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Pharmacology Exam 2
Chapters 18, 41-48,50,51,70,76,77
Terms in this set (65)
A nurse is teaching nursing students about the use of alpha-adrenergic antagonists. Which statement by the student indicates the need for further teaching?
A. "Alpha-adrenergic antagonists block alpha1 receptors on arterioles and veins."
B. "Dilation of arterioles has a direct effect on arterial pressure."
C. "Dilation of veins by alpha-adrenergic antagonists improves cardiac output."
D. "Venous dilation by alpha-adrenergic antagonists indirectly lowers arterial pressure."
Cardiac output is decreased as a result of the venous dilation caused by alpha-adrenergic antagonists. Alpha-adrenergic antagonists block alpha1 receptors on both arterioles and veins. When alpha1 receptors on arterioles are blocked by alpha-adrenergic antagonists, a direct effect on arterial pressure occurs. When alpha1 receptors on veins are blocked by alpha-adrenergic antagonists, an indirect effect on arterial pressure occurs.
A patient with pheochromocytoma is admitted for surgery. The surgeon has ordered an alpha-blocking agent to be given preoperatively. What does the nurse understand about this agent?
A. It is ordered to prevent perioperative hypertensive crisis.
B. It prevents secretion of catecholamines by the adrenal tumor.
C. It reduces contraction of smooth muscles in the adrenal medulla.
D. It is given chronically after the surgery to prevent hypertension.
Manipulation of the adrenal tumor in patients with pheochromocytoma can cause a massive catecholamine release. Alpha-adrenergic antagonists are given to reduce the risk of acute hypertension during surgery. These agents do not prevent secretion of catecholamines; they block catecholamine receptor sites. They do not act on the tissue of the adrenal medulla. They are given chronically in patients who have inoperable tumors.
A patient with type I diabetes is taking NPH insulin, 30 units every day. A nurse notes that the patient is also taking metoprolol (Lopressor). What education should the nurse provide to the patient?
A. "Metoprolol has no effect on diabetes mellitus or on your insulin requirements."
B. "Metoprolol interferes with the effects of insulin, so you may need to increase your insulin dose."
C. "Metoprolol may mask signs of hypoglycemia, so you need to monitor your blood glucose closely."
D. "Metoprolol may potentiate the effects of the insulin, so the dose should be reduced."
Because metoprolol may mask the signs of hypoglycemia, the patient should monitor the blood glucose closely and report changes to the prescriber. Metoprolol does have an indirect effect on diabetes mellitus and/or insulin requirements in that it may mask the signs of hypoglycemia, causing the patient to make a healthcare decision based on the drug-to-drug interaction rather than actual physiologic factors. The patient should not increase the insulin, because metoprolol will cause a decrease in blood glucose, increasing the risk of a hypoglycemic reaction. The patient should not reduce the dose of insulin when taking metoprolol, because this might alter serum glucose levels.
The nurse is discussing home management with a patient who will begin taking an alpha-adrenergic antagonist for hypertension. Which statement by the patient indicates understanding of the teaching?
A. "I need to stop the medication if my heart rate increases."
B. "I should not drive as long as I'm taking this medication."
C. "I should take the first dose at bedtime."
D. "I will stop taking the medication if I feel dizzy."
Orthostatic hypotension is a common side effect of this class of drugs and is most severe with the first dose. Administering the first dose at bedtime eliminates the risk associated with this first-dose effect. Tachycardia is an expected side effect; if severe, it can be treated with other medications. Patients should not drive during the first 12 to 24 hours after taking these agents, because fainting and dizziness may occur, but they may drive after that. Dizziness is not an indication for stopping the drug; patients who experience dizziness are instructed to sit or lie down until symptoms pass.
A nurse prepares to administer propranolol (Inderal) to a patient recovering from acute myocardial infarction. The patient's heart rate is 52 beats per minute, and the rhythm is regular. What action should the nurse take next?
A. Administer the drug as prescribed.
B. Request an order for atropine.
C. Withhold the dose and document the pulse rate.
D. Withhold the dose and notify the prescriber.
A beta blocker, such as propranolol, should not be given if the pulse is lower than 60 beats per minute; therefore, the nurse should withhold the dose and notify the prescriber. Administering the dose as prescribed would not be appropriate, because the patient's pulse rate is too slow at this time. The dose should be withheld and the prescriber notified. The patient's heart rate is slow, and atropine may be necessary if the bradycardia persists, but the first step is to withhold the dose of propranolol. Withholding the dose and documenting the pulse rate is an appropriate but incomplete nursing intervention. The nurse must notify the prescriber to obtain further orders related to the medication.
