure who takes a thiazide diuretic and digoxin (Lanoxin) is admitted for shortness of breath. The patient's heart rate is 66 beats per minute, and the blood pressure is 130/88 mm Hg. The serum potassium level is 3.8 mEq/L, and the digoxin level is 0.8 ng/mL. The nurse admitting this patient understands that the patient: digoxin toxicity. showing signs of renal failure. experiencing worsening of the disease. a potassium-sparing diuretic. experiencing worsening of the disease. This patient has a normal serum potassium level, and the digoxin level is normal. The patient is showing signs of pulmonary edema, which indicates progression of heart failure. The digoxin level is within normal limits, and the heart rate is above 60 beats per minute, so digoxin toxicity is not likely. There is no sign of renal failure. A potassium-sparing diuretic is not indicated. A patient has been taking digoxin (Lanoxin) 0.25 mg, and furosemide (Lasix) 40 mg, daily. Upon routine assessment by the nurse, the patient states, "I see yellow halos around the lights." The nurse should perform which action based on this assessment? a.Check the patient for other symptoms of digitalis toxicity. b.Withhold the next dose of furosemide. c.Continue to monitor the patient for heart failure. d.Document the findings and reassess in 1 hour. a.Check the patient for other symptoms of digitalis toxicity. Yellow halos around lights indicate digoxin toxicity. The use of furosemide increases the risk of hypokalemia, which in turn potentiates digoxin toxicity. The patient should also be assessed for headache, nausea, and vomiting, and blood should be drawn for measurement of the serum digoxin level. The nurse should not withhold the dose of furosemide until further assessment is done, including measurement of a serum digoxin level. No evidence indicates that the patient is in worsening heart failure. Documentation of findings is secondary to further assessment and prevention of digoxin toxicity. Which medications are included in first-line therapy for heart failure? (Select all that apply.) a.Agents that inhibit the renin-angiotensin-aldosterone system (RAAS) b.Aldosterone antagonists c.Beta blockers d.Cardiac glycosides e.Diuretics a.Agents that inhibit the renin-angiotensin-aldosterone system (RAAS) c.Beta blockers e.Diuretics For routine therapy, heart failure is treated with agents that inhibit the RAAS, beta blockers, and diuretics. Aldosterone antagonists and cardiac glycosides are not first-line drugs for HF. A nurse is providing teaching to a patient who is admitted to the hospital for initiation of treatment with amiodarone (Cordarone) for atrial fibrillation that has been refractory to other medications. Which statement by the patient indicates a need for further teaching? a."I may have itching, malaise, and jaundice, but these symptoms will subside." b."I need to use sun block to help keep my skin from turning bluish gray." c."I should not drink grapefruit juice while taking this medication." d."I should report shortness of breath and cough and stop taking the drug immediately." a."I may have itching, malaise, and jaundice, but these symptoms will subside." Amiodarone has many toxic effects. Liver toxicity is rare but serious and should be reported and the drug discontinued. Dermatologic toxicity can occur, and sun block helps protect the skin, which, with prolonged exposure to the sun, can turn bluish gray. Drinking grapefruit juice can increase amiodarone levels. Pulmonary toxicity is the greatest concern, and patients with pulmonary symptoms should report these to the provider. A prescriber orders verapamil (Covera HS) for a patient who is taking digoxin (Lanoxin) and warfarin. The nurse will expect the prescriber to _____ the dose of _____. digoxin ase; digoxin ; warfarin ase; warfarin ; ; digoxin Calcium channel blockers, such as verapamil, can increase levels of digoxin, so patients taking these drugs may need to have their digoxin dose reduced. Increasing the dose of digoxin can result in digoxin toxicity. Verapamil does not affect warfarin levels. A patient will be taking amiodarone (Cordarone). Which baseline tests are necessary before this medication is started? (Select all that apply.) a.Chest radiograph and pulmonary function tests b.Complete blood count with differential c.Ophthalmologic examination d.Renal function tests e.Thyroid function tests a.Chest radiograph and pulmonary function tests c.Ophthalmologic examination e.Thyroid function tests Amiodarone has many