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NSG 6320 AGNP BOARD EXAM (latest) CARDIOVASCULAR PRESCRIBING (113 Questions and Answers) – South University Savannah Question: Signs and symptoms of digitalis toxicity include:    consti... pation and muscle spasms.      bradycardia and tinnitus.      headache and dizziness.      blurred vision and persistent diarrhea.   Explanation: Signs and symptoms of digitalis toxicity include: confusion, irregular pulse, loss of appetite, nausea, vomiting, diarrhea, fast heart beat, and visual changes (blurred vision, blind spots, green-yellow color disturbances, halo effect). Regardless of route of administration, digoxin levels should be checked at 12-24 hours after the last dose. However, depending on the clinical situation, wait at least 6-8 hours after the last dose to check levels. Question: A side effect of beta-blockers that is more common in children than adults is:    decreased appetite.      muscle weakness.      vivid dreams.      a cough that produces mucus.   Explanation: Side effects of beta-blockers that are more common in children than adults may include a mucus-producing cough, difficulty breathing, or tightness in the chest. Beta-blockers are not recommended as initial therapy in children due to potential adverse outcomes including increased bronchial obstruction and airway reactivity in children with asthma. Question: Spironolactone (Aldactone) is highly protein bound and has a duration of:    6 hours.      12 hours.      24 hours.      48 hours.   Explanation: Spironolactone (Aldactone) is greater than 90% protein bound, has a half-life elimination of 1.4 hours and a duration of 48-72 hours. It is classified as an aldosterone receptor antagonist. This class blocks the effects of aldosterone, which increases sodium reabsorption by the kidneys. Question: Nonselective beta-blockers block the stimulation of:    beta-1 receptors in the heart.      beta-2 receptors in the lungs.      both beta-1 receptors in the heart and beta-2 receptors in the lungs.      neither beta-1 receptors in the heart nor beta-2 receptors in the lungs.   Explanation: Nonselective beta-blockers (i.e., propranolol [Inderal]) block the stimulation of both beta-1 receptors in the heart and beta-2 receptors in the lungs. Selective beta-blockers (i.e. metoprolol [Lopressor]) specifically block beta-1 receptors, but may also block beta-2 receptors at higher doses. Because they also block beta-2 receptors in the lungs, nonselective beta-blockers are contraindicated in patients with asthma or chronic obstructive pulmonary disease. Question: Dabigatran (Pradaxa), an anticoagulant, is also classified as a:    direct factor Xa inhibitor.      direct thrombin inhibitor.      indirect thrombin inhibitor.      factor V inhibitor.   Explanation: Dabigatran (Pradaxa) is a direct thrombin inhibitor (DTI). Medications in this class inactivate circulating and clotting thrombin (factor IIa). They prevent thrombin (central to the generation of a thrombus) from attaching fibrinogen to fibrin. DTIs bind directly to thrombin and do not require a cofactor such as antithrombin to exert their effect. They can inhibit both soluble thrombin and fibrin-bound thrombin. Key advantages of using DTIs instead of heparin is that they: produce a more predictable anticoagulant effect due to their lack of binding to other plasma proteins; exert an antiplatelet effect; and do not cause immune-mediated thrombocytopenia. Question: The brand name for candesartan cilexetil is:    Atacand.      Avandia.      Benicar.      Cozaar.   Explanation: The brand name for candesartan cilexetil is Atacand. The generic name for Avandia is rosiglitazone; Benicar is olmesartan medoxomil (an ARB); Cozaar is losartan. Candesartan, olmesartan and losartan are classified as angiotensin receptor blockers (ARBs) and are used in the treatment of hypertension. Notice that they all end in "sartan." Rosiglitazone is a thiazolidinedione and is used in the treatment of diabetes. Question: Gemfibrozil (Lopid), for the treatment of hypertriglyceridemia, is classified as a:    bile acid sequestrant.      nicotinic acid.      fibric acid.      statin.   Explanation: Gemfibrozil (Lopid) is a fibric acid. It is indicated in the treatment of hypertriglyceridemia and mixed dyslipidemia. Fibric acid derivatives, also known as fibrates, are the recommended treatment for very high triglyceride levels (>500 mg/dL). Fibrates lower serum triglyceride levels by reducing the liver's production of VLDL (triglyceride-carrying particle circulating in the blood) and by speeding up the removal of triglycerides from the blood. Gemfibrozil should not be used concurrently with statins. Question: In patients with normal renal function, the diuretic that has the greater antihypertensive effect is:    osmotic diuretics.      thiazide diuretics.      loop diuretics.      potassium-sparing diuretics.   Explanation: Among patients with normal renal function, thiazide diuretics, particularly chlorthalidone (Thalitone), have a greater antihypertensive effect than the loop diuretics. This may be related to the longer duration of action of thiazides compared to most loop diuretics. Diuretics lower blood pressure, at least initially, by inducing sodium and fluid loss. Other thiazide diuretics include hydrochlorothiazide (Microzide) and methyclothiazide. Question: An adverse effect of statin therapy for the treatment of hyperlipidemia is:    hypertension.      myalgia.      hypoglycemia.      edema.   Explanation: Statins may cause myalgia. The pain may be experienced as a soreness, fatigue or weakness in the muscles. The pain can be a mild discomfort, or it can be severe enough to make daily activities difficult. Other common side effects include diarrhea, arthralgia and nasopharyngitis. Question: Nitroglycerin sublingual (Nitrostat) tablets should be stored:    in a dark bottle, with the patient carrying all tablets at all times.      in a dark container in the refrigerator, with only a small quantity kept with the patient.      in a tightly capped medicine bottle at room temperature.      in a tightly sealed bag or container in a purse or wallet.   Explanation: Nitroglycerin sublingual (Nitrostat) tablets are both heat- and light-sensitive. They should be stored in a tightly capped dark bottle in the refrigerator. Only a small supply should be carried by the patient. Nitroglycerin tablets in an opened bottle should be discarded after 12 months. Question: Patients taking warfarin (Coumadin) therapy should:    increase intake of vitamin K-enriched foods.      avoid intake of vitamin K-enriched foods.      maintain a consistent intake of vitamin K-enriched foods.      decrease intake of vitamin K-enriched foods.   Explanation: Patients who are anticoagulated with warfarin (Coumadin) generally are sensitive to fluctuations in vitamin K intake. Adequate INR control requires a consistent intake of vitamin K. The goal of monitoring vitamin K intake is to maintain a moderate, constant level of intake rather than to eliminate vitamin K from the diet. Reducing vitamin K intake can cause the INR to increase, and increasing vitamin K can cause the INR to decrease, making it more difficult to control. Question: Non-dihydropyridine calcium channel blockers (i.e. verapamil) may be safely used in patients with:    heart failure.      bradycardia.      second-degree AV block.      chronic stable angina.   Explanation: Non-dihydropyridine CCBs (non-DHP CCB; i.e. verapamil [Calan] and diltiazem [Cardizem]) have negative chronotropic and inotropic effects. Therefore, they slow down heart rate and decrease force of ventricular contractions. Non-DHP CCBs are contraindicated in patients with heart failure who have reduced ejection fraction, sick sinus syndrome, and second- or third-degree atrioventricular block. Since non-DHP CCBs increase myocardial blood flow by dilating coronary arteries, they are beneficial in patients with chronic stable angina. Additionally, they can be given for rate control (tachycardia) or for the control of angina (chronic, stable) when left ventricular systolic function is normal. In general, the long-acting form of Non-DHP CCBs are recommended over the short-acting forms. Question: The generic name for Lopressor is:    atenolol.      metoprolol tartrate.      carvedilol.      bisoprolol.   Explanation: The generic name of Lopressor is metoprolol tartrate. The brand name for atenolol is Tenormin; carvedilol is Coreg; and bisoprolol is Zebeta. All of these drugs are classified as beta-blockers and end in "lol". Question: A patient is taking isosorbide dinitrate (Isordil) at 8 am, 2 pm and 9 pm and reports that the medication is no longer effective. The nurse practitioner knows that:    this is the time interval and the dose should be increased.      the dosing interval should be changed to allow a 14-hour nitrate-free interval.      the dosing interval should be every 12 hours.      the patient should be switched to transdermal delivery for better efficacy.   Explanation: Patients on continuous nitrates such as isosorbide (Isordil) may develop tolerance. A nitrate-free period of 12-14 hours per day should be considered to improve efficacy and prevent tolerance. The same holds true whether the nitrates are administered orally or transdermally. Question: Of the angiotensin receptor blockers (ARBs) used in the treatment of hypertension, the one with the longest biological half-life at 24 hours is:    irbesartan (Avapro).      losartan (Cozaar).      olmesartan (Benicar).      telmisartan (Micardis).   