Chapter 46 : Antianginal Agents
CAD is the leading cause of the death in the US
Heart receives blood supply during DIASTOLE while it is at rest.
PULSE PRESSURE is the systolic minus the diastolic
Narrowing of a vessels is ATHEROMAS in ATHEROSCLEROSIS
• Atheromas (fatty tumors)
• These deposits attract platelets and immune factors and causes SWELLING AND
DEVELOPMENT OF A LARGER DEPOSIT
People with atherosclerosis has a SUPPLY AND DEMAND PROBLEM
Imbalance between oxygen supply and demandANGINA PECTORIS (suffocation of the chest)
ANGINAthe lack of oxygen in the heart muscle is pain
When SUBSTANCE P is released, Pain is felt in that spot
STABLE ANGINAwhen you stop exercising or any strenuous activity and the pain goes away • No damage is done to the heart when stable angina occurs.
• Can continue to occur without a MI occurringCHRONIC ANGINA
UNSTABLE ANGINAchest pain even when the body is at rest
• Does not cause damage to heart muscle
• At increased risk of a complete blockage of blood supply to the heart muscle
PRINZMETAL ANGINAcaused spasms of the blood vessels and not just by vessel narrowing
• Has angina at rest, AT THE SAME TIME EACH DAY, ECG pattern change
MIocclusion of coronary vesselo
• Nausea
• Pain
• Development of arrhythmias o Most deaths of MI occurs as a result of fatal arrhythmias
• If heart muscle can heal within 6-10 weeks scar tissue will form and muscle will compensate for the injury
• If area is too large and muscle cant compensate for the loss, HF or CARDIOGENIC SHOCK can occur
Antianginal agents
• Dilate blood vessels (increase supply of oxygen)
• Decrease the work of the heart (decrease the demand for oxygen)
The demand for oxygen for heart is influenced by
• HR
• Preload
• Afterload
• Contractility
Drugs used to treat angina
• Beta-adrenergic blockers
• Calcium channel blockers
• Nitrates
• Piperazine acetamides
NITRATES cause relaxation and to depress muscle tone
• Nitrates relax and dilate veins, arteries, and capillariesallows increased blood flow through the vessels and lowering systemic BP because of a drop in resistance.
• NITRATES are used for the prevention and treatment of ANGINA PECTORIS
NITRATES=VASODILATION
Nitrates (NIA)
• Nitroglycerin
• Amyl Nitrateinhalation (wave underneath nose)
• Isosorbide
ANTIANGINAL LIFESPAN
Children
• Nitro can be given for congenital heart defects or cardiac surgery
• Dose determined by weight and age
• Monitor for adverse effects resulting in change in BP
Adults
• Determine what causes attacks and take anginal medications BEFORE event occurs
• Nonpharmacological measures that could decrease risk of CAD and improve effectiveness of med o Weight loss o Smoking
o Activity and diet changes
Avoid or decrease use of coffee and alcohol o Avoid stressful activities
Elderly
More likely to develop adverse effects
o Heart disease o Hypotension o Arrhythmias
• Mobility and balance may be altered
• Start at lower dose
Anal fissuresNitroglycerin ointment
Sublingual Nitro administration
• Check under tongue for lesions or abrasions
• Sip water before to moisten membranes so the tablet will dissolve quickly
• Tablet should “FIZZLE” OR BURN which indicates potency
• Works in 3-5 min
• Can be repeated in 5 minutes if no relief
• No OTC med
Transdermal administration
• Remove old transdermal patch
• Wash area before applying new patch to avoid severe hypotension
Nitro contraindications/cautions
• Severe anemia
• Head trauma or cerebral hemorrhage
• Hepatic or renal failure
• Hypotension
• Hypovolemia
• Tamponade
• Syncope
• Angina
REFLEX TACHYCARDIA CAN OCCUR IF BP DROPS
Nitrate Drug-Drug
• Ergot derivatives
• Drugs used to treat ERECTILE DYSUNCTION o Sildenafil o Tadalafil o Vardenafil
Nitro adverse effects
• Hypotension
• Flushing
• Headache • Sweating
Arrhythmias
Have emergency life support equipment ready in case reaction or MI occurs
Taper dose over 4-6 weeks after long term therapy
Fast acting nitrateacute anginal attacks
Slow acting nitrateprevent anginal attacks
REPORT
• Blurred vision
• Persistent/severe headache
• Rash
• Syncope
• More frequent angina
Beta Adrenergic Blockersblock the stimulatory effects of the SNS
Beta Blockers are used for LONG TERM management of angina pectoris CAUSED BY ATHESCLEROSIS
Metoprolol, nadolol, and propranolol are beta-blocker drugs
Beta blockers decrease the demand for oxygen
Beta blockers can be used in combination with nitrates to increase exercise tolerance
Beta blockers + Nitrates= Increased exercise tolerance
Beta blockers are NOT indicated for Prinzmetal angina because they could cause peripheral ischemia and may exacerbate vasospasm due to blocking of beta receptor sites.
DO NOT USED BETA BLOCKERS FOR PRINZMETAL ANGINA
Do NOT use beta blockers if pt has CV issues.
