PHARM HESI review

The nurse receives a call from a client concerned about eliminating brown-colored urine after taking nitrofurantoin for a urinary tract infection. The nurse should make which appropriate response?

*"Continue taking the medication; the brown urine occurs and is not harmful."* Nitrofurantoin imparts a harmless brown color to the urine and the medication should not be discontinued until the prescribed dose is completed. Magnesium hydroxide will not affect urine color. In addition, antacids should be avoided because they interfere with medication effectiveness.

The nurse has given medication instructions to a client receiving phenytoin. Which statement indicates that the client has an adequate understanding of the instructions?

*"Good oral hygiene is needed, including brushing and flossing."* Typical antiseizure medication instructions include taking the prescribed daily dosage to keep the blood level of the medication constant and having a sample drawn for serum medication level determination before taking the morning dose. The client is taught not to stop the medication abruptly, to avoid alcohol, to check with a health care provider before taking over-the-counter medications, to avoid activities in which alertness and coordination are required until medication effects are known, to provide good oral hygiene, and to obtain regular dental care. The client should also wear a MedicAlert bracelet.

The nurse is teaching the client about his prescribed prednisone. Which statement, if made by the client, indicates that further teaching is necessary?

*"I can take aspirin or my antihistamine if I need it."* Aspirin and other over-the-counter medications should not be taken unless the client consults with the HCP. The client needs to take the medication at the same time every day and should be instructed not to stop the medication. A slight weight gain as a result of an improved appetite is expected; however, after the dosage is stabilized, a weight gain of 5 pounds (2.25 kg) or more weekly should be reported to the HCP. Caffeine-containing foods and fluids need to be avoided because they may contribute to steroid-ulcer development.

The nurse is caring for a client with a diagnosis of influenza who first began to experience symptoms yesterday. Antiviral therapy is prescribed and the nurse provides instructions to the client about the therapy. Which statement by the client indicates an understanding of the instructions?

*"I must take the medication exactly as prescribed."* Antiviral medications for influenza must be taken exactly as prescribed. These medications do not prevent the spread of influenza and clients are usually contagious for up to 2 days after the initiation of antiviral medications. Secondary bacterial infections may occur despite antiviral treatment. Side effects occur with these medications and may necessitate a change in activities, especially when driving or operating machinery if dizziness occurs.

The nurse is providing discharge teaching for a client newly diagnosed with type 2 diabetes mellitus who has been prescribed metformin. Which client statement indicates the need for further teaching?

*"I need to constantly watch for signs of low blood sugar."* Metformin is classified as a biguanide and is the most commonly used medication for type 2 diabetes mellitus initially. It is also often used as a preventive medication for those at high risk for developing diabetes mellitus. When used alone, metformin lowers the blood sugar after meal intake as well as fasting blood glucose levels. Metformin does not stimulate insulin release and therefore poses little risk for hypoglycemia. For this reason, metformin is well suited for clients who skip meals. Unusual somnolence, as well as hyperventilation, myalgia, and malaise, are early signs of lactic acidosis, a toxic effect associated with metformin. If any of these signs or symptoms occur, the client should inform the health care provider immediately. While it is best to avoid consumption of alcohol, it is not always realistic or feasible for clients to quit drinking altogether; for this reason, clients should be informed that excessive alcohol intake can cause an adverse reaction with metformin.

The nurse teaches the client, who is newly diagnosed with diabetes insipidus, about the prescribed intranasal desmopressin. Which statements by the client indicate understanding? Select all that apply.

*"I should decrease my oral fluids when I start this medication."* *"I should report headache and drowsiness to my health care provider since these symptoms could be related to my desmopressin."* In diabetes insipidus, there is a deficiency in antidiuretic hormone (ADH), resulting in large urinary losses. Desmopressin is an analog of ADH. Clients with diabetes insipidus drink high volumes of fluid (polydipsia) as a compensatory mechanism to counteract urinary losses and maintain fluid balance. Once desmopressin is started, oral fluids should be decreased to prevent water intoxication. Therefore, clients with diabetes insipidus should decrease their oral fluid intake when they start desmopressin. Headache and drowsiness are signs of water intoxication in the client taking desmopressin and should be reported to the health care provider. Desmopressin does not turn urine orange. The amount of urine should decrease, not increase, when desmopressin is started. Desmopressin does not cause pancreatitis.

The client with hyperparathyroidism is taking alendronate. Which statements by the client indicate understanding of the proper way to take this medication? Select all that apply.

*"I should sit up for at least 30 minutes after taking this medication."* *"I should take this medication first thing in the morning on an empty stomach."* Alendronate is a bisphosphonate used in hyperparathyroidism to inhibit bone loss and normalize serum calcium levels. Esophagitis is an adverse effect of primary concern in clients taking alendronate. For this reason the client is instructed to take alendronate first thing in the morning with a full glass of water on an empty stomach, not to eat or drink anything else for at least 30 minutes after taking the medication, and to remain sitting upright for at least 30 minutes after taking it. A daily dosing schedule and a once-weekly dosing schedule is available for clients taking alendronate.

The nurse asks a nursing student to describe the procedure for administering erythromycin ointment to the eyes of a newborn. Which student statement indicates that further teaching is needed about administration of the eye medication?

*"I will flush the eyes after instilling the ointment."* Eye prophylaxis protects the newborn against Neisseria gonorrhoeae and Chlamydia trachomatis. The eyes are not flushed after instillation of the medication because the flush would wash away the administered medication. Options 2, 3, and 4 are correct statements regarding the procedure for administering eye medication to the newborn.

The nurse provides discharge instructions to a client who is taking warfarin sodium. Which statement, by the client, reflects the need for further teaching?

*"I will take coated aspirin for my headaches because it will coat my stomach."* Aspirin-containing products need to be avoided when a client is taking this medication. Alcohol consumption should be avoided by a client taking warfarin sodium. Taking the prescribed medication at the same time each day increases client compliance. The MedicAlert bracelet provides health care personnel with emergency information.

The nurse determines the client needs further instruction on cimetidine if which statements were made? Select all that apply.

*"I will take the cimetidine with my meals."* *"I'll know the medication is working if my diarrhea stops."* *"Taking the cimetidine with an antacid will increase its effectiveness."* Cimetidine, a histamine (H2)-receptor antagonist, helps to alleviate the symptom of heartburn, not diarrhea. Because cimetidine crosses the blood-brain barrier, central nervous system side and adverse effects, such as mental confusion, agitation, depression, and anxiety, can occur. Food reduces the rate of absorption, so if cimetidine is taken with meals, absorption will be slowed. Antacids decrease the absorption of cimetidine and should be taken at least 1 hour apart. If cimetidine is concomitantly administered with warfarin therapy, warfarin doses may need to be reduced, so prothrombin and international normalized ratio results must be followed.

The nurse teaches a client about the effects of diphenhydramine, which has been prescribed as a cough suppressant. The nurse determines that the client needs further instruction if the client makes which statement?

*"I will take the medication on an empty stomach."* Diphenhydramine has several uses, including as an antihistamine, antitussive, antidyskinetic, and sedative-hypnotic. Instructions for use include taking with food or milk to decrease gastrointestinal upset and using oral rinses, sugarless gum, or hard candy to minimize dry mouth. Because the medication causes drowsiness, the client should avoid use of alcohol or central nervous system depressants, operating a car, or engaging in other activities requiring mental awareness during use.

The home health care nurse is visiting a client with elevated triglyceride levels and a serum cholesterol level of 398 mg/dL (10 mmol/L). The client is taking cholestyramine and the nurse teaches the client about the medication. Which statement, by the client, indicates the need for further teaching?

*"I'll continue my nicotinic acid from the health food store."* Nicotinic acid, even an over-the-counter form, should be avoided because it may lead to liver abnormalities. All lipid-lowering medications also can cause liver abnormalities, so a combination of nicotinic acid and cholestyramine resin needs to be avoided. Constipation and bloating are the 2 most common adverse effects. Walking and the reduction of fats in the diet are therapeutic measures to reduce cholesterol and triglyceride levels.

A client is prescribed nicotinic acid for hyperlipidemia and the nurse provides instructions to the client about the medication. Which statement by the client indicates an understanding of the instructions?

*"Ibuprofen IB taken 30 minutes before the nicotinic acid should decrease the flushing."* Flushing is an adverse effect of this medication. Aspirin or a nonsteroidal antiinflammatory drug can be taken 30 minutes prior to taking the medication to decrease flushing. Alcohol consumption needs to be avoided because it will enhance this effect. The medication should be taken with meals to decrease gastrointestinal upset; however, taking the medication with meals has no effect on the flushing. Clay-colored stools are a sign of hepatic dysfunction and should be reported to the health care provider (HCP) immediately.

The nurse has just administered the first dose of omalizumab to a client. Which statement by the client would alert the nurse that the client may be experiencing a life-threatening effect?

*"My lips and tongue are swollen."* Omalizumab is an antiinflammatory used for long-term control of asthma. Anaphylactic reactions can occur with the administration of omalizumab. The nurse administering the medication should monitor for adverse reactions of the medication. Swelling of the lips and tongue are an indication of an anaphylaxis. The client statements in options 1, 2, and 3 are not indicative of an adverse reaction.

The nurse is providing instructions to the client newly diagnosed with diabetes mellitus who has been prescribed pramlintide. Which instruction should the nurse include in the discharge teaching?

*"Take your prescribed pills 1 hour before or 2 hours after the injection."* Pramlintide is used for clients with types 1 and 2 diabetes mellitus who use insulin. It is administered subcutaneously before meals to lower blood glucose level after meals, leading to less fluctuation during the day and better long-term glucose control. Because pramlintide delays gastric emptying, oral medications should be given 1 hour before or 2 hours after an injection of pramlintide; therefore, instructing the client to take his or her pills 1 hour before or 2 hours after the injection is correct. Pramlintide should not be taken at the same time as other medications. Pramlintide is given immediately before the meal in order to control postprandial rise in blood glucose, not necessarily to prevent stomach upset. It is incorrect to instruct the client to take the medication after eating, as it will not achieve its full therapeutic effect.

