FA DAVIS: Medications for Cardiovascular and Renal systems

Question 1

A patient will be starting on a medication regime of digoxin. Which information should the APN include in his education?

1. Missing or doubling doses is acceptable due to the drug’s long half-life.
2. Patients should eat a diet low in potassium.
3. Tablets cannot be crushed and administered with food.
4. Milk may have some effect on absorption, so doses should be separated by 1 hour of consumption.

Answer 1

4. Milk may have some effect on absorption, so doses should be separated by 1 hour of consumption.

Rationales

Option 1: Patients should take the drug exactly as prescribed, at the same time each day. The long half-life means that taking it at different times each day would be permissible, but the narrow therapeutic range means that missing a dose or doubling a dose could result in toxicity.

Option 2:Patients should eat a diet high in potassium (bananas, orange juice, tomato juice, spinach, melons, dates, raisins, soybeans, prunes, potatoes, and molasses), unless also taking a potassium-sparing diuretic or an angiotensin-converting enzyme inhibitor (ACEI).

Option 3:Tablets can be crushed and administered with food for patients who have difficulty swallowing.

Option 4:Patients should eat moderate amounts of calcium. Milk may have some effect on absorption, so doses should be separated by 1 hour. [Page reference: 294]

Question 2

Which drug is approved for cases of high triglycerides that do not respond to primary interventions?

1. Omega-3 carboxylic acid drug group
2. Fluvastatin
3. Atorvastatin
4. Rosuvastatin

Answer 2

1. Omega-3 carboxylic acid drug group

Rationales

Option 1:These drugs are approved for cases of high triglycerides that do not respond to primary interventions.

Option 2:Fluvastatin is drug used in low-intensity statin treatment that has less than a 30% reduction in LDL. Patients treated with statins may see just a modest decrease in triglycerides.

Option 3:Atorvastatin is drug used in moderate-intensity statin treatment. Patients treated with statins may see just a modest decrease in triglycerides.

Option 4: Rosuvastatin is drug used in high-intensity statin treatment. Patients treated with statins may see just a modest decrease in triglycerides. [Page reference: 1178]

Question 3

Which class of antianginal drugs negatively affects hypercholesterolemia by increasing triglycerides and low-density lipoprotein (LDL) cholesterol and reducing the level of high-density lipoprotein (HDL)?

1. Angiotensin-converting enzyme inhibitors (ACEIs)
2. Nonselective beta blockers
3. Cardioselective beta blockers
4. Calcium channel blockers

Answer 3

2. Nonselective beta blockers Rationales

Option 1:ACEIs have not been associated with a negative impact on hypercholesterolemia.

Option 2:The only class of antianginal drugs that negatively affects hypercholesterolemia is the nonselective beta blockers, which increase triglycerides and LDL cholesterol and reduce the level of HDL.

Option 3:The cardioselective beta blockers do not have as significant an effect on serum lipids.

Option 4:Calcium channel blockers have not been associated with a negative impact on hypercholesterolemia. [Page reference: 901]

Question 4

All calcium channel blockers (CCBs) are in which pregnancy category?

1. Pregnancy Category A
2. Pregnancy Category B
3. Pregnancy Category C
4. Pregnancy Category D

Answer 4

3. Pregnancy Category C

Rationales

Option 1:CCBs are not Pregnancy Category A, because teratogenic and embryotoxic effects have been demonstrated in small animals.

Option 2:CCBs are not Pregnancy Category B, because teratogenic and embryotoxic effects have been demonstrated in small animals.

Option 3:CCBs are Pregnancy Category C. Female patients capable of childbearing should be made aware of the risks of these drugs, and contraception should be instituted before CCBs are prescribed. They should be used only when benefits clearly outweigh risks.

Option 4:CCBs are not Pregnancy Category D because teratogenic and embryotoxic effects have been demonstrated in small animals. [Page reference: 286]

Question 5

Which information should be included in the education for a patient taking an antilipidemic?

1. Other drugs should be taken 1 hour before or 4 hours after the bile-acid sequestrant.
2. Lovastatin should be taken first thing in the morning.
3. Bile-acid sequestrants should be taken after meals.
4. A high-fiber diet may reduce the chance for muscle pain associated with reductase inhibitors.

Answer 5

1. Other drugs should be taken 1 hour before or 4 hours after the bile-acid sequestrant.

Rationales

Option 1: If other drugs are to be taken, administer them 1 hour before or 4 hours after the bile-acid sequestrant.

Option 2: Lovastatin is the only reductase inhibitor that should be taken with the evening meal to improve its absorption. Reductase inhibitors are traditionally taken in the evening because of their action on cholesterol synthesis; however, this is not clinically significant except for lovastatin.

Option 3: Bile-acid sequestrants are taken before meals and are mixed and vigorously shaken with 4 to 6 oz of water, milk, fruit juice, or a noncarbonated beverage. Rinsing the glass with a small amount of additional liquid ensures that the entire dose is taken.

Option 4: For all reductase inhibitors, muscle tenderness or pain may indicate a serious problem that may require discontinuance of the drug. [Page reference: 326]

Question 6

A patient who the APN has been treating with simvastatin presents today with complaints of diffuse myalgias and muscle tenderness and weakness. The APN notes that his creatine kinase (CK) value is more than 10 times the upper limit of normal. Which condition would the APN most likely suspect?

1. Hepatic injury
2. Renal insufficiency
3. Myopathy
4. Impaction

Answer 6

3. Myopathy

Rationales
Option 1:Hepatic injury would present with different signs and symptoms than exhibited by this patient.

Option 2:Renal insufficiency is not the most likely condition in this scenario.

Option 3:Myopathy should be considered in any patient with diffuse myalgias, muscle tenderness and weakness, and elevations in CK values more than 10 times the upper limit of normal.

Option 4:Impaction is associated with bile-acid sequestrants. This class of drugs has gastrointestinal (GI)-related adverse reactions. [Page reference: 317]

Question 7

A patient presents to the clinic today for follow up on hypertension. He states that he has noticed a dry “hacking” cough since he started lisinopril 4 weeks ago. He denies other respiratory or cardiovascular symptoms. Which action taken by the APN is most appropriate?