Do not use beta blockers if pt has
• Brady
• Heart block
• Cardiogenic shock
Caution should be used in pts with
• Diabetes
• Peripheral vascular disease
• Asthma • COPD
Thyrotoxicosis
Beta Adrenergic Blockers ADVERSE EFFECTS
• HF
• Reduced CO
• Arrhythmias
• Bronchospasms
• Dyspnea
• Cough
• Decreased exercise
• Malaise
Beta blockers Drug-Drug
• Clonidine (paradoxical HTN occurs)
• Clonidine withdrawal (rebound HTN)
• NSAIDS
• Epi
• Ergot alkaloids
• Insulin/antidiabetic agents
Calcium Channel Blockerstreatment for PRINZMETAL ANGINA and HTN
Calcium channel blockers, such as diltiazem, are indicated for the treatment of Prinzmetal
angin a.
Calcium channel blockers relieve coronary artery VASOSPASM
Calcium channel blockers BLOCK MUSCLE CONTRACTION
Verapamil (calcium channel blocker) used to treat cardiac tachyarrhythmias
Calcium channel blockers are contraindicated/cautioned in:
• Heart block or sick sinus syndrome
• Renal or hepatic dysfunction
• HF
Calcium channel blockers ADVERSE EFFECTS
• Hypotension
• Cardiac arrhythmias o Brady
o Heart block
• Peripheral edema
• Headache
Calcium channel blocker Drug-Drug
Cyclosporine
• Digoxin
Piperazine Acetamide AgentRANOLAZINE (first line treatment for angina or for use in combination with notrates, beta blockers, or amlodipine
Piperazine Acetamide Agent (RANOLAZINE)
• Decrease blood glucose levels
• Decrease incidence of V FIB, A FIB, brady, chronic angina
• PROLONGS QT intervals
Do NOT give TCA or grapefruit juice with Piperazine Acetamide Agent (RANOLAZINE)
A client with a hx of angina is preparing to do some yard maintenance. Adminsitration of what
medication will most likely prevent angina pain during this activity? NITRATES Nitrates (NAI)
• Nitroglycerin
• Amyl nitrate
• Isosorbide
Nitrates would be contraindicated in clients with anemia
Chapter 47
Lipid lowering agents
ANTIHYPERLIPIDEMIC AGENTS lower the serum levels of cholesterol and various lipids
1The client undergoing medication therapy to treat hyperlipidemia reports she just found out she is pregnant. What drug would be safe for the client to continue while pregnant?
Time Spent - 00:01:24
Rationale: If a lipid-lowering medication must be taken while pregnant, a bile acid sequestrant is the drug of choice. Pregnant women should not take HMG-CoA reductase inhibitors because of the high risk of adverse effects on the fetus or neonate. These drugs are labeled as pregnancy category X. The effect of this drug on the growing fetus is unknown and should be used only with caution. Omega-3 acid ethyl esters are not recommended during pregnancy or lactation.
2The nurse has completed an assessment of a female client. What assessment finding meets the criteria for metabolic syndrome?
Time Spent - 00:00:06
Your Response: Triglyceride level 159 mg/dL
Rationale: Characteristics of metabolic syndrome include fasting blood glucose levels greater than 110 mg/dL, waist measurement over 40 in in men and over 35 in in women, triglyceride levels greater than 150 mg/dL or HDL levels less than 40 mg/dL in men or less than 50 mg/dL in women, blood pressure greater than 130/85 mm Hg, increased macrophages, levels of interleukin6 and TNF, and increased plasminogen activator levels.
3What education should the nurse provide to a client who has been prescribed simvastatin?
Time Spent - 00:00:04 Your Response: Take the medication at bedtime.
Rationale: Simvastatin should be administered at bedtime because the highest rates of cholesterol synthesis occur between midnight and 5 AM, and the drug should be taken when it will be most effective. Extra doses are never taken, and the medication is taken once per day. Concurrent use of antibiotics is not contraindicated.
4When reviewing the clients' admission orders, what prescription should the nurse identify as being safest and most effective?
Time Spent - 00:00:08 Your Response: Administer ezetimibe 10 mg PO daily and atorvastatin 20 mg PO daily.
Rationale: Ezetimibe and atorvastatin would be safe to administer in combination with one another, and this order would not need to be questioned. HMG-CoA reductase inhibitors should not be administered in combination with niacin due to increased risk of toxicity. Erythromycin is contraindicated with atorvastatin because of increased risk of rhabdomyolysis. HMG-CoA reductase inhibitors should not be taken in combination with grapefruit or grapefruit juice due to increased risk of rhabdomyolysis and toxicity.
5Which agent would a nurse identify as a cholesterol absorption inhibitor?
Time Spent - 00:00:09
Rationale: Ezetimibe is a cholesterol absorption inhibitor. Simvastatin is a HMG-CoA reductase inhibitor. Colestipol is a bile acid sequestrant. Fenofibrate is classified as a fibrate.
6
The nurse teaches the client to mix cholestyramine with what liquids? Select all that apply.
Time Spent - 00:00:06
Your Response: Water, Fruit juices, Soups, Cereals
Cholestyramine can be mixed with fruit juices, soups, cereals, and water. Cholestyramine cannot be mixed with soda or seltzer water.
7When describing the action of atorvastatin, the nurse includes what important descriptor?
