Ch48 - Focus on Nursing Pharmacology 6e Instructor Test Bank PDF

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Chapter 48- Drugs Affecting Blood Coagulation   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 1. reverse the effects of heparin if the patient begins to bleed? A) Antithromb...

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Chapter 48- Drugs Affecting Blood Coagulation 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 1. 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. Prior to beginning anticoagulant therapy, the nurse will question the female patient about 2. 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. The nurse is caring for a female patient who is nursing her 3-month-old infant. What will 3. 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. 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 4. 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. 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 5. 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. The nurse is caring for a patient with a fever and severe diarrhea in addition to 6. 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. 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 7. 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. A patient is being discharged home on warfarin. The discharge teaching by the nurse 8. should include a warning to avoid what? St. John’s wort A)

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. The nurse administers clopidogrel (Plavix) appropriately to the patient with what 9. 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. The nurse is caring for a patient who is going home on warfarin (Coumadin). What lab 10. 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 PT and APTT D)

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. 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 12. 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.

The nurse evaluates the effects of warfarin (Coumadin) by monitoring what laboratory 13. 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. The nurse discovers a patient receiving warfarin is bleeding. What drug would the nurse 14. 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. The nurse evaluates that additional patient teaching is needed regarding anticoagulants 15. 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. The nurse teaches the patient taking warfarin (Coumadin) to minimize foods high in 16. 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. The nurse evaluates teaching about warfarin (Coumadin) is successful when the patient 17.

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. The nurse assesses blood in the urine of the 73-year-old patient receiving warfarin 18. (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. The nurse is caring for a patient following repeat coronary artery bypass grafting who has 19. 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). 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 20. 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. What intervention does the nurse include in the plan of care for a patient receiving a 21. 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. 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 22. 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. The nurse is caring for a child who needs anticoagulation therapy. What drug is approved 24. 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. When the nurse administers warfarin it is expected that the drug will have what effect on 25. 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. When the nurse administers heparin it is anticipated the drug will have what action on the 26. 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. A young man has been diagnosed with hemophilia and the nurse is planning his discharge 27. teaching and includes what teaching point? Using nonsteroidal anti-inflammatory drugs (NSAIDs) for mild pain A)

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. 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 28. what? A) Hypercoagulation Bleeding B)

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. The nurse reviews the patient’s lab values and determines warfarin therapy is at 29. 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 tim...