Focus on Nursing Pharmacology, 6th Edition by Amy M. Karch – Test Bank

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Focus on Nursing Pharmacology, 6th Edition by Amy M. Karch – Test Bank

Chapter 2- Drugs and the Body

1. Drugs do not metabolize the same way in all people. For what patient would a nurse expect to assess for an alteration in drug metabolism?
  A) A 35-year-old woman with cervical cancer
  B) A 41-year-old man with kidney stones
  C) A 50-year-old man with cirrhosis of the liver
  D) A 62-year-old woman in acute renal failure
  Ans: C
  Feedback:
  The liver is the most important site of drug metabolism. If the liver is not functioning effectively, as in patients with cirrhosis, drugs will not metabolize normally so that toxic levels could develop unless dosage is reduced. A patient with cervical cancer or kidney stones would not be expected to have altered ability to metabolize drugs so long as no liver damage existed. The patient with renal failure would have altered excretion of the drugs through the renal system but metabolism would not be impacted.

 

 

2. A patient presents to the emergency department with a drug level of 50 units/mL. The half-life of this drug is 1 hour. With this drug, concentrations above 25 units/mL are considered toxic and no more drug is given. How long will it take for the blood level to reach the non-toxic range?
  A) 30 minutes
  B) 1 hour
  C) 2 hours
  D) 3 hours
  Ans: B
  Feedback:
  Half-life is the time required for the serum concentration of a drug to decrease by 50%. After 1 hour, the serum concentration would be 25 units/mL (50/2) if the body can properly metabolize and excrete the drug. After 2 hours, the serum concentration would be 12.5 units/mL (25/2) and reach the nontoxic range. In 30 minutes the drug level would be 37.5 units/mL, whereas in 3 hours the drug level would be 6.25.

 

 

3. A patient has recently moved from Vermont to Southern Florida. The patient presents to the clinic complaining of “dizzy spells and weakness.” While conducting the admission assessment, the patient tells the nurse that he have been on the same antihypertensive drug for 6 years and had stable blood pressures and no adverse effects. Since his move, he has been having problems and he feels that the drug is no longer effective. The clinic nurse knows that one possible reason for the change in the effectiveness of the drug could be what?
  A) The impact of the placebo effect on the patient’s response.
  B) The accumulative effect of the drug if it has been taken for many years.
  C) The impact of the warmer environment on the patient’s physical status.
  D) Problems with patient compliance with the drug regimen while on vacation.
  Ans: C
  Feedback:
  Antihypertensive drugs work to decrease the blood pressure. When a patient goes to a climate that is much warmer than usual, blood vessels dilate and the blood pressure falls. If a patient is taking an antihypertensive drug and moves to a warmer climate, there is a chance that the patient’s blood pressure will drop too low, resulting in dizziness and feelings of weakness. Even mild dehydration could exacerbate these effects. Most antihypertensives are metabolized and excreted and do not accumulate in the body. Patients must be very compliant with their drug regimen on vacation. After several years on an antihypertensive drug, the effects of that drug are known; therefore, the placebo effect should not be an issue.

 

 

4. An important concept taught by the nurse when providing medication teaching is the need to provide a complete list of medications taken to health care providers to avoid what?
  A) Spending large amounts of money on medications
  B) Allergic reactions to medications
  C) Drug–drug interactions
  D) Critical concentrations of medications in the body
  Ans: C
  Feedback:
  It is important that all health care providers have a complete list of the patient’s medications to avoid drug–drug interactions caused by one provider ordering a medication, unaware of another medication the patient is taking that could interact with the new prescription. Using the same pharmacist for all prescriptions will also help to prevent this from happening. Informing the provider of all medications taken will not reduce costs of medications, which is best accomplished by requesting generic medications. Allergies should be disclosed to all health care providers as well, but this is not why it is important to provide a complete list of medications taken. Critical concentrations are desirable because that is the amount of drug needed to cause a therapeutic effect, or, in other words, to have the effect the drug is prescribed for.

 

 

5. A pharmacology student asks the instructor what an accurate description of a drug agonist is. What is the instructor’s best response?
  A) A drug that reacts with a receptor site on a cell preventing a reaction with another chemical on a different receptor site
  B) A drug that interferes with the enzyme systems that act as catalyst for different chemical reactions
  C) A drug that interacts directly with receptor sites to cause the same activity that a natural chemical would cause at that site
  D) A drug that reacts with receptor sites to block normal stimulation, producing no effect
  Ans: C
  Feedback:
  Agonists are drugs that produce effects similar to those produced by naturally occurring neurotransmitters, hormones, or other substances found in the body. Noncompetitive antagonists are drugs that react with some receptor sites preventing the reaction of another chemical with a different receptor site. Drug–enzyme interactions interfere with the enzyme systems that stimulate various chemical reactions.

 

 

6. A nurse is caring for a patient who has been receiving a drug by the intramuscular route but will receive the drug orally after discharge. How does the nurse explain the increased dosage prescribed for the oral dose?
  A) Passive diffusion
  B) Active transport
  C) Glomerular filtration
  D) First-pass effect
  Ans: D
  Feedback:
  The first-pass effect involves drugs that are absorbed from the small intestine directly into the portal venous system, which delivers the drug molecules to the liver. After reaching the liver, enzymes break the drug into metabolites, which may become active or may be deactivated and readily excreted from the body. A large percentage of the oral dose is usually destroyed and never reaches tissues. Oral dosages account for the phenomenon to ensure an appropriate amount of the drug in the body to produce a therapeutic action. Passive diffusion is the major process through which drugs are absorbed into the body. Active transport is a process that uses energy to actively move a molecule across a cell membrane and is often involved in drug excretion in the kidney. Glomerular filtration is the passage of water and water-soluble components from the plasma into the renal tubule.

 

 

7. A nurse is working as a member of a research team involved in exploring the unique response to drugs each individual displays based on genetic make-up. What is this area of study is called?
  A) Pharmacotherapeutics
  B) Pharmacodynamics
  C) Pharmacoeconomics
  D) Pharmacogenomics
  Ans: D
  Feedback:
  Pharmacogenomics is the area of study that includes mapping of the human genome. In the future, medical care and drug regimens may be personally designed based on a patient’s unique genetic make-up. Pharmacotherapeutics is the branch of pharmacology that deals with the uses of drugs to treat, prevent, and diagnose disease. Pharmacodynamics involves how a drug affects the body. Pharmacoeconomics includes the costs involved in drug therapy.

 

 

8. The nurse uses what term to describe the drug level required to have a therapeutic effect?
  A) Critical concentration
  B) Dynamic equilibrium
  C) Selective toxicity
  D) Active transport
  Ans: A
  Feedback:
  A critical concentration of a drug must be present before a reaction occurs within the cells to bring about the desired therapeutic effect. A dynamic equilibrium is obtained from absorption of a drug from the site of drug entry, distribution to the active site, metabolism in the liver, and excretion from the body to have a critical concentration. Selective toxicity is the ability of a drug to attach only to those systems found in foreign cells. Active transport is the process that uses energy to actively move a molecule across a cell membrane and is often involved in drug excretion in the kidney.

 

 

9. A nurse is caring for a patient who is supposed to receive two drugs at the same time. What is the nurse’s priority action?
  A) Wash her hands before handling the medications.
  B) Consult a drug guide for compatibility.
  C) Question the patient concerning drug allergies.
  D) Identify the patient by checking the armband and asking the patient to state his name.
  Ans: B
  Feedback:
  A nurse should first consult a drug guide for compatibility when two or more drugs are being given at the same time. After compatibility is determined the medication can be administered. The nurse will perform hand hygiene, check for patient allergies, and ensure the right patient receives the medication by using two identifiers.

 

 

10. The nurse is talking with a group of nursing students who are doing clinical hours on the unit. A student asks if all intramuscular (IM) drugs are absorbed the same. What factor would the floor nurse tell the students to affect absorption of the IM administration of drugs?
  A) Perfusion of blood to the subcutaneous tissue
  B) Integrity of the mucous membranes
  C) Environmental temperature
  D) Blood flow to the gastrointestinal tract
  Ans: C
  Feedback:
  A cold environmental temperature can cause blood vessels to vasoconstrict and decreases absorption or in a hot environment vasodilate and increase absorption of IM medications. Blood flow to the subcutaneous tissues interferes with subcutaneous injection and blood flow to the gastrointestinal (GI) tract causes alterations in absorption for oral medications. The condition of mucous membranes can interfere with sublingual (under the tongue) and buccal (in the cheek) administration of drugs.

 

 

11. The patient is taking a drug that affects the body by increasing cellular activity. Where does this drug work on the cell?
  A) Receptor sites
  B) Cell membrane
  C) Golgi body
  D) Endoplasmic reticulum
  Ans: A
  Feedback:
  Many drugs are thought to act at specific areas on cell membranes called receptor sites. After the receptor site is activated, this in turn activates the enzyme systems to produce certain effects, such as increased or decreased cellular activity, changes in cell membrane permeability, or alterations in cellular metabolism. Receptor sites are generally located on the outside of cells and allow the drug to bypass the cell membrane. The Golgi body and endoplasmic reticulum are not involved in this process.

 

 

12. Several processes enable a drug to reach a specific concentration in the body. Together they are called dynamic equilibrium. What are these processes? (Select all that apply.)
  A) Distribution to the active site
  B) Biotransformation
  C) Absorption from the muscle
  D) Excretion
  E) Interaction with other drugs
  Ans: A, B, D
  Feedback:
  The actual concentration that a drug reaches in the body results from a dynamic equilibrium involving several processes: Absorption from the site of entry (can be from the muscle, the gastrointestinal (GI) tract if taken orally, of the subcutaneous tissue if given by that route); Distribution to the active site; biotransformation (metabolism) in the liver; excretion from the body. Interaction with other drugs is not part of the dynamic equilibrium.

 

 

13. A nurse is administering digoxin to a patient. To administer medications so that the drug is as effective as possible, the nurse needs to consider what?
  A) Pharmacotherapeutics
  B) Pharmacokinetics
  C) Pharmacoeconomics
  D) Pharmacogenomics
  Ans: B
  Feedback:
  When administering a drug, the nurse needs to consider the phases of pharmacokinetics so that the drug regimen can be made as effective as possible. Pharmacogenomics is the area of study that includes mapping of the human genome. Pharmacotherapeutics is the branch of pharmacology that deals with the uses of drugs to treat, prevent, and diagnose disease. Pharmacoeconomics includes all costs involved in drug therapy.

 

 

14. The nurse is explaining how medications work to a group of peers and explains that disruption of a single step in any enzyme system disrupts what?
  A) Cell life
  B) Cell membrane
  C) Cell receptor sites
  D) Cell function
  Ans: D
  Feedback:
  If a single step in one of the many enzyme systems is blocked, normal cell function is disrupted. Cell life and cell membrane may be impacted by disruption of some enzymes but not all enzymes. Receptor sites would not be disrupted by disruption in a single step in the enzyme system.

 

 

15. The processes involved in dynamic equilibrium are key elements in the nurse’s ability to determine what?
  A) Dosage scheduling
  B) Amount of solution for mixing parenteral drugs
  C) Timing of other drugs the patient is taking
  D) How long the patient has to take the drug
  Ans: A
  Feedback:
  These processes are key elements in determining the amount of drug (dose) and the frequency of dose repetition (scheduling) required to achieve the critical concentration for the desired length of time. The processes in dynamic equilibrium are not key elements in determining the amount of diluents for intramuscular (IM) drugs; they do not aid in the timing of the other drugs the patient is taking or how long the patient has to take the drug.

 

 

16. What factor influences drug absorption?
  A) Kidney function
  B) Route of administration
  C) Liver function
  D) Cardiovascular function
  Ans: B
  Feedback:
  Drug absorption is influenced by the route of administration. IV administration is the fastest method; drug absorption is slower when given orally. Kidney function impacts excretion, liver function impacts metabolism, and cardiovascular function impacts distribution.

 

 

17. What does the lipid solubility of the drug influence?
  A) Absorption of the drug
  B) Metabolism of the drug
  C) Excretion of the drug
  D) Distribution of the drug
  Ans: D
  Feedback:
  Factors that can affect distribution include the drug’s lipid solubility and ionization and the perfusion of the reactive tissue. The lipid solubility of a drug does not influence absorption, metabolism, or excretion.

 

 

18. The nursing students are learning about the half-life of drugs. A student asks the instructor to explain half-life. What is the instructor’s best response?
  A) Half-life of a drug is the time it takes for the amount of drug in the body to decrease to half of the peak level it previously achieved.
  B) Half-life is the amount of time it takes for the drug to be metabolized by the body.
  C) Half-life is the amount of time it takes for half of the drug to reach peak level in the body.
  D) Half-life of a drug is the time it takes for the drug to reach half its potential peak level in the body.
  Ans: A
  Feedback:
  The half-life of a drug is the time it takes for the amount of drug in the body to decrease to half the peak level it previously achieved. Therefore Options B, C, and D are not correct.

 

 

19. The patient is taking a 2-mg dose of ropinerol XR. The drug has a half-life of 12 hours. How long will it be before only 0.25 mg of this drug remains in the patient’s system?
  A) 24 hours
  B) 36 hours
  C) 48 hours
  D) 60 hours
  Ans: B
  Feedback:
  The half-life of a drug is the time it takes for the amount of drug in the body to decrease to half of the peak level it previously achieved. At 12 hours there will be 1 mg of the drug available to the body. At 24 hours there will be 0.5 mg; at 36 hours there will be 0.25 mg; at 48 hours there will be 0.125 mg, and at 60 hours there will be 0.0625 mg.

 

 

20. The patient has a diagnosis of multiple sclerosis and is taking the drug interferon beta-1a (Rebif). The patient takes this drug by subcutaneous injection three times a week. The dosage is 44 mcg per injection. If the patient takes an injection on Monday, how much of the drug would still be in the patient’s system when she takes her next injection on Wednesday, assuming the half-life of the drug is 24 hours?
  A) 22 mcg
  B) 16.5 mcg
  C) 11 mcg
  D) 5.5 mcg
  Ans: C
  Feedback:
  The half-life of a drug is the time it takes for the amount of drug in the body to decrease to 1 half the peak level it previously achieved. On Tuesday, there would be 22 mcg remaining in the body, so option A is incorrect. On Wednesday 11 mcg would remain, so option C is the correct answer. At 12 hours before taking the next dose on Wednesday, there would be 16.5 mcg remaining. If the injection were not taken on Wednesday, 12 hours after the dose was due, there would be 5.5 mcg remaining.