1. Increase the dose of lisinopril and evaluate the patient in 2 weeks.
2. Treat the patient with an antibiotic and prednisone.
3. Stop the lisinopril and start losartan.
4. Add aliskiren to the current medication regime.

Answer 7

3. Stop the lisinopril and start losartan.

Rationales
Option 1:This symptom is a common adverse reaction associated with discontinuation of an angiotensin-converting enzyme inhibitor (ACEI). Increasing the dose will not address the adverse reaction or lessen the patient’s symptoms.

Option 2:The patient reported the symptom as starting after he started an angiotensin-converting enzyme inhibitor (ACEI). This is likely an adverse reaction to the lisinopril because the patient is not having additional symptoms. Without additional information regarding the patient’s cough, the APN should consider the presenting symptom as an adverse reaction to the ACEI.

Option 3:A dry, hacking cough is a common adverse reaction noted in angiotensin-converting enzyme inhibitors (ACEIs). Because the action of bradykinin may be responsible for the adversereaction of the cough, changing to an angiotensin II receptor blocker (ARB) can still provide the benefits similar to the ACEI, but with less likelihood of cough.

Option 4:In this scenario, the patient is likely experiencing an adverse reaction. Adding an angiotensin II receptor blocker (ARB) to a regimen does not offer an increased benefit and may result in a less desirable effect. [Page reference: 278]

Question 8

Which drug blocks synthesis of cholesterol in the liver by competitively inhibiting HMG-CoA reductase activity and induces an increase in high-affinity low-density lipoprotein (LDL) receptors, resulting in an increased catabolism of LDL, and an increase in the liver’s extraction of LDL precursors?

1. Ezetimibe (Zetia)
2. Colestipol (Colestid)
3. Fluvastatin (Lescol)
4. Gemfibrozil (Lopid)

Answer 8

3. Fluvastatin (Lescol)

Rationales
Option 1:Ezetimibe (Zetia) blocks the absorption of cholesterol across the intestinal border. This results in a 12% reduction in LDL; however, it is not considered a first-line therapy except in children with familial hypercholesterolemia.

Option 2:Bile acid sequestrants (colestipol [Colestid] and cholestyramine [Questran]) exchange chloride ions for negatively charged bile acids, promoting a 10-fold increase in bile-acid excretion. The increased clearance results in enhanced conversion of cholesterol to bile acids by the liver. Increased uptake of LDL from plasma results from the upregulation of high-affinity LDL receptors on cell membranes, especially in the liver.

Option 3:Reductase inhibitors (atorvastatin [Lipitor], fluvastatin [Lescol], lovastatin [Mevacor], pitavastatin [Livalo], pravastatin [Pravachol], rosuvastatin [Crestor], and simvastatin [Zocor]) block synthesis of cholesterol in the liver by competitively inhibiting HMG-CoA reductase activity. They induce an increase in high-affinity LDL receptors, resulting in an increased catabolism of LDL and an increase in the liver’s extraction of LDL precursors.

Option 4:Fibric acid derivatives (gemfibrozil [Lopid] and fenofibrate [Tricor]) increase lipolysis of triglycerides via lipoprotein lipase, resulting in a decrease of 50% or more in triglyceride levels. A decrease in very-low-density lipoprotein (VLDL) is also related to decreased secretion by the liver. [Page reference: 321]

Question 9

Arrhythmias are caused either by abnormal pacemaker activity or by abnormal impulse conduction. The goal of therapy with an antiarrhythmic is to reduce ectopic pacemaker activity or alter abnormal conduction. By which major mechanism do antiarrhythmics act to do this?
1. Increasing chloride serum levels

2. Blockade of sympathetic nervous system (SNS) effects on the heart
3. Shortening of the refractory period
4. Increases of sodium levels in the blood

Answer 9

2. Blockade of sympathetic nervous system (SNS) effects on the heart

Rationales
Option 1:Blockade of the calcium channel is a major mechanism by which antiarrhythmics act.

Option 2:The major mechanisms by which antiarrhythmics act to do this are (1) sodium channel blockade, (2) blockade of SNS effects on the heart, (3) prolongation of the effective refractory period, and (4) blockade of the calcium channel.

Option 3:Prolongation of the effective refractory period is a mechanism by which antiarrhythmics act.

Option 4:Sodium channel blockade is a major mechanism by which antiarrhythmics act. [Page reference: 299]

Question 10

The APN is treating a 14-year-old patient for a complicated urinary tract infection (UTI). The APN notes on the urine culture and sensitivity report that the organism is only susceptible to quinolones. Which quinolone should be prescribed?

1. Ciprofloxacin
2. Gemifloxacin
3. Moxifloxacin
4. Enoxacin

Answer 10

1. Ciprofloxacin

Rationales
Option 1:Fluoroquinolones are not recommended in pediatric patients because of concerns for joint disorders. The only exception is ciprofloxacin, which can be prescribed as second-line therapy in complicated UTIs and pyelonephritis in children ages 1 year to 17 years.

Option 2:Fluoroquinolones are not recommended in pediatric patients because of concerns for joint disorders. However, there is one exception, which can be prescribed in this patient.

Option 3:Fluoroquinolones are not recommended in pediatric patients because of concerns for joint disorders. Moxifloxacin is not indicated in children.

Option 4:Fluoroquinolones are not recommended in pediatric patients because of concerns for joint disorders. However, there is one exception, which can be prescribed in this patient. [Page reference: 1337]

Question 11

Which adverse reaction is uncommon with use of angiotensin-converting enzyme inhibitors (ACEIs)?

1. Dizziness
2. Fatigue
3. Neutropenia
4. Cough

Answer 11

3. Neutropenia

Rationales
Option 1:Adverse reactions for ACEIs, angiotensin II receptor blockers (ARBs), and direct renin inhibitors (DRIs) are usually transient, mild, and more common in longer-acting agents. Most common are those associated with hypotension (dizziness, headache, fatigue, orthostatic hypotension). Tachyphylaxis frequently occurs with continued therapy.

Option 2:Adverse reactions for ACEIs, angiotensin II receptor blockers (ARBs), and direct renin inhibitors (DRIs) are usually transient, mild, and more common in longer-acting agents. Most common are those associated with hypotension (dizziness, headache, fatigue, orthostatic hypotension).