Time Spent - 00:00:13
Your Response: Blocking the enzyme that is involved in cholesterol synthesis
Rationale: HMG-CoA reductase inhibitors, such as atorvastatin, block the enzyme involved in cholesterol synthesis. Bile acid sequestrants block bile acids to form insoluble complexes for excretion in the feces. Fibrates stimulate the breakdown of lipoproteins from the tissues and their removal from the plasma. Cholesterol absorption inhibitors work in the brush border of the small intestine to decrease absorption of dietary cholesterol from the small intestine.
8
A client has been diagnosed with hyperlipidemia and has been prescribed niacin 1.5 g PO daily in two divided doses. How many 500-mg tablets should the nurse administer for each dose? ___________ tablets
Time Spent - 00:00:05
Rationale: Each dose is 1.5 g ÷ 2 = 0.75 g. This is equivalent to 750 mg. 750 mg ÷ 500 mg/tablet = 1.5 tablets.
9
After reviewing the various agents used to lower lipid levels, the nurse should identify which agents as stimulating the breakdown of lipoproteins from the tissues and their removal from the plasma? Select all that apply.
Time Spent - 00:00:08
Your Response: Fenofibrate, Gemfibrozil
Rationale: Fibrates stimulate the breakdown of lipoproteins from the tissues and their removal from the plasma. Examples include fenofibrate and gemfibrozil. HMG-CoA reductase inhibitors block HMG-CoA reductase from completing the synthesis of cholesterol and include drugs such as atorvastatin. Bile acid sequestrants like cholestyramine work by binding with bile acids in the intestine to form an insoluble complex that is then excreted in the feces. Vitamin B3, known as niacin or nicotinic acid, inhibits the release of free fatty acids from adipose tissue, increases the rate of triglyceride removal from plasma, and generally reduces LDL and triglyceride levels and increases HDL levels.
10A client with atrial fibrillation is receiving warfarin therapy. The client is also prescribed ezetimibe. The nurse would instruct the client to watch for what?
Time Spent - 00:00:03
Warfarin levels increase with ezetimibe, increasing the client's risk for bleeding. Abdominal pain is a common adverse effect of ezetimibe but this is unrelated to the combination therapy. Yellowing of the skin suggests liver dysfunction, which is not associated with the combination therapy. Blurred vision is not associated with the combination therapy.
11
The nurse is teaching a client about fenofibric acid. What adverse effects would the nurse discuss in the teaching plan? Select all that apply.
Time Spent - 00:00:21
Correct Response: Runny nose, Respiratory infections
Rationale: The most common adverse effects that have been reported are headache, back pain, nausea, diarrhea, muscle pain, runny nose, and respiratory infections. Gallstones are not usually associated with fenofibric acid. Diarrhea is more likely than constipation when taking fenofibric acid. Abdominal pain is not an expected side effect.
12A client who is obese is told that his or her lipid levels are elevated. What is the first intervention the nurse will anticipate the provider will order?
Time Spent - 00:00:04
Your Response: Dietary change and exercise
Rationale: Before starting any medications, the client will be encouraged to change diet and exercise regularly for 3 to 6 months. Cholestyramine may be the first drug ordered but only after 3 to 6 months of lifestyle change were unsuccessful. Atorvastatin would only be ordered if lifestyle changes for at least 3 to 6 months were unsuccessful. Niacin is generally ordered only when other therapies have been unsuccessful.
13The nurse is assessing a client who has been taking atorvastatin for several months. What change in the client's health status should the nurse most likely attribute to the use of atorvastatin?
Time Spent - 00:00:04 Your Response: Recent nausea and constipation
Rationale: Nausea and constipation are among the common GI effects of HMG-CoA inhibitors. Edema, arrhythmias, and respiratory infections do not normally occur.
14A client with a complex medical history has been taking cholestyramine for several months following diagnosis with hyperlipidemia. The client's most recent blood work reveals increased blood urea nitrogen and creatinine levels. What is the nurse's best interpretation of this finding?
Time Spent - 00:00:06
Your Response: This is likely unrelated to cholestyramine use and will not likely affect future therapy.
Bile acid sequestrants are not absorbed systemically. They act while in the intestine
and are excreted directly in the feces. Because they are not excreted by the kidneys, changes in renal function should not have a direct effect on treatment. Nephrotoxicity is not an adverse effect of cholestyramine.
15What LDL-lowering medication would the nurse identify as inhibiting triglyceride synthesis in the liver?
Time Spent - 00:00:04
Rationale: Fenofibrate inhibits triglyceride synthesis in the liver, resulting in a reduction of LDL levels. Gemfibrozil inhibits the peripheral breakdown of lipids, reduces production of triglycerides and LDLs, and increases HDL concentrations. Niacin acts to inhibit the release of free fatty acids from adipose tissue, increases the rate of triglyceride removal from the plasma, and generally reduces LDL and triglyceride levels and increases HDL levels. Fenofibric acid activates a specific hepatic receptor that results in increased breakdown of lipids, elimination of triglyceride-rich particles from the plasma, and reduction in the production of an enzyme that naturally inhibits lipid breakdown.
16What adverse effects would a nurse assess for in a client taking ezetimibe?
Time Spent - 00:00:05
Rationale: Mild abdominal pain is a common adverse effect. Ezetimibe is not associated with bloating. Ezetimibe is not associated with flatulence. Diarrhea, not constipation, is a common adverse effect.