 

 

21. The patient is a 6-year-old child who is taking 125 mg of amoxicillin every 6 hours. Assuming that the half-life of Amoxicillin is 3 hours, how much Amoxicillin would be in the child’s body at the time of the next administration of the drug?
  A) 62.5 mg
  B) 46.875 mg
  C) 31.25 mg
  D) 15.625 mg
  Ans: C
  Feedback:
  The half-life of a drug is the time it takes for the amount of drug in the body to decrease to 1 half the peak level it previously achieved. Option A would occur at 3 hours after the original dose of amoxicillin. Option B would occur 4 1/2 hours after the original dose. Option C would occur at 6 hours after the original dose. Option D would occur at 7 1/2 hours after the original dose.

 

 

22. A drug with a half-life of 4 hours is administered at a dosage of 100 mg. How much of the drug will be in the patient’s system 8 hours after administration?
  A) 75 mg
  B) 50 mg
  C) 37.5 mg
  D) 25 mg
  Ans: D
  Feedback:
  The half-life of a drug is the time it takes for the amount of drug in the body to decrease to 1 half the peak level it previously achieved. Option A would occur 2 hours after administration of the drug. Option B would occur at 4 hours. Option C would occur at 6 hours. Option D would occur at 8 hours after the original administration of the drug.

 

 

23. The nurse administers amoxicillin 500 mg. The half-life of this drug is approximately 1 hour. At what point would the drug level in the body be 62.5 mg if the drug was not administered again?
  A) 1 hours after the original dose
  B) 2 hours after the original dose
  C) 3 hours after the original dose
  D) 4 hours after the original dose
  Ans: C
  Feedback:
  The half-life of a drug is the time it takes for the amount of drug in the body to decrease to one-half of the peak level it previously achieved. At a dose of 500 mg the drug level would be 250 mg in 1 hour, 125 mg in 2 hours, 62.5 mg in 3 hours, and 31.25 mg in 4 hours so the correct answer is 3 hours.

 

 

24. The nurse is caring for a patient who is receiving gentamicin, 250 mg and fluconazole (Diflucan), 500 mg at the same time. The nurse knows that if these two drugs competed with each other for protein-binding sites, what would this do?
  A) Make the patient gentamicin deficient
  B) Make the patient fluconazole deficient
  C) Counteract any positive benefit the drugs would have
  D) Alter the effectiveness of both drugs
  Ans: D
  Feedback:
  Some drugs compete with each other for protein-binding sites, altering effectiveness or causing toxicity when the two drugs are given together. Nothing in the scenario would indicate that the patient would be either Gentamicin or Diflucan deficient, nor does it indicate that these drugs cannot be given together because they would counteract each other.

 

 

25. The student nurse asks the instructor why a patient with a central nervous system infection is receiving antibiotics that will not cross the blood–brain barrier. What is the instructor’s most correct response?
  A) A severe infection alters the blood–brain barrier to allow the drug to cross.
  B) A medication that is water soluble is more likely to cross the blood-brain barrier.
  C) Antibiotics are the exception to the blood–brain barrier and cross easily.
  D) An infection that spreads outside the central nervous system helps drugs cross the barrier.
  Ans: A
  Feedback:
  Effective antibiotic treatment can occur only when the infection is severe enough to alter the blood–brain barrier and allow antibiotics to cross. Lipid-soluble, not water-soluble, medications cross the blood–brain barrier more easily and most antibiotics are lipid soluble, so they are not the exception. No matter where the infection originates, drugs must cross the blood–brain barrier to treat central nervous system infections.

 

 

26. The patient is taking low dose aspirin daily for his heart. The nurse knows only a portion of the medication taken actually reaches the tissue due to what process?
  A) Distribution
  B) First-pass effect
  C) Reduced absorption
  D) Gastrointestinal circulation
  Ans: B
  Feedback:
  Drugs that are taken orally are usually absorbed from the small intestine directly into the portal venous system and then delivers these absorbed molecules into the liver, which immediately break the drug into metabolites, some of which are active and cause effects in the body, and some of which are deactivated and can be readily excreted from the body. As a result, a large percentage of the oral dose is destroyed at this point and never reaches the tissues. This process is not caused by distribution, absorption, or gastrointestinal circulation.

 

 

27. What needs to happen to the protein–drug complex for the drugs to reach the cells where the drug can act?
  A) The protein–drug complex must break itself into smaller pieces to enter the capillaries.
  B) The binding site on the protein picks up a chemical to make it soluble in the serum.
  C) The drug must break away from the protein-binding site and float freely.
  D) The drug must be dissolved in the plasma so it can enter the capillaries and then the tissues.
  Ans: C
  Feedback:
  Most drugs are bound, to some extent, to proteins in the blood to be carried into circulation. The protein–drug complex is relatively large and cannot enter into capillaries and then into tissues to react. The drug must be freed from the protein’s binding site at the tissues. This occurs without the introduction of another chemical or by dissolving in it plasma.

 

 

28. The nurse is reviewing the results of the patient’s laboratory tests. What must the nurse keep in mind when reviewing these results related to medication administration?
  A) The patient’s emotional response to the disease process
  B) The timing of the last dose of medication relative to when blood was drawn
  C) The possibility of a drug–laboratory test interaction
  D) A change in the body’s responses or actions related to the drug
  Ans: C
  Feedback:
  The body works through a series of chemical reactions. Because of this, administration of a particular drug may alter results of tests that are done on various chemical levels or reactions as part of a diagnostic study. This drug–laboratory test interaction is caused by the drug being given and not necessarily by a change in the body’s responses or actions. The patient’s emotional response or timing of the last dose is not important in drug-laboratory interactions.

 

 

29. A patient has come to the clinic and been diagnosed with Lyme disease. The physician has ordered oral tetracycline. What is important for the nurse to include in the teaching plan about tetracycline? (Select all that apply.)
  A) Do not take the drug with anything high in sodium content to keep from producing a state of hypernatremia in the body.
  B) Do not take the drug with foods or other drugs that contain calcium.
  C) Do not take the drug at the same time you take an iron supplement or with foods that are high in iron content.
  D) Avoid exposure to the sun when taking this drug as it can turn your skin purple.
  E) Avoid eating bananas at the same time you take this drug as the potassium content of the tetracycline can produce hyperkalemia in the body.
  Ans: B, C
  Feedback:
  The antibiotic tetracycline is not absorbed from the gastrointestinal (GI) tract if calcium or calcium products (e.g., milk) are present in the stomach. It cannot be taken with iron products because a chemical reaction occurs preventing absorption. Although tetracycline can increase sun sensitivity, it does not turn the skin purple. Patients who take tetracycline do not need to avoid eating bananas or foods that are high in potassium.

 

 

30. A nurse is caring for a patient taking multiple drugs and is concerned about a possible drug–drug interaction. What is the nurse’s first and best means of avoiding this problem?
  A) Consult a drug guide.
  B) Call the pharmacist.
  C) Contact the provider.
  D) Ask another nurse.
  Ans: A
  Feedback:
  Whenever two or more drugs are being given together, first consult a drug guide for a listing of clinically significant drug–drug interactions. Sometimes problems can be avoided by staggering the administration of the drugs or adjusting their dosages. Consulting the pharmacist is not wrong, but it would not be the first action to take. The nurse holds responsibility for his or her own practice so asking a health care provider or another nurse is based on the assumption that that professional is knowledgeable about all drug–drug interactions, which is likely not the case.

 

 

31. The nurse promotes optimal drug effectiveness by doing what? (Select all that apply.)
  A) Incorporate basic history and physical assessment factors into the plan of care.
  B) Evaluate the effectiveness of drugs after they have been administered.
  C) Modify the drug regimen to modify adverse or intolerable effects.
  D) Minimize the number of medications administered to patients.
  E) Examine factors known to influence specific drugs if they are to be effective.
  Ans: A, B, C, E
  Feedback:
  Incorporate basic history and physical assessment factors into any plan of care so that obvious problems can be identified and handled promptly. If a drug simply does not do what it is expected to do, further examine the factors that are known to influence drug effects. Frequently, the drug regimen can be modified to deal with that influence. Minimizing the number of medications administered is usually not an option because each drug is ordered for a reason of necessity for the patient.

 

 

32. The nurse administers a specific medication to an older adult patient every 4 hours. The patient has a history of chronic renal failure. Why would this patient be at risk for toxic drug levels?
  A) Cumulative effect
  B) First-pass effect
  C) Drug interactions
  D) Cross-tolerance effect
  Ans: A
  Feedback:
  If a drug is taken in successive doses at intervals that are shorter than recommended, or if the body is unable to eliminate a drug properly, the drug can accumulate in the body, leading to toxic levels and adverse effects. This is a cumulative effect. First-pass effect addresses the reduction of available drug when taken orally due to metabolism in the liver before the drug reaches the bloodstream. Drug interactions occur when taken with other drugs, food, or complementary alternative therapies. Cross-tolerance is resistance to drugs within the same class.

 

 

33. The patient, diagnosed with cancer, is receiving morphine sulfate (a potent narcotic pain reliever) to relieve cancer pain. Approximately every 7 days the medication is no longer effective in controlling the patient’s pain and a larger dose is needed to have the same effect. How might the nurse explain why this is happening?
  A) Tolerance
  B) Cumulation
  C) Interactions
  D) Addiction
  Ans: A
  Feedback:
  The body may develop a tolerance to some drugs over time. Tolerance may arise because of increased biotransformation of the drug, increased resistance to its effects, or other pharmacokinetic factors. When tolerance occurs, the amount of the drug no longer causes the same reaction. Therefore, increasingly larger doses are needed to achieve a therapeutic effect. Cumulative effect occurs when the drug is not properly eliminated and more of the drug is administered, resulting in toxic levels accumulating. Interactions occur when the drug reacts badly with another substance such as food, another drug, or an alternative or complementary therapy. Addiction is the psychological need for a substance.

 

 

34. While administering a medication that the nurse has researched and found to have limited effectiveness, the patient tells the nurse, “I have read all about this drug and it is such a wonder drug. I’m so lucky my doctor prescribed it because I just know it will treat my problem.” The nurse suspects this drug will be more effective than usual for this patient because of what effect?
  A) Cumulative effect
  B) First-pass effect
  C) Placebo effect
  D) Cross-tolerance effect
  Ans: C
  Feedback:
  A drug is more likely to be effective if the patient thinks it will work than if the patient believes it will not work. This is called the placebo effect. If a drug is taken in successive doses at intervals that are shorter than recommended, or if the body is unable to eliminate a drug properly, the drug can accumulate in the body, leading to toxic levels and adverse effects. This is a cumulative effect. First-pass effect addresses the reduction of available drug when taken orally due to metabolism in the liver before the drug reaches the bloodstream. Cross-tolerance is resistance to drugs within the same class.

 

 

35. The nurse administers an intravenous medication with a half-life of 24 hours but recognizes what factors in this patient could extend the drug’s half-life? (Select all that apply.)
  A) Gastrointestinal disease
  B) Kidney disease
  C) Liver disease
  D) Cardiovascular disease
  E) Route of administration
  Ans: B, C, D
  Feedback:
  Kidney disease could slow excretion and extend the drug’s half-life. Liver disease could slow metabolism resulting in an extended half-life. Cardiovascular disease could slow distribution resulting in a longer half-life. Gastrointestinal disease would not impact half-life because the medication was injected directly into the bloodstream. Route of administration would not extend half-life because IV injection eliminates the absorption step in the process.

 

Chapter 16- Anti-inflammatory, Antiarthritis

1. A nurse has admitted a 10-year-old child to the short-stay unit. The child has complained of chronic headaches and his or her mother reports that he or she gives him or her acetaminophen (Tylenol) at least twice a day. What will the nurse evaluate?
  A) Renal function
  B) Hepatic function
  C) Respiratory function
  D) Cardiac function
  Ans: B
  Feedback:
  The nurse should evaluate the patient’s hepatic function. Severe hepatotoxicity can occur from overuse of acetaminophen. Significant interferences do not occur in the kidney, heart, or lung with acetaminophen.

 

 

2. The nurse is discussing ethnic differences in response to medication with your nursing students. What group of people would the nurse tell the students may have a decreased sensitivity to pain-relieving effects of anti-inflammatory drugs and should be educated concerning signs and symptoms of gastrointestinal bleeding from use of these drugs?
  A) African Americans
  B) White Americans
  C) Hispanics
  D) Asians
  Ans: A
  Feedback:
  African Americans have a documented decreased sensitivity to pain-relieving effects of many anti-inflammatory drugs. They also have an increased risk of developing GI adverse effects to these drugs. In general, White Americans, Hispanics, and Asians are at lower risk for these problems.

 

 

3. A patient, newly diagnosed with ulcerative colitis, has been admitted to the short-stay unit. What salicylates does the nurse anticipate will be ordered for this patient?
  A) Balsalazide (Colazal)
  B) Sodium thiosalicylate (generic)
  C) Choline magnesium trisalicylate (Tricosal)
  D) Salsalate (Argesic)
  Ans: A
  Feedback:
  Balsalazide is delivered intact to the colon, where it delivers a local anti-inflammatory effect that is most effective for patients with ulcerative colitis. Choline salicylate and salsalate are used to treat pain, fever, and inflammation. Sodium thiosalicylate is used mainly for episodes of acute gout, for muscular pain, and to treat rheumatic fever.

 

 

4. The nurse is caring for a 66-pound child with orders for choline magnesium trisalicylate (Tricosal). The orders read 50 mg/kg/d  PO in two divided doses. How many milligram will the patient receive per dose?
  A) 250 mg
  B) 500 mg
  C) 750 mg
  D) 1,000 mg
  Ans: C
  Feedback:
  First, the nurse must determine the child’s weight in kilogram. One kg is equal to 2.2 pounds. Divide 2.2 into 66 to equal 30 kg. Multiply 50 mg times 30 kg to equal 1,500 mg. Divide 1,500 by 2 for the divided doses, which will equal 750 mg per dose.

