NCLEX - CARDIOVASCULAR Day1 (Part 2)

The nurse is teaching the parent of a 4-year-old client with heart failure about digoxin administration. Which of the following statements by the parent would require follow-up?

• We will hold the dose of medication if our child's heart rate is above 90/min.
• We will not give a second dose of medication if our child vomits after the first.
• We will not mix the medication with any foods or liquids.
• We will notify our health care provider if our child experiences nausea or vomiting.
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Answer explanation

Digoxin is a cardiac glycoside given to clients with heart failure. It increases myocardial contraction, which increases cardiac output and improves circulation and tissue perfusion. Digoxin is a potentially dangerous medication due to its narrow margin of safety in dosage. Parents should receive thorough teaching and demonstrate accurate understanding of the correct administration of this medication. Teaching related to digoxin administration includes: Holding digoxin for a heart rate <90–110/min for infants and young children or <70/min for an older child; the child with a heart rate >90/min should receive the scheduled dose (Option 1). Administering oral liquid forms of digoxin in the side and back of the mouth. Not giving additional doses or not increasing the dose of future administrations if a dose is missed. Notifying the health care provider if more than two doses are missed. (Options 2 and 4) A second dose should not be given if the client vomits after the first. Nausea, vomiting, or decreased heart rate could indicate toxicity, and the health care provider should be notified. (Option 3) Digoxin should not be mixed with any foods or liquids because the client's refusal to consume them would result in an incomplete or missed dose.

The nurse is talking with a client with atrial fibrillation who has a new prescription for dabigatran. Which of the following statements by the client would require follow-up?

• I should use a soft-bristled toothbrush when brushing my teeth.
• I will notify my health care provider if I notice blood in my urine or stool.
• I should swallow the medication capsule whole with a full glass of water.
• I will have blood specimens obtained periodically while taking the medication.
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Answer explanation

Direct thrombin inhibitors (eg, dabigatran) are anticoagulants commonly prescribed to reduce the risk for thromboembolism and stroke in clients with chronic atrial fibrillation. The nurse should instruct the client to avoid injury and implement bleeding precautions (eg, soft-bristled toothbrush, electric razor) due to an increased risk for uncontrolled bleeding. However, unlike other anticoagulants (eg, warfarin), routine laboratory tests are not necessary when taking dabigatran (Option 4). (Option 1) The client should implement safety measures (eg, electric razor, soft-bristled toothbrush) to prevent bleeding due to the increased risk for hemorrhage. (Option 2) Blood in the urine or stool may indicate internal bleeding. The client should report these symptoms to the health care provider immediately. (Option 3) Dabigatran capsules should be swallowed whole; not crushed, chewed, or opened. Crushing pills can increase absorption and risk for bleeding.

The nurse evaluating a 52-year-old diabetic male client's therapeutic response to rosuvastatin would notice changes in which laboratory values? Select all that apply.

• Alanine aminotransferase from 20 U/L (0.33 µkat/L) to 80 U/L (1.34 µkat/L)
• High-density lipoprotein cholesterol from 48 mg/dL (1.24 mmol/L) to 30 mg/dL (0.78 mmol/L)
• Low-density lipoprotein cholesterol from 176 mg/dL (4.61 mol/L) to 98 mg/dL (2.54 mmol/L)
• Total cholesterol from 250 mg/dL (6.47 mmol/L) to 180 mg/dL (4.66 mmol/L)
• Triglycerides from 180 mg/dL (2.03 mmol/L) to 149 mg/dL (1.68 mmol/L)

Answer explanation

Statins (rosuvastatin, atorvastatin, simvastatin) are the most preferred agents to reduce low-density lipoprotein (LDL) cholesterol, total cholesterol, and triglyceride levels. This client's LDL level has decreased to a target range (diabetic client <100 mg/dL [2.6 mmol/L]), total cholesterol has decreased to a normal range (adult <200 mg/dL [5.2 mmol/L]), and triglyceride level has decreased to a normal range (adult <150 mg/dL [1.7 mmol/L]); all these changes indicate a therapeutic response (Options 3, 4, and 5). (Option 1) The adult therapeutic range of alanine aminotransferase (ALT) is 10-40 U/L (0.17-0.68 µkat/L). Increased aspartate aminotransferase (AST) and ALT may indicate hepatic dysfunction, a potential adverse effect of statin medication. (Option 2) The therapeutic range of high-density lipoprotein (HDL) cholesterol for adult men is >40 mg/dL (1.04 mmol/L). HDL is good cholesterol. This client's HDL level is below the therapeutic range, indicating a nontherapeutic response.

A client with coronary artery disease is being seen in the clinic for a follow-up examination. During medication reconciliation, the nurse identifies which reported medication as requiring further investigation?

