Chapter 32 - Pharmacology for the Primary Care Provider - Test Bank

Chapter 32: Diuretics Test Bank MULTIPLE CHOICE 1. A patient develops hypertension. The primary care nurse practitioner (NP) plans to begin diuretic therapy for this patient. The NP notes clear breath sounds, no organomegaly, and no peripheral edema. The patient?s serum electrolytes are normal. The NP should prescribe: a. furosemide (Lasix). b. triamterene (Dyrenium). c. acetazolamide (Diamox). d. hydrochlorothiazide (HydroDIURIL). ANS: D Thiazide diuretics are first-line drugs for treating hypertension. The other three drugs are not thiazide diuretics. DIF: Cognitive Level: Applying (Application) REF: 376 2. A patient takes hydrochlorothiazide to treat hypertension and asks the primary care NP why it is necessary to reduce sodium intake while taking this medication. The NP should explain that decreasing sodium is necessary to: a. prevent renal insufficiency. b. minimize the risk of hypokalemia. c. prevent postdiuretic sodium retention. d. increase the likelihood that the drug may be discontinued. ANS: C If dietary salt intake is high, the amount of sodium lost in response to the diuretic may be partially or completely offset by postdiuretic sodium retention. Sodium restriction does not prevent renal insufficiency or minimize the incidence of hypokalemia. Sodium restriction is necessary to maintain the drug?s effectiveness but does not increase the chance of discontinuing the medication. DIF: Cognitive Level: Applying (Application) REF: 372 3. A patient with congestive heart failure will begin therapy with a diuretic medication. The primary care NP orders laboratory tests, which reveal a glomerular filtration rate (GFR) of 25 mL/minute. The initial drug the NP should prescribe is: a. metolazone. b. furosemide (Lasix). c. spironolactone (Aldactone). d. hydrochlorothiazide (HydroDIURIL). ANS: A Thiazides are the most frequently used and the least expensive drugs administered to treat hypertension and are considered first-line treatments. In patients with a GFR less than 30 mL/minute, thiazides are relatively ineffective, with the exception of metolazone. Furosemide may be added as a second-line drug. Potassium-sparing diuretics, such as spironolactone, should be used with great caution or avoided altogether in patients with renal insufficiency. DIF: Cognitive Level: Applying (Application) REF: 372 4. A patient who has congestive heart failure and arthritis has been taking chlorthalidone (Zaroxolyn) 25 mg daily for 6 months. The primary care NP notes a persistent blood pressure of 145/90 mm Hg. The NP should: a. ask the patient which medications are used for pain. b. add furosemide (Lasix) to the patient?s drug regimen. c. increase the dose of chlorthalidone to 100 mg daily. d. recommend that the patient use salt substitutes to season foods. ANS: A For diuretic resistance, the NP should evaluate factors such as patient nonadherence, physiologic causes, and drugs that may increase resistance, including nonsteroidal antiinflammatory drugs (NSAIDs). This patient has arthritis, and it is likely that NSAID use may be causing diuretic resistance. A second drug, such as furosemide, should be added after the cause of diuretic resistance is determined. The maximum daily dose of chlorthalidone is 100 mg per day, but increasing the dose is not recommended to treat diuretic resistance. Recommending salt substitutes is not indicated. DIF: Cognitive Level: Applying (Application) REF: 373 5. The primary care NP is preparing to prescribe a diuretic for a patient who has heart failure. The patient reports having had an allergic reaction to sulfamethoxazole-trimethoprim (Bactrim) previously. The NP should prescribe: a. ethacrynic acid. b. furosemide (Lasix). c. acetazolamide (Diamox). d. hydrochlorothiazide (HydroDIURIL). ANS: A Patients who are allergic to sulfa drugs should avoid diuretics that are sulfonamide derivatives. Ethacrynic acid is the only choice that is not a sulfonamide derivative. DIF: Cognitive Level: Applying (Application) REF: 372 6. The primary care NP sees a patient several months after a myocardial infarction (MI). The patient has been taking furosemide to treat heart failure. The NP notes that the patient has edema of the hands, feet, and ankles. The NP should add which drug to this patient?s regimen? a. Ethacrynic acid b. Chlorothiazide (Lozol) c. Triamterene (Dyrenium) d. Spironolactone (Aldactone) ANS: B The addition of a thiazide to a loop diuretic along with sodium restriction may be useful in the treatment of refractory edema in patients with congestive heart failure. Ethacrynic acid is a loop diuretic. The other two options are potassium-sparing diuretics. DIF: Cognitive Level: Applying (Application) REF: 373 7. The primary care NP sees a patient who has a history of hypertension and alcoholism. The patient is not taking any medications. The NP auscultates crackles in both lungs and palpates the liver 2 cm below the costal margin. Laboratory tests show an elevated creatinine level. The NP will refer this patient to a cardiologist and should prescribe: a. albuterol metered-dose inhaler. b. furosemide (Lasix). c. spironolactone (Aldactone). d. chlorthalidone (Zaroxolyn). ANS: B In the treatment of heart failure, loop diuretics relieve the congestive symptoms of pulmonary and congestive edema. Loop diuretics are also useful to treat states of volume excess in cirrhosis and renal insufficiency. Because this patient has a history of alcoholism and has an enlarged liver on examination, furosemide is a good first choice to relieve this patient?s congestive symptoms. Spironolactone and chlorthalidone are not loop diuretics. Albuterol might be used for symptomatic treatment only. DIF: Cognitive Level: Applying (Application) REF: 373 8. The primary care NP sees a patient who has heart failure following an MI 6 months before this visit. The patient has been taking an ACE inhibitor, nitroglycerin, furosemide, and hydrochlorothiazide. The NP auscultates crackles in both lungs and notes pitting edema of both feet. The NP should prescribe: a. mannitol. b. metolazone. c. acetazolamide (Diamox). d. spironolactone (Aldactone). ANS: D Spironolactone has been shown to be of particular benefit in the treatment of severe congestive heart failure when added to an ACE inhibitor and a loop diuretic. DIF: Cognitive Level: Applying (Application) REF: 374 9. A patient has been taking furosemide 80 mg once daily for 4 weeks and returns for a follow-up visit. The primary care NP notes a blood pressure of 100/60 mm Hg. The patient?s lungs are clear, and there is no peripheral edema. The patient?s serum potassium is 3.4 mEq/L. The NP should: a. continue furosemide at the current dose. b. decrease furosemide to 60 mg once daily. c. increase furosemide to 80 mg twice daily. d. change furosemide dose the 40 mg twice daily. ANS: B The major toxicities related to loop diuretics result from fluid and electrolyte imbalances. This patient has a low potassium level just under the lower limit, so a reduction in dose is indicated. DIF: Cognitive Level: Applying (Application) REF: 374 10. A patient is taking spironolactone and comes to the clinic complaining of weakness and tingling of the hands and feet. The primary care NP notes a heart rate of 62 beats per minute and a blood pressure of 100/58 mm Hg. The NP should: a. obtain a serum drug level. b. order an electrocardiogram (ECG) and serum electrolytes. c. change the medication to a thiazide diuretic. d. question the patient about potassium intake. ANS: B The patient is showing signs of hyperkalemia, so the NP should order an ECG and serum electrolytes. This should be done before changing the medication. Because hyperkalemia can cause fatal arrhythmias, an ECG is necessary. DIF: Cognitive Level: Applying (Application) REF: 374