Option 3:Less common adverse reactions with ACEIs include a rash that is most common with captopril and neutropenia that increases with high doses, renal impairment, and concomitant collagen diseases. For ACEIs, the white blood cell (WBC) count with differential should be monitored. Therapy should be discontinued if the neutrophil count is fewer than 1,000/mm3.

Option 4:Adverse reactions for ACEIs, angiotensin II receptor blockers (ARBs), and direct renin inhibitors (DRIs) are usually transient, mild, and more common in longer-acting agents. Most common are those associated with hypotension (dizziness, headache, fatigue, orthostatic hypotension). Tachyphylaxis frequently occurs with continued therapy. Also common and often cited as the reason for discontinuance of ACEIs is a dry, hacking cough that usually occurs in the first week of therapy. [Page reference: 278]

Question 12

Which drug is considered to be a first-line therapy for the treatment of heart failure?

1. Non-dihydropyridine calcium channel blockers (CCBs)
2. Coenzyme Q10
3. Clopidogrel (Plavix)
4. Angiotensin-converting enzyme inhibitors (ACEIs)

Answer 12

4. Angiotensin-converting enzyme inhibitors (ACEIs)

Rationales
Option 1: Non-dihydropyridine CCBs should be avoided in heart failure based on their negative inotropism. The dihydropyridines amlodipine and felodipine (Plendil) are the only CCBs demonstrated to be safe in treating angina with concomitant heart failure caused by advanced left ventricular dysfunction.

Option 2: Coenzyme Q10 has not been shown to be effective as a therapy for heart failure.

Option 3: Clopidogrel (Plavix) is not considered a first-line treatment for heart failure.

Option 4: Several drugs used to treat angina also reduce blood pressure and improve myocardial function to reduce the risk for development of heart failure. ACEIs are associated with decreased morbidity and mortality from heart failure and are first-line therapy for that disorder. [Page reference: 891]

Question 13

The initial dose for an angiotensin II receptor blocker (ARB) may need to be lower in which of these?

1. Impaired hepatic function
2. Congestive heart failure
3. Diabetes
4. Male gender

Answer 13

1. Impaired hepatic function

Rationales
Option 1:For patients on ARBs, no change in dosage is required based on renal impairment; however, initial ARB doses may be lower for patients with impaired hepatic function. Liver function tests should be performed prior to initiating therapy and the dose may be increased as tolerated.

Option 2:Initial ARB doses may be lower in patients with impaired hepatic function.

Option 3:The presence of diabetes does not necessitate a lower initial start of dosage for an ARB.

Option 4:There is not an indication that the initiation of an ARB requires lower dosing in regard to gender. [Page reference: 273]

Question 14

Which drug inhibits the enzyme that converts T4 to T3, has iodine as a major component, and has a risk for patients with underlying predisposition to thyroid disease to develop thyrotoxicosis or hypothyroidism?

1. Enalapril
2. Amiodarone
3. Digoxin
4. Hydralazine

Answer 14

2. Amiodarone

Rationales
Option 1: Enalapril does not inhibit the enzyme that converts T4 to T3. Laboratory monitoring of renal function should take place with this drug.

Option 2: Amiodarone inhibits the enzyme that converts T4 to T3, and iodine is a major component of this drug. Therefore, about 5% of patients with an underlying predisposition to thyroid disease may develop thyrotoxicosis or hypothyroidism. If this drug must be used to treat the rhythm disturbance, careful monitoring and treatment of the thyroid disorder must be undertaken.

Option 3: Digoxin does not inhibit the enzyme that converts T4 to T3. Digoxin levels, serum electrolytes (potassium, calcium, magnesium) and renal status should be monitored.

Option 4: Hydralazine has no specific monitoring requirements beyond those used for patients with hypertension (HTN). Hydralazine sometimes induces a lupus-like syndrome. [Page reference: 303]

Question 15

Which action should be considered when planning the management of angiotensin II receptor blockers (ARBs)?

1. Stop diuretics for 2 to 3 days to allow hydration before starting an ARB.
2. Start at the highest dose and titrate as needed.
3. Increase the dose at 1- to 2-day intervals.
4. Increase the dose of diuretics before initiation of an ARB.

Answer 15

1. Stop diuretics for 2 to 3 days to allow hydration before starting an ARB.

Rationales
Option 1: When planning the initiation of an ARB, diuretics should be stopped for 2 to 3 days before starting an angiotensin-converting enzyme inhibitor (ACEI), ARB, or direct renin inhibitor (DRI).

Option 2: A general rule when initiating an ARB is to start at a low dose and increase the dose slowly. Adopting this approach reduces the risk for adverse effects.

Option 3: It is recommended that dosage increases should occur at 1- to 2-week intervals until the blood pressure is controlled.

Option 4: Diuretics should be stopped for 2 to 3 days to allow for hydration. An increased continued dose reduces rehydration and increases the risk of adverse effects. [Page reference: 278]

Question 16

Which precaution or contraindication is noted with the use of diuretics?

1. Hepatic dysfunction is an absolute contraindication to the use of a diuretic.
2. The use of diuretics can improve hyperuricemia in patients with a history of gout or renal calculi.
3. Potassium-sparing diuretics have an absolute contraindication for patients with severely impaired renal function.
4. Older adults are at increased risk for hypertension.

Answer 16

3. Potassium-sparing diuretics have an absolute contraindication for patients with severely impaired renal function.

Rationales
Option 1: Hepatic dysfunction is not an absolute contraindication. The guidelines instead suggest caution in patients with hepatic dysfunction with the use with all diuretics, especially those with some excretion in feces or bile.

Option 2: For patients with a history of gout or renal calculi, cautious use of diuretics is suggested because of the potential for hyperuricemia.

Option 3: Potassium-sparing diuretics have an absolute contraindication for patients with severely impaired renal function because they can produce hyperkalemia.

Option 4: Older adults are at increased risk for hypotension with these drugs. They require careful blood pressure (BP) monitoring and patient teaching about mobility with the background of possible orthostasis. The use of thiazide and loop diuretics has been associated with increased risk of falls in older adults. [Page reference: 329]

Question 17

Sudden withdrawal of calcium channel blockers (CCBs) can precipitate which condition?

