Question 1

A client is admitted with palpitations.  The ECG shows supraventricular tachycardia (SVT) with a rate of 220/min.  The nurse has received an order to administer adenosine 6 mg IV.  Which action should the nurse take?

Accepted Answer

Adenosine is the first-line drug of choice for the treatment of paroxysmal supraventricular tachycardia (SVT; a rapid rhythm exceeding 150/min). The half-life is <5 seconds, so adenosine should be administered rapidly as a 6-mg bolus IV over 1-2 seconds followed by a 20-mL saline flush. Repeat boluses of 12 mg may be given twice if the rapid rhythm persists. The injection site should be as close to the heart as possible (eg, antecubital area). The client's ECG should be monitored continuously. A brief period of asystole is due to adenosine slowing impulse conduction through the atrioventricular node. The client should be monitored for flushing, dizziness, chest pain, or palpitations during and after administration. (Option A) Adenosine is the first-line drug for paroxysmal SVT. (Option B) Although the drug should be administered as close to the heart as possible, central venous access is not required. (Option D) Because of the drug's short half-life (5-10 seconds), it should be administered rapidly, not slowly, and should not be diluted. Educational objective: Adenosine is the drug of choice for the treatment of paroxysmal supraventricular tachycardia. It has a short half-life and should be administered rapidly over 1-2 seconds, followed with a 20-mL saline bolus. A brief period of asystole can be common. Flushing from vasodilation is seen frequently.

Question 2

A nurse in the emergency department is titrating a continuous infusion of nitroglycerin to a client admitted for acute coronary syndrome.  The client's vital signs, including blood pressure (BP), heart rate (HR), and pain level, are being monitored frequently.  Which assessment findings indicate that the current rate of administration should be maintained?

Accepted Answer

Acute coronary syndrome (ACS) is a broad term that encompasses a range of cardiac events, including unstable angina and myocardial infarction (with or without ST-segment elevation). Clients with ACS require immediate treatment to prevent continued ischemia of cardiac muscle. Intravenous nitroglycerin (glyceryl trinitrate) is used to increase cardiac blood flow and provide pain relief for clients with ACS until a definitive treatment plan (eg, percutaneous coronary intervention, thrombolytic therapy, bypass surgery) is determined. Because nitroglycerin is a vasodilator, continuous hemodynamic monitoring is required to prevent severe hypotension. The infusion rate is titrated by the nurse based on pain level and blood pressure (BP), usually every 3-5 minutes until pain is relieved and BP is stable. If systolic BP drops to <90 mm Hg or falls >30 mm Hg below client baseline, the infusion rate should be decreased or stopped. (Option A) The client is hypotensive (systolic BP <90 mm Hg) and tachycardic. The infusion rate should be decreased or stopped. (Option B) The client's BP is low, but in an acceptable range. However, complete pain relief has not been achieved. The nurse should continue to increase the infusion rate while closely observing BP. (Option D) Although the BP is acceptable, pain relief has not been achieved. The nurse should continue titrating to a higher dose until the client's pain is relieved. Educational objective: Nitroglycerin and other nitrates increase cardiac blood flow and provide relief from the pain of ischemia in acute coronary syndrome by causing vasodilation. Their infusion should not cause systolic blood pressure to fall to <90 mm Hg or to drop >30 mm Hg below baseline.

Question 3

A client diagnosed with stable angina is being discharged home on the cholesterol-lowering drug rosuvastatin. The nurse should teach the client to report which side effect to the health care provider (HCP) immediately?

Accepted Answer

Rosuvastatin (Crestor) is a strong statin drug that can cut LDL drastically and reduce total cholesterol and triglycerides. It also increases HDL. A serious complication associated with statin medication is rhabdomyolysis. Rhabdomyolysis is the breakdown of muscle tissue that leads to the release of muscle fiber contents into the blood. These substances can be harmful to the kidney and often cause kidney damage. The client should immediately report any signs of muscle aches or weakness to the HCP. These could be early signs of rhabdomyolysis, which can be fatal. (Options A, B, and C) These can also be considered side effects of rosuvastatin calcium, but they are minor and do not need to be reported to the HCP immediately. If they persist, the client should consider reporting them. Educational objective: The nurse should teach all clients taking statin drugs (eg, atorvastatin, rosuvastatin) to immediately report any muscle aches or weakness, as these can lead to rhabdomyolysis, a muscle disintegration that can cause serious kidney injury.

