Pharmacology - UWorld

The home health nurse prepares to give benztropine to a 70-year-old client with Parkinson disease. Which client statement is most concerning and would warrant health care provider notification? 1. "I am going for repeat testing to confirm glaucoma." 2. "I am not able to exercise as much as I used to." 3. "I started taking esomeprazole for heartburn." 4. "My bowel movements are not regular."

1 Parkinson disease (PD) is a progressive neurological disorder characterized by bradykinesia (loss of autonomic movements), rigidity, and tremors. Clients with PD have an imbalance between dopamine and acetylcholine in which dopamine is not produced in high enough quantities to inhibit acetylcholine. Anticholinergic medications (eg, benztropine, trihexyphenidyl) are commonly used to treat tremor in these clients. However, in clients with benign prostatic hyperplasia or glaucoma, caution must be taken as anticholinergic drugs can precipitate urinary retention and an acute glaucoma episode. As a result, such medications are contraindicated in these clients. (Option 2) Decreased ability to exercise is common in clients with PD due to tremors and bradykinesia, and they require physical and occupational therapy consultations. However, acute glaucoma can be sight threatening and is the priority. (Option 3) Esomeprazole is safe to take with benztropine and will not cause an adverse reaction. (Option 4) Constipation is a common side effect of benztropine. Due to the characteristic decreased mobility, PD can also cause constipation. The client should be instructed to increase dietary fiber intake and drink plenty of water. However, this is not the most concerning issue. Educational objective: Anticholinergic medications (eg, benztropine, trihexyphenidyl) are used to treat Parkinson disease tremor. However, they can precipitate acute glaucoma and urinary retention and are therefore contraindicated in susceptible clients (eg, those with glaucoma or benign prostatic hyperplasia).

The nurse administers a dose of radioactive iodine to a female client for treatment of hyperthyroidism. Which of the following precautions should the nurse teach the client to follow on discharge? Select all that apply. 1. "Avoid close contact with pregnant women, infants, and children." 2. "If applicable, you may resume breastfeeding when you return home." 3. "If possible, use a separate toilet from your family, and flush 2 or 3 times after each use." 4. "Use disposable cups, plates, and utensils, and do not share food items with others." 5. "Wash your clothing and towels separately from the rest of the laundry in your home."

1, 3, 4, 5 Radioactive iodine (RAI) treats hyperthyroidism by partially damaging or destroying the thyroid gland. RAI has a delayed response, requiring up to 3 months for maximal effect. After treatment, the client emits radiation, and excreted bodily fluids are radioactive. The nurse teaches home precautions to protect those who come in contact with the client. Depending on the dosage, clients should use the following precautions for up to 1 week: - Limit close contact and time spent with pregnant women and children (Option 1). - Use a separate toilet, and flush 2 or 3 times after each use to remove urine residue (Option 3). - Use disposable cups, plates, and utensils, and do not share foods that could transfer saliva (Option 4). - Isolate personal laundry (eg, clothing, linens) and wash it separately (Option 5). - Sleep in a separate bed from others. - Do not sit near others for a prolonged time (eg, train or flight travel). (Option 2) After RAI therapy, breast milk excreted by the client is radioactive and can permanently damage an infant's thyroid. Breastfeeding should be stopped 6 weeks before treatment to prevent RAI from accumulating in the breasts after treatment. Breastfeeding is not resumed with the current child but can be resumed with future pregnancies. Educational objective: Radioactive iodine treats hyperthyroidism by damaging or destroying the thyroid gland. After ingesting radioactive iodine, clients and their bodily secretions are radioactive. They should avoid pregnant women and children, use a separate toilet and disposable tableware, sleep in a separate bed, and isolate personal laundry.

A client with primary hypothyroidism has been taking levothyroxine for a year. Laboratory results today show high levels of TSH. Which statement by the nurse to the client is appropriate? 1. "A new prescription will likely be issued for a decreased dose of levothyroxine." 2. "Dosages of levothyroxine may need to be increased to improve TSH levels." 3. "Levothyroxine should be held, and the TSH levels will be reassessed in 3 months." 4. "Start taking your levothyroxine with dietary fiber or calcium to increase its effectiveness."

2 Thyroid-stimulating hormone (TSH) is released from the pituitary gland to stimulate the thyroid to secrete hormones (T3, T4). When sufficient thyroid hormone is circulating, negative feedback causes a normally functioning pituitary to slow or stop the release of TSH. In primary hypothyroidism, the thyroid is unable to synthesize enough T3 or T4, slowing the metabolic rate. In response to low circulating thyroid hormones, the pituitary continues to release TSH, resulting in high TSH levels. Levothyroxine (Synthroid), a thyroid hormone replacement drug, is commonly used to treat hypothyroidism. Levothyroxine dosing is adjusted to regulate circulating thyroid hormone levels; this creates a euthyroid (normal) state and TSH levels are decreased (Option 2). (Options 1 and 3) Decreasing the dose or discontinuing levothyroxine would lead to increased TSH and worsening hypothyroidism as the amount of circulating thyroid hormone decreases. (Option 4) Levothyroxine should be taken on a consistent morning schedule, at least 30 minutes before a meal. Foods containing certain ingredients (eg, walnuts, soy products, dietary fiber, calcium) can decrease drug absorption. Educational objective: In primary hypothyroidism, the thyroid does not produce enough hormones (T3, T4). In response to low circulating thyroid hormones, the pituitary continues to release TSH, resulting in high levels of circulating TSH. Levothyroxine is usually started or increased to lead to a euthyroid (normal) state.

The nurse evaluating a 52-year-old diabetic male client's therapeutic response to rosuvastatin would notice changes in which laboratory values? Select all that apply. 1. Alanine aminotransferase from 20 U/L (0.33 µkat/L) to 80 U/L (1.34 µkat/L) 2. High-density lipoprotein cholesterol from 48 mg/dL (1.24 mmol/L) to 30 mg/dL (0.78 mmol/L) 3. Low-density lipoprotein cholesterol from 176 mg/dL (4.61 mol/L) to 98 mg/dL (2.54 mmol/L) 4. Total cholesterol from 250 mg/dL (6.47 mmol/L) to 180 mg/dL (4.66 mmol/L) 5. Triglycerides from 180 mg/dL (2.03 mmol/L) to 149 mg/dL (1.68 mmol/L)

3, 4, 5 Statins (rosuvastatin, atorvastatin, simvastatin) are the most preferred agents to reduce low-density lipoprotein (LDL) cholesterol, total cholesterol, and triglyceride levels. This client's LDL level has decreased to a target range (diabetic client <100 mg/dL [2.6 mmol/L]), total cholesterol has decreased to a normal range (adult <200 mg/dL [5.2 mmol/L]), and triglyceride level has decreased to a normal range (adult <150 mg/dL [1.7 mmol/L)); all these changes indicate a therapeutic response (Options 3, 4, and 5). (Option 1) The adult therapeutic range of alanine aminotransferase (ALT) is 10-40 U/L (0.17-0.68 µkat/L). Increased aspartate aminotransferase (AST) and ALT may indicate hepatic dysfunction, a potential adverse effect of statin medication. (Option 2) The therapeutic range of high-density lipoprotein (HDL) cholesterol for adult men is >40 mg/dL (1.04 mmol/L). HDL is good cholesterol. This client's HDL level is below the therapeutic range, indicating a nontherapeutic response. Educational objective: A therapeutic response to statin medication includes a decrease in a client's LDL cholesterol, total cholesterol, and triglyceride levels to within normal range. An increase in HDL cholesterol to within normal range is also an expected outcome. Potential adverse effects include hepatic dysfunction and muscle injury.

The nurse obtains a health history from a client who states, "I skip dinner most nights to lose weight. I don't want to get low blood sugar, so I don't take my evening dose of metformin when I skip dinner." Which response by the nurse is appropriate? 1. "Have your blood sugars been in the desired range when you skip doses?" 2. "Take half of the evening dose to prevent a low blood sugar level." 3. "The risk of low blood sugar is minimal when metformin is taken without food." 4. "Why are you skipping meals? That is not a healthy weight loss strategy."

3 Metformin is an oral antidiabetic medication used to manage hyperglycemia in clients with type 2 diabetes. Metformin increases the sensitivity of insulin receptors in cells and reduces glucose production by the liver. These actions increase the efficacy of insulin present in the body and prevent large rises in blood glucose after meals. Because metformin does not stimulate insulin secretion by the pancreas, the risk of hypoglycemia is minimal (Option 3). Although skipping meals would cause a drop in blood glucose, metformin would not cause further hypoglycemia. (Option 1) Investigating the effect that skipping meals and medication has on the client's blood glucose levels may imply affirmation of the incorrect action. The nurse should provide education about the drug action and appropriate means of weight loss. (Option 2) Instructing the client to alter the frequency or dose of prescribed medication is outside of the nurse's scope of practice. Alterations to treatment plans require the prescriptive authority of a health care provider. (Option 4) Skipping meals to lose weight is not a healthy weight-loss strategy as it causes cellular energy deficits and may lead to hypoglycemia. Educating the client to take medications as prescribed remains the priority. Furthermore, "Why" questions are not appropriate forms of therapeutic communication. Educational objective: Metformin is an oral antidiabetic medication that increases insulin sensitivity and inhibits liver glucose production. Metformin does not increase insulin secretion, so the risk of hypoglycemia is minimal even when meals are skipped.

The nurse is preparing to administer 160 mg of furosemide via IV piggyback to a client with chronic kidney disease and fluid overload. The nurse plans to give the dose slowly over 40 minutes to prevent which adverse effect? 1. Bradycardia 2. Hypokalemia 3. Nephrotoxicity 4. Ototoxicity

4 IV furosemide may cause ototoxicity, particularly when high doses are administered in clients with compromised renal function. The rate of administration should not exceed 4 mg/min in doses >120 mg. To determine the correct rate of administration for the dose above, use the following formula: (160 mg) / (4 mg/min) = 40 min (Option 1) Bradycardia is an adverse effect of beta blockers (eg, metoprolol, atenolol), calcium channel blockers (eg, verapamil), and digoxin. It is not an adverse effect of furosemide. (Option 2) Hypokalemia is common with furosemide administration due to the potassium-wasting effects of this loop diuretic. However, slower infusion is unlikely to prevent this adverse effect. (Option 3) Although nephrotoxicity can occur with IV furosemide administration, it is dependent on the dose, not the rate of administration. Educational objective: High doses of IV furosemide should be administered slowly to prevent ototoxicity.

The nurse performs medication reconciliation for a 94-year-old client who has type 2 diabetes, hypothyroidism, and heart failure caused by a previous myocardial infarction. Due to risks outweighing benefits, the nurse plans to talk with the health care provider about discontinuing which medication? 1. Aspirin 81 mg PO once a day 2. Furosemide 40 mg PO once a day 3. Glyburide 10 mg PO once a day 4. Levothyroxine 50 mcg PO once a day

3 Beers Criteria lists medications that may be inappropriate for the geriatric population due to risks outweighing benefits. The nurse collaborates with the health care provider to minimize polypharmacy and reduce adverse effects (eg, falls, confusion). Sulfonylureas (eg, glyburide) stimulate insulin release via the pancreas and carry a risk for severe and prolonged hypoglycemia in the geriatric population due to potential delayed elimination. Avoidance of these drugs is recommended by the Beers Criteria. Instead, other medications that are at lower risk for hypoglycemia should be used (eg, metformin) (Option 3). (Option 1) Aspirin is used to prevent platelet aggregation in clients with a history of stroke or myocardial infarction. Aspirin and other nonsteroidal anti-inflammatory medications (eg, ibuprofen) have an increased risk of gastrointestinal bleeding. Therefore, aspirin is used cautiously in the older adult population, and doses should not exceed 325 mg/day. (Option 2) Furosemide is a loop diuretic used to treat fluid overload in heart failure, making it an important part of symptom management. This drug may cause dehydration if the client is not ingesting food and fluids well; otherwise, it should be continued. (Option 4) Levothyroxine is required to maintain thyroid hormone levels in clients with hypothyroidism. Major side effects typically occur only with improper dosing (eg, elevated levels). Educational objective: The Beers Criteria can be used to identify potentially inappropriate drugs that contribute to adverse events (eg, falls, confusion) and drug toxicity in older adults. Sulfonylureas (eg, glyburide) should be avoided due to potential delayed elimination causing risk for prolonged hypoglycemia.

A client is receiving scheduled doses of carbidopa-levodopa. The nurse evaluates the medication as having the intended effect if which finding is noted? 1. Improvement in short-term memory 2. Improvement in spontaneous activity 3. Reduction in number of visual hallucinations 4. Reduction of dizziness with standing

Parkinson disease is caused by low levels of dopamine in the brain. Levodopa is converted to dopamine in the brain, but much of this drug is metabolized before reaching the brain. Carbidopa helps prevent the breakdown of levodopa before it can reach the brain and take effect. This combination medication is particularly effective in treating bradykinesia (generalized slowing of movement). Tremor and rigidity may also improve to some extent. Carbidopa-levodopa (Sinemet) once started should never be stopped suddenly as this can lead to akinetic crisis (complete loss of movement). However, prolonged use can also result in dyskinesias (spontaneous involuntary movements) and on/off periods when the medication will start or stop working unpredictably. (Option 1) Carbidopa-levodopa does not improve memory. Medications for the treatment of Alzheimer disease, such as donepezil and rivastigmine, are used to improve cognition and memory. (Options 3 and 4) Orthostatic hypotension and neuropsychiatric disturbances (eg, confusion, hallucinations, delusions, agitation, psychosis) are serious and important adverse effects of carbidopa-levodopa. Health care providers usually start the medications at low doses and gradually increase them to prevent these effects. Educational objective: The combination medication carbidopa-levodopa is most helpful for treating bradykinesia in Parkinson disease and can also improve tremor and rigidity to some extent. It is started in low doses to prevent orthostatic hypotension and neuropsychiatric adverse effects. Carbidopa-levodopa once started should never be stopped suddenly as doing so can lead to akinetic crisis (complete loss of movement).

The nurse is preparing medication for 4 clients on a respiratory medical-surgical unit. Which situation would prompt the nurse to clarify the prescribed treatment with the health care provider? 1. Client with bronchospasm who is due to receive nebulized acetylcysteine 2. Client with chronic obstructive pulmonary disease due to receive PO prednisone 3. Client with cystic fibrosis who is due to receive PO pancrelipase with breakfast 4. Client with suspected bacterial pneumonia due to receive IV levofloxacin

1 Acetylcysteine (Mucomyst) may be given via nebulizer to help loosen and liquefy respiratory secretions to more easily clear them from the airway. Inhaled acetylcysteine may be used for clients with cystic fibrosis or other respiratory conditions with thick bronchial mucus. Acetylcysteine has no therapeutic effect on airway smooth muscle as it works primarily on secretions and has been shown to cause and/or worsen bronchospasm. Nurses caring for clients with reactive airway diseases (eg, asthma) prescribed acetylcysteine should clarify the prescription with the health care provider (Option 1). (Option 2) Chronic obstructive pulmonary disease (COPD) is a respiratory illness in which excess mucus, inflamed bronchioles, and easily collapsible airways trap air within the alveoli. Oral corticosteroids (eg, prednisone) may be used to reduce airway inflammation and improve ventilation in clients with acute COPD exacerbation. (Option 3) Cystic fibrosis is a genetic condition that causes dehydration and thickening of mucus in the respiratory, gastrointestinal, and genitourinary systems. Thick mucus within the pancreas impairs the release of digestive enzymes (eg, lipase), requiring supplementation to improve digestion and prevent malnutrition in clients with CF. (Option 4) Levofloxacin (Levaquin) is a broad-spectrum antibiotic that may be used to treat respiratory tract infections, such as bacterial pneumonia. Educational objective: Acetylcysteine is a medication that can be inhaled to help loosen thick respiratory secretions. Nurses caring for clients with reactive airway diseases (eg, asthma) who are prescribed acetylcysteine should clarify the prescription with the health care provider as it may cause and/or worsen bronchospasm.

An elderly client with type 2 diabetes is admitted to the medical unit due to urosepsis. The client is wearing an insulin pump for continuous subcutaneous insulin infusion therapy. The client's significant other reports that the client self-manages the insulin pump extremely well and keeps blood glucose in the specified target range. What is the admitting nurse's priority action? 1. Assess the client's level of orientation 2. Assess the insulin pump infusion site 3. Check the prescribed insulin pump settings 4. Consult the diabetic resource nurse or educator

1 Change in mental status and confusion is a common presenting symptom of sepsis in the elderly. The nurse should assess the client's cognitive status and level of orientation and consciousness. Diminished mental acuity, side effects of medication, and impairment related to a medical condition during hospitalization affect the client's ability to manage the insulin pump safely. Mental status is the key to safe insulin pump use, so if the client is not competent to operate the pump, the nurse should notify the health care provider (HCP) and document the findings in the client's electronic medical record. The HCP will determine if continuing the use of the pump during hospitalization is appropriate. (Option 2) Assessing the infusion pump site for signs of infection and intactness of the infusion set is important, but it is not the priority action. (Option 3) The HCP prescribes the basal insulin along with the parameters for bolus and correction doses while the client is hospitalized. The nurse should check and document the make and model, pump settings, type of insulin, and the date that the infusion site and set were changed. However, this is not the priority action. (Option 4) Consulting with the diabetic resource nurse or educator to determine the client's competency and ability to manage a specific type of pump and provide ongoing client education is an appropriate action. However, this is not the priority. Educational objective: When caring for a hospitalized client wearing an insulin pump, the priority nursing action is to assess the client's mental capacity to determine the ability to self-manage the pump safely.

The home health nurse visits a client with hypertension whose blood pressure has been well controlled on oral valsartan 320 mg daily. The client's blood pressure is 190/88 mm Hg, significantly higher than it was 2 weeks ago. The client reports a cold, a stuffy nose, and sneezing for 3 days. Which question is most appropriate for the nurse to ask? 1. "Are you taking any over-the-counter medicines for your cold?" 2. "Are you taking extra vitamin C?" 3. "Did you babysit your granddaughter this past week?" 4. "Did you get a flu shot in the past week?"

1 Clients with hypertension should be instructed not to take potentially high-risk over-the-counter (OTC) medications such as high-sodium antacids, appetite suppressants, and cold and sinus preparations. It is appropriate to ask a client with hypertension about taking OTC cold medications as many cold and sinus medications contain phenylephrine or pseudoephedrine. These sympathomimetic decongestants activate alpha-1 adrenergic receptors, producing vasoconstriction. The resulting decreased nasal blood flow relieves nasal congestion. These agents have both oral and topical forms. With systemic absorption, these agents can cause dangerous hypertensive crisis. (Option 2) Taking extra vitamin C may offer some protection for the immune system, but it does not cause an increase in blood pressure. (Option 3) Exposure to young children increases the risk for contracting a contagious respiratory illness, but it does not directly increase blood pressure. (Option 4) A flu shot would not offer protection against the flu within a week and does not cause an increase in blood pressure. Educational objective: Clients with hypertension should be instructed not to take potentially high-risk over-the-counter medications, including high-sodium antacids, appetite suppressants, and cold and sinus preparations, as they can increase blood pressure.

The nurse is caring for a client with chronic, stable angina. The client takes the long-acting nitrate isosorbide mononitrate. Which client outcome indicates that the drug is effective? 1. Client is able to shower, dress, and fix hair without any chest pain 2. Client reports a reduction in stress level and anxiety 3. Client reports being able to sleep through the night 4. Client's blood pressure is 128/78 mm Hg and heart rate is 82/min

1 Long-acting nitrates are used to reduce the incidence of anginal attacks. Nitrates are effective if the client is able to do activities without the incidence of chest pain. The client should be taught to report any increase in chest pain and how to manage headaches, a common side effect of nitrates. (Options 2 and 3) A reduction in stress level and anxiety, and being able to sleep through the night are positive outcomes for any client with cardiovascular disease. However, these outcomes are not directly related to long-acting nitrate use. (Option 4) Nitrates are vasodilators and may decrease the client's blood pressure, which is a positive outcome but not the primary reason for taking the medication. This client is taking the medication for angina. Educational objective: The ability to perform activities without chest pain is a desirable client outcome of long-acting nitrate use. The nurse would want to assess for this outcome in clients taking these medications.

