Question 1

A 45-year-old client with atrial fibrillation has been prescribed diltiazem. Which client outcome would best indicate that the medication has had its intended effect?

Accepted Answer

11ecbb05_cc72_a9e9_b433_b7161f336668_MD0009_00 Atrial fibrillation is characterized by disorganized electrical activity in the atria due to multiple ectopic foci. It leads to loss of effective atrial contraction and places the client at risk for embolic stroke as a result of the thrombi formed in the atria. During atrial fibrillation, the atrial rate may be increased to 350-600/min. The ventricular response can vary. The higher the ventricular rate, the more likely the client will have symptoms of decreased cardiac output (ie, hypotension). The treatment goals are to reduce the ventricular rate to <100/min and prevent stroke. Ventricular rate control is the priority. Medications used for rate control include calcium channel blockers (ie, diltiazem), beta blockers (ie, metoprolol), and digoxin. (Option A) Diltiazem is unlikely to convert atrial fibrillation to sinus rhythm. Antiarrhythmic medications such as amiodarone or ibutilide will be used for conversion of the rhythm. (Option B) Calcium channel blockers such as diltiazem may reduce blood pressure, but the nurse is not evaluating this client in atrial fibrillation for this outcome. In this case, diltiazem is being used for ventricular rate reduction. (Option C) Having no signs or symptom of stroke is a positive outcome in this client; however, it is not a specific outcome of diltiazem. Anticoagulants (eg, warfarin, dabigatran, rivaroxaban, apixaban) are used for this purpose. Educational objective: The nurse should monitor for a reduction in ventricular rate in the client with atrial fibrillation who is receiving diltiazem, metoprolol, or digoxin. Anticoagulants are used to prevent embolic complications.

Question 2

The nurse teaches a client about the use of regular and neutral protamine Hagedorn (NPH) insulin.  Which statement by the client indicates that further teaching is needed?

Accepted Answer

11ecbb05_cc77_da0c_b433_43f4ac4a9676_MD0009_00 The Institute for Safe Medication Practices has labeled insulin a high-alert medication. These types of medication can be safe and effective when administered or taken according to recommendations. However, errors in administration may cause death or serious illness. NPH is an intermediate-acting insulin with a duration of 12-18 hours; it is generally prescribed 2 times daily (morning and evening). Regular insulin and other rapid-acting insulins (lispro, aspart, glulisine) are typically used with a sliding scale for tighter control of blood glucose throughout the day. These are generally taken before meals and at bedtime. (Options A, B, and C) These are correct statements and indicate the teaching objective was completed successfully. Educational objective: NPH is an intermediate-acting insulin with a duration of 12-18 hours and typically prescribed twice a day.

Question 3

The nurse is assessing a client 15 minutes after initiating nitroglycerin infusion for suspected acute coronary syndrome. Which clinical finding is the priority?

Accepted Answer

Nitroglycerin is a nitrate that causes vasodilation and relaxation of vascular smooth muscle. In clients with acute coronary syndrome, it is administered by IV infusion to decrease preload and prevent spasm of the coronary arteries, thereby increasing perfusion and oxygen supply to the cardiac muscle. Due to systemic vasodilation, this client is at risk for significant hypotension. The nurse should follow up immediately if the client reports dizziness or lightheadedness, which may indicate profound hypotension (Option B). If the client is found to be hypotensive, the nurse may need to decrease or discontinue the infusion. (Option A) Headache is a common side effect of nitroglycerin therapy and is often a sign that the medication is working properly. It is not a priority, although acetaminophen may be given for pain relief. (Options C and D) Systemic vasodilation and decreased cardiac preload may cause the client to feel flushed and nervous during infusion. However, reports of dizziness and lightheadedness should take priority. Educational objective: Nitroglycerin is a vasodilator that may be administered by IV infusion in the management of acute coronary syndrome. Clients receiving nitroglycerin are at risk for profound hypotension resulting from systemic vasodilation. The nurse should immediately assess a client with signs of hypotension (eg, dizziness, lightheadedness) because the nitroglycerin infusion may need to be decreased or stopped.

Question 4

A client is being discharged with a prescription for apixaban after being treated for a pulmonary embolus. Which clinical data is most concerning to the nurse?

