NRSG 2100 Unit 3

The pregnant client plans to breast-feed her baby. She asks the nurse about the use of herbal products during breastfeeding. What is the best response by the nurse?

"Most drugs, including herbal products can be transferred to the infant during breast-feeding, so this is not recommended."

The nurse plans to administer a medication to a preschool-age child. Which approach indicates the nurse has an understanding of growth and development?

A brief explanation, followed by quick administration of the medication, is best.

The nurse is administering medication to a group of pregnant women. At which stage of fetal development will congenital malformation least likely occur? A. 1-2 weeks B. 3-4 weeks C. 5-6 weeks D. 7-8 weeks

A. 1-2 weeks

The nurse knows that patients characterized as slow acetylators: A. Are more prone to drug toxicity B. Require more time to absorb enteral medications C. Must be given liquid medication only D. Should be advised to decrease protein intake

A. Are more prone to drug toxicity

Older adults experience adverse effects more frequently than young adults due to which of the following? Select all that apply: A. Excessive prescribing B. Multiple-drug therapy C. Increased drug sensitivity D. Increased body mass E. Lack of consistent exercise

A. Excessive prescribing B. Multiple-drug therapy C. Increased drug sensitivity

Which of the following is considered a gender factor that may influence effective pharmacotherapy? Select all that apply: A. Fat-to-muscle ratio B. Cerebral blood flow C. Limited drug research on females D. Health beliefs E. Dietary considerations

A. Fat-to-muscle ratio B. Cerebral blood flow C. Limited drug research on females D. Health beliefs

A pregnant patient asks the nurse what factors determine if a drug will cross the placenta. The nurse's response will be based on which of the following principles? A. Highly lipid-soluble drugs cross the placental membrane more easily than low lipids B. The lower the lipid content, the easier it crosses the placental membrane C. Drugs with large molecular weight pass rapidly through the placental membrane D. Highly protein-bound drugs pass rapidly through the placental membrane

A. Highly lipid-soluble drugs cross the placental membrane more easily than low lipids

The experienced pediatric nurse is teaching a new nursing student about injections in the pediatric population. Which statement by the student would indicate that teaching was effective? A. IM injections in infants are absorbed slowly B. Children experience rapid absorption of IM injections C. IM injections are encouraged due to their predictable absorption rate D. Strong muscle contractions result in delayed absorption of the IM medication

A. IM injections in infants are absorbed slowly

In general, drug absorption in the older adult is somewhat slowed. What physiological changes may account for this? Select all that apply: A. Increased gastric pH B. Decreased rate of blood flow to the GI tract C. Increased gastrointestinal motility D. Increased body surface area E. Decreased cardiac output

A. Increased gastric pH B. Decreased rate of blood flow to the GI tract

Which statement by the patient would inform the nurse that more teaching is necessary prior to discharge? A. It doesn't matter if the medication works as long as the doctor prescribed it B. This medication is fully covered by my health insurance C. I have been taking my medications by myself all my life D. I don't mind making changes to my lifestyle while I am on this drug

A. It doesn't matter if the medication works as long as the doctor prescribed it

The health care provider knows that the pediatric patient and parents will most likely adhere to the medication regimen if the: A. Regimen is simple and inexpensive B. Medications are costly but well known C. Medications are prescribed for a long period D. Medications are taken at different times each day

A. Regimen is simple and inexpensive

The nurse is preparing to administer medication to the pediatric patient. Which factor(s) is/are true regarding the pharmacokinetics in the pediatric population? Select all that apply: A. Slower gastric motility in young children will keep the drug in the stomach longer B. Before 6 months of age, there is greater plasma protein binding of drugs and drug distribution will be lower in this age group C. Before age 5, the liver may not metabolize drugs as readily as an adult's liver and doses must be adjusted accordingly D. Drug excretion by the kidneys will not equal an adult's until the child is at least 2 years old E. Drugs with CNS effects have little to no effect in infants and very young children

A. Slower gastric motility in young children will keep the drug in the stomach longer C. Before age 5, the liver may not metabolize drugs as readily as an adult's liver and doses must be adjusted accordingly

The nurse is preparing to give an IM injection to a 7 month old infant. Which is the preferred site? A. Vastus lateralis B. Deltoid C. Dorsogluteal D. Ventrogluteal