The nurse in the same-day surgery unit admits a client who will receive general anesthesia. The client has never had surgery before. Which question is most critical for the nurse to ask the client during the preoperative assessment and health history? 1. "Has any family member ever had a bad reaction to general anesthesia?" 2. "Have you ever experienced low back pain?" 3. "Have you ever had an anaphylactic reaction to a bee sting?" 4. "Have you ever received opioid pain medications?"

1 Malignant hyperthermia (MH) is a rare but life-threatening inherited muscle abnormality that is triggered by specific, inhaled anesthetic agents and the depolarizing muscle relaxant succinylcholine (Anectine) used to induce general anesthesia. In MH-susceptible clients, the triggering agent leads to excessive release of calcium from the muscles, leading to sustained muscle contraction and rigidity (usually of the jaw and upper body [early sign]), increased oxygen demand and metabolism, and dangerously high temperature (later sign). As MH is an inherited condition, proper screening and a thorough preoperative nursing assessment and health history can help minimize the client's risk (Option 1). (Option 2) Cervical spine problems should be assessed before the intubation. Low back pain history is not a priority for general anesthesia. (Option 3) It would be appropriate to ask about allergies (eg, drugs, latex). However, asking about an anaphylactic reaction to a bee sting is not the most critical question. (Option 4) History of prior opioid intake may be helpful, but the most important question is to ask about side effects and allergies. Educational objective: Malignant hyperthermia (MH) is a rare, life-threatening inherited muscular abnormality that is triggered by specific drugs used to induce general anesthesia. Therefore, it is critical for the perioperative nurse to screen for MH susceptibility by asking if any of the client's blood relatives had ever experienced an adverse reaction to general anesthesia, including unexplained death.

A client with a history of heart failure calls the clinic and reports a 3-lb (1.4-kg) weight gain over the past 2 days and increased ankle swelling. The nurse reviews the client's medications and anticipates the immediate need for dosage adjustment of which medication? 1. Bumetanide 2. Candesartan 3. Carvedilol 4. Isosorbide

1 Most clients with heart failure are prescribed a loop diuretic (eg, furosemide, torsemide, bumetanide) to reduce fluid retention. If the client has signs and symptoms of excessive fluid accumulation, the nurse will need to assess the situation by asking the client about dietary and fluid intake, adherence to prescribed medications, and the presence of any other associated symptoms (eg, shortness of breath). If the client is stable, the nurse may anticipate the need to increase the dosage of the prescribed loop diuretic (eg, bumetanide). (Option 2) Losartan, valsartan, and candesartan (sartans) are the commonly used angiotensin II receptor blockers. They are used in clients who cannot take ACE inhibitors (eg, lisinopril, ramipril). They block the renin-angiotensin-aldosterone system but will not affect the fluid status of the client with acute heart failure. (Option 3) Metoprolol, bisoprolol, and carvedilol (lols) are the commonly used beta blockers for treatment of chronic heart failure. They block the negative effects of the sympathetic nervous system (increased heart rate) and reduce the cardiac workload. However, they can worsen heart failure if used in the acute setting of this condition. (Option 4) Isosorbide (nitrate) and hydralazine are used in African American clients with heart failure; this combination decreases cardiac workload by reducing preload and afterload. However, it does not decrease excess fluid. Educational objective: A client who reports weight gain and edema requires evaluation for additional symptoms of fluid volume overload (eg, shortness of breath) and adherence to the current treatment plan. If the client is stable, an increase in the dosage of loop diuretic (eg, furosemide, torsemide, bumetanide) is anticipated.

The nurse reviews the laboratory results of several clients. Which finding should the nurse report to the health care provider immediately? 1. Client who is receiving tube feedings and has a phenytoin level of 8 mcg/mL (32 mcmol/L) 2. Client with a heart rate of 62/min who has a digoxin level of 1.3 ng/mL (1.7 nmol/L) 3. Client with a new prosthetic aortic valve who has an INR of 3.0 4. Client with a poor appetite and a lithium level of 0.8 mEq/L (0.8 mmol/L)

1 Narrow therapeutic index medications have a higher chance of producing adverse effects due to a very small difference between therapeutic and toxic levels. These medications require close monitoring of serum drug levels for adequate, but not toxic, dosing. Clients should also be monitored for signs of toxicity, which are specific to each medication. Phenytoin (Dilantin) is an antiseizure medication with a therapeutic index of 10-20 mcg/mL (40-79 mcmol/L) (Option 1). Tube feedings decrease phenytoin absorption, which reduces serum drug concentrations and may precipitate seizures. The nurse should pause tube feedings for 1-2 hours before and after phenytoin administration to ensure adequate absorption. Phenytoin toxicity produces nystagmus, dysarthria, ataxia, and encephalopathy. (Option 2) A heart rate of 62/min is expected in a client taking digoxin (therapeutic index 0.5-2.0 ng/mL [0.6-2.6 nmol/L]). Digoxin toxicity produces gastrointestinal symptoms (nausea, vomiting, diarrhea), bradycardia, and visual disturbances (blurred vision, yellow-green halos). (Option 3) The therapeutic INR for a client with a mechanical heart valve is 2.5-3.5. (Option 4) Anorexia is a common side effect of lithium (therapeutic index 0.6-1.2 mEq/L [0.6-1.2 mmol/L]). Lithium toxicity produces nausea, vomiting, ataxia, and tremors. Educational objective: Tube feedings decrease phenytoin (Dilantin) absorption, which reduces serum drug concentrations (therapeutic index 10-20 mcg/mL [40-79 mcmol/L]) and may precipitate seizures. The nurse should pause tube feedings for 1-2 hours before and after phenytoin administration to ensure adequate absorption.

The nurse is providing discharge instructions to a client receiving oxybutynin for overactive bladder. Which client statement indicates that further teaching is required? 1. "I am looking forward to our summer vacation at the beach." 2. "I plan to eat more fruits and vegetables to prevent constipation." 3. "I should not drive until I know how this drug affects me." 4. "I will drink at least 6-8 glasses of water daily."

1 Oxybutynin (Ditropan) is an anticholinergic medication that is frequently used to treat overactive bladder. Common side effects include: - New-onset constipation - Dry mouth - Flushing - Heat intolerance - Blurred vision - Drowsiness Decreased sweat production may lead to hyperthermia. The nurse should instruct the client to be cautious in hot weather and during physical activity (Option 1). (Options 2 and 4) Increasing dietary intake of fluids and bulk-forming foods (eg, fruits, vegetables) promotes normal bowel function and prevents constipation. (Option 3) Sedation is a common side effect of anticholinergic drugs. Clients should be taught not to drive or operate heavy machinery until they know how the drug affects them. Educational objective: Anticholinergic medications are commonly associated with constipation, urinary retention, flushing, dry mouth, and heat intolerance. Clients should be taught to prevent these side effects by increasing intake of fluids and bulk-forming foods (prevents dry mouth and constipation) and by avoiding locations or activities that may lead to hyperthermia.

The home health nurse reviews the serum laboratory test results for a client with seizures. The phenytoin level is 27 mcg/mL. The client makes which statement that may indicate the presence of dose-related drug toxicity and prompt the nurse to notify the health care provider? 1. "I am feeling unsteady when I walk." 2. "I am getting up to urinate about 4 times during the night." 3. "I have a metallic taste in my mouth when I eat." 4. "My gums are getting so puffy and red."

1 Phenytoin (Dilantin) is an anticonvulsant drug used to treat generalized tonic-clonic seizures. The therapeutic serum phenytoin reference range is between 10-20 mcg/mL. Levels are measured when therapy is initiated, periodically throughout treatment to guide dosing until a steady state is attained (3-12 months), and if seizure activity increases. Early signs of toxicity include horizontal nystagmus and gait unsteadiness. These may be followed by slurred speech, lethargy, confusion, and even coma. Bradyarrhythmias and hypotension are usually seen with intravenous phenytoin. (Option 2) Nocturia is an expected side effect of diuretics but not phenytoin. Nocturia is also seen with diabetes mellitus and benign prostatic hyperplasia. (Option 3) Metallic taste in the mouth is often seen with metronidazole but not with phenytoin. (Option 4) Gingival hyperplasia is a common expected side effect of phenytoin and does not indicate drug toxicity. It occurs more often in clients <23 years of age who are prescribed >500 mg/day. Good oral hygiene can limit symptoms. Educational objective: Phenytoin, an anticonvulsant drug, is used to treat generalized tonic-clonic seizures. Common symptoms of phenytoin drug-induced toxicity involve the central nervous system and include ataxia, nystagmus, slurred speech, and decreased alertness.

The office nurse, while reviewing a client's health information, notices that the client has recently started taking St. John's wort for symptoms of depression. What additional information is most important for the nurse to obtain? 1. Ask if the client is currently taking any prescription antidepressant medications 2. Ask if the client has been diagnosed with depression by a mental health care provider (HCP) 3. Ask if the client takes a multivitamin with iron 4. Ask if the client uses tanning beds

1 St. John's wort is an herbal product commonly used by many clients to treat depression. However, it may interact with medications used to treat depression or other mood disorders, including tricyclic antidepressants, selective serotonin and/or norepinephrine receptor inhibitors (SSRIs/SNRIs), and monoamine oxidase inhibitors (MAOIs). Taking St. John's wort with these medications tends to increase side effects and could potentially lead to a dangerous condition called serotonin syndrome. Serotonin is a chemical produced by the body that is needed for the nerve cells and brain to function. Excessive serotonin causes symptoms that can range from mild (shivering and diarrhea) to severe (muscle rigidity, fever, and seizures). Severe serotonin syndrome can be fatal if it is not treated. (Option 2) The nurse can ask the client if a diagnosis of depression has been made by an HCP, but inquiring about possible medications that can interact with St. John's wort is more important at this time. (Option 3) St. John's wort may interfere with the absorption of iron and other minerals. This is a teaching point, but it is not the highest priority question to ask the client. (Option 4) St. John's wort can cause photosensitivity which could be exacerbated by use of tanning beds. However, this is not the highest priority question to ask the client. Educational objective: St. John's wort interferes with many prescription medications. It is a priority for the nurse to assess for concomitant use of St. John's wort with prescription SSRIs, MAOIs, or tricyclic antidepressants as such combinations can cause serotonin syndrome.

The health care provider is starting an elderly client on terazosin to treat benign prostatic hyperplasia (BPH). Which information should be included when teaching this client about the new medication? 1. Change positions slowly when going from lying to standing 2. Do not drink grapefruit juice when taking this drug 3. Take this medication first thing in the morning, before breakfast 4. Your stool may become darker and that's normal

1 Terazosin is an alpha-adrenergic blocker that can relieve urinary retention in clients with BPH. It relaxes the smooth muscle in the bladder neck and prostate gland; however, it also relaxes smooth muscle in the peripheral vasculature, which can cause orthostatic hypotension, syncope (blacking out), and falls. This is particularly common when the drug is started (first-dose hypotension) or when the dosage is increased. The serious effects can be avoided by instructing the client to take the medication at bedtime, change positions slowly when going from lying to standing, and avoid any medications that also increase smooth muscle relaxation (eg, phosphodiesterase-5 inhibitors [sildenafil or vardenafil] used to treat erectile dysfunction). Some clients may also experience ejaculatory dysfunction (decreased or absent ejaculation). (Option 2) Grapefruit juice can cause significant interactions with drugs such as calcium channel blockers and sildenafil. However, it does not appear to interact with alpha blockers such as terazosin. (Option 3) Alpha-1-adrenergic antagonists (eg, terazosin, doxazosin, tamsulosin, alfuzosin) should be taken at bedtime, not in the morning, to avoid orthostatic hypotension. (Option 4) Oral iron tablets and bismuth salts (Pepto-Bismol) can turn stools dark, an expected side effect. This can be confused with upper gastrointestinal bleeding, which can also cause melena. Educational objective: Alpha blockers are commonly used to treat symptoms of urinary retention in clients with BPH. Orthostatic hypotension is a common side effect that can be avoided by teaching the client to take the medication at bedtime, avoid abrupt position changes, and avoid medications for erectile dysfunction, which can worsen hypotension.

The hospice nurse is caring for an actively dying client who is unresponsive and has developed a loud rattling sound with breathing ("death rattle") that distresses family members. Which prescription would be most appropriate to treat this symptom? 1. Atropine sublingual drops 2. Lorazepam sublingual tablet 3. Morphine sublingual liquid 4. Ondansetron sublingual tablet

1 The "death rattle" is a loud rattling sound with breathing that occurs in a client who is actively dying. When the client cannot manage airway secretions, the movement of these secretions during breathing causes a noisy rattling sound. This can distress family and friends at the bedside of the dying client. The "death rattle" can be treated using anticholinergic medications to dry the client's secretions. Medications include atropine drops administered sublingually or a transdermal scopolamine patch. (Option 2) Lorazepam is a benzodiazepine that is used to treat anxiety and restlessness in terminally ill clients. It can be effective for alleviating dyspnea exacerbated by anxiety, but it is ineffective for controlling secretions (the cause of the "death rattle"). (Option 3) Morphine is an opioid analgesic that is effective for pain treatment as well as terminal dyspnea. The client is not exhibiting these symptoms, so morphine would be inappropriate. (Option 4) Ondansetron will help the nausea and vomiting but is not very effective for treating the "death rattle." Educational objective: The "death rattle" is a noisy rattling sound with breathing commonly seen in a dying client who is unresponsive and no longer able to manage airway secretions. Anticholinergic medications such as transdermal scopolamine or atropine sublingual drops effectively treat this symptom by drying up the excess secretions.

The nurse is preparing 7:00 AM medications for a client with a urinary tract infection and a history of heart failure and type 2 diabetes. Based on the information from the medical and medication records, which prescription should the nurse question before administering? Click on the exhibit for more information. 0600 Wednesday: BP 148/84 mm Hg; 24-hour intake/output 1000/3000; Serum sodium 140 mEq/L (140 mmol/L); Serum potassium 4.2 mEq/L (4.2 mmol/L); Serum glucose 90 mg/dL (5 mmol/L) 0600 Thursday: BP 98/60 mm Hg; Serum sodium 150 mEq/L (150 mmol/L); Serum potassium 3.5 mEq/L (3.5 mmol/L); Serum glucose 99 mg/dL (5.5 mmol/L) 1. Furosemide 2. Glipizide 3. Levofloxacin 4. Potassium chloride

1 The nurse should question the prescription for furosemide (Lasix), a potent loop diuretic, before administering the medication. The client has a significant decrease in systolic blood pressure (50 mm Hg), a negative fluid balance of 2000 mL for 24 hours, hypernatremia (normal sodium, 135-145 mg/dL [135-145 mmol/L]), and a potassium level that is trending downward. These parameters indicate hypotonic dehydration, which is often caused by diuretic use. If the diuretic were administered, the fluid volume deficit would increase further. (Option 2) Glipizide, an oral sulfonylurea drug used to control blood sugar, is prescribed once or twice a day 30 minutes before meals. The client's blood sugar is within normal limits (70-99 mg/dL [3.9-5.5 mmol/L]), so there is no need for the nurse to question the prescription. (Option 3) Antibiotic therapy with levofloxacin (Levaquin) is appropriate for a client with a urinary tract infection, so there is no need for the nurse to question the prescription. (Option 4) Potassium chloride is usually prescribed with a diuretic to prevent hypokalemia. The potassium is within normal limits (normal, 3.5-5.0 mEq/L [3.5-5.0 mmol/L]) but is trending downward. A further decrease in potassium from the diuretic would increase the risk for cardiac dysrhythmias associated with hypokalemia. Most clients need a potassium level of around 4.0 mEq/L (4.0 mmol/L) to prevent arrhythmias. If the furosemide is discontinued, the health care provider and nurse should check serum potassium levels the next day to determine whether further dosing is necessary. Educational objective: Decrease in blood pressure, increase in pulse rate, output greater than intake, hypernatremia, and decrease in serum potassium are manifestations that can indicate hypotonic dehydration in a client receiving diuretic therapy.

A nurse is assessing a client with type 2 diabetes mellitus who was recently started on pioglitazone. Which client data obtained by the nurse is most important to bring to the attention of the health care provider? 1. Bilateral pitting edema in ankles 2. Blood pressure is 140/88 mm Hg 3. Most recent HbA1c is 6.7% 4. Retinal photocoagulation in right eye

1 Thiazolidinediones (rosiglitazone [Avandia] and pioglitazone [Actos]) are used to treat type 2 diabetes mellitus. These agents improve insulin sensitivity but do not release excess insulin, leading to a low risk for hypoglycemia (similar to metformin). These drugs can worsen heart failure by causing fluid retention and increase the risk of bladder cancer. Heart failure or volume overload is a contraindication to thiazolidinedione use. These medications also increase the risk of cardiovascular events such as myocardial infarction. (Option 2) The target blood pressure for a client with diabetes is <140/90 mm Hg. (Option 3) The goal HbA1c for diabetic clients is <7%. (Option 4) Diabetic retinopathy, a condition treated with retinal photocoagulation, is unrelated to thiazolidinedione use. If the client has a history of bladder cancer, then it should be reported. Educational objective: Thiazolidinediones (rosiglitazone [Avandia] and pioglitazone [Actos]) increase the risk of cardiovascular events (eg, mycoardial infarction, heart failure) and bladder cancer. Thiazolidinedione use increase insulin sensitivity but carries a low risk for hypoglycemia (similar to metformin).

The nurse is reviewing new prescriptions for assigned clients. Which prescription would require further clarification from the health care provider? 1. Alteplase for an ischemic stroke in a client with a blood pressure of 192/112 mm Hg 2. Amoxicillin for a respiratory infection in a client who is 20 weeks pregnant 3. Fentanyl for moderate to severe pain in a client post appendectomy with an allergy to codeine 4. Sodium chloride 3% infusion for a client with syndrome of inappropriate antidiuretic hormone

1 Thrombolytic agents (eg, alteplase, tenecteplase, reteplase) are often prescribed to resolve acute thrombotic events (eg, ischemic stroke, myocardial infarction, massive pulmonary embolism). They are recombinant plasminogen activators that activate the blood fibrinolytic system and dissolve thrombi. Thrombolytic agents are contraindicated in clients with active bleeding, recent trauma, aneurysm, arteriovenous malformation, history of hemorrhagic stroke, and uncontrolled hypertension (blood pressure >180/110 mm Hg). Therefore, the health care provider should be consulted for clarification. Administering alteplase in the presence of these conditions can cause hemorrhage, including life-threatening intracerebral hemorrhage (Option 1). (Option 2) Most penicillin derivates (eg, ampicillin, amoxicillin) and cephalosporins (eg, cephalexin, ceftriaxone) are generally considered safe for use by women who are pregnant or lactating. (Option 3) Fentanyl is appropriate in postoperative clients with moderate to severe pain, even those with a history of allergies to codeine. Both drugs have opiate agonist effects but are chemically different. Codeine is a derivative of natural opiates (eg, morphine), whereas fentanyl is completely synthetic. (Option 4) Syndrome of inappropriate antidiuretic hormone (SIADH) secretion results in water retention and dilutional hyponatremia. Clients with SIADH often require hypertonic saline for sodium repletion to increase serum sodium levels with a minimal infused volume of water. Educational objective: Thrombolytic agents (eg, alteplase, tenecteplase, reteplase) place clients at risk for bleeding. Therefore, they are contraindicated in clients with active bleeding, recent trauma, aneurysm, arteriovenous malformation, history of hemorrhagic stroke, and uncontrolled hypertension.