• 10 mg isosorbide dinitrate twice daily
• 20 mg atorvastatin once daily
• 500 mg naproxen twice daily
• 2,000 mg fish oil once daily
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Answer explanation

Nonsteroidal anti-inflammatory drugs (NSAIDs) (eg, naproxen, ibuprofen) are common medications used for their analgesic, antipyretic, and anti-inflammatory properties. However, the use of NSAIDs increases the risk of thrombotic events (eg, heart attack, stroke) in clients with cardiovascular disease (eg, coronary artery disease [CAD]), especially with long-term use. The nurse should investigate the reason a client with cardiovascular disease is taking an NSAID and alert the health care provider of the medication usage (Option 3). (Option 1) Isosorbide dinitrate (Isordil) is a long-acting nitrate medication prescribed to prevent angina in clients with CAD. Nitrate medications prevent angina by causing vasodilation of the peripheral vessels (decreasing cardiac workload) and the coronary arteries (improving coronary artery perfusion). (Option 2) Atorvastatin (Lipitor) is a statin drug prescribed to lower cholesterol, which can reduce the risk of atherosclerosis and coronary artery disease. (Option 4) Fish oil is an over-the-counter nutritional supplement often taken by clients with heart disease or individuals at risk. Fish oil contains omega-3 fatty acids, which may decrease blood triglyceride levels with consistent use.

The nurse is monitoring a client who has been on clopidogrel therapy. Which assessments are essential? Select all that apply.

• Assess for bruising
• Assess for tarry stools
• Monitor intake and output
• Monitor liver function tests
• Monitor platelets

Answer explanation

Antiplatelet therapy (eg, aspirin, clopidogrel, prasugrel, ticagrelor) is initiated to prevent platelet aggregation in clients at risk for myocardial infarction, stroke, or other thrombotic events. This therapy increases bleeding risk, so clients should be assessed for bruising, tarry stools, and other signs of bleeding (eg, hematuria, bleeding gums, epistaxis) (Options 1 and 2). Clients should be taught to self-monitor for these signs. In addition, clopidogrel may cause thrombotic thrombocytopenia purpura, so platelets should be monitored periodically (Option 5). (Option 3) Monitoring intake and output is indicated while a client is on diuretic medications (eg, furosemide, torsemide, bumetanide) but not for antiplatelet agents. (Option 4) Baseline liver enzymes are obtained for clients taking statins (eg, rosuvastatin, atorvastatin) and isoniazid (for tuberculosis). Elevated liver enzymes are an infrequent side effect of clopidogrel, and regular monitoring is usually not required in clients without hepatic impairment.

The nurse is preparing to administer medications to a client with a myocardial infarction. Which of the following medications are appropriate for the nurse to administer? Select all that apply.

• Aspirin
• Atorvastatin
• Docusate sodium
• Lisinopril
• Metoprolol

Answer explanation

Myocardial infarctions (MIs) damage heart muscle and require medications to improve heart function and prevent reinfarction (eg, aspirin). Aspirin, an antiplatelet agent, inhibits platelet aggregation, prevents thrombus formation, and reduces heart inflammation. Clients without signs of bleeding or low platelet levels may safely receive aspirin. Atorvastatin is a lipid-lowering medication given to clients to lower cholesterol levels (ie, LDL cholesterol), which reduces plaque and reinfarction risk. However, statins may cause rhabdomyolysis and require monitoring for muscle weakness and pain. Docusate sodium is a stool softener that reduces straining during bowel movements, thereby decreasing the workload on the heart. Straining can also cause bradycardia due to vagal response. Lisinopril is an ACE inhibitor often prescribed to clients after an MI to prevent ventricular remodeling and progression of heart failure. Lisinopril may cause hyperkalemia and hypotension, and should be administered only to clients with normokalemia and normotension. (Option 5) Metoprolol is a beta blocker prescribed to clients after MI to reduce the risk of reinfarction and heart failure. Metoprolol lowers blood pressure and heart rate; therefore, the nurse should hold the medication and notify the health care provider of hypotension or a heart rate <50/min.

The nurse is teaching a client with hypertension about newly prescribed clonidine. Which of the following information would be most important for the nurse to include?

• Avoid consuming high-sodium foods
• Do not stop taking the medication abruptly
• Limit alcohol intake while taking the medication
• Use an oral moisturizer to relieve dry mouth
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Answer explanation

Central-acting alpha2 agonists (eg, clonidine, methyldopa) decrease the sympathetic response from the brainstem to the peripheral vessels, resulting in decreased peripheral vascular resistance and vasodilation. Clonidine is a highly potent antihypertensive medication. Abrupt discontinuation (including the patch) can result in serious rebound hypertension due to the rapid surge of catecholamine secretion that was suppressed during therapy. Rebound hypertension may lead to dangerously high blood pressure and is accompanied by tachycardia, nervousness, and diaphoresis. To avoid this potential adverse reaction, clonidine should be tapered over 2–4 days. (Option 1) Avoiding high-sodium foods is important for blood pressure control but is not the most important advice for this client as consumption of these foods is not life-threatening. (Option 3) Drowsiness is a common side effect of clonidine use. Clients should avoid concurrent use of alcohol and other central nervous system depressants while taking clonidine. Dizziness is also a side effect of clonidine. Drowsiness and dizziness should diminish with continued use of the medication. (Option 4) Dry mouth is a common side effect of clonidine. Use of over-the-counter mouth moisturizers, chewing gum, or hard candy may be helpful for clients who experience dry mouth.

