Pharm questions 136-180

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136. A patient with asthma uses albuterol (Ventolin) for wheezing. The nurse assesses the patient and notes vital signs of HR, 96 beats per minute; RR, 18 breaths per minute; and BP, 116/78 mm Hg. The patient has clear breath sounds and hand tremors. What will the nurse do?

a. Ask the patient how often the inhaler is used.
b. Check the patient's blood glucose level.
c. Request an order for isoproterenol (Isuprel) to reduce side effects.
d. Stop the medication and report the tremors to the provider.

a. Ask the patient how often the inhaler is used.

Tachycardia is a response to activation of beta1 receptors. It can occur when large doses of albuterol are used and selectivity decreases. The nurse should question the patient about the number of inhalations used. Isoproterenol can cause hyperglycemia in diabetic patients. Isoproterenol has more side effects than albuterol. Tremors are an expected side effect and are not an indication for stopping the drug.

137. A nurse is teaching parents how to use an Epi-Pen for their child, who has a peanut allergy. Which statement by the parents indicates understanding of the teaching?

a. "After using the Epi-Pen, we must go to the emergency department."
b. "The Epi-Pen should be stored in the refrigerator, because epinephrine is sensitive to heat."
c. "The teacher should call us when symptoms start so that we can bring the Epi-Pen to school."
d. "We should jab the device into the thigh until it is empty of solution."

a. "After using the Epi-Pen, we must go to the emergency department."

After using the Epi-Pen, it is important that the individual get medical attention as quickly as possible. The effects of epinephrine fade in 10 to 20 minutes, and the anaphylactic reaction can be biphasic and prolonged. Epinephrine is sensitive to heat, but storing the device in the refrigerator can compromise the injection mechanism; the device should be stored at room temperature in a dark place. Individuals who need an Epi-Pen must have the device with them at all times; any delay in treatment can be fatal, because anaphylaxis can occur within minutes after exposure. The Epi-Pen contains 2 mL of epinephrine, but only 0.3 mL is injected; the device will not be empty with a successful injection.

138. Because they cause vasoconstriction, alpha1-adrenergic agonists are especially useful for:

a. extending the duration of local anesthetics.
b. producing mydriasis to facilitate ophthalmic examinations.
c. slowing the heart rate in tachycardic patients.
d. treating hypotension.

a. extending the duration of local anesthetics.

The vasoconstrictive effects of alpha1-adrenergic agonists, such as epinephrine, help delay absorption of a local anesthetic, prolonging the anesthetic's effects. These agents can increase blood pressure but are not the primary drugs used except in emergency situations. Alpha1 receptors in the radial muscles of the iris, not vasoconstriction, cause mydriasis. Reflex bradycardia is a side effect and not a clinical use of these agents.

139. A patient is admitted to the intensive care unit for treatment of shock. The prescriber orders isoproterenol (Isuprel). The nurse expects this drug to increase tissue perfusion in this patient by activating:

a. alpha1 receptors to cause vasoconstriction.
b. alpha1 receptors to increase blood pressure.
c. beta1 receptors to cause a positive inotropic effect.
d. beta2 receptors to cause bronchodilation.

c. beta1 receptors to cause a positive inotropic effect.


Isoproterenol is used for shock because of its actions on beta1 receptors in the heart. It has a positive inotropic effect, which improves cardiac output and thus increases tissue perfusion. Isoproterenol does not affect alpha1 receptors. Although it activates beta2 receptors to cause bronchodilation, this is not indicated for the treatment of shock.

140. A pregnant patient with diabetes and hypertension is given isoproterenol (Isuprel) to delay preterm labor. Which side effect might the nurse expect?

a. Bronchospasm
b. Decreased urine output
c. Hyperglycemia
d. Hypotension

c. Hyperglycemia

In diabetic patients, isoproterenol can cause hyperglycemia by promoting beta2-mediated glycogenolysis. It is also used to treat asthma and causes bronchodilation, not bronchospasm. It acts on beta1 receptors in the heart to increase cardiac output, which may increase urine output. It increases blood pressure.

141. A nursing student asks why albuterol, which is selective for beta2 receptors, causes an increased heart rate in some patients. How does the nurse respond?

a. "Adrenergic agonists can lose their selectivity when given at higher doses."
b. "Bronchodilation lowers blood pressure, which causes a reflex tachycardia."
c. "Some patients metabolize the drug differently and have unusual side effects."
d. "Systemic effects are intensified with inhaled doses."

a. "Adrenergic agonists can lose their selectivity when given at higher doses."

