NCLEX Review

isoniazid (INH) Drug Class: Antitubercular

* First-line med for tuberculosis; is a bactericidal * Contraindicated in clients with hypersensitivity or with acute liver disease * Use with caution in patients taking hepatotoxic medications; isoniazid increases risk for hepatotoxicity * May increase risk of toxicity of carbamazepine (Tegretol) and phenytoin (Dilantin) * Side effects: peripheral neuritis, neurotoxicity, hepatotoxicity, pyridoxine (vit B6) deficiency, dizziness, hyperglycemia, vision changes, hepatitis * Administered 1 hour before or 2 hours after meals; food delays absorption * Administered 1 hour before antacids, especially those that contain aluminum pyridoxine administered to reduce risk of neurotoxicity * Instruct client to avoid alcohol, avoid tyramine-containing foods & report signs of neurotoxicity, hepatitis & hepatotoxicity. Also, report visual changes. * Other first-line meds include rifampin (Rifadin), ethambutol (Myambutol), pyrazinamide, rifabutin (Mycobutin), and rifapentine (Priftin).

Tuberculosis

* Highly communicable disease caused by mycobacterium tuberculosis. * Signs and Symptoms: asymptomatic in primary infection, fatigue, lethargy, anorexia, weight loss, low-grade fever, chills, night sweats, persistent cough and the production of mucoid and mucopurulent sputum (may be streaked with blood), and chest tightness with dull aching chest pain that may accompany the cough. * Advanced disease: Dullness with percussion over the involved parenchymal areas, bronchial breath sounds, rhonchi, and crackles; partial obstruction of a bronchus caused by endobronchial disease or compression by lymph nodes may produce localized wheezing and dyspnea. * Increase intake of foods rich in iron, protein, and vitamin C. * Sputum cultures every 2-4 weeks once med therapy started; after 3 are negative, client is no longer infectious. * Individuals with active TB treated 6 to 9 months. Individuals with HIV treated for longer period of time. * Induration of 10mm or more is considered a positive Mantoux Test. Other tests: Chest x-ray, QuantiFERON-TB Gold test (blood analysis), and Sputum Cultures.

warfarin sodium (Coumadin) Drug Class: Anticoagulant

* Normal Dose Range: 2-10 mg * Suppresses coagulation by acting as an antagonist of vit K * Used for long-term anticoagulation; mainly to prevent thrombophlebitis, pulmonary embolism, and embolism formation caused by atrial fibrillation, thrombosis, myocardial infarction, or heart valve damage * Normal PT is 9.6 to 11.8; therapeutic range for warfarin is 1.5 to 2 times the control valve * Normal INR 0.9 to 1.1, therapeutic range for warfarin is 2 to 3; in patients with a mechanical prosthetic heart valve, 2.5 to 3.5 * If INR is below recommended range, increase warfarin * If INR is above recommended range; reduce warfarin

TB Tests/Treatment in Children

* Tests include Mantoux test, Sputum culture and chest x-ray. * Induration of 15mm or more is positive in children 4 or older with no risk factors; 10mm or more is positive in children 4 or older with chronic illness or high risk factor. * Because infants and children often swallow sputum, sputum cultures are done gastric washings (aspiration of lavages contents from the fasting stomach). Obtained in the early morning before breakfast. * Chest x-ray supplemental to sputum culture. * Treatment: 9-month isoniazid (INH) to prevent positive exposure from progressing to infection. For active TB, combination of isoniazid (INH), rifampin (Rifadin), and pyrazinamide daily for 2 months, and then isoniazid and rifampin twice weekly for 4 months.

digoxin (Lanoxin) Drug Class: Digitalis Glycoside

* Theraputic range is 0.5 to 2 ng/mL * Treats mild to severe systolic heart failure * Increases the force of contraction, slows the heart rate, decreases vasoconstriction * Hold if pulse is <60 or >100 beats/min in adults * Hold if pulse is <100 in infants * Antidote - digibind * Monitor for dig toxicity, hypokalemia, hypomagnesemia, or sudden increase in pulse rate that was previously normal

Electroconvulsive Therapy (ECT)