Question 4

A client is taking morphine sulfate for acute pain. Which statement will best assist the client worried about nausea and vomiting while taking this medication?

Accepted Answer

Nausea and vomiting are expected side effects of opioid medications (eg, morphine sulfate) when the treatment is initiated. However, tolerance develops quickly and persistent nausea is rare. It is recommended that the client take an anti-emetic with the pain medication. (Option A) Nausea and vomiting are expected side effects of this pain medication and occur up to 40% of the time. (Option B) Nausea and vomiting are less likely to occur in a recumbent client, and the risk increases up to 40% in clients who are up and walking. (Option C) Taking opioid medications on an empty stomach may increase the risk of nausea. Educational objective: Nausea and vomiting are expected side effects when opioid pain medications are initiated. However, tolerance develops quickly and persistent nausea is rare. Nausea and vomiting are decreased when the client lies still in a flat position. Anti-emetics may be needed initially.

Question 5

Which client is at greatest risk for respiratory depression when receiving opioids for pain control?

Accepted Answer

The following are at greatest risk for respiratory depression related to opioid use for analgesia: the elderly; those with underlying pulmonary disease, history of snoring (with or without apnea), obesity, or smoking (more than 20-pack-year history); the opiate naïve, especially if treated for acute pain; and post surgery (first 24 hours). The 70-year old client has 3 significant risk factors: advanced age, COPD, and surgery within 24 hours. COPD clients who have hypercarbia and hypoxemia are at even greater risk for respiratory depression when receiving opioids. (Option A) This client has 1 risk factor, pulmonary disease. (Option B) This client has 1 risk factor, surgery within 24 hours. His addiction to heroin gives him a higher tolerance for opioids. (Option C) This client has 1 risk factor, sleep apnea. Educational objective: Factors that increase risk for respiratory depression related to opioid use for pain control include advanced age, underlying pulmonary disease, snoring, obesity, smoking, opiate naïve, and surgery.

Question 6

A client is taking morphine sulfate for acute pain. The client stands, is immediately "lightheaded," and calls for the nurse. What is the nurse's priority action?

Accepted Answer

Opioids, including morphine sulfate, dilate peripheral blood vessels and can cause hypotension. The side effect is not as noticeable when the client is lying down; however, once the client attempts to stand, it can cause orthostatic hypotension. It is more common in clients who have some underlying volume depletion (eg, opioid-induced nausea/vomiting). Due to the safety risk, clients must be taught to rise slowly from a sitting to a standing position. The nurse should first assist the client to sit if the client feels lightheaded in a standing position. Safety is the client's priority. If orthostasis is evident, fluid bolus may be needed and should be communicated to the health care provider. (Options A and D) Assessing the client's orthostatic vital signs and recommending bed rest until the lightheadedness resolves are important but not first-priority actions. (Option C) Walking with the client is not recommended when the client is symptomatic on standing. Educational objective: Client safety is the priority action in any situation. The nurse should assist the client to a safe position prior to proceeding with other interventions.

Question 7

A client with a diagnosis of atrial fibrillation has just been placed on warfarin therapy.  The registered nurse (RN) overhears a student nurse teaching the client about potential food-drug interactions.  Which statement made by the student nurse requires an intervention by the RN?