Although albuterol affects the beta2 receptors, at higher doses it may also activate beta1 receptors, causing an increase in the heart rate. Bronchodilation does not lower the blood pressure, and activation of beta1 receptors actually may increase it. Tachycardia is a common side effect. The inhaled route reduces the likelihood of systemic side effects.

142. A patient is receiving dobutamine (Dobutrex) as a continuous infusion in the immediate postoperative period. The patient also is receiving a diuretic. What adverse drug reactions are possible in this patient? (Select all that apply.)

a. Angina
b. Dysrhythmias
c. Hypotension
d. Oliguria
e. Tachycardia

a. Angina
b. Dysrhythmias
e. Tachycardia

Angina, dysrhythmias, and tachycardia are the most common adverse effects of dopamine; general anesthetics can increase the likelihood of dysrhythmias. Dopamine elevates blood pressure by increasing cardiac output. Diuretics complement the beneficial effects of dopamine on the kidney, so urine output would be increased, not decreased.

143. A nurse is caring for an intubated patient who is receiving pancuronium for neuromuscular blockade. The patient's eyes are closed, and the patient is not moving any extremities. The heart rate is 76 beats per minute, and the blood pressure is 110/70 mm Hg. The nurse caring for this patient will do what?

a. Request an order for an antihistamine to prevent a further drop in blood pressure.
b. Request an order for serum electrolytes to evaluate for hyperkalemia.
c. Review the patient's chart for a history of myasthenia gravis (MG).
d. Talk to the patient while giving care and explain all procedures.

d. Talk to the patient while giving care and explain all procedures.

Pancuronium is a competitive neuromuscular blocker and is used to paralyze skeletal muscles by neuromuscular blockade. The first muscles affected are those of the eyelids, so patients given this medication cannot open their eyes. Inability to move the extremities is an expected effect. Because these medications do not have central nervous system (CNS) effects, the patient is conscious and awake; therefore, caregivers should continue to talk to the patient while providing care. Atracurium, not pancuronium, can cause hypotension secondary to histamine release. High potassium levels would reduce paralysis. Patients with a history of MG would have increased paralysis. Nothing indicates that this patient is experiencing extreme effects from this medication.

144. While preparing a patient for a procedure in which a neuromuscular blocking agent will be used, the nurse reviews the patient's preprocedure laboratory values. Which abnormality would cause the most concern?

a. Hyponatremia
b. Hypercalcemia
c. Hypomagnesemia
d. Hypokalemia

d. Hypokalemia

Low potassium levels can enhance paralysis, whereas high potassium levels can reduce paralysis. Because electrolyte status can influence the depth of neuromuscular blockade, it is important to maintain normal electrolyte balance. There are no indications that sodium, calcium, and/or magnesium have effects similar to those of potassium in relation to neuromuscular blocking agents.

145. Which of the following areas of the body shows the effects of tubocurarine last?

a. Levator muscle of the eyelids and the muscles of mastication
b. Muscles in the lower extremities
c. Muscles controlling the glottis
d. Muscles of respiration and the diaphragm

d. Muscles of respiration and the diaphragm

Although tubocurarine can paralyze all skeletal muscles, not all muscles are affected at once. The last muscles affected by tubocurarine are the muscles of respiration, including the intercostals, and the diaphragm. The first to become paralyzed are the levator muscle of the eyelids and the muscles of mastication. Paralysis occurs next in the muscles of the limbs, abdomen, and glottis.

146. A patient will receive atracurium (Tracrium) during surgery for neuromuscular blockade. The nurse caring for this patient will correctly perform which of the following actions?

a. Assess the patient for signs of CNS depression.
b. Ensure that dantrolene is available in case of a serious adverse reaction.
c. Monitor the patient's blood pressure closely.
d. Review the preprocedure laboratory values related to renal and hepatic function.

c. Monitor the patient's blood pressure closely.

Atracurium is used for muscle relaxation during surgery. Unlike other drugs in this class, it can cause hypotension secondary to antihistamine release. Cholinesterase inhibitors can reverse this reaction. Drugs in this class do not cause CNS depression. Dantrolene is the agent used to treat malignant hyperthermia, which is triggered by succinylcholine. Atracurium is eliminated primarily by plasma cholinesterase and not by the renal or hepatic routes.