1. Liver failure
2. Myocardial ischemia
3. Edema
4. Decreased heart rate

Answer 17

2. Myocardial ischemia

Rationales
Option 1: Liver failure with sudden withdrawal of CCBs is not noted. Liver function should be evaluated prior to initiating therapy. Dosage reductions for most CCBs are recommended with severe hepatic impairment because of the extensive metabolism of these drugs by the liver.

Option 2: It is important to induce a gradual withdrawal of CCBs because sudden withdrawal may precipitate myocardial ischemia.

Option 3: Edema can be noted as an adverse reaction associated with CCBs; sudden withdrawal is not noted to precipitate edema.

Option 4: Withdrawal from CCBs is not noted to induce a decreased heart rate independent of other factors. [Page reference: 291]

Question 18

Angiotensin-converting enzyme inhibitors (ACEIs) have a higher risk of angioedema and cough in which race?

1. Native American
2. Hispanic
3. White
4. Asian

Answer 18

4. Asian

Rationales
Option 1: The highest risk for the development of angioedema and cough is not noted in Native Americans.

Option 2: Hispanics are not considered to have the highest risk of developing angioedema and cough.

Option 3: Whites do not have the highest risk of developing angioedema and cough.

Option 4: Asians and African Americans have a 3- to 4-fold higher risk of angioedema and more coughs attributed to ACEIs than in whites. [Page reference: 278]

Question 19

Which calcium channel blocker (CCB) is the drug of choice during lactation if a CCB is required?

1. Verapamil
2. Nifedipine
3. Diltiazem
4. Nicardipine

Answer 19

2. Nifedipine

Rationales
Option 1: Verapamil is excreted extensively in breast milk.

Option 2: Nifedipine is excreted at less than 5% in breast milk, making it the drug of choice during lactation if a CCB is required.

Option 3: Diltiazem is excreted extensively in breast milk.

Option 4: Nicardipine (Cardene) is excreted extensively in breast milk. [Page reference: 286]

Question 20

Beta blockers (BBs) are generally contraindicated in which patient?

1. The patient who has unstable asthma
2. The patient who has had a myocardial infarction (MI)
3. The patient who has hypertension
4. The patient who has stable Type II diabetes

Answer 20

1. The patient who has unstable asthma

Rationales
Option 1: BBs are generally contraindicated for patients with unstable bronchospastic disorders such as asthma.

Option 2: BBs are the gold standard to help reduce the second cardiac event post-MI and are not contraindicated.

Option 3: BBs are used as a treatment for hypertension and are not contraindicated.

Option 4: BBs are used with caution for patients with diabetes who have major blood glucose variation ranges because they decrease insulin secretion and may mask many of the signs of hypoglycemia. [Page reference: 898]

Question 21

Nitrates can be used in which patient?

1. A 60-year-old patient with a recent cerebral hemorrhage
2. A 32-year-old patient with closed-angle glaucoma
3. A 55-year-old patient with bronchospastic asthma
4. A 40-year-old patient who has a hypersensitivity response to nitrates

Answer 21

3. A 55-year-old patient with bronchospastic asthma

Rationales
Option 1: Vasodilation can result in increased intracranial pressure; nitrates are contraindicated in head trauma or cerebral hemorrhage.

Option 2: Closed-angle glaucoma is a contraindication because intraocular pressure may be increased.

Option 3: There is not a contraindication to the use of nitrates in patients who have bronchospastic asthma.

Option 4: Some individuals have hypersensitivity or idiosyncratic responses to nitrates and must avoid them.

Question 22

Which condition has shown limited to no benefit with the initiation of HMG-CoA reductase inhibitors (statins)?

1. Advanced heart failure
2. Type II diabetes
3. Low-density lipoprotein (LDL) cholesterol levels above 150 mg/dL
4. Moderate atherosclerosis

Answer 22

1. Advanced heart failure

Rationales
Option 1: In the guidelines, there is a recommendation not to use statins in advanced heart failure patients. This disease state is a frequent comorbidity with lipid disorders; however, there is no evidence that statins affect mortality in this population. Any benefit is in early disease, when lipid reduction might be helpful. Once heart failure is advanced, these drugs have limited to no benefit.

Option 2: Diabetes is associated as a risk for atherosclerotic events and has been noted to benefit from this class of drugs.

Option 3: Persons with baseline LDL cholesterol at or above 130 mg/dL generally will require LDL-lowering drugs to achieve LDL cholesterol levels below 100 mg/dL, so drug therapy (usually with a statin) is initiated simultaneously with therapeutic lifestyle changes (TLC).

Option 4: Known moderate atherosclerosis is an indication for stating therapy.

Question 23

The APN is initiating an HMG-CoA reductase inhibitor. Which statement by the patient demonstrates understanding of the education of the drug?

1. “I will return in 6 to 8 weeks to repeat my lipid panel bloodwork.”
2. “I will require standard serial monitoring of liver laboratory tests every 4 weeks.”
3. “I will expect to experience some muscle pain 1 to 2 years after starting the medication.”
4. “If my dose is increased at my next appointment, I will return in one year to repeat my laboratory tests.”

Answer 23

1. “I will return in 6 to 8 weeks to repeat my lipid panel bloodwork.”

Rationales
Option 1: Levels of serum low-density lipoprotein (LDL) cholesterol should be evaluated 6 to 8 weeks after initiating therapy.

Option 2: Serial monitoring of liver laboratory test results is no longer indicated for most patients. In special circumstances, patients may need closer monitoring of laboratory tests.

Option 3: Myopathies do not occur in all patients and tend not to surface until 9 months into therapy.

Option 4: For all treatment regimens, if the dose of a drug is increased or another drug is added to the treatment regimen, the patient’s laboratory data should be evaluated in another 6 to 8 weeks.

Question 24

Angiotensin-converting enzyme inhibitors (ACEIs) can be prescribed in which condition?

1. Bilateral renal artery stenosis
2. Congestive heart failure
3. Pregnancy
4. Renal impairment

Answer 24

2. Congestive heart failure

Rationales
Option 1: The use of ACEIs represents an absolute contraindication in the presence of bilateral renal artery stenosis.