potential toxic side effects, including pulmonary toxicity, ophthalmic effects, and thyroid toxicity, so these systems should be evaluated at baseline and periodically while the patient is taking the drug. A complete blood count is not indicated. Renal function tests are not indicated. A prescriber has ordered rosuvastatin (Crestor) for a patient with non-alcoholic-related cirrhosis. Which intervention would be most appropriate for the nurse before administration of this drug? a.Question the order, because rosuvastatin is contraindicated in patients with liver disease. b.No intervention is necessary just administer the drug as ordered. c.Review the baseline liver function test results. d.Assess the patient for liver disease. ; c.Review the baseline liver function test results. Before administering rosuvastatin, the nurse should review the results of the baseline liver function tests (LFTs). Statins can be used by patients with liver disease but not by those with alcoholic or viral hepatitis. Administering the drug before obtaining baseline LFT results would not allow for an accurate baseline. The patient clearly already has liver disease. A patient with malaise has been taking daptomycin (Cubicin) for an infection and is concurrently taking simvastatin (Zocor). The nurse should be concerned if the patient complains of: a. ness. e pain. che. e pain. Statins can injure muscle tissue, causing muscle aches and pain known as myopathy/rhabdomyolysis. Daptomycin also can cause myopathy and therefore should be used with caution in patients concurrently taking simvastatin. Nausea, tiredness, and headache would not cause the nurse as much concern as the likelihood of myopathy. A patient who recently started therapy with an HMG-COA reductase inhibitor asks the nurse, "How long will it take until I see an effect on my LDL cholesterol?" The nurse gives which correct answer? a."At least 6 months is required to see a change." b."A reduction usually is seen within 2 weeks." c."Blood levels normalize immediately after the drug is started." d."Cholesterol will not be affected, but triglycerides will fall within the first week." b."A reduction usually is seen within 2 weeks." Reductions in LDL cholesterol are significant within 2 weeks and maximal within 4 to 6 weeks. It does not take 6 months too see a change. The blood level of LDL cholesterol is not reduced immediately upon starting the drug; a reduction is seen within 2 weeks. Blood cholesterol is affected, specifically LDL cholesterol, not triglycerides. A patient has begun taking an HMG-COA reductase inhibitor. Which statement about this class of drugs made by the nurse during patient education would be inappropriate? a."Statins reduce the risk of stroke." b."You should come into the clinic for liver enzymes in 1 month." c."Statins reduce the risk of coronary events in people with normal LDL levels." d."You should maintain a healthy lifestyle and avoid high-fat foods." b."You should come into the clinic for liver enzymes in 1 month." Baseline liver enzyme tests should be done before a patient starts taking an HMG-COA reductase inhibitor. They should be measured again in 6 to 12 months unless the patient has poor liver function, in which case the tests are indicated every 3 months. Statins do reduce the risk of stroke and coronary events in people with normal LDL levels. Maintaining a healthy lifestyle is important, as is avoiding high-fat foods. A nurse is instructing a patient receiving a cholesterol-lowering agent. Which information should the nurse include in the patient education? a."This medication will replace other interventions you have been trying." b."It is important for you to double your dose if you miss one to maintain therapeutic blood levels." c."Stop taking the medication if you experience constipation." d."You should continue your exercise program to increase your HDL serum levels." d."You should continue your exercise program to increase your HDL serum levels." Regular exercise can reduce LDL cholesterol and elevate high-density lipoprotein (HDL) cholesterol, thereby reducing the risk of coronary heart disease (CHD). The patient should consider the cholesterol-lowering drug an adjunct to a proper diet and exercise. Drug therapy cannot replace other important interventions, such as diet and exercise. The patient should never be instructed to double the dose. Constipation is a side effect of most cholesterol-lowering agents. The patient should be encouraged to eat a high-fiber diet and increase