legal and ethical issues
The nurse is discussing advance directives with a client. Which one of the following statements by the client indicates good understanding of the purpose of an advance directive?
a.“An advance directive will specify what I want done when I can no longer make decisions about health care”
b.“An advance directive will be completed as soon as I’m incapacitated and can’t make decisions for myself”
c.“An advance directive will keep my children from selling my home when I’m old”
d.“An advance directive will allow me to keep my money out of the reach of my family until after I die”
a. An advanced directives include living wills and durable power of attorneys. The advanced directive guides healthcare decisions....it has nothing to do with a person's material possessions. The durable power of attorney notes the selection of a health care proxy...someone who can make health care decisions for a patient if they are not able to or no longer competent. The living will represent written documents that direct medical treatment in accordance with the patient's wishes in hte event of a terminal illness or condition.
After administration of intravenous epinephrine to a patient, the nurse will closely observe for which one of the following effects:
a.Chest pain
b.Hypotension
c.Inability to urinate
d.Hypoglycemia
A
Epi activates all the receptors. You would expect hyperglycemia with activation of beta 2 and hypertension with activation of alpha 1. Epi should not cause the patient problems with urination – and if anything would increase their cardiac output and urine output. Chest pain could indicate too much vasoconstriction from alpha 1 or dysrhythmia from beta 1.
The client is receiving terazosin (Hytrin) for treatment of hypertension. Considering the client's history of benign prostatic hypertrophy, the nurse may see which of the following effects?
A SIGNS OF A UTI
B URINARY RETENTION
C DIULTE PALE YELLOW URINE
D IMPROVED URINE FLOW
D
While terazosin is being used for hypertension, it will also relax the smooth muscle in bladder neck and prostate which will help increase the urinary flow in a man with BPH. You would expect an increase in urine flow - not urinary retention. The urine flow though increased would not be dilute in color, nor would there be any cause for infection.
Which plasma lipoprotein level is most concerning when considering the risk of coronary atherosclerosis?
Question 1Select one:
a.Elevated cholesterol
b.Elevated high-density lipoprotein
c.Elevated low-density lipoprotein
d.Elevated very-low-density lipoprotein
C Elevated LDL levels make the greatest contribution to coronary atherosclerosis with the probability of developing coronary heart disease (CHD) directly related to the LDL level in the blood. Total cholesterol levels do not have the same direct link. HDL levels cause increased risk when they are low. The relation between elevated very-low-density lipoprotein levels and CHD is not clear.
A patient is taking a calcium channel blocker (CCB) for stable angina. The patient’s spouse asks how calcium channel blockers relieve pain. The nurse will explain that CCBs:
A HELP RELAX PERIPHERAL ARTERIOLES TO REDUCE AFTERLOAD
B IMPROVE CORONARY ARTERY PERFUSION
C INCREASE HR TO IMPROVE MYOCARDIAL CONTRACTILITY
D INCREASE QT INTERVAL
A CCBs promote relaxation of peripheral arterioles, resulting in a decrease in afterload, which reduces the cardiac oxygen demand. CCBs do not improve coronary artery perfusion. CCBs reduce the heart rate and suppress contractility; they do not affect the QT interval.
A client asks the nurse not to tell his wife that he has cancer. He does not want to burden her with this information. Which one of the following would be the most appropriate response by the nurse?
a.“Why don’t I call the chaplain to come speak with you"
b.“Don't you think she has a right to know? You’ve been married a long time"
c."I'm sorry, but I think the doctor has already told her."
d."Tell me your concerns about your wife knowing that you have cancer"
D
A patient brought to the emergency department requires sutures. The prescriber orders a local anesthetic with epinephrine. The nurse understands that epinephrine is ordered to:
a. prevent hypertension induced by the anesthetic
b, allow a reduced dose of the anesthetic
c reude anesthetic induced nausea
d reduce the pain of an injection
B Epinephrine prolongs absorption of the anesthetic, because it is an alpha1 agonist. It is frequently combined with a local anesthetic for this purpose, so that the amount of anesthetic required may be reduced. Local anesthetics do not induce hypertension; therefore, epinephrine would not be needed to prevent it. Epinephrine does not act as an antiemetic and would not reduce anesthetic-induced nausea. Epinephrine is not used to reduce the pain of an injection.
The nurse is discussing home management with a patient who will begin taking an alpha-adrenergic antagonist for hypertension. Which statement by the patient indicates understanding of the teaching?
Question 7Select one:a. “I should change position slowly while on this medication”
b. “I need to stop the medication if my heart rate increases.”
c.“I will stop taking the medication if I feel dizzy.”
d.“I should not drive while taking this medication.”
A
A nurse is instructing a patient receiving a cholesterol-lowering agent. Which information should the nurse include in the patient education?