17The nurse is describing the metabolism of fats to a client who has recently been diagnosed with hyperlipidemia. The nurse should describe what role of bile acids?
Time Spent - 00:00:04
Your Response: Facilitating the absorption of fats into the small intestine
Rationale: Bile acids, which contain high levels of cholesterol (a fat), act like a detergent in the small intestine and break up the fats into small units, called micelles, which can be absorbed into the wall of the small intestine. Bile acids do not transport fats into cells or prevent cholesterol deposits in blood vessels.
18The nurse is teaching a class on healthy lifestyle choices. The nurse explains that elevated HDL levels are beneficial because of what action?
Time Spent - 00:00:04 Your Response: Pick up remnants of fat and cholesterol left in the periphery by LDL breakdown.
Rationale: HDLs enter circulation as loosely packed lipids that are used for energy and to pick up remnants of fats and cholesterol that are left in the periphery by LDL breakdown. HDLs serve a protective role in cleaning up remnants in blood vessels. HDLs increase in response to estrogen but do not block estrogen effects. They play no role in fat absorption or LDL metabolism and excretion.
19A client who is receiving cholestyramine also takes digoxin. The nurse teaches the client about drug administration. The client demonstrates understanding of the teaching when making what statement?
Time Spent - 00:00:06
Your Response: "I will take the digoxin at least an hour before the cholestyramine."
Rationale: The absorption of digoxin can be decreased or delayed with cholestyramine, a bile acid sequestrant. Therefore, the digoxin should be taken 1 hour before for 4 to 6 hours after the cholestyramine.
20The nurse is caring for a male client who is obese and has a family history of coronary artery disease. The client had a myocardial infarction at age 40. What risk factor can the client modify?
Time Spent - 00:00:03
Rationale: The client has the ability to reduce weight, so obesity is a controllable risk factor. The client cannot change his genetic makeup. Family history is not modifiable nor is a history of MI.
21A client is receiving atorvastatin. The nurse would anticipate that the maximum effectiveness of the drug would occur within which time frame?
Time Spent - 00:00:02
Rationale: Atorvastatin peaks in 1 to 2 hours.
22A client with hyperlipidemia began taking atorvastatin several weeks ago and has phoned to report muscle pain, brown-tinged urine, and nausea. What is the nurse's best action?
Time Spent - 00:00:07 Your Response: Tell the client to present to the emergency department promptly.
Rationale: These signs and symptoms suggest rhabdomyolysis, which is a serious complication of HMG-CoA drugs. The client should present for care immediately and not delay. The timing of the medication is not a relevant variable. Fluid intake will not resolve this adverse effect.
23What does the nurse describe as a carrier for small units of fats?
Time Spent - 00:00:18
Rationale: Chylomicrons are carriers for micelles. Micelles are the small units of broken-down fats. Bile acids act like a detergent in the small intestine and break up fats into small units. High levels of cholesterol are part of bile acids.
24When administering a lipid-lowering agent, the nurse would anticipate administering the drug by which route?
Time Spent - 00:00:08
Rationale: Lipid-lowering agents are administered orally. There are no lipid-lowering agents administered sublingually, intramuscularly, or intravenously.
25The nurse admits a client who has recently begun taking bile acid sequestrants in order to control serum lipid levels and reduce the risk for CAD. When assessing the client for adverse effects, what assessment should the nurse prioritize?
Time Spent - 00:00:05 Your Response: Assessment of bowel sounds and recent pattern of bowel movements
Rationale: The most common adverse effect of bile acid sequestrants is direct GI irritation, constipation that may progress to fecal impaction and aggravation of hemorrhoids, so a careful assessment of the abdomen and bowel habits is important. Tetany and fluid imbalances would not normally be expected.
26
What factors would the nurse anticipate assessing in the client diagnosed with metabolic syndrome? Select all that apply.
Time Spent - 00:00:14
Your Response: High triglycerides, Hypertension, Abdominal fat
Rationale: Abdominal obesity is a factor in metabolic syndrome. High triglycerides are a component of metabolic syndrome. Hypertension is a factor found in metabolic syndrome. HDLs are usually low in metabolic syndrome. Anemia does not contribute to metabolic syndrome.
Chapter 48
1Warfarin typically takes 3 days to achieve its onset of action.
Time Spent - 00:00:05
Rationale: Warfarin's onset of action is about 3 days; its effects last for 4 to 5 days. Because of the time delay, warfarin is not the drug of choice in an acute situation, but it is convenient and useful for prolonged effects.
2The client is receiving a heparin infusion. The aPTT control is 28 seconds, and the client's result is 61 seconds. What is the nurse's best action?
Time Spent - 00:00:06 Your Response: Continue to monitor the client for medication effects.
Rationale: Therapeutic range for heparin would be 1.5 to 3 times the client's baseline. For a baseline value of 28 seconds, this would range from 42 to 70 seconds. The nurse should continue to care for the client, and there is no reason to administer vitamin K, which is an antidote for warfarin overdose Client.
3What would a nurse expect to administer for a heparin overdose?
Time Spent - 00:00:03
Rationale: Protamine sulfate is the antidote for heparin. Thrombin is a topical hemostatic agent. Pentoxifylline is a hemorrheologic agent (one that can induce hemorrhage). Urokinase is a thrombolytic agent.