Accepted Answer

A pulmonary embolism (PE) occurs when the pulmonary arteries are blocked by a thrombus. Initial management of PE includes low-molecular-weight heparin (eg, enoxaparin, dalteparin) or unfractionated IV heparin. Once the PE is resolved, maintenance drug therapy often includes oral anticoagulants such as factor Xa inhibitors (eg, apixaban, rivaroxaban, dabigatran). Anticoagulants place the client at increased risk of bleeding, and the nurse should provide education regarding signs and symptoms of bleeding (eg, bruising; blood in the urine; black, tarry stools) and bleeding precautions (eg, use of an electric razor and soft-bristled toothbrush). Concurrent NSAID use (eg, indomethacin, ibuprofen, meloxicam) significantly increases the risk of bleeding. The nurse should discuss this risk with the health care provider prior to initiation of apixaban therapy (Option C). (Option A) Vegetarian diets and the consumption of leafy green vegetables high in vitamin K affect the action of warfarin. However, factor Xa inhibitors such as apixaban are not affected by vitamin K. (Option B) Chronic atrial fibrillation increases the risk for thromboembolic events and would be an indication for anticoagulant therapy, such as apixaban. (Option D) The current platelet count is within a normal range (150-400 x10³/mm³ [150-400 x10⁹/L]) and is not a concern. Educational objective: Maintenance drug therapy after a pulmonary embolus typically includes administration of oral anticoagulants such as factor Xa inhibitors (eg, apixaban). NSAIDs (eg, indomethacin) increase the risk of bleeding when used concurrently with apixaban therapy. The nurse should question initiation of apixaban therapy in the context of NSAID use.

Question 5

A client with primary hypothyroidism has been taking levothyroxine for a year.  Laboratory results today show high levels of TSH.  Which statement by the nurse to the client is appropriate?

Accepted Answer

11ecbb05_cc78_9d5e_b433_77bd309f5634_MD0009_00 Thyroid-stimulating hormone (TSH) is released from the pituitary gland to stimulate the thyroid to secrete hormones (T3, T4). When sufficient thyroid hormone is circulating, negative feedback causes a normally functioning pituitary to slow or stop the release of TSH. In primary hypothyroidism, the thyroid is unable to synthesize enough T3 or T4, slowing the metabolic rate. In response to low circulating thyroid hormones, the pituitary continues to release TSH, resulting in high TSH levels. Levothyroxine (Synthroid), a thyroid hormone replacement drug, is commonly used to treat hypothyroidism. Levothyroxine dosing is adjusted to regulate circulating thyroid hormone levels; this creates a euthyroid (normal) state and TSH levels are decreased (Option B). (Options A and C) Decreasing the dose or discontinuing levothyroxine would lead to increased TSH and worsening hypothyroidism as the amount of circulating thyroid hormone decreases. (Option D) Levothyroxine should be taken on a consistent morning schedule, at least 30 minutes before a meal. Foods containing certain ingredients (eg, walnuts, soy products, dietary fiber, calcium) can decrease drug absorption. Educational objective: In primary hypothyroidism, the thyroid does not produce enough hormones (T3, T4). In response to low circulating thyroid hormones, the pituitary continues to release TSH, resulting in high levels of circulating TSH. Levothyroxine is usually started or increased to lead to a euthyroid (normal) state.

Question 6

A hospitalized client with thyrotoxicosis receives atenolol 50 mg PO daily.  Which statement by the nurse accurately reinforces the client's understanding of this medication's purpose?

Accepted Answer

Beta-adrenergic blockers (atenolol, metoprolol, and propranolol) are used to relieve some of the symptoms of thyrotoxicosis (thyroid storm), a complication of hyperthyroidism in which excessive thyroid hormones are released into the circulation. Beta blockers block the effects of the sympathetic nervous system and treat symptoms such as tachycardia, hypertension, irritability, tremors, and nervousness in hyperthyroidism. (Option A) Atenolol is not iodine based. Iodine is used to treat thyrotoxicosis or to prepare the client for a thyroidectomy. In large doses, iodine quickly blocks the release of T4 and T3 from the gland within hours. In addition, iodine decreases thyroid gland vascularity and is helpful when preparing the client for a thyroidectomy. (Option C) Atenolol does not contain radioactive iodine, the primary treatment for hyperthyroidism. It damages or destroys the thyroid tissue, therefore limiting thyroid secretion and eventually making the client hypothyroid. (Option D) Propylthiouracil and methimazole (Tapazole) are first-line antithyroid drugs used to inhibit thyroid hormone synthesis. Educational objective: Beta-adrenergic blockers (atenolol, metoprolol, and propranolol) are given to relieve some of the symptoms of thyrotoxicosis. They block the effects of the sympathetic nervous system and treat symptoms such as tachycardia, hypertension, irritability, tremors, and nervousness in hyperthyroidism.