Accepted Answer

Warfarin (Coumadin) works by blocking the availability of vitamin K, which is essential for blood clotting. As a result, the clotting mechanism is disrupted, reducing the risk of a stroke, venous thrombosis, or pulmonary embolism. Sudden increases or decreases in the consumption of vitamin K-rich foods could inversely alter the effectiveness of warfarin. An increase in vitamin K could decrease the effectiveness of warfarin, placing the client at increased risk of blood clot formation; a decrease could increase the effectiveness of warfarin, placing the client at increased risk for bleeding. (Option A) Many medications can interfere with warfarin metabolism. Nutritional supplements may contain vitamin K, and so any new medication or nutritional supplement should be approved by the health care provider. Cranberry juice, grapefruit, green tea, and alcohol may also interfere with the effectiveness of warfarin. (Option B) Rather than avoid vitamin K-rich foods, the client needs to keep vitamin K intake consistent from day to day to keep International Normalized Ratio (INR)/prothrombin time (PT) stable and within the recommended therapeutic range. If the client enjoys vitamin K-rich foods (eg, kale, broccoli, spinach, Brussels sprouts, cabbage, green leafy vegetables), these may be consumed in the same amounts, consistently on a daily basis. There is some evidence that a very low intake of vitamin K could decrease the overall effectiveness of warfarin. (Option D) INR/PT will be monitored on an ongoing basis to determine the safest, most therapeutic warfarin dosage. Educational objective: Sudden increases or decreases in the consumption of vitamin K-rich foods could inversely alter the effectiveness of warfarin. Rather than avoid vitamin K-rich foods, the client needs to keep vitamin K intake consistent from day to day to keep INR/PT stable and within the recommended therapeutic range. INR/PT is monitored at regular intervals. Pharmacy personnel and dieticians can provide additional teaching.

Question 8

The health care provider (HCP) prescribes naproxen for a client who has degenerative joint disease. What instructions regarding this drug does the nurse include in the client's discharge plan? Select all that apply.

Accepted Answer

Naproxen is a nonsteroidal anti-inflammatory drug (NSAID) commonly prescribed to decrease joint pain and inflammation. All NSAIDs (eg, indomethacin, ibuprofen) are associated with the following: Gastrointestinal (GI) toxicity - symptoms of GI bleeding such as black tarry stools should be reported. Gastrointestinal upset (eg, dyspepsia, pain) can be reduced if the medicine is taken with food. Kidney injury - long-term use is associated with kidney injury Hypertension and heart failure - NSAIDs can cause fluid retention, which can exacerbate conditions such as heart failure, cirrhosis/ascites, and hypertension Bleeding risk - clients should notify the HCP if taking concurrently with aspirin, other NSAIDs, or anticoagulant or antiplatelet drugs as they can increase the risk of GI bleeding. (Option A) Clients should not drive when taking sedating medications (eg, antihistamines, benzodiazepines). However, sedation is not associated with NSAID use. (Option B) Orthostatic hypotension is common with blood pressure medications (eg, ACE inhibitors, alpha blockers) but not with NSAIDs. (Option C) Suicidal thoughts are commonly associated with selective serotonin reuptake inhibitors (antidepressants) and varenicline (Chantix), a smoking cessation medication. Educational objective: All NSAIDs (eg, indomethacin, ibuprofen, naproxen) are associated with gastrointestinal toxicity, kidney injury, exacerbation of fluid overload/hypertension, and bleeding risk. They should be used at the lowest dose and for the shortest period possible.

Question 9

The home health nurse visits a client with hand osteoarthritis whose health care provider has recommended topical capsaicin for pain relief.  Which instruction about capsaicin should the nurse provide the client?

Accepted Answer

Topical capsaicin cream (Zostrix) is an over-the-counter analgesic that effectively relieves minor pain (eg, osteoarthritis, neuralgia). The nurse should instruct the client to wait at least 30 minutes after massaging the cream into the hands before washing to ensure adequate absorption (Option B). The client should avoid contact with mucous membranes (eg, nose, mouth, eyes) or skin that is not intact, as capsaicin is a component of hot peppers and can cause burning. When applying cream to other areas of the body (eg, knee), the client should wear gloves or wash hands immediately after application. (Option A) The application of heat with capsaicin is contraindicated as heat causes vasodilation, which increases medication absorption and can possibly lead to a chemical burn. (Option C) Local irritation (burning, stinging, erythema) is quite common and usually subsides within the first week of regular use. If the client experiences persistent pain, redness, or blistering, the cream should be discontinued and the health care provider notified. (Option D) Topical capsaicin is often used concurrently with acetaminophen or nonsteroidal anti-inflammatory drugs (eg, naproxen, celecoxib) to effectively treat osteoarthritis pain. Capsaicin should be used regularly (3-4 times daily) for long periods (eg, weeks to months) to achieve the desired effect. Educational objective: The topical analgesic capsaicin relieves minor peripheral pain (eg, osteoarthritis, neuralgia) with regular use. Local irritation (burning, stinging, erythema) is quite common. The client should wait at least 30 minutes before washing the affected area to ensure adequate absorption.