Explanation: Telmisartan (Micardis) has a biological half-life of 24 hours. Irbesartan (Avapro) has a half-life of 11-15 hours; olmesartan (Benicar) 13 hours; and losartan (Cozaar) 6-9 hours. These are all classified as angiotensin receptor blockers (ARBs) used in the treatment of hypertension. Question: A patient who has warfarin (Coumadin) toxicity should be treated with:    charcoal.      platelets.      vitamin K.      prothrombin.   Explanation: The antidote for a warfarin (Coumadin) overdose is vitamin K. Warfarin acts by inhibiting the synthesis of vitamin K-dependent clotting factors, including Factors II, VII, IX, and X, and the anticoagulant proteins C and S. The onset of anticoagulant action for oral warfarin (Coumadin) is 24-72 hours. The half-life elimination of warfarin (Coumadin) is 20-60 hours. Question: Clopidogrel (Plavix), an anticoagulant, may be coadministered with:    aspirin (Ecotrin).      fluoxetine (Prozac).      omeprazole (Prilosec).      ibuprofen (Motrin).   Explanation: Clopidogrel (Plavix) can be coadministered with antiplatelet medications (i.e., aspirin). Clopidogrel is often combined with aspirin to treat myocardial infarctions or unstable angina, and to prevent blood clots. Selective serotonin reuptake inhibitors (SSRIs; fluoxetine [Prozac]) and serotonin norepinephrine reuptake inhibitors (SNRIs; duloxetine [Cymbalta]) affect platelet activation. The concomitant administration of SSRIs and SNRIs with clopidogrel may increase the risk of bleeding. Coadministration of clopidogrel and NSAIDs (i.e., ibuprofen [Motrin]) increases a patient's risk for gastrointestinal bleeding. Avoid concomitant use of clopidogrel with omeprazole (Prilosec) or esomeprazole (Nexium). In clinical studies, omeprazole was shown to significantly reduce the antiplatelet activity of clopidogrel bisulfate when given concomitantly or 12 hours apart. Question: Which of the following drugs blocks the action of aldosterone in order to produce diuresis?    Furosemide (Lasix)      Hydrochlorothiazide (Microzide)      Spironolactone (Aldactone)      Bumetanide (Bumex)   Explanation: Spironolactone (Aldactone) is a potassium-sparing diuretic. Potassium-sparing diuretics enhance the action of thiazide and loop diuretics and counteract potassium loss by these agents. They block the action of aldosterone and cause the kidney to release fluid to produce diuresis while retaining potassium. Question: The lipid-lowering agent that has been proven most effective in raising high-density lipoprotein levels is:    the statin class.      the bile acid sequestrant class.      nicotinic acid.      fibric acid.   Explanation: Nicotinic acid (Niacin) has the highest potential for raising high-density lipoproteins (15-30%). Unfortunately, no improvement in cardiovascular outcomes has been documented when niacin is used with or without a statin. Consequently, the FDA has removed this as an indication on the product label. Other lipid-lowering agents may raise high-density lipoprotein at rates of: statins 5-15%; bile acid sequestrants 3-5%; fibric acids 10-20%. Question: A patient taking spironolactone (Aldactone) has a serum potassium of 5.8 meq/L. The nurse practitioner should:    discontinue spironolactone (Aldactone) immediately.      discontinue the spironolactone (Aldactone) and administer kayexalate.      hold spironolactone (Aldactone) until hyperkalemia is resolved.      discontinue spironolactone (Aldactone) and begin a thiazide diuretic.   Explanation: While on spironolactone (Aldactone), potassium levels should be monitored. If serum potassium increases to greater than 5.5 mEq/L or renal function worsens, further doses of Aldactone should be held until potassium is less than 5 mEq/L. Once hyperkalemia/renal insufficiency has resolved and is steady for at least 72 hours, consider restarting Aldactone at a reduced dose. Question: The mechanism of action of angiotensin-converting enzyme (ACE) inhibitors in lowering blood pressure is to:    block the formation of angiotensinogen in the liver.      convert angiotensin I to angiotensin II in the myocardium.      inhibit the enzyme that converts angiotensin I to angiotensin II in the serum.      inhibit the conversion of angiotensin enzyme production by the kidneys.   Explanation: Angiotensin-converting enzyme inhibitors (ACE inhibitors) slow (inhibit) the activity of the angiotensin-converting enzyme, which decreases the production of angiotensin II. Angiotensin I is formed from angiotensinogen, a protein produced by the liver and released into the blood. Angiotensin II, a vasoconstrictor, is formed from angiotensin I by angiotensin-converting enzyme (ACE). By blocking the production of angiotensin II, blood vessels dilate, and blood pressure is reduced. Question: The diuretic that blocks the reabsorption of sodium and water in the loop of Henle to produce diuresis is:    furosemide (Lasix).      hydrochlorothiazide (Microzide).      spironolactone (Aldactone).      triamterene (Dyrenium).   Explanation: The diuretic that blocks the reabsorption of sodium and water in the loop of Henle to produce diuresis is known as a loop diuretic. Furosemide (Lasix) is a loop diuretic. Hydrochlorothiazide (Microzide) inhibits sodium and water reabsorption, but this does not occur in the loop of Henle. Spironolactone (Aldactone) and triamterene (Dyrenium) are potassium-sparing diuretics. They antagonize aldosterone-specific mineralocorticoid receptors, primarily in the distal convoluted tubule. They decrease sodium and water reabsorption and increase potassium retention. Question: A 2-year-old child has a history of heart failure. To increase the force of ventricular contraction and decrease heart rate, the most appropriate drug choice is:    captopril (Capoten).      enalapril (Vasotec).      diltiazem (Cardizem).      digoxin (Lanoxin).   Explanation: Digoxin (Lanoxin) has a rapid onset. It increases the force of contraction, decreases heart rate, slows the conduction of impulses through the AV node, and indirectly enhances diuresis. When dosed appropriately, it is effective and indicated in pediatric patients. Captopril (Capoten) and enalapril (Vasotec) do not decrease heart rate. Diltiazem (Cardizem) decreases heart rate and decreases force of contraction. Question: A common side effect of cardioselective beta-blockers such as labetalol (Trandate) is:    weight loss.      shortness of breath.      tachycardia.      facial swelling.   Explanation: The most common side effects of cardioselective beta-blockers (i.e., labetalol [Trandate]) are exercise intolerance, shortness of breath, weight gain, fatigue, bradycardia, low blood pressure, shortness of breath, and in men, erectile dysfunction. Sexual side effects have not been reported in women. Question: A patient is receiving furosemide (Lasix) for edema secondary to heart failure. The patient should be informed that furosemide (Lasix) may cause:    hyperglycemia.      hypouricemia.      hypermagnesemia.      hyponatremia.   Explanation: Loop diuretics such as furosemide (Lasix) can cause hypokalemia, hyperglycemia and glucose intolerance, hyperlipidemia, hyponatremia, hyperuricemia, and hypomagnesemia. Hyperglycemia and carbohydrate intolerance have been linked to diuretic-induced hypokalemia. K+ deficiency is known to inhibit insulin secretion by beta cells. These symptoms are dose related, reversible with withdrawal of the diuretic, and are more common with hydrochlorothiazide (a thiazide diuretic) than furosemide. Question: The loop diuretic with the longest half-life is:    furosemide (Lasix).      torsemide (Demadex).      bumetanide (Bumex).      hydrochlorothiazide (Microzide).   Explanation: The loop diuretic with the longest half-life is torsemide (Demadex); its half-life is 3.5 hours. Furosemide (Lasix) has a half-life of 30-60 minutes; bumetanide (Bumex) has a half-life of 1-1.5 hours. Hydrochlorothiazide (Microzide) is not a loop diuretic. It is a thiazide diuretic and it has a half-life of 5.6-14.8 hours. Question: Angiotensin-converting enzyme (ACE) inhibitors such as ramipril (Altace) should not be used:    in the presence of bilateral renal artery stenosis.      after a myocardial infarction.      for prevention of diabetic nephropathy in the presence of normal blood pressures.      in patients with dilated cardiomyopathy.   Explanation: Angiotensin-converting enzyme (ACE) inhibitors used in the presence of bilateral renal artery stenosis may result in renal failure. In this condition, elevated circulating and intrarenal angiotensin II constricts the efferent arteriole more than the afferent arteriole within the kidney, which helps to maintain glomerular capillary pressure and filtration. ACE inhibitor administration would inhibit this constriction by blocking circulating and intrarenal angiotensin II formation and result in an abrupt fall in glomerular filtration rate. ACE inhibitors have been proven effective in patients after myocardial infarction because they help reduce deleterious remodeling that occurs postinfarction. They have proven to be effective in the treatment of heart failure caused by systolic dysfunction (e.g., dilated cardiomyopathy). ACE inhibitors are also effective in preventing diabetic nephropathy, even when hypertension is not present. Question: A child who is receiving furosemide (Lasix) to treat heart failure should be monitored for:    potassium level greater than 4.0 mEq/L.      muscle cramps.      vomiting and diarrhea.      oliguria.   Explanation: A major side effect of furosemide (Lasix) is hypokalemia. Symptoms of hypokalemia are nonspecific and are predominantly related to muscular or cardiac function. Complaints may include: weakness and fatigue, muscle cramps and pain, palpitations, and psychological symptoms. Question: Enoxaparin (Lovenox) is classified as a(n):    ADP receptor antagonist.      factor Xa inhibitor.      low molecular weight heparin.      