4The nurse is monitoring a client's heparin infusion. What potential nursing diagnosis should the nurse prioritize when planning assessments?
Time Spent - 00:02:46
Your Response: Ineffective tissue perfusion (total body) related to blood loss
Rationale: All anticoagulants carry a risk for bleeding that can result in ineffective tissue perfusion. Due to safety, this would be prioritized over client knowledge. There is no appreciable risk for infection or fluid imbalances.
5The nurse is caring for a client taking warfarin whose PT is four times the control. What is the nurse's best action, if ordered by the provider?
Time Spent - 00:00:07
Rationale: This client would receive vitamin K as an antidote to warfarin to lower the PT, which is extremely high. Therapeutic level of warfarin is a PT with 1.3 to 1.5 times control. Protamine sulfate is given as an antidote to heparin. The next dose of warfarin should not be given because the client's blood is taking too long to clot. There is no need to redraw another PT.
6A 6-year-old child is determined to have a high risk of venous thromboembolism. What medication would be safe to administer to this client?
Time Spent - 00:00:09
Rationale: Heparin may be used, but the dose should be carefully calculated based on weight and age and checked by another person before the drug is administered. Dabigatran and rivaroxaban are not approved for use in children. The safety of low molecular weight heparins has not been established in children.
7
A client is receiving warfarin. What would the nurse monitor to determine the effectiveness of therapy? Select all that apply.
Time Spent - 00:01:19
Your Response: Prothrombin time, International normalized ratio
Rationale: INR is used to monitor the effects of warfarin. Prothrombin time is used to monitor the effects of warfarin. Whole blood clotting time is used to monitor the effects of heparin. Partial thromboplastin time is used to monitor the effects of heparin. Vitamin K levels are not used to monitor the effects of anticoagulants.
8
What drugs does the nurse identify as blocking the formation of thrombin from prothrombin? Select all that apply.
Time Spent - 00:00:05
Your Response: Argatroban, Heparin, Bivalirudin
Rationale: Heparin blocks the formation of thrombin from prothrombin. Argatroban blocks the formation of thrombin from prothrombin. Bivalirudin blocks the formation of thrombin from prothrombin. Warfarin decreases the production of vitamin K–dependent clotting factors. Fondaparinux inhibits factor Xa and blocks the clotting cascade to prevent clot formation.
9A nurse would anticipate the need for an increased dosage of warfarin if the client was
Rationale: Carbamazepine decreases the anticoagulant effects of warfarin, necessitating an increased dose of warfarin. Clofibrate, amiodarone, and danazol increase the bleeding effects of warfarin necessitating a decreased dosage of warfarin.
10
An intravenous heparin infusion has been prescribed for a client who has deep vein thrombosis. The medication is available in a 250-mL minibag containing 25,000 units. The client's infusion has been prescribed to begin with a bolus of 80 units/kg and the client weighs 142 lbs. How many milliliters of heparin solution should the administer for the bolus? Provide your response to one decimal place. ___________ mL
Time Spent - 00:04:02
Rationale: The client's weight must be first converted from pounds to kilograms. 142 lbs ÷ 2.2 =
64.55 kg. To determine the dose, the client's weight must be multiplied by 80 units: 64.55 × 80 = 5,164 units. The heparin is available at a concentration of 100 units/mL (because there are 25,000 units in 250 mL). To determine the number of milliliters to administer, divide the dose by the concentration: 5,164 units ÷ 100 units/mL = 51.64 mL, which rounds to 51.6 mL.
11A client is to receive desirudin to prevent deep vein thrombosis following an elective hip surgery. The nurse would expect this drug to be administered by which route?
Time Spent - 00:00:05
Rationale: Desirudin is administered subcutaneously 5 to 15 minutes before the surgery and continuing for 9 to 12 days after the surgery.
12The nurse identifies what agent as a systemic hemostatic agent?
Time Spent - 00:00:04
Rationale: Aminocaproic acid is the only systemic hemostatic agent available. The other answer choices are topical hemostatic agents.
13A client is to receive abciximab. What aspect of this client's history is the most likely indication for this medication?
Time Spent - 00:00:04
Rationale: Abciximab is administered for early treatment of unstable angina and non–Q-wave myocardial infarction (MI). It is not used to treat venous thromboembolism or trauma.
14The nurse administers a thrombolytic agent to a client diagnosed with an acute MI. What is the priority nursing diagnosis for this client before and within the first hours after drug administration?
Time Spent - 00:00:04 Your Response: Ineffective cardiac tissue perfusion related to coronary artery blockage
Rationale: The priority concern for this client is ineffective cardiac tissue perfusion until it is determined that reperfusion has occurred following administration of the drug. Impaired gas exchange would not be anticipated in this client. Anxiety would not be the priority diagnosis but would certainly be a concern the nurse should address. There is little risk for fluid overload unless an error is made.
15A thrombolytic can be used to treat an acute MI as long as the onset of symptoms occurred within the last 3 hours.
Time Spent - 00:00:04
Rationale: Treatment with a thrombolytic must be instituted within 6 hours of the onset of symptoms of an acute MI to achieve maximum therapeutic effectiveness.
16Heparin is the anticoagulant of choice during pregnancy.