147. While preparing a patient for a second esophageal dilation procedure, the nurse explains that succinylcholine (Anectine) will be used for muscle relaxation. The patient is anxious and reports not being able to swallow for several hours after the previous procedure. What will the nurse do?

a. Be prepared to provide mechanical ventilation after the procedure.
b. Have dantrolene available, because this patient is at increased risk for side effects.
c. Reassure the patient that this is expected after neuromuscular blockade.
d. Request an order for a pseudocholinesterase level.

d. Request an order for a pseudocholinesterase level

Succinylcholine is used for muscle relaxation during short procedures, such as esophageal dilation, because of its short duration. The effects wear off minutes after the drug is withdrawn, because plasma pseudocholinesterase quickly degrades it. Patients who have prolonged effects may have low plasma pseudocholinesterase levels and should be evaluated if this is suspected. Mechanical ventilation may be necessary if the drug is given, but the prudent nurse would rather avoid this by taking preventive measures instead of treating the adverse reaction after the fact. Dantrolene should always be available when succinylcholine is used because of the risk of malignant hyperthermia; however, nothing indicates that this particular patient is at greater risk than others. Prolonged neuromuscular blockade is not a normal reaction.

148. A nurse is reviewing nursing actions for emergency treatment of malignant hyperthermia with a group of nursing students. Which statement by a student indicates a need for further teaching?

a. "Analgesics should be given to help with muscle pain."
b. "Dantrolene helps to slow the metabolic activity in skeletal muscles."
c. "If malignant hyperthermia occurs, the succinylcholine must be stopped immediately."
d. "The patient may need an intravenous infusion of cold saline."

a. "Analgesics should be given to help with muscle pain."

Malignant hyperthermia is a rare but potentially fatal adverse reaction that can be triggered by succinylcholine. Muscle pain is an expected adverse effect of succinylcholine that is thought to be caused by the muscle contractions that occur during induction; analgesics can be given, but this effect usually occurs 10 to 12 hours after the procedure and is not an emergency. Dantrolene is given because it slows metabolic activity in skeletal muscles, resulting in decreased heat production. Succinylcholine should be stopped immediately if malignant hyperthermia occurs. Cold saline, given intravenously, often is necessary to lower a patient's temperature

149. A patient receives a neuromuscular blocking agent before a procedure. The patient's eyes close. The nurse knows this is a sign that the patient:

a. has fallen asleep.
b. has received a toxic dose of the medication.
c. is beginning to feel the drug's effects.
d. may need mechanical ventilation

c. is beginning to feel the drug's effects.

Neuromuscular blocking agents relax skeletal muscle to produce flaccid paralysis; the first muscles to be affected are the levator muscle of the eyelids and the muscles of mastication. These agents do not affect the CNS. Because the drug has just taken effect, a toxic dose is not yet a concern. Mechanical ventilation is necessary when the drug affects the intercostal muscles and the diaphragm, interfering with respiration.

150. Small doses of tubocurarine are administered when patients are suspected of having a myasthenia gravis crisis. If the patient develops increased muscle weakness in response to the tubocurarine, the nurse should prepare to administer what kind of drug?

a. Cholinesterase inhibitor
b. Dopamine agonist
c. Ganglionic blocker
d. Neuromuscular blocking agent

a. Cholinesterase inhibitor

If the patient displays increased muscle weakness, this is an adverse effect of the tubocurarine, and respiratory depression may ensue. A dopamine antagonist would not be indicated to reverse the effects of the tubocurarine. Ganglionic blockers interrupt impulse transmission through ganglia of the autonomic nervous system; they are nonselective and no longer have therapeutic uses. A neuromuscular blocking agent would increase muscle paralysis and make the condition worse.

151. A patient with hepatitis requires endotracheal intubation. Which agent does the nurse expect to be administered to facilitate this procedure?

a. Atropine
b. Cisatracurium (Nimbex)
c. Rocuronium (Zemuron)
d. Vecuronium (Norcuron)

b. Cisatracurium (Nimbex)

Cisatracurium is used for muscle relaxation during intubation. It is eliminated by spontaneous degradation, not by hepatic metabolism or renal excretion. Atropine is not used for muscle relaxation; it is an anticholinergic drug used to control secretions during procedures. Rocuronium is eliminated by hepatic metabolism. Vecuronium is excreted in bile and can cause prolonged paralysis in patients with liver dysfunction.

152. A nurse is teaching a group of nursing students about neuromuscular blocking agents. For what may these agents be used? (Select all that apply.)

a. Analgesia
b. Electroshock therapy
c. Malignant hyperthermia
d. Mechanical ventilation
e. Surgery

b. Electroshock therapy
d. Mechanical ventilation
e. Surgery

Neuromuscular blocking agents are used to produce muscle paralysis in procedures including electroconvulsive therapy (ECT), intubation and ventilation, and surgery. They do not produce analgesia. They are not used to treat malignant hyperthermia.