fluids if not contraindicated. Lovastatin (Mevacor) is prescribed for a patient for the first time. The nurse should provide the patient with which instruction? a."Take lovastatin with your evening meal." b."Take this medicine before breakfast." c."You may take lovastatin without regard to meals." d."Take this medicine on an empty stomach." a."Take lovastatin with your evening meal." Patients should be instructed to take lovastatin with the evening meal. Statins should be taken with the evening meal, not before breakfast. Statins should not be administered without regard to meals and should not be taken on an empty stomach. A nurse is providing discharge teaching instructions for a patient taking cholestyramine (Questran). Which statement made by the patient demonstrates a need for further teaching? a."I will take warfarin (Coumadin) 1 hour before my medicine." b."I will increase the fluids and fiber in my diet." c."I can take cholestyramine with my hydrochlorothiazide." d."I will take digoxin 4 hours after taking the cholestyramine." c."I can take cholestyramine with my hydrochlorothiazide." Drugs known to form complexes with the sequestrants include thiazide diuretics, such as hydrochlorothiazide, digoxin, warfarin, and some antibiotics. To reduce the formation of sequestrant-drug complexes, oral medication should be administered either 1 hour before the sequestrant or 4 hours after. Further teaching is needed. Warfarin should be taken 1 hour before or 4 hours after cholestyramine. Adverse effects of Questran are limited to the gastrointestinal (GI) tract. Constipation, the principal complaint, can be minimized by increasing dietary fiber and fluids. Digoxin should be taken 1 hour before or 4 hours after cholestyramine. A nurse is providing patient education about colesevelam (Welchol), a bile acid sequestrant. Which statement made by the patient demonstrates a need for further teaching? a."Colesevelam will reduce my levels of low-density lipoprotein." b."Colesevelam will augment my statin drug therapy." c."I will not have to worry about having as many drug interactions as I did when I took cholestyramine." d."I cannot take digoxin while on this medication." d."I cannot take digoxin while on this medication." Digoxin can be taken 1 hour before or 4 hours after taking a bile acid sequestrant. Colesevelam reduces the LDL cholesterol level, which is one of its therapeutic uses. Colesevelam augments statin therapy. Colesevelam does not significantly interact with or reduce the absorption of statins, digoxin, warfarin, or most other drugs. A nurse is reviewing the medications of a patient with diabetes before discharge. The nurse realizes that the patient will be going home on colesevelam, a bile acid sequestrant, and insulin. What patient education should the nurse provide in the discharge teaching for this patient? a.The patient needs to monitor the blood sugar carefully, because colesevelam can cause hypoglycemia. b.The patient needs to monitor the blood sugar carefully, because colesevelam can cause hyperglycemia. c.The patient needs to take the insulin at least 3 hours before the colesevelam. d.The patient needs to use an oral antidiabetic agent or agents, not insulin, with colesevelam. a.The patient needs to monitor the blood sugar carefully, because colesevelam can cause hypoglycemia. Colesevelam can help control hyperglycemia in patients with diabetes; therefore, hypoglycemia is a possible risk. Hyperglycemia is not a risk for patients with diabetes who take colesevelam. Insulin and colesevelam do not interact; therefore, the insulin can be taken at the patient's preferred time or times. Either insulin or oral antidiabetic agents can be taken with colesevelam. During discharge instruction, a nurse wants to assess a patient's understanding of treatment with cholestyramine (Questran). Which statement made by the patient best demonstrates a need for additional teaching? a."I will take cholestyramine (Questran) 1 hour before my other medications." b."I will increase fluids and fiber in my diet." c."I will weigh myself weekly." d."I will have my blood pressure checked weekly." c."I will weigh myself weekly." Patients need not weigh themselves weekly when taking cholestyramine. Cholestyramine should be taken at least 1 hour before other medications. When taken with other medications, cholestyramine can inhibit the absorption of the other drugs. Constipation is the principal complaint with cholestyramine. It can be minimized by increasing dietary