Question 7

A client with uncontrolled hypertension is prescribed clonidine. What instruction is most important for the clinic nurse to give this client?

Accepted Answer

Central-acting alpha₂ agonists (eg, clonidine, methyldopa) decrease the sympathetic response from the brainstem to the peripheral vessels, resulting in decreased peripheral vascular resistance and vasodilation. ₂ Clonidine is a highly potent antihypertensive. Abrupt discontinuation (including the patch) can result in serious rebound hypertension due to the rapid surge of catecholamine secretion that was suppressed during therapy. Clonidine should be tapered over 2-4 days. Abrupt withdrawal of beta blockers can also result in rebound hypertension and in precipitation of angina, myocardial infarction, or sudden death. (Option A) Avoiding high-sodium foods is important for blood pressure control but is not the most important advice for this client as consumption of these is not immediately life-threatening. (Option B) Dizziness is a side effect of clonidine. The nurse should teach the client to change positions slowly and sit for a few minutes before rising to prevent falls. Drowsiness is also quite common with clonidine. Clients should not use it with alcohol or central nervous system depressants. However, dizziness and drowsiness should diminish with continued use of the medication. (Option D) Dry mouth is a side effect of clonidine. Use of over-the-counter mouth moisturizers, chewing gum, or hard candy may be helpful for clients with dry mouth. Educational objective: Clonidine is a very potent antihypertensive. Abrupt discontinuation can result in serious rebound hypertensive crisis. Other common side effects of clonidine include dizziness, drowsiness, and dry mouth (the 3 Ds). Beta blockers, another class of blood pressure medications, can result in withdrawal symptoms if discontinued suddenly.

Question 8

The nurse assesses pitting edema of the extremities, dyspnea, bilateral crackles posteriorly, and a serum sodium level of 130 mEq/L (130 mmol/L) in a client with chronic heart failure.  The nurse should question which prescription?

Accepted Answer

Chronic heart failure involves the inability of the heart to fill and pump blood effectively to meet the body's oxygen demands. As a result, clients can develop dilutional hyponatremia (serum sodium <135 mEq/L [135 mmol/L]), an electrolyte disturbance caused by an excess of total body water in relation to total sodium content. The nurse should question the prescription for the maintenance IV line. An infusion of an isotonic solution of 0.9% normal saline at 85 mL/h is contraindicated in this client as it would increase the circulating extracellular fluid volume, worsen the symptoms, and exceed the <2 L/day fluid restriction (ie, 85 mL × 24 hours = 2040 mL). Converting the running IV line to a lock for medication administration would be appropriate. (Option A) Furosemide (Lasix) is a fast-acting loop diuretic prescribed to decrease preload in clients with heart failure who are fluid overloaded and experiencing manifestations of pulmonary congestion (eg, crackles, dyspnea). Appropriate diuresis in this client would remove excess free water and correct dilutional hyponatremia. (Option C) Potassium chloride is administered to clients receiving furosemide to prevent or treat diuretic-associated hypokalemia. The nurse should not question this prescription. (Option D) Fluid restriction is prescribed to correct dilutional hyponatremia (sodium <135 mEq/L [135 mmol/L]) in a client with heart failure. In addition, all heart failure clients require a low-salt diet. Excess salt causes retention of more water. This client's low sodium is due to excess free water and not to low dietary sodium. Educational objective: Dilutional hyponatremia (serum sodium <135 mEq/L [135 mmol/L]) is an electrolyte disturbance caused by an excess of total body water in relation to total sodium content and can occur in clients with heart failure. Treatment includes the administration of diuretics and fluid/salt restriction.

Question 9

The nurse administers a dose of radioactive iodine to a female client for treatment of hyperthyroidism. Which of the following precautions should the nurse teach the client to follow on discharge? Select all that apply.