153. A nurse is caring for a patient who has myasthenia gravis. The prescriber has ordered neostigmine (Prostigmin). An important initial nursing action before administration of the medication includes assessing:

a. the ability to raise the eyelids.
b. level of fatigue.
c. skeletal muscle strength.
d. swallowing ability.

d. swallowing ability.


Many patients hospitalized for myasthenia gravis do not have the muscle strength to swallow well and need a parenteral form of the medication; therefore, assessing the patient's ability to swallow is an important initial safety measure. Evaluating the patient's ability to raise the eyelids, level of fatigue, and skeletal muscle strength are all important assessments both before drug administration and during drug treatment, because they indicate the effectiveness of the drug and help determine subsequent doses.

154. A nurse working in the emergency department is assigned to a child who is arriving by ambulance after being involved in a spill of organophosphate insecticides. What will the nurse expect to be the initial priority for treating this child?

a. Administering diphenhydramine to control secretions
b. Giving diazepam to control seizures
c. Providing mechanical ventilation and oxygen
d. Reporting the spill to the Environmental Protection Agency

c. Providing mechanical ventilation and oxygen

All of these courses of action may be part of the treatment. However, the initial concern is to prevent death from apnea caused by laryngospasm, bronchoconstriction, and paralysis leading to apnea; therefore, maintaining an airway is the most important consideration. Pralidoxime is the specific antidote and should be given next. Atropine is used to control secretions. Diazepam is given when seizures occur. Reporting the accident to the proper authorities is not a priority during a life-threatening emergency.

155. A patient who has myasthenia gravis will be taking neostigmine (Prostigmin). What will the nurse emphasize when teaching this patient about the medication?

a. "Stop taking the drug if you have diarrhea."
b. "Take a supplementary dose before exercise."
c. "Use atropine if you have excessive salivation."
d. "Withhold the dose if ptosis occurs."

b. "Take a supplementary dose before exercise."

Neostigmine doses must be adjusted continually, and patients usually need supplemental doses before exertion; therefore, patients must be taught how to modify doses as needed. Increased gastrointestinal (GI) secretions can cause loose stools; this is a known adverse effect that does not warrant stopping the drug. Atropine will help with excessive salivation but should not be used routinely, because it can mask the early signs of anticholinesterase overdose. Ptosis is one of the symptoms of myasthenia gravis and is an indication for taking neostigmine.

156. Two nurses are discussing the major differences between physostigmine (Antilirium) and neostigmine (Prostigmin). One nurse correctly makes which statement about physostigmine (Antilirium)?

a. "It is not effective for treating poisoning by muscarinic blocking drugs."
b. "It can readily cross the blood-brain barrier."
c. "It does not cause any side effects."
d. "It can be given by all routes."

b. "It can readily cross the blood-brain barrier."

The basic pharmacology of physostigmine is nearly identical to that of neostigmine, except that physostigmine readily crosses membranes, including the blood-brain barrier; neostigmine does not. Physostigmine and neostigmine are both effective for treating poisoning by muscarinic blocking drugs. Neither physostigmine nor neostigmine is devoid of side effects. Physostigmine can be given only intramuscularly (IM) or intravenously (IV); neostigmine is given orally (PO), IM, IV, and subcutaneously (subQ).

157. A nurse is helping a nursing student who is administering a medication to a patient with myasthenia gravis. Which statement by the student indicates the need for further teaching?

a. "I will ask the patient to sip some water before giving the medication."
b. "I will let the patient sleep after giving the medication, because rest is important."
c. "I will record muscle strength assessments before and after I give the medication."
d. "I will report excessive salivation to the patient's prescriber."

b. "I will let the patient sleep after giving the medication, because rest is important."

An important assessment indicating the medication's effectiveness is evaluating a patient's ability to raise the eyelids. Letting the patient sleep, even though rest is important, would prevent the nurse from making this assessment. To make sure the patient can safely swallow a pill, the nurse must evaluate swallowing ability by asking the patient to take a sip of water. Muscle strength assessments before and after medication administration help the nurse evaluate the medication's effectiveness. Excessive salivation may be a sign of drug toxicity and should be reported.