fiber and fluids. Regular blood pressure checks are a good idea. The patient is taking cholestyramine because of high cholesterol, which contributes to hypertension. A nurse is providing teaching for a patient with stable angina who will begin taking nitroglycerin. Which statement by the patient indicates understanding of the teaching? a."I should not participate in aerobic exercise while taking this drug." b."I should take aspirin daily to reduce my need for nitroglycerin." c."If I take nitroglycerin before exertion, I can reduce the chance of an anginal attack." d."I take nitroglycerin to increase the amount of oxygen to my heart." c."If I take nitroglycerin before exertion, I can reduce the chance of an anginal attack." Nitroglycerin can be taken before stressful events or exertion to reduce the chance of an attack of angina. Aerobic exercise is an important part of nondrug therapy to reduce the risk of heart attack. Aspirin therapy is an important adjunct to treatment to prevent coronary thrombus formation, but it does not reduce the need for nitroglycerin. Nitroglycerin reduces cardiac oxygen demand, but it does not increase the amount of oxygen available to the heart. A patient with new-onset exertional angina takes a nitroglycerin sublingual tablet, but the pain intensifies. The nurse notes that the patient has a heart rate of 76 beats per minute and a blood pressure of 120/82 mm Hg. The electrocardiogram is normal. The patient's lips and nail beds are pink, and there is no respiratory distress. The nurse will anticipate providing: angiotensin-converting enzyme (ACE) inhibitor. venous nitroglycerin and a beta blocker. azine (Ranexa) and quinidine. emental oxygen and intravenous morphine. venous nitroglycerin and a beta blocker. This patient has unstable angina, and the next step, when pain is unrelieved by sublingual nitroglycerin, is to give intravenous nitroglycerin and a beta blocker. ACE inhibitors should be given to patients with persistent hypertension if they have left ventricular dysfunction or congestive heart failure (CHF). Ranolazine is a first-line angina drug, but it should not be given with quinidine because of the risk of increasing the QT interval. Supplemental oxygen is indicated if cyanosis or respiratory distress is present. IV morphine may be given if the pain is unrelieved by nitroglycerin. A patient asks a nurse how nitroglycerin works to relieve anginal pain. The nurse correctly states, "Nitroglycerin: es coronary arteries to increase blood flow to the heart." ases the oxygen supply to the cardiac muscle." ases ventricular filling to improve cardiac output." tes vasodilation, which reduces preload and oxygen demand." tes vasodilation, which reduces preload and oxygen demand." Nitroglycerin dilates the veins, which reduces venous return to the heart, which in turn decreases ventricular filling. The resulting decrease in preload reduces the oxygen requirements of the heart. Nitroglycerin does not increase the blood flow or oxygen supply to the heart. An increase in ventricular filling would increase oxygen demand and result in increased anginal pain. A hospitalized patient complains of acute chest pain. The nurse administers a 0.3 mg sublingual nitroglycerin tablet, but the patient continues to complain of pain. Vital signs remain stable. What is the nurse's next step? a.Apply a nitroglycerin transdermal patch. b.Continue dosing at 10-minute intervals. c.Give a second dose of nitroglycerin in 5 minutes. d.Request an order for intravenous nitroglycerin. c.Give a second dose of nitroglycerin in 5 minutes. An initial dose of sublingual nitroglycerin is taken, and if the chest pain persists, as in this case, the patient should take another dose in 5 minutes. Transdermal delivery systems are not useful for terminating an ongoing attack. Dosing at 10-minute intervals is incorrect. If the patient fails to respond or if the pain intensifies, intravenous nitroglycerin may be indicated. A patient who has begun using transdermal nitroglycerin for angina reports occasional periods of tachycardia. The nurse will expect the prescriber to order: in (Lanoxin) to slow the heart rate. iate discontinuation of the nitroglycerin. ds of rest when the heart rate increases. amil as an adjunct to nitroglycerin therapy. amil as an adjunct to nitroglycerin therapy. Nitroglycerin lowers blood pressure by reducing venous return and dilating the arterioles. The lowered blood pressure activates the baroreceptor reflex, causing reflex tachycardia, which