Accepted Answer

Radioactive iodine (RAI) treats hyperthyroidism by partially damaging or destroying the thyroid gland. RAI has a delayed response, requiring up to 3 months for maximal effect. After treatment, the client emits radiation, and excreted bodily fluids are radioactive. The nurse teaches home precautions to protect those who come in contact with the client. Depending on the dosage, clients should use the following precautions for up to 1 week: Limit close contact and time spent with pregnant women and children (Option A). Use a separate toilet, and flush 2 or 3 times after each use to remove urine residue (Option C). Use disposable cups, plates, and utensils, and do not share foods that could transfer saliva (Option D). Isolate personal laundry (eg, clothing, linens) and wash it separately (Option E). Sleep in a separate bed from others. Do not sit near others for a prolonged time (eg, train or flight travel). (Option B) After RAI therapy, breast milk excreted by the client is radioactive and can permanently damage an infant's thyroid. Breastfeeding should be stopped 6 weeks before treatment to prevent RAI from accumulating in the breasts after treatment. Breastfeeding is not resumed with the current child but can be resumed with future pregnancies. Educational objective: Radioactive iodine treats hyperthyroidism by damaging or destroying the thyroid gland. After ingesting radioactive iodine, clients and their bodily secretions are radioactive. They should avoid pregnant women and children, use a separate toilet and disposable tableware, sleep in a separate bed, and isolate personal laundry.

Question 10

A nurse teaches a client who is being discharged on warfarin for atrial fibrillation. Which client statements indicate that teaching has been effective? Select all that apply.

Accepted Answer

A therapeutic INR for most conditions is 2-3 but can be up to 3.5 for heart valve disease. However, it is never between 4 and 5 (Option C). Intestinal bacteria produce vitamin K; most antibiotics kill these bacteria, leading to vitamin K deficiency. Warfarin is a vitamin K antagonist; therefore, INR would overshoot in the setting of vitamin K deficiency, placing the client at risk for bleeding (Option A). Leafy-green vegetables contain a high amount of vitamin K, which may lower a client's INR and make it difficult to maintain a therapeutic INR. Clients do not have to avoid consumption of leafy-green vegetables, but they should eat a consistent quantity and have their INR checked periodically (Option B). (Option D) It is important to take warfarin at the same time daily to maintain a consistent therapeutic drug level. (Option E) Clients should call their health care provider if they miss or forget to take a warfarin dose. Double dosing is contraindicated. Educational objective: Warfarin must be taken at the same time daily to reach a therapeutic INR of 2-3. A diet high in vitamin K may decrease warfarin's anticoagulant effect. Most antibiotics will increase INR by causing a vitamin K deficiency.

Question 11

The clinic nurse is reviewing telephone messages from four clients. Which client's call should the nurse return first?

Accepted Answer

Amiodarone is an antiarrhythmic medication used to treat life-threatening arrhythmias that cannot be controlled with other medications. Amiodarone therapy is used only if other treatments have failed, as it has many toxic, adverse effects that may be severe. Pulmonary toxicity is a life-threatening adverse effect of amiodarone, which is believed to cause direct cellular damage and activation of an immune response in the lungs. Clients who develop pulmonary toxicity may report respiratory symptoms such as dry cough, pleuritic chest pain, and dyspnea. Clients with clinical manifestations of pulmonary toxicity require immediate intervention to prevent fatal, irreversible lung damage (Option D). (Option A) Albuterol is a beta-2 agonist used to treat bronchospasm that commonly causes tachycardia and tremor. Clients reporting these symptoms may require a dose adjustment or change in medication regimen. (Option B) Frequent liquid stools in a client receiving antibiotics (eg, azithromycin) may indicate development of Clostridium difficile infection, a serious gastrointestinal complication. However, possible pulmonary toxicity is the priority. (Option C) Clients taking metformin, an oral antidiabetic, who report hyperglycemia and polyuria require follow-up to evaluate medication efficacy and glycemic control. Signs of pulmonary toxicity are more urgent, however. Educational objective: Amiodarone is an antiarrhythmic medication used to treat life-threatening arrhythmias. Pulmonary toxicity is a life-threatening complication that may cause symptoms such as dry cough, pleuritic chest pain, and dyspnea. Clients taking amiodarone with signs of pulmonary toxicity require immediate follow-up.