158. A patient with myasthenia gravis who is taking a cholinesterase inhibitor is being admitted to the intensive care unit and is on mechanical ventilation. The prescriber has ordered a challenge dose of edrophonium to distinguish between a myasthenic crisis and a medication overdose. The nurse will expect to do what?

a. Administer neostigmine if muscle strength decreases.
b. Be prepared to administer atropine if muscle weakness increases.
c. Give a second dose of edrophonium if no improvement is seen.
d. Give pralidoxime (Protopam) if cholinergic symptoms worsen.

b. Be prepared to administer atropine if muscle weakness increases.

Edrophonium is an ultra-short-acting cholinesterase inhibitor used to distinguish between a myasthenic crisis and a cholinesterase inhibitor overdose, because weakness or paralysis can occur with both. If the symptoms are intensified and muscle weakness increases, the crisis is cholinergic, meaning that the patient is having toxic effects from the cholinesterase inhibitor and needs atropine as an antidote. Neostigmine would be given if the patient shows improved muscle strength, because that would indicate that the patient's symptoms are the result of a myasthenic crisis. A second dose of edrophonium would only worsen the symptoms. Pralidoxime is used to treat poisoning caused by irreversible cholinesterase inhibitors.

159. A nurse is teaching a new emergency department nurse about emergency medications. When asked to describe the uses of pralidoxime (Protopam), the new nurse makes which correct statement?

a. "It exerts its greatest effects at muscarinic and ganglionic sites."
b. "It is used to treat poisoning by reversible cholinesterase inhibitors."
c. "It may not be effective if not given immediately."
d. "It reverses the effects of organophosphate insecticides in the central nervous system."

c. "It may not be effective if not given immediately."

Pralidoxime must be given soon after organophosphate poisoning has occurred because of a process called aging, in which the bond between the organophosphate inhibitor and cholinesterase increases in strength, making pralidoxime ineffective. For some of these poisons, aging can occur within minutes. Pralidoxime has its greatest effects at the neuromuscular junction, not the muscarinic and ganglionic sites. It is used to treat poisoning by irreversible cholinesterase inhibitors. It does not cross the blood-brain barrier and thus does not have effects in the CNS.

160. A patient is experiencing toxic side effects from atropine, including delirium and hallucinations. Which medication will the nurse expect to administer?

a. Donepezil (Aricept)
b. Edrophonium (Reversol)
c. Neostigmine (Prostigmin)
d. Physostigmine

d. Physostigmine

Physostigmine is the drug of choice for treating poisoning from atropine and other drugs that cause muscarinic blockade. Donepezil is used to treat Alzheimer's disease. Edrophonium is used to distinguish between a myasthenic crisis and a cholinesterase inhibitor overdose. Neostigmine does not cross the blood-brain barrier and would not effectively treat this patient's CNS symptoms.

161. A nurse is teaching a group of nursing students about irreversible cholinesterase inhibitors. Which statement by a student indicates understanding of the teaching?

a. "Diazepam is given to reverse inhibition of cholinesterase when overdose occurs."
b. "Irreversible cholinesterase inhibitors are rapidly absorbed by all routes."
c. "These agents are often used to treat glaucoma."
d. "Toxic doses of these agents produce an anticholinergic crisis."

b. "Irreversible cholinesterase inhibitors are rapidly absorbed by all routes."

Almost all of these agents are highly lipid soluble, making them readily absorbed from all routes of administration. Diazepam is used during overdose but only to control seizures and not to reverse effects. The only clinical use for these agents is to treat glaucoma, but this use is limited. Toxic doses of these agents produce a cholinergic, not an anticholinergic, crisis.

162. A prescriber has ordered pilocarpine (Pilocar). A nurse understands that the drug stimulates muscarinic receptors and would expect the drug to have which action?

a. Reduce excessive secretions in a postoperative patient
b. Lower intraocular pressure in patients with glaucoma
c. Inhibit muscular activity in the bladder
d. Prevent hypertensive crisis

Pilocarpine is a muscarinic agonist used mainly for topical therapy of glaucoma to reduce intraocular pressure. Pilocarpine is not indicated for the treatment of excessive secretions and mucus; in fact, pilocarpine is used to treat dry mouth. Pilocarpine does not inhibit muscular activity in the bladder. Pilocarpine is not used to prevent hypertensive crisis.