Question 2Select one:
a.“This medication will replace other interventions you have been trying.”
b.“It is important for you to double your dose if you miss one to maintain therapeutic blood levels.”
c.“Stop taking the medication if you experience constipation.”
d.“You should continue your exercise program to increase your HDL serum levels.”
D Regular exercise can reduce LDL cholesterol and elevate HDL cholesterol, thereby reducing the risk of coronary heart disease (CHD). The patient should consider the cholesterol-lowering drug an adjunct to a proper diet and exercise. Drug therapy cannot replace other important interventions, such as diet and exercise. The patient should never be instructed to double the dose. Constipation is a side effect of most cholesterol-lowering agents. The patient should be encouraged to eat a high-fiber diet and increase fluids if not contraindicated.
A nurse is discussing the difference between stable and variant angina with a group of nursing students. Which statement by a student indicates the need for further teaching?
Question 2Select one:
a.“Beta blockers are effective in stable angina but not in variant angina.”
b.“In both types of angina, prophylactic treatment is possible.”
c.“Variant angina is primarily treated with vasodilators to increase oxygen supply.”
d.“Variant angina is the result of increased oxygen demand by the heart.”
D Variant angina is caused by coronary artery spasm, which reduces the oxygen supply to the heart. Beta blockers are not effective in variant angina but are useful with stable angina. Medications may be given to prevent anginal attacks in both types of angina. Vasodilators are used in variant angina to relieve coronary artery spasm and increase the oxygen supply to the heart.
A 75 year old female patient with cancer tells the nurse that she is afraid to speak up regarding her desire to end care for fear of upsetting her husband and children. Which principle in the nursing code of ethics ensures that the nurse will promote the patient’s cause?
a.Accountability
b.Fidelity
c.Autonomy
d.Confidentiality
A acountability
A patient with asthma uses albuterol [Ventolin] for wheezing. The nurse assesses the patient and notes vital signs of HR, 96 beats/min; RR, 18 breaths per minute; and BP, 116/78 mm Hg. The patient has clear breath sounds and hand tremors. What will the nurse do?
Question 3Select one:
a.Ask the patient how often the inhaler is used.
Check the patient’s blood glucose level.
c.Request an order for isoproterenol [Isuprel] to reduce side effects.
d.Stop the medication and report the tremors to the provider.
A Tachycardia is a response to activation of beta1 receptors. It can occur when large doses of albuterol are used and selectivity decreases. The nurse should question the patient about the number of inhalations used. Isoproterenol can cause hyperglycemia in diabetic patients. Isoproterenol has more side effects than albuterol. Tremors are an expected side effect and are not an indication for stopping the drug.
A patient with type 1 diabetes is taking NPH insulin, 30 units every day. A nurse notes that the patient is also taking metoprolol [Lopressor]. What education should the nurse provide to the patient?
A IT HAS NO EFFECT ON DM OR INSULIN
B IT INTEREFES WITH EFFECTS OF INSULIN SO INCREASE IT
C IT CAN MASK HYPOGLYCEMIA
D IT CAN POTENTIATE EFFECTS SO RECUE IT
C
A nurse is reviewing a patient’s medications and realizes that gemfibrozil [Lopid] and warfarin [Coumadin] are to be administered concomitantly. Which effect will the nurse anticipate in this patient?
Question 3Select one:
a.Increased levels of gemfibrozil
b.Decreased levels of gemfibrozil
c.Increased anticoagulant effects
d.Reduced anticoagulant effects
C
Gemfibrozil displaces warfarin from the plasma albumin, thereby increasing anticoagulant effects. The level of gemfibrozil will not be increased or decreased. The anticoagulation effects will not be reduced, because free-floating drug is present in the system; the dosage of warfarin may have to be reduced.
A hospitalized patient complains of acute chest pain. The nurse administers a 0.3-mg sublingual nitroglycerin tablet, but the patient continues to complain of pain. Vital signs remain stable. What is the nurse’s next step?
a.Apply a nitroglycerin transdermal patch.
b.Continue dosing at 10-minute intervals.
c.Give a second dose of nitroglycerin in 5 minutes.
d.Request an order for intravenous nitroglycerin.
C An initial dose of sublingual nitroglycerin is taken, and if the chest pain persists, as in this case, the patient should take another dose in 5 minutes. Transdermal delivery systems are not useful for terminating an ongoing attack. Dosing at 10-minute intervals is incorrect. If the patient fails to respond or if the pain intensifies, intravenous nitroglycerin may be indicated.
A primary care provider prescribes one tablet, but the nurse accidentally administers two. After notifying the primary care provider, the nurse monitors the client carefully for untoward effects of which there are none. Is the client likely to be successful in suing the nurse for malpractice?
a.Yes, a breach of standard of care exists
b.Yes, causation is present
c.No, the nurse notified the primary care provider
d.No, the client was not harmed
D
The four criteria of malpractice include:
Duty, breach of standard of care, causation and damage/injury.