Question 10

The nurse administers the prescribed dose of hydromorphone 2 mg to a client who is 2 days postoperative from a colostomy. Which assessment finding is most important for the nurse to follow-up?

Accepted Answer

11ecbb05_cc5c_89d2_b433_85544f2eca9f_MD0009_00 Respiratory depression is the most serious side effect of narcotic medication. Sedation precedes respiratory depression. Falling asleep during a conversation scores "3" on the Pasero Opioid-Induced Sedation Scale (POSS); no additional narcotics should be given to the client. Other classes of drugs (eg, non-steroidal anti-inflammatory medications) can be given if the client is still in pain. The client will also be at increased risk for respiratory depression if the pain is completely relieved and/or it is night time. No additional narcotics should be given until the client is at level 2 sedation on POSS (eg, slightly drowsy, easily aroused). (Option A) Nausea or vomiting is a typical side-effect of narcotic administration, especially when it is given in a larger dose or to the opioid-naïve client. It usually lessens with time and repeat administration. Nausea or vomiting would not be a concern unless it is excessive or severe. The nurse should ensure that the client receives adequate hydration (eg, intravenous fluids, clear liquids, antiemetics). (Option B) Constipation is a known side effect of opioid administration and does not lessen with long-term administration. Proactive measures are needed as long as the client is on narcotics. However, large intestine peristalsis does not usually start until 2-3 days after surgery. (Option D) Pruritus (itching) is a known side effect of narcotic administration. It is usually treated with diphenhydramine (Benadryl) or some other antihistamine. Educational objective: Sedation precedes respiratory depression in narcotic administration. A client (especially if on high doses) should be assessed for sedation level. Level 3 sedation on POSS requires that no additional narcotics be administered to the client.

Question 11

A post-surgical client is unresponsive to painful stimuli and is given naloxone. Within 5 minutes, the client is arousable and responds to verbal commands. One hour later, the client is again difficult to arouse, with minimal response to physical stimuli. Which actions should the nurse take? Select all that apply.

Accepted Answer

A client in the post-operative period that is unresponsive to painful stimuli is likely still under the effects of medications used during anesthesia. Using the opioid antagonist naloxone (Narcan) will temporarily reverse the effects of any opioid medications. Unfortunately, the half-life of naloxone is much shorter than most opioid medications, wearing off in 1-2 hours. The nurse should make repeat assessments of the post-surgical client's respiratory rate and administer prescribed oxygen for respiratory support. The health care provider should be notified and a second dose of naloxone should be prepared and administered as prescribed (either as a one-time dose or a continuous drip, depending on the prescription). (Option C) An overly sedated client is not an indication for a rapid response team. Although this intervention is unlikely to cause harm to the client, it is not necessary and may result in overuse of personnel resources. If additional information indicates a more serious situation (eg, respiratory rate <8 breaths/min, oxygen saturation <90%), it may be appropriate to initiate the emergency response system. Educational objective: Naloxone (Narcan) is usually prescribed as needed for post-surgical clients for over-sedation related to opioid use. The nurse should continue to monitor clients who are given naloxone with the understanding that the opioid antagonist has a shorter half-life than most of the opioids it is meant to counteract. As a result, a second dose of naloxone may be necessary.

Question 12

During a routine office visit, the nurse documents the list of current medications of a client with a history of hypertension. Which statement by the client would cause the most concern?