* Treatment for depression that consists of inducing a grand-mal (tonic-clonic) seizure by passing an electrical current through electrodes attached to the temples. * Administration of a muscle relaxant such as succinylcholine (Anectine) minimizes seizure activity, preventing damage to long bones and cervical vertebrae. * 6-12 treatments given 2-3 times per week. * Not a permanent cure. * Not effective in clients with dysthymic depression, depression and personality disorders, drug dependent clients, or those with depression as a result of situational or social difficulties. * Used in clients with major depressive and bipolar-depressive disorders, especially when psychotic symptoms are present (delusions of guilt, somatic delusions, and delusions of infidelity). Clients who have depression with marked psychomotor retardation and stupor. Manic clients whose conditions are resistant to lithium and antipsychotic medications and in clients who are rapid cyclers. Clients with schizophrenia (especially catatonia). * NPO after midnight or at least 4 hours before treatment * Ask client to void * Remove hairpins, contact lenses, and dentures

spironolactone (Aldactone) Drug Class: Potassium-sparing Diuretic

* Treats hypertension and edema * Can cause hyperkalemia * Weight & I&O's daily to determine fluid loss * Administer in AM to avoid interference with sleep * Patients should avoid foods high in potassium; oranges, bananas, avocados, cantaloupe, carrots, fish mushrooms, potatoes, pork, veal, raisins, spinach, strawberries, & tomatoes

Crutch Walking

* Two-point gait: Move left foot and right crutch forward. Move right foot and left crutch forward * Three-point gait: Move both crutches and injured foot forward. Place weight on both crutches. Move good leg forward * Four-point gait: Move left foot forward. Advance left crutch. Move right foot forward. * Swing-through gait: Advance both crutches, keep weight on good leg. Swing body to or beyond crutches, keep weight on good leg.

Intermediate-Acting Insulin: NPH (Humulin N)

* Often used to initiate therapy * Total daily dose split; 2/3 administered before breakfast and remaining 1/3 administered 30 minutes before dinner * Onset 1-2 hours; Peak 4-12 hours; Duration 16-28 hours * Hyperglycemia before lunch when administered before breakfast the previous day * Hypoglycemia 3PM to supper when administered before breakfast the same day

TB Isolation Precautions

* Placed with respiratory isolation precautions/airborne precautions * negative pressure room; door must be tightly closed * 6-12 air exchanges per hour; vent room air to outside * Health care workers must wear an N95 or higher particulate respirator mask; must be fitted * Must use 2 hands to mold nose piece * Must seal check before use; cover mask completely with both hands & exhale sharply to check for leakage * To remove the respirator, hold with one gloved hand. With the other hand, pull the bottom strap over your head, and then pull the top strap off

tramadol (Ultram) Drug Class: Opiate Agonist

* A synthetic opiate agonist that acts as an analgesic by selectively binding to the u receptors and inhibiting the reuptake of norepinephrine and serotonin * Treats mild to severe pain * Drowsiness, dizziness, and confusion may occur * Make position changes slowly, orthostatic hypotension may occur

Short-Acting Insulin: regular (Humulin R, Novolin R)

* Administered 30-60 minutes before meals * Onset 30 mins to 1 hour; Peak 2.5-5 hours; Duration 5-10 hours Humulin R and 8 hours Novolin R * Hyperglycemia early AM when administered at bedtime the previous night (8 hrs.) * Hypoglycemia before lunch when administered before breakfast the same day (4 hrs.) * Regular insulin is the only insulin that can be administered intravenously and is used in emergency treatment of diabetic ketoacidosis

Cane Walking

* Hold cane in opposite hand of affected side * Advance cane at the same time as the affected leg

Rapid-Acting Insulin: aspart (NovoLog) lispro (Humalog) glulisine (Apidra)

* Administered within 10-15 minutes of meal * Onset 10-20 minutes; Peak 1-3 hours; Duration 3-5 hours * Hyperglycemia after lunch when administered before breakfast (5 hrs.) * Hypoglycemia within 1-3 hours after administration

calcitonin, salmon (Miacalcin) Drug Class: Parathyroid Agent (calcium regulator)

* Antiresorptive medication * Secreted by the thyroid gland and inhibits osteoclastic bone resorption. * Treats Paget's disease, postmenopausal osteoporosis, and hypercalcemia * Administered intranasal or subcutaneous * Intranasal route: examine nares for irritation; alternate nostrils for doses. * Important to monitor for hypocalcemia * Other antiresorptive meds include raloxifene (Evista), and bisphosphonates such as alendronate (Fosamax), risedronate (Actone), and ibandronate (Boniva)