The nurse is teaching a client recently diagnosed with heart failure who is being discharged with a prescription for lisinopril. Which of the following information should the nurse include?

• Instruct the client to have blood specimens obtained monthly to monitor serum medication levels
• Review foods that are high in potassium that the client should regularly include in the diet
• Teach the client to count the pulse for 1 minute and hold the medication if the pulse <60/min
• Teach the client to rise slowly and sit on the side of the bed for several minutes before standing up
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Answer explanation

ACE inhibitors (eg, lisinopril) are antihypertensive medications that are also commonly prescribed to decrease ventricular remodeling in chronic heart failure. ACE inhibitors alter the renin-angiotensin-aldosterone system by inhibiting conversion of angiotensin I to angiotensin II, thereby preventing the release of aldosterone. By reducing circulating aldosterone, ACE inhibitors promote vasodilation and urine production, resulting in lower blood pressure. Clients are prone to experience orthostatic hypotension and should be instructed to rise slowly and sit for several minutes before standing. Cough and angioedema are other side effects of ACE inhibitors that are thought to be caused by an accumulation of bradykinin. Additionally, ACE inhibitors are contraindicated in pregnancy due to their teratogenic effects on the fetus. (Option 1) Renal function (eg, blood urea nitrogen, creatinine) is commonly checked during the first week of therapy. Regular measurements to ensure therapeutic medication levels are not required. (Option 2) A common side effect of ACE inhibitors is mild hyperkalemia, which may require a lower intake of foods high in potassium. Clients taking loop diuretics (eg, furosemide) will need to increase their intake of foods high in potassium. (Option 3) ACE inhibitors do not directly affect the heart rate. Clients prescribed digoxin are taught to take their pulse and hold their medication if the heart rate is <60/min.

The nurse is preparing to administer medications scheduled at 0900 to a client. Which of the following values should the nurse check prior to administering the medications? Select all that apply.

• Blood pressure
• Blood glucose level
• Heart rate
• INR
• Potassium level

Answer explanation

Before administering medications, the nurse should assess relevant vital signs and laboratory test results. Beta blockers (eg, metoprolol, carvedilol) and angiotensin-converting enzyme (ACE) inhibitors (eg, quinapril, lisinopril, enalapril) are antihypertensive medications. Therefore, the nurse should assess the client's blood pressure prior to administering these medications. Beta blockers lower the heart rate by blocking the action of beta receptors that increase heart rate and contractility. Therefore, the nurse should assess the client's heart rate prior to administering beta blockers. ACE inhibitors increase serum potassium levels by decreasing urinary potassium excretion. Therefore, the nurse should assess the client's serum potassium level prior to administering ACE inhibitors. (Option 2) Clients with diabetes mellitus require monitoring of blood glucose levels. However, this client does not have diabetes mellitus, and beta blockers, ACE inhibitors, or antiplatelet medications do not require assessment of blood glucose levels prior to administration. (Option 4) Aspirin, an antiplatelet medication, reduces clot formation and can increase the risk for bleeding. The nurse should assess the client for bruising, bleeding gums, blood in stool, and gastrointestinal upset. INR is monitored in clients receiving warfarin.

The nurse cares for a transgender client who is prescribed estrogen therapy. Which side effect is most important for the nurse to report to the health care provider?

• Breast tenderness
• Generalized weight gain
• Leg swelling
• Nausea and vomiting
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Answer explanation

Transgender women clients are often prescribed antiandrogen medications (eg, spironolactone) to reduce androgen levels (eg, testosterone) and estrogen therapies to induce feminizing traits (eg, breast enlargement, reduction in body hair, decrease in testicular size and erectile function). Estrogen places clients at an increased risk for developing blood clots, due to hypercoagulability, and therefore adverse thrombotic events (eg, stroke, myocardial infarction, venous thromboembolism). Signs and symptoms of deep venous thrombosis (eg, leg swelling, redness, pain) should be reported to the health care provider (HCP) immediately (Option 3). The client should also be taught smoking cessation and diabetes management, and to avoid long periods of immobilization to further decrease the risk of thrombus formation. (Option 1) Breast tenderness and enlargement are common, expected side effects of estrogen therapy. (Option 2) Generalized weight gain during estrogen therapy is caused by fluid retention and is generally mild. However, if weight gain with cardiovascular symptoms (eg, pedal edema) occurs, the HCP should be notified. (Option 4) Nausea and vomiting can occur with estrogen therapy and may be remedied with dosage adjustments or taking oral estrogen with food.