A patient taking a beta blocker complains of shortness of breath. The patient has respirations of 28 breaths per minute, a blood pressure of 162/90 mm Hg, and a pulse of 88 beats per minute. The nurse auscultates crackles in all lung fields. The nurse understands that these assessments are consistent with:
B. left-sided heart failure.
C. rebound cardiac excitation.
D. sinus bradycardia.
The signs and symptoms describe left-sided heart failure, in which the blood normally handled by the left ventricle and forced out through the aorta into the body backs up into the lungs, producing respiratory signs and symptoms. The patient's signs and symptoms are not indicative of bronchoconstriction, which would cause wheezing and diminished breath sounds. Rebound cardiac excitation occurs when the beta blocker is withdrawn, not during administration of the drug. The patient's heart rate is elevated, so sinus bradycardia is not present.
A patient is taking a beta-adrenergic antagonist medication for angina pectoris and asks the nurse how the drug works to relieve the discomfort associated with this condition. Which statement by the patient after the nurse's teaching indicates understanding of the drug's effects?
A. "It causes bronchodilation, which increases oxygen flow."
B. "It helps reduce the heart's oxygen needs."
C. "It improves blood flow to the heart."
D. "It increases cardiac output."
Blockade of beta1 receptors in the heart reduces cardiac work by reducing the heart rate, the force of contraction, and the velocity of impulse conduction through the AV node. Beta blockers result in bronchoconstriction, not bronchodilation. They do not increase blood flow to the heart. Cardiac output is decreased, not increased.
A patient will begin taking propranolol (Inderal) for hypertension. Which statement by the nurse is important when teaching this patient about the medication?
A. "Check your hands and feet for swelling and report that to your provider."
B. "It is safe to take this medication with a calcium channel blocker."
C. "Stop taking the drug if you become short of breath."
D. "Take your pulse and do not take the medication if your heart rate is fast."
Patients taking propranolol can develop heart failure because of the suppression in myocardial contractility. Patients should be taught to watch for signs, which include shortness of breath, night coughs, and swelling of the extremities. Use of these agents with calcium channel blockers is contraindicated, because the effects are identical and excessive cardiosuppression can occur. Shortness of breath should be reported to the provider, but abrupt cessation of the drug can cause rebound cardiac excitability. Propranolol reduces the heart rate and should not be given if the pulse is less than 60 beats per minute.
Which are adverse effects of alpha blockade? (Select all that apply.)
B. Reflex tachycardia
C. Nasal congestion
Correct: B, C, E
Adverse effects of alpha blockade include reflex tachycardia, nasal congestion, and hypernatremia. Other adverse effects include orthostatic hypotension and inhibition of ejaculation. Hypertension and ejaculation are not adverse effects of alpha blockade.
A patient is taking a beta1-adrenergic drug to improve the stroke volume of the heart. The nurse caring for this patient knows that this drug acts by increasing:
A. cardiac afterload.
B. cardiac preload.
C. myocardial contractility.
D. venous return.
Beta1-adrenergic agents help increase the heart's stroke volume by increasing myocardial contractility. Cardiac afterload is determined primarily by the degree of peripheral resistance caused by constriction of arterioles; increasing afterload would decrease stroke volume. Beta1-adrenergic agents do not affect afterload. Cardiac preload is the amount of stretch applied to the cardiac muscle before contraction and is determined by the amount of venous return. Beta1-adrenergic agents do not affect cardiac preload. Venous return is determined by the systemic filling pressure and auxiliary muscle pumps and is not affected by beta1-adrenergic agents.
A nurse is caring for a patient who is receiving a drug that causes constriction of arterioles. The nurse expects to observe which effect from this drug?
A. Decreased stroke volume
B. Increased stroke volume
C. Decreased myocardial contractility
D. Increased myocardial contractility
Constriction of arterioles increases the load against which the heart must pump to eject blood. Increased constriction of arterioles would decrease, not increase, the stroke volume of the heart. Myocardial contractility is determined by the sympathetic nervous system, acting through beta1-adrenergic receptors in the myocardium.
A patient with a history of hypertension is admitted for a procedure. If the patient's arterial pressure decreases, which clinical manifestation would the nurse expect to see?
A. Decreased heart rate
B. Increased heart rate
C. Decreased blood pressure
When arterial pressure decreases, the vasoconstrictor center causes constriction of nearly all arterioles, leading to an increase in peripheral resistance, constriction of veins, increasing venous return, and subsequent acceleration of the heart rate. A decrease in arterial pressure would not cause a decrease in the heart rate or blood pressure, nor would it cause syncope.
A nurse is teaching a nursing student how blood can return to the heart when pressure in the venous capillary beds is very low. Which statement by the student indicates a need for further teaching? Skeletal muscle contraction, along with one-way venous valves, help create an "auxiliary" venous pump that helps drive blood toward the heart.
A. "Constriction of small muscles in the venous wall increases venous pressure."
B. "Negative pressure in the left atrium draws blood toward the heart."
C. "Skeletal muscles relax to allow the free flow of blood."
D. "Venous valves help prevent the backflow of blood."
Constriction of small muscles in venous walls helps increase venous pressure. Negative pressure in the left atrium sucks blood toward the heart. Valves, which are one-way, work with the contraction of skeletal muscles to create a venous pump.