Option 2: The use of ACEIs can be prescribed for congestive heart failure and can be protective in the disease.

Option 3: ACEIs can cause fetal and neonatal morbidity and mortality. They are a Pregnancy Category C in the first trimester of pregnancy and a Pregnancy Category D in the second and third trimesters and during lactation.

Option 4: ACEIs in individuals with renal impairment should be used cautiously but are not considered an absolute contraindication. The vasodilating effects of these medications prevent the kidney from maintaining its perfusion, and ischemic renal failure may develop, requiring caution in the use in patients with impaired renal function.

Question 25

A new patient presents today for evaluation of hypertension. The patient states that he has been feeling weak and thinks that his heartbeat is irregular at times. The APN notes that the patient is being treated with lisinopril and spironolactone. Which condition would the APN most likely suspect?

1. Hypernatremia
2. Renal insufficiency
3. Hyperkalemia
4. Hypokalemia

Answer 25

3. Hyperkalemia Rationales

Option 1: In this patient scenario, the patient is taking an angiotensin-converting enzyme inhibitor (ACEI) and a potassium-sparing diuretic, which does not pose a risk for hypernatremia.

Option 2: In this patient scenario, the patient is taking an angiotensin-converting enzyme inhibitor (ACEI) and a potassium-sparing diuretic, which does not pose a risk for renal insufficiency.

Option 3: In this patient scenario, the patient is taking an angiotensin-converting enzyme inhibitor (ACEI) and a potassium-sparing diuretic. Concurrent administration of potassium-sparing diuretics and ACEIs may lead to significant hyperkalemia.

Option 4: Synergistic hypokalemia is probable between thiazide and loop diuretics. In this patient scenario, the patient is taking an angiotensin-converting enzyme inhibitor (ACEI) and a potassium-sparing diuretic.

Question 26

Calcium channel blockers (CCBs) are indicated to treat which condition?

1. Migraine headache prophylaxis
2. Raynaud’s syndrome
3. Esophageal spasm
4. Chronic angina

Answer 26

4. Chronic angina

Rationales
Option 1: Migraine headache prophylaxis is an unlabeled indication for CCBs; verapamil is the most common drug used.

Option 2: Raynaud’s syndrome is also an unlabeled indication. Type 2 CCBs are the choice for this disorder because of their peripheral vasodilating effects and some platelet inhibition. The drug most studied and the first choice is long-acting nifedipine.

Option 3: CCBs may be used unlabeled to offer transient improvement for patients with mild spasm. Diltiazem (90 mg, four doses daily) has been used. Because this drug makes gastroesophageal reflux disease (GERD) worse, this disorder might cause a CCB to be discontinued.

Option 4: Both type 1 and type 2 CCBs are effective in the treatment of stable and exertional angina. They act on both sides of the supply–demand equation: peripheral vasodilation and negative inotropes reduce oxygen demand; dilation of coronary arteries increases oxygen supply.

Question 27

Which laboratory abnormality can commonly occur with treatment of loop diuretics?

1. Elevated thyroid-stimulating hormone levels
2. Low potassium levels
3. Elevated hepatic enzymes
4. Hematuria

Answer 27

2. Low potassium levels

Rationales
Option 1: Elevated thyroid-stimulating hormone levels are not associated with treatment of loop diuretics.

Option 2: The most common electrolyte problem is hypokalemia. Any potassium supplementation must be based on serum levels because not all patients become hypokalemic or require supplementation beyond dietary changes.

Option 3: Hepatic impairment is not noted to be associated with the treatment of loop diuretics. Hypokalemia is common and must be assessed during therapy.

Option 4: Hematuria is a laboratory abnormality commonly associated with renal disease and is not noted with concurrent treatment with loop diuretics.

Question 28

Which angiotensin-converting enzyme inhibitor (ACEI) requires frequent dosing, which can subsequently negatively impact patient adherence in therapy?

1. Captopril
2. Benazepril
3. Ramipril
4. Lisinopril

Answer 28

1. Captopril

Rationales
Option 1: Captopril has a half-life of less than 2 hours and is the only short-acting ACEI. It requires two to three doses daily with steady state achieved in 2 to 3 days. The other drugs have longer half-lives and can be given daily.

Option 2: Benazepril has a longer half-life and duration in comparison with the drug described and does not require frequent dosing.

Option 3: The half-life of ramipril is one of the longest in the ACEI class and can be dosed less frequently.

Option 4: Lisinopril has a longer half-life in comparison with the drug described.

Question 29

CYP3A4 isoenzymes are involved in the metabolism of all calcium channel blockers (CCBs). The APN should educate that which food should be avoided if the patient is taking certain CCBs?

1. Celery
2. Grapefruit juice
3. Diet cola
4. Yogurt

Answer 29

2. Grapefruit juice

Rationales
Option 1: Celery is not a food to be avoided.

Option 2: CYP3A4 isoenzymes are involved in the metabolism of all CCBs. Drugs that inhibit this system, including grapefruit juice, may increase free drug levels.

Option 3: Diet cola is not a food to be avoided due to impact on CYP 3A4 isoenzymes.

Option 4: Yogurt is not a food to be avoided.

Question 30

A patient presents today for initiation of medication for his hypertension. He has a history of gout and takes antigout medication. Which medication can cause hyperuricemia in this patient?

1. Calcium channel blockers
2. Angiotensin-converting enzyme inhibitors
3. Thiazide diuretics
4. Nitrates

Answer 30

3. Thiazide diuretics

Rationales
Option 1: Calcium channel blockers are not noted to cause hyperuricemia.

Option 2: Angiotensin-converting enzyme (ACE) inhibitors are not noted to increase uric acid levels.

Option 3: For patients with a history of gout or renal calculi, cautious use of diuretics is suggested because of the potential for hyperuricemia. High levels of uric acid may occur with all diuretics. Thiazide and loop diuretics and spironolactone are the most likely to cause it, and indapamide (Lozol) is the least likely.

Option 4: Nitrates have not been associated with an increase in uric acid levels.