can increase cardiac demand and negate the therapeutic effects of nitroglycerin. Treatment with a beta blocker or verapamil suppresses the heart to slow the rate. Digoxin is not recommended. Discontinuation of the nitroglycerin is not indicated. Resting does not slow the heart when the baroreceptor reflex is the cause of the tachycardia. A patient with angina who uses sublingual nitroglycerin tells the nurse that the episodes are increasing in frequency and usually occur when the patient walks the dog. The patient reports needing almost daily doses of the nitroglycerin and states that one tablet usually provides complete relief. What will the nurse do? a.Contact the provider to suggest ordering a transdermal patch for this patient. b.Question the patient about consumption of grapefruit juice. c.Suggest that the patient limit walking the dog to shorter distances less frequently. d.Suggest that the patient take two tablets of nitroglycerin each time, because the symptoms are increasing in frequency. a.Contact the provider to suggest ordering a transdermal patch for this patient. Transdermal patches are good for sustained prophylaxis for anginal attacks and are especially useful when patients have a regular pattern of attacks. Grapefruit juice does not affect the metabolism of nitroglycerin. Patients with angina should be encouraged to increase, not decrease, exercise. Taking two tablets is not recommended when one is effective. A patient with stable exertional angina has been receiving a beta blocker. Before giving the drug, the nurse notes a resting heart rate of 55 beats per minute. Which is an appropriate nursing action? a.Administer the drug as ordered, because this is a desired effect. b.Withhold the dose and notify the provider of the heart rate. c.Request an order for a lower dose of the medication. d.Request an order to change to another antianginal medication. a.Administer the drug as ordered, because this is a desired effect. When beta blockers are used for anginal pain, the dosing goal is to reduce the resting heart rate to 50 to 60 beats per minute. Because this heart rate is a desired effect, there is no need to withhold the dose or notify the provider. The dosage does not need to be lowered, because a heart rate of 55 beats per minute is a desired effect. There is no indication of a need to change medications for this patient. A patient is taking a calcium channel blocker (CCB) for stable angina. The patient's spouse asks how calcium channel blockers relieve pain. The nurse will explain that CCBs: relax peripheral arterioles to reduce afterload. ve coronary artery perfusion. ase the heart rate to improve myocardial contractility. ase the QT interval. relax peripheral arterioles to reduce afterload. CCBs promote relaxation of peripheral arterioles, resulting in a decrease in afterload, which reduces the cardiac oxygen demand. CCBs do not improve coronary artery perfusion. CCBs reduce the heart rate and suppress contractility. CCBs do not affect the QT interval. A nurse provides teaching to a patient with angina who also has type 2 diabetes mellitus, asthma, and hypertension. Which statement by the patient indicates a need for further teaching? a."An ACE inhibitor, in addition to nitroglycerin, will lower my risk of cardiovascular death." b."Beta blockers can help control hypertension." c."I should begin regular aerobic exercise." d."Long-acting, slow-release calcium channel blockers can help with anginal pain." b."Beta blockers can help control hypertension." Beta blockers can be used for angina in most patients but are contraindicated in patients with asthma, because they cause bronchoconstriction. ACE inhibitors help reduce the risk of death in patients with hypertension. Regular aerobic exercise is recommended to control weight and improve cardiovascular function. Long-acting, slow-release CCBs are recommended for patients who have coexisting type 2 diabetes. A nursing student who is preparing to care for a postoperative patient with deep vein thrombosis asks the nurse why the patient must take heparin rather than warfarin. Which response by the nurse is correct? a"Heparin has a longer half-life." b."Heparin has fewer adverse effects." c."The onset of warfarin is delayed." d."Warfarin prevents platelet aggregation." c."The onset of warfarin is delayed." Warfarin is not useful for treating existing thromboses or for emergencies because the onset of action is delayed. Heparin has a shorter half life and has more side effects. Warfarin