A miotic medication has been prescribed for the client with glaucoma and the client asks the nurse about the purpose of the medication. Which response should the nurse provide to the client?

*"The medication causes the pupil to constrict and will lower the pressure in the eye."* Miotics cause pupillary constriction and are used to treat glaucoma. They lower the intraocular pressure, thereby increasing blood flow to the retina and decreasing retinal damage and loss of vision. Miotics cause a contraction of the ciliary muscle and a widening of the trabecular meshwork. Options 1, 2, and 4 are incorrect.

Silver sulfadiazine is prescribed for a client with a partial-thickness burn and the nurse provides teaching about the medication. Which statement made by the client indicates a need for further teaching about the treatments?

*"The medication is likely to cause stinging every time it is applied."* Silver sulfadiazine is an antibacterial that has a broad spectrum of activity against gram-negative bacteria, gram-positive bacteria, and yeast. It is applied directly to the wound to assist in healing. It does not cause stinging when applied.

A client with a peptic ulcer is diagnosed with a Helicobacter pylori infection. The nurse is teaching the client about the medications prescribed, including clarithromycin, esomeprazole, and amoxicillin. Which statement by the client indicates the best understanding of the medication regimen?

*"The medications will kill the bacteria and decrease the acid production."* Triple therapy for H. pylori infection usually includes 2 antibacterial medications and a proton pump inhibitor. Clarithromycin and amoxicillin are antibacterials. Esomeprazole is a proton pump inhibitor. These medications will kill the bacteria and decrease acid production.

Tamoxifen citrate is prescribed for a client with metastatic breast carcinoma. The client asks the nurse if her family member with bladder cancer can also take this medication. The nurse most appropriately responds by making which statement?

*"This medication can be taken to prevent and treat clients with breast cancer."* Tamoxifen is an antineoplastic medication that competes with estradiol for binding to estrogen in tissues containing high concentrations of receptors. Tamoxifen is used to treat metastatic breast carcinoma in women and men. Tamoxifen is also effective in delaying the recurrence of cancer following mastectomy and for preventing breast cancer in those that are at high risk.

The nurse has given instructions to a client who has just been prescribed cholestyramine. Which statement by the client indicates a need for further instruction?

*"This medication should only be taken with water."* Cholestyramine is a bile acid sequestrant used to lower the cholesterol level, and client compliance is a problem because of its taste and palatability. The use of flavored products or fruit juices can improve the taste. Some side effects of bile acid sequestrants include constipation and decreased vitamin absorption.

A clinic nurse prepares a teaching plan for a client receiving an antineoplastic medication. When implementing the plan, the nurse should make which statement to the client?

*"You need to consult with the health care provider (HCP) before receiving immunizations."* Because antineoplastic medications lower the resistance of the body, clients must be informed not to receive immunizations without the HCP's approval. Clients also need to avoid contact with individuals who have recently received a live virus vaccine. Clients need to avoid aspirin and aspirin-containing products to minimize the risk of bleeding, and they need to avoid alcohol to minimize the risk of toxicity and side/adverse effects.

A client who is receiving digoxin daily has a serum potassium level of 3 mEq/L (3 mmol/L) and is complaining of anorexia. The health care provider prescribes a serum digoxin level to be done. The nurse checks the results and should expect to note which level that is outside of the therapeutic range?

*1.0 ng/mL* The optimal therapeutic range for digoxin is 0.5 to 0.8 ng/mL. If the client is experiencing symptoms such as anorexia and is experiencing hypokalemia as evidenced by a low potassium level, digoxin toxicity is a concern. Therefore, option 4 is correct because it is outside of the therapeutic level and an elevated level.

A client with myasthenia gravis has become increasingly weaker. The health care provider prepares to identify whether the client is reacting to an overdose of the medication (cholinergic crisis) or an increasing severity of the disease (myasthenic crisis). An injection of edrophonium is administered. Which finding would indicate that the client is in cholinergic crisis?

*A temporary worsening of the condition* An edrophonium injection makes the client in cholinergic crisis temporarily worse. An improvement in the weakness indicates myasthenia crisis. Muscle spasms are not associated with this test.

The nurse is caring for a client in the emergency department who has been diagnosed with Bell's palsy. The client has been taking acetaminophen, and acetaminophen overdose is suspected. Which antidote should the nurse prepare for administration if prescribed?

*Acetylcysteine* The antidote for acetaminophen is acetylcysteine. The normal therapeutic serum level of acetaminophen is 10 to 20 mcg/mL (40 to 79 mcmol/L). A toxic level is higher than 50 mcg/mL (200 mcmol/L), and levels higher than 100 mcg/mL (400 mcmol/L) could indicate hepatotoxicity. Auranofin is a gold preparation that may be used to treat rheumatoid arthritis. Pentostatin and fludarabine are antineoplastic agents.

A client was just admitted to the hospital to rule out a gastrointestinal (GI) bleed. The client has brought several bottles of medications prescribed by different specialists. During the admission assessment, the client states, "Lately, I have been hearing some roaring sounds in my ears, especially when I am alone." Which medication would the nurse identify as the cause of the client's complaint?

*Acetylsalicylic acid* Aspirin is contraindicated for GI bleeding and is potentially ototoxic. The client should be advised to notify the prescribing health care provider so the medication can be discontinued and/or a substitute that is less toxic to the ear can be taken instead. Options 1, 2, and 4 do not have effects that are potentially associated with hearing difficulties.

A client with atrial fibrillation is receiving a continuous heparin infusion at 1000 units/hour. The nurse determines that the client is receiving the therapeutic effect based on which results?

*Activated partial thromboplastin time of 60 seconds* Common laboratory ranges for activated partial thromboplastin time (aPTT) are 30 to 40 seconds. Because the aPTT should be 1.5 to 2.5 times the normal value, the client's aPTT would be considered therapeutic if it was 60 seconds. Prothrombin time assesses response to warfarin therapy.

A client with hyperthyroidism has been given methimazole. Which nursing considerations are associated with this medication? Select all that apply.

*Administer methimazole with food.* *Assess the client for unexplained bruising or bleeding.* *Instruct the client to report side and adverse effects such as sore throat, fever, or headaches.* Common side effects of methimazole include nausea, vomiting, and diarrhea. To address these side effects, this medication should be taken with food. Because of the increase in metabolism that occurs in hyperthyroidism, the client should consume a high-calorie diet. Antithyroid medications can cause agranulocytosis with leukopenia and thrombocytopenia. Sore throat, fever, headache, or bleeding may indicate agranulocytosis and the health care provider should be notified immediately. Methimazole is not radioactive and should not be stopped abruptly, due to the risk of thyroid storm.

A client is prescribed an eye drop and an eye ointment for the right eye. How should the nurse best administer the medications?

*Administer the eye drop first, followed by the eye ointment.* When an eye drop and an eye ointment are scheduled to be administered at the same time, the eye drop is administered first. The instillation of two medications is separated by 3 to 5 minutes.

A client has an as needed prescription for loperamide hydrochloride. For which condition should the nurse administer this medication?

*An episode of diarrhea* Loperamide is an antidiarrheal agent. It is used to manage acute and chronic diarrhea in conditions such as inflammatory bowel disease. Loperamide also can be used to reduce the volume of drainage from an ileostomy. It is not used for the conditions in options 1, 2, and 4.

The camp nurse asks the children preparing to swim in the lake if they have applied sunscreen. The nurse reminds the children that chemical sunscreens are most effective when applied at which times?

*At least 30 minutes before exposure to the sun* Sunscreens are most effective when applied at least 30 minutes before exposure to the sun so that they can penetrate the skin. All sunscreens should be reapplied after swimming or sweating.

Which medication, if prescribed for the client with glaucoma, should the nurse question?

*Atropine sulfate* Atropine sulfate is a mydriatic and cycloplegic (also anticholinergic) medication, and its use is contraindicated in clients with glaucoma. Mydriatic medications dilate the pupil and can cause an increase in intraocular pressure in the eye.

A client is being treated with procainamide for a cardiac dysrhythmia. Following intravenous administration of the medication, the client complains of dizziness. What intervention should the nurse take first?

*Auscultate the client's apical pulse and obtain a blood pressure.* Signs of toxicity from procainamide include confusion, dizziness, drowsiness, decreased urination, nausea, vomiting, and tachydysrhythmias. If the client complains of dizziness, the nurse should assess the vital signs first. Although measuring the heart rate on the rhythm strip and obtaining a 12-lead electrocardiogram may be interventions, these would be done after the vital signs are taken. Nitroglycerin is a vasodilator and will lower the blood pressure.

The nurse is preparing discharge instructions for a client receiving baclofen. Which instruction should be included in the teaching plan?

*Avoid the use of alcohol.* Baclofen is a skeletal muscle relaxant. The client should be cautioned against the use of alcohol and other central nervous system depressants because baclofen potentiates the depressant activity of these agents. Constipation rather than diarrhea is a side effect. Restriction of fluids is not necessary, but the client should be warned that urinary retention can occur. Fatigue is related to a central nervous system effect that is most intense during the early phase of therapy and diminishes with continued medication use. The client does not need to notify the HCP about fatigue.

The nurse is applying a topical corticosteroid to a client with eczema. The nurse should apply the medication to which body area? Select all that apply.

*Back* *Soles of the feet* *Palms of the hands* Topical corticosteroids can be absorbed into the systemic circulation. Absorption is higher from regions where the skin is especially permeable (scalp, axilla, face, eyelids, neck, perineum, genitalia), and lower from regions where permeability is poor (back, palms, soles). The nurse should avoid areas of higher absorption to prevent systemic absorption.

Rho(D) immune globulin is prescribed for a client after delivery and the nurse provides information to the client about the purpose of the medication. The nurse determines that the woman understands the purpose if the woman states that it will protect her next baby from which condition?

*Being affected by Rh incompatibility* Rh incompatibility can occur when an Rh-negative mother becomes sensitized to the Rh antigen. Sensitization may develop when an Rh-negative woman becomes pregnant with a fetus who is Rh positive. During pregnancy and at delivery, some of the fetus's Rh-positive blood can enter the maternal circulation, causing the mother's immune system to form antibodies against Rh-positive blood. Administration of Rho(D) immune globulin prevents the mother from developing antibodies against Rh-positive blood by providing passive antibody protection against the Rh antigen.