163. A patient has developed muscarinic antagonist toxicity from ingestion of an unknown chemical. The nurse should prepare to administer which medication?

a. Atropine (Sal-Tropine) IV
b. Physostigmine (Antilirium)
c. An acetylcholinesterase activator
d. Pseudoephedrine (Ephedrine)

b. Physostigmine (Antilirium)

Physostigmine is indicated for muscarinic antagonist toxicity. Atropine is a drying agent and would only complicate the drying action that arises from the muscarinic antagonist. An acetylcholinesterase activator would only contribute to dryness that arises from the muscarinic antagonist. Ephedrine is not indicated for muscarinic antagonist toxicity.

164. A prescriber has ordered bethanechol (Urecholine) for a postoperative patient who has urinary retention. The nurse reviews the patient's chart before giving the drug. Which part of the patient's history would be a contraindication to using this drug?

a. Asthma as a child
b. Gastroesophageal reflux
c. Hypertension
d. Hypothyroidism

a. Asthma as a child

Bethanechol is contraindicated in patients with active or latent asthma, because activation of muscarinic receptors in the lungs causes bronchoconstriction. It increases the tone and motility of the gastrointestinal (GI) tract and is not contraindicated in patients with reflux. It causes vasodilation and would actually lower blood pressure in a hypertensive patient. It causes dysrhythmias in hyperthyroid patients.

165. A patient will begin using a transdermal preparation of a muscarinic antagonist for overactive bladder (OAB). The nurse teaches the patient what to do if side effects occur. Which statement by the patient indicates the need for further teaching?

a. "I can use sugar-free gum for dry mouth."
b. "I may need laxatives for constipation."
c. "I should keep the site covered to prevent other people from getting the medicine."
d. "I will take Benadryl for any itching caused by a local reaction to the patch."

d. "I will take Benadryl for any itching caused by a local reaction to the patch."

Benadryl is an antihistamine, and even though it is not classified as a muscarinic antagonist, it has anticholinergic effects. Giving it with a muscarinic antagonist greatly enhances these effects, so it should not be used. Muscarinic antagonists cause dry mouth, and patients should be taught to use sugar-free gum or candies to help with this. Muscarinic antagonists can cause constipation, and laxatives may be used. Medication applied topically can be transferred to others who come in contact with the skin, so the site should be covered

166. An older adult patient who lives alone and is somewhat forgetful has an overactive bladder and reports occasional constipation. Which treatment will the nurse anticipate for this patient?

a. Behavioral therapy
b. Oxybutynin (Ditropan XL) extended-release tablets
c. Oxybutynin (Oxytrol) transdermal patch
d. Percutaneous tibial nerve stimulation (PTNS)

c. Oxybutynin (Oxytrol) transdermal patch

The transdermal patch is applied weekly and may be the best option for a patient who is more likely to forget to take a daily medication. The transdermal preparation has fewer side effects than the systemic dose so is less likely to increase this patient's constipation. Behavioral therapy should be tried first in patients who can participate. However, it is not the best option for a forgetful patient who lives alone, because it requires scheduled voiding and timing of fluid intake. The extended-release tablets must be given daily, and this patient may not remember to take them. PTNS is used after behavioral and drug therapies have failed.

167. A patient received atropine intravenously before surgery. The recovery room nurse notes that the patient is delirious upon awakening, has a heart rate of 96 beats per minute, a respiratory rate of 22 breaths per minute, and a blood pressure of 110/78 mm Hg. The nurse notifies the anesthesiologist, who will order:

a. activated charcoal to minimize intestinal absorption of the antimuscarinic agent.
b. an acetylcholinesterase inhibitor to compete with the antimuscarinic agent at receptors.
c. an antipsychotic medication to treat the patient's central nervous system symptoms.
d. ipratropium bromide (Atrovent) to counter the respiratory effects of the antimuscarinic agent.

b. an acetylcholinesterase inhibitor to compete with the antimuscarinic agent at receptors.

This patient is showing signs of antimuscarinic toxicity, caused by the atropine given during surgery. The most effective antidote is physostigmine, which inhibits acetylcholinesterase, allowing acetylcholine to build up at cholinergic junctions and compete with the antimuscarinic agent for receptor binding. Activated charcoal is only useful if an antimuscarinic agent has been ingested, because it impedes absorption from the GI tract. Because this patient's psychotic symptoms are caused by an antimuscarinic agent, physostigmine should be given to treat the cause; an antipsychotic medication would only treat the symptom. Ipratropium bromide is an antimuscarinic agent and would only compound the effects. This patient's respiratory rate is only mildly elevated

168. Bethanechol (Urecholine) is used to treat urinary retention but is being investigated for use in which other condition?

a. Gastric ulcers
b. Gastroesophageal reflux
c. Hypotension
d. Intestinal obstruction

b. Gastroesophageal reflux

Bethanechol is being investigated for treatment for gastroesophageal reflux disease (GERD) because of its effects on esophageal motility and the lower esophageal sphincter. Bethanechol stimulates acid secretion and could intensify ulcer formation. Bethanechol can cause hypotension. Because bethanechol increases the motility and tone of intestinal smooth muscle, the presence of an obstruction could lead to bowel rupture.