A. Vastus lateralis

The community health nurse is visiting a postpartum mother who is breastfeeding her 3.2kg (7lb) infant daughter. Which of the following statements, if made by the mother indicates that further teaching is necessary? Select all that apply: A. When using OTC meds, I should only take the lowest effective dose B. The higher the dose of medication, the more likely it will be secreted into the breast milk C. I shouldn't take any drug during breast-feeding, even my prescriptions D. Medication in liquid form should be avoided since it more readily enters the breast milk E. Now that I am no longer pregnant, I don't need to worry about medicines affecting my baby

A. When using OTC meds, I should only take the lowest effective dose C. I shouldn't take any drug during breast-feeding, even my prescriptions D. Medication in liquid form should be avoided since it more readily enters the breast milk E. Now that I am no longer pregnant, I don't need to worry about medicines affecting my baby

How is absorption affected in a geriatric patient?

Absorption slows with aging. Due to increased gastric pH, oral tablets and capsules that require high levels of acid for absorption dissolve more slowly and take longer to reach their target tissue. Decreased blood flow to and from the GI delays the absorption of drugs. Slowed motility of the GI allows drugs to remain in the GI longer, allowing more time for absorption and increasing the risk for side effects.

Category X Drugs for Pregnancy

Adequate well-controlled or observational studies in animals or pregnant women have demonstrated positive evidence of fetal abnormalities or risks. The use of the product is contraindicated in women who are or may become pregnant. There is no indication for use in pregnancy. Examples: clomiphene, fluorouracil, isotretinoin, leuprolide, menotropins, methotrexate, misoprostol, nafarelin, oral contraceptives, raloxiphene, ribavirin, statins, temazepam, testosterone, thalidomide, and warfarin

Category D Drugs for Pregnancy

Adequate well-controlled or observational studies in pregnant women have demonstrated a risk to the fetus. However, the benefits of therapy may outweigh the potential risk. For example, the drug may be acceptable if needed in a life threatening situation or serious disease for which safer drugs cannot be used or are ineffective. Examples: ACE inhibitors, alcohol, alprazolam, ARBs in the second and third trimesters, carbamazepine, cyclophosphamide, gentamicin, lithium carbonate, methimazole, mitomycin, nicotine, NSAIDs in the third trimester, penicillamine, phenytoin, propylthiouracil, streptomycin, tetracyclines, and valproic acid

Category A Drugs for Pregnancy

Adequate, well-controlled studies in pregnant women have not shown an increased risk of fetal abnormalities to the fetus in any trimester of pregnancy. Examples: prenatal vitamins, insulin, thyroxine, folic acid

How is metabolism affected in a geriatric patient?

Age related changes in the liver can make it harder for the liver to metabolize drugs. Reduced metabolism means drugs will have extended durations of action and a longer half-life, thus they are able to accumulate in tissues for a more potent reaction.

How is distribution affected in a geriatric patient?

Age related fat storage increase causes lipid-soluble drugs to be stored in the body for longer, thus there is increased drug concentrations in the tissues, causing a greater response and a greater risk for adverse effects. Decrease in total body water can allow water-soluble drugs to be less diluted. The higher concentration produces more intense actions. Declining liver function results in fewer plasma proteins, thus there is more free drug in the blood. Higher levels of drugs are also able to enter the brain due to an inefficient blood-brain-barrier in the elderly.

Category B Drugs for Pregnancy

Animal studies have revealed no evidence of harm to the fetus; however, there are no adequate and well-controlled studies in pregnant women. OR. Animal studies have shown an adverse effect, but adequate and well-controlled studies in pregnant women have failed to demonstrate risk to the fetus in any trimester. Examples: penicillins, cephalosporins, azithromycin, acetaminophen, ibuprofen in the first and second trimesters

Category C Drugs for Pregnancy

Animal studies have shown an adverse effect and there are no adequate and well-controlled studies in pregnant women. OR. No animal studies have been conducted and there are no adequate and well controlled studies in pregnant women. Examples: most prescription medicines; antimicrobials such as clarithromycin, fluoroquinolones, and bactrim; selective serotonin repuptake inhibitors (SSRIs); corticosteroids, and most antihypertensives

What class of drug is most commonly prescribed for children?

Antibiotics

What is a teratogen?

Any substance, organism, or physical agent that interferes with growth or development of the embryo or fetus and produces a permanent abnormality or death.

Give an example of how gender affects pharmacotherapy

Aspirin is more effective at preventing heart attacks in men than in women.

The nurse has several educational pamphlets for the client about prescribed medications. Prior to giving the client these pamphlets, what is a primary assessment for the nurse?