A nurse is assessing a patient with heart failure. The patient complains of shortness of breath, and the nurse auscultates crackles in both lungs. The nurse understands that these symptoms are the result of:
A. decreased force of ventricular contraction.
B. increased force of ventricular contraction.
C. decreased ventricular filling.
D. increased ventricular filling.
In the failing heart Starling's law breaks down, and the force of contraction no longer increases in proportion to the amount of ventricular filling. The result is the backup of blood into the lungs and the symptoms of shortness of breath and crackles caused by fluid. Increased ventricular contraction would not result in a backup of blood into the lungs. Changes in ventricular filling are not the direct cause of this symptom.
A patient with hypertension is admitted to the hospital. On admission the patient's heart rate is 72 beats per minute, and the blood pressure is 140/95 mm Hg. After administering an antihypertensive medication, the nurse notes a heart rate of 85 beats per minute and a blood pressure of 130/80 mm Hg. What does the nurse expect to occur?
A. A decrease in the heart rate back to baseline in 1 to 2 days
B. An increase in the blood pressure within a few days
C. An increase in potassium retention in 1 to 2 days
D. A decrease in fluid retention within a week
When blood pressure drops, the baroreceptors in the aortic arch and carotid sinus sense this and relay information to the vasoconstrictor center of the medulla; this causes constriction of arterioles and veins and increased sympathetic impulses to the heart, resulting in an increased heart rate. After 1 to 2 days, this system resets to the new pressure, and the heart rate returns to normal. The blood pressure will not increase when this system resets. Increased potassium retention will not occur. Over time, the body will retain more fluid to increase the blood pressure.
A patient is taking a drug that interferes with venous constriction. The nurse will tell the patient to:
A. ask for assistance when getting out of bed.
B. expect bradycardia for a few days.
C. notify the provider if headache occurs.
D. report shortness of breath.
A drop in venous pressure reduces venous return to the heart, and as blood pools in the extremities, orthostatic hypotension can occur. Patients taking drugs that reduce venous constriction should be cautioned to ask for assistance when getting out of bed. Bradycardia, headache, and shortness of breath are not expected effects.
A nurse is administering a vasodilator that dilates resistance vessels. The nurse understands that this drug will have which effect on the patient?
A. Decreased cardiac preload
B. Decreased cardiac output
C. Increased tissue perfusion
D. Increased ventricular contraction
Vasodilators that dilate resistance vessels, or arterioles, cause a decrease in afterload, which allows cardiac output and tissue perfusion to increase. A decrease in preload would be the result of dilation of capacitance vessels, or veins. Dilation of arterioles increases cardiac output. Ventricular contraction results when preload is increased.
A patient is taking a vasodilator that relaxes smooth muscles in veins. To help minimize drug side effects, the nurse caring for this patient will:
A. caution the patient not to get up without assistance.
B. encourage the patient to increase fluid intake.
C. tell the patient to report shortness of breath.
D. warn the patient about the possibility of bradycardia.
Postural hypotension occurs when moving from a supine or seated position to an upright position. It is caused by relaxation of smooth muscle in veins, which allows blood to pool in veins and decreases venous return of blood to the heart. Patients taking such drugs should ask for assistance when getting up to prevent falls. Prolonged use of vasodilators can lead to expansion of blood volume and fluid overload, so increasing fluid intake is not appropriate. Shortness of breath is a symptom associated with heart failure. Tachycardia can occur when the blood pressure drops as a result of the baroreceptor reflex.
A nurse is caring for a patient with hypertension and diabetes. The patient's prescriber recently ordered an angiotensin-converting enzyme (ACE) inhibitor. Which statement by the patient indicates understanding of the nurse's teaching about this drug?
A. "ACE inhibitors only dilate veins, so I may have more edema in my ankles."
B. "ACE inhibitors prevent the nervous system from causing increased blood pressure."
C. "This drug can also cause shortness of breath because of bronchoconstriction."
D. "This drug will help lower my blood pressure and will benefit my kidneys."
ACE inhibitors reduce blood pressure and help preserve renal function in people with diabetes. ACE inhibitors dilate both veins and arterioles. ACE inhibitors work on the renin-angiotensin-aldosterone system, not the nervous system. ACE inhibitors do not have effects on the bronchioles of the lungs.
The nurse is caring for a patient who is taking a vasodilator that dilates capacitance vessels. The nurse will expect which effect in this patient?
A. Decrease in cardiac work
B. Increase in cardiac output
C. Increase in tissue perfusion
D. Increase in venous return
Vasodilators that dilate capacitance vessels, or veins, lead to a decrease in venous return to the heart, which reduces preload and the force of ventricular contraction. The resultant effect is a decrease in cardiac work. With a decrease in ventricular contraction, cardiac output is reduced, as is tissue perfusion. Dilation of veins causes a decrease in venous return.