 

 

5. A nurse is caring for a patient with severe rheumatoid arthritis who takes anti-inflammatory agents on a regular basis. What medication should the nurse question if ordered by the physician to be taken in addition to the anti-inflammatory agent?
  A) Oral antidiabetic agent
  B) Calcium channel blocker
  C) Beta-blocker
  D) Antibiotic
  Ans: C
  Feedback:
  Nonsteroidal anti-inflammatory drugs have the potential to decrease antihypertensive effects from beta blockers if these drugs are taken at the same time. Patients who receive these combinations should be monitored closely and appropriate dosage adjustments made if needed. Drug interactions do not usually occur with oral antidiabetic agents, calcium channel blocking medications, or antibiotics.

 

 

6. A nurse is assessing a patient who has been taking nonsteroidal anti-inflammatory drugs (NSAID). What statement by the patient indicates to the nurse that the patient has a good understanding of the use of this therapy?
  A) “I drink a glass of wine just about every night.”
  B) “I asked my doctor to check for blood in my stool regularly.”
  C) “I do not like to swallow tablets so I crush them.”
  D) “I drink as little water as possible when I take my medication.”
  Ans: B
  Feedback:
  Taking certain anti-inflammatory drugs can irritate the gastric mucosa and increase the risk of bleeding; therefore, by asking his or her doctor to check his or her stool for bleeding, the nurse knows that the patient is aware of this. Alcohol and crushing the tablets can interfere with anti-inflammatory metabolism. A full glass of water should be taken with this medication to increase absorption.

 

 

7. A salicylate has been prescribed for a 15-year-old patient who has been diagnosed with arthritis. The mother is concerned about giving her child a salicylate. What salicylates could the nurse tell this mother are recommended for use in children?
  A) Salsalate (Argesic)
  B) Olsalazine (Dipentum)
  C) Sodium thiosalicylate (generic)
  D) Choline magnesium trisalicylate (Tricosal)
  Ans: D
  Feedback:
  Aspirin and choline magnesium trisalicylate are the only salicylates recommended for use in children. They should not be used when any risk of Reye’s syndrome exists. Salsalate (Argesic), olsalazine (Dipentum), and sodium thiosalicylate (generic) have not been approved for pediatric use and do not provide pediatric dosing guidelines as a result.

 

 

8. A mother has brought her 6-year-old child to the clinic. The child has a fever of 102.8ºF and is diagnosed with the flu. What medication will the nurse suggest for this child?
  A) Etanercept (Enbrel)
  B) Penicillamine (Depen)
  C) Acetaminophen (Tylenol)
  D) Aspirin (Bayer)
  Ans: C
  Feedback:
  Acetaminophen would be the suggested medication. It is prescribed for relief of pain and fever for influenza in children. Aspirin would be contraindicated because it increases the risk for Reye’s syndrome. Etanercept and penicillamine are given for severe rheumatoid arthritis therapy.

 

 

9. A nurse is presenting an educational event for a group of new parents. One topic that the nurse addresses is the overuse of acetaminophen, which can cause liver toxicity. What would the nurse tell the parents it is important to do?
  A) “Do not give acetaminophen (Tylenol) unless you receive a doctor’s order.”
  B) “Check the label of over-the-counter (OTC) medications carefully to watch for inclusions of acetaminophen in the ingredients.”
  C) “Monitor their child’s temperature carefully and regulate the Tylenol dose based on the fever.”
  D) “Mix OTC children’s medications to get the best coverage for their child’s symptoms.”
  Ans: B
  Feedback:
  Inadvertent overdose with acetaminophen frequently occurs because of the combining of OTC drugs that contain the same ingredients. Parents should be taught to carefully check the labels of OTC products and follow the dosage guidelines. A prescription is not required for acetaminophen. Dosage guidelines are the best guide to follow to prevent overdose.

 

 

10. A mother asks the nurse how acetaminophen works. What statement best describes the therapeutic action of acetaminophen?
  A) Acetaminophen (Tylenol) works by blocking the increase of interleukin-1.
  B) Acetaminophen reacts with free-floating tumor necrosis (TNF) factor released by active leukocytes.
  C) Acetaminophen acts directly on the hypothalamus to cause vasodilation and sweating.
  D) Acetaminophen is taken up by macrophages, thus inhibiting phagocytosis and release of lysosomal enzymes.
  Ans: C
  Feedback:
  Acetaminophen acts on the hypothalamus to cause vasodilation and sweating to reduce fever. The mechanism of action as an analgesic is not understood. Anakinra (Kineret) blocks the increased interleukin-1, which is responsible for the degradation of cartilage in rheumatoid arthritis. Etanercept (Enbrel) reacts with free-floating TNF released by active leukocytes in autoimmune inflammatory disease to prevent the damage caused by TNF. Gold compounds are taken up by macrophages, which, in turn, inhibits phagocytosis and releases lysosomal enzymes, which causes damage associated with inflammation.

 

 

11. Antipyretic drugs (e.g., aspirin, ibuprofen, acetaminophen) often are used to alleviate the discomforts of fever and to protect vulnerable organs, such as the brain, from extreme elevations in body temperature. However, the use of aspirin in children is limited due to the possibility of what disease?
  A) Munchausen’s syndrome
  B) Guillain-Barré syndrome
  C) Angelman’s syndrome
  D) Reye’s syndrome
  Ans: D
  Feedback:
  Salicylates like aspirin are contraindicated for the treatment of childhood fevers because of the risk of Reye’s syndrome in children and teenagers. Munchausen’s syndrome is an unusual condition characterized by habitual pleas for treatment and hospitalization for a symptomatic but imaginary acute illness. Guillain-Barré syndrome is an idiopathic, peripheral polyneuritis that occurs 1 to 3 weeks after a mild episode of fever associated with a viral infection or with immunization. Angelman’s syndrome is an autosomal recessive syndrome characterized by jerky puppet-like movements, frequent laughter, mental and motor retardation, a peculiar open-mouthed facial expression, and seizures. Salicylates like aspirin are not contraindicated for patients with Munchausen’s syndrome, Guillain-Barré syndrome, or Angelman’s syndrome.

 

 

12. A patient has been diagnosed with severe rheumatoid arthritis and hylan G-F 20 has been ordered. How is this drug given?
  A) Injected into the joint
  B) Orally
  C) IM
  D) Sub Q
  Ans: A
  Feedback:
  Hyaluronidase derivatives (e.g., hylan G-F 20, sodium hyaluronate) have elastic and viscous properties. These drugs are injected directly into the joints of patients with severe rheumatoid arthritis of the knee. They seem to cushion and lubricate the joint and relieve the pain associated with degenerative arthritis. They are given weekly for 3 to 5 weeks and are not given by any other route.

 

 

13. A nurse is caring for a patient in the early stage of rheumatoid arthritis. The nurse would expect what medication classification to be used in the treatment of this patient?
  A) Antimalarial agents
  B) Nonsteroidal anti-inflammatory drugs (NSAIDs)
  C) Xanthine oxidase inhibitors
  D) Uricosuric agents
  Ans: B
  Feedback:
  NSAIDs are indicated for relief of the signs and symptoms of rheumatoid arthritis and osteoarthritis, for relief of mild to moderate pain, for treatment of primary dysmenorrhea, and for fever reduction. Antimalarial agents are used in the treatment of systemic lupus erythematosus. Xanthine oxidase inhibitors and uricosuric agents are used in the treatment of gout.

 

 

14. The nurse is caring for a patient who receives anakinra (Kineret) for arthritis. By what route will the nurse administer this medication?
  A) Into the affected joint directly
  B) Oral
  C) Intramuscular
  D) Subcutaneous
  Ans: D
  Feedback:
  Anakinra is administered subcutaneously every day and is often used in combination with other antiarthritis drugs. No other route is appropriate.

 

 

15. The nurse is preparing to administer a nonsteroidal anti-inflammatory drug (NSAID) to an older patient. What NSAID is associated with increased toxicity and should be avoided if possible?
  A) Naproxen (Aleve)
  B) Ibuprofen (Motrin)
  C) Indomethacin (Indocin)
  D) Etodolac (Lodine)
  Ans: A
  Feedback:
  Geriatric warnings have been associated with naproxen, ketorolac, and ketoprofen because of reports of increased toxicity when they are used by older patients. These NSAIDs should be avoided in this population if possible. No such warnings exist for ibuprofen, indomethacin, or etodolac.

 

 

16. What medication used to treat rheumatic arthritis not only has anti-inflammatory effects but is also used in premature infants to close a patent ductus arteriosus?
  A) Penicillamine
  B) Indomethacin
  C) Antimalarials
  D) Prednisone
  Ans: B
  Feedback:
  Indomethacin given IV is used in premature infants to close a patent ductus arteriosus and avoid a surgical procedure. Penicillamine, antimalarials, and prednisone are not used for this purpose.

 

 

17. When the nurse learns that the patient with rheumatic arthritis is complaining of stomatitis, the nurse should further assess the patient for the adverse effects of what medication?
  A) Corticosteroids
  B) Gold-containing compounds
  C) Antimalarials
  D) Salicylate therapy
  Ans: B
  Feedback:
  Various adverse effects are common with the use of gold salts and are probably related to their deposition in the tissues and effects at that local level: stomatitis, glossitis, gingivitis, pharyngitis, laryngitis, colitis, diarrhea, and other GI inflammation; gold-related bronchitis and interstitial pneumonitis; bone marrow depression; vaginitis and nephrotic syndrome; dermatitis, pruritus, and exfoliative dermatitis; and allergic reactions ranging from flushing, fainting, and dizziness to anaphylactic shock. The disease-modifying antirheumatic drug (DMARD) category of antimalarials may cause visual changes, GI upset, rash, headaches, photosensitivity, and bleaching of hair. Tinnitus is associated with salicylate therapy. Hirsutism is associated with corticosteroid therapy.

 

 

18. A patient with rheumatoid arthritis is taking gold salts. What drugs should the nurse teach this patient that are contraindicated when taking gold salts? (Select all that apply.)
  A) Antimalarials
  B) Cytotoxic drugs
  C) Salicylates
  D) Penicillamine
  E) Anticoagulants
  Ans: A, B, D
  Feedback:
  These drugs should not be combined with penicillamine, antimalarials, cytotoxic drugs, or immunosuppressive agents other than low-dose corticosteroids because of the potential for severe toxicity. No contraindication exists for therapy involving gold salts and salicylates or anticoagulants.

 

 

19. The nurse teaches a patient with rheumatic disease who is being prescribed salicylate therapy to monitor himself or herself for what?
  A) Tinnitus
  B) Visual changes
  C) Stomatitis
  D) Hirsutism
  Ans: A
  Feedback:
  Tinnitus is associated with salicylates. The disease-modifying antirheumatic drug (DMARD) category of antimalarials may cause visual changes, GI upset, skin rash, headaches, photosensitivity, and bleaching of hair. Eighth cranial nerve damage and stomatitis are associated with gold therapy. Hirsutism is associated with corticosteroid therapy.

 

 

20. The nurse assesses laboratory results related to blood clotting when the assigned patient takes what drug regularly? (Select all that apply.)
  A) Salicylates
  B) Nonsteroidal anti-inflammatory drugs (NSAIDs)
  C) Gold compounds
  D) Acetaminophen
  E) Disease-modifying antirheumatic drugs (DMARDs)
  Ans: A, B
  Feedback:
  Salicylates and NSAIDs can both inhibit blood clotting resulting in bleeding if not monitored. Gold compounds, acetaminophen, and DMARDs do not have a known impact on blood clotting.

 

 

21. What is chrysotherapy?
  A) Treatment with antimalarials
  B) Treatment with salicylates
  C) Treatment with disease-modifying antirheumatic drugs (DMARDs)
  D) Treatment with gold salts
  Ans: D
  Feedback:
  Chrysotherapy is the clinical name for treatment with gold salts in which gold is taken up by macrophages, which then inhibit phagocytosis. It is reserved for use in patients who are unresponsive to conventional therapy and can be very toxic. Options A, B, and C are incorrect.

 

 

22. What drugs used to treat rheumatoid arthritis are contraindicated in a patient who has a history of toxic levels of heavy metals?
  A) Gold salts
  B) COX-2 inhibitors
  C) Propionic acids
  D) Fenamates
  Ans: A
  Feedback:
  Gold salts can be extremely toxic and are contraindicated in the presence of any known allergy to gold, severe diabetes mellitus, congestive heart failure, severe debilitation, renal or hepatic impairment, hypertension, blood dyscrasias, recent radiation treatment, history of toxic levels of heavy metals, and pregnancy or lactation. COX-2 inhibitors, propionic acids, and fenamates have no contraindications related to prior toxic levels of heavy metals.

 

 

23. Which of these anti-inflammatory drugs have geriatric warnings? (Select all that apply.)
  A) Sulindac (Clinoril)
  B) Indomethacin (Indocin)
  C) Ketorolac (Toradol)
  D) Naproxen (Naprosyn)
  E) Ketoprofen (Orudis)
  Ans: C, D, E
  Feedback:
  Geriatric warnings have been associated with naproxen, ketorolac, and ketoprofen because of reports of increased toxicity when they are used by older patients. These nonsteroidal anti-inflammatory drugs should be avoided if possible. Sulindac and indomethacin are not associated with toxicity in older patients.

 

 

24. A patient presents at the emergency department complaining of dizziness, mental confusion, and difficulty hearing. What should the nurse suspect is wrong with the patient?
  A) Anakinra toxicity
  B) Ibuprofen toxicity
  C) Salicylism
  D) Acetaminophen toxicity
  Ans: C
  Feedback:
  Salicylism can occur with high dosage of aspirin. Dizziness, ringing in the ears, difficulty hearing, nausea, vomiting, diarrhea, mental confusion, and lassitude can occur. This combination of adverse effects is not associated with anakinra toxicity, ibuprofen toxicity, or acetaminophen toxicity.

 

 

25. A mother brings her 3-year-old child to the emergency department telling the nurse the child has eaten a bottle of baby aspirin. The mother cannot tell the nurse how many tablets were in the bottle. What dose of salicylate would be toxic in a child?
  A) 2 g
  B) 3 g
  C) 4 g
  D) 5 g
  Ans: C
  Feedback:
  Acute salicylate toxicity may occur at doses of 20 to 25 g in adults or 4 g in children. Therefore, options A, B, and D are incorrect.

 

 

26. A patient arrives at the emergency department brought by his or her friends. The friends tell the nurse that the patient has taken a whole bottle of aspirin. Blood work for salicylate toxicity is run. What does the nurse expect the results to be?
  A) >5 g
  B) >10 g
  C) >15 g
  D) >20 g
  Ans: D
  Feedback:
  Acute salicylate toxicity may occur at doses of 20 to 25 g in adults or 4 g in children. Options A, B, and C would not be high enough to indicate salicylate toxicity.