A client in the emergency department has an acute myocardial infarction. The health care provider (HCP) has prescribed thrombolytic therapy. Which assessment data should the nurse report immediately to the HCP? 1. Client has a history of cerebral arteriovenous malformation 2. Client is currently menstruating 3. Client rates chest pain as 8 on a scale of 0-10 4. Current blood pressure is 170/92 mm Hg

1 Thrombolytic therapy aims to stop the infarction process, dissolve the thrombus in the coronary artery, and reperfuse the myocardium. This treatment is used when facilities do not have an interventional cardiac catheterization laboratory or when such a facility is too far away to transfer the client safely. Client selection is important because all thrombolytics lyse the pathologic clot but may also lyse other clots (eg, at a postoperative site). Minor or major bleeding can be a complication. Inclusion criteria for thrombolytic therapy in clients with acute myocardial infarction include chest pain lasting ≤12 hours, 12-lead ECG findings indicating acute ST-elevation myocardial infarction, and no absolute contraindications (eg, history of cerebral arteriovenous malformation) (Option 1). (Option 2) Active menstruation is not a contraindication for thrombolytic therapy. Research shows that the risk of increased menstrual bleeding due to thrombolytic administration is low and not life-threatening. Physiologic menstrual bleeding is also not a contraindication for anticoagulation therapy. (Option 3) Chest pain is one of the inclusion criteria for thrombolytic therapy. (Option 4) Uncontrolled blood pressure of >180 mm Hg systolic or >110 mm Hg diastolic is a relative contraindication for thrombolytic therapy. This client's blood pressure (170/92 mm Hg) is elevated but not uncontrolled, which does not rule out this therapy. Educational objective: The candidate for thrombolytic therapy should be screened for absolute and relative contraindications. The nurse should immediately notify the health care provider if the client has history of arteriovenous malformation, which is an absolute contraindication to the use of thrombolytics.

A client having an ischemic stroke arrives at the emergency department. The health care provider prescribes tissue plasminogen activator (tPA). Which client statement would be most important to clarify before administering tPA? 1. "I can't believe this is happening right after my stomach surgery." 2. "I had a concussion after a car accident a year ago." 3. "I started noticing my right arm becoming weak approximately an hour ago." 4. "I stopped taking my warfarin 4 weeks ago."

1 Tissue plasminogen activator (tPA) dissolves clots and restores perfusion in clients with ischemic stroke. It must be administered within a 3- to 4½-hour window from onset of symptoms for full effectiveness. The nurse assesses for contraindications to tPA due to the risk of hemorrhage. The client should not have a history of intracranial hemorrhage or be actively bleeding. Surgery within the last 2 weeks is a contraindication as tPA dissolves all clots in the body and may disrupt the surgical site. This client indicates a recent stomach surgery, which would need further clarification to determine eligibility to receive tPA (Option 1). (Option 2) A client's history of stroke or head trauma in the last 3 months could exclude tPA use. (Option 3) The nurse should determine when the client first developed stroke symptoms. tPA can be administered if symptoms started within the last 3 to 4½ hours or based on facility guidelines. (Option 4) Current anticoagulant use may exclude a client from receiving tPA. The duration of action for warfarin is 2-5 days; this client can safely receive tPA as warfarin was discontinued 4 weeks ago. However, if pending coagulation studies drawn prior to tPA administration are elevated, the infusion may be discontinued. Educational objective: Tissue plasminogen activator (tPA) dissolves clots in an ischemic stroke and must be administered within a 3- to 4½-hour window from onset of symptoms. The nurse assesses for contraindications to tPA due to the risk of hemorrhage.

The nurse is monitoring a client who has been on clopidogrel therapy. Which assessments are essential? Select all that apply. 1. Assess for bruising 2. Assess for tarry stools 3. Monitor intake and output 4. Monitor liver function tests 5. Monitor platelets

1, 2, 5 Antiplatelet therapy (eg, aspirin, clopidogrel, prasugrel, ticagrelor) is initiated to prevent platelet aggregation in clients at risk for myocardial infarction, stroke, or other thrombotic events. This therapy increases bleeding risk, so clients should be assessed for bruising, tarry stools, and other signs of bleeding (eg, hematuria, bleeding gums, epistaxis) (Options 1 and 2). Clients should be taught to self-monitor for these signs. In addition, clopidogrel may cause thrombotic thrombocytopenic purpura, so platelets should be monitored periodically (Option 5). (Option 3) Monitoring intake and output is indicated while a client is on diuretic medications (eg, furosemide, torsemide, bumetanide) but not for antiplatelet agents. (Option 4) Baseline liver enzymes are obtained for clients taking statins (eg, rosuvastatin, atorvastatin) and isoniazid (for tuberculosis). Elevated liver enzymes are an infrequent side effect of clopidogrel, and regular monitoring is usually not required in clients without hepatic impairment. Educational objective: Antiplatelet therapy (eg, aspirin, clopidogrel, prasugrel, ticagrelor) can pose a risk for serious bleeding. Clients should be monitored for bruising, signs of bleeding (eg, tarry stools, hematuria), and decreased platelet counts.

A client with Parkinson disease is prescribed carbidopa-levodopa. Which of the following instructions should the nurse include with the client's discharge teaching? Select all that apply. 1. "Change positions slowly, and sit on the side of the bed before standing." 2. "This medication takes several weeks to reach maximum benefit." 3. "You may experience some facial and eye twitching, but this is not harmful." 4. "Your tremors should disappear completely while on this medication." 5. "Your urine and saliva may turn reddish-brown, but this is not harmful."

1, 2, 5 Parkinson disease (PD) is characterized by decreased dopamine levels, uncontrolled acetylcholine, and formation of abnormal protein clusters (Lewy bodies) in the brain. PD causes both physical and neurological (eg, mood alterations, dementia) symptoms. Carbidopa-levodopa is a combination antiparkinsonian medication used to reduce physical symptoms of PD by increasing dopamine levels in the brain. Levodopa is converted to dopamine in the brain but is largely metabolized before reaching the brain. Carbidopa does not have a therapeutic effect on PD but prevents breakdown of levodopa before reaching the brain, which makes levodopa more effective. Client teaching for carbidopa-levodopa includes: - Implementing fall precautions (eg, changing positions slowly, removing rugs), as orthostatic hypotension is a common side effect (Option 1) - Knowing that carbidopa-levodopa takes several weeks to reach its maximum effectiveness (Option 2) - Understanding that harmless discoloration (eg, red, brown, black) of secretions (eg, urine, perspiration, saliva) may occur while taking carbidopa-levodopa (Option 5) - Avoiding high-protein meals, which interfere with the absorption of carbidopa-levodopa (Option 3) Dyskinesia (eg, facial or eyelid twitching, tongue protrusion, facial grimacing) may indicate overdose or toxicity of carbidopa-levodopa and should be reported immediately to the health care provider. (Option 4) Carbidopa-levodopa often decreases, but does not eliminate, tremor and rigidity. Educational objective: Carbidopa-levodopa is a medication used to reduce symptoms of tremor and rigidity in clients with Parkinson disease. Teach clients that the medication takes several weeks to become effective; urine, perspiration, or saliva discoloration is a common side effect; and fall precautions should be implemented for client safety.

The community health nurse prepares a teaching plan for a client with latent tuberculosis who is prescribed oral isoniazid (INH). Which instructions should the nurse include? Select all that apply. 1. Avoid drinking alcohol 2. Expect body fluids to change color to red 3. Report yellowing of skin or sclera 4. Report numbness and tingling of extremities 5. Take with aluminum hydroxide to prevent gastric irritation

1, 3, 4 Isoniazid (INH) is a first-line antitubercular drug prescribed as monotherapy to treat latent tuberculosis infection. Combined with other drugs, INH is also used for active tuberculosis treatment. Two serious adverse effects of INH use are hepatotoxicity and peripheral neuropathy. A teaching plan for a client prescribed INH includes the following: - Avoid intake of alcohol and limit use of other hepatotoxic agents (eg, acetaminophen) to reduce risk of hepatotoxicity (Option 1) - Take pyridoxine (vitamin B6) if prescribed to prevent neuropathy - Avoid aluminum-containing antacids (eg, aluminum hydroxide (Maalox)) within 1 hour of taking INH - Report changes in vision (eg, blurred vision, vision loss) - Report signs/symptoms of severe adverse effects such as: > Hepatoxicity (eg, scleral and skin jaundice, vomiting, dark urine, fatigue) (Option 3) > Peripheral neuropathy (eg, numbness, tingling of extremities) (Options 4) (Option 2) Rifampin, another antitubercular drug, often causes a red-orange discoloration of body fluids (ie, urine, sweat, saliva, tears). However, this effect is not associated with INH use. (Option 5) Concurrent use of antacids containing aluminum decreases INH absorption. The medication may be taken with food if gastric irritation is a concern. Educational objective: Common potential side effects of INH include hepatotoxicity (eg, jaundice, vomiting, dark urine, fatigue) and peripheral neuropathy (eg, numbness, tingling of extremities). Clients should avoid alcohol use and aluminum-containing antacids, and report any experienced side effects to the health care provider immediately.

The nurse administers 15 units of aspart insulin subcutaneously to a hospitalized client with type 1 diabetes mellitus at 7:00 AM for a fasting blood glucose of 180 mg/dL (10 mmol/L). Which nursing action is a priority? 1. Ensure that the client continues to fast for at least 30 more minutes 2. Give the client breakfast within 15 minutes 3. Recheck the blood glucose in 1 hour 4. Teach the client about the signs and symptoms of hyperglycemia

2 Aspart (NovoLOG) is a rapid-acting insulin with an onset of 10-15 minutes. Onset is the time it takes for the insulin to enter the circulation and begin to lower blood glucose. The peak effect takes 30 minutes-3 hours and the duration of action is 3-5 hours. It is important for the nurse to ensure that the client eats within 15 minutes of administration of aspart/lispro/glulisine to prevent an insulin-related hypoglycemic reaction (Option 2). (Option 1) The client is at risk for a hypoglycemic reaction if breakfast is delayed for 30 minutes. (Option 3) Rechecking the blood glucose in 1 hour is not indicated unless hypoglycemia is suspected. (Option 4) Teaching is vital, but it is most important to ensure that the client eats breakfast to prevent a hypoglycemic reaction at drug onset. Educational objective: It is important for the nurse to ensure that the client eats within 15 minutes of administration of rapid-acting insulins such as aspart (NovoLOG), lispro (HumaLOG), and glulisine (Apidra) to prevent an insulin-related hypoglycemic reaction.

The nurse assesses pitting edema of the extremities, dyspnea, bilateral crackles posteriorly, and a serum sodium level of 130 mEq/L (130 mmol/L) in a client with chronic heart failure. The nurse should question which prescription? 1. Furosemide 20 mg IV push twice daily 2. Maintenance IV line of 0.9% normal saline at 85 mL/h 3. Potassium chloride 20 mEq orally twice daily 4. Sodium-restricted diet

2 Chronic heart failure involves the inability of the heart to fill and pump blood effectively to meet the body's oxygen demands. As a result, clients can develop dilutional hyponatremia (serum sodium <135 mEq/L [135 mmol/L]), an electrolyte disturbance caused by an excess of total body water in relation to total sodium content. The nurse should question the prescription for the maintenance IV line. An infusion of an isotonic solution of 0.9% normal saline at 85 mL/h is contraindicated in this client as it would increase the circulating extracellular fluid volume, worsen the symptoms, and exceed the <2 L/day fluid restriction (ie, 85 mL × 24 hours = 2040 mL). Converting the running IV line to a lock for medication administration would be appropriate. (Option 1) Furosemide (Lasix) is a fast-acting loop diuretic prescribed to decrease preload in clients with heart failure who are fluid overloaded and experiencing manifestations of pulmonary congestion (eg, crackles, dyspnea). Appropriate diuresis in this client would remove excess free water and correct dilutional hyponatremia. (Option 3) Potassium chloride is administered to clients receiving furosemide to prevent or treat diuretic-associated hypokalemia. The nurse should not question this prescription. (Option 4) Fluid restriction is prescribed to correct dilutional hyponatremia (sodium <135 mEq/L [135 mmol/L]) in a client with heart failure. In addition, all heart failure clients require a low-salt diet. Excess salt causes retention of more water. This client's low sodium is due to excess free water and not to low dietary sodium. Educational objective: Dilutional hyponatremia (serum sodium <135 mEq/L [135 mmol/L]) is an electrolyte disturbance caused by an excess of total body water in relation to total sodium content and can occur in clients with heart failure. Treatment includes the administration of diuretics and fluid/salt restriction.

The nurse is administering medications to a client experiencing heart palpitations who is scheduled to receive a dose of furosemide. Based on the client's laboratory results, what is the nurse's priority action? Click on the exhibit button for additional information. Serum electrolytes: Potassium 2.9 mEq/L (2.9 mmol/L) Magnesium 2.0 mEq/L (1.0 mmol/L) Calcium 8.9 mg/dL (2.23 mmol/L) Sodium 138 mEq/L (138 mmol/L) 1. Calculate total urinary output 2. Hold the furosemide 3. Notify the health care provider (HCP) 4. Obtain a 12-lead electrocardiogram (ECG)

2 Furosemide (Lasix) is a potassium-depleting loop diuretic, and this client's potassium level is low. The normal reference range is 3.5-5.0 mEq/L (3.5-5.0 mmol/L). Hypokalemia can lead to heart palpitations and/or dysrhythmias. The nurse should initially hold the client's scheduled dose of furosemide. If furosemide is administered, the client's potassium level could further decrease, leading to worsening cardiac symptoms. (Option 1) A brief, focused assessment, including calculating intake and output, may be important before notifying the HCP. However, the first action is to hold the scheduled dose of furosemide based on the lab results. A low potassium level is justification for not administering the furosemide regardless of intake and output. (Option 3) The priority action is to hold the dose of furosemide (Lasix); after assessing the client, the nurse should notify the HCP of the potassium level and reported heart palpitations. (Option 4) A 12-lead ECG may be ordered when notifying the HCP; however, the priority action is to first hold the dose of furosemide. Educational objective: Furosemide is a potassium-depleting loop diuretic. The nurse should assess the client's potassium level before administration and be aware of signs of hypokalemia such as palpitations and dysrhythmias. Furosemide should be held and the HCP notified if the potassium level is low.

A client with type 1 diabetes has a prescription for 30 units of insulin glargine at bedtime. Fingerstick blood glucose measurements are prescribed before meals and at bedtime with regular insulin based on a sliding scale. At 9 PM, the client's blood glucose measurement is 180 mg/dL (10.0 mmol/L). What action should the nurse take? Click on the exhibit button for additional information. Sliding scale blood glucose levels + Regular insulin dose <150 mg/dL (<8.3 mmol/L) 0 units 150-199 mg/dL (8.3-11.0 mmol/L) 2 units 200-249 mg/dL (11.1-13.8 mmol/L) 4 units 250-299 mg/dL (13.9-16.6 mmol/L) 6 units ≥300 mg/dL (≥16.7 mmol/L) 8 units and notify HCP 1. Administer 30 units of glargine; give the client a snack, then administer 2 units of regular insulin 2. Administer 30 units of glargine and 2 units of regular insulin in 2 different injections 3. Mix 30 units of glargine with 2 units of regular insulin in the same syringe, drawing up the glargine first 4. Mix 30 units of glargine with 2 units of regular insulin in the same syringe, drawing up the regular insulin first

2 Insulin is a medication commonly used to control and lower blood glucose levels in clients with diabetes mellitus. Clients may require a combination of long-acting insulin (eg, glargine) with rapid- (eg, lispro) or short-acting (eg, regular) insulin to manage glucose levels. The different onsets, peaks, and durations mimic the body's natural insulin levels and enhance glycemic control. Insulin glargine, a long-acting (basal) insulin, has no peak and may last 24 hours or longer. Short-acting insulins peak 2-5 hours after administration and last approximately 5-8 hours. Regular or rapid-acting insulins may be given on a sliding scale at prescribed intervals (eg, before meals and at bedtime) and are dosed based on the client's blood glucose measurement. Insulin glargine and regular insulin may be safely given concurrently due to the differences in onset, peak, and duration (Option 2). (Option 1) Insulin glargine has no peak effect and should not potentiate hypoglycemia, whereas regular insulin may cause hypoglycemia. Concurrent administration of regular insulin with insulin glargine will not increase the risk of hypoglycemia as each medication has a different onset, peak, and duration; therefore, a snack is not required. (Options 3 and 4) Insulin glargine should not be mixed in a single syringe with any other insulin as the mixture may alter the pharmacodynamics of the drug. Educational objective: Sliding-scale regular insulin can be administered safely with scheduled insulin glargine without potentiating hypoglycemia if both medications are properly dosed and administered as separate injections. Insulin glargine should not be mixed in a syringe with any other insulin.

The nurse administers 8 units of regular insulin subcutaneously at 11:30 AM to a client with type 1 diabetes mellitus and serves the client lunch 30 minutes later. The client eats a few bites, becomes nauseated, and is unable to finish the meal. When is the client at highest risk for experiencing an insulin-related hypoglycemic reaction? 1. 12:30 PM 2. 2:00 PM 3. 5:00 PM 4. 6:00 PM

2 Insulin is a medication commonly used to control and lower blood glucose levels in clients with diabetes mellitus. The nurse must be familiar with the various insulin types and their times of peak effect, which are the periods of highest risk for hypoglycemic events. Regular insulin is a short-acting insulin that reaches the peak effect within 2-5 hours after subcutaneous administration. Therefore, clients who receive regular insulin subcutaneously at 11:30 AM are at highest risk for hypoglycemia between 1:30 PM and 4:30 PM (Option 2). (Option 1) Rapid-acting insulins (eg, lispro, aspart) take peak effect in 30 minutes to 3 hours. Clients who receive rapid-acting insulin at 11:30 AM would be most at risk for hypoglycemia from 12:00-2:30 PM. (Options 3 and 4) Both insulin NPH, an intermediate-acting insulin, and insulin detemir, a long-acting insulin, have peak effect times that may cause hypoglycemia at 5-6 PM in clients who receive the medication at 11:30 AM. Educational objective: Insulin is a medication used to control and lower blood glucose levels in clients with diabetes mellitus. Peak effect times vary according to insulin type and represent the time of highest risk for hypoglycemic events. Regular insulin, a short-acting insulin, reaches peak effect 2-5 hours after subcutaneous administration.

The nurse is reinforcing education to a client newly prescribed levetiracetam for seizures. Which statement made by the client indicates a need for further instruction? 1. "Drowsiness is a common side effect of this medication and will improve over time." 2. "I can begin driving again after I have been on this medication for a few weeks." 3. "I need to immediately report any new or increased anxiety when on this medication." 4. "I need to immediately report any new rash when on this medication."

2 Levetiracetam (Keppra) is an anticonvulsant prescribed for seizure disorders. As with other antiseizure medications, levetiracetam has a depressing effect on the central nervous system (CNS), which may cause drowsiness, somnolence, and fatigue as clients adjust to the medication. Clients should be assured that this is common and typically improves within 4-6 weeks (Option 1). However, the CNS-depressing effects of levetiracetam may be enhanced if taken with other CNS-depressing substances (eg, alcohol) or medications. New or increased agitation, anxiety, and/or depression or mood changes should be reported immediately as levetiracetam is associated with suicidal ideation (Option 3). Like other anticonvulsants, levetiracetam can trigger Stevens-Johnson syndrome, a rare but life-threatening blistering reaction of the skin. Rash, blistering, muscle/joint pain, or conjunctivitis should be reported and assessed immediately (Option 4). (Option 2) Clients with seizure disorders should avoid driving or operating heavy machinery until they have permission from their health care provider and have met the requirements of their department of transportation. Typically, the client must be free from seizures for an allotted time period. Educational objective: Levetiracetam is an anticonvulsant prescribed for seizure disorders. It may have depressing effects on the central nervous system (eg, drowsiness) as the body adjusts to therapy. Serious adverse effects include suicidal ideation and Stevens-Johnson syndrome. Clients with seizure disorders must meet the guidelines of their department of transportation and receive permission from their health care provider prior to legally operating a motor vehicle.

A client is admitted to the ambulatory care unit for an endoscopic procedure. The gastroenterologist administers midazolam 1 mg intravenously for sedation and titrates the dosage upward to 3.5 mg. The client becomes hypotensive (86/60 mm Hg), develops severe respiratory depression (SpO2 86%), and has periods of apnea. The nurse anticipates the administration of which antidote drug? 1. Benztropine 2. Flumazenil 3. Naloxone 4. Phentolamine

2 Midazolam (Versed) is a benzodiazepine commonly used to induce conscious sedation in clients undergoing endoscopic procedures. The initial dose is 1 mg and is titrated up slowly (eg, 2 minutes before each 1-mg increment) until speech becomes slurred. Usually no more than 3.5 mg is necessary to induce conscious sedation. It is commonly administered with an opioid analgesic (eg, morphine, Fentanyl) because of their synergistic effects. Side effects can include airway occlusion, apnea, hypotension (especially in the presence of an opioid), and oxygen desaturation with resultant respiratory arrest. Flumazenil (Romazicon) is the antidote drug used to reverse the sedative effects of benzodiazepines. (Option 1) Benztropine (Cogentin) is used in the treatment of extrapyramidal side effects associated with antipsychotic medications or metoclopramide. (Option 3) Naloxone (Narcan) is the antidote drug to reverse the effects of opioids. (Option 4) Phentolamine (Regitine) is the antidote drug used to treat a norepinephrine (Levophed) extravasation. Educational objective: Flumazenil is a drug used to reverse the sedative effects of benzodiazepines such as midazolam.