Question 12

The nurse administers 15 units of aspart insulin subcutaneously to a hospitalized client with type 1 diabetes mellitus at 7:00 AM for a fasting blood glucose of 180 mg/dL (10 mmol/L). Which nursing action is a priority?

Accepted Answer

11ecbb05_cc77_3dca_b433_25160b93a474_MD0009_00 Aspart (NovoLOG) is a rapid-acting insulin with an onset of 10-15 minutes. Onset is the time it takes for the insulin to enter the circulation and begin to lower blood glucose. The peak effect takes 30 minutes-3 hours and the duration of action is 3-5 hours. It is important for the nurse to ensure that the client eats within 15 minutes of administration of aspart/lispro/glulisine to prevent an insulin-related hypoglycemic reaction (Option B). (Option A) The client is at risk for a hypoglycemic reaction if breakfast is delayed for 30 minutes. (Option C) Rechecking the blood glucose in 1 hour is not indicated unless hypoglycemia is suspected. (Option D) Teaching is vital, but it is most important to ensure that the client eats breakfast to prevent a hypoglycemic reaction at drug onset. Educational objective: It is important for the nurse to ensure that the client eats within 15 minutes of administration of rapid-acting insulins such as aspart (NovoLOG), lispro (HumaLOG), and glulisine (Apidra) to prevent an insulin-related hypoglycemic reaction.

Question 13

A home health nurse is preparing to start a milrinone infusion via a peripherally inserted central catheter for a client with end-stage heart failure. What equipment is most important to be present in the home? Select all that apply.

Accepted Answer

Milrinone (Primacor) is a phosphodiesterase-3 inhibitor given via IV infusion to increase contractility and promote vasodilation. Milrinone, an inotropic agent, is often prescribed to clients with heart failure unresponsive to other pharmacologic therapies. The medication is usually infused over 48-72 hours in a hospital setting; however, home infusion through a central line is becoming more common as a palliative measure for end-stage heart failure. Milrinone infusion requires central venous access (eg, peripherally inserted central catheter) as the medication is a vesicant and can cause extravasation if infused through a peripheral IV line. The home health nurse should perform the following: Ensure that an infusion pump is used to control the rate, and instruct the family on basic troubleshooting (Option D). Evaluate medication effectiveness and possible side effects. Monitor the central line insertion site for infection. Change the central line dressing as prescribed (Option C). Monitor daily weight (Option A). Monitor blood pressure for possible hypotension (Option B). Implement safety precautions as hypotension increases the client's risk of falling. (Option E) Milrinone causes vasodilation, which may result in increased urinary output; however, intermittent catheterization is not indicated. Educational objective: A client may receive a milrinone infusion in the home for palliative treatment of end-stage heart failure. The infusion is set up via an infusion pump and infused through a central line. The client and family should be instructed on basic pump troubleshooting as well as the importance of measuring daily weight and blood pressure.

Question 14

The nurse reinforces teaching a client on prescribed dabigatran for chronic atrial fibrillation. Which statement by the client indicates a need for further teaching?

Accepted Answer

Thrombin inhibitors such as dabigatran (Pradaxa) reduce the risk of clot formation and stroke in clients with chronic atrial fibrillation. The nurse should educate the client about implementing bleeding precautions (eg, using a soft-bristle toothbrush, shaving with an electric razor). Dabigatran capsules should be kept in their original container or blister pack until time of use to prevent moisture contamination (Option C). (Option A) Red urine or blood in the stool may indicate internal bleeding caused by thrombin inhibitors. The client should report these symptoms to the health care provider. (Option B) Thrombin inhibitors should only be stopped under the direction of the health care provider. The nurse should educate the client that stopping dabigatran will increase the risk for stroke. Taking the medication with food will not affect how much is absorbed, and food or a full glass of water may prevent gastrointestinal side effects (eg, nausea, indigestion). (Option D) Thrombin inhibitor capsules should not be crushed or opened as crushing pills increases absorption and risk of bleeding. Educational objective: Thrombin inhibitors such as dabigatran reduce the risk for clots and stroke in clients with chronic atrial fibrillation. The nurse should teach the client to use bleeding precautions and monitor for symptoms of bleeding, swallow capsules whole with a full glass of water, and keep capsules in their original container until time of use.