 

 

27. The nursing instructor is discussing COX-2 inhibitors with her nursing students. Where would the instructor tell her students that COX-2 inhibitors work?
  A) At sites of trauma and injury
  B) Wherever prostaglandins are present
  C) At the sites of blood clotting
  D) In the kidney
  Ans: A
  Feedback:
  The COX-2 inhibitors are thought to act only at sites of trauma and injury to more specifically block the inflammatory reaction. COX-1 is present in all tissues and seems to be involved in many body functions including blood clotting, protecting the stomach lining, and maintaining sodium and water balance in the kidney.

 

 

28. The clinic nurse is caring for a patient who is taking a COX-2 inhibitor and knows that this patient needs to be assessed for what? (Select all that apply.)
  A) Bleeding time
  B) Liver function
  C) Altered hearing
  D) Gastrointestinal (GI) effects
  E) Water retention
  Ans: A, D, E
  Feedback:
  COX-2 inhibitors have an impact on many body functions and patients receiving this therapy should be assessed for GI effects, changes in bleeding time, and water retention. Patients taking COX-2 inhibitors do not need to be evaluated for liver function or altered hearing because these are not common adverse effects.

 

 

29. Why do COX-2 inhibitors increase the risk for cardiovascular problems? (Select all that apply.)
  A) Vasoconstriction is blocked.
  B) Vasodilation is blocked.
  C) Platelet clumping is blocked.
  D) Water and sodium balance is altered.
  E) Gastrointestinal (GI) integrity is altered.
  Ans: B, C
  Feedback:
  Recent studies suggest that COX-2 inhibitors may block some protective responses in the body, such as vasodilation and inhibited platelet clumping, which is protective if vessel narrowing or blockage occurs. Blocking this effect could lead to cardiovascular problems. Vasoconstriction is not blocked, water and sodium balance is not altered, and GI integrity is not impacted by COX-2 inhibitors but can be impacted by COX-1 inhibitors.

 

 

30. When nonsteroidal anti-inflammatory drugs (NSAIDs) are combined with loop diuretics, there is a potential for what?
  A) Decreased antihypertensive effect
  B) Decreased diuretic effect
  C) Lithium toxicity
  D) Anaphylactoid reactions
  Ans: B
  Feedback:
  Diuretic effect is often decreased when NSAIDs are taken with loop diuretics. There is a potential for decreased antihypertensive effect of beta-blockers if NSAIDs are combined and there have also been reports of lithium toxicity, especially when lithium is combined with ibuprofen.

 

 

31. The nurse is caring for a patient who reports taking 800 mg of ibuprofen three times a day for relief of menstrual cramps. What lab results will the nurse find most significant in assessing this patient?
  A) Complete blood count
  B) White blood cell differential
  C) Arterial blood gas
  D) Cholesterol and triglyceride profile
  Ans: A
  Feedback:
  Ibuprofen, like all nonsteroidal anti-inflammatory drugs, can cause irritation to the GI mucosa and block platelet clumping, both of which can result in bleeding. Blood loss due to dysmenorrhea can exacerbate these risks so it is important to assess the complete blood count to monitor for excessive blood loss. White blood cell differential would be impacted by infection, which is not indicated here. Arterial blood gas, cholesterol, and triglyceride levels would not be impacted by ibuprofen.

 

 

32. When caring for a patient diagnosed with rheumatoid arthritis, the patient tells the nurse that he or she has had insufficient response to nonsteroidal anti-inflammatory drugs (NSAIDs) and his or her condition continues to worsen. What drug does the nurse anticipate will be ordered next for this patient?
  A) Auranofin (Ridaura)
  B) Ibuprofen (Motrin)
  C) Acetaminophen (Tylenol)
  D) Ketorolac (Toradol)
  Ans: A
  Feedback:
  Gold compounds such as auranofin are prescribed when more usual anti-inflammatory therapies are ineffective and the patient’s condition worsens despite weeks or months of standard pharmacological treatment. Ibuprofen and ketorolac are NSAIDs, which have been tried without good results. Acetaminophen is not an anti-inflammatory and would not be appropriate to control this patient’s condition.

 

 

33. The patient has been diagnosed with rheumatoid arthritis. She also reports pain in various muscle groups secondary to a diagnosis of fibromyalgia and dysmenorrhea with painful cramping during menses. What drug would be most effective in treating all three of this patient’s problems?
  A) Naproxen (Naprosyn)
  B) Acetaminophen (Tylenol)
  C) Etanercept (Enbrel)
  D) Sodium hyaluronate (Hyalgan)
  Ans: A
  Feedback:
  Naproxen is effective in treating muscle pain, arthritis, and dysmenorrhea. Acetaminophen has no anti-inflammatory effects and would not be helpful for treating arthritis or dysmenorrhea other than some pain relief. Etanercept is useful only for treating rheumatoid arthritis; sodium hyaluronate is used to treat rheumatoid arthritis when other traditional treatment has been ineffective and the condition continues to worsen.

 

 

34. The nurse is teaching the patient, who has been newly prescribed etanercept (Enbrel), how to administer the medication. What statement is accurate?
  A) “Be sure to drink a whole glass of water when swallowing the pill.”
  B) “Do not take this medication for at least 1 hour after taking an antacid.”
  C) “You can use each of the subcutaneous injection sites to avoid tissue damage.”
  D) “Inject this medication deeply into the muscle to promote absorption.”
  Ans: C
  Feedback:
  Etanercept is given by injecting it into the subcutaneous tissues. The injection sites should be rotated to avoid tissue damage. Because it is not taken orally, there is no requirement related to amount of water to be taken or waiting an hour after taking an antacid. Etanercept is not injected into the muscle but rather into the subcutaneous tissue.

 

 

35. The pediatric patient has a fever and the nurse is preparing to administer an antipyretic. What drug would be the best choice for this patient?
  A) Balsalazide (Colazal)
  B) Naproxen (Naprosyn)
  C) Indomethacin (Indocin)
  D) Aspirin
  Ans: B
  Feedback:
  Naproxen is approved for pediatric use and has antipyretic properties. Balsalazide is used to treat ulcerative colitis and would not be appropriate for treating a fever. Indomethacin has anti-inflammatory effects but does not have antipyretic effects. Aspirin would not be appropriate for treating a child with a fever of unknown origin due to risk of Reye’s syndrome.

 

Chapter 32- Cholinergic Agonists

1. The patient has had cevimeline (Evoxac) prescribed. What would be an appropriate dosing schedule for the nurse to administer this drug?
  A) Once a day
  B) Twice a day
  C) Three times a day
  D) Every 4 hours
  Ans: C
  Feedback:
  Cevimeline should be given three times a day with meals. Once or twice a day dosing would cause a decrease in therapeutic effects of the drug and every 4 hours could lead to toxicity.

 

 

2. A student asks the pharmacology instructor to describe the function of a cholinergic agonist. What would the instructor reply?
  A) Cholinergic agonists increase the activity of dopamine receptor sites throughout the brain and spinal cord.
  B) Cholinergic agonists decrease the activity of gamma-aminobutyric acid (GABA) receptor sites throughout the body.
  C) Cholinergic agonists increase the activity of acetylcholine receptor sites throughout the body.
  D) Cholinergic agonists decrease the activity of norepinephrine receptor sites throughout the brain and spinal cord.
  Ans: C
  Feedback:
  Cholinergic agonists are drugs that increase the activity of acetylcholine receptor sites throughout the body. Dopamine, GABA, and norepinephrine are not associated with cholinergic agonist function.

 

 

3. A 10-year-old child with spina bifida is receiving bethanechol (Urecholine) for treatment of neurogenic bladder. What adverse effect will the nurse assess for?
  A) Constipation
  B) Loss of bowel and bladder control
  C) Decrease salivation
  D) Increased appetite
  Ans: B
  Feedback:
  Loss of bowel and bladder control is an adverse effect of cholinergic agents that would cause stress in a child. Diarrhea and increased salivation are also adverse effects. Increased appetite is not associated with these drugs. Children are more likely to have gastrointestinal (GI) upset that could result in a decrease in appetite.

 

 

4. A nurse is writing a plan of care for a patient who is taking bethanechol (Urecholine). What would be an appropriate outcome for this patient?
  A) Pupillary dilation
  B) Increased blood pressure
  C) Improved bladder function
  D) Decreased secretions
  Ans: C
  Feedback:
  Bethanechol is prescribed for nonobstructive urinary retention and neurogenic bladder. The appropriate outcome for this patient would be improved bladder function. This drug causes pupillary constriction and increased secretions. This drug would not increase blood pressure. However, it could cause hypotension in the older patient.

 

 

5. What drug is the nurse likely to administer to diagnose myasthenia gravis in a child?
  A) Atropine (generic)
  B) Bethanechol (Urecholine)
  C) Edrophonium (Enlon, Reversol)
  D) Neostigmine (Prostigmine)
  Ans: C
  Feedback:
  Edrophonium is the drug of choice for diagnosing myasthenia gravis. Bethanechol is used to treat neurogenic bladder. Neostigmine is used for treatment of myasthenia gravis and could be used for diagnosis if edrophonium could not be used. Atropine is an anticholinergic drug and would not be used to test for myasthenia gravis.

 

 

6. A patient is brought to the emergency department having a cholinergic reaction, which includes a severe drop in blood pressure. What drug will the nurse expect to administer?
  A) Atropine (generic)
  B) Edrophonium (Enlon, Reversol)
  C) Propranolol (Inderal)
  D) Succinylcholine (Anectine)
  Ans: A
  Feedback:
  The antidote for a cholinergic reaction is atropine. This drug will block the cholinergic sites. Edrophonium would cause an accumulation of acetylcholine and worsen the situation. Propranolol blocks beta-receptors in the sympathetic system. Succinylcholine is a neuromuscular junction drug and would not affect other sites.

 

 

7. Memantine hydrochloride (Namenda) has been prescribed for a 63-year-old patient who has a confirmed diagnosis of Alzheimer’s disease. What would be the target dose for this patient?
  A) 5 mg/d
  B) 10 mg b.i.d.
  C) 15 mg/d
  D) 20 mg b.i.d.
  Ans: B
  Feedback:
  The drug is started at 5 mg/d PO, increasing by 5 mg/d at weekly intervals. The target dose is 20 mg/d given as 10 mg b.i.d.

 

 

8. An Alzheimer’s patient taking donepezil (Aricept) has a complete blood count that indicates he or she is anemic. What drug taken in combination with donepezil could be the cause of the anemia?
  A) Cimetidine (Tagamet)
  B) Ibuprofen (Advil)
  C) Diltiazem (Cardizem)
  D) Furosemide (Lasix)
  Ans: B
  Feedback:
  There could be an increased risk of gastrointestinal (GI) bleeding if donepezil is taken with a nonsteroidal anti-inflammatory drug (NSAID) because of the combination of increased GI secretions and the GI mucosal erosion associated with the use of NSAIDs. Cimetidine, diltiazem, and furosemide would not affect GI bleeding.

 

 

9. The Air Force nurse is treating a patient who was exposed to a particular nerve gas. What drug has been approved to treat this patient?
  A) Neostigmine (Prostigmin)
  B) Pyridostigmine (Mestinon)
  C) Ambenonium (Mytelase)
  D) Edrophonium (Enlon, Reversol)
  Ans: B
  Feedback:
  Pyridostigmine has been approved for use by military personnel who have been exposed to particular nerve gases. Neostigmine, ambenonium, and edrophonium are not approved for this use.

 

 

10. The nurse administers a direct-acting cholinergic agonist to the patient. When assessing this patient for drug effects, the nurse would expect to see effects arising from stimulation of what receptors?
  A) Nicotinic
  B) Alpha
  C) Beta
  D) Muscarinic
  Ans: D
  Feedback:
  The direct-acting cholinergic agonists are similar to acetylcholine (ACh) and react directly with receptor sites to cause the same reaction as if Ach had stimulated the receptor sites. These drugs usually stimulate muscarinic receptors within the parasympathetic system. They are used as systemic agents to increase bladder tone, urinary excretion, and gastrointestinal (GI) secretions. One drug is used as an ophthalmic agent to induce miosis to relieve the increased intraocular pressure of glaucoma. They have no effect on alpha and beta receptors in the sympathetic nervous system and little impact on nicotinic receptors.

 

 

11. The nurse is caring for a 49-year-old patient, who has been receiving bethanechol (Duvoid) for 1 week. The patient develops progressive muscle weakness and respiratory difficulty. Edrophonium is ordered and injected and the patient’s symptoms worsen. How would the nurse interpret this response?
  A) Myasthenic crisis
  B) Cholinergic crisis
  C) Anaphylactic reaction
  D) Pulmonary edema
  Ans: B
  Feedback:
  The patient with a cholinergic crisis presents with progressive muscle weakness and respiratory difficulty because the accumulation of acetylcholine at the cholinergic receptor site leads to reduced impulse transmission and muscle weakness. This is a crisis when the respiratory muscles are involved. Myasthenic crisis and cholinergic crisis display similar clinical pictures. The drug edrophonium can be used as a diagnostic agent to distinguish the two conditions. If the patient improves immediately after the edrophonium injection, the problem is a myasthenic crisis, which is improved by administration of the cholinergic drug. If the patient gets worse, the problem is probably a cholinergic crisis, so withdrawal of the patient’s cholinergic drug along with intense medical support is indicated. The situation does not depict an anaphylactic reaction or pulmonary edema.

 

 

12. A 70-year-old female patient has just been diagnosed with Alzheimer’s disease. What cholinergic drug is used for the treatment of Alzheimer’s disease?
  A) Bethanechol (Duvoid)
  B) Neostigmine (Prostigmin)
  C) Donepezil (Aricept)
  D) Edrophonium (Enlon, Reversol)
  Ans: C
  Feedback:
  Currently, there are four reversible indirect-acting cholinergic agonists available to slow the progression of this disease. These include tacrine (Cognex), galantamine (Razadyne), rivastigmine (Exelon), and donepezil (Aricept). Edrophonium (Enlon, Reversol) is used to diagnose myasthenia gravis; neostigmine is used for the diagnosis and management of myasthenia gravis; and bethanechol is used to treat neurogenic bladder.