A client in preterm labor (31 weeks) who is dilated to 4 cm has been started on magnesium sulfate and contractions have stopped. If the client's labor can be inhibited for the next 48 hours, the nurse anticipates a prescription for which medication?

*Betamethasone* Betamethasone, a glucocorticoid, is given to increase the production of surfactant to stimulate fetal lung maturation. It is administered to clients in preterm labor at 28 to 32 weeks of gestation if the labor can be inhibited for 48 hours. Nalbuphine is an opioid analgesic. Rho(D) immune globulin is given to Rh-negative clients to prevent sensitization. Dinoprostone vaginal insert is a prostaglandin given to ripen and soften the cervix and to stimulate uterine contractions.

The nurse is caring for a postrenal transplantation client taking cyclosporine. The nurse notes an increase in one of the client's vital signs and the client is complaining of a headache. What vital sign is most likely increased?

*Blood pressure* Hypertension can occur in a client taking cyclosporine, and because this client is also complaining of a headache, the blood pressure is the vital sign to be monitored most closely. Other adverse effects include infection, nephrotoxicity, and hirsutism. Options 1, 2, and 4 are unrelated to the use of this medication.

Methylergonovine is prescribed for a woman to treat postpartum hemorrhage. Before administration of methylergonovine, what is the priority assessment?

*Blood pressure* Methylergonovine, an ergot alkaloid, is used to prevent or control postpartum hemorrhage by contracting the uterus. Methylergonovine causes continuous uterine contractions and may elevate the blood pressure. A priority assessment before the administration of the medication is to check the blood pressure. The health care provider needs to be notified if hypertension is present. Although options 1, 3, and 4 may be components of the postpartum assessment, blood pressure is related specifically to the administration of this medication.

Following kidney transplantation, cyclosporine is prescribed for a client. Which laboratory result would indicate an adverse effect from the use of this medication?

*Blood urea nitrogen level of 25 mg/dL (8.8 mmol/L)* Cyclosporine is an immunosuppressant. Nephrotoxicity can occur from the use of cyclosporine. Nephrotoxicity is evaluated by monitoring for elevated blood urea nitrogen and serum creatinine levels. The normal blood urea nitrogen level is 10 to 20 mg/dL (3.6 to 7.1 mmol/L). The normal creatinine level for a male is 0.6 to 1.2 mg/dL (53 to 106 mcmol/L) and for a female 0.5 to1.1 mg/dL (44 to 97 mcmol/L). Cyclosporine can lower complete blood cell count levels. A normal hemoglobin is Male: 14 to 18 g/dL (140 to 180 mmol/L); Female: 12 to 16 g/dL (120 to 160 mmol/L). A normal hemoglobin is not an adverse effect. Cyclosporine does affect the glucose level. The normal fasting glucose is 70 to 110 mg/dL (4 to 6 mmol/L).

The nurse, who is administering bethanechol chloride, is monitoring for cholinergic overdose associated with the medication. The nurse should check the client for which sign of overdose?

*Bradycardia* Cholinergic overdose of bethanechol chloride produces manifestations of excessive muscarinic stimulation such as salivation, sweating, involuntary urination and defecation, bradycardia, and severe hypotension. Remember that the sympathetic nervous system speeds the heart rate and the cholinergic (parasympathetic) nervous system slows the heart rate. Treatment includes supportive measures and the administration of atropine sulfate (anticholinergic) subcutaneously or intravenously.

The nurse is administering an intravenous dose of methocarbamol to a client with multiple sclerosis. For which adverse effect should the nurse monitor?

*Bradycardia* Intravenous administration of methocarbamol can cause hypotension and bradycardia. The nurse needs to monitor for these adverse effects. Options 1, 2, and 4 are not effects with administration of this medication.

A cromolyn sodium inhaler is prescribed for a client with allergic asthma. The nurse provides instructions regarding the adverse effects of this medication and should tell the client that which undesirable effect is associated with this medication?

*Bronchospasm* Cromolyn sodium is an inhaled nonsteroidal antiallergy agent and a mast cell stabilizer. Undesirable effects associated with inhalation therapy of cromolyn sodium are bronchospasm, cough, nasal congestion, throat irritation, and wheezing. Clients receiving this medication orally may experience pruritus, nausea, diarrhea, and myalgia.

A client with metastatic breast cancer is receiving tamoxifen. The nurse specifically monitors which laboratory value while the client is taking this medication?

*Calcium level* Tamoxifen may increase calcium, cholesterol, and triglyceride levels. Before the initiation of therapy, a complete blood count, platelet count, and serum calcium level should be assessed. These blood levels, along with cholesterol and triglyceride levels, should be monitored periodically during therapy. The nurse should assess for hypercalcemia while the client is taking this medication. Signs of hypercalcemia include increased urine volume, excessive thirst, nausea, vomiting, constipation, hypotonicity of muscles, and deep bone and flank pain.

A client has been started on long-term therapy with rifampin. The nurse should provide which information to the client about the medication?

*Causes orange discoloration of sweat, tears, urine, and feces* Rifampin causes orange-red discoloration of body secretions and will stain soft contact lenses permanently. Rifampin should be taken exactly as directed. Doses should not be doubled or skipped. The client should not stop therapy until directed to do so by a health care provider. It is best to administer the medication on an empty stomach unless it causes gastrointestinal upset, and then it may be taken with food. Antacids, if prescribed, should be taken at least 1 hour before the medication.

A client with Crohn's disease is scheduled to receive an infusion of infliximab. What intervention by the nurse will determine the effectiveness of treatment?

*Checking the frequency and consistency of bowel movements* The principal manifestations of Crohn's disease are diarrhea and abdominal pain. Infliximab is an immunomodulator that reduces the degree of inflammation in the colon, thereby reducing the diarrhea. Options 1, 3, and 4 are unrelated to this medication.

A client has begun therapy with theophylline. The nurse should plan to teach the client to limit the intake of which items while taking this medication?

*Coffee, cola, and chocolate* Theophylline is a methylxanthine bronchodilator. The nurse teaches the client to limit the intake of xanthine-containing foods while taking this medication. These foods include coffee, cola, and chocolate.

A client with a clot in the right atrium is receiving a heparin sodium infusion at 1000 units/hour and warfarin sodium 7.5 mg at 5:00 p.m. daily. The morning laboratory results are as follows: activated partial thromboplastin time (aPTT), 32 seconds; international normalized ratio (INR), 1.3. The nurse should take which action based on the client's laboratory results?

*Collaborate with the HCP to obtain a prescription to increase the heparin infusion and administer the warfarin sodium as prescribed* When a client is receiving warfarin for clot prevention due to atrial fibrillation, an INR of 2 to 3 is appropriate for most clients. Until the INR has achieved a therapeutic range, the client should be maintained on a continuous heparin infusion with the aPTT ranging between 60 and 80 seconds. Therefore, the nurse should collaborate with the HCP to obtain a prescription to increase the heparin infusion and to administer the warfarin as prescribed.

An older client recently has been taking cimetidine. The nurse monitors the client for which most frequent central nervous system side effect of this medication?

*Confusion* Cimetidine is a histamine (H2)-receptor antagonist. Older clients are especially susceptible to central nervous system side effects of cimetidine. The most frequent of these is confusion. Less common central nervous system side effects include headache, dizziness, drowsiness, and hallucinations.

In preparation for cataract surgery, the nurse is to administer cyclopentolate eye drops at 0900 for surgery that is scheduled for 0915. What initial action should the nurse take in relation to the characteristics of the medication action?

*Consult the surgeon, as there is not sufficient time for the dilative effects to occur.* Cyclopentolate is a rapidly acting mydriatic and cycloplegic medication. Cyclopentolate is effective in 25 to 75 minutes, and accommodation returns in 6 to 24 hours. Cyclopentolate is used for preoperative mydriasis, not pupil constriction. The nurse should consult with the surgeon about the time of administration of the eye drops since 15 minutes is not adequate time for dilation to occur.

A client with non-Hodgkin's lymphoma is receiving daunorubicin. Which finding would indicate to the nurse that the client is experiencing an adverse effect related to the medication?

*Crackles on auscultation of the lungs* Cardiotoxicity noted by abnormal electrocardiographic findings or cardiomyopathy manifested as heart failure (lung crackles) is an adverse effect of daunorubicin. Bone marrow depression is also an adverse effect. Fever is a frequent side effect and sores in the mouth and throat can occur occasionally. Nausea and vomiting is a frequent side effect associated with the medication that begins a few hours after administration and lasts 24 to 48 hours. Options 1, 2, and 3 are not adverse effects.

A client who has a cold is seen in the emergency department with an inability to void. Because the client has a history of benign prostatic hyperplasia, the nurse determines that the client should be questioned about the use of which medication?

*Decongestants* In the client with benign prostatic hyperplasia, episodes of urinary retention can be triggered by certain medications, such as decongestants, anticholinergics, and antidepressants. These medications lessen the voluntary ability to contract the bladder. The client should be questioned about the use of these medications if he has urinary retention. Diuretics increase urine output. Antibiotics and antlipemics do not affect ability to urinate.

Terbutaline is prescribed for a client with bronchitis. The nurse checks the client's medical history for which disorder in which the medication should be used with caution?

*Diabetes mellitus* Terbutaline is a bronchodilator and is contraindicated in clients with hypersensitivity to sympathomimetics. It should be used with caution in clients with impaired cardiac function, diabetes mellitus, hypertension, hyperthyroidism, or a history of seizures. The medication may increase blood glucose levels.

The home health care nurse is visiting a client who was recently diagnosed with type 2 diabetes mellitus. The client is prescribed repaglinide and metformin. The nurse should provide which instructions to the client? Select all that apply.