Question 15

The nurse administers 8 units of regular insulin subcutaneously at 11:30 AM to a client with type 1 diabetes mellitus and serves the client lunch 30 minutes later. The client eats a few bites, becomes nauseated, and is unable to finish the meal. When is the client at highest risk for experiencing an insulin-related hypoglycemic reaction?

Accepted Answer

11ecbb05_cc77_8beb_b433_7b67f17d954d_MD0009_00 Insulin is a medication commonly used to control and lower blood glucose levels in clients with diabetes mellitus. The nurse must be familiar with the various insulin types and their times of peak effect, which are the periods of highest risk for hypoglycemic events. Regular insulin is a short-acting insulin that reaches the peak effect within 2-5 hours after subcutaneous administration. Therefore, clients who receive regular insulin subcutaneously at 11:30 AM are at highest risk for hypoglycemia between 1:30 PM and 4:30 PM (Option B). (Option A) Rapid-acting insulins (eg, lispro, aspart) take peak effect in 30 minutes to 3 hours. Clients who receive rapid-acting insulin at 11:30 AM would be most at risk for hypoglycemia from 12:00-2:30 PM. (Options C and D) Both insulin NPH, an intermediate-acting insulin, and insulin detemir, a long-acting insulin, have peak effect times that may cause hypoglycemia at 5-6 PM in clients who receive the medication at 11:30 AM. peak effect times Educational objective: Insulin is a medication used to control and lower blood glucose levels in clients with diabetes mellitus. Peak effect times vary according to insulin type and represent the time of highest risk for hypoglycemic events. Regular insulin, a short-acting insulin, reaches peak effect 2-5 hours after subcutaneous administration.

Question 16

The nurse is caring for a child with Kawasaki disease who is receiving IV immunoglobulin.  The child's parent wants to know why this treatment is required.  The nurse explains that this therapy is given to:

Accepted Answer

Kawasaki disease (KD), also known as mucocutaneous lymph node syndrome, is characterized by ≥5 days of fever, bilateral nonexudative conjunctivitis, mucositis, cervical lymphadenopathy, rash, and extremity swelling. Coronary artery aneurysms are the most serious potential sequelae in untreated clients, leading to complications such as myocardial infarction and death. Echocardiography is used to monitor these cardiovascular complications. Intravenous immunoglobulin (IVIG) along with aspirin is used to prevent coronary aneurysms and subsequent occlusion. KD is one of the few pediatric illnesses in which aspirin therapy is warranted due to its antiplatelet and anti-inflammatory properties. However, parents should be cautioned about the risk of Reye syndrome. Cardiopulmonary resuscitation should also be taught to parents of children with coronary artery aneurysms. (Option A) KD is a vasculitis of unknown etiology, but it is not an infectious process. Because the child will often have a similar clinical presentation to that of an infection (eg, persistent fever, inflammatory immune response), KD may be mistaken for a bacterial or viral illness. (Option B) Polymorphous rash of the trunk and extremities is an expected finding in a child with KD. Cool compresses, unscented lotions, and loose-fitting clothing can minimize discomfort. IVIG is not given to control rash. (Option D) Lymphadenopathy (usually a single palpable anterior cervical node >1.5 cm) and splenomegaly are included in the clinical presentation of KD. IVIG therapy is not indicated to reduce incidence of these findings. Educational objective: IVIG along with aspirin is the recommended initial treatment for Kawasaki disease, with the primary goal of coronary disease prevention.

Question 17

The nurse should call the primary health care provider to obtain a new prescription prior to administering which medication to a client with type 1 diabetes mellitus?

Accepted Answer

11ecbb05_cc78_011d_b433_35ff59aaf8e8_MD0009_00 Subcutaneous injection is the indicated route for NPH insulin administration; it should never be administered via IV push. Regular insulin is the only insulin that can be administered via IV push; this is typically performed only in an acute care facility under close observation by the nurse. (Option A) Administration of 10 units regular insulin IV push for blood glucose >250 mg/dL (13.9 mmol/L) is appropriate and a new prescription is not required. (Option B) Administration of 14 units glargine insulin subcutaneous injection every night at 8:00 PM is appropriate and a new prescription is not required. (Option C) Administration of 18 units aspart insulin subcutaneous injection 15 minutes before breakfast is appropriate and a new prescription is not required. Educational objective: Subcutaneous injection is the indicated route for NPH insulin administration; it should never be administered IV push. Regular insulin is the only insulin that can be administered IV push.