 

 

13. The 38-year-old patient has just been administered edrophonium (Enlon, Reversol). The nurse will know whether this patient has myasthenia gravis if the patient exhibits what within 30 minutes after receiving the medication?
  A) Increased muscle strength
  B) Decreased adventitious breath sounds
  C) Decreased muscle spasms
  D) Increased urinary output
  Ans: A
  Feedback:
  Edrophonium is administered to diagnose myasthenia gravis because administration of this drug will cause a marked increase in muscle strength within 30 minutes of administration if the patient has this disease. Edrophonium does not produce decreased adventitious breath sounds, decreased muscle spasms, or increased urinary output.

 

 

14. When the nurse administers a cholinergic agonist to the patient, the nurse’s expectation is that what system will be stimulated?
  A) Sympathetic nervous system
  B) Parasympathetic nervous system
  C) Central nervous system
  D) Voluntary nervous system
  Ans: B
  Feedback:
  Cholinergic agonists act at the same site as the neurotransmitter acetylcholine (ACh) and increase the activity of the ACh receptor sites throughout the body. Because these sites are found extensively throughout the parasympathetic nervous system, their stimulation produces a response similar to what is seen when the parasympathetic system is activated. These drugs do not stimulate the sympathetic, central, or voluntary nervous systems.

 

 

15. A 78-year-old patient is admitted to the emergency department and is diagnosed with bradycardia. The patient tells the nurse he or she is taking donepezil (Aricept), a cholinergic agent, for Alzheimer’s disease. The nurse will anticipate what drug will be ordered to treat the patient’s bradycardia?
  A) Atropine
  B) Pseudoephedrine
  C) Propranolol
  D) Bethanechol
  Ans: A
  Feedback:
  Maintain a cholinergic blocking drug on standby, such as atropine, to use as an antidote for excessive doses of cholinergic drugs to reverse overdose or counteract severe reactions arising from use of cholinergic agonists. Atropine will block cholinergic effects that are causing this patient’s heart rate to decline. Bethanechol will slow the heart rate further whereas propranolol and pseudoephedrine will not reverse the cholinergic stimulation.

 

 

16. The nurse administers bethanechol (Duvoid, Urecholine) to treat what condition?
  A) Hypertension
  B) Urinary retention
  C) Bradycardia
  D) Asthma
  Ans: B
  Feedback:
  Bethanechol is used for the treatment of nonobstructive postoperative and postpartum urinary retention, neurogenic bladder atony in adults and children older than 8 years; diagnosis and treatment of reflux esophagitis in adults, and orally in infants and children for treatment of esophageal reflux. It would be ineffective in treating hypertension, bradycardia, and asthma.

 

 

17. The nurse is caring for a patient who has indirect-acting cholinergic agonists prescribed to treat myasthenia gravis. When administering this classification of drug, the nurse should assess the patient for toxic effects of the drugs including what?
  A) Paralytic ileus
  B) Abdominal distension
  C) Hypertension
  D) Muscle weakness
  Ans: D
  Feedback:
  The patient with a cholinergic crisis presents with progressive muscle weakness and respiratory difficulty because the accumulation of acetylcholine at the cholinergic receptor site leads to reduced impulse transmission and muscle weakness. This is a crisis when the respiratory muscles are involved. Toxic effects of the drug would not include paralytic ileus, abdominal distention, or hypertension.

 

 

18. Which indirect-acting anticholinesterase medication will the nurse administer as an antidote to neuromuscular junction blockers?
  A) Pyridostigmine (Mestinon)
  B) Donepezil (Aricept)
  C) Rivastigmine (Exelon)
  D) Ambenonium (Mytelase)
  Ans: A
  Feedback:
  Pyridostigmine is indicated for management of myasthenia gravis; antidote to neuromuscular junction blockers; increased survival after exposure to nerve gas. Donepezil and rivastigmine are used to treat Alzheimer’s disease. Ambenonium is used to treat myasthenia gravis.

 

 

19. A patient is brought to the emergency department after a motor vehicle accident. The patient is diagnosed with multiple injuries including a bladder injury. The patient is taken to surgery and develops a nonobstructive postoperative urinary retention. What drug would the nurse expect to be ordered for this patient?
  A) Neostigmine
  B) Bethanechol
  C) Ambenonium
  D) Pyridostigmine
  Ans: B
  Feedback:
  The agent bethanechol, which has an affinity for the cholinergic receptors in the urinary bladder, is available for use orally and subcutaneously to treat nonobstructive postoperative and postpartum urinary retention and to treat neurogenic bladder atony. The other options are not indicated for this purpose.

 

 

20. A patient is taking memantine for Alzheimer’s disease. This drug does not affect what?
  A) Nicotinic receptor sites
  B) Glucagon receptor sites
  C) Gamma-aminobutyric acid (GABA) receptor sites
  D) Muscarinic receptor sites
  Ans: C
  Feedback:
  The drug, memantine hydrochloride (Namenda) has a low-to-moderate affinity for N-methyl-D-aspartate (NMDA) receptors with no effects on dopamine, GABA, histamine, glycine, or adrenergic receptor sites. It is believed that persistent activation of the central nervous system NMDA receptors contributes to the symptoms of Alzheimer’s disease. By blocking these sites, it is thought that the symptoms are reduced or delayed. Other options are incorrect.

 

 

21. A patient is brought to the emergency department and is found to have cholinergic toxicity. What is the drug of choice to treat this condition?
  A) Atropine
  B) Epinephrine
  C) Lidocaine
  D) Edrophonium (injectable)
  Ans: A
  Feedback:
  Maintain atropine sulfate on standby as an antidote in case of overdose or severe cholinergic reaction. Epinephrine, lidocaine, and edrophonium would not be used for this purpose.

 

 

22. A 47-year-old man is suspected of having been exposed to nerve gas. Atropine is given to temporarily block cholinergic activity and to activate acetylcholine sites in the central nervous system. What drug does the nurse give with the atropine to free up the acetylcholinesterase to start breaking down acetylcholine?
  A) Pyridostigmine
  B) Pralidoxime
  C) Neostigmine
  D) Rivastigmine
  Ans: B
  Feedback:
  If nerve gas exposure is expected, patients who may have been exposed are given intramuscular injections of atropine (to temporarily block cholinergic activity and to activate acetylcholine sites in the central nervous system) and pralidoxime (to free up the acetylcholinesterase to start breaking down acetylcholine). An auto-injection is provided to military personnel who may be at risk. The injector is used to give atropine and then pralidoxime. The injections are repeated in 15 minutes. If symptoms of nerve gas exposure exist after an additional 15 minutes, the injections are repeated. If symptoms still persist after a third set of injections, medical help should be sought. Pyridostigmine, neostigmine, and rivastigmine are not used in nerve gas exposure.

 

 

23. A 77-year-old man is brought to the emergency department with a cholinergic overdose. The nurse knows that older adults are likely to have a greater number of adverse drug effects for what reason?
  A) They are more likely to take the medications inconsistently.
  B) All older adults have some type of chronic health problem.
  C) Older adults have a number of different physiological changes.
  D) Older adults have a poor memory and are more likely to overdose.
  Ans: C
  Feedback:
  Older patients are more likely to experience the adverse effects associated with these drugs (e.g., central nervous system, cardiovascular, gastrointestinal, respiratory, and urinary) because of normal physiological changes associated with aging. Those patients with known renal or hepatic impairment would receive a lower dosage to avoid overdose. Older people are not more likely to take medications inconsistently or to take too much medication. Not all older adults have chronic health problems.

 

 

24. The nurse is caring for a 45-year-old female patient who is in chronic renal failure. What cholinergic drug is contraindicated for this patient?
  A) Neostigmine
  B) Pyridostigmine
  C) Edrophonium
  D) Galantamine
  Ans: D
  Feedback:
  Drugs used to treat Alzheimer’s disease are metabolized in the liver and excreted in the urine, so caution should be used in the presence of hepatic or renal dysfunction, which could interfere with the metabolism and excretion of the drugs. Dosage adjustments may be needed for neostigmine, edrophonium, and pyridostigmine if the patient has renal disease but they are not contraindicated.

 

 

25. A 72-year-old man is newly diagnosed with Alzheimer’s disease. The patient’s daughter asks the nurse how her father’s medication is going to help him. What will the nurse explain in layman’s terms?
  A) “The drugs work by increasing acetylcholine (ACh) levels in the brain and slowing the progression of the disease.”
  B) “The drugs work by crossing the blood–brain barrier and cure the disease in the brain.”
  C) “The drugs work by increasing ACh levels in the brain and reverse the progression of the disease.”
  D) “The drugs work by crossing the blood–brain barrier and decreasing ACh levels in the neuromuscular junctions.”
  Ans: A
  Feedback:
  Acetylcholinesterase inhibitors that cross the blood–brain barrier are used to manage Alzheimer’s disease by increasing ACh levels in the brain and slowing the progression of the disease. Decreasing ACh levels in the brain does not slow the progression, reverse the progression, or cure the disease. Decreasing ACh levels at the neuromuscular junctions has no effect on Alzheimer’s disease.

 

 

26. A patient has been newly diagnosed with myasthenia gravis. What important teaching will the nurse provide the family?
  A) If one dose of medication is missed double the next dose
  B) The warning signs of drug overdose
  C) How to encourage activity when the patient is tired
  D) Importance of monitoring level of consciousness
  Ans: B
  Feedback:
  The patient who is being treated for myasthenia gravis and his or her significant other should both receive instruction in drug administration, warning signs of drug overdose, and signs and symptoms to report immediately to enhance patient knowledge about drug therapy and to promote compliance. Missed doses should not be doubled with next dose because this will lead to overdosage. Patients with myasthenia gravis will experience muscle weakness and should not be pushed to do more than they can tolerate. Level of consciousness is not a concern in patients with myasthenia gravis.

 

 

27. A new patient has come to the clinic. The patient tells the nurse he or she takes donepezil (Aricept). What is the priority nursing assessment related to the medication? (Select all that apply.)
  A) Nutritional status
  B) Blood pressure
  C) History of incontinence
  D) Breath sounds
  E) Muscle strength
  Ans: A, B, C
  Feedback:
  Gastrointestinal (GI) adverse effects can include nausea, vomiting, cramps, diarrhea, increased salivation, and involuntary defecation, so it is important for the nurse to assess nutritional status. This is made all the more important by the condition the drug is treating that often results in patients forgetting to eat healthfully. Blood pressure should be monitored because adverse effects of donepezil include hypotension, bradycardia, and heart block. Involuntary defecation and relaxation of bladder sphincter can result in incontinence so the nurse should assess for both incontinence and, if it occurred, skin integrity. Respiratory adverse effects are not associated with donepezil and muscle strength should not be impacted either.

 

 

28. What family of drugs is used in the treatment of myasthenia gravis?
  A) Direct-acting cholinergic agonists
  B) Muscarinic inhibitors
  C) Indirect-acting cholinergic agonists
  D) Nicotinic agonists
  Ans: C
  Feedback:
  The drugs used to treat patients with myasthenia gravis include several indirect-acting cholinergic agonists that do not cross the blood–brain barrier and do not effect acetylcholine transmission in the brain. These drugs include ambenonium (Mytelase), edrophonium (Enlon, Reversol), neostigmine (Prostigmin), and pyridostigmine (Mestinon). Other options are incorrect.

 

 

29. For what purpose would the nurse in the critical care unit administer pyridostigmine?
  A) To reverse neuromuscular junction blockers
  B) To reverse smooth muscle blockade
  C) To reverse cholinergic crisis
  D) To prevent myasthenic crisis
  Ans: A
  Feedback:
  Pyridostigmine is approved for management of myasthenia gravis, as an antidote to neuromuscular junction blockers, and to increase survival after exposure to nerve gas. Other options are not indications for use of this drug.

 

 

30. A patient diagnosed with myasthenia gravis is having trouble swallowing. What anticholinesterase inhibitor would be the drug of choice for this patient?
  A) Galantamine
  B) Pyridostigmine
  C) Donepezil
  D) Bethanechol
  Ans: B
  Feedback:
  Pyridostigmine is preferred in some cases for the management of myasthenia gravis because it does not need to be taken as frequently and can be given parenterally for patients who are having difficulty swallowing. Galantamine and bethanechol cannot be given parenterally to the patient having difficulty swallowing. Donepezil is not indicated for the treatment of myasthenia gravis but is used to manage Alzheimer dementia, including severe dementia.

 

 

31. The nurse is treating a patient who has been exposed to nerve gas. The provider ordered pyridostigmine (Mestinon) 0.25 mg/kg. The patient weighs 96 kg. What dosage will the nurse administer to this patient?
  A) 24 mg
  B) 384 mg
  C) 11 mg
  D) 31.7 mg
  Ans: A
  Feedback:
  Multiply the patient’s weight times the ordered dose per kilogram: 0.25 × 96 = 24 mg. Other options are incorrect.

 

 

32. The nurse is caring for a patient diagnosed with Sjögren’s syndrome. What medication will the nurse anticipate administering to treat this condition?
  A) Bethanechol
  B) Carbachol
  C) Ambenonium
  D) Pilocarpine
  Ans: D
  Feedback:
  Only pilocarpine is indicated for treatment of Sjögren’s syndrome. None of the other medications are indicated for this purpose.

 

 

33. The nurse administers bethanechol to the patient on an empty stomach for what purpose?
  A) To promote rapid absorption
  B) To prevent destruction of the drug
  C) To reduce irritation of stomach lining
  D) To decrease nausea and vomiting
  Ans: D
  Feedback:
  Administer bethanechol and all oral forms of direct-acting cholinergic agonists on an empty stomach to decrease nausea and vomiting. The other options do not correctly explain the rationale for administering bethanechol on an empty stomach.

 

 

34. The nurse in the pediatric intensive care unit is caring for an infant with severe gastroesophageal reflux. What medication, if ordered, would the nurse administer to treat this condition?
  A) Bethanechol
  B) Carbachol
  C) Cevimeline
  D) Pilocarpine
  Ans: B
  Feedback:
  Only bethanechol is indicated for the treatment of esophageal reflux in infants and children. The other drugs treat intraocular pressure, dry mouth, or to allow surgeons to perform certain surgical procedures.

 

 

35. The nurse is caring for a patient receiving carbachol to treat glaucoma. The patient says he or she has stopped driving at night because he or she just does not see well in the dark. What is the best nursing diagnosis for this patient?
  A) Anxiety related to poor vision
  B) Grief related to loss of driving privileges
  C) Risk for injury related to visual changes
  D) Pain related to altered vision
  Ans: C
  Feedback:
  This patient is at risk for injury related to visual changes and requires safety teaching to make the home as safe as possible. Nothing indicates the patient is experiencing anxiety, grief, or pain.