Time Spent - 00:00:04
Rationale: Because of the many risks associated with increased bleeding or increased blood clotting during pregnancy, these drugs should not be used during pregnancy unless the benefit to the mother clearly outweighs the potential risk to the fetus and to the mother at delivery. However, if an anticoagulant must be used during pregnancy, heparin would be the drug of choice.
17Which agent would a nurse expect to administer to a client with Christmas disease?
Time Spent - 00:00:03
Rationale: Factor IX complex is used to treat hemophilia B, also known as Christmas disease. Antihemophilic factor is used to treat hemophilia A. Aminocaproic acid is used to treat excessive bleeding in hyperfibrinolytic states. Vitamin K would be used to treat an overdose of warfarin.
18
What drugs should the nurse identify as having a drug–drug interaction with warfarin that increases the risk of bleeding? Select all that apply.
Time Spent - 00:00:36
Correct Response: Cefoxitin, Ranitidine, Salicylates, Metronidazole
Rationale: Salicylates, ranitidine, metronidazole, and cefoxitin interact with warfarin resulting in the increased risk of bleeding. Carbamazepine interacts with warfarin resulting in a decreased anticoagulant effect.
19The nurse is admitting a new client and is reviewing the client's medication regimen. The nurse reads that the client takes warfarin 5 mg PO daily. What assessment most likely addresses the client's underlying diagnosis?
Time Spent - 00:02:02
Correct Response: Auscultation of the client's apical heart rate
Rationale: Atrial fibrillation is among the most common indications for warfarin. Auscultation of the client's heart rate would identify this or any other arrhythmias. Palpating the client's peripheral pulses or measuring blood pressure would not normally identify an arrhythmia. Warfarin is not used for the treatment of hemorrhage.
20The nurse is caring for a client brought to the emergency department and diagnosed with an acute myocardial infarction. Before administering the thrombolytic drug ordered by the provider, the nurse will assess for what contraindication to the drug?
Time Spent - 00:00:09
Correct Response: Recent invasive procedures
Rationale: The nurse must carefully assess the client for recent falls, closed head injuries, or invasive procedures because any recent blood clot will be dissolved and bleeding will occur from the old injury. Renal and liver disease may impact the dosage but would not contraindicate the drug. Fever or infection would not be a contraindication.
21The nurse identifies what drug as blocking the production of platelets in the bone marrow?
Time Spent - 00:00:04
Rationale: Anagrelide blocks the production of platelets in the bone marrow. The other answer choices inhibit platelet aggregation and adhesion by blocking receptor sites on the platelet membrane, thereby preventing platelet–platelet interaction or the interaction of platelets with other clotting chemicals.
22Aspirin is the prototype anticoagulant.
Time Spent - 00:00:07
Rationale: Aspirin is the prototype antiplatelet agent.
23What would the nurse identify as the end of the intrinsic pathway?
Time Spent - 00:00:18
Rationale: Thrombin formation occurs at the end of the intrinsic pathway. The first reaction to a blood vessel injury is local vasoconstriction. In addition, injury then exposes blood to the collagen and other substances under the endothelial lining of the vessel, then causing platelet aggregation. Release of factor XI occurs in response to activation of the Hageman factor.
24What client would be most likely to benefit from the daily administration of clopidogrel?
Time Spent - 00:00:18
Correct Response: A client who has had two myocardial infarctions over the past 5 years Rationale: Clopidogrel is used for the treatment of clients who are at risk for ischemic events; clients with a history of MI, peripheral artery disease, or ischemic stroke; and clients with acute coronary syndrome. It would not be effective for clients with hemophilia because they lack clotting factors. It is not used for the immediate treatment of DVT or for postoperative DVT prophylaxis.
25Which client would be most likely to benefit from the administration of a thrombolytic drug?
Time Spent - 00:00:06
Your Response: A client with an acute myocardial infarction
Rationale: Thrombolytic drugs can dissolve thrombi that contribute to MI. They are not used to treat DIC, hemophilia, or cirrhosis.
26The most common adverse effects associated with antiplatelet agents are headache and dizziness.
Time Spent - 00:00:09
Rationale: Increased bruising and bleeding from the gums while brushing the teeth are the most common adverse effects associated with antiplatelet agents.
27
What actions should the nurse associate with low molecular weight heparins? Select all that apply.
Time Spent - 00:00:41
Correct Response: Blockage of factor Xa, Blockage of factor IIa
Rationale: Low molecular weight heparins block factor Xa. Low molecular weight heparins block factor IIa. Heparin blocks the formation of thrombin from prothrombin. Warfarin decreases the production of vitamin K clotting factors. Thrombolytic agents activate the natural anticlotting system and stimulate the conversion of plasminogen to plasmin.
28A client is to receive eptifibatide. The nurse would expect to administer this drug by which route?
Time Spent - 00:00:11
Rationale: Eptifibatide is administered intravenously.
Chapter 49
1There is a risk of antibody production with the use of epoetin.
Time Spent - 00:00:03
Rationale: In late 2005, the makers of epoetin and darbepoetin sent out warning letters to healthcare professionals to bring attention to serious adverse effects that had been noted in postmarketing studies. Cases of pure red cell aplasia (defective or insufficient production) and severe anemias, with or without cytopenias (decreased levels of other blood cells), had been reported. These cases were associated with the development of neutralizing antibodies to erythropoietin. Use of any therapeutic protein brings with it the risk of antibody production. All of the erythropoietic proteins (Aranesp, Epogen, Procrit) now carry a warning about the potential for this problem.