A client was prescribed phenytoin (100 mg PO 3 times a day) a month ago. Today, the client has a serum phenytoin level of 32 mcg/mL (127 mcmol/L). The nurse notifies the health care provider and expects which prescription? 1. Continue phenytoin as prescribed 2. Decrease phenytoin daily dose 3. Increase phenytoin daily dose 4. Repeat serum phenytoin level in 2 hours

2 Phenytoin (Dilantin) is an anticonvulsant drug used to treat generalized tonic-clonic seizures. The therapeutic serum phenytoin range is 10-20 mcg/mL (40-79 mcmol/L). In the presence of an elevated phenytoin level (32 mcg/mL [127 mcmol/L]), the nurse anticipates that the health care provider will prescribe a decreased daily dose (Option 2). The nurse should continue to monitor for signs of toxicity, typically presenting as neurological manifestations (eg, ataxia, nystagmus, slurred speech, decreased mentation). (Options 1 and 3) The serum phenytoin level is above the therapeutic level, so administering the prescribed dose or increasing the dose can further increase the risk for drug-induced toxicity. (Option 4) Repeating the serum phenytoin level in 2 hours will not result in a significant change because the average half-life of the drug is 22 hours. Educational objective: Phenytoin (Dilantin) is used to treat generalized tonic-clonic seizures. Common symptoms of phenytoin toxicity involve the central nervous system (eg, nystagmus, ataxia, slurred speech, decreased mentation) and can occur when serum phenytoin levels exceed the therapeutic range (10-20 mcg/mL [40-79 mcmol/L]).

The health care provider has prescribed spironolactone to be given in addition to hydrochlorothiazide to a client with hypertension. Which finding by the nurse indicates that the spironolactone is having the desired effect? 1. Blood glucose of 95 mg/dL (5.3 mmol/L) 2. Potassium level of 4.2 mEq/L (4.2 mmol/L) 3. Reduction in dizziness 4. Sodium level of 138 mEq/L (138 mmol/L)

2 Potassium-sparing diuretics (eg, spironolactone, amiloride, triamterene eplerenone) are generally very weak diuretics and antihypertensives. However, they are useful when combined with thiazide diuretics to reduce potassium (K+) loss. Thiazide diuretics can cause hypokalemia when used as monotherapy. A potassium level of 4.2 mEq/L (4.2 mmol/L) falls in the normal range (3.5-5.0 mEq/L [3.5-5.0 mmol/L]), which indicates that spironolactone has been effective in preventing hypokalemia in this client receiving a thiazide diuretic (eg, hydrochlorothiazide, chlorthalidone) (Option 2). (Option 1) Blood glucose levels can be increased by thiazide diuretics but are not affected by potassium-sparing diuretics. (Option 3) All diuretics, including spironolactone, have the potential to cause dizziness. The nurse should monitor the client for orthostatic hypotension and implement safety precautions. (Option 4) Potassium-sparing diuretics exchange sodium for potassium in the kidneys; potassium is saved but sodium is lost. Therefore, a normal sodium level (135-145 mEq/L [135-145 mmol/L]) is not the desired effect. Educational objective: Potassium-sparing diuretics (eg, spironolactone, amiloride, triamterene, eplerenone) are often combined with thiazide diuretics to reduce potassium loss.

The nurse prepares to administer a dose of radioactive iodine (RAI) to a 39-year-old female client with Graves' disease. Which action is most important for the nurse to take? 1. Ask client when her last menstrual cycle occurred 2. Confirm pregnancy test result is negative 3. Obtain a baseline assessment of the mouth and throat 4. Teach the client the signs and symptoms of hypothyroidism

2 RAI is the primary treatment for nonpregnant adults with hyperthyroid disorders such as Graves' disease (a type of autoimmune hyperthyroid disease). The use of RAI is contraindicated in pregnancy and could cause harm to a fetus. Pregnancy results should therefore be confirmed using a valid pregnancy test in all clients who still have menstrual cycles rather than using a subjective form of assessment such as asking when the last menstrual period occurred (Option 1). (Option 3) Radiation thyroiditis and parotitis, which cause dryness and irritation to the mouth, may occur after RAI treatment. A baseline assessment is helpful but is not the most important action listed. The nurse can teach the client to take sips of water frequently or to use a salt and soda gargle solution 3-4 times daily to relieve these symptoms. (Option 4) RAI damages or destroys the thyroid tissue, thereby limiting thyroid secretion, and can result in hypothyroidism. Clients need to take thyroid supplementation (levothyroxine) for life. Because these symptoms are delayed, this teaching can occur before or after the procedure. It is not as important as assessing pregnancy status. Educational objective: RAI destroys the thyroid gland, making clients permanently hypothyroid and requiring life-long thyroid supplements. In female clients, a nonpregnant status should be confirmed with a valid pregnancy test prior to administering RAI. RAI is contraindicated in pregnancy and may cause harm to a fetus.

The nurse is preparing medications scheduled at 8 AM for a client with type 1 diabetes mellitus. After reviewing the client's prescriptions and morning laboratory results, which action by the nurse is most appropriate? Click on the exhibit button for additional information. Insulin NPH: 75 units subcutaneously, twice daily 0800 & 2000 Insulin lispro: Sliding scale dosing, before meals and at bedtime 0800, 1130, 1730, 2100 Serum glucose 328 mg/dL; Serum sodium 141 mEq/L; Serum potassium 3.0 mEq/L 1. Administer insulin lispro per protocol and 75 units NPH 2. Contact the health care provider 3. Obtain a urine specimen to check for ketonuria 4. Recheck the client's blood glucose

2 Type 1 diabetes mellitus is an endocrine disorder characterized by the absence of insulin production in the pancreas, causing hyperglycemia and intracellular energy deficits. Clients with type 1 diabetes mellitus require regular administration of insulin to prevent hyperglycemia and provide energy to the cells. Insulin shifts glucose and potassium from the intravascular to the intracellular space. This shift of potassium into cells may cause or worsen hypokalemia (<3.5 mEq/L [3.5 mmol/L]) and place the client at risk for life-threatening dysrhythmias (eg, ventricular tachycardia, ventricular fibrillation). The nurse should notify the health care provider (HCP) before administering insulin to clients with hypokalemia, as supplemental potassium may be required to prevent cardiac dysrhythmias (Option 2). (Option 1) The nurse should notify the HCP of the client's hypokalemia before administering insulin, as such administration may worsen the hypokalemia and result in potentially fatal cardiac dysrhythmias. Once supplemental potassium is administered, insulin should be administered to address the client's hyperglycemia and prevent diabetic ketoacidosis. (Options 3 and 4) Assessing for ketonuria and rechecking the client's blood glucose are appropriate but do not address the potentially life-threatening hypokalemia caused by insulin administration. These checks can occur after potassium has been replaced. Educational objective: Clients with diabetes mellitus receiving insulin therapy should be monitored for electrolyte shifts, especially of potassium. The nurse should clarify the prescription for insulin with the health care provider if the client is hypokalemic and should seek a prescription for supplemental potassium before giving more insulin.

The nurse is providing discharge teaching to a client with a new prescription for warfarin. The nurse should instruct the client to avoid excess or inconsistent intake of which foods? Select all that apply. 1. Bananas 2. Broccoli 3. Liver 4. Oranges 5. Spinach

2, 3, 5 Warfarin (Coumadin) is a vitamin K antagonist used to prevent blood clots in clients with atrial fibrillation, artificial heart valves, or a history of thrombosis. Excessive intake of vitamin K-rich foods (eg, broccoli, spinach, liver) can decrease the anticoagulant effects of warfarin therapy (Options 2, 3, and 5). Clients should be consistent with intake of foods high in vitamin K after initiation of warfarin because dosing is individualized to the client and dietary changes may require dose adjustment. (Options 1 and 4) Bananas and oranges are rich in potassium, not vitamin K, and are not known to interact with warfarin. The chemical symbol for potassium (K+) should not be confused with vitamin K because they are two different micronutrients; potassium (K+) is an element involved in muscle contraction, whereas vitamin K is a fat-soluble vitamin involved in blood clotting. Educational objective: Clients receiving warfarin therapy should maintain consistent intake of foods high in vitamin K; it is not necessary to remove vitamin K-rich foods completely. Clients should avoid excess or inconsistent intake of green vegetables (eg, broccoli, spinach) and liver to promote steady warfarin efficacy.

A client is being discharged with a prescription for apixaban after being treated for a pulmonary embolus. Which clinical data is most concerning to the nurse? 1. Client eats a vegetarian diet 2. Client has chronic atrial fibrillation 3. Client takes indomethacin for osteoarthritis 4. Client's platelet count is 176 x103/mm3 (176 x109/L)

3 A pulmonary embolism (PE) occurs when the pulmonary arteries are blocked by a thrombus. Initial management of PE includes low-molecular-weight heparin (eg, enoxaparin, dalteparin) or unfractionated IV heparin. Once the PE is resolved, maintenance drug therapy often includes oral anticoagulants such as factor Xa inhibitors (eg, apixaban, rivaroxaban, dabigatran). Anticoagulants place the client at increased risk of bleeding, and the nurse should provide education regarding signs and symptoms of bleeding (eg, bruising; blood in the urine; black, tarry stools) and bleeding precautions (eg, use of an electric razor and soft-bristled toothbrush). Concurrent NSAID use (eg, indomethacin, ibuprofen, meloxicam) significantly increases the risk of bleeding. The nurse should discuss this risk with the health care provider prior to initiation of apixaban therapy (Option 3). (Option 1) Vegetarian diets and the consumption of leafy green vegetables high in vitamin K affect the action of warfarin. However, factor Xa inhibitors such as apixaban are not affected by vitamin K. (Option 2) Chronic atrial fibrillation increases the risk for thromboembolic events and would be an indication for anticoagulant therapy, such as apixaban. (Option 4) The current platelet count is within a normal range (150-400 x103/mm3 [150-400 x109/L]) and is not a concern. Educational objective: Maintenance drug therapy after a pulmonary embolus typically includes administration of oral anticoagulants such as factor Xa inhibitors (eg, apixaban). NSAIDs (eg, indomethacin) increase the risk of bleeding when used concurrently with apixaban therapy. The nurse should question initiation of apixaban therapy in the context of NSAID use.

A client with gout who was started on allopurinol a week ago calls the health care provider's (HCP's) office with several concerns. The nurse should recognize which report by the client as being significant and requiring immediate follow-up? 1. Also takes ibuprofen for pain 2. Frequency of urination has increased 3. Mild red rash has developed over torso 4. Nausea occurs after each dose

3 Allopurinol is a medication frequently used in the prevention of gout. Gout is a buildup of uric acid deposited in the joints that causes pain and inflammation. The medication helps to prevent uric acid deposits in the joints and the formation of uric acid kidney stones. Any rash in a client taking allopurinol, even if mild, should be reported immediately to the HCP. The nurse should direct the client to stop taking the medication immediately, schedule an appointment, and notify the HCP. A rash caused by allopurinol may be followed by more severe hypersensitivity reactions that can be fatal, including Stevens-Johnson syndrome and toxic epidermal necrolysis. (Option 1) Allopurinol can take several months to become effective. Its primary use is to prevent gout attacks; it is not effective in treating acute attacks. The client will need to continue to take anti-inflammatory drugs (eg, nonsteroidal anti-inflammatory drugs or colchicine) for acute attacks. (Option 2) Clients are directed to take allopurinol with a full glass of water and to increase daily fluid intake to prevent kidney stones. This will cause an increase in urination and is an expected outcome. (Option 4) Nausea can be prevented by instructing the client to take the medication with food or following a meal. Educational objective: The nurse should direct the client taking allopurinol for gout to immediately discontinue the medication and report to the HCP if any rash develops. Allopurinol-induced rashes can develop into severe and sometimes fatal hypersensitivity reactions, such as Stevens-Johnson syndrome. Similar instructions should be given to clients taking anticonvulsants (eg, carbamazepine, phenytoin, lamotrigine) and sulfa antibiotics.

The nurse teaches the client taking atorvastatin to call the health care provider (HCP) if experiencing which symptom associated with a serious adverse effect of atorvastatin? 1. Diarrhea 2. Headache 3. Muscle aches 4. Numbness in the feet

3 Atorvastatin (Lipitor) is a statin drug, or HMG-CoA reductase inhibitor, prescribed to lower cholesterol and reduce the risk of atherosclerosis and coronary artery disease. A serious adverse effect of statins, including atorvastatin and rosuvastatin (Crestor), is myopathy with ongoing generalized muscle aches and weakness. A client who develops muscle aches while on a statin drug should call the HCP who will then obtain a blood sample to assess the creatine kinase (CK) level. If myopathy is present, CK will be significantly elevated (≥10x normal), and the drug will then be discontinued. (Option 1) Diarrhea is not a side effect of statin drugs. Colchicine used for gout and acute pericarditis commonly leads to diarrhea. Many antibiotics can induce diarrhea, and some may cause Clostridium difficile infection. (Option 2) Headache is not a serious side effect of statin drugs. It is often a bothersome side effect of nitrates and calcium channel blockers as they dilate intracranial vessels; however, tolerance usually develops over time. (Option 4) Numbness in the feet (neuropathy) is not a common side effect of statin drugs. It is commonly associated with isoniazid, amiodarone, and chemotherapy agents (eg, vincristine, cisplatin). Educational objective: The client taking a statin such as atorvastatin or rosuvastatin should be taught to call the HCP if generalized muscle aches develop as this may be a symptom of myopathy, a serious adverse effect of this type of medication.

A client with uncontrolled hypertension is prescribed clonidine. What instruction is most important for the clinic nurse to give this client? 1. Avoid consuming high-sodium foods 2. Change positions slowly to prevent dizziness 3. Don't stop taking this medication abruptly 4. Use an oral moisturizer to relieve dry mouth

3 Central-acting alpha2 agonists (eg, clonidine, methyldopa) decrease the sympathetic response from the brainstem to the peripheral vessels, resulting in decreased peripheral vascular resistance and vasodilation. Clonidine is a highly potent antihypertensive. Abrupt discontinuation (including the patch) can result in serious rebound hypertension due to the rapid surge of catecholamine secretion that was suppressed during therapy. Clonidine should be tapered over 2-4 days. Abrupt withdrawal of beta blockers can also result in rebound hypertension and in precipitation of angina, myocardial infarction, or sudden death. (Option 1) Avoiding high-sodium foods is important for blood pressure control but is not the most important advice for this client as consumption of these is not immediately life-threatening. (Option 2) Dizziness is a side effect of clonidine. The nurse should teach the client to change positions slowly and sit for a few minutes before rising to prevent falls. Drowsiness is also quite common with clonidine. Clients should not use it with alcohol or central nervous system depressants. However, dizziness and drowsiness should diminish with continued use of the medication. (Option 4) Dry mouth is a side effect of clonidine. Use of over-the-counter mouth moisturizers, chewing gum, or hard candy may be helpful for clients with dry mouth. Educational objective: Clonidine is a very potent antihypertensive. Abrupt discontinuation can result in serious rebound hypertensive crisis. Other common side effects of clonidine include dizziness, drowsiness, and dry mouth (the 3 Ds). Beta blockers, another class of blood pressure medications, can result in withdrawal symptoms if discontinued suddenly.

A nurse is caring for a client with an exacerbation of chronic obstructive pulmonary disease (COPD) and a history of type 2 diabetes mellitus requiring insulin. The client has been prescribed prednisone. The nurse anticipates which need? 1. Close monitoring for hypotension 2. Gradually increasing the prednisone dose 3. Increasing the insulin dose 4. Monitoring and recording intake and output

3 Corticosteroids (eg, methylprednisolone, prednisone, dexamethasone) are given to combat inflammation in the lungs in clients with COPD exacerbation. All glucocorticoids can cause an increase in blood sugar. This may lead to the need for a higher dose of insulin based on the client's blood sugar level. (Option 1) Most glucocorticoids have some mineralocorticoid activity, causing fluid retention and worsening hypertension. (Option 2) Prednisone is started at a higher dose and then gradually decreased for COPD exacerbation and most other conditions. A slow taper will prevent adrenal crisis. (Option 4) Intake and output are not affected by corticosteroids. Educational objective: Corticosteroids commonly cause hyperglycemia and worsen hypertension. When taken in combination with NSAIDs, they can increase the risk of peptic ulcer disease. Corticosteroids in general are started at high doses and slowly tapered to reduce the risk of sudden adrenal crisis.

A client with coronary artery disease and stable angina is being discharged home on sublingual nitroglycerin (NTG). The nurse has completed discharge teaching related to this medication. Which statement by the client indicates that the teaching has been effective? 1. "I can keep a few pills in a plastic bag in my pocket in case I need them while I'm out." 2. "I can still take this with my vardenafil prescription." 3. "I can take up to 3 pills in a 15-minute period if I am experiencing chest pain." 4. "I should stop taking the pills if I experience a headache."

3 Current evidence shows that up to 50% of clients lack knowledge about NTG administration procedures, storage, and side effects. Proper teaching can prevent many hospital visits for chest pain due to stable angina. Instructions for proper NTG administration include: - Tablets are heat and light sensitive: They should be kept in a dark bottle and capped tightly. An opened bottle should be discarded after 6 months (Option 1). - Take up to 3 pills in a 15-minute period: Take 1 pill every 5 minutes (up to 3 doses). Emergency medical services (EMS) should be called if pain does not improve or worsens 5 minutes after the first tablet has been taken. Previously, clients were taught to call after the third dose was taken, but newer studies suggest this causes a significant delay in treatment (Option 3). - Avoid fatal drug interactions: Concurrent use of erectile dysfunction drugs (sildenafil, tadalafil, vardenafil) or alpha blockers (terazosin, tamsulosin) is contraindicated due to potentially fatal hypotension (Option 2). - Headache may occur: Headache and flushing are common side effects of NTG due to systemic vasodilation and do not warrant medication discontinuation (Option 4). Educational objective: The nurse should instruct the client who is taking sublingual NTG to keep the tablets in a tightly capped, dark bottle away from heat and light. The client should be taught to take 1 tablet every 5 minutes (up to 3 tablets), but notify EMS if the pain does not improve or worsens 5 minutes after the first pill has been taken. These instructions should be reinforced at each appointment.

The nurse evaluates the effectiveness of desmopressin use for diabetes insipidus in a client with a pituitary tumor. Which client assessment finding indicates that the medication is having the desired effect? 1. Appetite has improved 2. Blood glucose is 110 mg/dL (6.1 mmol/L) 3. Urine output has decreased 4. Urine specific gravity is lower

3 Diabetes insipidus (DI) results in low levels of antidiuretic hormone (ADH), which is produced by the hypothalamus and stored in the pituitary gland. The function of ADH is to concentrate urine by signaling the kidneys to retain water in the setting of thirst. When ADH levels are insufficient, the kidneys excrete large quantities of very dilute urine (polyuria). This causes hypernatremia (elevated serum sodium due to deficit of free water) and increased serum osmolality, which lead to excessive thirst (polydipsia). Desmopressin acetate (DDAVP) is a synthetic form of ADH, which can be administered intravenously, orally, or via nasal spray. Effectiveness of therapy with desmopressin would be manifested by decreased urinary output and increased urine specific gravity as the urine becomes less dilute (Option 3). (Option 1) A client's thirst, not appetite, is affected by DI. (Option 2) DI is related to water balance, but not to diabetes mellitus, a disorder of glucose metabolism. (Option 4) If desmopressin therapy is effective, the client's urine specific gravity will be higher due to the urine output decreasing and becoming less dilute. Educational objective: Use of desmopressin acetate (DDAVP) in clients with diabetes insipidus will lower urinary output and cause the urine specific gravity to increase.