 

Chapter 48- Drugs Affecting Blood Coagulation

1. A patient is admitted to the hospital with deep vein thrombosis. A 10,000-unit dose of heparin is administered subcutaneously. What drug does the nurse keep on hand to reverse the effects of heparin if the patient begins to bleed?
  A) Antithrombin (Thrombate III)
  B) Desirudin (Iprivask)
  C) Protamine sulfate
  D) Vitamin K
  Ans: C
  Feedback:
  The antidote for heparin is protamine sulfate. This drug forms stable salts as soon as it comes in contact with heparin. The reaction immediately reverses heparin’s anticoagulation effects. Vitamin K reverses the effect of warfarin. Antithrombin and desirudin are anticoagulants that would not be administered with heparin.

 

 

2. Prior to beginning anticoagulant therapy, the nurse will question the female patient about what?
  A) Last menstrual period
  B) Peptic ulcers
  C) Urinary tract infection
  D) Weight
  Ans: B
  Feedback:
  The nurse should screen for conditions that could be exacerbated by increased bleeding tendencies, including hemorrhagic disorders, recent trauma, spinal puncture, gastrointestinal (GI) ulcers, recent surgery, intrauterine device placement, tuberculosis, presence of indwelling catheters, and threatened abortion. Beginning anticoagulant therapy with active peptic ulcers could result in severe bleeding. Last menstrual period, urinary tract infection, and weight should not impact anticoagulant therapy.

 

 

3. The nurse is caring for a female patient who is nursing her 3-month-old infant. What will the nurse instruct the patient to do prior to starting heparin to treat venous thrombosis?
  A) “Wait an hour after taking the anticoagulant before feeding the infant.”
  B) “Push fluids to clear the drug from her system before feeding the infant.”
  C) “Find another method of feeding the infant while taking this drug.”
  D) “Continue breast-feeding because heparin does not enter breast milk.”
  Ans: D
  Feedback:
  Although some adverse fetal effects have been reported with its use during pregnancy, heparin does not enter breast milk, and so it is the anticoagulant of choice if one is needed during lactation. As a result, there is no need to wait an hour, push fluids, or find another method of feeding the baby.

 

 

4. The nurse receives a patient having an acute myocardial infarction (MI) to the emergency department. What drug will the nurse administer before transferring the patient to a larger facility?
  A) Anagrelide (Agrylin)
  B) Clopidogrel (Plavix)
  C) Ticlopidine (Ticlid)
  D) Tenecteplase (TNKase)
  Ans: D
  Feedback:
  Arrange to administer tenecteplase to reduce mortality associated with acute MI as soon as possible after the onset of symptoms because the timing for the administration of tenecteplase is critical to resolve the clot before permanent damage occurs to the myocardial cells. Anagrelide is used to treat essential thrombocytopenia. Clopidogrel is used to treat patients who are at risk for ischemic events; ticlopidine is used to reduce the risk of thrombotic stroke.

 

 

5. A nurse is preparing to discharge a patient newly prescribed warfarin (Coumadin). While assessing the patient’s knowledge of the drug, what would indicate that the patient needs further instruction concerning drug therapy?
  A) “I love to eat homegrown tomatoes in the summer.”
  B) “I take aspirin for my arthritis.”
  C) “I walk 2 miles a day.”
  D) “I drink a glass of wine about once a week.”
  Ans: B
  Feedback:
  Increased bleeding can occur if a salicylate is taken in combination with warfarin. The nurse will instruct the patient to stop taking aspirin. Walking, eating tomatoes, and drinking an occasional glass of wine should not interfere with the therapeutic effects of warfarin.

 

 

6. The nurse is caring for a patient with a fever and severe diarrhea in addition to thrombophlebitis. How will this patient’s condition impact the clotting process?
  A) Depleted production of Hageman factor
  B) Increased production of thrombin
  C) Activation of plasminogen
  D) Reduced production of fibrinolysin
  Ans: C
  Feedback:
  Plasminogen is the basis for the clot-dissolving system. It is converted to plasmin (fibrinolysin) by several factors including Hageman’s factor, which is factor XII found in circulating blood. Activated thrombin breaks down fibrinogen to form fibrin threads, which form a clot inside the blood vessel. Patients with diarrhea or fever could alter the normal clotting process by, respectively, loss of vitamin K from the intestine or activation of plasminogen.

 

 

7. The nurse is caring for a patient who received protamine sulfate in error. The patient is not receiving, and has never received, heparin. What effect does the nurse assess for in this patient?
  A) Coagulation effects
  B) No effect
  C) Anticoagulant effects
  D) Antiplatelet effects
  Ans: C
  Feedback:
  Paradoxically, if protamine is given to a patient who has not received heparin, it has anticoagulant effects. Protamine is normally used as an antidote to heparin overdose but if heparin was not administered, it does not have coagulation or antiplatelet effects. Since it has anticoagulant effects it cannot be said to have no effect.

 

 

8. A patient is being discharged home on warfarin. The discharge teaching by the nurse should include a warning to avoid what?
  A) St. John’s wort
  B) Tarragon
  C) Ginkgo
  D) Saw palmetto
  Ans: C
  Feedback:
  Many of the herbal remedies are known to alter blood coagulation and should be avoided when taking anticoagulants. Patients taking these drugs should be cautioned to avoid angelica, cat’s claw, chamomile, chondroitin, feverfew, garlic, Ginkgo, goldenseal, grape seed extract, green leaf tea, horse chestnut seed, psyllium, and turmeric. If a patient who is taking an anticoagulant presents with increased bleeding and no other interaction or cause is found, question the patient about the possibility of use of herbal therapies. St. John’s wort, tarragon, and saw palmetto are not implicated as having an interaction with anticoagulants.

 

 

9. The nurse administers clopidogrel (Plavix) appropriately to the patient with what condition?
  A) Maintaining the patency of grafts
  B) Treating peripheral artery disease
  C) Preventing emboli from valve replacements
  D) Dissolving a pulmonary embolus and improving oxygenation
  Ans: B
  Feedback:
  Clopidogrel is used to inhibit platelet aggregation, decreasing the formation of clots in narrowed or injured blood vessels like those found in peripheral artery disease. Maintaining the patency of grafts or preventing emboli from valve replacements would be accomplished using an anticoagulant. Dissolving emboli would be accomplished using streptokinase or a similar enzyme to stimulate the conversion of plasminogen to plasmin.

 

 

10. The nurse is caring for a patient who is going home on warfarin (Coumadin). What lab test will the patient require to evaluate therapeutic effects of the drug?
  A) Activated partial thromboplastin time (APTT) only
  B) International normalized ratio (INR) only
  C) Prothrombin time (PT) and INR
  D) PT and APTT
  Ans: C
  Feedback:
  PT and INR are ordered to evaluate for therapeutic effects of warfarin. Normal values of PT is 1.3 to 1.5 times the control value and the ratio of PT to INR is 2 to 3.5.

 

 

11. What drug would the nurse administer for its antiplatelet effects? (Select all that apply.)
  A) Ticlid
  B) Iprivask
  C) Arixtra
  D) ReoPro
  E) Activase
  Ans: A, D
  Feedback:
  Antiplatelet agents available for use include abciximab (ReoPro), anagrelide (Agrylin), aspirin, cilostazol (Pletal), clopidogrel (Plavix), dipyridamole (Persantine), eptifibatide (Integrilin), ticlopidine (Ticlid), ticagrelor (Brilinta), and tirofiban (Aggrastat). Iprivask and Arixtra are anticoagulants, and Actuvase is a thrombolytic agent.

 

 

12. A 76-year-old patient is receiving IV heparin 5,000 units every 8 hours. An activated thromboplastin time (aPTT) is drawn 1 hour before the 8:00 AM dose; the aPTT is at 3.5 times the control value. What is the nurse’s priority action?
  A) Give a larger dose to increase the aPTT.
  B) Give the dose as ordered and chart the results.
  C) Check the patient’s vital signs prior to administering the dose.
  D) Hold the dose and call the result to the physician.
  Ans: D
  Feedback:
  The therapeutic level of heparin is demonstrated by an activated partial thromboplastin time (aPTT) that is 1.5 to 3 times the control value. The patient’s value is 3.5 times control, which indicates clotting time is a bit too delayed and the dosage will likely either be reduced or a dosage may be held according to the order received from the physician. It would be inappropriate to give two doses at once, give the dose and chart the results, or simply check the vital signs without holding the dose and calling the physician.

 

 

13. The nurse evaluates the effects of warfarin (Coumadin) by monitoring what laboratory test?
  A) Red blood cell count (RBC)
  B) Activated thromboplastin time (APT)
  C) Prothrombin time (PT) and international normalized ratio (INR)
  D) Platelet count
  Ans: C
  Feedback:
  The warfarin dose is regulated according to the INR. INR is based upon the PT. The other options are incorrect.

 

 

14. The nurse discovers a patient receiving warfarin is bleeding. What drug would the nurse prepare to counteract this drug?
  A) Vitamin E
  B) Vitamin K
  C) Protamine sulfate
  D) Calcium gluconate
  Ans: C
  Feedback:
  Injectable vitamin K is used to reverse the effects of warfarin. Protamine sulfate is used to reverse the effects of heparin. Vitamin E reduces effects of warfarin but is not used for that purpose. Calcium gluconate would not be indicated for this patient.

 

 

15. The nurse evaluates that additional patient teaching is needed regarding anticoagulants when the patient states that he will do what?”
  A) “Carry a Medic Alert card with him.”
  B) “Report to the lab once a month.”
  C) “Use acetaminophen for arthritis pain.”
  D) “Use a disposable safety razor to shave.”
  Ans: D
  Feedback:
  The patient should use an electric razor to shave rather than a disposable razor that could nick his skin and increase risk of bleeding. Carrying a MedicAlert card, getting regular follow-up lab work, and use of acetaminophen would all be appropriate actions that would not indicate the need for further teaching.

 

 

16. The nurse teaches the patient taking warfarin (Coumadin) to minimize foods high in vitamin K including what type of food?
  A) Eggs
  B) Dairy products
  C) Citrus fruits
  D) Green leafy vegetables
  Ans: D
  Feedback:
  Injectable vitamin K is used to reverse the effects of warfarin. Vitamin K is responsible for promoting the liver synthesis of several clotting factors. When these pathways have been inhibited by warfarin, clotting time is increased. If an increased level of vitamin K is provided, more of these factors are produced, and the clotting time can be brought back within a normal range. Green leafy vegetables are high in vitamin K and should be avoided or minimized in the diet to prevent reversal of warfarin effects. The other food options are not high in vitamin K.

 

 

17. The nurse evaluates teaching about warfarin (Coumadin) is successful when the patient makes what statement?
  A) “If I miss a dose, I will take two pills the next day.”
  B) “I will check with the pharmacist before taking any herbal supplements.”
  C) “I will increase the dark-green leafy vegetables in my diet.”
  D) “I will take a multivitamin daily.”
  Ans: B
  Feedback:
  Warfarin is involved in many drug–drug and drug–herb interactions so the patients statement about checking with the doctor before starting any new drugs or supplements would be correct. The other statements made by the patient indicate the need for further teaching because he or she should not take two pills after missing a dose, there is no need to increase green leafy vegetables containing vitamin K, and multivitamin use is contraindicated.

 

 

18. The nurse assesses blood in the urine of the 73-year-old patient receiving warfarin (Coumadin) this morning. What actions will the nurse take? (Select all that apply.)
  A) Assess prothrombin time (PT).
  B) Assess international normalized ratio (INR).
  C) Expect to administer protamine sulfate.
  D) Expect to administer vitamin K.
  E) Assess partial thromboplastin time (PTT).
  Ans: A, B, D
  Feedback:
  Vitamin K is the antidote for warfarin. PT and INR are used to assess therapeutic levels of warfarin. PTT is used to assess therapeutic levels of heparin. Protamine sulfate is given as an antidote for heparin.

 

 

19. The nurse is caring for a patient following repeat coronary artery bypass grafting who has excessive bleeding. What systemic hemostatic drug will the nurse expect to administer?
  A) Thrombin recombinant
  B) Microfibrillar collagen
  C) Human fibrin sealant
  D) Aminocaproic acid (Amicar)
  Ans: D
  Feedback:
  The hemostatic drug that is used systemically is aminocaproic acid (Amicar). Topical hemostatic agents include absorbable gelatin (Gelfoam), human fibrin sealant (Artiss, Evicel), microfibrillar collagen (Avitene), thrombin (Thrombinar, Thrombostat), and thrombin recombinant (Recothrom).

 

 

20. The 86-year-old patient, admitted with thrombophlebitis, is being sent home on enoxaparin (Lovenox). The nurse evaluates that he understands why enoxaparin is being used if he states that it will do what?
  A) Inhibit the formation of additional clots
  B) Stimulate production of certain clotting factors
  C) Prevent the blood from clotting
  D) Dissolve the clot
  Ans: A
  Feedback:
  Low-molecular-weight heparins inhibit thrombus and clot formation by blocking factors Xa and IIa. Because of the size and nature of the molecules, these drugs do not greatly affect thrombin, clotting, or the PT; therefore, they cause fewer systemic adverse effects.

 

 

21. What intervention does the nurse include in the plan of care for a patient receiving a continuous intravenous infusion of heparin?
  A) Avoiding intramuscular injections
  B) Assessing for symptoms of respiratory depression
  C) Measuring hourly urinary outputs
  D) Monitoring BP hourly
  Ans: A
  Feedback:
  The most commonly encountered adverse effect of the anticoagulants is bleeding, ranging from bleeding gums during toothbrushing to severe internal hemorrhage. Avoid all invasive procedures, including giving IM injections, while the patient is on heparin therapy. It would not be necessary to assess for respiratory depression, measure hourly output, or monitor the BP hourly as related because of heparin administration.

 

 

22. The nurse is sending a patient home who will remain on anticoagulant therapy. What teaching point does the nurse make when teaching the patient about the drug? (Select all that apply.)
  A) “Brush teeth gently with soft bristle brush.”
  B) “Wear or carry a MedicAlert notification.”
  C) “Warning signs of bleeding include fatigue, pallor, and increased heart rate.”
  D) “Treat minor side effects with over-the-counter (OTC) medications.”
  E) “Obtain follow-up lab work regularly as ordered.”
  Ans: A, B, C, E
  Feedback:
  Patients should be taught to avoid bleeding risk by brushing teeth gently, using electric razors, and avoiding dangerous activities or falls that could cause bleeding. The patient should have a MedicAlert to notify other health care providers of anticoagulant therapy. Teach patients to recognize the signs of blood loss and stress the importance of follow-up lab work. Patients should be taught to avoid adding any new medication, prescription or OTC, without first talking to the health care provider or pharmacist to ensure safety.