Accepted Answer

Over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen can cause cardiovascular side effects, including heart attack, stroke, high blood pressure, and heart failure from fluid retention. These drugs also decrease the effectiveness of diuretics and other blood pressure medications. The risks can be even higher in the client who already has cardiovascular disease or takes NSAIDs routinely or for a long time. In addition, long-term use of NSAIDs is associated with peptic ulcers and chronic kidney disease. These clients should use NSAIDs cautiously, at the lowest dose necessary and for a short time. The nurse should notify the health care provider that this client is routinely taking ibuprofen. (Option A) Taking docusate sodium occasionally for constipation is appropriate. (Option C) Hydrochlorothiazide is a weak diuretic and is commonly used to treat hypertension. (Option D) Omeprazole for heartburn is appropriate for this client. Educational objective: NSAIDs may cause heart attack, stroke, high blood pressure, and possible heart failure after long-term use. NSAIDs decrease the effectiveness of diuretic and blood pressure medications. Long-term use is also associated with chronic kidney disease and peptic ulcers.

Question 13

A postoperative client is prescribed IV patient-controlled analgesia (PCA) with morphine. The client tells the nurse, "I am pushing the button, but I'm still having a lot of pain." What is the priority nursing action?

Accepted Answer

When providing care for a client prescribed IV PCA, the nurse assesses pain on a regular and as-needed basis. The client's self-report is considered to be the most reliable indicator of pain, so the priority nursing action is to perform a thorough pain assessment to determine the cause of worsening/continuous pain despite the medication. This includes location, quality, radiation, severity, and associated factors (eg, nausea, diaphoresis) for the severe pain. The assessment data will guide the nurse's subsequent interventions (Option C). (Option A) An IV PCA bolus is an extra, as-needed dose of analgesia (eg, 1-2 mg) for increased pain (eg, before a painful procedure) that is prescribed by the HCP when the PCA is initiated. If needed, the nurse programs the pump to deliver the bolus dose because no one but the client is permitted to push the button. However, this is not the priority action. (Option B) If the client's attempts are twice the number of doses actually delivered and adequate pain relief is not achieved, the nurse would notify the HCP to request a dose increase or shorter dose interval. However, this is done after the pain assessment. (Option D) The client learns how to use the IV PCA pump when it is initiated. The nurse should reassess the client's knowledge level regarding proper use and reinforce previous teaching. However, it is not the priority intervention. Educational objective: When providing care for a client prescribed IV PCA, the nurse assesses pain on a regular and as-needed basis, assesses the client's knowledge level regarding its use, and reinforces previous teaching.

Question 14

The home health hospice nurse visits a client who is newly prescribed extended-release oxycodone 40 mg orally, scheduled every 12 hours to treat severe chronic cancer pain. Which information is most important to reinforce to the client's caregiver?

Accepted Answer

Extended-release oxycodone (Oxycontin) is a long-acting opioid agonist prescribed to manage severe chronic pain when nonopioids and immediate-release opioids (eg, immediate-release oxycodone, hydrocodone) are inadequate. The nurse should teach the client's caregiver to administer extended-release oxycodone as scheduled, even if the client does not report pain. Administration twice daily is necessary to maintain a therapeutic level and provide continuous relief as the duration of the analgesic effect is 12 hours. (Option B) Immediate-release opioids and nonopioids are coadministered with long-acting opioids for relief of breakthrough pain. Respiratory status should be monitored; however, clients who receive long-term therapy become opioid tolerant and are less likely to experience adverse effects. Because the goal of hospice care is comfort, this client should be relieved of breakthrough pain regardless of respiratory status. (Option C) The dose and frequency cannot be changed without a prescription. Also, breakthrough pain is best treated with short-acting opioids. (Option D) Long-term opioid therapy leads to drug tolerance and physical dependence; higher doses are eventually required for therapeutic effect. In the dying client, it is not appropriate to taper the dose. Rather, it should be titrated upward for effective pain relief. Educational objective: Long-acting controlled-release opioid drugs for chronic pain require regularly scheduled dosing to maintain a therapeutic drug level. Immediate-release opioids may be required for breakthrough pain. Long-term opioid use leads to tolerance and physical dependence; higher doses are eventually required for therapeutic effect.