The nurse is performing discharge teaching for the parents of a 4-year-old with heart failure. Which statement by the parents indicates the need for further teaching related to the administration of digoxin? 1. "If our child vomits after a dose, we won't give a second one." 2. "Symptoms of nausea and vomiting should be reported to our health care provider (HCP)." 3. "We will hold the dose if our child's heart rate is above 90/min." 4. "We will not mix the medication with other foods or liquids."

3 Digoxin is a cardiac glycoside given to infants and children in heart failure. It is given to increase myocardial contraction, which increases cardiac output and improves circulation and tissue perfusion. Digoxin is a potentially dangerous drug due to its narrow margin of safety in dosage. Parents should receive thorough education and in return demonstrate appropriate administration procedures for this medication. Parent teaching for administration of digoxin includes the following: - Inform parents of the pulse rate at which to hold the medication based on HCP prescription. In general, digoxin is held if pulse <90-110/min for infants and young children or <70/min for an older child. - Administer oral liquid in the side and back of the mouth - Do not mix the drug with food or liquids as the refusal to take these would result in inaccurate intake of medication (Option 4) - If a dose is missed, do not give an extra dose or increase the dose. Stay on the same schedule. - If more than 2 doses are missed, notify the HCP - If the child vomits, do not give a second dose (Option 1). Nausea, vomiting, or slow pulse rate could indicate toxicity. Notify the HCP (Option 2). - Give water or brush the client's teeth after administration to remove the sweetened liquid Educational objective: Nausea, vomiting, or slow pulse rate can indicate digoxin toxicity. General guidelines are to hold digoxin for pulse <90-110/min in infants and young children and <70/min in older children.

A nurse is preparing for a medical relief trip to West Africa and is concerned about a disruption in circadian rhythm from traveling across several time zones. Which herbal supplement might help synchronize the body to environmental time? 1. Evening primrose 2. Ginseng 3. Melatonin 4. St. John's wort

3 Melatonin supplements are thought to help the body adjust quickly to new surroundings and time zones (jet lag). Most practitioners agree that the lowest possible dose should be used and should be taken only for a short time. There are no long-term studies on the safety of melatonin. Higher doses may cause side effects such as vivid dreams and nightmares. Research suggests that taking melatonin once a person has reached the travel destination is sufficient and that starting it prior to or during air travel may actually slow the recovery of jet lag, energy, and alertness. (Option 1) Evening primrose may be used for eczema or skin irritations. (Option 2) Ginseng is used to promote mental alertness and enhance the immune system. (Option 4) St. John's wort is used for treatment of depression. It has many interactions with other prescription medications. Educational objective: Short-term use of low-dose melatonin may be considered to treat jet lag and fatigue from traveling across time zones.

The nurse assesses a client who is receiving methotrexate for rheumatoid arthritis. Which statement by the client is most concerning? 1. "I am nauseated and vomited three times today." 2. "I drink four large cups of coffee every day." 3. "I have small, purple spots all over my skin." 4. "I plan to stop taking birth control today."

3 Methotrexate is an antirheumatic drug prescribed to treat rheumatoid arthritis. It acts by interfering with folic acid metabolism, which inhibits DNA synthesis and cell reproduction. Adverse effects associated with methotrexate include bone marrow suppression, hepatotoxicity (ie, drug-induced liver injury), and gastrointestinal irritation (eg, nausea, vomiting, diarrhea). Bone marrow suppression is a serious adverse effect that leads to anemia, leukopenia, and thrombocytopenia. Thrombocytopenia (especially platelet count <100,000/mm3 [100 × 109/L]) is characterized by petechiae (ie, small, purple hemorrhagic spots), purpura, and/or other signs of bleeding (eg, melena, hematemesis, bleeding gums) (Option 3). Bone marrow suppression is managed by dose reduction or discontinuation of the medication. (Option 1) Nausea and vomiting are the most common side effects associated with methotrexate. The nurse should notify the health care provider and request a prescription for an antiemetic; however, vomiting is not the priority concern. (Option 2) Some substances decrease the effectiveness of methotrexate (eg, caffeine, folic acid) and should be avoided. (Option 4) Methotrexate is teratogenic, so pregnancy must be prevented. Effective contraceptives must be used throughout treatment and for one ovulatory cycle after completing treatment for women (three months after completion for men). This statement requires follow-up but is not priority as the client has not yet stopped taking birth control. Educational objective: Adverse effects of methotrexate include hepatotoxicity, gastrointestinal irritation, and bone marrow suppression. Bone marrow suppression can lead to anemia, leukopenia, and thrombocytopenia.

A client with seizure activity is receiving a continuous tube feeding via a small-bore enteral tube. The nurse prepares to administer phenytoin oral suspension via the enteral route. What is the nurse's priority action before administering this medication? 1. Check renal function laboratory results 2. Flush tube with normal saline, not water 3. Stop the feeding for 1 to 2 hours 4. Take the blood pressure (BP)

3 Phenytoin (Dilantin) is an anticonvulsant drug commonly used to treat seizure disorders. Steady absorption is necessary to maintain a therapeutic dosage range and drug level to control seizure activity. The nurse's priority action is to stop the feeding for 1 to 2 hours before and after administering phenytoin as products containing calcium (eg, antacids, calcium supplements) and/or nutritional enteral tube feedings can decrease the absorption and the serum level of this drug. (Option 1) Unless clients have renal insufficiency, renal function tests are not routinely monitored during prescribed phenytoin therapy. Phenytoin is metabolized in the liver and can cause liver damage. Monitoring of liver function test during therapy is recommended. (Option 2) Flushing the tube with 30-50 mL of water before and after administering phenytoin is recommended to minimize drug loss and drug-drug incompatibility. Flushing with normal saline before and after drug administration is recommended in clients receiving intravenous (IV) phenytoin. (Option 4) BP is not usually affected in clients prescribed oral phenytoin therapy for seizure disorders. However, IV phenytoin can cause hypotension and arrhythmias. Educational objective: Phenytoin is an anticonvulsant drug commonly used to treat seizure disorders. Steady absorption is necessary to maintain a therapeutic dosage range and drug level to control seizure activity. Administration of phenytoin concurrent with certain drugs (eg, antacids, calcium) and/or enteral feedings can affect the absorption of phenytoin.

The nurse plans teaching for a client who was newly prescribed levothyroxine sodium after thyroid removal. Which instructions will the nurse include in the teaching plan? Select all that apply. 1. Drowsiness is a common side effect; taking the dose at bedtime will make this less noticeable 2. Notify the health care provider if you become pregnant as the medication is harmful to the fetus 3. Notify the health care provider if you feel a fluttering or rapid heartbeat 4. Take the medication with a meal to prevent stomach upset 5. You will need to take this medication for the rest of your life

3, 5 Levothyroxine sodium (eg, Levoxyl, Levothroid, Synthroid) is used to replace thyroid hormone in clients with hypothyroidism (inadequate thyroid hormone) and for those who have had their thyroid removed. These clients must understand that this medication must be taken for the rest of their lives (Option 5). A client's dose is adjusted based on serum TSH levels to prevent too much or too little hormone. Clients must be taught to report signs of excess thyroid hormone such as heart palpitations/tachycardia, weight loss, and insomnia (Option 3). (Option 1) Clients with hypothyroidism experience lethargy and somnolence. Hormone replacement therapy will increase metabolic activity and alertness. (Option 2) This medication is a hormone that is normally present in the body, so it is safe to take during pregnancy. The dose may need to be altered due to the metabolic demands of pregnancy, but the drug will not harm the fetus. (Option 4) It is best to take this medication first thing in the morning as it is best absorbed on an empty stomach (1 hour before or 2 hours after a meal). Educational objective: Clients receiving thyroid hormone replacement therapy (levothyroxine sodium) should understand that treatment is lifelong and be taught the signs of excess hormone (eg, tachycardia/palpitations, weight loss, insomnia). The medication is best absorbed on an empty stomach and is safe to take during pregnancy.

A client recently diagnosed with heart failure is being discharged with a prescription for lisinopril. Which client teaching related to this new medication is important to review at discharge? 1. Instruct client to report for monthly blood work to monitor drug levels 2. Review foods high in potassium that client should include in diet 3. Teach client to count own pulse for 1 minute; hold medication if pulse <60/min 4. Teach client to rise slowly and sit on side of bed for several minutes before rising

4 Angiotensin converting enzyme (ACE) inhibitors (eg, captopril, enalapril, lisinopril, ramipril) prevent the pathological enlargement of the left ventricle of the heart. They work by blocking a crucial step in the renin-angiotensin-aldosterone system, the main hormonal mechanism involved in blood pressure regulation. Interrupting this step of the renin-angiotensin-aldosterone system has following effects: 1. A shortage of angiotensin II results in an absence of the vasoconstrictive responses (orthostatic reflex, renal blood flow regulation) causing orthostatic hypotension. Clients may be more prone to experiencing orthostatic hypotension early in treatment with ACE inhibitors and should be taught ways to prevent it. 2. A shortage of aldosterone causes hyperkalemia. Aldosterone Saves Sodium and Pushes Potassium out of the body. 3. ACE inhibitors are contraindicated in pregnancy due to teratogenic effects on the fetus (eg, oligohydramnios, fetal kidney injury). The other important side effects of ACE inhibitors, cough and angioedema, are thought to be due to the accumulation of bradykinin. (Option 1) Renal function (blood urea nitrogen, creatinine) is commonly checked during the first week of treatment. Regular measurements to ensure therapeutic drug levels are required for lithium, phenytoin, and digoxin. (Option 2) A common side effect of ACE inhibitor is mild hyperkalemia, which may require a lower intake of foods high in potassium. Clients taking loop diuretics (eg, furosemide) will need to increase their intake of foods high in potassium. (Option 3) ACE inhibitors do not directly affect the heart rate. Clients prescribed digoxin are taught to take their pulse and hold their medication if the heart rate is <60/min. Educational objective: Client education after initiation of an angiotensin converting enzyme inhibitor (eg captopril, lisinopril) includes a discussion on development of a dry cough, taking several minutes to get out of bed, possible allergic reactions (rash, angioedema), and the teratogenic effects of the drug.3.

A client with coronary artery disease was discharged home with a prescription for sublingual nitroglycerin (NTG) to treat angina. Which statement by the client indicates that further teaching is required? 1. "I may experience flushing but will continue to take the medication as prescribed." 2. "I should lie down before taking the medication." 3. "I should not swallow the tablet." 4. "I will wait to call 911 if I don't experience relief after the third tablet."

4 Current evidence indicates that up to 50% of clients lack knowledge about administration procedures, storage, and side effects of NTG. Proper teaching can prevent many hospital visits for chest pain from stable angina. The client should be instructed to take 1 pill (or 1 spray) every 5 minutes for up to 3 doses, but emergency medical services (EMS) should be called if pain is unimproved or worsening 5 minutes after the first tablet. Previously, clients were taught to call EMS after the third dose, but newer studies suggest that this causes a significant delay in treatment (Option 4). NTG should cause a slight tingling sensation under the tongue if it is potent; otherwise, the medication is likely outdated. The oral mucosa needs to be moist for adequate absorption of NTG, and clients should be instructed to take a drink of water before administration if needed for dry mouth. Sublingual tablets should never be swallowed (Option 3). If using a spray, the client should not inhale it but direct it onto/under the tongue instead. (Option 1) Headache and flushing are common side effects of NTG due to systemic vasodilation. (Option 2) The client should lie down before taking the pill as it can cause dizziness from possible orthostatic hypotension. Educational objective: The nurse should instruct clients taking sublingual NTG that they should call EMS if their chest pain is unrelieved or worsening 5 minutes after the first tablet. The tablet should be allowed to dissolve under the tongue to allow for adequate absorption and should never be swallowed.

The nurse is speaking to a client who takes desmopressin nasal spray for diabetes insipidus. Which statement by the client is most important for the nurse to report to the health care provider? 1. "I am tired of restricting my fluids but know I need to." 2. "I feel like I am beginning to get sick with a bad cold." 3. "I have been getting a lot of nasal pain with this spray." 4. "I have recently started to experience frequent headaches."

4 Desmopressin is a medication often used to treat central diabetes insipidus, a disease characterized by reduced antidiuretic hormone (ADH) levels that may result in dehydration and hypernatremia. Desmopressin mimics the effects of naturally occurring ADH, which increases renal water resorption and concentrates urine. However, this effect also increases the risk for water intoxication from decreased urine output. Clients receiving desmopressin must have their fluid and electrolyte status closely monitored for symptoms of water intoxication/hyponatremia (eg, headache, mental status changes, weakness). The nurse should immediately notify the health care provider (HCP) of client reports of water intoxication symptoms, as severe hyponatremia may progress to seizure, neurologic damage, or death (Option 4). (Option 1) Clients on desmopressin are often on fluid restriction as part of therapy. Frequent reinforcement may be necessary. (Option 2) Rhinitis and upper respiratory infection (eg, a cold) can decrease the effectiveness of desmopressin nasal spray therapy and may require dosage adjustments by the HCP. However, dosage adjustments can be addressed after symptoms of water intoxication. (Option 3) Side effects of desmopressin nasal spray include nasal irritation, congestion, and pain. If the client cannot tolerate side effects of nasal spray, oral dosing may be prescribed by the HCP. Educational objective: Clients taking desmopressin for diabetes insipidus are at risk for water intoxication and hyponatremia. Client reports of headache, mental status change, and/or muscle weakness may indicate hyponatremia from water intoxication and should be reported to the health care provider immediately.

A client with atrial fibrillation is being discharged home after being stabilized with medications, including digoxin. Which of the following statements regarding digoxin toxicity indicates that further teaching is needed? 1. "I must visit my health care provider (HCP) to check my drug levels." 2. "I should report to my HCP if I develop nausea and vomiting." 3. "I should tell my HCP if I feel my heart skip a beat." 4. "I will need to increase my potassium intake."

4 Drug toxicity is common with digoxin due to its narrow therapeutic range. Many contributing factors (eg, hypokalemia) can cause toxicity. However, in the absence of other factors, potassium does not need to be increased just because a client is on digoxin. If the client also takes some other potassium-depleting medications, such as diuretics, potassium supplements may be needed. Signs and symptoms of digoxin toxicity include the following: - Gastrointestinal symptoms (eg, anorexia, nausea, vomiting, abdominal pain) are frequently the earliest symptoms (Option 2) - Neurologic manifestations (eg, lethargy, fatigue, weakness, confusion) - Visual symptoms are characteristic and include alterations in color vision, scotomas, or blindness - Cardiac arrhythmias - most dangerous (Option 1) Drug levels are frequently monitored until a steady state is achieved and when changes are expected, such as in clients with chronic kidney disease and electrolyte disturbances (eg, hypokalemia, hypomagnesemia). (Option 3) Digoxin toxicity can result in bradycardia and heart block. Clients are instructed to check their pulse and report to the HCP if it is low or has skipped beats. Educational objective: Drug toxicity is common with digoxin due to its narrow therapeutic range. Drug levels are frequently monitored. Nonspecific gastrointestinal symptoms similar to gastroenteritis are common and can lead to serious cardiac arrhythmias if not recognized.

The nurse is providing education to a pregnant client diagnosed with symptomatic hypothyroidism regarding levothyroxine therapy during pregnancy. Which is appropriate teaching for the nurse to include? 1. After symptoms resolve, levothyroxine may be discontinued 2. Levothyroxine should be taken in the evening with a prenatal vitamin 3. Medication dose will remain the same throughout pregnancy 4. Symptoms should begin improving within 4 weeks of starting levothyroxine

4 Hypothyroidism during pregnancy places clients at increased risk for other complications of pregnancy (eg, preeclampsia, placental abruption, preterm labor). Symptoms of hypothyroidism may include fatigue, cold intolerance, constipation, dry skin, and brittle hair/nails. Levothyroxine (Synthroid) is the first-line medication for treatment of hypothyroidism during pregnancy. The client may experience some relief of symptoms beginning approximately 3-4 weeks after initiating levothyroxine therapy (Option 4). Hormone levels are usually rechecked every 4-6 weeks until normal thyroid hormone levels are achieved. It may take up to 8 weeks after initiation to see the full therapeutic effect. (Option 1) Adequate levels of maternal thyroid hormones are important for fetal brain development, particularly during the first trimester. Levothyroxine should not be stopped during pregnancy, even if symptoms resolve. (Option 2) Prenatal vitamins containing iron can affect the absorption of levothyroxine and decrease its effectiveness. The nurse should instruct the client to take levothyroxine in the morning on an empty stomach, at least 4 hours before or after taking a prenatal vitamin. (Option 3) As the pregnancy advances, the client's dose of levothyroxine may need to be increased. Thyroid stimulating hormone (TSH) levels are closely monitored during pregnancy, and the client's dose is modified as needed to maintain normal levels. Educational objective: Levothyroxine is the first-line treatment for hypothyroidism during pregnancy to maintain adequate levels of maternal thyroid hormones, which are critical for fetal brain development. Symptoms of hypothyroidism typically begin to improve approximately 3-4 weeks after initiating levothyroxine. Therapy should not be stopped, even if symptoms resolve.

A client with hypertension is prescribed lisinopril. The nurse instructs the client to notify the health care provider immediately if which adverse effect occurs when taking this medication? 1. Cough 2. Dizziness 3. Rapid-onset confusion 4. Swelling of the lips and tongue

4 Lisinopril (Prinivil, Zestril) is an angiotensin-converting enzyme (ACE) inhibitor prescribed to treat hypertension and slow the progression of heart failure. Lisinopril has a low incidence of serious adverse effects except angioedema (rapid swelling of lips, tongue, throat, face, and larynx). Angioedema can lead to airway obstruction and possible death. ACE inhibitors are the most frequent medications causing drug-induced angioedema. The risk is 5 times greater for African Americans than for Caucasians. If clients experience symptoms of angioedema, they are instructed to discontinue the drug and notify the HCP immediately. (Options 1 and 2) Persistent, dry cough is a common (5%-20%), annoying adverse effect of ACE inhibitors that is caused by a buildup of bradykinin in the lung. If the client cannot tolerate this side effect, the HCP can prescribe an angiotensin-receptor blocker instead, which has a similar action. Other common adverse effects of ACE inhibitors include orthostatic hypotension (dizziness) and hyperkalemia. (Option 3) Rapid-onset confusion is not an adverse effect associated with lisinopril. Educational objective: ACE inhibitors (eg, captopril, enalapril, lisinopril, ramipril) have a low incidence of serious adverse effects except angioedema (rapid swelling of lips, tongue, throat, face, and larynx). More common adverse effects of ACE inhibitors include dry cough, orthostatic hypotension, and hyperkalemia.

A client with stable angina is being discharged home with a prescription for a transdermal nitroglycerin patch. The nurse has reviewed discharge instructions on the medication with the client. Which statement by the client indicates that teaching has been effective? 1. "I can continue to take my prescription of sildenafil." 2. "I should take the patch off when I shower." 3. "I will remove the patch if I develop a headache." 4. "I will rotate the site where I apply the patch."

4 Nitroglycerin patches are transdermal patches used to prevent angina in clients with coronary artery disease. They are usually applied once a day (not as needed) and worn for 12-14 hours and then removed. Continuous use of patches without removal can result in tolerance. No more than one patch at a time should be worn. The patch should be applied to the upper body or upper arms. Clean, dry, hairless skin that is not irritated, scarred, burned, broken, or calloused should be used. A different location should be chosen each day to prevent skin irritation. (Option 1) Phosphodiesterase inhibitors used in erectile dysfunction (eg, tadalafil, sildenafil, vardenafil) are contraindicated with the use of nitrates. Both have similar mechanisms and cause vascular smooth muscle dilation. Combined use can result in severe hypotension. (Option 2) Patches may be worn in the shower. (Option 3) Headaches are common with the use of nitrates. The client may need to take an analgesic. Educational objective: Nursing education about transdermal nitroglycerin includes application of the patch to the upper arms or body, rotating the sites daily, removing the patch at night, taking no erectile dysfunction medications, and informing clients that headaches are common. Patches do not need to be removed for bathing.

The clinic nurse is teaching a client about levothyroxine, which the health care provider has prescribed for newly diagnosed hypothyroidism. Which statement made by the client indicates that further teaching is needed? 1. "I will need to get my blood drawn to see if I'm taking the right dose." 2. "I will probably need to take this the rest of my life." 3. "I will take this once a day in the morning." 4. "If this makes my stomach upset, I will take it with an antacid."