*Diarrhea may occur secondary to the metformin.* *The repaglinide is not taken if a meal is skipped.* *The repaglinide is taken 30 minutes before eating.* *A simple sugar food item is carried and used to treat mild hypoglycemia episodes.* Repaglinide, a rapid-acting oral hypoglycemic agent that stimulates pancreatic insulin secretion, should be taken before meals (approximately 30 minutes before meals) and should be withheld if the client does not eat. Hypoglycemia is a side effect of repaglinide and the client should always be prepared by carrying a simple sugar at all times. Metformin is an oral hypoglycemic given in combination with repaglinide and works by decreasing hepatic glucose production. A common side effect of metformin is diarrhea. Muscle pain may occur as an adverse effect from metformin but it might signify a more serious condition that warrants health care provider notification, not the use of acetaminophen.

The nurse is monitoring a client who is taking digoxin for adverse effects. Which findings are characteristic of digoxin toxicity? Select all that apply.

*Diarrhea* *Blurred vision* *Nausea and vomiting* Digoxin is a cardiac glycoside. The risk of toxicity can occur with the use of this medication. Toxicity can lead to life-threatening events and the nurse needs to monitor the client closely for signs of toxicity. Early signs of toxicity include gastrointestinal manifestations such as anorexia, nausea, vomiting, and diarrhea. Subsequent manifestations include headache; visual disturbances such as diplopia, blurred vision, yellow-green halos, and photophobia; drowsiness; fatigue; and weakness. Cardiac rhythm abnormalities can also occur. The nurse also monitors the digoxin level. The optimal therapeutic range for digoxin is 0.5 to 0.8 ng/mL.

The nurse has given a client taking ethambutol information about the medication. The nurse determines that the client understands the instructions if the client states that he or she will immediately report which finding?

*Difficulty in discriminating the color red from green* Ethambutol causes optic neuritis, which decreases visual acuity and the ability to discriminate between the colors red and green. This poses a potential safety hazard when a client is driving a motor vehicle. The client is taught to report this symptom immediately. The client also is taught to take the medication with food if gastrointestinal upset occurs. Impaired hearing results from antitubercular therapy with streptomycin. Orange-red discoloration of secretions occurs with rifampin.

A client with trigeminal neuralgia tells the nurse that acetaminophen is taken daily for the relief of generalized discomfort. Which laboratory value would indicate toxicity associated with the medication?

*Direct bilirubin level of 2 mg/dL (34 mcmol/L)* In adults, overdose of acetaminophen causes liver damage. The correct option is an indicator of liver function and is the only option that indicates an abnormal laboratory value. The normal direct bilirubin level is 0.1 to 0.3 mg/dL (1.7 to 5.1 mcmol/L). The normal sodium level is 135 to 145 mEq/L (135 to 145 mmol/L). The normal prothrombin time is 11 to 12.5 seconds (11 to 12.5 seconds). The normal platelet count is 150,000 to 400,000 mm3 (150 to 400 × 109/L).

Allopurinol is prescribed for a client and the nurse provides medication instructions to the client. Which instruction should the nurse provide?

*Drink 3000 mL of fluid a day.* Clients taking allopurinol are encouraged to drink 3000 mL of fluid a day, unless otherwise contraindicated. A full therapeutic effect may take 1 week or longer. Allopurinol is to be given with, or immediately after, meals or milk. A client who develops a rash, irritation of the eyes, or swelling of the lips or mouth should contact the health care provider because this may indicate hypersensitivity.

The nurse is providing discharge instructions to a client receiving trimethoprim-sulfamethoxazole. Which instruction should be included in the list?

*Drink 8 to 10 glasses of water per day.* Each dose of trimethoprim-sulfamethoxazole should be administered with a full glass of water, and the client should maintain a high fluid intake to avoid crystalluria. The medication is more soluble in alkaline urine. The client should not be instructed to taper or discontinue the dose. Clients should be advised to use sunscreen since the skin becomes sensitive to the sun. Some forms of trimethoprim-sulfamethoxazole cause urine to turn dark brown or red. This does not indicate the need to notify the HCP.

A daily dose of prednisone is prescribed for a client. The nurse provides instructions to the client regarding administration of the medication and should instruct the client that which time is best to take this medication?

*Early morning* Corticosteroids (glucocorticoids) should be administered before 9 a.m. Administration at this time helps to minimize adrenal insufficiency and mimics the burst of glucocorticoids released naturally by the adrenal glands each morning. Options 1, 2, and 4 are incorrect.

The nurse is reviewing the laboratory results for a client receiving tacrolimus. Which laboratory result would indicate to the nurse that the client is experiencing an adverse effect of the medication?

*Fasting blood glucose of 200 mg/dL (11.1 mmol/L)* A fasting blood glucose level of 200 mg/dL (11.1 mmol/L) is significantly elevated above the normal range of 70 to 110 mg/dL (4 to 6 mmol/L) and suggests an adverse effect. Recall that fasting blood glucose levels are sometimes based on health care provider preference. Other adverse effects include neurotoxicity evidenced by headache, tremor, and insomnia; gastrointestinal effects such as diarrhea, nausea, and vomiting; hypertension; and hyperkalemia. The remaining options identify normal reference levels. The normal potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). The normal platelet count is 150,000 to 400,000 mm3 (150 to 400 × 109/L). The normal white blood cell count is 5000 to 10,000 mm3 (5 to 10 × 109/L).

The nurse is monitoring a client in preterm labor who is receiving intravenous magnesium sulfate. The nurse should monitor for which adverse effects of this medication? Select all that apply.

*Flushing* *Depressed respirations* *Extreme muscle weakness* Magnesium sulfate is a central nervous system depressant and relaxes smooth muscle, including the uterus. It is used to halt preterm labor contractions and is used for preeclamptic clients to prevent seizures. Adverse effects include flushing, depressed respirations, depressed deep tendon reflexes, hypotension, extreme muscle weakness, decreased urine output, pulmonary edema, and elevated serum magnesium levels.

A client who is human immunodeficiency virus seropositive has been taking stavudine. The nurse should monitor which most closely while the client is taking this medication?

*Gait* Stavudine is an antiretroviral used to manage human immunodeficiency virus infection in clients who do not respond to or who cannot tolerate conventional therapy. The medication can cause peripheral neuropathy, and the nurse should monitor the client's gait closely and ask the client about paresthesia. Options 2, 3, and 4 are unrelated to this medication.

Cyclobenzaprine is prescribed for a client for muscle spasms and the nurse is reviewing the client's record. Which disorder, if noted in the record, would indicate a need to contact the health care provider about the administration of this medication?

*Glaucoma* Because cyclobenzaprine has anticholinergic effects, it should be used with caution in clients with a history of urinary retention, glaucoma, and increased intraocular pressure. Cyclobenzaprine should be used only for a short time (2 to 3 weeks). The conditions in options 2, 3, and 4 are not a concern with this medication.

The nurse is providing dietary instructions to a client who has been prescribed cyclosporine. Which food item should the nurse instruct the client to exclude from the diet?

*Grapefruit juice* A compound present in grapefruit juice inhibits metabolism of cyclosporine through the cytochrome P450 system. As a result, consumption of grapefruit juice can raise cyclosporine levels by 50% to 100%, thereby greatly increasing the risk of toxicity. Red meats, orange juice, and green, leafy vegetables do not interact with the cytochrome P450 system.

Amikacin is prescribed for a client with a bacterial infection. The nurse instructs the client to contact the health care provider (HCP) immediately if which occurs?

*Hearing loss* Amikacin is an aminoglycoside. Adverse effects of aminoglycosides include ototoxicity (hearing problems), confusion, disorientation, gastrointestinal irritation, palpitations, blood pressure changes, nephrotoxicity, and hypersensitivity. The nurse instructs the client to report hearing loss to the HCP immediately. Lethargy and muscle aches are not associated with the use of this medication. It is not necessary to contact the HCP immediately if nausea occurs. If nausea persists or results in vomiting, the HCP should be notified.

A client has been taking omeprazole for 4 weeks. The ambulatory care nurse evaluates that the client is receiving the optimal intended effect of the medication if the client reports the absence of which symptom?

*Heartburn* Omeprazole is a proton pump inhibitor classified as an antiulcer agent. The intended effect of the medication is relief of pain from gastric irritation, often called heartburn by clients. Omeprazole is not used to treat the conditions identified in options 1, 3, and 4.

A client with chronic kidney disease is receiving epoetin alfa. Which laboratory result would indicate a therapeutic effect of the medication?

*Hematocrit of 33% (0.33)* Epoetin alfa is synthetic erythropoietin, which the kidneys produce to stimulate red blood cell production in the bone marrow. It is used to treat anemia associated with chronic kidney disease. The normal hematocrit level is Male: 42% to 52% (0.42 to 0.52); Female: 37% to 47% (0.37 to 0.47). Therapeutic effect is seen when the hematocrit reaches between 30% and 33% (0.30 and 0.33). The normal platelet count is 150,000 to 400,000 mm3 (150 to 400 × 109/L). The normal blood urea nitrogen level is 10 to 20 mg/dL (3.6 to 7.1 mmol/L). The normal white blood cell count is 5000 to 10,000 mm3 (5 to 10 × 109/L). Platelet production, white blood cell production, and blood urea nitrogen do not respond to erythropoietin.

A burn client is receiving treatments of topical mafenide acetate to the site of injury. The nurse monitors the client, knowing that which finding indicates that a systemic effect has occurred?

*Hyperventilation* Mafenide acetate is a carbonic anhydrase inhibitor and can suppress renal excretion of acid, thereby causing acidosis. Clients receiving this treatment should be monitored for signs of an acid-base imbalance (hyperventilation). If this occurs, the medication will probably be discontinued for 1 to 2 days. Options 3 and 4 describe local rather than systemic effects. An elevated blood pressure may be expected from the pain that occurs with a burn injury.

A client is taking Humulin NPH insulin and regular insulin every morning. The nurse should provide which instructions to the client? Select all that apply.

*Hypoglycemia may be experienced before dinnertime.* *The insulin should be administered at room temperature.* Humulin NPH is an intermediate-acting insulin. The onset of action is 60 to 120 minutes, it peaks in 6 to 14 hours, and its duration of action is 16 to 24 hours. Regular insulin is a short-acting insulin. Depending on the type, the onset of action is 30 to 60 minutes, it peaks in 1 to 5 hours, and its duration is 6 to 10 hours. Hypoglycemic reactions most likely occur during peak time. Insulin should be at room temperature when administered. Clients may need their insulin dosages increased during times of illness. Insulin vials should never be shaken vigorously. Regular insulin is always drawn up before NPH.

