Chapter 20 - Pharmacology for the Primary Care Provider - Test Bank

Chapter 20: Beta-Blockers Test Bank MULTIPLE CHOICE 1. An 80-year-old patient with chronic stable angina has begun taking nadolol (Corgard) 20 mg once daily in addition to taking nitroglycerin as needed. After 1 week, the patient reports no change in frequency of nitroglycerin use. The primary care nurse practitioner (NP) should change the dose of nadolol to _____ mg _____ daily. a. 40; once b. 80; once c. 20; twice d. 40; twice ANS: A b-Blockers are the treatment of choice for chronic stable and unstable angina. Their therapeutic effect is dose dependent, and drug titration should be based on frequency of angina symptoms and nitroglycerin use. Nadolol should be started at 20 mg daily for elderly patients when treating angina and should be increased by 20 mg every 3 to 7 days if symptoms do not improve. Nadolol is given once daily. DIF: Cognitive Level: Applying (Application) REF: 259| Table 20-7 2. A patient is in the clinic for a follow-up examination after a myocardial infarction (MI). The patient has a history of left ventricular systolic dysfunction. The primary care NP should expect this patient to be taking: a. nadolol (Corgard). b. carvedilol (Coreg). c. timolol (Blocadren). d. propranolol (Inderal). ANS: B The 2012 guides for prevention of cardiovascular disease recommend that b-blocker therapy should be used in all patients with left ventricular systolic dysfunction with heart failure or prior MI. Use should be limited to carvedilol, metoprolol succinate, or bisoprolol. DIF: Cognitive Level: Understanding (Comprehension) REF: 259 3. An 80-year-old patient has begun taking propranolol (Inderal) and reports feeling tired all of the time. The primary care NP should: a. tell the patient to stop taking the medication immediately. b. recommend that the patient take the medication at bedtime. c. tell the patient that tolerance to this side effect will occur over time. d. contact the patient?s cardiologist to discuss decreasing the dose of propranolol. ANS: D Elderly patients have described sedation and sleep disturbances with b-blockers. Elderly patients often need lower doses of these drugs. Patients should not be advised to discontinue the medication abruptly. DIF: Cognitive Level: Applying (Application) REF: 260 4. A patient with a history of coronary heart disease develops atrial fibrillation. The primary care NP refers the patient to a cardiologist who performs direct current cardioversion. The NP should expect the patient to begin taking which b-blocker medication? a. Nadolol (Corgard) b. Sotalol (Betapace) c. Timolol (Blocadren) d. Propranolol (Inderal) ANS: B Sotalol is classified as a class II and III antiarrhythmic and is a preferred agent in patients with a history of coronary heart disease. DIF: Cognitive Level: Applying (Application) REF: 259 5. A patient who has migraine headaches has begun taking timolol and 2 months after beginning this therapy reports no change in frequency of migraines. The patient?s current dose is 30 mg once daily. The primary care NP should: a. change the medication to propranolol. b. increase the dose to 40 mg once daily. c. obtain serum drug levels to see if the dose is therapeutic. d. tell the patient to continue taking the timolol and return in 1 month. ANS: D When giving timolol for migraine prophylaxis, the provider should inform the patient that it may take several weeks for therapy to be effective. The dose should be titrated and maintained for a minimum of 3 months before the treatment is deemed a failure. It may be necessary to change to propranolol if the therapy is not effective in 1 month. The maximum dose of timolol for migraine prophylaxis is 30 mg. Drug effectiveness is determined by patient response, not serum drug levels. DIF: Cognitive Level: Applying (Application) REF: 259 - 260 6. A patient who has been taking propranolol for 6 months reports having nocturnal cough and shortness of breath. The primary care NP should: a. tell the patient to stop taking the medication. b. obtain serum drug levels to monitor for toxicity of this medication. c. instruct the patient to increase activity and exercise to counter these side effects. d. contact the patient?s cardiologist to discuss changing to a selective b-blocker. ANS: D Nocturnal cough and shortness of breath may be a side effect of propranolol, which can cause bronchospasm because it is a nonselective â-blocker. The NP should discuss a selective b-blocker with the patient?s cardiologist. â-Blockers should never be stopped abruptly. Bradycardia and hypotension are signs of toxicity. Increasing activity would not counter these side effects if bronchospasm is the cause. DIF: Cognitive Level: Applying (Application) REF: 260 - 261 7. A patient is in the clinic for an annual physical examination. The primary care NP obtains a medication history and learns that the patient is taking a b-blocker and nitroglycerin. The NP orders laboratory tests, performs a physical examination, and performs a review of systems. Which finding may warrant discontinuation of the b-blocker in this patient? a. Increased triglycerides b. Decreased exercise tolerance c. Wheezing, dyspnea, and cough d. Nausea, vomiting, and anorexia ANS: C b-Blockers may cause bronchospasm in susceptible patients, and discontinuation of the b-blocker may be required. b-Blockers may cause an insignificant increase in serum triglycerides. Exercise intolerance, fatigue, and gastrointestinal side effects are common. DIF: Cognitive Level: Applying (Application) REF: 257 8. A primary care NP provides teaching for a patient who will begin taking propranolol (Inderal). Which statement by the patient indicates understanding of the teaching? a. ?I should take this medication on an empty stomach.? b. ?I should use caution while driving while taking this medication.? c. ?I should not take the medication if my pulse is less than 60 beats per minute.? d. ?If I have shortness of breath, I should discontinue the medication immediately.? ANS: B Because the medication can cause fatigue and drowsiness, patients should be advised to use caution when driving. The medication should be taken with food. Patients should not take a dose if the heart rate is less than 50 beats per minute. Patients should be advised to report shortness of breath but should not abruptly stop taking the medication. DIF: Cognitive Level: Applying (Application) REF: 258