4 Several medications impair the absorption of levothyroxine (Synthroid). Common offenders are antacids, calcium, and iron preparations. Some of these could be present in several over-the-counter multivitamin and mineral tablets. Therefore, clients with hypothyroidism should be instructed to take levothyroxine on an empty stomach, preferably in the morning, separately from other medications. The most common reason for inadequately treated hypothyroidism is deficient knowledge related to the medication regimen (eg, not taking daily, taking with other medications). (Option 1) Levothyroxine dosing is adjusted based on blood tests for thyroid-stimulating hormone or other thyroid hormone levels. The dose is not the same for each client. (Option 2) Thyroid supplementation with levothyroxine usually requires lifelong therapy. (Option 3) Levothyroxine has a long half-life, so dosing is once daily. Educational objective: Levothyroxine should be taken on an empty stomach, preferably in the morning, separately from other medications.

The nurse admits a client with newly diagnosed unstable angina. Which information obtained during the admission health history is most important for the nurse to report to the health care provider (HCP) immediately? 1. Drinks 6 cans of beers on the weekend 2. Gets up 4 times during the night to void 3. Smokes 1 pack of cigarettes daily 4. Uses sildenafil occasionally

4 Sildenafil (Viagra) is a phosphodiesterase inhibitor used to treat erectile dysfunction. The use of sildenafil is most important for the nurse to report to the HCP. This must be communicated immediately as concurrent use of nitrate drugs (commonly prescribed to treat unstable angina) is contraindicated as it can cause life-threatening hypotension. Before any nitrate drugs can be administered, further action is necessary to determine when sildenafil was taken last (ie, half-life is about 4 hours). (Option 1) Clients do not always report the amount of alcohol they consume accurately. The nurse should monitor all clients for alcohol withdrawal syndrome as it is quite common in hospitalized clients. (Option 2) Getting up 4 times during the night to void can be associated with medication, an enlarged prostate gland, or drinking fluids at bedtime. Further action may be needed to determine the cause of the nocturia, but this is not the most significant information to report to the HCP. (Option 3) Smoking 1 pack of cigarettes daily needs to be addressed as tobacco causes vasoconstriction and decreased oxygen supply to the body tissues. Further action is needed regarding smoking cessation education. However, the client's tobacco history is not the most important information to report to the HCP. Educational objective: Nitrate drugs are prescribed to treat angina. The concurrent use sildenafil (Viagra) and nitrates is contraindicated as it can cause life-threatening hypotension.

The nurse should call the primary health care provider to obtain a new prescription prior to administering which medication to a client with type 1 diabetes mellitus? 1. 10 units regular insulin IV push for blood glucose >250 mg/dL (13.9 mmol/L) 2. 14 units glargine insulin subcutaneous injection every night at 8:00 PM 3. 18 units aspart insulin subcutaneous injection 15 minutes before breakfast 4. 20 units NPH insulin IV push administered every morning at 7:00 AM

4 Subcutaneous injection is the indicated route for NPH insulin administration; it should never be administered via IV push. Regular insulin is the only insulin that can be administered via IV push; this is typically performed only in an acute care facility under close observation by the nurse. (Option 1) Administration of 10 units regular insulin IV push for blood glucose >250 mg/dL (13.9 mmol/L) is appropriate and a new prescription is not required. (Option 2) Administration of 14 units glargine insulin subcutaneous injection every night at 8:00 PM is appropriate and a new prescription is not required. (Option 3) Administration of 18 units aspart insulin subcutaneous injection 15 minutes before breakfast is appropriate and a new prescription is not required. Educational objective: Subcutaneous injection is the indicated route for NPH insulin administration; it should never be administered IV push. Regular insulin is the only insulin that can be administered IV push.

The nurse is caring for a client with diabetes who is being discharged with a prescription for glyburide. Which statement by the client indicates a need for further instruction? 1. "I should avoid alcohol intake with this new medication." 2. "I should call my primary health care provider if my morning blood glucose is below 60 mg/dL (3.3 mmol/L)." 3. "I should read the labels on all foods I eat, including those that say 'sugarless'." 4. "This medication will help me lose weight."

4 The major adverse effects of sulfonylurea medications (eg, glyburide, glipizide, glimepiride) are hypoglycemia and weight gain. Weight gain should be addressed. Clients taking glyburide should be taught to use sunscreen and protective clothing as serious sunburns can occur. (Option 1) Clients taking sulfonylureas should avoid alcohol as it lowers blood glucose and can lead to severe hypoglycemia. (Option 2) Hypoglycemia (serum glucose <70 mg/dL [3.9 mmol/L]) is a major side effect of sulfonylurea medications. A fasting blood glucose <60 mg/dL (3.3 mmol/L) indicates moderate to severe hypoglycemia and the medication needs to be reassessed. (Option 3) Even foods labeled "diabetic", "sugar free," or "sugarless" may contain carbohydrates such as honey, brown sugar, and corn syrup, all of which can elevate blood sugar. Educational objective: The major adverse effects of sulfonylurea medications are hypoglycemia and weight gain. Alcohol must be avoided while taking these medications due to the risk of severe hypoglycemia. Glyburide can also make clients sunburn easily.

The nurse is teaching a client with advanced chronic obstructive pulmonary disease who was prescribed oral theophylline. Which client statement indicates that additional teaching is required? 1. "I need to avoid caffeinated products." 2. "I need to get my blood drug levels checked periodically." 3. "I need to report anorexia and sleeplessness." 4. "I take cimetidine rather than omeprazole for heartburn."

4 Theophylline is a bronchodilator with a low therapeutic index and a narrow therapeutic range (10-20 mcg/mL). The serum level should be monitored frequently to avoid severe adverse effects. Toxicity is likely to occur at levels >20 mcg/mL. Individual titration is based on peak serum theophylline levels, so it is necessary to draw a blood level 30 minutes after dosing. Theophylline can cause seizures and life-threatening arrhythmias. Toxicity is usually due to intentional overdose or concurrent intake of medications that increase serum theophylline levels. Cimetidine and ciprofloxacin can dramatically increase serum theophylline levels (>80%). Therefore, they should not be used in these clients. (Option 1) Caffeinated products (eg, coffee, cola, chocolate) should be avoided as they would intensify the adverse effects (eg, tachycardia, insomnia, restlessness) of theophylline. (Option 2) The best way to prevent toxicity is to monitor drug levels periodically and adjust the dose. (Option 3) The signs of toxicity that should be reported are anorexia, nausea, vomiting, restlessness, and insomnia. Educational objective: Theophylline can cause seizures and life-threatening arrhythmias due to its narrow therapeutic range (10-20 mcg/mL). The dose is adjusted based on peak drug levels, obtained 30 minutes after the dose is given. Clients should avoid caffeinated products and medications that increase serum theophylline levels (eg, cimetidine, ciprofloxacin).

A client diagnosed with trigeminal neuralgia is given a prescription of carbamazepine by the health care provider. Which intervention does the nurse add to this client's care plan? 1. Encourage client to drink cold beverages 2. Encourage client to eat a high-fiber diet 3. Encourage client to perform facial massage 4. Encourage client to report any fever or sore throat

4 Trigeminal neuralgia is sudden, sharp pain along the distribution of the trigeminal nerve. The symptoms are usually unilateral and primarily in the maxillary and mandibular branches. Clients may experience chronic pain with periods of less severe pain, or "cluster attacks" of pain between long periods without pain. Triggers can include washing the face, chewing food, brushing teeth, yawning, or talking. Pain is severe, intense, burning, or electric shock-like. The primary intervention for trigeminal neuralgia is consistent pain control with medications and lifestyle changes. The drug of choice is carbamazepine. It is a seizure medication but is highly effective for neuropathic pain. Carbamazepine is associated with agranulocytosis (leukopenia) and infection risk. Clients should be advised to report any fever or sore throat. Behavioral interventions include the following: - Oral care - use a small, soft-bristled toothbrush or a warm mouth wash - Use lukewarm water; avoid beverages or food that are too hot or cold (Option 1) - Room should be kept at an even and moderate temperature - Avoid rubbing or facial massage. Use cotton pads to wash the face if necessary. - Have a soft diet with high calorie content; avoid foods that are difficult to chew. Chew on the unaffected side of the mouth. (Option 2) A high-fiber diet is not required for a client with trigeminal neuralgia, and the additional chewing with higher-fiber foods may serve as a pain trigger. (Option 3) Clients with trigeminal neuralgia are encouraged not to massage the face as this can trigger pain. Educational objective: The primary intervention for trigeminal neuralgia includes pain control and limiting pain triggers. The drug of choice is carbamazepine. Triggers can include washing the face, chewing food, brushing teeth, yawning, or talking. Carbamazepine is associated with agranulocytosis (leukopenia) and infection risk. Clients should be advised to report any fever or sore throat.

The school nurse is assisting a student with type 1 diabetes mellitus to calculate the insulin dosage needed based on the student's lunch menu selections. Using the prescribed carbohydrate-to-insulin ratio, how much insulin should the student receive? Record your answer using a whole number. Click on the exhibit button for additional information. Menu selection + Carbohydrate content 2 soft tacos 45 g Unsweetened applesauce 15 g 2% milk carton (8 oz [240 mL]) 15 g Insulin lispro: 1 unit subcutaneously per 15 g carbohydrate consumed, before each meal Answer: ___________ (units)

5 units insulin lispro Carbohydrate-based insulin dosing uses carbohydrate counting to calculate the insulin dosage required at meal times. Carbohydrate-based insulin dosing is a form of basal-bolus insulin therapy, which typically involves fixed, basal doses of a short- or intermediate-acting insulin (eg, regular insulin, insulin NPH) and variable, bolus doses of rapid-acting insulin (eg, insulin lispro) at specific intervals (eg, before meals). The client's individually prescribed carbohydrate-to-insulin ratio is used to calculate the insulin bolus dose. Total carbohydrates: 45 g+15 g+15 g=75 g carbohydrates 5 units insulin lispro Educational objective: Carbohydrate-based insulin dosing is a form of basal-bolus insulin therapy. To calculate the required dosage of insulin, the nurse should first identify the client's individually prescribed carbohydrate-to-insulin ratio (eg, 1 unit insulin/15 g carbohydrates), calculate the total carbohydrate content in the meal (eg, 75 g), and then convert to units per meal (eg, 5 units).

The nurse in an outpatient clinic is caring for a client with Addison disease who has been taking hydrocortisone 20 mg daily for the last 8 years. Which client data is most important to report to the health care provider? 1. Blood pressure of 140/90 mm Hg 2. Low-grade fever of 100.4 F (38 C) 3. Mild increase in fasting blood glucose 4. Weight gain of 6 lb (2.7 kg) in 3 months

2 Addison disease (primary adrenocortical insufficiency) is characterized by a deficiency in all three types of adrenal steroids (ie, glucocorticoids, androgens, mineralocorticoids), most commonly caused by an autoimmune response. Corticosteroid therapy (eg, hydrocortisone, dexamethasone, prednisone) is the primary treatment for Addison disease. Long-term use of corticosteroids can cause immunosuppression, and the anti-inflammatory effects may also mask signs of infection (eg, inflammation, redness, tenderness, heat, fever, edema). Signs and symptoms of infection (eg, low-grade fever) should be reported to the health care provider immediately as infection can develop quickly and spread rapidly (Option 2). In addition, physiological stress such as infection can trigger Addisonian crisis, a life-threatening complication of Addison disease that would require an increase in the corticosteroid dose. (Options 1, 3, and 4) Side effects of long-term corticosteroid therapy mimic the signs and symptoms of Cushing syndrome, including buffalo hump, moon-shaped face, and hypokalemia. Increased weight, blood pressure, and blood glucose levels can also occur; however, these effects are not as life-threatening as infection. Educational objective: In clients taking corticosteroids, it is imperative to notify the health care provider of signs and symptoms of infection, even a low-grade fever. The anti-inflammatory properties of corticosteroids can mask signs of infection, and their immunosuppressive effects can cause the infection to develop and spread quickly.

The nurse is caring for a client on IV heparin infusion and oral warfarin. Current laboratory values indicate that the client's aPTT is 5 times the control value and the PT/INR is 2 times the control value. What action does the nurse anticipate? 1. Clarify vegetable consumption with client 2. Decrease the heparin rate 3. Decrease the warfarin dose 4. Obtain an order for vitamin K injection

2 The anticoagulant heparin has to be administered intravenously or subcutaneously. The duration is 2-6 hours intravenously and 8-12 hours subcutaneously. It is measured by the aPTT (activated partial thromboplastin time) laboratory value. Warfarin (Coumadin) is taken orally, with onset/therapeutic effects reached after 2-7 days. It is measured by prothrombin time (PT) or International Normalized Ratio (INR). The therapeutic range for aPTT or PT/INR is generally 1.5-2.0 times the control value (up to 3 times the control value at times). An aPTT value above the therapeutic range places the client at risk for excess bleeding. The heparin administration would need to be stopped or decreased. (Option 1) Clients on warfarin must eat the same amount of dark green leafy vegetables because these foods contain vitamin K and will alter the effects of warfarin. The PT/INR is at therapeutic level so there is no concern related to this client's diet. (Option 3) The warfarin dose has achieved the therapeutic range for PT/INR and does not need adjustment. (Option 4) Vitamin K is the antidote for warfarin; the antidote for heparin is protamine sulfate. However, due to the short half-life of heparin, usually the dose is just held instead of administering an antidote when the values are too high. Educational objective: The therapeutic effect from heparin or warfarin (Coumadin) is 1.5-2.0 times the control value. Heparin is measured with aPTT and warfarin is measured with PT/INR. Vitamin K is the antidote for warfarin; protamine sulfate is the antidote for heparin.

The nurse reviews the analgesia prescriptions for assigned clients. The nurse should question the health care provider about which prescription? 1. Lidocaine 5% patch over intact skin for a client with chronic postherpetic neuralgia who reports intolerable, persistent, burning pain 2. Hydromorphone IV for a client who has a fractured femur, is a known IV heroin abuser, and rates pain as 9 on a 0-10 scale 3. Tramadol for a client who is being prepared for discharge following a laparoscopic cholecystectomy and rates abdominal pain as 6 on a 0-10 scale 4. Transdermal fentanyl patch for a client who is 1 day postoperative above-the-knee amputation and reports intermittent, throbbing stump pain

4 A transdermal fentanyl patch is prescribed for clients suffering from moderate to severe chronic pain. The patch provides continuous analgesia for up to 72 hours. However, the drug is absorbed slowly through the skin into the systemic circulation and can take up to 17 hours to reach its full analgesic effect. Therefore, it is not recommended for treating acute postoperative, temporary, or intermittent pain as it does not provide immediate analgesia when applied. (Option 1) A lidocaine 5% transdermal patch provides a localized, topical anesthetic to intact skin. It is commonly prescribed for clients with chronic postherpetic neuralgia, a painful, debilitating condition that can develop following a herpes zoster (shingles) infection. (Option 2) The client with opioid abuse history would be experiencing the same type and degree of pain as other clients with a fractured femur. However, a higher dose or a stronger opioid analgesic (eg, hydromorphone) is needed for pain relief due to the client's increased opioid tolerance. (Option 3) Tramadol is a synthetic opioid analgesic prescribed to treat moderate to severe postoperative pain. It is appropriate to prescribe at discharge as it has fewer complications related to respiratory depression compared with other opioids. Educational objective: A transdermal fentanyl patch is indicated to treat moderate to severe chronic pain. It is not recommended for treating acute postoperative, temporary, or intermittent pain as it does not provide immediate analgesia when applied.

A home health nurse visits a client 2 weeks after the client is discharged from treatment for an acute myocardial infarction and heart failure. After a review of the home medications, which symptom reported by the client is most concerning to the nurse? Click on the exhibit button for additional information. Home medications: Aspirin: 81 mg PO, daily Clopidogrel: 75 mg PO, daily Metoprolol XL: 50 mg PO, daily Furosemide: 40 mg PO, twice daily Fish oil: 4 g PO, daily 1. Bruising easily, especially on the arms 2. Fatigue 3. Feeling depressed 4. Muscle cramps in the legs

4 Hypokalemia (<3.5 mEq/L [<3.5 mmol/L]) is a common, adverse effect of potassium-wasting diuretics (eg, furosemide, bumetanide) that may cause muscle cramps, weakness, or paresthesia. Unmanaged hypokalemia can lead to lethal cardiac dysrhythmias and paralysis. Therefore, the nurse should immediately notify the health care provider of symptoms of hypokalemia (Option 4). Additional causes of hypokalemia include gastrointestinal losses (eg, vomiting, diarrhea, nasogastric suctioning) and medications (eg, insulin). To combat hypokalemia in clients receiving potassium-wasting diuretics, supplemental potassium and/or a high-potassium diet may be required. (Option 1) Bruising is common with the use of antiplatelet agents (eg, aspirin, clopidogrel). However, the nurse should monitor for and report signs of uncontrolled bleeding, such as bloody stools and signs of stroke (eg, headache, slurred speech). (Option 2) Myocardial infarction and heart failure often cause activity intolerance and fatigue due to decreases in heart muscle function. In addition, fatigue is a common side effect experienced on initiation of beta blocker (eg, metoprolol) therapy, but typically improves over time. (Option 3) Feelings of depression are common after an acute health-related event such as a myocardial infarction. The nurse should further explore and evaluate feelings of depression; however, these symptoms are not immediately life-threatening unless the client exhibits suicidal ideation. Educational objective: Nurses caring for clients receiving potassium-wasting diuretics (eg, furosemide) should monitor for and report signs of hypokalemia (eg, muscle cramps), as unmanaged hypokalemia may result in lethal complications. Bruising, a side effect of antiplatelet medications, and fatigue, a side effect of beta blockers, should be monitored, but are not lethal.

The nurse is caring for a client who is taking riluzole for amyotrophic lateral sclerosis (ALS). The client asks, "There's no cure for ALS, so why should I keep taking this expensive drug?" What is the nurse's best response? 1. "It may be able to slow the progression of ALS." 2. "It reduces the amount of glutamate in your brain." 3. "The case manager may be able to find a program to assist with cost." 4. "You have the right to refuse the medication."

1 Amyotrophic lateral sclerosis (ALS), also known as Lou Gehrig disease, is a debilitating, progressive neurodegenerative disease with no cure. Clients develop fatigue and muscle weakness that progresses to paralysis, dysphagia, difficulty speaking, and respiratory failure. Most clients diagnosed with ALS survive only 3-5 years. Riluzole (Rilutek) is the only medication approved for ALS treatment. Riluzole, a glutamate antagonist, is thought to slow neuron degeneration by decreasing the production and activity of the neurotransmitter glutamate in the brain and spinal cord. In some clients, riluzole may slow disease progression and prolong survival by 3-6 months. The nurse should provide teaching about the purpose of the medication so that the client can make an informed decision about taking it (Option 1). (Option 2) Explaining the pharmacology of riluzole is not the best response for helping the client understand the purpose of taking the medication. (Option 3) It would be appropriate to consult the case manager if the client expresses concern about not having the appropriate resources to acquire a costly medication, but the nurse should first ensure that the client understands the medication's purpose. (Option 4) The client has the right to refuse any medication, but the nurse should first ensure that the client is informed and understands the purpose of the medication. Educational objective: Although there is no cure for amyotrophic lateral sclerosis, the medication riluzole may slow disease progression and prolong survival.

The clinic nurse evaluates a client's response to levothyroxine after 8 weeks of treatment. What therapeutic responses to the medication should the nurse expect? Select all that apply. 1. Apical heart rate of 88/min 2. Elevation of mood 3. Improved energy levels 4. Skin is cool and dry 5. Slight weight gain

1, 2, 3 The client's therapeutic response to levothyroxine (Synthroid) is evaluated by resolution of hypothyroidism symptoms. The expected response includes improved well-being with elevated mood (Option 2), higher energy levels (Option 3), and a heart rate that is within normal limits (Option 1). The nurse should consult the health care provider if the heart rate is >100/min, or if the client reports chest pain, nervousness, or tremors; this may indicate that the dose is higher than necessary. Pharmacological therapy manages the symptoms of hypothyroidism, but it takes up to 8 weeks after initiation to see the full therapeutic effect. (Option 4) In hypothyroidism, the skin is cool, pale, and rough (due to dryness). These characteristics result from decreased blood flow. A therapeutic response to levothyroxine would be skin that is normal. (Option 5) The client experiencing a therapeutic response to levothyroxine would experience weight loss due to the increased metabolic rate. However, the client with untreated hypothyroidism would experience weight gain. Educational objective: The expected therapeutic response to levothyroxine (Synthroid) includes an increased sense of well-being with elevated mood, greater energy levels, and a heart rate within normal limits. It takes up to 8 weeks to see the full effect of pharmacological therapy.