Deep Vein Thrombosis (DVTs)

* Calf or groin pain with or without swelling * Positive Homan's sign * Warm skin that is tender to touch * Bedrest; elevate affected extremity above level of heart (10-20 mins every few hours each day) * Avoid using knee gatch or pillow under knees * Do not massage; use TED hose; intermittent or continuous warm, moist compresses * Avoid prolonged sitting or standing, constrictive clothing, or crossing legs when seated * Inspect for edema and measure leg circumference * Avoid smoking; avoid medications unless prescribed; wear Medic-Alert bracelet

losartan (Cozarr) Drug Class: Antihypertensive

*Used to treat high blood pressure, to lower risk of stoke in certain people with heart disease, and to slow long-term kidney damage in people with type 2 diabetes *PT should avoid sunlight/wear sunscreen; photosensitivity may occur *Notify prescriber of mouth sores, fever, swelling of hands or feet, irregular heartbeat, chest pain *May cause dizziness, fainting; light-headedness *Rise slowly to minimize orthostatic hypotension *Use contraception while taking losartan; contraindicated in pregnancy 2nd/3rd trimester *Avoid salt substitutes, alcohol, grapefruit juice, OTC products unless approved by prescriber

A nurse is preparing to administer furosemide (Lasix) to a client with a diagnosis of heart failure. The most important laboratory test result for the nurse to check before administering this medication is: 1. Potassium level 2. Creatinine level 3. Cholesterol level 4. Blood urea nitrogen

1. Potassium level Rationale: Furosemide is a loop diuretic. The medication causes a decrease in the client's electrolytes, especially potassium, sodium, and chloride. Administering furosemide to a client with low electrolyte levels could precipitate ventricular dysrhythmias. Options 2 and 4 reflect renal function. The cholesterol level is unrelated to the administration of this medication.

Long-Acting Insulin: glargine (Lantus) detemir (Levemir)

* Most commonly injected in the evening * Onset 1 hour; No pronounced peak; Duration 24 hours * Hyperglycemia mid-AM to mid-PM when administered at bedtime the previous night * Because it is absorbed in a uniform manner without large fluctuations in insulin levels, there is little possibility of hypoglycemic reactions * Should not be mixed with other insulins

furosemide (Lasix) Drug Class: Loop Diuretic

*Inhibits tubular reabsorption of sodium and chloride *Most potent of all diuretics; may lead to significant electrolyte depletion *Used in patients with impaired kidney function *Used in nephrotic syndrome, heart failure, pulmonary edema, *Side effects: associated with rapid fluid loss; vertigo, hypotension, and possible circulatory collapse

A client has been taking isoniazid (INH) for 2 months. The client complains to a nurse about numbness, paresthesias, and tingling in the extremities. The nurse interprets that the client is experiencing: 1. Hypercalcemia 2. Peripheral neuritis 3. Small blood vessel spasm 4. Impaired peripheral circulation

2. Peripheral neuritis Rationale: A common side effect of the TB drug INH is peripheral neuritis. This is manifested by numbness, tingling, and paresthesias in the extremities. This side effect can be minimized by pyridoxine (vitamin B6) intake. Options 1, 3, and 4 are incorrect.

A client is to begin a 6-month course of therapy with isoniazid (INH). A nurse plans to teach the client to: 1. Drink alcohol in small amounts only. 2. Report yellow eyes or skin immediately. 3. Increase intake of Swiss or aged cheeses. 4. Avoid vitamin supplements during therapy.

2. Report yellow eyes or skin immediately. Rationale: INH is hepatotoxic, and therefore the client is taught to report signs and symptoms of hepatitis immediately (which include yellow skin and sclera). For the same reason, alcohol should be avoided during therapy. The client should avoid intake of Swiss cheese, fish such as tuna, and foods containing tyramine because they may cause a reaction characterized by redness and itching of the skin, flushing, sweating, tachycardia, headache, or lightheadedness. The client can avoid developing peripheral neuritis by increasing the intake of pyridoxine (vitamin B6) during the course of INH therapy for TB.