does not prevent platelet aggregation. A patient is receiving heparin postoperatively to prevent deep vein thrombosis. The nurse notes that the patient has a blood pressure of 90/50 mm Hg and a heart rate of 98 beats per minute. The patient's most recent aPTT is greater than 90 seconds. The patient reports lumbar pain. The nurse will request an order for: a.a repeat aPTT to be drawn immediately. esic medication. ing heparin to aspirin. mine sulfate. mine sulfate. Heparin overdose may cause hemorrhage, which can be characterized by low blood pressure, tachycardia, and lumbar pain. Protamine sulfate should be given, and the heparin should be discontinued. An aPTT may be drawn later to monitor the effectiveness of protamine sulfate. Analgesics are not indicated because the lumbar pain is likely caused by adrenal hemorrhage. Aspirin will only increase the risk of hemorrhage. A patient with atrial fibrillation is receiving warfarin (Coumadin). The nurse notes that the patient's INR is 2.7. Before to giving the next dose of warfarin, the nurse will notify the provider and: ister the dose as ordered. st an order to decrease the dose. st an order to give vitamin K (phytonadione). st an order to increase the dose. ister the dose as ordered. This patient has an INR in the appropriate range, so no change in warfarin dosing is necessary. It is not correct to request an order to either decrease or increase the dose of warfarin. It is not necessary to give vitamin K, which is an antidote for warfarin toxicity. A patient who takes warfarin for atrial fibrillation undergoes hip replacement surgery. On the second postoperative day, the nurse assesses the patient and notes an oxygen saturation of 83%, pleuritic chest pain, shortness of breath, and hemoptysis. The nurse will contact the provider to report possible _____ and request an order for _____. stive heart failure furosemide (Lasix) rhage; vitamin K (phytonadione) rdial infarction: tissue plasminogen activator (tPA) nary embolism; heparin ; nary embolism; heparin This patient is exhibiting signs of pulmonary embolism. Heparin is used when rapid onset of anticoagulants is needed, as with pulmonary embolism. The patient would have respiratory cracks and a cough with congestive heart failure. Hemorrhage involves a decrease in blood pressure, bruising, and lumbar pain. The patient has pleuritic pain, which is not consistent with the chest pain of an MI. A patient who takes warfarin (Coumadin) is brought to the emergency department after accidentally taking too much warfarin. The patient's heart rate is 78 beats per minute and the blood pressure is 120/80 mm Hg. A dipstick urinalysis is normal. The patient does not have any obvious hematoma or petechiae and does not complain of pain. The nurse will anticipate an order for: in K (phytonadione). mine sulfate. c.a PTT. d.a PT and an INR d.a PT and an INR This patient does not exhibit any signs of bleeding from a warfarin overdose. The vital signs are stable, there are no hematomas or petechiae, and the patient does not have pain. A PT and INR should be drawn to evaluate the anticoagulant effects. Vitamin K may be given if laboratory values indicate overdose. Protamine sulfate is given for heparin overdose. PTT evaluation is used to monitor heparin therapy. A patient has been taking warfarin (Coumadin) for atrial fibrillation. The provider has ordered dabigatran etexilate (Pradaxa) to replace the warfarin. The nurse teaches the patient about the change in drug regimen. Which statement by the patient indicates understanding of the teaching? a."I may need to adjust the dose of dabigatran after weaning off the warfarin." b."I should continue to take the warfarin after beginning the dabigatran until my INR is greater than 3." c."I should stop taking the warfarin 3 days before starting the dabigatran." d."I will stop taking the warfarin and will start taking the dabigatran when my INR is less than 2." d."I will stop taking the warfarin and will start taking the dabigatran when my INR is less than 2." When switching from warfarin to dabigatran, patients should stop taking the warfarin and begin taking the dabigatran when the INR is less than 2. It is not correct to begin taking the dabigatran before stopping the warfarin. While warfarin is stopped before beginning the dabigatran, the decision to start taking the dabigatran is based on the patient's INR and not on the amount of time that has elapsed. A patient will begin taking dabigatran etexilate (Pradaxa) to prevent