direct thrombin inhibitor.   Explanation: Enoxaparin (Lovenox) is classified as a low molecular weight heparin. Factor Xa inhibitors include rivaroxaban (Xarelto), apixaban (Eliquis), and edoxaban (Savaysa). Dabigatran (Pradaxa) is classified as a direct thrombin inhibitor. Ticlopidine and clopidogrel (Plavix) are ADP receptor antagonists. Question: When prescribing nitroglycerin for the treatment of angina, the first-pass effect bioavailability should be considered with:    sublingual nitroglycerin 0.4 mg.      intravenous nitroglycerin 200 mcg/min.      oral nitroglycerin 2.5 mg ER.      topical nitroglycerin 1 inch.   Explanation: Sublingual, IV and topical administrations of a drug are not subject to the first-pass effect. The first-pass effect (also known as first-pass metabolism or presystemic metabolism) is a phenomenon of drug metabolism in which the concentration of a drug is greatly reduced before it reaches the systemic circulation. It is the fraction of drug lost during the process of absorption, which is generally related to the liver and gut wall. Alternative routes of administration (i.e., suppository, intravenous, intramuscular, inhalational aerosol, transdermal and sublingual) avoid the first-pass effect because they allow drugs to be absorbed directly into the systemic circulation. Question: Isosorbide dinitrate (Isordil) is indicated for the treatment of:    acute angina.      chronic angina.      myocardial infarction.      esophageal spasm.   Explanation: Isosorbide dinitrate (Isordil) titradose tablets are indicated for the prevention of angina pectoris due to coronary artery disease. The onset of action of immediate-release oral isosorbide dinitrate is not sufficiently rapid for this product to be useful in aborting an acute anginal episode. Therefore, it is not indicated in the treatment of acute angina and myocardial infarction. The treatment of esophageal spasms disorders is an off-label use. Question: A patient with a prosthetic heart valve is taking warfarin (Coumadin) therapy. The appropriate action prior to dental surgery is to:    hold the warfarin (Coumadin) 5 days prior to surgery and begin a low molecular weight heparin.      hold the warfarin (Coumadin) 2 days before surgery and resume immediately afterwards.      decrease the dose of warfarin (Coumadin) by 50% for the week prior to surgery.      hold warfarin (Coumadin) 3 days prior to surgery and administer vitamin K about 2 hours prior to surgery.   Explanation: The onset of anticoagulant action for oral warfarin (Coumadin) is 24-72 hours with a half-life elimination of 20-60 hours. Due to the long half-life elimination of warfarin and the high risk for thrombus development in a patient with a prosthetic heart valves, the warfarin should be stopped at least 5 days prior to surgery and the patient bridged with a low-molecular weight heparin (i.e. enoxaparin [Lovenox]). Warfarin acts by inhibiting the synthesis of vitamin K-dependent clotting factors, including Factors II, VII, IX, and X, and the anticoagulant proteins C and S. Question: The efficacy of angiotensin receptor blockers (ARBs) may be enhanced, without an increase in side effects, when administered in combination with:    aliskiren (Tekturna).      chlorothiazide (Diuril).      ramipril (Altace).      spironolactone (Aldactone).   Explanation: The efficacy of angiotensin receptor blockers (ARBs) is enhanced by concomitant administration of low doses of a thiazide diuretic (i.e., chlorothiazide [Diuril]). This combination also reduces the potential for hyperkalemia. ARBs will enhance the adverse/toxic effect of angiotensin-converting enzyme inhibitors such as ramipril (Altace). The coadministration of potassium-sparing diuretics such as spironolactone (Aldactone) and aliskiren (Tekturna) may enhance the hyperkalemic effects of ARBs. Question: A 3-year-old patient has a history of congenital heart disease. To reduce the afterload and decrease right and left atrial pressures, the drug of choice should be:    lisinopril (Prinivil).      captopril (Capoten).      benazepril (Lotensin).      ramipril (Altace).   Explanation: Angiotensin-converting enzyme (ACE) inhibitors (i.e., captopril [Capoten]) are key in the treatment of heart failure with systolic dysfunction. ACE inhibitors reduce afterload and decrease right and left atrial pressures. The mechanisms of action of ACE inhibitors in treating heart failure is not completely understood, but is thought to be a combination of effects on the intracardiac and/or intravascular renin-angiotensin system, reduction in sympathetic activity, increased levels of kinins, improvement of endothelial function, reduction in a hypercoagulable state, modulation of plasma fibrinolytic activity, effect on lung function, effects on arterial compliance, and prevention of adverse cardiac and vascular remodeling. Among the choices, captopril (Capoten) is the only ACE inhibitor that is indicated for children younger than 6 years. Question: Statins lower cholesterol by:    competitively inhibiting HMG-CoA reductase.      promoting the action of lipoprotein lipase.      modulating the low-density lipoprotein (LDL) receptor and ligand interaction.      limiting substrate availability for triglyceride synthesis in the liver.   Explanation: Statins act by competitively inhibiting HMG-CoA (3-hydroxy-3-methylglutaryl coenzyme A reductase) reductase, the first and key rate-limiting enzyme of the cholesterol biosynthetic pathway. Statins mimic the natural substrate molecule, HMG-CoA, and compete for binding to the HM GCR enzyme. This competition slows the rate of mevalonate production, the next molecule in the serial steps to producing cholesterol. Question: The negative inotropic activity of nifedipine (Adalat CC) that leads to an exacerbation of heart failure may be further pronounced if combined with:    angiotensin-converting enzyme inhibitors.      nitrates.      beta-blockers.      angiotensin receptor blockers.   Explanation: Nifedipine (Adalat CC) can exacerbate heart failure in patients with cardiac dysfunction due to its negative inotropic activity. This effect is more pronounced in patients who are also treated with a beta-blocker (i.e., atenolol [Tenormin]). This combination is NOT generally used. Question: Which beta-blocker is highly variable in bioavailability, has a shorter plasma half-life, is mostly lipid-soluble, and is almost completely absorbed by the small intestine?    Nebivolol (Bystolic)      Sotalol (Betapace)      Atenolol (Tenormin)      Metoprolol (Lopressor)   Explanation: Metoprolol (Lopressor) is eliminated by hepatic metabolism. It is mostly lipid-soluble, almost completely absorbed by the small intestine, and largely metabolized by the liver. It has a highly variable bioavailability and a relatively short plasma half-life. Nebivolol (Bystolic), sotalol (Betapace) and atenolol (Tenormin) are excreted unchanged by the kidney. They are more water soluble, incompletely absorbed through the gut, show less variance in bioavailability, and have longer plasma half-lives. They are all classified as beta-blockers. Question: Avoid concomitant use of oral digoxin (Lanoxin) and:    ibuprofen (Advil).      famotidine (Pepcid).      acetaminophen (Tylenol).      levothyroxine (Synthroid).   Explanation: Proton pump inhibitors (i.e., esomeprazole [Nexium]) and histamine-2 antagonists or blockers (i.e., famotidine [Pepcid]) should NOT be used concomitantly with digoxin (Lanoxin). These medications will increase the level or effect of digoxin (Lanoxin) by increasing gastric pH. Question: A patient being treated with enoxaparin (Lovenox) twice daily for atrial fibrillation is scheduled for surgery. The patient should be advised to:    refrain from taking the enoxaparin (Lovenox) dose on the morning of surgery.      refrain from taking the enoxaparin (Lovenox) dose 24 hours prior to surgery.      refrain from taking the enoxaparin (Lovenox) 36 hours prior to surgery.      reduce the dose by 50% 2 days prior to surgery and refrain from dosing on the morning of surgery.   Explanation: Low molecular weight (LMW) heparin should be discontinued 24 hours before a planned surgery or procedure. The onset of action of LMW heparin (i.e. enoxaparin [Lovenox]) is 3-5 hours, with a duration of about 12 hours. If a twice-daily LMW heparin regimen is given, the evening dose the night before surgery is omitted. If a once-daily regimen is given (e.g., dalteparin 200 international units/kg), one-half of the total daily dose is given on the morning of the day before surgery. Question: The onset of anticoagulation action for warfarin (Coumadin) is:    4-6 hours.      8-10 hours.      12-24 hours.      24-72 hours.   Explanation: The onset of anticoagulant action for oral warfarin (Coumadin) is 24-72 hours. Warfarin acts by inhibiting the synthesis of vitamin K-dependent clotting factors, including Factors II, VII, IX, and X, and the anticoagulant proteins C and S. The half-life elimination of warfarin (Coumadin) is 20-60 hours. Question: Beta-blockers such as atenolol (Tenormin) should not be used in patients with:    a history of myocardial infarction.      a diagnosis of heart failure.      variant (Prinzmetal) angina.      stable angina.   Explanation: Beta-blockers should not be used in patients with vasospastic or variant (Prinzmetal) angina. In such patients, they are ineffective and may increase the tendency to induce coronary vasospasm from unopposed alpha-receptor activity. Beta-blockers are indicated in the treatment of post-MI prevention, heart failure and stable angina. Question: Gemfibrozil (Lopid) should NOT be administered in combination with:    atorvastatin (Lipitor).      montelukast (Singulair).      glimepiride (Amaryl).      clindamycin (Cleocin).   