A nurse is reviewing the phenomenon of reflex tachycardia with a group of nursing students. Which statement by a student indicates understanding of this phenomenon?
A. "Baroreceptors in the aortic arch stimulate the heart to beat faster."
B. "Reflex tachycardia can negate the desired effects of vasodilators."
C. "Reflex tachycardia is more likely to occur when beta blockers are given."
D. "Venous dilation must occur for reflex tachycardia to occur."
Reflex tachycardia, which is a compensatory mechanism in response to decreased blood pressure, can negate the desired effect of a vasodilator by eventually increasing blood pressure. Baroreceptors relay information to the vasomotor center of the medulla; the medulla sends impulses to the heart. Beta blockers are given to counter reflex tachycardia. Reflex tachycardia can be produced by dilation of both arterioles and veins.
A female patient with essential hypertension is being treated with hydralazine (Apresoline) 25 mg twice daily. The nurse assesses the patient and notes a heart rate of 96 beats per minute and a blood pressure of 110/72 mm Hg. The nurse will request an order to:
A. administer a beta blocker.
B. administer a drug that dilates veins.
C. reduce the dose of hydralazine.
D. give the patient a diuretic.
This patient is showing signs of reflex tachycardia, so a beta blocker is indicated to slow the heart rate. Patients with heart failure who take hydralazine often require the addition of isosorbide dinitrate, which also dilates veins. There is no indication for reducing the dose of hydralazine. A diuretic can be given with hydralazine if sodium and water retention is present.
A nurse is obtaining a medication history on a newly admitted patient, who reports taking minoxidil for hypertension. Admission vital signs reveal a heart rate of 78 beats per minute and a blood pressure of 120/80 mm Hg. What is an important part of the initial assessment for this patient?
A. Evaluating ankle edema
B. Monitoring for nausea and vomiting
C. Noting the presence of hypertrichosis
D. Obtaining a blood glucose
Fluid retention is a common and serious adverse effect of minoxidil, because it can lead to cardiac decompensation. If present, a diuretic is indicated. Nausea and vomiting may occur with this drug but is not a serious side effect. Hypertrichosis occurs in about 80% of patients taking the drug, but its effects are cosmetic and not life threatening. It may be important to monitor the blood glucose level in some patients, because the drug can alter glucose tolerance, but this effect is not as serious as fluid retention.
A patient is admitted with severe hypertensive crisis. The nurse will anticipate administering which medication?
A. Captopril PO
B. Hydralazine (Apresoline) 25 mg PO
C. Minoxidil 20 mg PO
D. Sodium nitroprusside (Nitropress) IV
Sodium nitroprusside is the drug of choice for hypertensive emergencies and is given intravenously. ACE inhibitors, such as captopril, are not used. Hydralazine may be used but should be given IV. Minoxidil is effective, but its severe side effects make it a second-line drug.
A nursing student asks a nurse why a patient in hypertensive crisis is receiving both intravenous sodium nitroprusside (Nitropress) and oral hydralazine (Apresoline). The nurse will explain that this is done to prevent:
A. cyanide poisoning.
B. fluid retention.
C. rebound hypertension.
D. reflex tachycardia.
Sodium nitroprusside acts rapidly and is given only intravenously. Rebound hypertension occurs immediately when the IV is stopped, so an oral antihypertensive should be given simultaneously. Cyanide poisoning can occur with sodium nitroprusside, but giving hydralazine does not counter this adverse effect. Hydralazine does not prevent fluid retention or reflex tachycardia.
Which medications are most likely to cause postural hypotension? (Select all that apply.)
B. Diltiazem (Cardizem)
C. Prazosin (Minipress)
D. Captopril (Capoten)
E. Losartan (Cozaar)
Correct: C, D, E
Postural, or orthostatic, hypotension is defined as a fall in blood pressure related to a change in position. Minoxidil and diltiazem dilate arterioles; therefore, they are not likely to cause postural hypotension. Prazosin, captopril, and losartan all reportedly can cause orthostatic hypotension.
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. Incorrect a beta blocker.
B. a loop diuretic and spironolactone.
C. a thiazide diuretic.
D. counseling on lifestyle changes.
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
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 has three separate blood pressure (BP) readings of 120/100 mm Hg, 138/92 mm Hg, and 126/96 mm Hg. Which category describes this patient's BP?
B. Isolated systolic hypertension
Hypertension is defined as systolic BP over 140 mm Hg or diastolic BP over 90 mm Hg. When systolic and diastolic BP fall into different categories, classification is based on the higher category. This patient has a hypertensive diastolic BP. Isolated systolic hypertension occurs if the systolic BP is greater than 140 mm Hg with a diastolic BP less than 90 mm Hg. Because this patient has an elevated diastolic BP, it is not considered normal. Prehypertension occurs with a systolic BP of 120 to 139 mm Hg or a diastolic BP of 80 to 89 mm Hg.