169. A patient receives topical atropine to facilitate an eye examination. The nurse will tell the patient to remain in a darkened room or to wear sunglasses for several hours until the effects of the medication wear off. This teaching is based on the nurse's knowledge that muscarinic antagonists cause:

a. elevation of intraocular pressure.
b. miosis and ciliary muscle contraction
c. paralysis of the iris sphincter.
d. relaxation of ciliary muscles.

c. paralysis of the iris sphincter.

By blocking muscarinic receptors in the eye, atropine causes paralysis of the iris sphincter, which prevents constriction of the pupil; consequently, the eye cannot adapt to bright light. This also causes an elevation in intraocular pressure, which increases the risk of glaucoma. However, it is not an indication for wearing darkened glasses. Muscarinic agonists cause miosis; atropine causes mydriasis. The effect of relaxing ciliary muscles focuses the eye for far vision, causing blurred vision.

170. The nurse understands that patients are given beta1 agonists to treat _____ failure.

a. heart
b. kidney
c. respiratory
d. liver

a. heart

A beta1 agonist increases the patient's heart rate and blood pressure and is used in heart failure. Beta1 agonists would not be used for kidney, respiratory, or liver failure.

171. A nurse is teaching a patient about a medication that alters sympathetic nervous system functions. To evaluate understanding, the nurse asks the patient to describe which functions the sympathetic nervous system regulates. Which answer indicates the need for further teaching?

a. "The digestive functions of the body"
b. "The cardiovascular system"
c. "The fight-or-flight response"
d. "Body temperature"

a. "The digestive functions of the body"

The sympathetic nervous system does not regulate digestive functions of the body—the parasympathetic nervous system does; further education is needed. The sympathetic nervous system regulates the cardiovascular system, the fight-or-flight response, and the body temperature; no further education is needed.

172. A patient is wheezing and short of breath. The nurse assesses a heart rate of 88 beats per minute, a respiratory rate of 24 breaths per minute, and a blood pressure of 124/78 mm Hg. The prescriber orders a nonspecific beta agonist medication. Besides evaluating the patient for a reduction in respiratory distress, the nurse will monitor for which side effect?

a. Hypotension
b. Tachycardia
c. Tachypnea
d. Urinary retention

b. Tachycardia

Beta agonists are used for asthma because of their beta2 effects on bronchial smooth muscle, causing dilation. Beta1 effects cause tachycardia and hypertension. Beta receptors do not exert effects on the bladder.

173. A nurse is teaching a group of nursing students about neurotransmitters. Which statement by a student about acetylcholine indicates a need for further teaching?

a. "It activates three cholinergic receptor subtypes."
b. "It has effects in the parasympathetic, sympathetic, and somatic nervous systems."
c. "It is used at most junctions of the peripheral nervous system."
d. "Its transmission is terminated by reuptake into the cholinergic nerve terminal."

d. "Its transmission is terminated by reuptake into the cholinergic nerve terminal."

Acetylcholine (ACh) is destroyed by acetylcholinesterase, an enzyme that degrades ACh into two inactive products: acetate and choline. Choline is taken up into the nerve terminal. ACh activates three receptor sites: nicotinicN, nicotinicM, and muscarinic. ACh has effects throughout the peripheral nervous system (PNS) and is used at most junctions in the PNS.

174. A nurse is administering an agonist drug that acts on postganglionic neurons of the sympathetic nervous system. Which response will the nurse expect to see?

a. Decreased sweating
b. Bronchodilation
c. Increased cardiac output
d. Pinpoint pupils

c. Increased cardiac output

Norepinephrine (NE) is the most common neurotransmitter released by all postganglionic neurons of the sympathetic nervous system except those going to sweat glands where ACh is the neurotransmitter. NE acts on alpha1, alpha2, and beta1 receptors to increase the force and rate of cardiac contraction, thus increasing cardiac output. ACh would increase sweating. Bronchodilation occurs when epinephrine activates beta2 receptors on bronchial smooth muscle. NE affects alpha1 receptors to dilate the pupils.