The nurse is planning to administer hydrochlorothiazide to a client. The nurse should monitor for which adverse effects related to the administration of this medication?

*Hypokalemia, hyperglycemia, sulfa allergy* Thiazide diuretics such as hydrochlorothiazide are sulfa-based medications, and a client with a sulfa allergy is at risk for an allergic reaction. Also, clients are at risk for hypokalemia, hyperglycemia, hypercalcemia, hyperlipidemia, and hyperuricemia.

Carbidopa-levodopa is prescribed for a client with Parkinson's disease. The nurse monitors the client for side and adverse effects of the medication. Which finding indicates that the client is experiencing an adverse effect?

*Impaired voluntary movements* Dyskinesia and impaired voluntary movements may occur with high carbidopa-levodopa dosages. Nausea, anorexia, dizziness, orthostatic hypotension, bradycardia, and akinesia are frequent side effects of the medication.

The nurse is providing medication instructions to a client with breast cancer who is receiving cyclophosphamide. The nurse should tell the client to take which action?

*Increase fluid intake to 2000 to 3000 mL daily.* Hemorrhagic cystitis is an adverse effect that can occur with the use of cyclophosphamide. The client needs to be instructed to drink copious amounts of fluid during the administration of this medication. Clients also should monitor urine output for hematuria. The medication should be taken on an empty stomach, unless gastrointestinal upset occurs. Hyperkalemia can result from the use of the medication; therefore, the client would not be told to increase potassium intake. The client would not be instructed to alter sodium intake.

The nurse is analyzing the laboratory results of a client with leukemia who has received a regimen of chemotherapy. Which laboratory value would the nurse specifically note as a result of the massive cell destruction that occurred from the chemotherapy?

*Increased uric acid level* Hyperuricemia is especially common following treatment for leukemias and lymphomas because chemotherapy results in massive cell kill. Although options 1, 2, and 4 also may be noted, an increased uric acid level is related specifically to cell destruction.

A client with a urinary tract infection is receiving ciprofloxacin by the intravenous (IV) route. The nurse appropriately administers the medication by performing which action?

*Infusing slowly over 60 minutes* Ciprofloxacin is prescribed for treatment of mild, moderate, severe, and complicated infections of the urinary tract, lower respiratory tract, and skin and skin structure. A single dose is administered slowly over 60 minutes to minimize discomfort and vein irritation. Ciprofloxacin is not light-sensitive, may be infused through a peripheral IV access, and is not given by IV push method.

The nurse is monitoring a client receiving levothyroxine sodium for hypothyroidism. Which findings indicate the presence of a side effect associated with this medication? Select all that apply.

*Insomnia* *Weight loss* *Mild heat intolerance* Insomnia, weight loss, and mild heat intolerance are side effects of levothyroxine sodium. Bradycardia and constipation are not side effects associated with this medication, and rather are associated with hypothyroidism, which is the disorder that this medication is prescribed to treat.

The nurse is preparing to administer exogenous surfactant to a premature infant who has respiratory distress syndrome. The nurse prepares to administer the medication by which route?

*Intratracheal* Respiratory distress syndrome is a serious lung disorder caused by immaturity and the inability to produce surfactant, resulting in hypoxia and acidosis. It is common in premature infants and may be due to lung immaturity as a result of surfactant deficiency. The mainstay of treatment is the administration of exogenous surfactant, which is administered by the intratracheal route. Options 1, 3, and 4 are not routes of administration for this medication.

The clinic nurse is performing an admission assessment on a client and notes that the client is taking azelaic acid. The nurse determines that which client complaint may be associated with use of this medication?

*Itching* Azelaic acid is a topical medication used to treat mild to moderate acne. Adverse effects include burning, itching, stinging, redness of the skin, and hypopigmentation of the skin in clients with a dark complexion. The effects noted in the other options are not specifically associated with this medication.

Colchicine is prescribed for a client with a diagnosis of gout. The nurse reviews the client's record, knowing that this medication would be used with caution in which disorder?

*Kidney disease* Colchicine is used with caution in older clients, debilitated clients, and clients with cardiac, kidney, or gastrointestinal disease. The disorders in options 1, 3, and 4 are not concerns with administration of this medication.

A client with tuberculosis is being started on antituberculosis therapy with isoniazid. Before giving the client the first dose, the nurse should ensure that which baseline study has been completed?

*Liver enzyme levels* Isoniazid 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 older than 50 years or abuses alcohol. The laboratory tests in options 1, 2, and 4 are not necessary.

The nurse is analyzing the laboratory studies on a client receiving dantrolene. Which laboratory test would identify an adverse effect associated with the administration of this medication?

*Liver function tests* Dose-related liver damage is the most serious adverse effect of dantrolene. To reduce the risk of liver damage, liver function tests should be performed before treatment and throughout the treatment interval. Dantrolene is administered at the lowest effective dosage for the shortest time necessary.

Zafirlukast is prescribed for a client with bronchial asthma. Which laboratory test does the nurse expect to be prescribed before the administration of this medication?

*Liver function tests* Zafirlukast is a leukotriene receptor antagonist used in the prophylaxis and long-term treatment of bronchial asthma. Zafirlukast is used with caution in clients with impaired hepatic function. Liver function laboratory tests should be performed to obtain a baseline, and the levels should be monitored during administration of the medication. It is not necessary to perform the other laboratory tests before administration of the medication.

Chemotherapy dosage is frequently based on total body surface area (BSA), so it is important for the nurse to perform which assessment before administering chemotherapy?

*Measure the client's current weight and height.* To ensure that the client receives optimal doses of chemotherapy, dosing is usually based on the total BSA, which requires a current accurate height and weight for BSA calculation (before each medication administration). Asking the client about his or her height and weight may lead to inaccuracies in determining a true BSA and dosage. Calculating body mass index and measuring abdominal girth will not provide the data needed.

The nurse is caring for a client with chronic back pain. Codeine has been prescribed for the client. Specific to this medication, which intervention should the nurse include in the plan of care while the client is taking this medication?

*Monitor bowel activity.* While the client is taking codeine, the nurse would monitor vital signs and assess for hypotension. The nurse also should increase fluid intake, palpate the bladder for urinary retention, auscultate bowel sounds, and monitor the pattern of daily bowel activity and stool consistency because the medication causes constipation. The nurse should monitor respiratory status and initiate deep-breathing and coughing exercises. In addition, the nurse monitors the effectiveness of the pain medication.

A client is diagnosed with an ST segment elevation myocardial infarction (STEMI) and is receiving a tissue plasminogen activator, alteplase. Which action is a priority nursing intervention?

*Monitor for signs of bleeding.* Tissue plasminogen activator is a thrombolytic. Hemorrhage is a complication of any type of thrombolytic medication. The client is monitored for bleeding. Monitoring for renal failure and monitoring the client's psychosocial status are important but are not the most critical interventions. Heparin may be administered after thrombolytic therapy, but the question is not asking about follow-up medications.

Ketoconazole is prescribed for a client with a diagnosis of candidiasis. Which interventions should the nurse include when administering this medication? Select all that apply.

*Monitor liver function studies.* *Instruct the client to avoid alcohol.* *Instruct the client to avoid exposure to the sun.* Ketoconazole is an antifungal medication. There is no reason for the client to restrict fluid intake; in fact, this could be harmful to the client. The medication is hepatotoxic, and the nurse monitors liver function. It is administered with food (not on an empty stomach) and antacids are avoided for 2 hours after taking the medication to ensure absorption. The client is also instructed to avoid alcohol. In addition, the client is instructed to avoid exposure to the sun because the medication increases photosensitivity.

Betaxolol hydrochloride eye drops have been prescribed for a client with glaucoma. Which nursing action is most appropriate related to monitoring for side and adverse effects of this medication?

*Monitoring blood pressure* Hypotension, dizziness, nausea, diaphoresis, headache, fatigue, constipation, and diarrhea are side and adverse effects of the medication. Nursing interventions include monitoring the blood pressure for hypotension and assessing the pulse for strength, weakness, irregular rate, and bradycardia. Options 1, 2, and 4 are not specifically associated with this medication.

An opioid analgesic is administered to a client in labor. The nurse assigned to care for the client ensures that which medication is readily accessible should respiratory depression occur?

*Naloxone* Opioid analgesics may be prescribed to relieve moderate to severe pain associated with labor. Opioid toxicity can occur and cause respiratory depression. Naloxone is an opioid antagonist, which reverses the effects of opioids and is given for respiratory depression. Morphine sulfate and hydromorphone hydrochloride are opioid analgesics. Betamethasone is a corticosteroid administered to enhance fetal lung maturity.

A client has an as needed prescription for ondansetron. For which condition(s) should the nurse administer this medication?

*Nausea and vomiting* Ondansetron is an antiemetic used to treat postoperative nausea and vomiting, as well as nausea and vomiting associated with chemotherapy. The other options are incorrect reasons for administering this medication.

The nurse is caring for a client who has been taking a sulfonamide and should monitor for signs and symptoms of which adverse effects of the medication? Select all that apply.

*Nephrotoxicity* *Bone marrow suppression* *Gastrointestinal (GI) effects* Adverse effects of sulfonamides include nephrotoxicity, bone marrow suppression, GI effects, hepatotoxicity, dermatological effects, and some neurological symptoms, including headache, dizziness, vertigo, ataxia, depression, and seizures. Options 1, 2, and 6 are unrelated to these medications.

Potassium chloride intravenously is prescribed for a client with hypokalemia. Which actions should the nurse take to plan for preparation and administration of the potassium? Select all that apply.