A nurse checks a patient's vital signs in the hospital and notes a blood pressure of 146/98 mm Hg. What will the nurse do?
A. Instruct the patient to consume a low-sodium diet.
B. Prepare the patient for an electrocardiogram and blood tests.
C. Recheck the patient's blood pressure in the other arm.
D. Request an order for a thiazide diuretic.
Diagnosis of hypertension should be based on several blood pressure readings, not just one. High readings should be confirmed in the contralateral arm. Low-sodium diets are indicated for patients with confirmed hypertension. An electrocardiogram and blood tests are indicated for patients with confirmed hypertension to rule out primary causes. Thiazide diuretics are first-line drugs for confirmed hypertension.
A patient who does not consume alcohol or nicotine products reports a strong family history of hypertension and cardiovascular disease. The patient has a blood pressure of 126/82 and a normal weight and body mass index for height and age. The nurse will expect to teach this patient about:
A. ACE inhibitors and calcium channel blocker medications.
B. the DASH diet, sodium restriction, and exercise.
C. increased calcium and potassium supplements.
D. thiazide diuretics and lifestyle changes.
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.
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 patient has been taking chlorthalidone to treat hypertension. The patient's prescriber has just ordered the addition of spironolactone to the patient's drug regimen. Which statement by the patient indicates a need for further teaching?
A. "I should continue following the DASH diet when adding this drug."
B. "I should not take an ACE inhibitor when adding this drug."
C. "I will need to take potassium supplements when adding this drug."
D. "I will not experience a significant increase in diuresis when adding this drug."
Spironolactone is given in addition to thiazide diuretics to balance potassium loss caused by the thiazide diuretic. Patients should be advised against taking potassium supplements with spironolactone, because hyperkalemia can result. The DASH diet may be continued. ACE inhibitors are contraindicated because they promote hyperkalemia. Spironolactone does not significantly increase diuresis.
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."
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 with hypertension will begin taking an alpha1 blocker. What will the nurse teach this patient?
A. A persistent cough is a known side effect of this drug.
B. Eat foods rich in potassium while taking this drug.
C. Move slowly from sitting to standing when taking this drug.
D. Report shortness of breath while taking this drug.
The most disturbing side effect of alpha blockers is orthostatic hypotension. Patients taking these drugs should be cautioned to stand up slowly to avoid lightheadedness or falls. A persistent cough is a common side effect of ACE inhibitors. It is not necessary to increase dietary potassium intake when taking this drug. Shortness of breath may occur in individuals with asthma who are taking beta blockers.
A patient is taking clonidine for hypertension and reports having dry mouth and drowsiness. What will the nurse tell the patient?
A. Beta blockers can reverse these side effects.
B. Discontinue the medication immediately and notify the provider.
C. Drink extra fluids and avoid driving when drowsy.
D. Notify the provider if symptoms persist after several weeks.
Clonidine can cause dry mouth and sedation; patients should be warned to drink extra fluids and avoid driving. Beta blockers do not reverse these drug side effects. Discontinuing clonidine abruptly can cause severe rebound hypertension. These are common side effects that do not abate over time.
A patient takes an ACE inhibitor to treat hypertension and tells the nurse that she wants to become pregnant. She asks whether she should continue taking the medication while she is pregnant. What will the nurse tell her?
A. Controlling her blood pressure will decrease her risk of preeclampsia.
B. Ask the provider about changing to an ARB during pregnancy.
C. Continue taking the ACE inhibitor during her pregnancy.
D. Discuss using methyldopa instead while she is pregnant.
Methyldopa has limited effects on uteroplacental and fetal hemodynamics and does not adversely affect the fetus or neonate. Controlling blood pressure does not lower the risk of preeclampsia. ACE inhibitors and ARBs are specifically contraindicated during pregnancy.
A hospitalized patient has a blood pressure of 145/96 mm Hg. The nurse caring for this patient notes that the blood pressure the day before was 132/98 mm Hg. The patient reports ambulatory blood pressure readings of 136/98 and 138/92 mm Hg. The patient has a history of a previous myocardial infarction and has adopted a lifestyle that includes use of the DASH diet and regular exercise. What will the nurse do?
A. Notify the provider and discuss ordering a beta blocker for this patient.
B. Notify the provider and suggest a thiazide diuretic as initial therapy.
C. Order a diet low in sodium and high in potassium for this patient.
D. Recheck the patient's blood pressure in 4 hours to verify the result.
Initial drug selection is determined by the presence or absence of a compelling indication or comorbid condition. This patient has a history of MI; beta blockers are indicated for patients with pre-existing heart disease. Thiazide diuretics are first-line drugs of choice in patients without compelling indications. The patient is already consuming a DASH diet; closer monitoring of sodium or potassium will not help lower blood pressure. The patient has a record of hypertension, so it is unnecessary to recheck the blood pressure to verify the condition.