Explanation: Gemfibrozil (Lopid) may enhance the myopathic (rhabdomyolysis) effect of atorvastatin (Lipitor). Gemfibrozil (Lopid) may increase the serum concentration of statins. This combination should be avoided. Question: Enoxaparin (Lovenox), used in the prevention of deep vein thrombosis, should be administered:    twice daily by mouth.      daily via intramuscular injection.      twice daily via subcutaneous injection.      weekly via subcutaneous injection.   Explanation: Enoxaparin (Lovenox) is administered subcutaneously once or twice daily. Twice daily is the more commonly prescribed dosing. Oral forms of enoxaparin are not available. Enoxaparin is a low molecular weight heparin. The onset of action is 3-5 hours and the drug has a duration of about 12 hours. Question: Angiotensin II receptor blockers (ARBs) lower blood pressure by:    blocking vasodilation and water retention effects of angiotensin II.      suppressing the renin-angiotensin-aldosterone system.      blocking the vasoconstricting and sodium retention effects of angiotensin II.      blocking beta receptors in the heart, resulting in a decrease in myocardial contractility.   Explanation: Angiotensin II receptor blockers (ARBs) act by blocking the vasoconstricting and sodium retention effects of angiotensin II. They block the action of angiotensin II by preventing angiotensin II from binding to angiotensin II receptors on the muscles surrounding blood vessels. As a result, blood vessels enlarge (vasodilate) and blood pressure is reduced. The generic names of ARBs end in "sartan." An example is losartan (Cozaar). Question: Protamine sulfate, used to reduce the bleeding caused by low molecular weight heparin, should be used cautiously in patients who are allergic to:    sulfa drugs.      aspirin.      nuts.      fish.   Explanation: Protamine sulfate is a hemostatic agent that ionically binds to heparin, forming a stable complex that neutralizes anticoagulant effects. It is a protein derived from fish sperm and it carries a risk for anaphylaxis in patients who have previously been exposed, including patients with diabetes who have received protamine-containing insulin (e.g., NPH, PZI), and patients who have an allergy to fish. Question: Aliskiren (Tekturna), a renin inhibitor, is indicated for the treatment of:    atrial fibrillation.      left ventricular hypertrophy.      primary essential hypertension.      stable angina.   Explanation: (Tekturna) is the first in a class of drugs called direct renin inhibitors. It is indicated for the treatment of essential (primary) hypertension. When renin is released into the blood, it acts upon angiotensinogen, which undergoes proteolytic cleavage to form angiotensin I. Angiotensin-converting enzyme (ACE) then cleaves off two amino acids to form angiotensin II, an octapeptide. Tekturna decreases plasma renin activity and inhibits conversion of angiotensinogen to angiotensin I, thus preventing the vasoconstricting effects of angiotensin II. It is not indicated for the treatment of atrial fibrillation, left ventricular hypertrophy or stable angina. Question: The dosage of apixaban (Eliquis) in the treatment of nonvalvular atrial fibrillation should be reduced for the patient with a(n):    weight between 60-80 kg.      serum creatinine greater than 1.5 mg/dL.      weight greater than 120 kg.      age older than 65 years.   Explanation: The dosage of apixaban (Eliquis) in the treatment of nonvalvular atrial fibrillation should be reduced for the patient with a serum creatinine greater than or equal to 1.5 mg/dL, greater than or equal to 80 years of age, or patients who weigh less than or equal to 60 kg. Apixaban (Eliquis) is a direct factor Xa (FXa) inhibitor. These drugs work by inactivating circulating and clot-bound factor Xa. Apixaban has no direct effect on platelet aggregation, but indirectly inhibits platelet aggregation induced by thrombin. It is 27% excreted in the urine. Question: A patient is receiving atenolol (Toprol XL) for angina and needs to be started on a second agent for hypertension. Caution should be used if prescribing:    lisinopril (Prinivil).      losartan (Cozaar).      verapamil (Verelan).      hydrochlorothiazide (Microzide).   Explanation: Caution and close monitoring are required when combining a beta-blocker (i.e., atenolol [Tenormin]) and a calcium channel blocker (i.e., verapamil [Verelan]). The combination of these drugs may cause reductions in heart rate, cardiac conduction, and cardiac contractility. These effects are especially prevalent when combining verapamil and diltiazem (Cardizem), both calcium channel blockers, with beta-blockers. While this combination may be useful and effective in some situations, potentially serious cardiovascular adverse effects, such as bradyarrhythmias, heart failure, severe hypotension, and/or exacerbation of angina, may occur. Question: While taking aliskiren (Tekturna), the patient should be advised to avoid:    almonds.      grape juice.      salt substitutes.      calcium-containing products.   Explanation: Aliskiren (Tekturna) may cause hyperkalemia. Salt substitutes, potassium supplements and potassium-containing salts should be avoided. Salt substitutes contain potassium chloride in place of sodium chloride. This risk is increased in patients with renal impairment or diabetes. The concomitant use of angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs) and nonsteroidal anti-inflammatory drugs (NSAIDs) may also increase the risk of hyperkalemia, and this should be avoided. Question: Which medication is considered a cholesterol absorption inhibitor?    Gemfibrozil (Lopid)      Colestipol (Colestid)      Fluvastatin (Lescol)      Ezetimibe (Zetia)   Explanation: Ezetimibe (Zetia) is classified as a cholesterol absorption inhibitor. Fluvastatin (Lescol) is a statin. Colestipol (Colestid) is a bile acid sequestrant. Gemfibrozil (Lopid) is a fibric acid. Question: Inotropes (positive or negative) are indicated for patients diagnosed with:    hypertension.      stable angina.      atrial fibrillation.      acute coronary syndrome.   Explanation: Medical indications for positive or negative inotropes include atrial fibrillation, heart failure, nonobstructive oliguria, and shock. Drugs that slow conduction across the atrioventricular (AV) node include beta-blockers, non-dihydropyridine calcium channel blockers, and digoxin (Lanoxin). Digoxin is a positive inotrope. Negative inotropes (also called chronotropes), such as calcium channel blockers, are used to treat stable angina, vasospastic angina, hypertension, hypertrophic cardiomyopathy and supraventricular arrhythmias. Question: The side effect profile of angiotensin receptor blockers (ARBs) is similar to the side effects of:    angiotensin-converting enzymes (ACE) inhibitors.      beta-blockers.      calcium channel blockers.      pressors.   Explanation: The angiotensin II receptor blockers (ARBs) are typically well tolerated. The side effect profile is generally similar to that seen with angiotensin-converting enzyme (ACE) inhibitors (e.g., increased incidence of hyperkalemia and of acute renal failure in renovascular hypertension or states of effective volume depletion). Patients who are on both an ACE inhibitor and an ARB are at higher risk for adverse effects. Thus, combined therapy should not be considered in the treatment of hypertension or other disorders unless there is compelling evidence of benefit. Question: Which of the following is a brand name for enoxaparin?    Xarelto.      Fragmin.      Lovenox.      Aggrenox.   Explanation: The brand name of enoxaparin is Lovenox. It is classified as a low molecular weight (LMW) heparin. The generic name of Xarelto is rivaroxaban (factor Xa inhibitor); Fragmin is dalteparin (LMW heparin); and Aggrenox is a combination of aspirin and dipyridamole (antiplatelet). Question: To reduce the risk of cardiovascular events in patients with asymptomatic peripheral arterial disease, the patient should be treated with:    aspirin (Ecotrin)      enoxaparin (Lovenox).      rivaroxaban (Xarelto).      warfarin (Coumadin).   Explanation: Aspirin (Ecotrin) is the antiplatelet agent of choice to reduce the risk of cardiovascular events in patients with asymptomatic peripheral arterial disease. Clopidogrel (Plavix) may be used if aspirin cannot be tolerated. Peripheral arterial disease is a coronary heart disease risk equivalent. Secondary prevention measures are recommended to reduce the risk of future cardiovascular events, and to potentially limit the progression of atherosclerosis. To reduce the risk for myocardial infarction, stroke, and vascular death, long-term antiplatelet therapy is recommended for patients with lower extremity PAD. Question: Beta-blockers that block the beta-2 receptors may cause:    decreased perfusion of target organs.      bronchoconstriction.      decreased insulin secretion.      increased gastrointestinal mobility.   Explanation: Nonselective beta-blockers that block the beta-2 receptors in the lungs may cause decreased central motor activity, inhibition of renin release from the kidneys, reduction of norepinephrine from neurons, and mild bronchoconstriction. Nonselective beta-blockers (i.e., propranolol [Inderal]) block the stimulation of both beta-1 receptors in the heart and beta-2 receptors in the lungs. Selective beta-blockers (i.e., metoprolol [Lopressor]) specifically block beta-1 receptors, but may also block beta-2 receptors at higher doses. Question: Warfarin (Coumadin) therapy may be safely used by a patient who has:    active tuberculosis.      moderate renal impairment.      chronic obstructive pulmonary disease.      malnutrition.   