Pharmacology Practice Test #6: Cardiac Medications

Answer: B. Hold the dose, document the apical pulse, and notify the provider as the prescription directs

Rationale: Metoprolol is a beta blocker. It slows the heart rate and lowers blood pressure, so the nurse checks the apical pulse and blood pressure before each dose. Hold parameters are set by the provider and differ from client to client, so the nurse follows the numbers written in this prescription. Here the pulse of 52/min is below the limit of 55/min, so the nurse holds the dose, documents the findings, and notifies the provider. Meeting one parameter does not cancel the other. Option A is wrong because the heart rate alone meets the hold criterion. Option C is wrong because the nurse cannot change a dose without a prescription, and splitting the tablet still slows the heart further. Option D is wrong because the dose would already be in the client before the recheck.

Answer: D. Make sure at least 36 hours have passed since the last enalapril dose before giving the first dose of sacubitril/valsartan

Rationale: Sacubitril/valsartan combines a neprilysin inhibitor with an angiotensin receptor blocker. Taking it together with, or too soon after, an ACE inhibitor such as enalapril greatly raises the risk of angioedema, a swelling of the face, lips, tongue or throat that can block the airway. The product labeling requires the ACE inhibitor to be stopped at least 36 hours before the first dose, and the two must never be given together. The nurse checks the time of the last enalapril dose and confirms the start time with the provider and pharmacy. A history of angioedema with an ACE inhibitor is a reason not to give the drug at all. Options A, B and C all give the drugs together or too close together.

Answer: A. A new dry cough and shortness of breath when climbing stairs

Rationale: Amiodarone can cause pulmonary toxicity, an inflammation and scarring of lung tissue that can be fatal. A new dry cough and shortness of breath on exertion in a client taking amiodarone must be reported promptly so the provider can assess with tests such as a chest X-ray or pulmonary function tests. Amiodarone can also affect the thyroid, liver and eyes, so clients have baseline and follow-up tests as prescribed. Option B is wrong because sun sensitivity is a common effect that is managed with sunscreen and protective clothing. Option C is wrong because mild nausea is common and is often reduced by taking the drug with food, as directed. Option D is wrong because corneal microdeposits are common and usually do not affect vision; changes in vision should be reported.

Answer: C. "Please don't take it. Sildenafil with any nitrate can drop your blood pressure to a dangerous level. Talk with your provider about safe options."

Rationale: Phosphodiesterase-5 (PDE-5) inhibitors such as sildenafil, tadalafil and vardenafil widen blood vessels. Nitrates do the same. Taken together, they can cause severe, sometimes life-threatening hypotension. The combination is contraindicated with every form of nitrate, including long-acting isosorbide mononitrate, and spacing the doses apart does not make it safe. The client should also not take medication prescribed for someone else. Teach the client to tell emergency staff about any PDE-5 inhibitor use if chest pain occurs, because nitrates are avoided for a period after a dose; how long depends on the drug taken. Options A, B and D all permit a contraindicated combination.

Answer: D. "I'll swallow the capsule whole and won't open, crush or chew it."

Rationale: Extended-release capsules release the drug slowly over many hours. Opening, crushing or chewing them can release the whole dose at once, which can cause a sudden drop in blood pressure and heart rate. Diltiazem is a calcium channel blocker that slows the heart and relaxes blood vessels. Option A is wrong because doubling a dose can cause hypotension and bradycardia; the client follows the missed-dose advice given by the pharmacist or provider. Option B is wrong because ankle swelling is a possible adverse effect that should be reported, but the client should not stop the drug without talking with the provider. Option C is wrong because extra doses are not taken for symptoms; a racing heart is reported.

Answer: A. Give the adenosine as a rapid IV push through the port closest to the client, followed right away by a rapid normal saline flush

Rationale: Adenosine slows conduction through the AV node and can stop SVT. It is broken down within seconds, so it must reach the heart fast: it is given as a rapid IV push, as close to the heart as possible (often an antecubital site), and followed at once by a rapid saline flush. The dose and flush volume follow the prescription and protocol. The client must be on a continuous cardiac monitor with emergency equipment ready. Warn the client that brief flushing, chest discomfort or a feeling of doom can occur, and expect a short pause or brief asystole on the monitor before a normal rhythm returns. Options B, C and D all deliver the drug too slowly for it to work.

Answer: C. "I have muscle aches and weakness in both thighs that I can't explain, and my urine looks dark."

Rationale: Statins can cause muscle injury, ranging from muscle aches (myopathy) to rare but serious rhabdomyolysis, in which muscle breakdown releases myoglobin that can damage the kidneys. Unexplained muscle pain or weakness, especially with dark urine, needs prompt follow-up; the provider may check a creatine kinase level and kidney function and may stop the drug. Risk is higher with high doses, older age, kidney problems and some interacting drugs. Option A is wrong because a mild headache that has resolved is not urgent. Option B is wrong because atorvastatin has a long half-life and can be taken at any time of day, as long as it is taken at the same time each day. Option D is wrong because mild constipation can be handled with routine advice.

Answer: B. "Stopping clonidine suddenly can make your blood pressure rise quickly and sharply. Please talk with your provider, who can lower the dose gradually if it should be stopped."

Rationale: Clonidine is a centrally acting alpha-2 agonist that lowers sympathetic activity. Stopping it suddenly can cause rebound hypertension, along with nervousness, agitation, headache, tremor and a rapid heart rate, usually within a day or two of the last dose. If clonidine is to be stopped, the provider tapers it over several days. Teach the client not to stop it on their own, to arrange refills so doses are not missed, and to report symptoms of withdrawal. Options A and C allow abrupt withdrawal. Option D is wrong because the client should not set up a taper without the provider; the schedule depends on the dose and the client.

Answer: A. Asthma treated with an albuterol inhaler

Rationale: Propranolol is a nonselective beta blocker. Besides blocking beta-1 receptors in the heart, it blocks beta-2 receptors in the airways, which can cause bronchospasm in a client with asthma. It can also blunt the effect of beta-2 agonists such as albuterol. The nurse holds the dose and clarifies the prescription; the provider may choose a different drug. Options B, C and D are all conditions that propranolol is commonly used to treat: migraine prevention, control of a fast heart rate and tremor in hyperthyroidism, and essential tremor.

Answer: D. "Take the first dose at bedtime, and get up slowly, sitting on the edge of the bed before you stand."

Rationale: Doxazosin is an alpha-1 blocker that relaxes blood vessels. The first dose, and the first doses after a dose increase or a missed stretch of doses, can cause a sudden drop in blood pressure on standing, with dizziness or fainting (the first-dose effect). Taking the first dose at bedtime and rising slowly lowers the risk of a fall. Teach the client to sit or lie down if dizzy and to report fainting. Option A is wrong because alpha blockers do not cause potassium loss; that teaching applies to loop and thiazide diuretics. Option B is wrong because a dry cough is linked with ACE inhibitors, not alpha blockers. Option C is wrong because the client should report dizziness rather than stop the drug without the provider's advice.