Which two-drug regimen would be appropriate for a patient with hypertension who does not have other compelling conditions?
A. Hydrochlorothiazide and nadolol
B. Hydralazine and minoxidil
C. Spironolactone and amiloride
D. Trichlormethiazide and hydrochlorothiazide
When using two or more drugs to treat hypertension, each drug should come from a different class. Hydrochlorothiazide is a diuretic and nadolol is a beta blocker, so this choice is appropriate. Hydralazine and minoxidil are both vasodilators. Spironolactone and amiloride are both potassium-sparing diuretics. Trichlormethiazide and hydrochlorothiazide are both thiazide diuretics.
A nursing student asks the nurse why multi-drug therapy is often used to treat hypertension. Which statement by the student indicates a need for further teaching?
A. "Multi-drug therapy often means that drugs may be given in lower doses."
B. "Some agents are used to offset adverse effects of other agents."
C. "Treatment of hypertension via different mechanisms increases success."
D. "Two or more drugs will lower blood pressure more quickly."
Multi-drug therapy does not lower blood pressure more quickly. Using more than one drug often means that doses can be decreased. Some agents can offset adverse effects of other agents. Treatment via different mechanisms increases the likelihood of success.
A patient with a recent onset of nephrosclerosis has been taking an ACE inhibitor and a thiazide diuretic. The patient's initial blood pressure was 148/100 mm Hg. After 1 month of drug therapy, the patient's blood pressure is 130/90 mm Hg. The nurse will contact the provider to discuss:
A. adding a calcium channel blocker to this patient's drug regimen.
B. lowering doses of the antihypertensive medications.
C. ordering a high potassium diet.
D. adding spironolactone to the drug regimen.
In patients with renal disease, the goal of antihypertensive therapy is to lower the blood pressure to 130/80 mm Hg or less. Adding a third medication is often indicated. Lowering the dose of the medications is not indicated because the patient's blood pressure is not in the target range. Adding potassium to the diet and using a potassium-sparing diuretic are contraindicated.
A 5-year-old patient seen in an outpatient clinic is noted to have hypertension on three separate visits. Ambulatory blood pressure monitoring confirms that the child has hypertension. As an initial intervention with the child's parents, the nurse will expect to:
A. perform a detailed health history on the child.
B. provide teaching about antihypertensive medications.
C. reassure the parents that their child may outgrow this condition.
D. teach the parents about lifestyle changes and a special diet.
Because the incidence of secondary hypertension is much higher in children than adults, it is important to obtain an accurate health history to help uncover primary causes. Once the type of hypertension is established, the teaching interventions may be useful. Hypertension must be treated, and it is incorrect to reassure parents that their child may just outgrow the condition.
The nurse is caring for a pregnant patient who is in labor. The woman reports having had mild preeclampsia with a previous pregnancy. The nurse notes that the woman has a blood pressure of 168/102 mm Hg. The nurse will contact the provider to request an order for which drug?
A. Angiotensin-converting enzyme (ACE) inhibitor
B. Hydralazine (Apresoline)
C. Magnesium sulfate
D. Sodium nitroprusside
The drug of choice for lowering blood pressure in a patient with severe preeclampsia is hydralazine. Sodium nitroprusside is not indicated. Magnesium sulfate is given as prophylaxis against seizures but does not treat hypertension. ACE inhibitors are contraindicated because of their potential for fetal harm.
A nurse has provided education for a patient newly diagnosed with hypertension who is just beginning therapy with antihypertensive medications. Which statement by the patient indicates a need for further teaching?
A. "I may experience serious long-term problems even if I am not having symptoms."
B. "I should report side effects to the provider since other drugs may be substituted."
C. "I will need to take medications on a long-term basis."
D. "When my symptoms subside, I may discontinue the medications."
Patients should be taught that hypertension treatment is lifelong and that medications must be continued even when symptoms subside. Long-term problems may still occur without symptoms. Reporting drug side effects is necessary so that other drugs may be tried if needed.
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)
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
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)
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).
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
A. Bumetanide (Bumex)
B. Chlorothiazide (Diuril)
C. Hydrochlorothiazide (HydroDIURIL)
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 who was in a motor vehicle accident sustained a severe head
injury and is brought into the emergency department. The provider orders
intravenous mannitol (Osmitrol). The nurse knows that this is given to:
A. reduce intracranial pressure.
B. reduce renal perfusion.
C. reduce peripheral edema.
D. restore extracellular fluid.
Mannitol is an osmotic diuretic that is used to reduce intracranial pressure by relieving cerebral edema. The presence of mannitol in blood vessels in the brain creates an osmotic force that draws edematous fluid
from the brain into the blood. It can also be used to increase renal perfusion. It can cause peripheral edema and is not used to restore extracellular fluid.