The nurse administers a moderate dose of dopamine (Inotropin) to a client. What data collected by the nurse demonstrates that the drug is effective?
Question 4Select one:
a.Decrease in blood sugar
b.Increased heart rate & blood pressure
c. Bronchoconstriction
d. Increased urine retention
B Dopamine at a moderate dose will activate dopamine (increase in renal perfusion) AND beta 1 which will (increase HR and BP and cardiac output - and thus increase urine output -not cause urine retention). It does not affect beta 2 so neither BG or lungs should be affected.
A patient complains to the nurse that the clonidine [Catapres] recently prescribed for hypertension is causing drowsiness. Which response by the nurse to this concern is appropriate?
A THIS IS OFTEN SEEN WITH ORTHO HYPO
B THIS IS A CNS REACTION SO YOURE ADDICTED
C ITS A COMMON SE INITIALLY BUT WILL LESSEN WITH TIME
D THIS IS SERIOUS AND YOU SHOULD STOP TAKING IT
C
Lovastatin [Mevacor] is prescribed for a patient for the first time. The nurse should provide the patient with which instruction?
Question 4Select one:
a.“Take lovastatin after dinner in the evening.”
b.“Take this medicine before breakfast.”
c.“You should take this medication with a meal"
d.“Take this medicine on an empty stomach.”
A
Patients should be instructed to take lovastatin with the evening meal. Statins should be taken with the evening meal, not before breakfast. Statins should not be administered without regard to meals and should not be taken on an empty stomach.
A patient who takes nitroglycerine to treat stable angina reports having erectile dysfunction and states that he plans to ask his primary provider for a prescription for tadalafil [Cialis]. What will the nurse tell this patient?
A “You may take these two drugs together safely as long as you take them as directed.”
b. “You should not take tadalafil and nitroglycerine within 30 to 60 minutes of each other.”
c.“You should discuss another antiangina medication with your provider.”
d.“You should avoid sexual activity since this increases oxygen demands on the heart.”
C
Use of nitroglycerine with any phosphodiesterase type 5 inhibitor, such as sildenafil or tadalafil, is absolutely contraindicated. The patient should be advised to discuss another antianginal agent with the provider. Patients should be taught to increase all activity to maintain as normal a lifestyle as possible.
Which one of the following people may legally give informed consent?
a.
J. A. who needs to have her appendix removed and just had 625mg of acetaminophen
b.A.G. who just came to the ER with a high blood alcohol level
c.J. S. who came out of surgery with general anesthesia 30 minutes ago and now needs a blood transfusion
d.90 year old M.T. who has Alzheimer’s and is confused
A
J.A. is on a pain killer which will not alter her ability to make decisions. The rest have altered or impaired consciousness from anesthesia, alcohol, or Alzheimer's.
A patient is receiving dobutamine [Dobutrex] as a continuous infusion in the immediate postoperative period. The patient also is receiving a diuretic. What adverse drug reactions are possible in this patient?
a.Tachycardia
b.Dysrhythmias
c.Hypotension
d.Angina
e.Oliguria
ABDDobutamine works on beta 1 only. Beta 1 increases contractility and heart rate which can result in increased cardiac output (positive) but also tachycardia, dysrhythmias, and angina.
A prescriber has ordered methyldopa for a female patient with hypertension. The nurse understands that which laboratory tests are important before beginning therapy with this drug? (Select all that apply.)
a.Hgb and Hct
b.Pregnancy test
c.Urinalysis
d.Liver function tests
e.Coomb's test
ADE
A patient who is taking simvastatin [Zocor] develops an infection and the provider orders azithromycin [Zithromax] to treat the infection. The nurse should be concerned if the patient complains of:
Question 5Select one:
a.nausea.
b.tiredness.
c.muscle pain.
d.headache
C Statins can injure muscle tissue, causing muscle aches and pain known as myopathy/rhabdomyolysis. Daptomycin also can cause myopathy and therefore should be used with caution in patients concurrently taking simvastatin. Nausea, tiredness, and headache would not cause the nurse as much concern as the likelihood of myopathy.
A patient asks a nurse how nitroglycerin works to relieve stable anginal pain. The nurse correctly states, “Nitroglycerin:
a.dilates coronary arteries to increase blood flow to the heart.”
b.increases the oxygen supply to the cardiac muscle.”
c.increases ventricular filling to improve cardiac output.”
d.promotes vasodilation, which reduces preload and oxygen demand.”
D
Nitroglycerin dilates the veins, which reduces venous return to the heart, which in turn decreases ventricular filling. The resulting decrease in preload reduces the oxygen requirements of the heart. Nitroglycerin does not increase the blood flow or oxygen supply to the heart (at least for stable angina). An increase in ventricular filling would increase oxygen demand and result in increased anginal pain.