2The nurse identifies the client as having what type of anemia upon learning of the client's inability to produce intrinsic factor?
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Rationale: Pernicious anemia occurs when the gastric mucosa cannot produce the intrinsic factor and vitamin B12 cannot be absorbed. Iron deficiency anemia occurs when blood is lost or the diet is insufficient in supplying adequate iron. Sickle cell anemia results from a genetically inherited hemoglobin S. Folic acid deficiency anemia results from inadequate folic acid intake or malabsorption.
3
A client has been prescribed darbepoetin alfa 0.45 mcg/kg IV once per week. The client weighs 185 lbs. How many micrograms of the medication should the nurse administer?
Provide your response to the nearest microgram. ___________ mcg
Time Spent - 00:00:19
Rationale: The client's weight must be first converted to kilograms: 185 ÷ 2.2 = 84.1 kg. The prescribed dose is 0.45 mcg/kg, and 84.1 × 0.45 = 37.85 mcg, which rounds to 38 mcg.
4Folic acid is necessary for cell growth and maintenance of the myelin sheath.
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Rationale: Folic acid is necessary for cell growth and development; vitamin B12 is necessary for maintenance of the myelin sheath.
5A client develops anemia secondary to chronic hemodialysis. The healthcare provider prescribes iron sucrose. The nurse expects this drug to be administered by which route?
Time Spent - 00:00:16
Rationale: Iron sucrose is administered one to three times per week IV during dialysis.
6The nurse is caring for a client taking an iron preparation who is admitted to the facility with septicemia. What antibiotic, if ordered by the provider, should the nurse question?
Time Spent - 00:00:11
Rationale: Antiinfective response to ciprofloxacin, norfloxacin, or ofloxacin can decrease if these drugs are taken with iron because of a decrease in absorption; they also should be administered at least 2 hours apart. There is no associated drug–drug interaction between iron and penicillin, erythromycin, or gentamicin.
7The nurse teaches the parents to administer an iron solution to their child who has anemia. What action should the nurse recommend?
Time Spent - 00:00:03 Your Response: Have the child drink the solution with a straw.
Rationale: If a liquid iron solution is being used, the child should drink it through a straw to avoid staining the teeth. It should not be taken with antacids or milk, and there is no need to sip it over a prolonged time.
8The nurse is providing care for a client who has been admitted to the hospital with urosepsis and who takes hydroxyurea on an ongoing, daily basis. In addition to assessing the course of the client's infection, the nurse should prioritize what other assessment?
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Rationale: The client likely has sickle cell anemia, and the presence of an infection is likely to precipitate a sickle cell crisis that is accompanied by intense pain. Sickle cell crisis do not normally affect respiratory, neurologic, or cardiac status.
9The nurse suspects the client has what type of anemia upon learning the client takes hydroxyurea?
Time Spent - 00:00:04
Rationale: Hydroxyurea is indicated for the treatment of sickle cell anemia to increase the amount of fetal hemoglobin produced in the bone marrow and to dilute the formation of abnormal hemoglobin S in adults who have sickle cell anemia. Epoetin alfa is indicated for treatment of anemia associated with renal failure and for those on dialysis. Epoetin alfa is indicated for treatment of anemia associated with cancer chemotherapy. Ferrous sulfate and iron dextran are indicated for the treatment of iron deficiency anemia.
10The component of the red blood cell that is not recycled is bilirubin.
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Rationale: The only part of the RBC that cannot be recycled is the toxic pigment bilirubin, which is conjugated in the liver, passed into the bile, and excreted from the body in the feces or the urine. Bilirubin is what gives color to both of these excretions.
11The mature red blood cell contains a nucleus.
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Rationale: There is no nucleus in a mature red blood cell. It does, however, have a vast surface area to improve its ability to transport oxygen and carbon dioxide.
12
After teaching a client about the adverse effects of iron therapy, the client demonstrates understanding of the information by identifying what potential adverse effects? Select all that apply.
Time Spent - 00:00:21
Correct Response: Dark stools, Constipation, Anorexia
Rationale: Adverse effects of iron therapy include dark stools, constipation, anorexia, diarrhea, nausea, vomiting, and GI upset.
13
What would a nurse identify as contraindications for iron therapy? Select all that apply.
Time Spent - 00:00:34
Correct Response: Peptic ulcer disease, Colitis, Hemolytic anemia
Rationale: Clients with hemolytic anemia may develop iron toxicity with iron therapy. Clients with peptic ulcer disease or colitis may experience increased tissue irritation, exacerbating the condition when iron is used. Gastroesophageal reflux and esophageal varices do not contraindicate the use of iron therapy.
14What drug would be appropriate for the nurse to administer to treat iron toxicity?
Time Spent - 00:00:12
Rationale: Deferoxamine mesylate is the antidote for iron toxicity and can be administered IM, IV, or subcutaneously. Calcium disodium edetate and succimer are indicated for the treatment of lead toxicity. Dimercaprol is indicated for the treatment of arsenic, gold, and mercury toxicity.