 

 

23. Indications for the nurse to administer heparin include what? (Select all that apply.)
  A) Treatment of hemophilia
  B) Prevention and treatment of pulmonary emboli
  C) Treatment of atrial fibrillation with embolization
  D) Prevention and treatment of venous thrombosis
  E) Diagnosis and treatment of disseminated intravascular coagulation (DIC)
  Ans: B, C, D, E
  Feedback:
  Indications include prevention and treatment of venous thrombosis and pulmonary emboli, treatment of atrial fibrillation with embolization, and diagnosis and treatment of DIC. Heparin is not given to patients with hemophilia because the drug would worsen bleeding.

 

 

24. The nurse is caring for a child who needs anticoagulation therapy. What drug is approved for pediatric use?
  A) Heparin
  B) Dabigatran
  C) Rivaroxaban
  D) Low-molecular-weight heparins
  Ans: A
  Feedback:
  Heparin is approved for pediatric use. If heparin is used, the dosage should be carefully calculated based on weight and age. It should be verified 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.

 

 

25. When the nurse administers warfarin it is expected that the drug will have what effect on the body?
  A) Decrease in production of vitamin K–dependentt clotting factors
  B) Increase in prothrombin
  C) Increase in vitamin K–dependent factors in the liver
  D) Increase in procoagulation factors
  Ans: A
  Feedback:
  Warfarin, an oral anticoagulant drug, causes a decrease in the production ovitamin K–dependent clotting factors in the liver. The eventual effect is a depletion of these clotting factors and a prolongation of clotting times. It is used to maintain a state of anticoagulation in situations in which the patient is susceptible to potentially dangerous clot formation. It does not increase prothrombin, vitamin K–dependent factors in the liver, or procoagulation factors.

 

 

26. When the nurse administers heparin it is anticipated the drug will have what action on the patient’s body?
  A) Binds to factor X
  B) Blocks the formation of thrombin
  C) Binds to factor Xa
  D) Promotes the inactivation of factor VIII
  Ans: B
  Feedback:
  Heparin blocks the formation of thrombin from prothrombin. Heparin does not bind to factors X and Xa. Heparin does not inactivate factor VIII.

 

 

27. A young man has been diagnosed with hemophilia and the nurse is planning his discharge teaching and includes what teaching point?
  A) Using nonsteroidal anti-inflammatory drugs (NSAIDs) for mild pain
  B) Preventing trauma to the body
  C) Receiving IV factor VIII therapy at home
  D) Understanding the condition is an X-linked recessive disorder
  Ans: B
  Feedback:
  The nurse’s thorough patient teaching must include the name of the drug, dosage prescribed, measures to avoid adverse effects, warning signs of problems, and the need for periodic monitoring and evaluation. Hemophilia A is an X-linked recessive disorder that primarily affects males. Approximately 90% of persons with hemophilia produce insufficient quantities of the factor VIII. The prevention of trauma is important in people with hemophilia. The other options are incorrect.

 

 

28. The nurse admits a 32-year-old woman who takes oral contraceptives; she is expected to need aminocaproic acid postoperatively. The nurse recognizes this patient is at risk for what?
  A) Hypercoagulation
  B) Bleeding
  C) Pregnancy
  D) Infertility
  Ans: A
  Feedback:
  Aminocaproic acid is associated with the development of hypercoagulation states if it is combined with oral contraceptives or estrogens. Oral contraceptives do not increase the risk of pregnancy, bleeding, or infertility.

 

 

29. The nurse reviews the patient’s lab values and determines warfarin therapy is at therapeutic levels with what lab result?
  A) Partial thromboplastin time (PTT) 1.5 to 2.5 times the control
  B) Prothrombin time (PT) 1.3 to 1.5 times the control
  C) International normalized ratio (INR) of 3 to 4
  D) Activated partial thromboplastin time (aPTT) 3 to 4 times the control
  Ans: B
  Feedback:
  Warfarin is at therapeutic level when the INR is 2 to 3.5 and the PT is 1.3 to 1.5 times control. PTT and aPTT should be 1.5 to 2.5 to indicate heparin dosage is at therapeutic level.

 

 

30. The patient receives a new diagnosis of peripheral artery disease and the nurse anticipates an order for what drug?
  A) Clopidogrel
  B) Persantine
  C) Aspirin
  D) Warfarin
  Ans: A
  Feedback:
  Clopidogrel (Plavix) is indicated for the treatment of patients who are at risk for ischemic events; patients with a history of myocardial infarction, peripheral artery disease, or ischemic stroke; and patients with acute coronary syndrome. Persantine, aspirin, and warfarin would not be indicated for this patient.

 

 

31. The nurse admits a patient in acute respiratory distress secondary to pulmonary emboli. What drug will the nurse administer to lyse the clots?
  A) Urokinase
  B) Tenecteplase
  C) Rivaroxaban
  D) Fondaparinux
  Ans: A
  Feedback:
  Urokinase is used for lysis of pulmonary emboli and treatment of coronary thrombosis. Reteplase is used to treat coronary artery thrombosis associated with an acute myocardial infarction. Rivaroxaban is used to prevent deep vein thromboses that may lead to pulmonary emboli. Fondaparinux is used to treat and prevent venous thromboembolic events.

 

 

32. The nurse is caring for a postpartum patient admitted to the intensive care unit with a diagnosis of disseminated intravascular coagulation (DIC). What is the drug of choice to treat this problem?
  A) Heparin
  B) Urokinase
  C) Aspirin
  D) Warfarin
  Ans: A
  Feedback:
  The treatment of choice for DIC is heparin, an anticoagulant. It prevents the clotting phase from being completed, thus inhibiting the breakdown of fibrinogen. It may also help avoid hemorrhage by preventing the body from depleting its entire store of coagulation factors. None of the other medications listed in this question are indicated for treatment of DIC and may, in fact, make the condition worse.

 

 

33. By what route will the nurse administer the antihemophilic agent to the patient with hemophilia following a car accident?
  A) Oral
  B) Topical
  C) IV
  D) Sublingual
  Ans: C
  Feedback:
  All antihemophilic agents are administered IV and are not available for administration by any other route.

 

 

34. The nurse administers agents that control bleeding to patients with hemophilia and what other condition?
  A) Liver disease
  B) Lyme’s disease
  C) Disseminated intravascular coagulation (DIC)
  D) Pheochromocytoma
  Ans: A
  Feedback:
  Drugs to control bleeding are also given to patients with liver disease because liver disease prohibits clotting factors and proteins needed for clotting from being produced in adequate quantities. Lyme’s disease, DIC, and pheochromocytoma are not indications for administration of agents to control bleeding.

 

 

35. The nurse is caring for a pediatric patient with hemophilia who receives antihemophilic factor several times a year. What should this patient be regularly screened for? (Select all that apply.)
  A) HIV
  B) Hepatitis
  C) Anemia
  D) Infection
  E) Cardiomyopathy
  Ans: A, B, C
  Feedback:
  The most common adverse effects associated with antihemophilic agents involve risks associated with the use of blood products (e.g., in a patient with hepatitis or AIDS). Patients with hemophilia should also be monitored for anemia secondary to blood loss. There is no associated risk for infection or cardiomyopathy.

 

Chapter 58- Drugs Affecting Gastrointestinal Motility

1. The nurse teaches the patient to best maintain optimal GI function by including what in the daily routine?
  A) Exercise, adequate sleep, and avoiding caffeine
  B) Proper diet, fluid intake, and exercise
  C) Proper diet, avoiding alcohol, and cautious use of laxatives
  D) Avoiding prescription medications, increased fluid intake, and vigorous exercise
  Ans: B
  Feedback:
  The best way to maintain gastrointestinal (GI) function is through proper diet including optimizing fiber intake, adequate fluid intake, and exercise, which will stimulate GI activity. Drugs should only be used when normal function cannot be maintained. Options A, C, and D are not correct.

 

 

2. The nurse admits to the clinic a 7-month-old infant whose mother reports that the baby has not had a bowel movement in 6 days. What drug would be appropriate to treat this patient?
  A) Cascara (generic)
  B) Magnesium hydroxide (Milk of Magnesia)
  C) Polyethylene glycol-electrolyte solution (GoLYTELY)
  D) Glycerin (Sani-Supp)
  Ans: D
  Feedback:
  Glycerin suppositories are the best choice for infants and young children when constipation is a problem. The other choices are not recommended for infants or children.

 

 

3. The nurse provides drug teaching to the patient who will begin taking polycarbophil (FiberCon). What is the nurse’s priority teaching point?
  A) Do not eat or drink anything for 2 hours after taking the medication.
  B) Drink lots of water when taking the drug.
  C) Take at night before bedtime.
  D) The drug can be taken up to six times per day.
  Ans: B
  Feedback:
  Patients must take plenty of water with polycarbophil. If only a little water is consumed, the medication may absorb enough fluid in the esophagus to swell the food into a gelatin-like mass that can cause obstruction and other severe problems. The drug should be taken no more than four times a day and should not be taken at night.

 

 

4. A new mother required an episiotomy during the birth of her baby. Two days after delivery, the patient is in need of a laxative. What will be the most effective drug for the nurse to administer?
  A) Bisacodyl (Dulcolax)
  B) Castor oil (Neolid)
  C) Magnesium sulfate (epsom salts)
  D) Docusate (Colace)
  Ans: D
  Feedback:
  Docusate is a stool softener that will make expulsion of stool easier in a traumatized body area following an episiotomy. Care must be taken to choose a mild laxative that will not enter breast milk and not affect the newborn if the mother is nursing. Docusate is the drug of choice from this list because it is mild and will produce a soft stool and decrease the need to strain. The other options would not be appropriate because they do not soften the stool and are harsher laxatives that can enter breast milk.

 

 

5. The nurse, teaching a patient to be discharged with an order to use chemical stimulant laxatives PRN, instructs the patient that one of the most common adverse effects of this type of laxative is what?
  A) Abdominal cramping
  B) Rectal bleeding
  C) Confusion
  D) Iron deficiency anemia
  Ans: A
  Feedback:
  Common adverse effects of laxatives are diarrhea, abdominal cramping, and nausea. Central nervous system (CNS) adverse effects such as dizziness, headache, and weakness can occur. Rectal bleeding, confusion, and iron deficiency anemia are not associated with appropriate use of laxatives but may occur when laxatives are abused.

 

 

6. A patient taking a chemical stimulant laxative and medications for heart failure and osteoarthritis calls the clinic and reports to the nurse that she is not feeling right. What is the priority question the nurse should ask this patient?
  A) Effectiveness of laxatives
  B) Timing of medication administration
  C) The amount of fiber in her diet
  D) Amount of fluid ingested
  Ans: B
  Feedback:
  Because laxatives increase the motility of the gastrointestinal (GI) tract and some laxatives interfere with the timing or process of absorption, it is not advisable to take laxatives with other prescribed medications. The administration of laxatives and other medications should be separated by at least 30 minutes, so the nurse should question when the patient is taking the laxatives and other medication. Other options may be questions the nurse would eventually ask, but the priority is timing of medication administration.

 

 

7. A patient who is taking metoclopramide (Reglan) has come to the clinic for a follow-up visit. The nurse will be most concerned about a drug-drug interaction when learning the patient is taking what other medication?
  A) Albuterol (Proventil)
  B) Digoxin (Lanoxin)
  C) Furosemide (Lasix)
  D) Acetylsalicylic acid (ASA)
  Ans: B
  Feedback:
  Metoclopramide has been associated with decreased absorption of digoxin from the gastrointestinal (GI) tract. The nurse should monitor patients taking this combination carefully. The other options do not pose a concern about drug–drug interactions.

 

 

8. What should the nurse tell the patient who will begin taking rifaximin (Xifaxan) for traveler’s diarrhea?
  A) “Do not start taking the drug until the diarrhea has persisted for at least 24 hours.”
  B) “Taking the antibiotic will allow you to enjoy the local water and food without concern.”
  C) “Do not take the drug if you have bloody diarrhea.”
  D) “Start the drug 3 days before leaving for your trip and continue until you return.”
  Ans: C
  Feedback:
  Rifaximin should not be taken if a patient has bloody diarrhea or diarrhea that persists for more than 48 hours. It is started after the signs and symptoms of the disease develop and is taken for 3 days. The traveler should still avoid exposure to foreign bacteria by not drinking tap water and by avoiding fruits and vegetables washed in tap water. Options A, B, and D are not correct.

 

 

9. A clinic patient with a history of heart failure requires a laxative for treatment of chronic constipation. What medication would be most appropriate for this patient?
  A) Senna (Senokot)
  B) Lactulose (Chronulac)
  C) Magnesium sulfate (Milk of Magnesia)
  D) Castor oil (Neoloid)
  Ans: B
  Feedback:
  Lactulose is often the drug of choice when a patient with cardiovascular problems requires a laxative. It is salt free, an important consideration in patients with heart failure; it acts by exerting a gentle osmotic pull of fluid into the intestinal lumen. Senna, magnesium sulfate, and castor oil are more aggressive laxatives and might not be the best choice for a patient with cardiovascular problems.

 

 

10. A man with irritable bowel syndrome reports ongoing diarrhea and asks for a prescription for alosetron (Lotronex), which was helpful for his coworker who recently started taking the drug. What is the nurse’s best response?
  A) This drug is only approved for use in women.
  B) This drug is used as a laxative.
  C) This drug is contraindicated with irritable bowel syndrome.
  D) This drug is no longer on the market for prescription use.
  Ans: A
  Feedback:
  Alosetron (Lotronex) is approved for use in women with irritable bowel syndrome with diarrhea being the predominant complaint and should be discontinued immediately if the patient develops constipation or symptoms of ischemic colitis. Patients must read and sign a patient–physician agreement before it can be prescribed. Options B, C, and D are not correct.