Explanation: Warfarin (Coumadin) is not contraindicated in patients with chronic obstructive pulmonary disease. In patients with active tuberculosis, moderate renal impairment or malnutrition, warfarin should be used with caution or avoided. Question: The recommended pharmacologic management of elevated low density lipoprotein (LDL) cholesterol in primary prevention of cardiovascular disease is:    bile acid sequestrants.      fibric acids.      nicotinic acid.      statin therapy.   Explanation: Lipid lowering with statins is beneficial for primary and secondary prevention of coronary heart disease in patients with dyslipidemias. Statins reduce low-density lipoprotein (LDL) cholesterol by 30-63%. Even though statins are not the most effective medications in reducing serum triglyceride levels, they are the most effective hypolipidemic agents in reducing cardiovascular risk and, as such, should be first-line therapy in patients with mild to moderate hypertriglyceridemia (150 to 500 mg/dL) in whom the goal of therapy is CV risk reduction. Question: Concomitant use of beta-blockers with digitalis glycosides can increase the risk of:    hypertension.      hypokalemia.      bradycardia.      hyperglycemia.   Explanation: Concomitant use of beta-blockers (i.e., atenolol [Tenormin]) with digitalis glycosides (i.e., digoxin [Lanoxin]) can increase bradycardia risk because both decrease heart rate. Careful monitoring of heart rate is required and the combination is discouraged. Question: Baseline and periodic monitoring for patients receiving hydralazine (Apresoline) should include serum:    liver function tests.      thyroid panel.      complete blood count.      blood urea nitrogen and creatinine.   Explanation: Routine monitoring for patients receiving hydralazine (Apresoline) should include blood pressure (standing and sitting/supine), heart rate, complete blood cell count (CBC), and antinuclear antibody (ANA) titer. Hydralazine (Apresoline) may cause a drug-induced lupus-like syndrome and blood dyscrasias (e.g., reduction in hemoglobin and red blood cell count, leukopenia, agranulocytosis, purpura). Discontinue therapy if these hematologic effects occur. Question: The recommended prophylactic treatment agent for infective endocarditis is:    clindamycin (Cleocin).      cephalexin(Keflex).      amoxicillin (Amoxil).      clarithromycin (Biaxin).   Explanation: The recommended standard prophylactic treatment agent for infective endocarditis is amoxicillin. The common causative organisms are Staphylococcus aureus and Streptococcus viridans; both are gram-positive organisms. Clindamycin (Cleocin) is recommended when a patient is allergic to amoxicillin. Cephalexin (Keflex), azithromycin (Zithromax), and clarithromycin (Biaxin) are acceptable second-line regimens. Question: Bile acid sequestrants such as colesevelam (Welchol):    are metabolized by the liver and block the formation of low-density lipoproteins by bile acids.      bind to bile acids in the stomach and prohibit the absorption of cholesterol in the intestines.      bind to bile acids and excrete them in feces, forcing the liver to use cholesterol to produce more bile acids.      prohibit the exchange of sodium ions with bile acids, therefore inhibiting the production of cholesterol.   Explanation: Bile acid sequestrants such as colesevelam (Welchol) exchange anions (i.e., chloride ions) for bile acids, thus binding bile acids and sequestering them from enterohepatic circulation. The liver then produces more bile acids to replace those that have been lost. Because the body uses cholesterol to make bile acids, this reduces the amount of LDL cholesterol circulating in the blood. Bile acid sequestrants are large polymeric structures, and they are not significantly absorbed from the gut into the bloodstream. Thus, bile acid sequestrants, along with any bile acids bound to the drug, are excreted via the feces after passage through the gastrointestinal tract. The major adverse reactions are gastrointestinal, including nausea, bloating, cramping, and anorexia. Question: Ranolazine (Ranexa) is indicated in the treatment of:    acute angina.      acute coronary syndrome.      intermittent claudication.      chronic angina.   Explanation: Ranolazine (Ranexa) is indicated in the treatment of chronic angina. It exerts antianginal and anti-ischemic effects without changing heart rate or blood pressure. Ranexa reduces intracellular sodium concentrations, thereby reducing calcium influx via sodium (Na+) -calcium (Ca2+) exchange. Decreased intracellular calcium reduces ventricular tension and myocardial oxygen consumption. Ranexa will not relieve acute angina episode and has not demonstrated benefit in acute coronary syndrome. Question: Gemfibrozil (Lopid) should be discontinued if:    a mild decrease in hemoglobin is experienced.      symptoms of biliary colic are present.      the patient complains of syncope.      the patient develops cataracts.   Explanation: Patients receiving gemfibrozil (Lopid) are at increased risk for cholelithiasis. The medication should be discontinued if symptoms of biliary colic are present and gallstones are found upon ultrasound. No relationship has been established between gemfibrozil (Lopid) and the development of syncope and cataracts. Mild decreases in hemoglobin, hematocrit and WBC may occur upon initiation of therapy, but they usually stabilize with long-term use. Question: A 52-year-old man is receiving metoprolol tartrate (Lopressor) after a myocardial infarction. This patient should be educated to:    stop the medication abruptly if any side effects occur.      take an extra dose if he experiences angina.      take two tablets if he misses a dose.      avoid abruptly stopping the medication.   Explanation: Acute withdrawal of a beta-blocker (i.e., metoprolol [Lopressor]) can lead to substantial morbidity and even mortality. The most important concern with beta-blocker withdrawal is the exacerbation of ischemic symptoms in patients with known coronary artery disease--including the precipitation of an acute myocardial infarction. In some cases, precipitation of serious ventricular tachyarrhythmias, including sudden cardiac death, may occur. This medication should be tapered for discontinuation. Question: Hydralazine (Apresoline) is indicated for the treatment of:    hypertrophic cardiomyopathy.      coronary artery disease.      unstable angina.      hypertension.   Explanation: Hydralazine is indicated for the treatment of hypertension. There is no indication for the use of hydralazine in the treatment of unstable angina. It is contraindicated in coronary artery disease. The benefits versus risks should be calculated before using hydralazine in a patient with hypertrophic cardiomyopathy . Question: By decreasing cardiac output, beta-blockers may also:    increase sympathetic stimulation.      strengthen myocardial contractibility.      increase mortality associated with heart failure.      worsen symptoms of peripheral arterial disease.   Explanation: Beta-blocker receptors in the heart depress myocardial contractibility and decrease sympathetic stimulation. By decreasing cardiac output, beta blockers can worsen symptoms of peripheral artery disease. They may also decrease morbidity and mortality associated with heart failure. Examples of beta-blockers include metoprolol (Lopressor), atenolol (Tenormin), and propranolol (Inderal). Question: The generic name for Vasotec is:    benazepril.      captopril.      enalapril.      verapamil.   Explanation: The generic name for Vasotec is enalapril. The brand name for benazepril is Lotensin; captopril is Capoten; verapamil is Calan. Enalapril, benazepril and captopril are classified as angiotensin-converting enzyme (ACE) inhibitors. Notice that they all have the suffix of "pril." Verapamil is a calcium channel blocker. Question: It is safe to use ranolazine (Ranexa) concomitantly with:    fluconazole (Diflucan).      phenytoin (Dilantin).      amlodipine (Norvasc).      clarithromycin (Cleocin).   Explanation: Ranolazine (Ranexa) may be used concomitantly with amlodipine (Norvasc), a calcium channel blocker. Due to serious drug-drug interactions, ranolazine (Ranexa) should not be combined with azole antifungals (e.g., fluconazole, ketoconazole), barbiturates (e.g., phenobarbital), carbamazepine, hydantoins (e.g., phenytoin), certain macrolide antibiotics (e.g., clarithromycin), nefazodone, certain protease inhibitors (e.g., indinavir, nelfinavir, ritonavir, saquinavir), a rifamycin (e.g., rifampin), St. John's wort, or telithromycin. Question: The medication that produces vasodilation and thus lowers blood pressure by inhibiting the formation of angiotensin II is:    amlodipine (Norvasc).      losartan (Cozaar).      enalapril (Vasotec).      metoprolol (Lopressor).   Explanation: Angiotensin-converting enzyme (ACE) inhibitors (i.e., enalapril [Vasotec]) cause vasodilation by inhibiting the formation of angiotensin II. When renin is released into the blood, it acts upon angiotensinogen, which undergoes proteolytic cleavage to form angiotensin I. Angiotensin-converting enzyme (ACE) then cleaves off two amino acids to form the octapeptide angiotensin II. ACE inhibitors block this enzyme, thus inhibiting the formation of angiotensin II. Generic names for ACE inhibitors end in "pril" (i.e., enalapril, lisinopril, ramipril, captopril, etc.). Amlodipine (Norvasc) is a calcium channel blocker, losartan (Cozaar) is an angiotensin II receptor blocker, and metoprolol (Lopressor) is a beta-blocker. Question: The maximum benefits of fibrates on triglyceride reduction occur at approximately:    2 weeks.      4 weeks.      6 weeks.      10 weeks.   