Question 15

The nurse is administering IV hydromorphone to a client every 3-4 hours as needed for postoperative pain. Which interventions should the nurse implement? Select all that apply.

Accepted Answer

Opioid analgesics (eg, hydromorphone, morphine) are effective for controlling moderate to severe pain. Major side effects include sedation, respiratory depression, hypotension, and constipation. The client is at risk for falls from sedation or hypotension and should not get out of bed unassisted (Option E). Slowed bowel motility persists throughout opioid use, and measures to prevent constipation (eg, administration of daily stool softeners) should be implemented (Option B). (Option A) IV hydromorphone should be administered slowly over 2-3 minutes. Rapid IV administration of opioid analgesics can cause severe hypotension and respiratory or cardiac arrest. (Option C) Postoperative clients may experience pain with breathing exercises (eg, turning, coughing, deep breathing, incentive spirometry). Uncontrolled postoperative pain may cause clients to avoid deep breathing and lead to atelectasis and pneumonia. The nurse should administer opioids to achieve adequate pain control as needed to encourage participation in postoperative exercises and prevent complications. (Option D) The nurse should reassess pain and sedation level during the opioid's peak effect, which is 15-30 minutes after administration of IV hydromorphone. Educational objective: Opioid analgesics are effective for managing postoperative pain, which encourages participation in deep breathing exercises. Side effects of opioid analgesics include sedation, respiratory depression, hypotension, and constipation. The nurse should administer IV hydromorphone slowly over 2-3 minutes, monitor sedation level, instruct the client not to get out of bed unassisted, and administer PRN stool softeners.

Question 16

The postoperative client on hydromorphone becomes hypoxic, and naloxone is administered per protocol. What is most important for the nurse to consider in the follow-up care of this client?

Accepted Answer

Hydromorphone duration of action is 3-4 hours. The effects of naloxone (Narcan) start to wane at 20-40 minutes after administration, and its duration of action is approximately 90 minutes. Therefore, depending on the hydromorphone dose, its duration of action can continue beyond the duration of the naloxone. Repeat naloxone doses may be necessary. (Option B) Documentation is essential, but client care is more important than paperwork. (Option C) Naloxone will reverse the effects of the narcotic in the body and, as long as it is in the body, will reverse the effects of any additional narcotic administered. This client will need a different class of analgesic at this time. However, adequate respiration/oxygenation as the naloxone wears off is more important. (Option D) Naloxone is the reversal agent for narcotics, and a drug-drug interaction is not a concern. Educational objective: The half-life of naloxone (Narcan) is shorter than most narcotics. When naloxone is used to reverse the effects of narcotics, the nurse must monitor the client to ensure that the client does not fall again into excessive sedation and/or respiratory depression.

Question 17

The home health nurse visits a client with atrial fibrillation who is newly prescribed digoxin 0.25 mg orally on even-numbered days. Which of the following client statements show that teaching has been effective? Select all that apply.

Accepted Answer

Digoxin (Lanoxin) is a cardiac glycoside used to treat heart failure and atrial fibrillation. Cardiac glycosides have positive inotropic effects (eg, increased cardiac output) and negative chronotropic effects (eg, decreased heart rate). However, drug toxicity is common due to digoxin having narrow therapeutic-range levels (0.5-2.0 ng/mL). Cardiac arrhythmias are the most dangerous symptoms. Digoxin toxicity can result in bradycardia and heart block, which can cause dizziness or lightheadedness (Option E). Clients are instructed to check their pulse and if it is low (<60/min) or has skipped beats to hold the medication and notify the health care provider (Option D). Other manifestations of digoxin toxicity that clients should report include: Visual symptoms (eg, alterations in color vision, scotomas, blindness) (Option A) Gastrointestinal symptoms (eg, anorexia, nausea, vomiting, abdominal pain) - frequently the earliest symptoms (Option C) Neurologic manifestations (eg, lethargy, fatigue, weakness, confusion) (Option B) There is no need to routinely check blood pressure before taking digoxin as it does not affect blood pressure. Clients should check the pulse prior to administration. Educational objective: Cardiac glycosides (eg, digoxin) have positive inotropic effects (eg, increased cardiac output) and negative chronotropic effects (eg, decreased heart rate). Clients are instructed to check their pulse before administration and to report gastrointestinal (eg, anorexia, nausea), neurologic, and cardiac symptoms and visual changes.