*Obtain an intravenous (IV) infusion pump.* *Monitor urine output during administration.* *Monitor the IV site for signs of infiltration or phlebitis.* *Ensure that the medication is diluted in the appropriate volume of fluid.* *Ensure that the bag is labeled so that it reads the volume of potassium in the solution.* Potassium chloride administered intravenously must always be diluted in IV fluid and infused via an infusion pump. Potassium chloride is never given by bolus (IV push). Giving potassium chloride by IV push can result in cardiac arrest. The nurse should ensure that the potassium is diluted in the appropriate amount of diluent or fluid. The IV bag containing the potassium chloride should always be labeled with the volume of potassium it contains. The IV site is monitored closely because potassium chloride is irritating to the veins and there is risk of phlebitis. In addition, the nurse should monitor for infiltration. The nurse monitors urinary output during administration and contacts the health care provider if the urinary output is less than 30 mL/hour.

The nurse is providing instructions to a client who will be self-administering eye drops. To minimize systemic absorption of the eye drops, the nurse should instruct the client to take which action?

*Occlude the nasolacrimal duct with a finger after instilling the drops.* Applying pressure on the nasolacrimal duct prevents systemic absorption of the medication. Options 1, 2, and 3 will not prevent systemic absorption.

The nurse provides instructions to a client who is taking levothyroxine. The nurse should tell the client to take the medication in which way?

*On an empty stomach* Oral doses of levothyroxine should be taken on an empty stomach to enhance absorption. Dosing should be done in the morning before breakfast.

A client with a gastric ulcer has a prescription for sucralfate 1 gram by mouth 4 times daily. The nurse should schedule the medication for which times?

*One hour before meals and at bedtime* Sucralfate is a gastric protectant. The medication should be scheduled for administration 1 hour before meals and at bedtime. The medication is timed to allow it to form a protective coating over the ulcer before food intake stimulates gastric acid production and mechanical irritation. The other options are incorrect.

A client with small cell lung cancer is being treated with etoposide. The nurse monitors the client during administration, knowing that which adverse effect is specifically associated with this medication?

*Orthostatic hypotension* An adverse effect specific to etoposide is orthostatic hypotension. Etoposide should be administered slowly over 30 to 60 minutes to avoid hypotension. The client's blood pressure is monitored during the infusion. Hair loss occurs with nearly all antineoplastic medications. Chest pain and pulmonary fibrosis are unrelated to this medication.

The nurse is reviewing the history and physical examination of a client who will be receiving asparaginase, an antineoplastic agent. The nurse contacts the health care provider before administering the medication if which disorder is documented in the client's history?

*Pancreatitis* Asparaginase is contraindicated if hypersensitivity exists, in pancreatitis, or if the client has a history of pancreatitis. The medication impairs pancreatic function and pancreatic function tests should be performed before therapy begins and when a week or more has elapsed between dose administrations. The client needs to be monitored for signs of pancreatitis, which include nausea, vomiting, and abdominal pain. The conditions noted in options 2, 3, and 4 are not contraindicated with this medication.

A client has been taking isoniazid for 2 months. The client complains to the nurse about numbness, paresthesias, and tingling in the extremities. The nurse interprets that the client is experiencing which problem?

*Peripheral neuritis* Isoniazid is an antitubercular medication. A common side effect of isoniazid is peripheral neuritis, manifested by numbness, tingling, and paresthesias in the extremities. This can be minimized with pyridoxine (vitamin B6) intake. Options 1, 3, and 4 are not associated with the information in the question.

A client with ovarian cancer is being treated with vincristine. The nurse monitors the client, knowing that which manifestation indicates an adverse effect specific to this medication?

*Peripheral neuropathy* An adverse effect specific to vincristine is peripheral neuropathy, which occurs in almost every client. Peripheral neuropathy can be manifested as numbness and tingling in the fingers and toes. Depression of the Achilles tendon reflex may be the first clinical sign indicating peripheral neuropathy. Constipation rather than diarrhea is most likely to occur with this medication, although diarrhea may occur occasionally. Hair loss occurs with nearly all antineoplastic medications. Chest pain is unrelated to this medication.

Methylergonovine is prescribed for a client with postpartum hemorrhage. Before administering the medication, the nurse should contact the health care provider who prescribed the medication if which condition is documented in the client's medical history?

*Peripheral vascular disease* Methylergonovine is an ergot alkaloid used to treat postpartum hemorrhage. Ergot alkaloids are contraindicated in clients with significant cardiovascular disease, peripheral vascular disease, hypertension, preeclampsia, or eclampsia. These conditions are worsened by the vasoconstrictive effects of the ergot alkaloids. Options 1, 2, and 3 are not contraindications related to the use of ergot alkaloids.

A client with diabetes mellitus visits a health care clinic. The client's diabetes mellitus previously had been well controlled with glyburide daily, but recently the fasting blood glucose level has been 180 to 200 mg/dL (10.2 to 11.4 mmol/L). Which medication, if added to the client's regimen, may have contributed to the hyperglycemia?

*Prednisone* Prednisone may decrease the effect of oral hypoglycemics, insulin, diuretics, and potassium supplements. Option 2, a beta blocker, and option 3, a monoamine oxidase inhibitor, have their own intrinsic hypoglycemic activity. Option 4 decreases urinary excretion of sulfonylurea agents, causing increased levels of the oral agents, which can lead to hypoglycemia.

Intravenous heparin therapy is prescribed for a client. While implementing this prescription, the nurse ensures that which medication is available on the nursing unit?

*Protamine sulfate* The antidote to heparin is protamine sulfate; it should be readily available for use if excessive bleeding or hemorrhage should occur. Vitamin K is an antidote for warfarin sodium. Potassium chloride is administered for a potassium deficit. Aminocaproic acid is the antidote for thrombolytic therapy.

A client with squamous cell carcinoma of the larynx is receiving bleomycin intravenously. The nurse caring for the client anticipates that which diagnostic study will be prescribed?

*Pulmonary function studies* Bleomycin is an antineoplastic medication that can cause interstitial pneumonitis, which can progress to pulmonary fibrosis. Pulmonary function studies along with hematological, hepatic, and renal function tests need to be monitored. The nurse needs to monitor lung sounds for dyspnea and crackles, which indicate pulmonary toxicity. The medication needs to be discontinued immediately if pulmonary toxicity occurs. Options 1, 2, and 3 are unrelated to the specific use of this medication.

Glimepiride is prescribed for a client with diabetes mellitus. The nurse instructs the client that which food items are most acceptable to consume while taking this medication? Select all that apply.

*Red meats* *Whole-grain cereals* *Carbonated beverages* When alcohol is combined with glimepiride, a disulfiram-like reaction may occur. This syndrome includes flushing, palpitations, and nausea. Alcohol can also potentiate the hypoglycemic effects of the medication. Clients need to be instructed to avoid alcohol consumption while taking this medication. Low-calorie desserts should also be avoided. Even though the calorie content may be low, carbohydrate content is most likely high and can affect the blood glucose. The items in options 2, 3, and 5 are acceptable to consume.

A client has begun medication therapy with pancrelipase. The nurse evaluates that the medication is having the optimal intended benefit if which effect is observed?

*Reduction of steatorrhea* Pancrelipase is a pancreatic enzyme used in clients with pancreatitis as a digestive aid. The medication should reduce the amount of fatty stools (steatorrhea). Another intended effect could be improved nutritional status. It is not used to treat abdominal pain or heartburn. Its use could result in weight gain but should not result in weight loss if it is aiding in digestion.

The home care nurse visits a client recently diagnosed with diabetes mellitus who is taking Humulin NPH insulin daily. The client asks the nurse how to store the unopened vials of insulin. The nurse should tell the client to take which action?

*Refrigerate the insulin.* Insulin in unopened vials should be stored under refrigeration until needed. Vials should not be frozen. When stored unopened under refrigeration, insulin can be used up to the expiration date on the vial. Options 1, 3, and 4 are incorrect.

A client who uses nonsteroidal antiinflammatory drugs (NSAIDs) has been taking misoprostol. The nurse determines that the misoprostol is having the intended therapeutic effect if which finding is noted?

*Relief of epigastric pain* The client who uses NSAIDs is prone to gastric mucosal injury. Misoprostol is a gastric protectant and is given specifically to prevent this occurrence in clients taking NSAIDs frequently. Diarrhea can be a side effect of the medication but is not an intended effect. Options 3 and 4 are unrelated to the purpose of misoprostol.

A client is to begin a 6-month course of therapy with isoniazid. The nurse should plan to teach the client to take which action?

*Report yellow eyes or skin immediately.* Isoniazid 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 isoniazid therapy.

A pregnant client is receiving magnesium sulfate for the management of preeclampsia. The nurse determines that the client is experiencing toxicity from the medication if which findings are noted on assessment? Select all that apply.

*Respirations of 10 breaths/minute* *Urine output of 20 mL in an hour* Magnesium toxicity can occur from magnesium sulfate therapy. Signs of magnesium sulfate toxicity relate to the central nervous system depressant effects of the medication and include respiratory depression, loss of deep tendon reflexes, and a sudden decline in fetal heart rate and maternal heart rate and blood pressure. Respiratory rate below 12 breaths per minute is a sign of toxicity. Urine output should be at least 25 to 30 mL per hour. Proteinuria of 3+ is an expected finding in a client with preeclampsia. Presence of deep tendon reflexes is a normal and expected finding. Therapeutic serum levels of magnesium are 4 to 7.5 mEq/L (2 to 3.75 mmol/L).

Oxybutynin chloride is prescribed for a client with urge incontinence. Which sign would indicate a possible toxic effect related to this medication?

*Restlessness* Toxicity (overdosage) of oxybutynin produces central nervous system excitation, such as nervousness, restlessness, hallucinations, and irritability. Other signs of toxicity include hypotension or hypertension, confusion, tachycardia, flushed or red face, and signs of respiratory depression. Drowsiness is a frequent side effect of the medication but does not indicate overdosage.

The nurse is preparing to administer a dose of naloxone intravenously to a client with an opioid overdose. Which supportive medical equipment should the nurse plan to have at the client's bedside if needed?

*Resuscitation equipment* The nurse administering naloxone for suspected opioid overdose should have resuscitation equipment readily available to support naloxone therapy if it is needed. Other adjuncts that may be needed include oxygen, a mechanical ventilator, and vasopressors.

The nurse has a prescription to give a client salmeterol, 2 puffs, and beclomethasone dipropionate, 2 puffs, by metered-dose inhaler. The nurse should administer the medication using which procedure?