Explanation: Pharmacologic therapies vary in how quickly they reduce triglyceride levels. The maximum effect of fibrates is achieved at 6 to 8 weeks. Therefore, triglyceride levels should be checked 6 to 8 weeks after starting or altering therapy. Fibrates lower serum triglyceride levels by reducing the liver's production of very low-density lipoprotein and by speeding up the removal of triglycerides from the blood. Question: For the patient receiving dabigatran (Pradaxa) who needs anticoagulation reversal, the nurse practitioner knows that:    no reversal agent is available.      vitamin K should be administered.      idarucizumab (Praxbind) is the emergency reversal agent.      administration of fresh frozen plasma is the only available option.   Explanation: Idarucizumab (Praxbind) can be used for emergency reversal of the anticoagulant effect of dabigatran (Pradaxa). This agent should be administered only to patients who require emergency surgery or who have life-threatening bleeding that has not responded to more conservative bleeding management measures. It should only be administered after seeing convincing evidence of significant dabigatran levels (i.e., clinical history of ingestion or laboratory testing). Question: Bile acid sequestrants to treat hypercholesterolemia should be dosed:    on an empty stomach.      with milk prior to bedtime.      mixed in carbonated beverages.      1 hour before or 4 hours after other medications.   Explanation: Bile acid sequestrants can bind to and impair the absorption of other drugs, such as digoxin (Lanoxin), warfarin (Coumadin), and fat-soluble vitamins (A, D, E, and K). This effect can be minimized by administering the other drugs 1 hour before or 4 hours after the bile acid sequestrant. Examples of bile acid sequestrants are cholestyramine (Questran, Prevalite), colestipol (Colestid, Flavored Colestid ), and colesevelam (Welchol). Question: Direct thrombin inhibitors such as dabigatran (Pradaxa) are NOT indicated for:    the prevention of venous thromboembolism.      patients with atrial fibrillation.      the treatment of acute coronary syndrome.      patients with prosthetic heart valves.   Explanation: Direct thrombin inhibitors (DTI) such as dabigatran (Pradaxa) are NOT indicated for the management of patients with prosthetic heart valves. They are indicated for the prevention and treatment of blood clots in patients with venous thromboembolic disease, atrial fibrillation, acute coronary syndrome and heparin-induced thrombocytopenia. DTIs should NOT be used in the presence of renal insufficiency or pregnancy. Question: An adverse reaction to angiotensin receptor blockers (ARBs) used in the treatment of hypertension is:    photosensitivity.      hypokalemia.      angioedema.      Barrett's esophagus.   Explanation: Angiotensin receptor blockers (ARBs) may cause angioedema. Angioedema is characterized by swelling of the mouth, tongue, pharynx, and eyelids. The risk of angioedema appears to be lower with ARBs than angiotensin-converting enzyme inhibitors. ARBs may cause hyperkalemia and hyperhidrosis. ARBs do not produce photosensitivity. Question: Beta-blockers that block the beta-1 receptors cause a(n):    increase in heart rate.      increase in respiratory rate.      decrease in cardiac output.      decrease in respiratory rate.   Explanation: Beta-blockers that block the beta-1 receptors in the heart cause a decrease in heart rate, blood pressure and cardiac output. Nonselective beta-blockers (i.e. propranolol [Inderal]) block the stimulation of both beta-1 receptors in the heart and beta-2 receptors in the lungs. Selective beta-blockers (i.e. metoprolol [Lopressor]) specifically block beta-1 receptors, but may also block beta-2 receptors at higher doses. Question: Aliskiren (Tekturna), used in the treatment of essential hypertension, is classified as a(n):    alpha agonist.      aldosterone receptor antagonists.      calcium channel blocker.      direct renin inhibitor.   Explanation: Aliskiren (Tekturna) is the first in a class of drugs called direct renin inhibitors. It is indicated for the treatment of essential (primary) hypertension. When renin is released into the blood, it acts upon angiotensinogen, which undergoes proteolytic cleavage to form angiotensin I. Angiotensin-converting enzyme (ACE) then cleaves off two amino acids to form the octapeptide angiotensin II. Tekturna decreases plasma renin activity and inhibits conversion of angiotensinogen to angiotensin I, thus preventing the vasoconstricting effects of angiotensin II. The maximum antihypertensive effect is seen within 2 weeks. Question: Loop diuretics such as bumetanide (Bumex):    produce a large volume of diuresis even at very low doses.      are more commonly used in patients with a decreased glomerular filtration rate.      reduce blood pressure as effectively as thiazide diuretics when used as monotherapy.      can be safely administered to patients who have sulfonamide agent allergies.   Explanation: Loop diuretics are commonly used to control volume retention and are more commonly prescribed for patients with decreased glomerular filtration rate or heart failure. Loop diuretics do not reduce blood pressure as effectively as thiazide diuretics when they are used as monotherapy. They possess a sulfonamide group, which has important clinical relevance for patients with allergies to sulfonamide agents. Little if any diuresis occurs with very low doses, but progressively increased diuresis is achieved at higher doses until an individualized plateau is reached. Commonly prescribed loop diuretics include furosemide (Lasix), bumetanide (Bumex), and torsemide (Demadex). Question: Initial and routine monitoring of patients receiving spironolactone (Aldactone) includes:    serum potassium, blood urea nitrogen and creatinine.      urine aldosterone and potassium levels.      serum platelets and liver function.      serum CBC and TSH.   Explanation: Initial and routine monitoring of patients receiving spironolactone (Aldactone) includes serum potassium and renal function. These should be checked 3 days after initiation, 1 week after initiation, at least monthly for the first 3 months of therapy, and every 3 months thereafter. If serum potassium increases to greater than 5.5 mEq/L or renal function worsens, further spironolactone doses should be held until potassium is less than 5 mEq/L. At that time, consider restarting with a reduced dose. Question: Signs of digoxin toxicity in a 2-year-old with heart failure is:    tachycardia and difficulty feeding.      lethargy, nausea, and/or vomiting.      tachypnea, respiratory distress (retractions), grunting.      diaphoresis during feedings and failure to thrive.   Explanation: Signs and symptoms of digitalis toxicity in a 2-year-old child with heart failure include lethargy, nausea, and/or vomiting. Tachycardia, difficulty feeding, tachypnea, respiratory distress (retractions), grunting, diaphoresis during feedings, and failure to thrive are all signs of heart failure. Question: Patients should be advised to take ezetimibe (Zetia), a cholesterol absorption inhibitor,:    at least 2 hours after a statin.      only with meals.      at the same time as bile acid sequestrants.      without regard to meals.   Explanation: Patients should be advised to take ezetimibe (Zetia), a cholesterol absorption inhibitor, without regard to meals. Cholesterol absorption inhibitors should be taken at the same time as a statin or fenofibrate. If taken with a bile acid sequestrant, they should be administered more than 2 hours before or at least 4 hours after bile acid sequestrants. Question: The peak effect of enalapril (Vasotec), an angiotensin-converting enzyme (ACE) inhibitor, occurs in:    1 hour.      3 hours.      5 hours.      8 hours.   Explanation: The peak effect of enalapril (Vasotec) is 4-6 hours. The onset of action is about 1 hour, and the duration of action is 12-24 hours. Enalapril is excreted in the urine and feces and is about 50% protein bound. Angiotensin-converting enzyme (ACE) inhibitors (i.e., enalapril [Vasotec]) cause vasodilation by inhibiting the formation of angiotensin II. Question: An angiotensin II receptor blocker (ARB) that is indicated for the treatment of hypertension in children younger than 6 years old is:    ramipril (Altace).      candesartan (Atacand).      amlodipine (Norvasc).      losartan (Cozaar).   Explanation: An angiotensin II receptor blocker (ARB) indicated for use in children younger than 6 years who have been diagnosed with hypertension is candesartan (Atacand). Losartan (Cozaar) is indicated for children older than 6 years. Ramipril (Altace) is an angiotensin-converting enzyme (ACE) inhibitor and is not indicated for use in pediatrics. Amlodipine (Norvasc) is a calcium channel blocker and is approved for use in children 6-17 years old. Question: Apixaban (Eliquis) may be a better choice than warfarin (Coumadin) in the patient who:    is pregnant.      has heparin-induced thrombocytopenia.      has renal impairment.      is uninsured.   Explanation: Warfarin (Coumadin) is contraindicated in the treatment of heparin-induced thrombocytopenia. Factor Xa Inhibitors, such as apixaban (Eliquis), should NOT be used in patients who are pregnant. Drugs in this class are expensive. They are excreted renally and should be avoided in patients who have renal impairment. Question: Increased toxicity effects may be experienced when administering furosemide (Lasix) with:    amoxicillin (Amoxil).      captopril (Capoten).      gentamicin (Garamycin).      budesonide (Entocort).   