A client is having a severe asthma attack lasting over 4 hours after exposure to animal dander. On arrival, the pulse is 128/min, respirations are 36/min, pulse oximetry is 86% on room air, and the client is using accessory muscles to breathe. Lung sounds are diminished and high-pitched wheezes are present on expiration. Based on this assessment, the nurse anticipates the administration of which of the following medications? Select all that apply. 1. Inhaled albuterol nebulizer every 20 minutes 2. Inhaled ipratropium nebulizer every 20 minutes 3. Intravenous methylprednisolone 4. Montelukast 10 mg by mouth STAT 5. Salmeterol metered-dose inhaler every 20 minutes

1, 2, 3 Clinical manifestations characteristic of moderate to severe asthma exacerbations include tachycardia (>120/min), tachypnea (>30/min), saturation <90% on room air, use of accessory muscles to breathe, and peak expiratory flow (PEF) <40% of predicted or best (<150 L/min). Pharmacologic treatment modalities recommended by the Global initiative for Asthma (2014) to correct hypoxemia, improve ventilation, and promote bronchodilation include the following: - Oxygen to maintain saturation >90% - High-dose inhaled short-acting beta agonist (SABA) (albuterol) and anticholinergic agent (ipratropium) nebulizer treatments every 20 minutes - Systemic corticosteroids (Solu-Medrol) (Option 4) Montelukast (Singulair) is a leukotriene receptor blocker with both bronchodilator and anti-inflammatory effects; it is used to prevent asthma attacks but is not recommended as an emergency rescue drug in asthma. (Option 5) A long-acting beta agonist (Salmeterol) is administered with an inhaled corticosteroid for long-term control of moderate to severe asthma; it is not used as an emergency rescue drug in asthma. Educational objective: Clinical manifestations characteristic of moderate to severe asthma exacerbations include tachycardia, tachypnea, saturation <90% on room air, use of accessory muscles of respiration, and PEF <40% predicted. Management includes the administration of high-dose inhaled SABA and ipratropium nebulizer, systemic corticosteroids, and oxygen to maintain saturation >90%.

The nurse is reviewing the medication administration record of a client with atrial fibrillation. Which of the following should the nurse monitor before giving these medications? Select all that apply. Click the exhibit button for more information. Allergies: None Medications & Time: Prednisone: 20 mg by mouth, daily0900 Metoprolol: 50 mg by mouth, daily0900 Digoxin: 0.5 mg by mouth, daily1300 Enoxaparin: 40 mg subcutaneously, every 12 hours0900 and 2100 1. Digoxin level 2. Glucose 3. INR 4. Platelet count 5. Serum potassium

1, 2, 4, 5 The complete blood count (hemoglobin, hematocrit, platelet count) should be assessed periodically with the administration of enoxaparin, an anticoagulant that can cause bleeding and thrombocytopenia (Option 4). Digoxin levels are monitored for suspicion of digoxin toxicity (ie, serum levels >2 ng/mL) (Option 1). Potassium levels should also be monitored in clients receiving digoxin, as hypokalemia can potentiate digoxin toxicity (Option 5). Prednisone is a glucocorticoid that can cause hyperglycemia. Glucose levels should be monitored periodically in clients receiving this medication (Option 2). (Option 3) Low-molecular-weight heparins (eg, enoxaparin, dalteparin) produce a stable response at recommended dosages and negate the need for monitoring of activated partial thromboplastin time (aPTT) or international normalized ratio (INR) levels. aPTT is monitored when administering unfractionated heparin. INR is monitored in clients receiving warfarin (Coumadin). Educational objective: The nurse should routinely monitor laboratory values prior to administering medications. A complete blood count should be assessed periodically in clients receiving enoxaparin to monitor for bleeding and thrombocytopenia. Digoxin and potassium levels should be assessed with the administration of digoxin. Glucose levels should be monitored in the client receiving glucocorticoids.

A post-surgical client is unresponsive to painful stimuli and is given naloxone. Within 5 minutes, the client is arousable and responds to verbal commands. One hour later, the client is again difficult to arouse, with minimal response to physical stimuli. Which actions should the nurse take? Select all that apply. 1. Administer oxygen 2. Assess respiratory rate 3. Initiate rapid response or code team 4. Notify the health care provider 5. Prepare a second dose of naloxone

1, 2, 4, 5 A client in the post-operative period that is unresponsive to painful stimuli is likely still under the effects of medications used during anesthesia. Using the opioid antagonist naloxone (Narcan) will temporarily reverse the effects of any opioid medications. Unfortunately, the half-life of naloxone is much shorter than most opioid medications, wearing off in 1-2 hours. The nurse should make repeat assessments of the post-surgical client's respiratory rate and administer prescribed oxygen for respiratory support. The health care provider should be notified and a second dose of naloxone should be prepared and administered as prescribed (either as a one-time dose or a continuous drip, depending on the prescription). (Option 3) An overly sedated client is not an indication for a rapid response team. Although this intervention is unlikely to cause harm to the client, it is not necessary and may result in overuse of personnel resources. If additional information indicates a more serious situation (eg, respiratory rate <8 breaths/min, oxygen saturation <90%), it may be appropriate to initiate the emergency response system. Educational objective: Naloxone (Narcan) is usually prescribed as needed for post-surgical clients for over-sedation related to opioid use. The nurse should continue to monitor clients who are given naloxone with the understanding that the opioid antagonist has a shorter half-life than most of the opioids it is meant to counteract. As a result, a second dose of naloxone may be necessary.

A hospitalized client with thyrotoxicosis receives atenolol 50 mg PO daily. Which statement by the nurse accurately reinforces the client's understanding of this medication's purpose? 1. "Atenolol is an iodine-based medication that blocks the release of thyroid hormones." 2. "It is used to treat some of the symptoms of hyperthyroidism, such as increased heart rate." 3. "This drug is radioactive and damages or destroys the thyroid tissue." 4. "This first-line antithyroid drug inhibits the synthesis of thyroid hormones."

2 Beta-adrenergic blockers (atenolol, metoprolol, and propranolol) are used to relieve some of the symptoms of thyrotoxicosis (thyroid storm), a complication of hyperthyroidism in which excessive thyroid hormones are released into the circulation. Beta blockers block the effects of the sympathetic nervous system and treat symptoms such as tachycardia, hypertension, irritability, tremors, and nervousness in hyperthyroidism. (Option 1) Atenolol is not iodine based. Iodine is used to treat thyrotoxicosis or to prepare the client for a thyroidectomy. In large doses, iodine quickly blocks the release of T4 and T3 from the gland within hours. In addition, iodine decreases thyroid gland vascularity and is helpful when preparing the client for a thyroidectomy. (Option 3) Atenolol does not contain radioactive iodine, the primary treatment for hyperthyroidism. It damages or destroys the thyroid tissue, therefore limiting thyroid secretion and eventually making the client hypothyroid. (Option 4) Propylthiouracil and methimazole (Tapazole) are first-line antithyroid drugs used to inhibit thyroid hormone synthesis. Educational objective: Beta-adrenergic blockers (atenolol, metoprolol, and propranolol) are given to relieve some of the symptoms of thyrotoxicosis. They block the effects of the sympathetic nervous system and treat symptoms such as tachycardia, hypertension, irritability, tremors, and nervousness in hyperthyroidism.

The nurse provides medication teaching to a client with primary adrenal insufficiency (Addison's disease) who is prescribed hydrocortisone 10 mg by mouth 3 times a day. Which instructions should be included in the client's teaching plan? Select all that apply. 1. "Discontinue hydrocortisone if you note mood changes or disruptions in behavior." 2. "Make an appointment with an optometrist yearly to assess for cataracts." 3. "Report even a low-grade fever to the health care provider (HCP) immediately." 4. "Report signs of hyperglycemia, including increased urine, hunger, and thirst." 5. "Take the medication on an empty stomach." 6. "The dose of hydrocortisone may need to be decreased during times of stress."

2, 3, 4 Clients taking long-term corticosteroid replacement should be taught the following: 1. Do not discontinue glucocorticoid therapy abruptly. Abrupt discontinuation could lead to addisonian crisis, a life-threatening complication (Option 1). 2. Report any signs and symptoms of infection to the HCP immediately. Corticosteroid use can cause immunosuppression, and infection can develop quickly and spread rapidly. Corticosteroids' anti-inflammatory effects may also mask signs of infection such as inflammation, redness, tenderness, heat, fever, and edema (Option 3). 3. Stay attuned to signs and symptoms of stress and increase dose of corticosteroid during times of stress. A stress response (surgery, trauma) can cause a sudden decrease in cortisol levels, triggering addisonian crisis (Option 6). 4. A side effect of corticosteroid therapy is hyperglycemia. Report signs of hyperglycemia, including increased urine, hunger, and thirst. Clients with diabetes mellitus must be vigilant in checking blood glucose levels (Option 4). 5. Corticosteroids are catabolic to bone (osteoporosis) and muscle (muscle weakness). A diet high in calcium (at least 1500 mg/day) and protein (1.5 g/kg/day) but low in fat and simple carbohydrates is recommended. 6. Cataracts are a side effect of corticosteroids, particularly glucocorticoid therapy. Make an appointment with an optometrist yearly to assess for cataracts (Option 2). 7. Corticosteroid medications can cause gastric irritation and should not be taken on an empty stomach (Option 5). 8. Recognize signs and symptoms of Cushing syndrome and report to the PHCP. 9. Develop a regular HCP-approved exercise program. Educational objective: Corticosteroids are the primary drugs used to treat Addison's disease. It is imperative that the nurse teach the client about this medication, including points such as never to stop it abruptly, notify the HCP of signs and symptoms of infection, and monitor blood glucose closely if diabetes is a comorbid condition.

The clinic nurse prepares to administer a newly prescribed dose of sumatriptan to a client with a migraine headache. Which item in the client's history would cause the nurse to question the prescription? 1. Blood urea nitrogen of 12 mg/dL (4.28 mmol/L) 2. BMI of 34 kg/m2 recorded during today's examination 3. Past medical history of uncontrolled hypertension 4. Takes alprazolam as prescribed for anxiety

3 Sumatriptan is a selective serotonin agonist prescribed to treat migraine headaches, which are thought to be caused by dilated cranial blood vessels. Triptan drugs, like sumatriptan, work by constricting cranial blood vessels, and clients should be instructed to take a dose at the first sign of a migraine to help prevent and relieve symptoms. Sumatriptan is contraindicated in clients with coronary artery disease and uncontrolled hypertension because its vasoconstrictive properties increase the risk of angina, hypertensive urgency, decreased cardiac perfusion, and acute myocardial infarction. The nurse should question the client about a past medical history of uncontrolled hypertension and report this to the health care provider (Option 3). (Option 1) A blood urea nitrogen level of 12 mg/dL (4.28 mmol/L) is a normal value (normal range 6-20 mg/dL [2.1-7.1 mmol/L]). (Option 2) Sumatriptan is not contraindicated for underweight or overweight clients. (Option 4) Sumatriptan is not contraindicated with alprazolam therapy. However, because of its serotonergic effects, clients already taking selective serotonin reuptake inhibitors (eg, sertraline, paroxetine) or selective norepinephrine reuptake inhibitors (eg, venlafaxine, duloxetine) should be monitored for signs of serotonin syndrome. Educational objective: Sumatriptan relieves migraines by constricting dilated cranial blood vessels. Sumatriptan is contraindicated in clients with coronary artery disease and uncontrolled hypertension because the vasoconstrictive effects can cause hypertensive urgency, angina, decreased cardiac perfusion, and acute myocardial infarction.

A client is admitted to the cardiac care unit with atrial fibrillation. Vital signs are shown in the exhibit. Which prescription should the nurse perform first? Click on the exhibit button for additional information. Vital signs: Temperature 98.2 F (36.8 C) Blood pressure 120/80 mm Hg Heart rate140/min, irregular Respirations18/min SpO298% 1. Administer diltiazem 20 mg IVP 2. Administer rivaroxaban 20 mg PO 3. Draw blood for a thyroid function test 4. Send the client for echocardiogram

1 Atrial fibrillation is characterized by a disorganization of electrical activity in the atria due to multiple ectopic foci. It results in loss of effective atrial contraction and places the client at risk for embolic stroke due to thrombi formed in the atria from stasis of blood. During atrial fibrillation, the atrial rate may be increased to 350-600/min. The ventricular response (pulse rate) can vary. The higher the ventricular rate, the more likely the client will have symptoms of decreased cardiac output (ie, hypotension). Ventricular rate control is a priority in clients with atrial fibrillation. This client has an irregular heart rate of 140/min and is not currently hypotensive. However, if the high ventricular response is allowed to continue, it is likely that the client will begin to show signs and symptoms of decreased cardiac output such as hypotension. Therefore, giving the client diltiazem (a calcium channel blocker) is the priority as its purpose is to decrease the ventricular response rate to <100/min. Other medications such as beta blockers (metoprolol) or digoxin may also be used to control the ventricular rate. (Option 2) Anticoagulants (eg, rivaroxaban [Xarelto], dabigatran [Pradaxa], apixaban [Eliquis], and warfarin) are used for long-term prevention of atrial thrombus and embolic complications. This is not a priority. (Option 3) The HCP will investigate possible causes of the atrial fibrillation; one of these is an overactive thyroid gland (hyperthyroidism). The thyroid function test would be useful for confirmation, but it is not a priority. (Option 4) An echocardiogram can be obtained once the rate is controlled, but it is not a priority. Educational objective: Ventricular rate control is a priority in the client with atrial fibrillation; therefore, the nurse should administer the medication (diltiazem, metoprolol, or digoxin) that will accomplish this first.

A client with coronary artery disease and atrial fibrillation is being discharged home following coronary artery stent placement. Discharge medications are shown in the exhibit. The nurse identifies which educational topic as the highest priority for this client? Click on the exhibit button for additional information. Discharge medications:Aspirin: 81 mg by mouth, once daily; Clopidogrel: 75 mg by mouth, once daily; Rivaroxaban: 20 mg by mouth, once daily; Metoprolol: 25 mg by mouth, twice daily; Rosuvastatin: 20 mg by mouth, once daily; Lisinopril: 10 mg by mouth, once daily 1. Bleeding risk 2. Bronchospasm 3. Muscle injury 4. Tinnitus

1 This client is on 3 different medications that affect bleeding risk (aspirin, clopidogrel, and rivaroxaban); this drug combination places the client at increased risk for bleeding. Teaching the client about the signs and symptoms of bleeding and risk reduction is the highest priority. The nurse should instruct the client to monitor for black, tarry stools, bleeding gums, and excessive bruising. The client should also use a soft bristle toothbrush, shave with an electric razor, and refrain from playing contact sports. (Option 2) Bronchospasm rarely occurs with high doses of aspirin and metoprolol. This client is on low-dose aspirin and metoprolol. Although this should be a teaching topic for the client, bleeding is more likely to occur than this adverse reaction. (Option 3) Muscle cramps can be common with statins (eg, rosuvastatin, atorvastatin, simvastatin). However, muscle injury is rare and not as high in priority as bleeding risk. (Option 4) Tinnitus may occur with aspirin toxicity. However, this client is on baby aspirin (81 mg) and is very unlikely to experience adverse effects. Educational objective: Clients taking a combination of antiplatelet agents (eg, aspirin, clopidogrel, ticagrelor, prasugrel) and anticoagulants (eg, warfarin, rivaroxaban, apixaban) are at very high risk for life-threatening bleeding complications. The nurse should teach the client how to recognize and prevent signs and symptoms of increased bleeding.

A male client with hypertension was prescribed amlodipine. Which of these adverse effects is most important to teach the client to watch for? 1. Erectile dysfunction 2. Dizziness 3. Dry cough 4. Leg edema

2 Calcium channel blockers (nifedipine, amlodipine, felodipine, nicardipine) are vasodilators used to treat hypertension and chronic stable angina. They promote relaxation of vascular smooth muscles leading to decreased systemic vascular resistance and arterial blood pressure. The most important adverse effects of calcium channel blockers include dizziness (Option 2), flushing, headache, peripheral edema (Option 4), and constipation. The reduced blood pressure may initially cause orthostatic hypotension. The client should be taught to change positions slowly to prevent falls. Leg elevation and compression can help to reduce the edema. Constipation should be prevented with daily exercise and increased intake of fluids, fruits/vegetables, and high-fiber foods. (Option 3) Angiotensin-converting enzyme (ACE) inhibitors prevent the breakdown of bradykinin, which may produce a nonproductive cough in susceptible individuals. Discontinuation of the medication stops the cough. (Option 1) Adverse effects of beta-blockers include bradycardia, bronchospasm, depression, and decreased libido with erectile dysfunction. Educational objective: Calcium channel blockers are utilized to treat hypertension and chronic stable angina. Adverse effects of these medications include dizziness, flushing, headache, peripheral edema, and constipation.

A client is 6 hours postoperative from hip surgery after receiving regional anesthesia and has epidural continuous anesthesia in place. Which is the most important reason for the nurse to contact the health care provider? 1. Client reports paresthesia bilaterally since the surgery 2. Fondaparinux is prescribed for STAT administration 3. Lower-extremity muscle strength is 3/5 bilaterally 4. Postoperative laboratory results show hemoglobin of 9.9 g/dL (99 g/L)

2 Fondaparinux (Arixtra), unfractionated heparin, and low molecular weight heparin (eg, enoxaparin, dalteparin) are anticoagulants commonly used for deep vein thrombosis and pulmonary embolism prophylaxis after hip/knee replacement or abdominal surgery. However, fondaparinux is not administered until more than 6 hours after any surgery, and anticoagulants are not given while an epidural catheter is in place (Option 2). Fondaparinux is associated with epidural hematoma. Any bleeding in the tight epidural space, which does not expand, could result in spinal cord compression. Signs of epidural spinal hematoma can include severe back pain and paralysis. (Option 1) Paresthesia is an expected finding from postoperative analgesia for 2-24 hours after surgery, depending on the agent and location. Continuously administered analgesia usually results in some paresthesia until approximately 4-6 hours after discontinuance. As long as the level remains relatively stable or improves, it is an acceptable finding. However, paresthesia or motor weakness is a concern when the sensory or motor block outlasts the expected duration. (Option 3) Client response to operative analgesia and postoperative continued analgesia can range from minimal to significant. As long as the analgesic is infusing and findings remain stable, reduced muscle strength is expected. (Option 4) Major orthopedic surgery can result in significant blood loss, and it is not unusual for the client to have hemoglobin drop of 1-2 g/dL (10-20 g/L). Blood loss should be monitored over time; transfusion usually is not indicated unless hemoglobin is <7-8 g/dL (70-80 g/L). Educational objective: Residual paresthesia and motor weakness for several hours are expected findings after regional anesthesia. Anticoagulants are not given while an epidural catheter is in place.

A nurse receives an electrocardiogram of a client with type 2 diabetes, heart failure, and hypothyroidism. Based on the findings, which of the following medications should the nurse suspect as the most likely cause? Click the exhibit button for more information. sinus bradycardia 1. Captopril 2. Carvedilol 3. Glimepiride 4. Levothyroxine

2 The client has sinus bradycardia, which can be caused by: - Drugs (eg, beta blockers, calcium channel blockers, digoxin). Consider withholding beta blockers if systolic blood pressure <100 mm Hg or heart rate <60 and notify the provider. - Vagal stimulation (eg, carotid sinus massage, Valsalva maneuver) - Diseases (eg, hypothyroidism, myocardial infarction, increased intracranial pressure) The clinical significance of sinus bradycardia depends on how the client tolerates the effect of slow heart rate on cardiac output. Sinus bradycardia is usually asymptomatic. However, symptomatic bradycardia can manifest as pale, cool skin; hypotension; weakness; confusion; dyspnea; chest pain; and syncope. (Options 1, 3, and 4) The side effects of these drugs include tachycardia (Table). Educational objective: Sinus bradycardia may be caused by drugs (eg, beta blockers), vagal stimulation, hypothyroidism, inferior wall myocardial infarction, and increased intracranial pressure. It is normal in some people (eg, trained athletes).