*Salmeterol first and then the beclomethasone* Salmeterol is an adrenergic type of bronchodilator and beclomethasone dipropionate is a glucocorticoid. Bronchodilators are always administered before glucocorticoids when both are to be given on the same time schedule. This allows for widening of the air passages by the bronchodilator, which then makes the glucocorticoid more effective.

The nurse is reviewing the results of serum laboratory studies drawn on a client with acquired immunodeficiency syndrome who is receiving didanosine. The nurse interprets that the client may have the medication discontinued by the health care provider if which elevated result is noted?

*Serum amylase level* Didanosine can cause pancreatitis. A serum amylase level that is increased to 1.5 to 2 times normal may signify pancreatitis in the client with acquired immunodeficiency syndrome and is potentially fatal. The medication may have to be discontinued. The medication is also hepatotoxic and can result in liver failure.

The nurse is assigned to care for a client with cytomegalovirus retinitis and acquired immunodeficiency syndrome who is receiving foscarnet, an antiviral medication. The nurse should monitor the results of which laboratory study while the client is taking this medication?

*Serum creatinine level* Foscarnet is toxic to the kidneys. The serum creatinine level is monitored before therapy, two or three times per week during induction therapy, and at least weekly during maintenance therapy. Foscarnet also may cause decreased levels of calcium, magnesium, phosphorus, and potassium. Thus, these levels also are measured with the same frequency.

Prior to administering a client's daily dose of digoxin, the nurse reviews the client's laboratory data and notes the following results: serum calcium, 9.8 mg/dL (2.45 mmol/L); serum magnesium, 1.0 mEq/L (0.5 mmol/L); serum potassium, 4.1 mEq/L (4.1 mmol/L); serum creatinine, 0.9 mg/dL (79.5 mcmol/L). Which result should alert the nurse that the client is at risk for digoxin toxicity?

*Serum magnesium level* An increased risk of toxicity exists in clients with hypercalcemia, hypokalemia, hypomagnesemia, hypothyroidism, and impaired renal function. The calcium, creatinine, and potassium levels are all within normal limits. The normal range for magnesium is 1.3 to 2.1 mEq/L (0.65 to 1.05 mmol/L) and the results in the correct option are reflective of hypomagnesemia.

Rifabutin is prescribed for a client with active Mycobacterium avium complex (MAC) disease and tuberculosis. For which side and adverse effects of the medication should the nurse monitor? Select all that apply.

*Signs of hepatitis* *Flulike syndrome* *Low neutrophil count* *Ocular pain or blurred vision* Rifabutin may be prescribed for a client with active MAC disease and tuberculosis. It inhibits mycobacterial DNA-dependent RNA polymerase and suppresses protein synthesis. Side and adverse effects include rash, gastrointestinal disturbances, neutropenia (low neutrophil count), red-orange-colored body secretions, uveitis (blurred vision and eye pain), myositis, arthralgia, hepatitis, chest pain with dyspnea, and flulike syndrome. Vitamin B6 deficiency and numbness and tingling in the extremities are associated with the use of isoniazid.

A client is taking the prescribed dose of phenytoin to control seizures. Results of a phenytoin blood level study reveal a level of 35 mcg/mL (140 mcmol/L). Which finding would be expected as a result of this laboratory result?

*Slurred speech* The therapeutic phenytoin level is 10 to 20 mcg/mL (40 to 79 mcmol/L). At a level higher than 20 mcg/mL, involuntary movements of the eyeballs (nystagmus) occur. At a level higher than 30 mcg/mL (120 mcmol/L), ataxia and slurred speech occur.

Trimethoprim-sulfamethoxazole is prescribed for a client. The nurse should instruct the client to report which symptom if it develops during the course of this medication therapy?

*Sore throat* Clients taking trimethoprim-sulfamethoxazole should be informed about early signs and symptoms of blood disorders that can occur from this medication. These include sore throat, fever, and pallor, and the client should be instructed to notify the health care provider (HCP) if these occur. The other options do not require HCP notification.

The nurse is monitoring the intravenous (IV) infusion of an antineoplastic medication. During the infusion, the client complains of pain at the insertion site. On inspection of the site, the nurse notes redness and swelling and that the infusion of the medication has slowed in rate. The nurse suspects extravasation and should take which actions? Select all that apply.

*Stop the infusion.* *Notify the health care provider (HCP).* *Prepare to apply ice or heat to the site.* *Prepare to administer a prescribed antidote into the site.* Redness and swelling and a slowed infusion indicate signs of extravasation. If the nurse suspects extravasation during the IV administration of an antineoplastic medication, the infusion is stopped and the HCP is notified. Ice or heat may be prescribed for application to the site and an antidote may be prescribed to be administered into the site. Increasing the flow rate can increase damage to the tissues. Restarting an IV in the same vein can increase damage to the site and vein.

Alendronate is prescribed for a client with osteoporosis and the nurse is providing instructions on administration of the medication. Which instruction should the nurse provide?

*Take the medication with a full glass of water after rising in the morning.* Precautions need to be taken with the administration of alendronate to prevent gastrointestinal adverse effects (especially esophageal irritation) and to increase absorption of the medication. The medication needs to be taken with a full glass of water after rising in the morning. The client should not eat or drink anything for 30 minutes following administration and should not lie down after taking the medication.

Tacrolimus is prescribed for a client who underwent a kidney transplant. Which instruction should the nurse include when teaching the client about this medication?

*Take the oral medication every 12 hours at the same times every day.* Tacrolimus is a potent immunosuppressant used to prevent organ rejection in transplant clients. It is important that the medication be taken at 12-hour intervals to maintain a stable blood level to prevent organ rejection. Adverse effects include hyperglycemia and hypertension, so the client does not eat frequently to avoid hypoglycemia or use precautions to avoid orthostatic hypotension. Tacrolimus is metabolized through the cytochrome P450 system, so grapefruit juice is not allowed.

A client has a prescription to take guaifenesin. The nurse determines that the client understands the proper administration of this medication if the client states that he or she will perform which action?

*Take the tablet with a full glass of water.* Guaifenesin is an expectorant and should be taken with a full glass of water to decrease the viscosity of secretions. Extra doses should not be taken. The client should contact the health care provider if the cough lasts longer than 1 week or is accompanied by fever, rash, sore throat, or persistent headache. Fluids are needed to decrease the viscosity of secretions. The medication does not have to be taken with meals.

The client with acquired immunodeficiency syndrome and Pneumocystis jiroveci infection has been receiving pentamidine. The client develops a temperature of 101°F (38.3°C). The nurse continues to assess the client, knowing that this sign most likely indicates which condition?

*That the client has developed another infection caused by leukopenic effects of the medication* Frequent adverse effects of this medication include leukopenia, thrombocytopenia, and anemia. The client should be monitored routinely for signs and symptoms of infection. Options 1, 2, and 3 are inaccurate interpretations.

Nitrofurantoin is prescribed for a client with a urinary tract infection. The client contacts the nurse and reports a cough, chills, fever, and difficulty breathing. The nurse should make which interpretation about the client's complaints?

*The client is experiencing a pulmonary reaction requiring cessation of the medication.* Nitrofurantoin can induce 2 kinds of pulmonary reactions: acute and subacute. Acute reactions, which are most common, manifest with dyspnea, chest pain, chills, fever, cough, and alveolar infiltrates. These symptoms resolve 2 to 4 days after discontinuing the medication. Acute pulmonary responses are thought to be hypersensitivity reactions. Subacute reactions are rare and occur during prolonged treatment. Symptoms (e.g., dyspnea, cough, malaise) usually regress over weeks to months following nitrofurantoin withdrawal. However, in some clients, permanent lung damage may occur. The remaining options are incorrect interpretations.

The nurse is monitoring a client who is taking propranolol. Which assessment finding indicates a potential adverse complication associated with this medication?

*The development of audible expiratory wheezes* Audible expiratory wheezes may indicate a serious adverse reaction, bronchospasm. Beta blockers may induce this reaction, particularly in clients with chronic obstructive pulmonary disease or asthma. Normal decreases in blood pressure and heart rate are expected. Insomnia is a frequent mild side effect and should be monitored.

A client has been on treatment for rheumatoid arthritis for 3 weeks. During the administration of etanercept, which is most important for the nurse to assess?

*The white blood cell counts and platelet counts* Infection and pancytopenia are adverse effects of etanercept. Laboratory studies are performed prior to and during medication treatment. The appearance of abnormal white blood cell counts and abnormal platelet counts can alert the nurse to a potentially life-threatening infection. Injection site itching is a common occurrence following administration. A metallic taste and loss of appetite are not common signs of adverse effects of this medication.

The home health nurse visits a client who is taking phenytoin for control of seizures. During the assessment, the nurse notes that the client is taking birth control pills. Which information should the nurse include in the teaching plan?

*There is the potential of decreased effectiveness of birth control pills while taking phenytoin.* Phenytoin enhances the rate of estrogen metabolism, which can decrease the effectiveness of some birth control pills. Options 1, 2, and 4 are inappropriate instructions. Pregnancy does not need to be "avoided" while taking phenytoin; however, because phenytoin may cause some risk to the fetus (Pregnancy Category D medication), consultation with the health care provider should be done if pregnancy is considered. Telling a client that there is an increased risk of thrombophlebitis is incorrect and inappropriate and could cause anxiety in the client. A client should not be instructed to stop antiseizure medication.

The client arrives at the emergency department complaining of back spasms. The client states, "I have been taking 2 to 3 aspirin every 4 hours for the last week, and it hasn't helped my back." Since acetylsalicylic acid intoxication is suspected, the nurse should assess the client for which manifestation?

*Tinnitus* Mild intoxication with acetylsalicylic acid is called salicylism and is experienced commonly when the daily dosage is higher than 4 g. Tinnitus (ringing in the ears) is the most frequent effect noted with intoxication. Hyperventilation may occur because salicylate stimulates the respiratory center. Fever may result because salicylate interferes with the metabolic pathways coupling oxygen consumption and heat production. Options 2, 3, and 4 are not associated specifically with toxicity.

Salicylic acid is prescribed for a client with a diagnosis of psoriasis. The nurse monitors the client, knowing that which finding indicates the presence of systemic toxicity from this medication?