Nalidixic acid (NegGram) is prescribed for a client with a urinary tract infection. On review of the client's record, the nurse notes that the client is taking warfarin sodium (Coumadin) daily. Which prescription should the nurse anticipate for this client? 1. Discontinuation of warfarin sodium (Coumadin) 2. A decrease in the warfarin sodium (Coumadin) dosage 3. An increase in the warfarin sodium (Coumadin) dosage 4. A decrease in the usual dose of nalidixic acid (NegGram)

2. A decrease in the warfarin sodium (Coumadin) dosage Rationale: Nalidixic acid can intensify the effects of oral anticoagulants by displacing these agents from binding sites on plasma protein. When an oral anticoagulant is combined with nalidixic acid, a decrease in the anticoagulant dosage may be needed.

A nurse provides dietary instructions to a client who will be taking warfarin sodium (Coumadin). The nurse tells the client to avoid which food item? 1. Grapes 2. Spinach 3. Watermelon 4. Cottage cheese

2. Spinach Rationale: Warfarin sodium is an anticoagulant. Anticoagulant medications act by antagonizing the action of vitamin K, which is needed for clotting. When a client is taking an anticoagulant, foods high in vitamin K often are omitted from the diet. Vitamin K-rich foods include green, leafy vegetables, fish, liver, coffee, and tea.

A nurse is caring for a client who has been prescribed furosemide (Lasix) and is monitoring for adverse effects associated with this medication. Which of the following should the nurse recognize as a potential adverse effect? Select all that apply. 1. Nausea 2. Tinnitus 3. Hypotension 4. Hypokalemia 5. Photosensitivity 6. Increased urinary frequency

2. Tinnitus 3. Hypotension 4. Hypokalemia Rationale: Furosemide is a loop diuretic; therefore, an expected effect is increased urinary frequency. Nausea is a frequent side effect, not an adverse effect. Photosensitivity is an occasional side effect. Adverse effects include tinnitus (ototoxicity), hypotension, and hypokalemia and occur as a result of sudden volume depletion.

A client complaining of not feeling well is seen in a clinic. The client is taking several medications for the control of heart disease and hypertension. These medications include a β-blocker, digoxin (Lanoxin), and a diuretic. A tentative diagnosis of digoxin toxicity is made. Which of the following assessment data would support this diagnosis? 1. Dyspnea, edema, and palpitations 2. Chest pain, hypotension, and paresthesia 3. Double vision, loss of appetite, and nausea 4. Constipation, dry mouth, and sleep disorder

3. Double vision, loss of appetite, and nausea Rationale: Double vision, loss of appetite, and nausea are signs of digoxin toxicity. Additional signs of digoxin toxicity include bradycardia, difficulty reading, visual alterations such as green and yellow vision or seeing spots or halos, confusion, vomiting, diarrhea, decreased libido, and impotence. *gastrointestinal (GI) and visual disturbances occur with digoxin toxicity*

A client with tuberculosis is being started on antituberculosis therapy with isoniazid (INH). Before giving the client the first dose, a nurse ensures that which of the following baseline studies has been completed? 1. Electrolyte levels 2. Coagulation times 3. Liver enzyme levels 4. Serum creatinine level

3. Liver enzyme levels Rationale: INH therapy can cause an elevation of hepatic enzyme levels and hepatitis. Therefore, liver enzyme levels are monitored when therapy is initiated and during the first 3 months of therapy. They may be monitored longer in the client who is greater than age 50 or abuses alcohol.

A nurse reinforces discharge instructions to a postoperative client who is taking warfarin sodium (Coumadin). Which statement, if made by the client, reflects the need for further teaching? 1. "I will take my pills every day at the same time." 2. "I will be certain to avoid alcohol consumption." 3. "I have already called my family to pick up a Medic-Alert bracelet." 4. "I will take Ecotrin (enteric-coated aspirin) for my headaches because it is coated."

4. "I will take Ecotrin (enteric-coated aspirin) for my headaches because it is coated." Rationale: Ecotrin is an aspirin-containing product and should be avoided. Alcohol consumption should be avoided by a client taking warfarin sodium. Taking prescribed medication at the same time each day increases client compliance. The Medic-Alert bracelet provides health care personnel emergency information.