A patient is taking gentamicin (Garamycin) and furosemide (Lasix). The nurse should counsel this patient to report which symptom?
A. Frequent nocturia
C. Ringing in the ears
D. Urinary retention
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
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."
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.
Besides having diuretic effects for patients with congestive heart
failure, thiazides are also used to treat what? (Select all that apply.)
A. Diabetes insipidus
B. Hepatic failure
C. Increased intracranial pressure
D. Incorrect Intraocular pressure
E. Postmenopausal osteoporosis
Correct: A, B, E
A patient who is a chronic alcoholic is admitted to the hospital. Admission laboratory work reveals a magnesium level of 1.2 mEq/L. The
prescriber orders intravenous magnesium sulfate in a 10% solution at a rate of 10 mL/min. What will the nurse do?
A. Administer the IV dose as ordered and have calcium gluconate on hand.
B. Administer the IV dose and make preparations for mechanical ventilation.
C. Hold the IV dose until the infusion rate has been clarified with the provider.
D. Request an order for renal function tests before administering the IV dose.
This patient has hypomagnesemia and should be given magnesium sulfate intravenously. The percent of magnesium in solution is correct; however, magnesium should not be infused faster than 1.5 mL/min, so the nurse is correct to
question the rate of infusion. Calcium gluconate should be available when magnesium is given, but the nurse needs to clarify the rate of infusion first. Mechanical ventilation is necessary with excessivemagnesium. Renal function tests are not indicated.
A patient who was injured at home is brought to the emergency
department. The nurse caring for this patient notes a respiratory rate
of 32 breaths per minute and a heart rate of 90 beats per minute. The
injuries are minor, but the patient is inconsolable and hysterical. The
nurse expects that initial management will include:
A. administering a gas mixture of 5% carbon dioxide (CO2).
B. providing 100% oxygen via nasal cannula.
C. giving sodium bicarbonate IV.
D. providing sedatives to calm the patient.
The patient is at risk for respiratory alkalosis as a result of hyperventilation, and giving the patient a gas mixture containing CO2 will help correct the
alkalosis. Administering oxygen would worsen the problem. Sodium bicarbonate is given to correct metabolic acidosis. Sedatives may be necessary if initial measures fail.
A child who ingested a handful of aspirin tablets from a medicine
cabinet at home is brought to the emergency department. The nurse caring for the child notes a respiratory rate of 48 breaths per minute. The nurse understands that this child's respiratory rate is the result of the body's attempt to compensate for:
A. metabolic acidosis.
B. metabolic alkalosis.
C. respiratory acidosis.
D. respiratory alkalosis.
Metabolic acidosis can result from the ingestion of aspirin. The body responds by hyperventilating to reduce CO2, which represents volatile carbonic acid, and raise pH. This child has a rapid respiratory rate in response to metabolic acidosis. In
patients with metabolic alkalosis, the body responds with hypoventilation in an effort to increase the CO2 level. Patients with
respiratory acidosis usually have retention of CO2 secondary to hypoventilation, and compensation is the result of retention of
bicarbonate by the kidneys, which is a slow process. Respiratory alkalosis is caused by hyperventilation; treatment involves having the patient rebreathe CO2 or administering sedatives.
A patient with congestive heart failure is admitted to the hospital.
During the admission assessment, the nurse learns that the patient is
taking a thiazide diuretic. The nurse notes that the admission
electrolyte levels include a sodium level of 142 mEq/L, a chloride level
of 95 mEq/L, and a potassium level of 3 mEq/L. The prescriber has
ordered digoxin to be given immediately. What will the nurse do
A. Give the digoxin and maintain close cardiac monitoring.
B. Hold the digoxin and report the laboratory values to the provider.
C. Hold the thiazide diuretic and give the digoxin.
D. Request an order for an electrocardiogram (ECG).
Potassium depletion is common with thiazide diuretics, and hypokalemia is especially dangerous for patients receiving digoxin, because the drug can precipitate a fatal dysrhythmia and digoxin toxicity. The provider should be notified of the serum potassium level so that it can be corrected before the digoxin is administered. Giving
the digoxin could produce a fatal adverse effect, so this is not an appropriate course of action. Holding the thiazide diuretic will not correct the potassium deficiency. An ECG is not the initial priority.
A patient collapses after running a marathon on a hot day and is brought to the emergency department to be treated for dehydration. The nurse will expect to provide which therapy?
A. Intravenous hypertonic fluids given slowly over several hours
B. Intravenous hypotonic fluids administered in stages
C. Intravenous isotonic fluids given as a rapid bolus
D. Oral electrolyte replacement fluids with potassium
Because this patient is experiencing fluid volume loss as the result of excessive sweating, this is most likely hypertonic dehydration, in which loss of water
exceeds loss of electrolytes. This should be treated with a hypotonic solution or with fluids that contain no solutes at all. Initial
treatment may consist of having the patient drink water. When intravenous therapy is provided, volume replenishment should occur in stages. Hypertonic fluids are used to treat hypotonic contraction, usually caused by excessive sodium loss through the kidneys as the result of diuretic therapy. Isotonic fluids are used to treat isotonic contraction, which is generally caused by vomiting and diarrhea. An oral
electrolyte solution would only increase the hypertonicity; if oral rehydration is used in this case, the patient should drink plain water.