stroke. The nurse will include which statement when teaching this patient? a.Dabigatran should be taken on an empty stomach to improve absorption. b.It is important not to crush, chew, or open capsules of dabigatran. c.The risk of bleeding with dabigatran is less than that with warfarin (Coumadin). d.To remember to take dabigatran twice daily, a pill organizer can be useful. b.It is important not to crush, chew, or open capsules of dabigatran. Patients should be taught to swallow capsules of dabigatran intact; absorption may be increased as much as 75%, increasing the risk of bleeding, if the capsules are crushed, chewed, or opened. Dabigatran may be taken with or without food. The risk of bleeding is not less than that of warfarin. Dabigatran is unstable when exposed to moisture, so using a pill organizer is not recommended. A postoperative patient will begin anticoagulant therapy with rivaroxaban (Xarelta) after knee replacement surgery. The nurse performs a history and learns that the patient is taking erythromycin. The patient's creatinine clearance is 50 mL/min. The nurse will: ister the first dose of rivaroxaban as ordered. y the provider to discuss changing the patient's antibiotic. st an order for a different anticoagulant medication. st an order to increase the dose of rivaroxaban. y the provider to discuss changing the patient's antibiotic. Patients with impaired renal function who are taking macrolide antibiotics will experience increased levels of rivaroxaban, increasing the risk of bleeding. It is correct to discuss using a different antibiotic if possible. The nurse should not administer the dose without discussing the situation with the provider. The patient's renal impairment is minor; if it were more severe, using a different anticoagulant might be appropriate. It is not correct to increase the dose of rivaroxaban. A nurse caring for a patient receiving heparin therapy notes that the patient has a heart rate of 98 beats per minute and a blood pressure of 110/72 mm Hg. The patient's fingertips are purplish in color. A stat CBC shows a platelet count of less than 100,000 mm3. The nurse will: ister oxygen and notify the provider. ntinue the heparin and notify the provider. st an order for protamine sulfate. st an order for vitamin K (phytonadione). ntinue the heparin and notify the provider. This patient is showing signs of heparin-induced thrombocytopenia, so the heparin should be discontinued immediately and the provider should be notified. The purplish color of the fingertips is caused by thrombosis, not hypoxia, so oxygen is not indicated. This patient may need continued anticoagulation therapy, so a request for protamine sulfate is not correct. Heparin is not a vitamin K inhibitor. A patient with epistaxis and a history of hemophilia A is admitted to the unit and is scheduled for replacement therapy. The nurse should prepare to administer which medication? a.Tranexamic acid (Cyklokapron) b.Aminocaproic acid (Amicar) c.Desmopressin (Stimate) d.Factor VIII d.Factor VIII The cornerstone of treatment for hemophilia A is replacement therapy with factor VIII. Tranexamic acid and aminocaproic acid are antifibrinolytic agents that act primarily by preventing the formation of plasmin from its precursor. Desmopressin promotes the release of factor VIII from the vascular endothelium and has the advantage of being cheaper than factor VIII. Also, it can be administered by nasal spray or by IV infusion. However, repeated use of desmopressin can deplete stored factor VIII. The parents of a boy with hemophilia A want to know why their son will receive factor replacement on an ongoing basis rather than when needed for bleeding episodes. They tell the nurse that the boy's grandfather, who had the same disease, received the drug only when he had bleeding. The nurse will give the parents which information about ongoing therapy? a.It can reverse progression of the disease. b.It is cheaper, because the amounts of the drug used are less. c.It is used to minimize pathologic developments in the joints. d.It prevents the development of inhibitors. c.It is used to minimize pathologic developments in the joints. Primary prophylaxis, especially in young children, minimizes bleeding episodes and long-term damage to joints. Ongoing treatment does not reverse the progression of the disease. Ongoing therapy is not less expensive, nor does it prevent the development of inhibitors. A patient with renal failure is undergoing chronic hemodialysis. The patient's