Question 31

Which drug can be used to treat hyperlipidemia in a patient with active liver disease?

1. Cholestyramine (Questran)
2. Simvastatin (Zocor)
3. Rosuvastatin (Crestor)
4. Fluvastatin (Lescol)

Answer 31

1. Cholestyramine (Questran)

Rationales
Option 1: Active liver disease is a contraindication for all antilipidemics except the bile-acid sequestrants. Bile acid sequestrants (colestipol [Colestid] and cholestyramine [Questran]) are the drugs noted in this class.

Option 2: Reductase inhibitors (atorvastatin [Lipitor], fluvastatin [Lescol], lovastatin [Mevacor], pitavastatin [Livalo], pravastatin [Pravachol], rosuvastatin [Crestor], and simvastatin [Zocor]) are contraindicated in active liver disease.

Option 3: Reductase inhibitors (atorvastatin [Lipitor], fluvastatin [Lescol], lovastatin [Mevacor], pitavastatin [Livalo], pravastatin [Pravachol], rosuvastatin [Crestor], and simvastatin [Zocor]) are contraindicated in active liver disease.

Option 4: The reductase inhibitors are extensively metabolized by the liver, often employing CYP 2C6 and 3A4 enzyme systems, and usually on first pass. Fluvastatin (Lescol) should not be used in patients with active liver disease.

Question 32

Which dosing consideration should the APN consider when initiating a calcium channel blocker (CCB) in the older adult?

1. Start at the highest dose and decrease the dose as needed.
2. Start on a fourth of the usual dose and increase daily.
3. Start on half the usual dose and increase doses gradually.
4. No dosing changes are needed in the older adult.

Answer 32

3. Start on half the usual dose and increase doses gradually.

Rationales
Option 1: Starting at a higher dose is the most likely to cause adverse drug responses.

Option 2: Starting at a low dose is a good option; however, increasing daily is not optimal because this can quickly increase the dose to high levels.

Option 3: For all CCBs, older adults should be started on half of the usual dose, and increases in dosage should be gradual to reduce adverse drug responses.

Option 4: As a rule, dosing in older adults for most medications is best at a lower dose and titrate up gradually. Dosing at the young to middle adult ranges are more likely to result in adverse drug reactions.

Question 33

Which patient is at risk for cardiac glycoside (CG) toxicity?

1. A 65-year-old healthy older adult
2. A 45-year-old who is on loop diuretics
3. A 25-year-old Type II diabetic
4. A 56-year-old who is on albuterol

Answer 33

2. A 45-year-old who is on loop diuretics

Rationales
Option 1: Older age is not a risk factor of CG toxicity. However, in older adults who are taking multiple medications, there is an increased risk of interactions between the drugs due to polypharmacy.

Option 2: Loop diuretics are more likely to cause CG toxicity because they can cause hypokalemia. Toxicity is commonly caused by excessive administration of a CG, too much diuresis resulting in hypokalemia, concurrent development of renal insufficiency, or by administration of drugs that interfere with excretion of digoxin.

Option 3: Diabetes Type II is not generally associated with an increased risk for CG toxicity.

Option 4: Albuterol is not listed as an interacting drug with cardiac glycosides.

Question 34

Which of these represents a rare adverse reaction associated with cardiac glycosides (CGs)?

1. Nausea
2. Gynecomastia
3. Vomiting
4. Anorexia

Answer 34

2. Gynecomastia

Rationales
Option 1: The gastrointestinal (GI) tract is the most common site of adverse drug reactions, including nausea. These result from central nervous system (CNS) actions, including chemoreceptor trigger zone stimulation.

Option 2: Gynecomastia is listed as a rare adverse reaction to cardiac glycosides.

Option 3: The gastrointestinal (GI) tract is the most common site of adverse drug reactions, including vomiting. These result from central nervous system (CNS) actions, including chemoreceptor trigger zone stimulation.

Option 4: The gastrointestinal (GI) tract is the most common site of adverse drug reactions, including anorexia. These result from central nervous system (CNS) actions, including chemoreceptor trigger zone stimulation.

Question 35

A patient presents for a follow-up appointment of her hypertension and is taking telmisartan. The APN notes that her blood pressure is elevated today and reviews her medication profile. Which medications could decrease the antihypertensive response and result in the elevated blood pressure reading?

1. Nitrates
2. Phenothiazines
3. Other antihypertensives
4. NSAIDs

Answer 35

4. NSAIDs

Rationales
Option 1: Additive hypotension may also occur with other antihypertensives, nitrates, phenothiazines, and acute alcohol ingestion. The antihypertensive response is reduced by NSAIDs because of their effect on prostaglandins.

Option 2: The antihypertensive response is reduced by NSAIDs because of their effect on prostaglandins. Additive hypotension may also occur with other antihypertensives, nitrates, phenothiazines, and acute alcohol ingestion.

Option 3: Additive hypotension may also occur with other antihypertensives, nitrates, phenothiazines, and acute alcohol ingestion. The antihypertensive response is reduced by NSAIDs because of their effect on prostaglandins.

Option 4: The antihypertensive response is reduced by NSAIDs because of their effect on prostaglandins. Patients should avoid concurrent use. NSAIDs should be avoided because they may counteract the effects of all three drug classes. The patient should be taught that it is important to not take over-the-counter drugs without informing their provider.

Question 36

The highest rate of adverse reactions is found in which calcium channel blocker (CCB)?

1. Diltiazem ER
2. Amlodipine
3. Verapamil ER
4. Nifedipine

Answer 36

4. Nifedipine

Rationales
Option 1: Diltiazem ER is a type 1 CCB, and the ER formulation is a sustained-release form. All adverse drug reactions for CCBs are less common with sustained-release forms because the amount of drug in the system at any given time is more stable.

Option 2: The highest rate of adverse reactions is found in the short-acting dihydropyridines (17%), with the lowest rate for this group being for amlodipine (less than 4%). All adverse drug reactions for CCBs are less common with sustained-release forms because the amount of drug in the system at any given time is more stable.

Option 3: Verapamil is a type 1 CCB, and the ER formulation is a sustained-release form. All adverse drug reactions for CCBs are less common with sustained-release forms because the amount of drug in the system at any given time is more stable.