Assess the client's reading level.

Evaluation in pharmacology

Assess the patient for expected therapeutic outcomes and determine if any adverse effects have occurred. All adverse effects should be documented and reported to the health care provider as well as the oncoming nurse. Have the patient teach you in order to assess their understanding.

A nursing diagnosis is created from which step of the nursing process?

Assessment

Best Pharmaceuticals for Children Act (BPCA) 2002

Authorized the FDA to contract for the testing of already approved pediatric drugs or when the pharmaceutical company declines the option of exclusivity.

Pediatric Research Equity Act of 2003

Authorized the FDA to require research of pediatric uses for new drugs when an approved use includes a condition or conditions applicable to pediatric patients.

In initiating holistic care with a patient who has chronic headaches, which action would the nurse take? A. Tell the patient to take Tylenol as directed on the label B. Ask the patient what he or she believes may be contributing the problem C. Monitor the patient's pupil response to light D. Refer the patient to an ophthalmologist for an eye exam

B. Ask the patient what he or she believes may be contributing the problem

A Native American patient states, "I will only take medications that are approved by the Shaman." The nurse understands that this statement reflects the patient's: A. Ethnicity B. Cultural Belief C. Genetic polymorphisms D. Health-related bias

B. Cultural Belief

Which age-related change in the older patient makes it necessary to reduce drug dosages? A. Decrease in total body fat B. Decrease in renal blood flow C. Increase in plasma protein levels D. Increase in total body water

B. Decrease in renal blood flow

One third of older adult patients report that they are often nonadherent with drug therapy. Which response is given most frequently for nonadherence? A. The drugs prevented me from doing other things I wanted to do B. I didn't have my medicine with me C. I wanted to save money D. I didn't believe the drugs were effective

B. I didn't have my medicine with me

The nurse completes an initial home assessment of an independent 82 year old woman recently diagnosed with type 2 diabetes mellitus managed with insulin injections. What is the most appropriate nursing action for insulin administration for this patient? A. Teach the daughter how to administer the insulin to her mother B. Instruct the patient how to administer the insulin C. Recommend daily visits by a home health aide to give the insulin D. Ask the health care provider to change the order to an oral antidiabetic medication

B. Instruct the patient how to administer the insulin

A patient in her first trimester of pregnancy asks the nurse which medications should be avoided during pregnancy. The nurse's response is based on the knowledge that during pregnancy: A. Most OTC medications are safe B. When possible, drug therapy is postponed until after pregnancy and lactation C. It is wise to discontinue all drugs used in treating medical conditions D. The decision whether or not to take medication is the responsibility of the woman

B. When possible, drug therapy is postponed until after pregnancy and lactation

The nurse is administering medications to a patient who is 32 weeks pregnant. Which of the following normal physiological principles associated with pregnancy will affect drug absorption? A. Medications are absorbed and distributed more quickly in pregnant women B. There is greater hemoconcentration of drugs in pregnant patients C. Drugs remain longer in the GI tract, leading to extended time for absorption D. Drug metabolism is highly affected by pregnancy

C. Drugs remain longer in the GI tract, leading to extended time for absorption

Drugs that are most likely to create drug interactions in pediatric patients are those with: A. Low potency B. Wide therapeutic index C. Extensive protein binding D. Effects on the skin

C. Extensive protein binding

Various psychosocial variable may influence nonadherence to pharmacotherapy. An example of this would occur when the patient reports that the prescribed drug: A. Produces and unpleasant aftertaste B. Is a very large tablet and difficult to swallow C. Is too expensive for the patient to afford D. Potentially causes hepatotoxicity

C. Is too expensive for the patient to afford

It is time to give a 3 year old oral medication. Which comment by the nurse is most therapeutic? A. This is the medicine that makes you better B. If you don't take your medicine you can't go home C. Would you like to take your medicine with water or juice D. See how easily your roommate has taken his medicine

C. Would you like to take your medicine with water or juice

What is adherence?

Compliance and willingness and ability to take medications as instructed on the label or by the health care provider.

Which is the most effective method for a nurse to recognize patient-specific genetic influences? A. Ask the patient if there have been drug-dose-related problems in the past B. Consult reference books and the internet for information C. Observe the effects with other patients of similar racial-ethnic background D. Be cautious with all drugs and observe for individual patient responses

D. Be cautious with all drugs and observe for individual patient responses

The nurse is preparing to discuss drug use during pregnancy with a group of nursing students. The main topic is the FDA drug classifications. Which of the following drugs should the nurse inform the students are the most detrimental to the fetus? A. Category A B. Category B C. Category C D. Category X

D. Category X

How is the absorption of drugs affected by pregnancy?