 

 

11. The nurse administers psyllium hydrophilic mucilloid (Metamucil) expecting it to have what action?
  A) Slows peristalsis
  B) Promotes reabsorption of water into bowel
  C) Has antibacterial properties
  D) Adds bulk to the stool
  Ans: D
  Feedback:
  Metamucil is a natural substance that forms a gelatin-like bulk of the intestinal contents. This agent stimulates local activity. It is considered milder and less irritating than many other bulk stimulants. Patients must use caution and take it with plenty of water because Metamucil absorbs large amounts of water and produces stools of gelatin-like consistency. It does not slow peristalsis, promote water reabsorption, or have antibacterial properties.

 

 

12. The nurse administers loperamide (Imodium) to decrease the number and liquidity of stool by what mechanism?
  A) Decreasing intestinal motility
  B) Absorbing toxins
  C) Binding with fecal material to increase bulk
  D) Blocking the chemoreceptor trigger zone (CTZ)
  Ans: A
  Feedback:
  Systemic antidiarrheal agents slow the motility of the gastrointestinal (GI) tract through direct action on the lining of the GI tract to inhibit local reflexes (bismuth subsalicylate), through direct action on the muscles of the GI tract to slow activity (loperamide), or through action on central nervous system (CNS) centers that cause GI spasm and slowing (opium derivatives). Options B, C, and D are not correct.

 

 

13. The nurse teaches the patient that a common adverse effect of loperamide (Imodium) is what?
  A) Fatigue
  B) Flatulence
  C) Disorientation
  D) Tremors
  Ans: A
  Feedback:
  Adverse effects associated with antidiarrheal drugs, such as constipation, distention, abdominal discomfort, nausea, vomiting, dry mouth, and even toxic megacolon, are related to their effects on the gastrointestinal (GI) tract. Other adverse effects that have been reported include fatigue (option A), weakness, dizziness, and rash. options B, C, and D are not correct.

 

 

14. The nurse will question an order for bismuth salts (Pepto-Bismol) in a patient with what condition?
  A) Rheumatoid arthritis
  B) Allergy to aspirin
  C) Hypertension
  D) Viral gastroenteritis
  Ans: B
  Feedback:
  Pepto-Bismol has aspirin in it and should not be given to a patient with an allergy to aspirin. There is no contraindication for a patient with rheumatoid arthritis, hypertension, or viral gastroenteritis.

 

 

15. The home health nurse is caring for a 72-year-old man in his home. He complains about almost daily diarrhea. The nurse assesses for what common cause of diarrhea in older adults?
  A) Diabetes
  B) Hypertensive medications
  C) Laxative overuse
  D) Glaucoma
  Ans: C
  Feedback:
  Diarrhea in older adults may result from laxative overuse so the nurse should assess what over-the-counter (OTC) products the patient is using. Diabetes, hypertension medications, and glaucoma are not common causes of diarrhea in patients.

 

 

16. What is the antidiarrheal of choice the nurse will administer to children older than 2 years of age with diarrhea?
  A) Bismuth salts (Pepto-Bismol)
  B) Loperamide (Imodium)
  C) Paregoric (generic)
  D) Difenoxin (Motofen)
  Ans: B
  Feedback:
  Loperamide may be the antidiarrheal of choice in children older than 2 years of age if such a drug is needed. Special precautions need to be taken to monitor for electrolyte and fluid disturbances and supportive measures should be taken as needed. Serious fluid volume deficits may rapidly develop in children with diarrhea. Appropriate fluid replacement should include oral rehydration solutions. Although bismuth salts and paregoric may be given to children, they are not the drugs of choice. Difenoxin is not for use in children under 12 years of age.

 

 

17. What antidiarrheal would the nurse administer to reduce the volume of discharge from the patient’s ileostomy?
  A) Diphenoxylate (Lomotil)
  B) Octreotide (Sandostatin)
  C) Psyllium (Metamucil)
  D) Loperamide (Imodium)
  Ans: D
  Feedback:
  Loperamide (Imodium), bismuth subsalicylate (Pepto-Bismol), and opium derivatives (paregoric) are indicated for the reduction of volume of discharge from ileostomies. The other options would not serve this purpose.

 

 

18. The nurse teaches the patient who was prescribed a chemical stimulant laxative that this medication may have either a slow, steady effect or may cause severe cramping and rapid evacuation of the contents of the large intestine. What drug is the nurse teaching this patient about?
  A) Bismuth salts
  B) Bisacodyl
  C) Castor oil
  D) Cascara
  Ans: D
  Feedback:
  Specifically related to chemical stimulants, cascara, although a reliable agent, may have a either slow, steady action or may cause severe cramping and rapid evacuation of the contents of the large intestine. Bisacodyl and castor oil do not have potential adverse effect. Bismuth salts are an antidiarrheal.

 

 

19. What is the priority nursing diagnosis for an 89-year-old patient with frequent liquid stools?
  A) Imbalanced nutrition: less than body requirements
  B) Deficient fluid volume
  C) Deficient knowledge related to medications
  D) Pain related to abdominal cramping
  Ans: B
  Feedback:
  Fluid volume deficits may develop rapidly in older adults with diarrhea. Older adults are more likely to develop adverse effects associated with the use of these drugs, including sedation, confusion, dizziness, electrolyte disturbances, fluid imbalance, and cardiovascular effects. Although nutrition, pain, and knowledge deficit may be concerns for this patient, they are not the priority concern.

 

 

20. What drug does the nurse recognize as being classified as a chemical stimulant?
  A) Bisacodyl (Dulcolax)
  B) Polycarbophil (FiberCon)
  C) Magnesium hydroxide (Milk of Magnesia)
  D) Docusate (Colace)
  Ans: A
  Feedback:
  Bisacodyl is a chemical stimulant. Polycarbophil and magnesium hydroxide are bulk laxatives. Docusate is a lubricant laxative.

 

 

21. The nurse is caring for a patient who has had impacted stools twice in the past month. What is an appropriate laxative for this patient?
  A) Milk of Magnesia
  B) Agoral Plain
  C) Colace
  D) Dulcolax
  Ans: B
  Feedback:
  Mineral oil (Agoral Plain) is not absorbed and forms a slippery coat on the contents of the intestinal tract. When the intestinal bolus is coated with mineral oil, less water is drawn out of the bolus and the bolus is less likely to become hard or impacted. Other options shown do not have this same effect of reducing the risk of another impaction as well as helping to eliminate stool.

 

 

22. The home health nurse is caring for a patient with encopresis who was started on mineral oil therapy. The nurse teaches the patient and family that a common adverse effect is what?
  A) Nausea
  B) Vomiting
  C) Leakage
  D) Vitamin C deficiency
  Ans: C
  Feedback:
  Leakage and staining may be a problem when mineral oil is used and the stool cannot be retained by the external sphincter. Mineral oil does not cause nausea, vomiting, or vitamin C deficiency.

 

 

23. When would it be appropriate for the nurse to administer a cathartic laxative to the patient? (Select all that apply.)
  A) Partial small-bowel obstruction
  B) Appendicitis
  C) After having a baby
  D) After a myocardial infarction (MI)
  E) After anthelmintic therapy
  Ans: C, D, E
  Feedback:
  Laxative, or cathartic, drugs are indicated for the short-term relief of constipation; to prevent straining when it is clinically undesirable (such as after surgery, myocardial infarction, or obstetric delivery); to evacuate the bowel for diagnostic procedures; to remove ingested poisons from the lower gastrointestinal (GI) tract; and as an adjunct in anthelmintic therapy when it is desirable to flush helminths from the GI tract. They are not indicated when a patient has an appendicitis or a partial small-bowel obstruction.

 

 

24. When would it be appropriate for the nurse to administer castor oil as a laxative?
  A) To ease the passage of stool in the patient who recently had a baby
  B) To remove ingested poisons from the lower gastrointestinal (GI) tract
  C) To evacuate the bowel for diagnostic procedures
  D) To treat chronic constipation
  Ans: C
  Feedback:
  Indications include evacuating the bowel for diagnostic procedures and for short-term treatment of constipation. Castor oil is not indicated to remove ingested poisons nor to ease the passage of stool after having a baby. This drug should only be used on a short-term basis and is not for the treatment of chronic constipation because repeated use will cause GI tract exhaustion.

 

 

25. For what action would the nurse administer magnesium citrate?
  A) Block absorption of fats
  B) Directly stimulate the nerve plexus in the intestinal wall
  C) Form a slippery coat on the contents of intestine
  D) Increase motility, increase fluid, and enlarge bulk of fecal matter
  Ans: D
  Feedback:
  Magnesium citrate is a rapid-acting, aggressive laxative that causes fecal matter to increase in bulk. It increases the motility of the gastrointestinal (GI) tract by increasing the fluid in the intestinal contents, which enlarges bulk, stimulates local stretch receptors, and activates local activity. It does not block absorption of fats, stimulate the nerve plexus, or form a slippery coat.

 

 

26. The nurse administers metoclopramide to the patient with what condition?
  A) Chronic diabetic gastroparesis
  B) Impaction
  C) Encopresis
  D) Patients requiring diagnostic procedures
  Ans: A
  Feedback:
  Indications for metoclopramide include relief of acute and chronic diabetic gastroparesis, short-term treatment of gastroesophageal reflux disorder in adults who cannot tolerate standard therapy, prevention of postoperative or chemotherapy-induced nausea and vomiting, facilitation of small-bowel intubation, stimulation of gastric emptying, and promotion of intestinal transit of barium. It would not be used for treatment of impaction, encopresis, and in patients requiring diagnostic procedures.

 

 

27. What drug does the nurse administer that inhibits intestinal peristalsis through direct effects on the longitudinal and circular muscles of the intestinal wall?
  A) Bismuth subsalicylate
  B) Loperamide
  C) Paregoric
  D) Magnesium citrate
  Ans: B
  Feedback:
  Actions of loperamide include that it inhibits intestinal peristalsis through direct effects on the longitudinal and circular muscles of the intestinal wall, slowing motility and movement of water and electrolytes. Bismuth subsalicylate inhibits local reflexes. Paregoric works through action on CNS centers that cause GI spasm and slowing. Magnesium citrate is a laxative.

 

 

28. The family brings a patient to the emergency department saying he has been hallucinating and falls so deeply asleep he stops breathing when not stimulated. The nurse learns the patient has been self-treating diarrhea and suspects the patient was taking what medication?
  A) Paregoric
  B) Bismuth subsalicylate
  C) Loperamide
  D) Colace
  Ans: A
  Feedback:
  Opium derivatives, like paregoric, are associated with light-headedness, sedation, euphoria, hallucinations, and respiratory depression related to their effect on opioid receptors. Nonopioids such as bismuth subsalicylate and loperamide would not cause respiratory depression. Colace is a stool softener, not an antidiarrheal.

 

 

29. The nurse develops a teaching plan for a 77-year-old patient who has been prescribed loperamide PRN. The nurse’s priority teaching point is what?
  A) May cause hallucinations or respiratory depression
  B) Take drug after each loose stool
  C) Drug remains in the bowel without being absorbed into the bloodstream
  D) Avoid pregnancy and breast-feeding while taking drug.
  Ans: B
  Feedback:
  Loperamide is taken repeatedly after each loose stool. Teaching the patient when to take the drug is the priority teaching point. Paregoric, and not loperamide, can cause hallucinations and respiratory depression. The drug is absorbed systemically. It is unlikely a 77-year-old patient will get pregnant or breast-feed so this is not the highest priority.

 

 

30. A patient receiving loperamide (Imodium) should be alerted by the nurse to what possible adverse effect?
  A) Anxiety
  B) Bradycardia
  C) Fatigue
  D) Urinary retention
  Ans: C
  Feedback:
  Patients should be aware that they should not drive or operate machinery while taking loperamide (Imodium) because it can cause fatigue. Anxiety, bradycardia, and urinary retention are not commonly associated with loperamide.

 

 

31. The patient had surgery 2 days ago and bowel motility has not returned. What drug might the nurse administer to stimulate the gastrointestinal (GI) tract?
  A) Dexpanthenol
  B) Docusate
  C) Psyllium (Metamucil)
  D) Senna
  Ans: A
  Feedback:
  Dexpanthenol is indicated for the prevention of intestinal atony or loss of intestinal muscle tone in postoperative adults. Docusate, psyllium, and senna are laxatives that would not be indicated for the postoperative patient with no bowel activity.

 

 

32. The hospice nurse is caring for a patient diagnosed with bone cancer who is receiving large doses of opioid medications to relieve pain. The patient has used other laxatives in the past to treat opioid-induced constipation but nothing is working now. What drug would the nurse request the family doctor to order for this patient?
  A) Methylnaltrexone (Relistor)
  B) Castor oil
  C) Paregoric
  D) Mineral oil
  Ans: A
  Feedback:
  Methylnaltrexone (Relistor) was approved in 2008 for the treatment of opioid-induced constipation in patients with advanced disease who are receiving palliative care and are no longer responsive to traditional laxatives. Castor oil, mineral oil, and paregoric would likely be ineffective in this patient.

 

 

33. The nurse, providing patient teaching, explains that difenoxin and diphenoxylate are chemically related to what medication?
  A) Morphine
  B) Demerol
  C) Diphenhydramine
  D) Diflucan
  Ans: B
  Feedback:
  Difenoxin and diphenoxylate are chemically related to meperidine and are used at doses that decrease gastrointestinal activity without having analgesic or respiratory effects.

 

 

34. The nurse collects a stool culture from a patient diagnosed with traveler’s diarrhea. What bacterium does the nurse expect the culture to grow?
  A) Escherichia coli
  B) Staphylococcus aureus
  C) Streptococcus type B
  D) Pseudomonas
  Ans: A
  Feedback:
  Escherichia coli is the most common cause of traveler’s diarrhea. Staphylococcus, Streptococcus, and Pseudomonas would be highly unlikely to grow in the stool of a patient with traveler’s diarrhea.

 

 

35. The nurse administers lubiprostone (Amitiza) to the patient with irritable bowel syndrome and anticipates what therapeutic action from the drug?
  A) Secretion of chloride-rich intestinal fluid leading to increased motility
  B) Adding bulk to the fecal matter to ease the process of stooling
  C) Irritation of the inner lining of the bowel to increase bowel motility
  D) Stimulate the bowel by increasing innervation
  Ans: A
  Feedback:
  Lubiprostone is a locally acting chloride channel activator that increases the secretion of a chloride-rich intestinal fluid without changing sodium or potassium levels. Increasing the intestinal fluid leads to increased motility. It does not add bulk, irritate the inner lining, or innervate the bowel.

 

 

 

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