*Tinnitus* Salicylic acid is absorbed readily through the skin, and systemic toxicity (salicylism) can result. Symptoms include tinnitus, dizziness, hyperpnea, and psychological disturbances. Constipation and diarrhea are not associated with salicylism.

The nurse should tell the client, who is taking levothyroxine, to notify the health care provider (HCP) if which problem occurs?

*Tremors* Excessive doses of levothyroxine can produce signs and symptoms of hyperthyroidism. These include tachycardia, chest pain, tremors, nervousness, insomnia, hyperthermia, extreme heat intolerance, and sweating. The client should be instructed to notify the HCP if these occur. Options 1, 3, and 4 are signs of hypothyroidism.

Meperidine has been prescribed for a client to treat pain. Which side and adverse effects should the nurse monitor for? Select all that apply.

*Tremors* *Drowsiness* *Hypotension* Meperidine is an opioid analgesic. Side and adverse effects include respiratory depression, drowsiness, hypotension, constipation, urinary retention, nausea, vomiting, and tremors.

Isotretinoin is prescribed for a client with severe acne. Before the administration of this medication, the nurse anticipates that which laboratory test will be prescribed?

*Triglyceride level* Isotretinoin can elevate triglyceride levels. Blood triglyceride levels should be measured before treatment and periodically thereafter until the effect on the triglycerides has been evaluated. There is no indication that isotretinoin affects potassium, hemoglobin A1C, or total cholesterol levels.

A client with acute myelocytic leukemia is being treated with busulfan. Which laboratory value would the nurse specifically monitor during treatment with this medication?

*Uric acid level* Busulfan can cause an increase in the uric acid level. Hyperuricemia can produce uric acid nephropathy, renal stones, and acute kidney injury. Options 1, 3, and 4 are not specifically related to this medication.

Bethanechol chloride is prescribed for a client with urinary retention. Which disorder would be a contraindication to the administration of this medication?

*Urinary strictures* Bethanechol chloride can be hazardous to clients with urinary tract obstruction or weakness of the bladder wall. The medication has the ability to contract the bladder and thereby increase pressure within the urinary tract. Elevation of pressure within the urinary tract could damage or rupture the bladder in clients with these conditions.

Phenazopyridine is prescribed for a client with a urinary tract infection. The nurse evaluates that the medication is effective based on which observation?

*Urination is not painful.* Phenazopyridine is a urinary analgesic. It is effective when it eliminates pain and burning with urination. It does not eliminate the bacteria causing the infection, so it would not make the urine clear amber. It does not treat urge incontinence. It will cause the client to have reddish-orange discoloration of urine but this is a side effect of the medication, not the desired effect.

A client being treated for heart failure is administered intravenous bumetanide. Which outcome indicates that the medication has achieved the expected effect?

*Urine output increases from 10 mL/hour to greater than 50 mL hourly.* Bumetanide is a diuretic and expected outcomes include increased urine output, decreased crackles, and decreased weight. Options 1, 3, and 4 are incorrect.

The nurse is monitoring a client who is receiving oxytocin to induce labor. Which assessment findings should cause the nurse to immediately discontinue the oxytocin infusion? Select all that apply.

*Uterine hyperstimulation* *Late decelerations of the fetal heart rate* Oxytocin stimulates uterine contractions and is a pharmacological method to induce labor. Late decelerations, a nonreassuring fetal heart rate pattern, is an ominous sign indicating fetal distress. Oxytocin infusion must be stopped when any signs of uterine hyperstimulation, late decelerations, or other adverse effects occur. Some health care providers prescribe the administration of oxytocin in 10-minute pulsed infusions rather than as a continuous infusion. This pulsed method, which is more like endogenous secretion of oxytocin, is reported to be effective for labor induction and requires significantly less oxytocin use. Drowsiness and fatigue may be caused by the labor experience. Early decelerations of the fetal heart rate are a reassuring sign and do not indicate fetal distress.

Megestrol acetate, an antineoplastic medication, is prescribed for a client with metastatic endometrial carcinoma. The nurse reviews the client's history and should contact the health care provider if which diagnosis is documented in the client's history?

*Venous thromboembolism* Megestrol acetate suppresses the release of luteinizing hormone from the anterior pituitary by inhibiting pituitary function and regressing tumor size. Megestrol is used with caution if the client has a history of venous thromboembolism. Options 1, 2, and 3 are not contraindications for this medication.

A client with severe acne is seen in the clinic and the health care provider (HCP) prescribes isotretinoin. The nurse reviews the client's medication record and would contact the HCP if the client is also taking which medication?

*Vitamin A* Isotretinoin is a metabolite of vitamin A and can produce generalized intensification of isotretinoin toxicity. Because of the potential for increased toxicity, vitamin A supplements should be discontinued before isotretinoin therapy. There are no contraindications associated with digoxin, phenytoin, or furosemide.

A client has a new prescription for metoclopramide. On review of the chart, the nurse identifies that this medication can be safely administered with which condition?

*Vomiting following cancer chemotherapy* Metoclopramide is a gastrointestinal stimulant and antiemetic. Because it is a gastrointestinal stimulant, it is contraindicated with gastrointestinal obstruction, hemorrhage, or perforation. It is used in the treatment of vomiting after surgery, chemotherapy, or radiation.

The nurse prepares a client for ear irrigation as prescribed by the health care provider. Which action should the nurse take when performing the procedure?

*Warm the irrigating solution to 98.6°F (37.0°C)* Before ear irrigation, the nurse should inspect the tympanic membrane to ensure that it is intact. The irrigating solution should be warmed to 98.6°F (37.0°C) because a solution temperature that is not close to the client's body temperature will cause ear injury, nausea, and vertigo. The affected side should be down following the irrigation to assist in drainage of the fluid. When irrigating, a direct and slow steady stream of irrigation solution is directed toward the wall of the canal, not toward the eardrum. The client is positioned sitting, facing forward with the head in a natural position; if the ear is faced upward, the nurse would not be able to visualize the canal.

The nurse is preparing to administer eye drops. Which interventions should the nurse take to administer the drops? Select all that apply.

*Wash hands.* *Put gloves on.* *Place the drop in the conjunctival sac.* *Pull the lower lid down against the cheekbone* To administer eye medications, the nurse should wash hands and put gloves on. The client is instructed to tilt the head backward, open the eyes, and look up. The nurse pulls the lower lid down against the cheekbone and holds the bottle like a pencil with the tip downward. Holding the bottle, the nurse gently rests the wrist of the hand on the client's cheek and squeezes the bottle gently to allow the drop to fall into the conjunctival sac. The client is instructed to close the eyes gently and not to squeeze the eyes shut to prevent the loss of medication.

Silver sulfadiazine is prescribed for a client with a burn injury. Which laboratory finding requires the need for follow-up by the nurse?

*White blood cell count of 3000 mm3 (3.0 × 109/L)* Silver sulfadiazine is used for the treatment of burn injuries. Adverse effects of this medication include rash and itching, blue-green or gray skin discoloration, leukopenia, and interstitial nephritis. The nurse should monitor a complete blood count, particularly the white blood cells, frequently for the client taking this medication. If leukopenia develops, the health care provider is notified and the medication is usually discontinued. The white blood cell count noted in option 4 is indicative of leukopenia. The other laboratory values are not specific to this medication, and are also within normal limits.

A client with trigeminal neuralgia is being treated with carbamazepine, 400 mg orally daily. Which value indicates that the client is experiencing an adverse effect to the medication?

*White blood cell count, 3000 mm3 (3.0 × 109/L)* Adverse effects of carbamazepine appear as blood dyscrasias, including aplastic anemia, agranulocytosis, thrombocytopenia, and leukopenia; cardiovascular disturbances, including thrombophlebitis and dysrhythmias; and dermatological effects. The low white blood cell count reflects agranulocytosis. The laboratory values in options 1, 2, and 4 are normal values.

The nurse is teaching a client how to mix regular insulin and NPH insulin in the same syringe. Which action, if performed by the client, indicates the need for further teaching?

*Withdraws the NPH insulin first* When preparing a mixture of short-acting insulin, such as regular insulin, with another insulin preparation, the short-acting insulin is drawn into the syringe first. This sequence will avoid contaminating the vial of short-acting insulin with insulin of another type. Options 2, 3, and 4 identify correct actions for preparing NPH and short-acting insulin.

The health care provider (HCP) prescribes exenatide for a client with type 1 diabetes mellitus who takes insulin. The nurse should plan to take which most appropriate intervention?

*Withhold the medication and call the HCP, questioning the prescription for the client.* Exenatide is an incretin mimetic used for type 2 diabetes mellitus only. It is not recommended for clients taking insulin. Hence, the nurse should withhold the medication and question the HCP regarding this prescription. Although options 2 and 3 are correct statements about the medication, in this situation the medication should not be administered. The medication is packaged in prefilled pens ready for injection without the need for drawing it up into another syringe.

In monitoring a client's response to disease-modifying antirheumatic drugs (DMARDs), which assessment findings would the nurse consider acceptable responses? Select all that apply.

-*Control of symptoms during periods of emotional stress* -*Normal white blood cell, platelet, and neutrophil counts* -*Radiological findings that show no progression of joint degeneration* -*An increased range of motion in the affected joints 3 months into therapy* Because emotional stress frequently exacerbates the symptoms of rheumatoid arthritis, the absence of symptoms is a positive finding. DMARDs are given to slow the progression of joint degeneration. In addition, an improvement in the range of motion after 3 months of therapy with normal blood work is a positive finding. Temperature elevation and inflammation and irritation at the medication injection site could indicate signs of infection.

The nurse caring for a client who is taking an aminoglycoside should monitor the client for which adverse effects of the medication? Select all that apply.

-*Ototoxicity* -*Renal toxicity* -*Dysrhythmias* Aminoglycosides are administered to inhibit the growth of bacteria. Adverse effects of this medication include confusion, ototoxicity, renal toxicity, gastrointestinal irritation, palpitations or dysrhythmias, blood pressure changes, and hypersensitivity reactions. Therefore, the remaining options are incorrect.