Drugs remain in the GI tract for a longer period of time, so there is more time for oral drugs to be absorbed. High estrogen levels cause increased hydrochloric acid in the stomach, which can affect the absorption of certain acid labile drugs. During early pregnancy, many women struggle to keep medication down due to nausea and vomiting.

How is the excretion of drugs affected by pregnancy?

Excretion is enhanced during pregnancy due to increased renal plasma flow during the first two trimesters. Because of these changes, doses may need to be adjusted.

What is the best way to explain a medication to a toddler?

Give the child a short, concrete explanation followed by immediate drug administration.

How might diet and alternative therapies affect pharmacotherapy?

If a patient's diet includes high amounts of foods or herbs that interact with certain medications, it can cause adverse effects.

How is distribution affected in pediatric patients?

Infants have a higher proportion of water in their body. This water dilutes water-soluble drugs, thus requiring a higher dose to cause adequate therapeutic effects. Lack of plasma proteins can lead to more free drug in infants and therefore lead to potential toxicity. The BBB is not fully developed in infants, so drugs can penetrate the CNS.

How does psychosocial nursing influence pharmacotherapy?

Information regarding the patient's social roles, stressors, culture, values, family, health, and well-being affects whether or not a medication is prescribed or given. For example if a patient is highly stressed or depressed, giving them a medication with a side effect of developing suicidal thoughts is not in the patient's best interest.

Potential fetal consequences of drug use

Intrauterine fetal death, physical malformations, growth impairment, behavioral abnormalities, and neonatal toxicity

The nurse knows that pregnancy affects the absorption, distribution, metabolism, and excretion of drugs. Which one is thought to be the least affected by pregnancy?

Metabolism

How is metabolism affected in pediatric patients?

Metabolism is significantly slower in children due to the immaturity of the liver enzymes. This leads to reduced clearance rates and extended half-lives for drugs metabolized by the liver. This leads to liver toxicity if the dose is not accurately determined and administered in adequately spaced intervals of time.

Planning in pharmacology

Minimize factors that contribute to med errors. Avoid using abbreviations, question unclear orders, do not accept verbal orders, and follow specific facility policies and procedures related to med administration. Be aware of situations or settings that may increase the risk of errors.

Assessment in pharmacology

Obtain a thorough medication history every time the patient enters the health care setting. Ask about food or medication allergies, health concerns, and use of OTC meds and herbal supplements. Assess renal and hepatic function. Identify areas of needed patient education with regard to medications.

How is absorption affected in pediatric patients?

Pediatric patients have increased gastric pH and delayed gastric emptying. This increases the time of absorption. The rate of bile salt secretion is diminished in preemies and newborns, which delays the absorption of lipid-soluble drugs/vitamins. Infants have slow and erratic absorption of IM injections due to low blood flow to skeletal muscles and subcutaneous tissues. Infant skin is thin and highly permeable and thus allows topical drugs and lotions to be absorbed rapidly

What are some variables that affect drugs transferring to breast milk?

Plasma drug level in the mother, solubility of the drug, molecular size and protein binding, drug ionization, drug half-life.

What are some variables that impact the transfer of drugs across the placenta?

Plasma drug level in the mother, solubility of the drug, molecular size, protein binding, drug ionization, blood flow to the placenta.

How is metabolism of drugs affected by pregnancy?

Pregnancy significantly affects metabolism as it changes the way certain liver enzymes act. The fetal liver is put in danger by some medications since it is not able to metabolize drugs at such an immature stage.

How can you encourage school-age children to take medications?

Provide the child with choices such as, taking one medication before another or what drink they want to take their medication with will distract children from the issue of whether or not they want the medicine or not.

What are some symptoms to watch for that could indicate drug adverse effects?

Sudden change in mental status, rapid weight loss, dehydration, restlessness, falls, anorexia, urinary/fluid retention, change in bowel habits, or major change in functional status of any organ system.

What is polypharmacy?

Taking multiple drugs concurrently

What is the primary role of nurses with regard to medications, as defined by state nurse practice acts and by regulating bodies such as the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO)?

Teaching clients about medications

What are the 2 methods of calculating pediatric dosages?