The health care provider prescribes phenazopyridine hydrochloride for a client with a urinary tract infection. What would the office nurse teach the client to expect while taking this medication? 1. Constipation 2. Difficulty sleeping 3. Discoloration of urine 4. Dry mouth

3 Phenazopyridine hydrochloride (Pyridium) is a urinary analgesic prescribed to relieve the pain and burning associated with a urinary tract infection. The urine will turn bright red-orange while on this medication; other body fluids can be discolored as well. Because staining of underwear, clothing, bedding, and contact lenses can occur, the nurse should suggest that the client use sanitary napkins and wear eyeglasses while taking the medication. Phenazopyridine hydrochloride provides symptomatic relief but no antibiotic action, and so it is important that the client take a full course of antibiotics. (Options 1, 2, and 4) Constipation, difficulty sleeping, and dry mouth are not common adverse effects of phenazopyridine hydrochloride. Educational objective: Phenazopyridine hydrochloride (Pyridium) is a urinary analgesic prescribed to relieve symptoms of dysuria associated with a urinary tract infection. An expected side effect of the drug is orange-red discoloration of urine.

The health care provider (HCP) has prescribed amitriptyline 25 mg orally every morning for an elderly client with recent herpes zoster infection (shingles) and severe postherpetic neuralgia. What is the priority nursing action? 1. Encourage increased fluid intake 2. Provide frequent rest periods 3. Teach the client to get up slowly from the bed or a sitting position 4. Tell the client to wear sunglasses when outdoors

3 Tricyclic antidepressants (eg, amitriptyline, nortriptyline, desipramine, imipramine) are commonly used for neuropathic pain. Side effects are especially common in elderly clients, including: - orthostatic hypotension - constipation, urinary retention - drowsiness, confusion - photosensitivity Due to the increased risk of falling, the priority nursing action is to teach the client to get up slowly from the bed or a sitting position. (Options 1, 2, and 4) These are important instructions but not priority ones. Educational objective: The most common side effects experienced by clients taking tricyclic antidepressants include dizziness, drowsiness, dry mouth, constipation, photosensitivity, urinary retention, and blurred vision. The priority nursing action is to teach caution in changing positions due to the increased risk for falls from dizziness and orthostatic hypotension, especially in elderly clients.

During shift report it was noted that the off-going nurse had given the client a PRN dose of morphine 2 mg every 2 hours for incisional pain. What current client assessment would most likely affect the oncoming nurse's decision to discontinue the administration every 2 hours? 1. Client reports burning during injection into the IV line 2. Client reports dizziness when getting up to use the bathroom 3. Client's blood pressure is 106/68 mm Hg 4. Client's respiratory rate is 11/min

4 Morphine is an opioid analgesic that can be given intravenously for moderate to severe pain. An adverse reaction to morphine administration is respiratory depression. A respiratory rate <12/min would be a reason to hold morphine administration. The nurse should perform a more in-depth assessment of the client's pain and causes. The morphine dose may need to be decreased or the time between administrations may need to be increased. The nurse should not administer additional doses until the respiratory rate increases. (Option 1) Morphine can cause burning during IV administration. This can be reduced by diluting the morphine with normal saline and administering it slowly over 4-5 minutes. (Option 2) The nurse should instruct the client to call for help before getting up to go to use the bathroom to avoid falls caused by dizziness from the morphine. (Option 3) Morphine can lower blood pressure, and clients receiving it should have blood pressure monitored. This blood pressure reading is not severely low and is not a priority over the respiratory depression. Educational objective: Morphine administration can cause respiratory depression. The nurse should hold a dose of morphine for a client whose respiratory rate is <12/min.

What intervention is essential prior to starting a client on atorvastatin therapy? 1. Assessing for muscle strength 2. Assessing the client's dietary intake 3. Determining if the client is on digoxin therapy 4. Monitoring liver function tests

4 Prior to starting therapy with statin medications (eg, rosuvastatin, simvastatin, pravastatin, atorvastatin), the client's liver function tests should be assessed. The drug is metabolized by the hepatic enzyme system and could cause drug-induced hepatitis and increased liver enzymes. Liver function tests should be assessed prior to the start of therapy. (Option 1) Statins can also cause muscle aches and, rarely, severe muscle injury (rhabdomyolysis). Clients should be educated to report the development of muscle pains while on therapy. Assessment of muscle strength is not necessary prior to starting therapy. (Option 2) Assessment of dietary intake prior to therapy is not essential. Dietary teaching would have been performed prior to determining that medication therapy was necessary. (Option 3) Atorvastatin may slightly increase serum digoxin levels; however, it is not essential to determine if the client is on this medication prior to starting therapy. Educational objective: Statin medications (eg, rosuvastatin, atorvastatin) can cause hepatotoxicity and muscle aches. Liver function tests should be assessed prior to the start of therapy.

The clinic nurse is instructing a client who is newly prescribed transdermal scopolamine to prevent motion sickness during an upcoming vacation on a cruise ship. Which of the following statements made by the nurse are appropriate? Select all that apply. 1. "Apply the patch when the ship starts moving and not before." 2. "Dispose of the patch out of reach of children and pets." 3. "Make sure to remove the old patch before applying a new one." 4. "Place the patch on a hairless, clean, dry area behind the ear." 5. "Wash your hands with soap and water after handling the patch."

2, 3, 4, 5 Scopolamine is an anticholinergic medication used to prevent nausea and vomiting from motion sickness and as an adjunct to anesthesia to control secretions. Transdermal scopolamine is placed on a hairless, clean, dry area behind the ear for proper absorption (Option 4). Clients should be instructed to: - Apply the patch ≥4 hours before starting travel to allow for absorption and medication onset (Option 1). Transdermal patches have a slower onset but a longer duration of action. - Replace the patch every 72 hours as prescribed to ensure continuous medication delivery. - Remove and discard the old patch before placing a new one to prevent accidental overdose (Option 3). - Dispose of the old patch out of reach of children and pets to avoid accidental ingestion (Option 2). - Wash hands with soap and water after handling the patch to avoid inadvertent drug absorption or contact with the eyes (Option 5). Educational objective: To prevent motion sickness, transdermal scopolamine should be applied to a hairless, clean, dry area behind the ear ≥4 hours prior to travel. Clients should change the patch every 72 hours, discard old patches out of reach of children and pets, and wash hands after handling patches. The old patch must be removed before a new one is placed.

The nurse reinforces teaching a client on prescribed dabigatran for chronic atrial fibrillation. Which statement by the client indicates a need for further teaching? 1. "I will call my health care provider if I notice red urine or blood in my stool." 2. "I will not stop taking dabigatran even if I get a stomachache." 3. "I will place capsules in my pill box so I will not forget to take a dose." 4. "I will swallow the capsule whole with a full glass of water."

3 Thrombin inhibitors such as dabigatran (Pradaxa) reduce the risk of clot formation and stroke in clients with chronic atrial fibrillation. The nurse should educate the client about implementing bleeding precautions (eg, using a soft-bristle toothbrush, shaving with an electric razor). Dabigatran capsules should be kept in their original container or blister pack until time of use to prevent moisture contamination (Option 3). (Option 1) Red urine or blood in the stool may indicate internal bleeding caused by thrombin inhibitors. The client should report these symptoms to the health care provider. (Option 2) Thrombin inhibitors should only be stopped under the direction of the health care provider. The nurse should educate the client that stopping dabigatran will increase the risk for stroke. Taking the medication with food will not affect how much is absorbed, and food or a full glass of water may prevent gastrointestinal side effects (eg, nausea, indigestion). (Option 4) Thrombin inhibitor capsules should not be crushed or opened as crushing pills increases absorption and risk of bleeding. Educational objective: Thrombin inhibitors such as dabigatran reduce the risk for clots and stroke in clients with chronic atrial fibrillation. The nurse should teach the client to use bleeding precautions and monitor for symptoms of bleeding, swallow capsules whole with a full glass of water, and keep capsules in their original container until time of use.

A client with deep vein thrombosis (DVT) is receiving a continuous infusion of unfractionated heparin. The client asks the nurse what the heparin is for. How should the nurse respond? 1. "Heparin is a blood thinner that will help to dissolve the clot in your leg." 2. "Heparin will help stabilize the clot in your leg and prevent it from breaking off and traveling to your lungs." 3. "Heparin will keep the current clot from getting bigger and help prevent new clots from forming." 4. "I'm sorry. This is something that your health care provider (HCP) can answer better upon arriving."

3 Venous thrombosis involves the formation of a thrombus (clot) and the inflammation of the vein. Anticoagulant therapy such as heparin does not dissolve the clot. The clot will be broken down by the body's intrinsic fibrinolytic system over time. The heparin slows the time it takes blood to clot, thereby keeping the current clot from growing bigger and preventing new clots from forming. (Option 1) Anticoagulants do not dissolve clots. Thrombolytic agents (fibrinolytics), such as tissue plasminogen activator (tPA), are used to break the clots, but they also carry the risk of serious intracranial hemorrhage and are used only for acute life-/organ-threatening conditions. The body will break down the clot over a period of time. (Option 2) Heparin does not prevent the clot from breaking off but will deter the clot from growing larger. (Option 4) The nurse should be able to answer client questions regarding medications being administered. The HCP can answer any further questions the client may have. Educational objective: The nurse should teach the client that the purpose of unfractionated heparin infusion in the treatment of DVT is to slow the time it takes blood to clot, thereby keeping the current clot from getting bigger and preventing new clots from forming.

The nurse is providing discharge teaching to several clients with new prescriptions. Which instructions by the nurse are correct in regard to medication administration? Select all that apply. 1. Avoid salt substitutes when taking valsartan for hypertension 2. Take levofloxacin with an aluminum antacid to avoid gastric irritation 3. Take sucralfate after meals to minimize gastric irritation associated with a gastric ulcer 4. When taking ethambutol, notify the health care provider (HCP) of any changes in vision 5. When taking rifampin, notify the HCP if the urine turns red-orange

1, 4 Both ACE inhibitors ("prils" - captopril, enalapril, lisinopril, ramipril) and angiotensin receptor blockers ("sartans" - valsartan, losartan, telmisartan) cause hyperkalemia. Salt substitutes contain high potassium and must not be consumed unless approved by the health care provider (HCP) (Option 1). Ethambutol (Myambutol) is used to treat tuberculosis but can cause ocular toxicity, resulting in vision loss and loss of red-green color discrimination. Vision acuity and color discrimination must be monitored regularly (Option 4). (Option 2) Levofloxacin (Levaquin) is a quinolone antibiotic. For this class of antibiotics, 2 hours should pass between drug ingestion and consumption of aluminum/magnesium antacids, iron supplements, multivitamins with zinc, or sucralfate. These substances can bind up to 98% of the drug and make it ineffective. (Option 3) Sucralfate (Carafate, Sulcrate), prescribed to treat gastric ulcers, should be administered before meals to coat the mucosa and prevent irritation of the ulcer during meals. It should also be given at least 2 hours before or after other medications to prevent interactions that reduce drug efficacy. (Option 5) Rifampin (Rifadin), used to treat tuberculosis, normally causes red-orange discoloration of all body fluids. The client should be alerted to expect this change but does not need to notify the HCP. Educational objective: The nurse should watch for vision changes with ethambutol. Potassium supplements or salt substitutes should not be given to a client taking an ACE inhibitor or angiotensin receptor blocker. Sucralfate must be given before meals to prevent irritation of the ulcer. Quinolone antibiotics should not be given with antacids or supplements that reduce drug efficacy. Rifampin commonly causes red-orange discoloration of body fluids.

The nurse teaches a client about the use of regular and neutral protamine Hagedorn (NPH) insulin. Which statement by the client indicates that further teaching is needed? 1. "I will always check my blood glucose prior to using the sliding scale." 2. "I will eat breakfast 30 minutes after taking my morning NPH and regular insulin." 3. "I will use a new insulin syringe each time I give myself an injection." 4. "I will use the sliding scale to determine my NPH dose 4 times a day."

4 The Institute for Safe Medication Practices has labeled insulin a high-alert medication. These types of medication can be safe and effective when administered or taken according to recommendations. However, errors in administration may cause death or serious illness. NPH is an intermediate-acting insulin with a duration of 12-18 hours; it is generally prescribed 2 times daily (morning and evening). Regular insulin and other rapid-acting insulins (lispro, aspart, glulisine) are typically used with a sliding scale for tighter control of blood glucose throughout the day. These are generally taken before meals and at bedtime. (Options 1, 2, and 3) These are correct statements and indicate the teaching objective was completed successfully. Educational objective: NPH is an intermediate-acting insulin with a duration of 12-18 hours and typically prescribed twice a day.

A client is receiving a continuous heparin infusion and the most recent aPTT is 140 seconds. The nurse notices blood oozing at the surgical incision and IV insertion sites. What interventions should the nurse implement? Select all that apply. 1. Continue heparin infusion and recheck aPTT in 6 hours 2. Prepare to administer vitamin K 3. Redraw blood for laboratory tests 4. Review guidelines for administration of protamine 5. Stop infusion of heparin and notify the health care provider (HCP)

4, 5 Depending on the institution and HCP, a therapeutic aPTT level for a client being heparinized is somewhere between 46-70 seconds (1.5-2.0 times the baseline value). An aPTT of 140 seconds is too long and this client is showing signs of bleeding. The nurse should stop the heparin infusion, notify the HCP, and review administration guidelines for possible administration of protamine (reversal agent for heparin). (Option 1) Continuing the heparin infusion will put the client at risk for a severe bleeding episode. (Option 2) Vitamin K is the reversal agent for warfarin. (Option 3) There is no reason to redraw blood for laboratory workup at this time as the abnormal aPTT result is consistent with the client's bleeding. Laboratory studies may need to be redone within 1 hour of stopping the infusion or giving a reversal agent. Educational objective: The nurse should stop the infusion of heparin when there is evidence of bleeding. The HCP should be notified immediately and the nurse should be prepared to give protamine if ordered.

A client with type I diabetes mellitus is prescribed an insulin pump. The nurse reinforces the diabetic educator's teaching regarding transitioning from multiple daily injections to continuous subcutaneous insulin infusion (CSII) therapy. Which statement indicates that the client understands the advantages of using this therapy? 1. "I won't need a bolus dose of insulin before my meals anymore." 2. "I'm glad my blood sugars won't go way up and way down, like they did before." 3. "I'm so glad I don't have to stick my finger 4 times a day to test my sugar anymore." 4. "It'll finally be easier for me to lose some weight."

2 An insulin pump is a small, battery-operated device about the size of a pager. The infusion set holds a syringe (reservoir) filled with rapid-acting insulin (175-315 units) and delivers the drug from the pump to the client through a needle or catheter that is usually secured to the abdomen with an adhesive patch. The pump delivers insulin in 2 ways: - As a steady, measured, and continuous dose (basal rate) 24 hours a day - As an intermittent dose (bolus) administered manually at mealtime to cover carbohydrate intake and as a supplemental dose to correct pre- or postprandial hyperglycemia. CSII therapy delivers the insulin more accurately than injections, so the client experiences fewer swings in blood glucose levels and hypoglycemic episodes, as compared with the administration of insulin using a needle and syringe, or pen. (Option 1) Although the pump can calculate and deliver a more precise dose to regulate blood glucose levels more effectively, a bolus dose must be administered manually at mealtime to cover carbohydrate intake. (Option 3) Pumps used most commonly (open-loop) cannot respond to changes in the client's glucose levels. The American Diabetes Association recommends that clients using CSII check their blood glucose levels 4-8 times a day: fasting, pre-meal, 2-hours postprandial, bedtime, at 3:00 AM weekly, when experiencing symptoms of hypoglycemia, after treating low blood sugar, and before exercise. Some insulin pumps (closed-loop system) are equipped with continuous blood glucose monitoring (CBGM) systems, which can detect blood glucose levels without a fingerstick. However, CBGM does not completely eliminate the need to test blood sugar because some machines must be calibrated every day to validate accuracy. (Option 4) Use of the insulin pump facilitates tighter glucose control, leading to more normal metabolism. However, if the client continues to take in more calories than needed for a given amount of activity or exercise, glucose that is not used by the cells accumulates as fat and results in weight gain. Educational objective: A client prescribed CSII is taught how to self-manage the insulin pump. Key points include the importance of checking blood glucose levels at least 4 times a day, how to administer a bolus dose at mealtime to cover carbohydrate intake, how to administer a supplemental bolus dose to correct pre- and postprandial hyperglycemia, and the importance of balancing diet and exercise to avoid excess weight gain.

A client with a brain tumor is admitted for surgery. The health care provider prescribes levetiracetam. The client asks why. What is the nurse's response? 1. "It destroys tumor cells and helps shrink the tumor." 2. "It prevents seizure development." 3. "It prevents blood clots in legs." 4. "It reduces swelling around the tumor."

2 Levetiracetam (Keppra) is a medication often used to treat seizures in various settings. It has minimal drug-drug interactions compared to phenytoin and is often the preferred antiepileptic medication. (Option 1) Chemotherapy and radiation therapy would kill tumor cells and reduce tumor size. (Option 3) Hospitalized clients and clients with malignancy are at higher risk for venous thromboembolism. These clients would benefit from anticoagulation (eg, heparin, enoxaparin, rivaroxaban, apixaban). (Option 4) Dexamethasone, a corticosteroid, is used to treat cerebral edema associated with a brain injury/tumor by decreasing inflammation. Educational objective: Levetiracetam (Keppra) is a medication often used to treat seizures in various settings. Corticosteroids are used to reduce inflammation and cerebral edema in clients with brain injury and tumors.

The nurse is assessing a client 15 minutes after initiating nitroglycerin infusion for suspected acute coronary syndrome. Which clinical finding is the priority? 1. The client reports a headache 2. The client reports feeling dizzy and lightheaded 3. The client reports feeling flushed 4. The client reports feeling nervous

2 Nitroglycerin is a nitrate that causes vasodilation and relaxation of vascular smooth muscle. In clients with acute coronary syndrome, it is administered by IV infusion to decrease preload and prevent spasm of the coronary arteries, thereby increasing perfusion and oxygen supply to the cardiac muscle. Due to systemic vasodilation, this client is at risk for significant hypotension. The nurse should follow up immediately if the client reports dizziness or lightheadedness, which may indicate profound hypotension (Option 2). If the client is found to be hypotensive, the nurse may need to decrease or discontinue the infusion. (Option 1) Headache is a common side effect of nitroglycerin therapy and is often a sign that the medication is working properly. It is not a priority, although acetaminophen may be given for pain relief. (Options 3 and 4) Systemic vasodilation and decreased cardiac preload may cause the client to feel flushed and nervous during infusion. However, reports of dizziness and lightheadedness should take priority. Educational objective: Nitroglycerin is a vasodilator that may be administered by IV infusion in the management of acute coronary syndrome. Clients receiving nitroglycerin are at risk for profound hypotension resulting from systemic vasodilation. The nurse should immediately assess a client with signs of hypotension (eg, dizziness, lightheadedness) because the nitroglycerin infusion may need to be decreased or stopped.

A client is started on lisinopril therapy. Which assessment finding requires immediate action? 1. Blood pressure 129/80 mm Hg 2. Heart rate 100/min 3. Serum creatinine 2.5 mg/dL (221 µmol/L) 4. Serum potassium 3.5 mEq/L (3.5 mmol/L)

3 The dosage of angiotensin-converting enzyme (ACE) inhibitors (eg, lisinopril, enalapril, ramipril) should be adjusted for clients with renal impairment. A serum creatinine of 2.5 mg/dL (221 µmol/L ) indicates renal impairment (normal 0.6-1.3 mg/dL [53-115 µmol/L]). The nurse should notify the health care provider so that the dosage can be decreased or held. (Options 1, 2, and 4) The client's blood pressure, heart rate, and serum potassium (normal 3.5-5.0 mEq/L [3.5-5.0 mmol/L]) are within normal limits. They do not require immediate action. Hyperkalemia and hypotension are contraindications for giving ACE inhibitors. Educational objective: Evaluation of kidney function is essential for clients taking medications that are excreted renally or can worsen renal injury. These include ACE inhibitors (eg, lisinopril, enalapril), aminoglycosides (eg, gentamicin), and digoxin.