Question 18

A client is 6 hours postoperative from hip surgery after receiving regional anesthesia and has epidural continuous anesthesia in place. Which is the most important reason for the nurse to contact the health care provider?

Accepted Answer

Fondaparinux (Arixtra), unfractionated heparin, and low molecular weight heparin (eg, enoxaparin, dalteparin) are anticoagulants commonly used for deep vein thrombosis and pulmonary embolism prophylaxis after hip/knee replacement or abdominal surgery. However, fondaparinux is not administered until more than 6 hours after any surgery, and anticoagulants are not given while an epidural catheter is in place (Option B). Fondaparinux is associated with epidural hematoma. Any bleeding in the tight epidural space, which does not expand, could result in spinal cord compression. Signs of epidural spinal hematoma can include severe back pain and paralysis. (Option A) Paresthesia is an expected finding from postoperative analgesia for 2-24 hours after surgery, depending on the agent and location. Continuously administered analgesia usually results in some paresthesia until approximately 4-6 hours after discontinuance. As long as the level remains relatively stable or improves, it is an acceptable finding. However, paresthesia or motor weakness is a concern when the sensory or motor block outlasts the expected duration. (Option C) Client response to operative analgesia and postoperative continued analgesia can range from minimal to significant. As long as the analgesic is infusing and findings remain stable, reduced muscle strength is expected. (Option D) Major orthopedic surgery can result in significant blood loss, and it is not unusual for the client to have hemoglobin drop of 1-2 g/dL (10-20 g/L). Blood loss should be monitored over time; transfusion usually is not indicated unless hemoglobin is <7-8 g/dL (70-80 g/L). Educational objective: Residual paresthesia and motor weakness for several hours are expected findings after regional anesthesia. Anticoagulants are not given while an epidural catheter is in place.

Question 19

The nurse prepares to administer morning medications to assigned clients.  Which prescription should the nurse clarify with the health care provider?

Accepted Answer

Losartan is an angiotensin II receptor blocker (ARB) prescribed to treat hypertension. ACE inhibitors (eg, lisinopril, enalapril) and ARBs are teratogenic, causing renal and cardiac defects or death of the fetus. ARBs and ACE inhibitors have black box warnings that indicate contraindication in pregnancy. The nurse should not give an ARB to a pregnant client (Option B). The health care provider should be notified so that an alternate antihypertensive may be prescribed that is safe to take during pregnancy (eg, labetalol, methyldopa). (Option A) Antiplatelet agents (eg, clopidogrel) are prescribed to prevent thromboembolic events in clients with increased risk for stroke or myocardial infarction. Laboratory values are monitored periodically as these drugs increase bleeding time (normal, 2-7 minutes [120-420 seconds]) and, rarely, may lower platelet count (normal, 150,000-400,000/mm³ [150-400 × 10⁹/L]) (Option C) Bell palsy presents as acute onset of unilateral facial paralysis related to inflammation of the facial nerve (ie, cranial nerve VII) that may be triggered by a viral illness (eg, herpes simplex virus). Standard treatment includes corticosteroids (eg, prednisone) within 72 hours of symptom onset. (Option D) Tiotropium is an inhaled anticholinergic drug that inhibits receptors in the smooth muscles of the airways. It is prescribed daily for the long-term management of bronchospasm in clients with chronic obstructive pulmonary disease. Educational objective: Angiotensin II receptor blockers and ACE inhibitors are teratogenic, causing fetal injury or death, and are contraindicated in pregnancy.

Question 20

A client with a history of heart failure calls the clinic and reports a 3-lb (1.4-kg) weight gain over the past 2 days and increased ankle swelling. The nurse reviews the client's medications and anticipates the immediate need for dosage adjustment of which medication?