The body weight method: calculate the number of milligrams of drug, based on the child's weight in kilograms. (mg/kg) Body surface area method (BSA): uses an estimate of the child's BSA. The child's height and weight are plotted on a nomogram and a line is drawn between the points. The point where the line intersects the surface area line is the BSA. BSA/1.73 X adult dose X pediatric dose.

Which stage of fetal development is the baby most sensitive to teratogens?

The embryonic period, from 3 to 8 weeks postconception when internal structures are developing rapidly.

How is the distribution of drugs affected by pregnancy?

The increase of water in a woman's body during pregnancy leads to greater hemodilution of plasma proteins and drugs. Because plasma proteins are diluted, fewer are available to bind with drugs, thus there is more free drug in the plasma. This makes more drug available to be transferred across the placenta or secreted in breast milk. Heart rate may increase during pregnancy, leading to greater drug distribution.

What are some common conditions in teenagers that pharmacotherapy is used for?

The most common needs for pharmacotherapy in teens are for skin problems, headaches, menstrual symptoms, sex-related concerns, eating disorders, contraception, alcohol and tobacco use, and sports-related injuries.

How is excretion affected in a geriatric patient?

The rate of drug clearance decreases due to the decrease in renal function in older adults. The half-life of drugs is increased and thus the frequency and dosages should be decreased to avoid toxicity.

What is one of the most important factors that increase the risk for adverse effects in elders?

They have an increased number of drugs prescribed to them.

What are some ways that geriatric patients misuse drugs?

They may take more than their prescribed dose to try to speed their recovery. Some may split doses in order to make their prescription last longer. They may forget to take the medicine, or forget that they have already taken it and take another dose. They might not take the medicine because they don't like the side effects.

Reasons medication is used during pregnancy

Treatment of certain preexisting illnesses (epilepsy, asthma, hypertension, psychiatric) Treatment of complications related to pregnancy (thromboembolic disorders, gestational diabetes, gestational hypertension) Treatment of conditions unrelated to pregnancy (UTI or other infections)

What is the best site for an IM injection in infants?

Vastus lateralis (the thigh muscles) is the preferred IM site for infants because it has few nerves and is well developed in infants.

Preimplantation Period

Weeks 1-2 of the first trimester. Before implantation the developing embryo has not yet established a blood supply with the mother. This is called the "all-or-none" period because exposure to a teratogen either causes death of the embryo or has no effect. Drugs are less likely to cause congenital malformations during this period because the baby's organ systems have not yet begun to form. Drugs such as nicotine, however, can create a negative environment for the embryo and potentially cause intrauterine growth retardation

Embryonic Period

Weeks 3-8 postconception. Internal structures are developing rapidly. This is the period of maximum sensitivity to teratogens. Teratogenic agents taken during this phase can lead to structural malformation and spontaneous abortion. The specific abnormality depends on which organ is forming at the time of exposure.

Fetal Period

Weeks 9-40 postconception. During this time there is continued growth and maturation of the baby's organ systems. Blood flow to the placenta increases and placental vascular membranes become thinner. This maximizes the transfer of substances for mom to baby. This may result in baby receiving larger doses of medication and other substances from mom. Because the fetus lacks mature metabolic enzymes and efficient excretion mechanisms, medications will have a prolonged duration of action within the baby. Exposure will most likely cause slowed growth or impaired organ function, rather than gross structural malformations

Implementation in pharmacology

When engaged in a medication-related task, focus entirely on the task. Noise, other events, and talking coworkers can distract the nurse's attention and lead to med error. Verify the identity of each patient before administering medication, use correct procedures/techniques for all routes of administration, calculate doses correctly, double check doses with another nurse, open packages/bottles immediately prior to administering medication, record the med and dosage on the MAR immediately after administration, always confirm the patient has swallowed an oral med, never leave medication at the bedside, be alert for long-acting oral dosage forms (they must not be crushed, chewed, or broken in half).

How is excretion affected in pediatric patients?

Young children have immature renal systems with slower renal clearance, resulting in accumulation of drugs excreted by the kidneys.

What age-related change in the older patient makes it necessary to reduce drug dosages?

decrease in renal blood flow

Which physiologic difference in a pediatric patient would indicate a need for lower drug dosages?`

decreased glomerular filtration

A patient has been taking an antibiotic that has caused severe diarrhea as an adverse effect. Which nursing diagnosis would be a priority for this patient?

deficient fluid volume related to diarrhea

The nurse is taking care of a patient with liver dysfunction. What two issues should the nurse be concerned about?

metabolism of drugs protein binding