Explanation: When used in combination, furosemide (Lasix) and gentamicin (Garamycin) may increase the risk of ototoxicity, nephrotoxicity, and hypocalcemia (additive toxicity, additive effects). Captopril (Capoten) and budesonide (Entocort) can be administered in combination with furosemide (Lasix); however, potassium levels and blood pressure readings need to be monitored. Amoxicillin (Amoxil) is safe to use with furosemide (Lasix). Question: Patients receiving short-acting nitrates for the management of acute angina should be advised of the potential for:    headaches and postural hypotension.      bradycardia and tinnitus.      headaches and hypertension.      dizziness and constipation.   Explanation: Patients who are receiving short-acting nitrates for acute angina should be advised of the high possibility for headaches and postural hypotension with each use. Nitroglycerin (Nitro-Dur) is a short-acting nitrate. The nitrates are primarily venodilators due to increased bioavailability to venous smooth muscle cells. Venodilation lowers preload (left ventricular end-diastolic pressure) and therefore reduces wall stress, resulting in a decrease in myocardial oxygen demand. Question: A common side effect of niacin (Niaspan) is:    hair loss.      dry mouth.      joint pain.      flushing.   Explanation: Flushing and pruritus are commonly reported side effects of niacin (Niaspan). These effects can be reduced by gradually increasing the dose, taking with food, avoiding the concurrent ingestion of ethanol or hot liquids, and/or by taking aspirin (adults: 325 mg) 30 minutes before the niacin dose. Question: The mechanism of action of angiotensin receptor blockers (ARBs) in lowering blood pressure is to:    block the receptor sites of angiotensinogen in the liver.      block the angiotensin I receptors in the cardiomyocytes and fibroblasts.      inhibit the binding of angiotensin II to receptor sites on vascular smooth muscles.      inhibit the conversion of angiotensin I to angiotensin II, blocking the renin-angiotensin system.   Explanation: Angiotensin II receptor blockers (ARBs) interfere with the renin-angiotensin system by impairing the binding of angiotensin II to the angiotensin II receptors on the vascular smooth muscle. This inhibits the action of angiotensin II, thus blocking its vasoconstrictor and aldosterone-secreting effects. By blocking this effect, vasodilation occurs and blood pressure is lowered. Question: Reduced doses of lovastatin (Mevacor) are recommended when used concomitantly with:    losartan (Cozaar).      verapamil (Calan).      glimepiride (Amaryl).      phenytoin (Dilantin).   Explanation: Reduced doses of lovastatin (Mevacor) are recommended when administered concomitantly with amiodarone (Cordarone), diltiazem (Cardizem), verapamil (Calan), danazol, dronedarone (Multaq) and lomitapide (Juxtapid). Administration of phenytoin (Dilantin) and lovastatin (Mevacor) may cause decreased serum concentrations of lovastatin (Mevacor). No significant drug-drug interactions between losartan (Cozaar) and glimepiride (Amaryl) have been reported in the literature. Question: Nitrates cause vasodilation of veins and coronary arteries by:    blocking acetylcholine receptors in the myocardium.      sympathetic stimulation of arterioles in skeletal muscle.      relaxing vascular smooth muscles to lower preload.      reducing the effects of atrial natriuretic peptide in the myocardium.   Explanation: Nitrates (i.e., isosorbide [Isordil]) dilate veins, arteries, and coronary arteries by relaxing vascular smooth muscle. The nitrates are primarily venodilators, due to increased bioavailability to venous smooth muscle cells. Venodilation lowers preload (left ventricular end-diastolic pressure) and therefore reduces wall stress, resulting in a decrease in myocardial oxygen demand. Question: The brand name for isosorbide dinitrate is:    Nipride.      Nifediac.      Isordil.      Isuprel.   Explanation: The brand name for isosorbide dinitrate is Isordil. It is classified as a vasodilator and a nitrate. The generic name for Nipride is nitroprusside; Nifediac is nifedipine; Isuprel is isoproterenol. Question: Aliskiren (Tekturna) should not be administered concurrently with:    angiotensin-converting enzyme (ACE) inhibitors.      amphetamines.      antipsychotic agents.      barbiturates.   Explanation: Aliskiren (Tekturna) may enhance the hyperkalemic, hypotensive and nephrotoxic effect of angiotensin-converting enzyme (ACE) Inhibitors. The combined use of aliskiren and angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) in patients with diabetes is contraindicated. Combined use in other patients should be avoided, particularly when CrCl is less than 60 mL/min. The combined use of aliskiren and amphetamines, antipsychotic agents, and barbiturates may cause a reduction in efficacy or enhanced efficacy of the aliskiren and should be monitored. However, they are not contraindicated. Question: Triamterene (Dyrenium), a diuretic, should not be used in the presence of:    hypokalemia.      anuria.      edema secondary to cirrhosis.      idiopathic edema.   Explanation: Triamterene (Dyrenium) is a potassium-sparing diuretic. It is a potential nephrotoxin, can induce the formation of triamterene crystals and granular casts, and may cause nephrolithiasis or acute kidney injury. It is contraindicated in the presence of anuria and hyperkalemia. Triamterene is used in the treatment of edema associated with congestive heart failure, cirrhosis of the liver, nephrotic syndrome, steroid-induced edema, idiopathic edema, and edema due to secondary hyperaldosteronism. Dyrenium may be used alone or with other diuretics, either for its added diuretic effect or its potassium-sparing potential. Question: An example of a cardioselective beta-blocker used in the treatment of heart failure is:    nicardipine (Cardene).      losartan (Cozaar).      metoprolol (Lopressor).      propranolol (Inderal).   Explanation: Both metoprolol (Lopressor) and propranolol (Inderal) are classified as beta-blockers. However, Lopressor is a cardioselective beta-blocker (selectively blocks beta1 receptors) and propranolol is a nonselective (blocks beta1 and beta2 receptors) beta-blocker. Examples of other cardioselective beta-blockers include acebutolol (Sectral), atenolol (Tenormin), and bisoprolol (Zebeta). Nicardipine (Cardene) is a calcium channel blocker. Losartan (Cozaar) is an angiotensin receptor blocker (ARB). Question: What is the earliest time a digoxin level can be obtained on a patient whose most recent dose was at 7 am?    9:00 AM      10:00 AM      12:00 PM      1:00 PM   Explanation: Regardless of route of administration, digoxin levels should be checked 12-24 hours after the last dose. However, depending on the clinical situation, wait at least 6-8 hours after the last dose to check levels. Signs and symptoms of digitalis toxicity include: confusion, irregular pulse, loss of appetite, nausea, vomiting, diarrhea, fast heart beat, and visual changes (blurred vision, blind spots, green-yellow color disturbances, halo effect). Question: A common side effect of angiotensin II receptor blockers (ARBs) such as candesartan (Atacand) is:    tinnitus.      hypertension.      hyperkalemia.      hypernatremia.   Explanation: Common side effects of angiotensin II receptor blockers (ARBs; i.e., candesartan [Atacand]) include dizziness, headaches, drowsiness, sexual dysfunction, hyperkalemia, hypotension, and muscle or bone pain. A dry cough may occur with ARBs, but is less likely than with angiotensin-converting enzyme (ACE) inhibitors. Question: Nifedipine (Adalat CC), a calcium channel blocker, is indicated in the treatment of:    heart failure.      cardiovascular shock.      chronic stable angina.      ST-elevation myocardial infarction.   Explanation: Nifedipine (Adalat CC), a calcium channel blocker, is indicated for the treatment of chronic stable or vasoactive angina and hypertension. Nifedipine is a dihydropyridine. The most smooth muscle-selective class of calcium channel blockers is the dihydropyridines. Adalat is contraindicated in patients with ST-elevation myocardial infarction, cardiovascular shock and heart failure. Question: Aspirin can be prescribed for children who have rheumatic fever, pericarditis, or:    fever associated with varicella.      Kawasaki disease.      thrombocytopenic purpura.      hemophilia.   Explanation: Aspirin can be prescribed for children who have rheumatic fever, pericarditis, or Kawasaki disease. If given to children who have hemophilia or thrombocytopenic purpura, it will cause increased bleeding. Aspirin use in children who have fever related to varicella could develop Reye's syndrome. It should be administered with food to decrease stomach upset or bleeding. Question: Fibric acid derivatives such as fenofibrate (Tricor) should be discontinued if:    AST increases from 35 units per liter to 45 units per liter.      low-density lipoprotein decreases from 200 mg/dL to 145 mg/dL.      high-density lipoprotein decreases from 50 mg/dL to 10 mg/dL.      white blood cell counts decrease from 4.5 109 per liter (L) to 3.3 109 per liter (L).   Explanation: A paradoxical, severe, reversible decrease in high-density lipoproteins has occurred with the administration of fibric acid derivatives (i.e., fenofibrate [Tricor]; gemfibrozil [Lopid]). If this occurs, fibrates should be discontinued and should not be restarted. White blood cell counts may decrease, but they generally stabilize as therapy continues. Baseline and regular periodic monitoring of liver function should be performed with fibric acid therapy. Therapy should be discontinued if enzyme levels persist above three times the normal limit. A decrease in low-density lipoproteins is expected. Question: Cardioselective beta-blockers:    specifically block beta-1 receptors.      should never be administered to patients who have asthma.      are recommended as first-line treatment for hypertension.      should be discontinued 5 days prior to surgery.   