15The nurse is teaching a client diagnosed with renal failure who will begin receiving epoetin alfa. What education is should the nurse prioritize?
Time Spent - 00:00:06
Your Response: Teaching the client to self-administer subcutaneous injections
Rationale: Epoetin alfa is typically administered three times per week. Current guidelines recommend IV administration as the safest choice, but many clients are still prescribed subcutaneous injections. The client should not independently adjust the dose. Photophobia is not a noted adverse effect.
16A client with anemia is prescribed ferrous sulfate. The nurse should recommend what action to relieve the likely adverse effects?
Time Spent - 00:00:05 Your Response: Increase fluid and fiber intake.
Rationale: Like other iron supplements, ferrous sulfate can cause constipation. The nurse should suggest preventive strategies. There is no need to take the medication at bedtime or to avoid sodium intake. Antacids will impair absorption.
17What client is most likely to benefit from the use of a folic acid supplement?
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Your Response: A client who is attempting to become pregnant
Rationale: Pregnant women are urged to take folic acid supplements to help prevent fetal abnormalities, particularly neural tube defects. Folic acid would not benefit a client with anemia secondary to renal failure or blood loss. Clients on low-calorie diets do not necessarily need to supplement their folic acid intake.
18
The nurse is teaching a client who is to receive epoetin alfa about possible adverse effects.
What would the nurse include? Select all that apply.
Time Spent - 00:00:05
Your Response: Asthenia, Diarrhea, Vomiting
Rationale: Epoetin alfa is associated with CNS effects of headache, fatigue, asthenia, dizziness, and the potential for serious seizures. Nausea, vomiting, and diarrhea are also common effects. Dehydration and hypotension do not occur with this drug.
19After teaching a client who is receiving ferrous sulfate about the drug therapy regimen, which client statement indicates that the teaching was successful?
Time Spent - 00:00:03
Your Response: "My stools might turn dark or green."
Rationale: The client needs to know that his or her stools may become dark or green. Small, frequent meals with snacks can help minimize nausea and GI upset associated with this drug. The client may take the drug with meals as long as those meals do not include eggs, milk, coffee, and tea. Constipation is possible, so the client needs to increase the fiber in his or her diet.
20
The provider orders darbepoetin alfa 0.45 mcg/kg for a 210-lb adult. How many micrograms of the drug should the nurse administer? ___________ mcg
Time Spent - 00:00:20
Rationale: Begin calculations by converting client's weight to kilograms: 210/2.2 = 95.45. Then, multiply weight in kilograms by ordered dose: 95.45 × 0.45 = 43 mcg.
21
The nurse teaches the client prescribed iron therapy to allow at least 2 hours to lapse before or after taking what? Select all that apply.
Time Spent - 00:00:06 Your Response: Antacids, Tetracycline, Cimetidine
Rationale: Administration of antacids and iron should be separated by at least 2 hours.
Administration of tetracycline and iron should be separated by at least 2 hours. Administration of cimetidine and iron should be separated by at least 2 hours. Ranitidine does not affect iron absorption. Chloramphenicol interacts with iron to increase iron levels; the client needs to be monitored closely for iron toxicity. Separating administration is not necessary.
22The client, diagnosed with anemia, asks what that means. The nurse best explains the disorder by saying anemia is characterized by what?
Time Spent - 00:00:04
Your Response: Altered red blood cell production or function
Rationale: Anemias are disorders that involve too few or ineffective red blood cells that alter the ability of the blood to carry oxygen. They result from some alteration in erythropoiesis or the process of red blood cell production. White blood cells are associated with the immune response. Lack of vitamin B12 is associated with a specific type of anemia. Platelets are associated with blood clotting.
23Cyanocobalamin is a form of vitamin B12 in a nasal formulation.
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Rationale: Cyanocobalamin is administered nasally as replacement therapy or treatment of megaloblastic anemia.
24A client has been receiving intramuscular injections of hydroxocobalamin as treatment for pernicious anemia. Which statement by the client indicates an understanding of the therapy?
Time Spent - 00:00:05
Your Response: "I will need these injections monthly for the rest of my life."
Rationale: Hydroxocobalamin must be given intramuscularly every day for 5 to 10 days to build up levels and then once a month for life. It cannot be taken orally because the problem with pernicious anemia is the inability to absorb vitamin B12 secondary to low levels of intrinsic factor.
25The nurse is caring for a client taking ferrous sulfate. What dietary guideline should the nurse recommend to the client?
Time Spent - 00:00:05 Your Response: Avoid taking the medication with eggs or dairy.
Rationale: Iron is not absorbed if taken with antacids, eggs, milk, coffee, or tea. These substances should not be administered concurrently. Grapefruit juice is not absolutely contraindicated, and there is no reason to avoid sodium or fat.
26The nurse is preparing to discharge a client with a prescription of ferumoxytol. What is an important warning for the nurse to share with this client?
Time Spent - 00:00:06 Your Response: Avoid magnetic resonance imaging.
Rationale: Ferumoxytol is a super-magnetic iron oxide that can alter MRIs and interpretation for up to 3 months after administration; clients should be aware that they have been given this drug and cautioned to report it before undergoing any medical testing. Avoiding milk or iron containing foods is not necessary. Increase fiber intake if constipation occurs.
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