Option 4: The highest rate of adverse reactions is found in the short-acting dihydropyridines (17%), with the lowest rate for this group being for amlodipine (less than 4%). All adverse drug reactions for CCBs are less common with sustained-release forms because the amount of drug in the system at any given time is more stable.

Question 37

A patient with left ventricular dysfunction is taking a calcium channel blocker (CCB) and a beta blocker (BB). This combination may induce which condition?

1. Heart failure or bradycardia
2. Tachycardia and hypotension
3. Angina and tachycardia
4. Hypoglycemia

Answer 37

1. Heart failure or bradycardia

Rationales
Option 1: Combinations of BBs and CCBs have been shown to be more effective than the individual drugs used alone. However, these combinations are questionable for patients with left ventricular dysfunction because together they may induce heart failure or bradycardia. Verapamil and diltiazem also should be avoided in these combinations.

Option 2: Combinations of long-acting nitrates and CCBs are rarely used because of the high risk for hypotension and because their adverse reaction profiles are additive. This combination is usually reserved for refractory cases of vasospastic angina. The use of a CCB and a BB is not associated with tachycardia.

Option 3: The combination of a CCB and a BB in the presence of left ventricular dysfunction may induce heart failure or bradycardia. The combination of both drugs will not induce angina and tachycardia.

Option 4: The combination of a CCB and a BB in the presence of left ventricular dysfunction may induce heart failure or bradycardia. The combination of both drugs will not induce hypoglycemia.

Question 38

A patient has been started on a calcium channel blocker (CCB). The APN should provide which instruction to the patient regarding use of CCBs?

1. Contact the health-care provider if the heart rate is greater than 80 beats per minute (bpm) and you experience fatigue.
2. Notify your health-care provider if you experience diarrhea and stomach cramping.
3. Contact your health-care provider if you notice any migraine headaches during the use of the medication.
4. Notify your health-care provider if you experience unusual swelling of hands, feet, or ankles, and/or decreased urine output.

Answer 38

4. Notify your health-care provider if you experience unusual swelling of hands, feet, or ankles, and/or decreased urine output.

Rationales
Option 1: Bradycardia is a possible adverse reaction, especially for patients on type 2 CCBs. Patients should learn how to monitor their own pulse rate and contact the health-care provider if the rate is fewer than 50 bpm or if they have irregular beats. Fatigue is a nonspecific symptom.

Option 2: Constipation is a common side effect noted with CCBs, especially with use of verapamil. Preventive action is required to alleviate the expected constipation. The patient should increase dietary fiber and fluid (if allowed). Stool softeners are prescribed prophylactically with verapamil and as needed with other CCBs.

Option 3: Migraine headaches are not noted as an adverse reaction associated with the use of CCBs.

Option 4: The patient should be educated regarding symptoms of heart failure, which include dyspnea, pronounced dizziness, nausea, more than the usual swelling of hands, feet, or ankles, and/or decreased urine output. The patient should contact their provider if they experience these symptoms, because CCBs can increase heart failure risk.

Question 39

Which drugs act uniquely by the direct blocking of renin itself, not on its genesis or on the angiotensin components of the renin-angiotensin-aldosterone (RAA) system?

1. Direct renin inhibitors (DRI)
2. Angiotensin-converting enzyme inhibitors (ACEIs)
3. Angiotensin II receptor blockers (ARBs)
4. Cardiac glycosides (CGs)

Answer 39

1. Direct renin inhibitors (DRI)

Rationales
Option 1: DRIs are related to the angiotensin-converting enzymes (ACEs) and angiotensin II receptor blockers (ARBs), but act uniquely by direct blocking of renin itself, not on its genesis or on the angiotensin components of the RAA system. DRIs directly impact renin levels with subsequent angiotensin I (AT I) and AT II reductions.

Option 2: ACEIs work by inhibiting angiotensin-converting enzyme (ACE) activity, which results in decreased production of angiotensin II (AT II) and aldosterone.

Option 3: ARBs do not affect angiotensin-converting enzyme (ACE) activity, but rather block the angiotensin II (AT II) receptor. They have similar actions to angiotensin-converting enzyme inhibitors (ACEIs) on vasoconstriction and aldosterone secretion, but no activity related to bradykinin.

Option 4: All CGs are strong and highly selective inhibitors of the sodium-potassium adenosine triphosphatase (ATPase) system—the “sodium pump.” The preferential binding of CGs to ATPase occurs following phosphorylation of the alpha subunit of the enzyme.

Question 40

The APN is prescribing sublingual nitroglycerin (NTG) to a patient. Which statement by the patient indicates that he understands the education regarding the drug?

1. “Once I open the nitroglycerin bottle, it is generally effective for 2 years.”
2. “I can store the unopened bottle on my car dash in case I need it.”
3. “If my chest pain is not relieved by the second dose of the nitroglycerin, I should take a third dose and call 911.”
4. “This medication takes a long time to start working.”

Answer 40

3. “If my chest pain is not relieved by the second dose of the nitroglycerin, I should take a third dose and call 911.”

Rationales
Option 1: Once a bottle is opened, it is generally only effective for about 6 months.

Option 2: NTG is volatile and must be kept in a tightly capped, amber-colored glass container and stored in a cool place.

Option 3: For an angina episode, sublingual dosing is 0.4 to 0.6 mg every 5 minutes for up to three doses. If the angina is not relieved by the second dose, the recommendation is to take the third dose and call 911.

Option 4: Sublingual NTG has rapid action, long-established efficacy, easy use, and low cost. A disadvantage is its short duration of action.

Question 41

The patient is an older adult who has a diagnosis of Type II diabetes mellitus and hypertension. The APN is prescribing her a beta blocker today. The APN should teach her that which symptom is an indication of hypoglycemia that is not masked by beta blockers?

1. Dizziness
2. Diaphoresis
3. Fatigue
4. Syncope

Answer 41

2. Diaphoresis

Rationales
Option 1: Dizziness is not an indication of hypoglycemia. The more common adverse reactions of antiarrhythmics are extensions of their actions. Reduction in blood pressure may result in dizziness.