Explanation: Selective beta-blockers specifically block beta-1 receptors, although they can be nonselective at higher doses. Beta-blockers are generally not recommended as first-line agents for the treatment of hypertension. The use of cardioselective beta-blockers in the presence of asthma or severe chronic obstructive pulmonary disease (COPD) are generally safe in low doses. Exacerbations of angina and, in some cases, myocardial infarction, have been reported following abrupt discontinuation of beta-blocker therapy. Examples of selective beta-blockers are atenolol (Tenormin) and metoprolol (Lopressor). Question: Baseline and follow-up monitoring of ranolazine (Ranexa) should include:    serum transaminase and potassium.      serum BUN, creatinine and ECG.      blood pressure, pulse and CPK.      urine protein and CBC.   Explanation: Baseline and follow-up monitoring of ranolazine (Ranexa) should include serum BUN, creatinine and electrocardiogram (ECG). An ECG is obtained in order to evaluate for prolonged QT interval (>500 msec). Renal function should be monitored since acute renal failure has been observed, especially in patients with moderate to severe renal impairment. Ranexa exerts antianginal and anti-ischemic effects without changing heart rate or blood pressure. Serum potassium levels should be maintained within normal limits. Question: Acetaminophen (Tylenol) use in infants and children is:    calculated at 10-15 mg/kg/dose with a maximum of 4 g/24 hours.      a potent anti-inflammatory and is preferred over ibuprofen (Motrin).      not used in the presence of viruses due to the potential for Reye's syndrome.      administered as needed every 8 hours with a maximum of 2 g/24 hours.   Explanation: Dosing for acetaminophen (Tylenol) in infants and children is based on the child's weight. The standard dose is 10-15 mg/kg/dose with a maximum of 4 grams in 24 hours. Acetaminophen has little or no anti-inflammatory properties. It safe to use with varicella; it does not have to be administered with regard to food. The dosing interval can be every 4 hours, not to exceed 6 doses in a 24-hour period. Question: Warfarin (Coumadin) should be administered:    daily with or without food.      daily, only on an empty stomach.      twice daily with food.      three times daily with or without food.   Explanation: Warfarin is administered daily without regard to meals. The onset of anticoagulant action for oral warfarin (Coumadin) is 24-72 hours. The half-life elimination of warfarin (Coumadin) is 20-60 hours. Question: Patients who are started on olmesartan (Benicar) should be advised to report:    bladder spasms and dysuria.      constipation and weakness.      diarrhea and weight loss.      metallic taste and easy bruising.   Explanation: Patients should be advised to report persistent chronic diarrhea and weight loss while taking olmesartan medoxomil (Benicar). This drug can produce a sprue-like enteropathy characterized by severe chronic diarrhea and weight loss occurring months to years after initiation of the drug. Benicar is an angiotensin receptor blocker (ARB). Once other etiologies have been excluded, discontinue Benicar and consider an alternative hypertension treatment. Question: Ranolazine (Ranexa) exerts antianginal and anti-ischemic effects by:    donating nitric oxide to induce relaxation and vasodilation.      inhibiting the ability of calcium to serve as an intracellular messenger.      blocking voltage-gated potassium channels, terminating action potentials.      reducing sodium concentrations and calcium influx, thus decreasing oxygen consumption.   Explanation: Ranolazine (Ranexa) exerts antianginal and anti-ischemic effects by reducing intracellular sodium concentrations, thereby reducing calcium influx via sodium (Na+) -calcium (Ca2+) exchange. Decreased intracellular calcium reduces ventricular tension and myocardial oxygen consumption. Ranexa is indicated in the treatment of chronic angina. Question: What is the maximum half-life elimination of warfarin (Coumadin)?    8 hours      12 hours      16 hours      60 hours   Explanation: The half-life elimination of warfarin (Coumadin) is 20-60 hours. The onset of anticoagulant action for oral warfarin (Coumadin) is 24-72 hours. Warfarin acts by inhibiting the synthesis of vitamin K-dependent clotting factors, including Factors II, VII, IX, and X, and the anticoagulant proteins C and S. Question: Thiazide diuretics are indicated for the treatment of:    hypokalemia.      hypercalcemia.      hypertension.      urinary retention.   Explanation: Thiazide diuretics are used to treat hypertension, edema associated with heart failure, and cirrhosis of the liver. Diuretics lower blood pressure, at least initially, by inducing sodium and fluid loss. Examples of thiazide diuretics include chlorthalidone (Thalitone), hydrochlorothiazide (Microzide) and methyclothiazide. Question: A disadvantage of vitamin K antagonists for anticoagulation is their:    decreased efficacy.      numerous medication interactions.      expense and availability.      predictable pharmacokinetics.   Explanation: Disadvantages of vitamin K antagonists (VKAs) include various food interactions; multiple strong drug interactions; unpredictable pharmacokinetic and pharmacodynamic properties; a prolonged onset and offset of action; a long half-life; and the need for laboratory monitoring. Advantages include low cost, availability and the ability to increase anticoagulation effects based on dosing. Question: An example of a dihydropyridine calcium channel blocker is:    nebivolol (Bystolic).      verapamil (Calan).      diltiazem (Cardizem).      amlodipine (Norvasc).   Explanation: Dihydropyridines are a class of calcium channel blockers. They include nifedipine (Procardia), amlodipine (Norvasc) and nicardipine (Cardene). The dihydropyridines have a greater selectivity for vascular smooth muscle than for the myocardium, making them more potent vasodilators. Question: To reduce the flushing effects caused by nifedipine (Adalat CC), it should be taken with:    grapefruit.      milk.      an aspirin.      low-fat meals.   Explanation: To reduce the flushing effects caused by nifedipine (Adalat CC), it should be taken with low-fat meals. The capsule is rapidly absorbed orally if it is administered without food, but it may result in vasodilator side effects. In general, Adalat can be taken with or without food. Food may decrease the rate, but not the extent, of nifedipine absorption. Taking nifedipine with grapefruit can increase serum nifedipine concentrations, resulting in therapeutic and vasodilator side effects. Question: The brand name for hydralazine is:    Apresoline.      Imdur.      Nipride.      Vistaril.   Explanation: The brand name for hydralazine is Apresoline. It is classified as a vasodilator and a nitrate. The generic name for Imdur is isosorbide mononitrate; Nipride is nitroprusside, and Vistaril is hydroxyzine. Question: When prescribing angiotensin-converting enzyme (ACE) inhibitors for the treatment of hypertension, the patient should be instructed to:    take the medication with food.      return to the clinic for blood pressure checks every 3 months.      avoid adding potassium supplements to the diet.      expect a decrease in urinary output.   Explanation: Patients taking angiotensin-converting enzyme (ACE) inhibitors should avoid adding potassium to the diet. Hyperkalemia is a side effect of this class of drugs, and increasing potassium in the diet puts the patient at greater risk for hyperkalemia. ACE inhibitors can be taken without regard to food. They promote renal excretion of sodium and water (natriuretic and diuretic effects) by blocking the effects of angiotensin II in the kidney, therefore a decrease in urinary output would be a cause for concern. Blood pressure checks should initially occur weekly, then monthly until stable. Question: Increased adverse events are likely with the concomitant use of angiotensin-converting enzyme (ACE) inhibitors such as ramipril (Altace) and:    digoxin (Lanoxin).      irbesartan (Avapro).      acebutolol (Sectral).      furosemide (Lasix).   Explanation: The combination of angiotensin-converting enzyme (ACE) inhibitors and irbesartan (Avapro), an angiotensin II receptor blocker (ARB), puts the patient at higher risk for adverse events without additional benefits. ACE inhibitors and ARBs both work within the renin-angiotensin system. Significant adverse events including hypotension, hyperkalemia, and worsening renal function are experienced when they are combined. The other choices can be safely combined with ACE inhibitors. Question: A common side effect of angiotensin-converting enzyme (ACE) inhibitors used in the treatment of hypertension is:    tinnitus.      impotence.      hypokalemia.      a dry cough.   Explanation: Angiotensin-converting enzyme (ACE) inhibitors such as lisinopril (Zestril) have a relatively low incidence of side effects and are well tolerated. A common, annoying side effect of ACE inhibitors is a dry cough occurring in about 10% of patients. ACE inhibitor-induced cough is thought to be related to increased levels of kinins and substance P caused by the converting enzyme inhibition. Kinins are thought to induce bronchial irritation and cough via enhanced production of prostaglandins, which then stimulates afferent C-fibers in the airway. Hypotension can also be a problem, especially in patients with heart failure. Angioedema and hyperkalemia are also adverse effects of ACE inhibitors. The incidence of angioedema is 2 to 4 times higher in black patients compared to white patients. Impotence may occur, but is rare. [Show More]

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