Question 18

A client recently diagnosed with heart failure is being discharged with a prescription for lisinopril.  Which client teaching related to this new medication is important to review at discharge?

Accepted Answer

11ecbb05_cc61_6bd3_b433_eb7719bc8f20_MD0009_00 Angiotensin converting enzyme (ACE) inhibitors (eg, captopril, enalapril, lisinopril, ramipril) prevent the pathological enlargement of the left ventricle of the heart. They work by blocking a crucial step in the renin-angiotensin-aldosterone system, the main hormonal mechanism involved in blood pressure regulation. Interrupting this step of the renin-angiotensin-aldosterone system has following effects: A shortage of angiotensin II results in an absence of the vasoconstrictive responses (orthostatic reflex, renal blood flow regulation) causing orthostatic hypotension. Clients may be more prone to experiencing orthostatic hypotension early in treatment with ACE inhibitors and should be taught ways to prevent it. A shortage of aldosterone causes hyperkalemia. Aldosterone Saves Sodium and Pushes Potassium out of the body. ACE inhibitors are contraindicated in pregnancy due to teratogenic effects on the fetus (eg, oligohydramnios, fetal kidney injury). The other important side effects of ACE inhibitors, cough and angioedema, are thought to be due to the accumulation of bradykinin. (Option A) Renal function (blood urea nitrogen, creatinine) is commonly checked during the first week of treatment. Regular measurements to ensure therapeutic drug levels are required for lithium, phenytoin, and digoxin. (Option B) A common side effect of ACE inhibitor is mild hyperkalemia, which may require a lower intake of foods high in potassium. Clients taking loop diuretics (eg, furosemide) will need to increase their intake of foods high in potassium. (Option C) ACE inhibitors do not directly affect the heart rate. Clients prescribed digoxin are taught to take their pulse and hold their medication if the heart rate is <60/min. Educational objective: Client education after initiation of an angiotensin converting enzyme inhibitor (eg captopril, lisinopril) includes a discussion on development of a dry cough, taking several minutes to get out of bed, possible allergic reactions (rash, angioedema), and the teratogenic effects of the drug.

Question 19

A client with chronic heart failure developed an intractable cough and an incident of angioedema after starting enalapril.  Which prescription does the nurse anticipate for this client?

Accepted Answer

Major side effects of angiotensin-converting enzyme (ACE) inhibitors include: Symptomatic hypotensionIntractable coughHyperkalemiaAngioedema (allergic reaction involving edema of the face and airways)Temporary increase in serum creatinine Symptomatic hypotension Intractable cough Hyperkalemia Angioedema (allergic reaction involving edema of the face and airways) Temporary increase in serum creatinine For clients unable to tolerate ACE inhibitors, angiotensin II receptor blockers (ARBs) such as valsartan or losartan are recommended. ARBs prevent the vasoconstrictor and aldosterone-secreting effects of angiotensin II by binding to the angiotensin II receptor sites. (Option A) Alprazolam is an anxiolytic. It is not used in the treatment of heart failure. (Option B) Dextromethorphan is a cough suppressant. A cough caused by an ACE inhibitor will not be improved by a cough suppressant. (Option C) Lisinopril is an ACE inhibitor. This client has been unable to tolerate this class of drug. Educational objective: ARBs are recommended for clients unable to tolerate ACE inhibitors.

Question 20

A client with cancer pain is prescribed oxycodone. Which teaching is most essential to help prevent long-term complications?