175. Many medications list side effects that include dry mouth, constipation, and urinary retention. What kind of effects are these?

a. Alpha adrenergic
b. Anticholinergic
c. Beta adrenergic
d. Sympathetic

Cholinergic stimulation by ACh causes increased salivation, increased gastrointestinal (GI) motility, and relaxation of the bladder trigone and sphincter. Anticholinergic medications inhibit these responses, causing dry mouth, constipation, and urinary retention. Alpha-adrenergic agents effect processes in the sympathetic nervous system, causing peripheral vasoconstriction and pupil dilation, among other effects. The effects of beta-adrenergic medications are seen mostly in the heart and blood vessels. The sympathetic nervous system has both cholinergic and adrenergic transmitters.

176. A nurse is explaining activation of beta2 receptors to some student nurses during a clinical rotation at the hospital. Which statement by a student demonstrates a need for further teaching?

a. "Beta2 activation results in bronchodilation."
b. "Beta2 activation results in contraction of uterine muscle."
c. "Beta2 activation results in glycogenolysis."
d. "Beta2 activation results in vasodilation of skeletal muscles."

b. "Beta2 activation results in contraction of uterine muscle."

Beta2 activation would result in relaxation of uterine smooth muscle, not contraction; this statement indicates a need for further teaching. Bronchodilation is an effect of beta2 activation; no further teaching is needed. Beta2 activation does result in glycogenolysis; no further teaching is needed. Beta2 activation does result in vasodilation of skeletal muscle; no further teaching is needed.

177. A pregnant patient is in premature labor. Which class of drug will she be given?

a. Alpha1 agonist
b. Anticholinergic
c. Beta2 agonist
d. Beta2 antagonist

c. Beta2 agonist

Beta2 agonists cause relaxation of uterine muscle, slowing or stopping the contractions that precipitate labor. An alpha1 agonist would have effects on the heart and arterioles. Anticholinergic drugs generally are given for their effects on the urinary and GI tracts and do not affect uterine muscle. A beta2 antagonist would cause increased constriction of uterine muscle.

178. A patient is to receive a beta agonist. Before administration of this medication, which assessment finding would most concern the nurse?

a. Pulse oximetry reading of 88%
b. Blood pressure of 100/60 mm Hg
c. Respiratory rate of 28 breaths per minute
d. Heart rate of 110 beats per minute

d. Heart rate of 110 beats per minute

A beta agonist dilates respiratory smooth muscle, but as a side effect, it can stimulate the heart. A heart rate of 110 beats per minute is a concern, because this medication may further increase the already elevated heart rate. A pulse oximetry reading of 88% is a concern, but the medication causes bronchodilation and increased oxygenation; this should increase the pulse oximetry reading. A blood pressure of 100/60 mm Hg is on the low side, but this medication may actually cause an increase in blood pressure as a side effect; this should not concern the nurse before administration of the medication. A respiratory rate of 28 breaths per minute is elevated; however, this medication should increase oxygenation by bronchodilation, and the patient's respiratory rate should decrease once oxygenation has improved. Therefore, this should not concern the nurse.

179. A patient receives morphine and shows signs of toxicity. The prescriber orders naloxone (Narcan) to reverse the effects of the morphine. The nurse understands that the naloxone works at the same receptor sites as the morphine to:

a. block transmitter reuptake.
b. inhibit transmitter release.
c. interfere with transmitter storage.
d. prevent activation of receptors.

d. prevent activation of receptors.

Morphine and its antagonist, naloxone, both act directly at the same receptors. Morphine causes activation, and naloxone prevents activation. Neither morphine nor naloxone acts to alter transmitter reuptake, release, or storage.

180. A nurse is teaching a group of nursing students about neuropharmacology. Which statement by a student about peripheral nervous system (PNS) drugs indicates a need for further teaching?

a. "Drugs affecting axonal conduction have a variety of uses."
b. "Drugs that alter synaptic transmission can be highly selective."
c. "Many PNS drugs act by altering synaptic transmission."
d. "These drugs work by influencing receptor activity."

a. "Drugs affecting axonal conduction have a variety of uses."

Local anesthetics are the only drugs shown to work by altering axonal conduction. Any drug affecting axonal conduction would be nonselective, because axonal conduction of impulses is essentially the same in all neurons. In contrast, drugs that affect synaptic transmission can be highly selective, because each transmitter has different effects on receptor sites. Most PNS drugs work on synaptic transmission processes. Through their effects on transmitters, they influence receptor activity.

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