A nurse is caring for a child whose respirations are shallow and marked
by a prolonged expiratory phase. The nurse auscultates wheezes and poor air movement bilaterally. The child's respiratory rate is 26 breaths per minute, and the oxygen saturation is 89%. What does the nurse suspect?
A. Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Respiratory alkalosis
Respiratory acidosis results from retention of CO2 secondary to hypoventilation caused either by depression of the medullary respiratory center in the central nervous system (CNS) or by a pathologic lung condition, such as asthma. This child has shallow respirations with evidence of airway obstruction and poor ventilation. Metabolic acidosis occurs in chronic renal failure, loss of bicarbonate with severe
diarrhea, metabolic disorders, and ingestion of acids such as salicylates; hyperventilation is a compensatory mechanism. Metabolic alkalosis is usually caused by excessive loss of gastric acid or by ingestion of alkalinizing salts; hypoventilation is a compensatory
mechanism. Respiratory alkalosis is produced by hyperventilation and can
occur in any condition that increases the respiratory rate and depth.
A nurse is caring for a postoperative patient who has a nasogastric tube
with continuous suction. The nurse notes that the patient has shallow
respirations and suspects that this patient has developed:
A. metabolic acidosis.
B. metabolic alkalosis.
C. respiratory acidosis.
D. respiratory alkalosis.
Metabolic alkalosis occurs with excessive loss of acid, such as gastric acid, or
an excessive increase in alkalinizing salts. The body compensates for metabolic alkalosis by hypoventilating in an attempt to retain CO2. Metabolic acidosis is usually caused by ingestion of acids or with
excessive loss of bicarbonate and is compensated by hyperventilation.
Respiratory acidosis results from hypoventilation. Respiratory alkalosis
is the result of hyperventilation.
While performing an admission assessment on a patient, the nurse learns that the patient is taking furosemide (Lasix), digoxin, and
spironolactone (Aldactone). A diet history reveals the use of salt
substitutes. The patient is confused and dyspneic and complains of hand
and foot tingling. Which is an appropriate nursing action for this
A. Contact the provider to request orders for an electrocardiogram and
serum electrolyte levels.
B. Evaluate the patient's urine output and request an order for intravenous potassium.
C. Hold the next dose of furosemide and request an order for intravenous
D. Request an order for intravenous insulin to help this patient regulate
This patient is taking a potassium-sparing diuretic and is ingesting dietary potassium in salt substitutes. The patient shows signs of hyperkalemia: confusion, shortness of breath, and tingling of the
hands and feet. The cardiac effects can be fatal, especially if a patient also is taking digoxin. The most appropriate first action would be to obtain an ECG and serum electrolyte levels to evaluate the extent
of the patient's hyperkalemia. The patient does not need increased potassium. Furosemide is a potassium-wasting diuretic and would be helpful. Magnesium sulfate is not indicated. Until the patient's status has been assessed further, intravenous insulin is not indicated.
A patient arrives in the emergency department complaining of muscle
weakness and drowsiness. The nurse notes a heart rate of 80 beats per minute, a respiratory rate of 18 breaths per minute, and a blood
pressure of 90/50 mm Hg. The electrocardiogram reveals an abnormal rhythm. The nurse will question the patient about which over-the-counter medication?
D. Potassium supplements
Hypermagnesemia can occur when patients are taking magnesium-containing antacids. Symptoms include muscle weakness, sedation, hypotension, and ECG changes. Aspirin would cause metabolic acidosis. Laxatives can contribute to hypokalemia. Potassium supplements would cause hyperkalemia.
A patient is admitted to the hospital after several days of vomiting and
diarrhea. After an initial bolus of isotonic (0.9%) sodium chloride
solution, the prescriber orders dextrose 5% in normal saline (D5NS) with 20 mEq potassium chloride to infuse at a maintenance rate. What should the nurse review before implementing this order? (Select all that apply.)
B. Arterial blood gas levels
C. Serum electrolyte levels
D. Serum glucose level
E. Urine output
Correct: A, C, E
Which order for potassium (KCl) would the nurse question? (Select all that apply.)
A. D5 NS with 20 mEq KCl to start after patient voids
B. D5 NS with 60 mEq KCl for a patient with a serum potassium of 3.2 mEq/L
C. K-Dur, 1 tablet daily for a patient in diabetic ketoacidosis
D. K-Dur, 1 tablet with a full glass of water
E. Potassium chloride, 10 mEq rapid IV push
Correct: B, C, E
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