Accepted Answer

Most clients with heart failure are prescribed a loop diuretic (eg, furosemide, torsemide, bumetanide) to reduce fluid retention. If the client has signs and symptoms of excessive fluid accumulation, the nurse will need to assess the situation by asking the client about dietary and fluid intake, adherence to prescribed medications, and the presence of any other associated symptoms (eg, shortness of breath). If the client is stable, the nurse may anticipate the need to increase the dosage of the prescribed loop diuretic (eg, bumetanide). (Option B) Losartan, valsartan, and candesartan (sartans) are the commonly used angiotensin II receptor blockers. They are used in clients who cannot take ACE inhibitors (eg, lisinopril, ramipril). They block the renin-angiotensin-aldosterone system but will not affect the fluid status of the client with acute heart failure. (Option C) Metoprolol, bisoprolol, and carvedilol (lols) are the commonly used beta blockers for treatment of chronic heart failure. They block the negative effects of the sympathetic nervous system (increased heart rate) and reduce the cardiac workload. However, they can worsen heart failure if used in the acute setting of this condition. (Option D) Isosorbide (nitrate) and hydralazine are used in African American clients with heart failure; this combination decreases cardiac workload by reducing preload and afterload. However, it does not decrease excess fluid. Educational objective: A client who reports weight gain and edema requires evaluation for additional symptoms of fluid volume overload (eg, shortness of breath) and adherence to the current treatment plan. If the client is stable, an increase in the dosage of loop diuretic (eg, furosemide, torsemide, bumetanide) is anticipated.

Exam 8: Pharmacology

A 45-year-old client with atrial fibrillation has been prescribed diltiazem. Which client outcome would best indicate that the medication has had its intended effect?

The nurse teaches a client about the use of regular and neutral protamine Hagedorn (NPH) insulin. Which statement by the client indicates that further teaching is needed?

The nurse is assessing a client 15 minutes after initiating nitroglycerin infusion for suspected acute coronary syndrome. Which clinical finding is the priority?

A client is being discharged with a prescription for apixaban after being treated for a pulmonary embolus. Which clinical data is most concerning to the nurse?

A client with primary hypothyroidism has been taking levothyroxine for a year. Laboratory results today show high levels of TSH. Which statement by the nurse to the client is appropriate?

A hospitalized client with thyrotoxicosis receives atenolol 50 mg PO daily. Which statement by the nurse accurately reinforces the client's understanding of this medication's purpose?

A client with uncontrolled hypertension is prescribed clonidine. What instruction is most important for the clinic nurse to give this client?

The nurse assesses pitting edema of the extremities, dyspnea, bilateral crackles posteriorly, and a serum sodium level of 130 mEq/L (130 mmol/L) in a client with chronic heart failure. The nurse should question which prescription?

The nurse administers a dose of radioactive iodine to a female client for treatment of hyperthyroidism. Which of the following precautions should the nurse teach the client to follow on discharge? Select all that apply.

A nurse teaches a client who is being discharged on warfarin for atrial fibrillation. Which client statements indicate that teaching has been effective? Select all that apply.

The clinic nurse is reviewing telephone messages from four clients. Which client's call should the nurse return first?

The nurse administers 15 units of aspart insulin subcutaneously to a hospitalized client with type 1 diabetes mellitus at 7:00 AM for a fasting blood glucose of 180 mg/dL (10 mmol/L) . Which nursing action is a priority?

A home health nurse is preparing to start a milrinone infusion via a peripherally inserted central catheter for a client with end-stage heart failure. What equipment is most important to be present in the home? Select all that apply.

The nurse reinforces teaching a client on prescribed dabigatran for chronic atrial fibrillation. Which statement by the client indicates a need for further teaching?

The nurse is caring for a child with Kawasaki disease who is receiving IV immunoglobulin. The child's parent wants to know why this treatment is required. The nurse explains that this therapy is given to:

The nurse should call the primary health care provider to obtain a new prescription prior to administering which medication to a client with type 1 diabetes mellitus?

A client is 6 hours postoperative from hip surgery after receiving regional anesthesia and has epidural continuous anesthesia in place. Which is the most important reason for the nurse to contact the health care provider?

The nurse prepares to administer morning medications to assigned clients. Which prescription should the nurse clarify with the health care provider?

A client with a history of heart failure calls the clinic and reports a 3-lb (1.4-kg) weight gain over the past 2 days and increased ankle swelling. The nurse reviews the client's medications and anticipates the immediate need for dosage adjustment of which medication?