Accepted Answer

Oxycodone is a morphine-like opioid medication. Opioid medications bind to opioid receptors in the intestine, which slows peristalsis and increases water absorption, leading to constipation. Constipation is an almost universally expected side effect from opioid medications. Clients will not develop tolerance to this side effect. Although clients with idiopathic chronic constipation are not commonly advised to take laxatives, opioid-induced constipation is treated with simultaneous use of senna (stimulant) and docusate (stool softener). (Options A and C) Opioids cause the release of histamine, a vasodilator, which is responsible for pruritus and flushing. Opioids can also cause peripheral vasodilation and nervous system depression; both can lead to hypotension. These develop in some clients when the treatment is initiated but usually resolve over time. Antihistamines (eg, diphenhydramine) can prevent the pruritus. Lifestyle changes (eg, rising slowly from a seated position) and adequate hydration can prevent hypotension. (Option D) Opioids stimulate the opioid receptors in the gastrointestinal tract and the chemoreceptor trigger zone in the brain, producing nausea. This is also not seen with long-term use. Antiemetics (eg, ondansetron) can be helpful. Educational objective: Constipation is an expected long-term side effect of opioid use; clients will not develop tolerance to this side effect. It is important to teach aggressive preventive measures (eg, defecate when the urge is felt, drink 2-3 L of fluid/day, high-fiber diet, exercise) and simultaneous use of a stool softener and a stimulant.

Exam 8: Pharmacology

A client is admitted with palpitations. The ECG shows supraventricular tachycardia (SVT) with a rate of 220/min. The nurse has received an order to administer adenosine 6 mg IV. Which action should the nurse take?

A client diagnosed with stable angina is being discharged home on the cholesterol-lowering drug rosuvastatin. The nurse should teach the client to report which side effect to the health care provider (HCP) immediately?

A client is taking morphine sulfate for acute pain. Which statement will best assist the client worried about nausea and vomiting while taking this medication?

Which client is at greatest risk for respiratory depression when receiving opioids for pain control?

A client is taking morphine sulfate for acute pain. The client stands, is immediately "lightheaded," and calls for the nurse. What is the nurse's priority action?

A client with a diagnosis of atrial fibrillation has just been placed on warfarin therapy. The registered nurse (RN) overhears a student nurse teaching the client about potential food-drug interactions. Which statement made by the student nurse requires an intervention by the RN?

The health care provider (HCP) prescribes naproxen for a client who has degenerative joint disease. What instructions regarding this drug does the nurse include in the client's discharge plan? Select all that apply.

The home health nurse visits a client with hand osteoarthritis whose health care provider has recommended topical capsaicin for pain relief. Which instruction about capsaicin should the nurse provide the client?

The nurse administers the prescribed dose of hydromorphone 2 mg to a client who is 2 days postoperative from a colostomy. Which assessment finding is most important for the nurse to follow-up?

During a routine office visit, the nurse documents the list of current medications of a client with a history of hypertension. Which statement by the client would cause the most concern?

A postoperative client is prescribed IV patient-controlled analgesia (PCA) with morphine. The client tells the nurse, "I am pushing the button, but I'm still having a lot of pain." What is the priority nursing action?

The home health hospice nurse visits a client who is newly prescribed extended-release oxycodone 40 mg orally, scheduled every 12 hours to treat severe chronic cancer pain. Which information is most important to reinforce to the client's caregiver?

The nurse is administering IV hydromorphone to a client every 3-4 hours as needed for postoperative pain. Which interventions should the nurse implement? Select all that apply.

The postoperative client on hydromorphone becomes hypoxic, and naloxone is administered per protocol. What is most important for the nurse to consider in the follow-up care of this client?

The home health nurse visits a client with atrial fibrillation who is newly prescribed digoxin 0.25 mg orally on even-numbered days. Which of the following client statements show that teaching has been effective? Select all that apply.

A client recently diagnosed with heart failure is being discharged with a prescription for lisinopril. Which client teaching related to this new medication is important to review at discharge?

A client with chronic heart failure developed an intractable cough and an incident of angioedema after starting enalapril. Which prescription does the nurse anticipate for this client?

A client with cancer pain is prescribed oxycodone. Which teaching is most essential to help prevent long-term complications?