Option 2: For patients with diabetes who must take a beta blocker, these drugs do not mask the diaphoresis associated with hypoglycemia. Diabetic patients should be taught to recognize this indication of hypoglycemia.

Option 3: Fatigue is not an indication of hypoglycemia. The more common adverse reactions of antiarrhythmics are extensions of their actions. Reduction in blood pressure may result in fatigue.

Option 4: Syncope is not an indication of hypoglycemia. The more common adverse reactions of antiarrhythmics are extensions of their actions. Reduction in blood pressure may result in syncope.

Question 42

A patient presents with a new complaint of nausea, vomiting, palpitations, and yellow-green halos around lights since he completed an antibiotic for a sinus infection. He has been taking brand name Lanoxin (digoxin) for several years with normal laboratory ranges. He recently had a basic chemistry profile, thyroid stimulating hormone, and a renal profile, all of which were within normal ranges. Which action taken by the APN is most appropriate?

1. Change his Lanoxin to generic digoxin.
2. Start sodium supplements and order laboratory tests to assess for renal impairment.
3. Order a digoxin level due to the recent use of an antibiotic.
4. Increase Lanoxin (digoxin) and order laboratory tests to assess potassium and sodium levels.

Answer 42

3. Order a digoxin level due to the recent use of an antibiotic.

Rationales
Option 1: Changing from a brand name to a generic could induce variably in bioavailability. Generic tablet preparations have a bioavailability of 70% to 80%; the bioavailability is 90% to 100% for digoxin elixir and encapsulated gel. The narrow safety margin between therapeutic effect, loss of effect, and toxicity means that even small variations in bioavailability can have serious consequences.

Option 2: Cardiac glycosides (CGs) are used cautiously for patients with electrolyte abnormalities because the concentrations of potassium, calcium, and magnesium in the extracellular compartment affect sensitivity to CGs and may result in toxicity.

Option 3: Approximately 10% of individuals have intestinal bacteria that inactivate digoxin in the gut, greatly reducing bioavailability and requiring higher-than-average doses to produce a therapeutic response. Treatment of these individuals with antibiotics can cause a sudden increase in bioavailability, which results in toxicity.

Option 4: In this scenario, it is likely that the patient is experiencing toxicity, so increasing the dose before assessing potassium and sodium levels is not recommended.

Question 43

Which medication has been associated with elongation, thickening, and enhanced pigmentation of fine body hair and has been used in treating male pattern baldness?

1. Amiodarone
2. Furosemide
3. Lisinopril
4. Minoxidil

Answer 43

4. Minoxidil

Rationales
Option 1: Amiodarone has not been associated with elongation, thickening, and enhanced pigmentation of fine body hair.

Option 2: There has not been an associated elongation, thickening, and enhanced pigmentation of fine body hair with the use of furosemide.

Option 3: Lisinopril has not been associated with elongation, thickening, and enhanced pigmentation of fine body hair.

Option 4: Minoxidil has been associated with elongation, thickening, and enhanced pigmentation of fine body hair. This effect has resulted in its use in treating male pattern baldness.

Question 44

The action of angiotensin-converting enzyme inhibitors (ACEIs), angiotensin II receptor blockers (ARBs), and direct renin inhibitors on the renin-angiotensin-aldosterone (RAA) system lowers blood pressure and reduces the adverse effects of which disease on the kidney?

1. Peripheral artery disease
2. Diabetes
3. Glycosuria
4. Multiple sclerosis

Answer 44

2. Diabetes

Rationales
Option 1: There is no clear connection that the use of these drugs has a protective effect with peripheral artery disease on the kidney.

Option 2: The action of ACEIs, ARBs, and direct renin inhibitors on the RAA system lowers blood pressure and reduces the adverse effects of diabetes on the kidney.

Option 3: Glycosuria is not a disease, but instead it is a symptom. ACEIs and ARBs do have renoprotective properties in individuals with proteinuria.

Option 4: Multiple sclerosis is a neurological disease. There is not a specific indication for the use of these drugs to reduce the adverse effects of multiple sclerosis on the kidney.

Question 45

Which medication sometimes induces a lupus-like syndrome that appears to be dose-related with an incidence highest in white women?

1. Hydralazine
2. Digoxin
3. Propranolol
4. Furosemide

Answer 45

1. Hydralazine

Rationales
Option 1: Hydralazine sometimes induces a lupus-like syndrome. It appears to be dose-related in that it occurs almost exclusively with doses above 50 mg. The incidence is highest in white women. A positive antinuclear antibody (ANA) test is found in these patients, but no renal impairment is seen. Discontinuing the drug reverses the syndrome, but the ANA does not return to normal until 6 to 8 months after the drug is stopped.

Option 2: This reaction is not seen with use of digoxin.

Option 3: This reaction is not seen with use of propranolol.

Option 4: This reaction is not seen with use of furosemide.

Question 46

These drugs are useful in the treatment of hypertension (HTN) and act by direct relaxation and dilation of arteriolar smooth muscle, thereby decreasing peripheral vascular resistance. They do not dilate the epicardial coronary arteries and do not relax venous smooth muscle. This best describes which type of drug?

1. Calcium channel blockers (CCBs)
2. Nitrates
3. Peripheral vasodilators
4. Cardiac glycosides (CGs)

Answer 46

3. Peripheral vasodilators

Rationales
Option 1: CCBs directly block the influx of calcium at the onset of the cycle, like the sodium channel blockade in local anesthetics. The drugs act from the inner side of the membrane and bind to channels in depolarized membranes, converting the mode of operation of the channel from frequent openings to rare openings. The result is a marked decrease in transmembrane calcium content and prolonged vascular smooth muscle relaxation.

Option 2: Nitroglycerin and its analogues act largely by providing more nitric oxide to vascular endothelium and arterial smooth muscle, resulting in vasodilation.

Option 3: Peripheral vasodilators, useful in the treatment of HTN, act by direct relaxation and dilation of arteriolar smooth muscle, thereby decreasing peripheral vascular resistance (PVR). They do not dilate the epicardial coronary arteries and do not relax venous smooth muscle.

Option 4: All CGs are strong and highly selective inhibitors of the sodium-potassium adenosine triphosphatase (ATPase) system—the “sodium pump.”