N1240 Case Study: Pharmacology Medical Surgical Drugs

For each potential nursing intervention, click to indicate whether it is indicated, not indicated, or contraindicated. Nursing Intervention 1. Assess for headache 2. Prepare client for transcutaneous pacing 3. Educate patient about signs of stroke 4. Consult occupational therapy 5. Administer atropine sulfate as ordered 6. Obtain order for rivaroxaban

1 = Indicated 2 = Contraindicated 3 = Indicated 4 = Not indicated 5 = Contraindicated 6 = Indicated Rationale: Resolving the client's inadequate cardiac output and inadequate tissue perfusion are priorities for the nurse. The nurse would initiate continuous cardiac monitoring, initiate IV access, and administer diltiazem to normalize (decrease) the client's heart rate. The client's oxygen saturation is >92%, negating the need to apply supplemental oxygen. The client's "bed rest with bathroom privileges" order only requires the nurse to ensure the client ambulates only to the bathroom, which does not address the client's needs for increased tissue perfusion. Inserting an indwelling urinary catheter may reduce the risk for falls but it is not as important as increasing tissue perfusion for the client.

The nurse reviews the electronic health record and documents visit-related care in the nursing progress notes. Labs and follow-up appointments scheduled per provider orders. A health care provider prescribes aspirin therapy for a client with arthritis. The nurse will advise the client to report which adverse effect immediately? Select all that apply. One, some, or all responses may be correct. 1. Ongoing nausea 2. Diarrhea 3. Easy bruising 4. Decreased pulse 5. Sour stomach 6. Ringing in the ears 7. Trouble sleeping 8. Dry mouth

1, 2, 3, 6 Rationale: Aspirin is a gastrointestinal irritant that can cause nausea, vomiting, and gastrointestinal bleeding. Salicylates can irritate gastric mucous membranes, leading to diarrhea. Salicylates decrease platelet aggregation, resulting in easy bruising and gastrointestinal bleeding. Tinnitus and hearing loss can occur as a result of the effects of the medication on the eighth cranial nerve. Salicylates may increase, not decrease, the heart rate. A sour stomach, trouble sleeping, and dry mouth are all known side effects of aspirin that do not require immediate medical attention.

The nurse obtains report and reviews the electronic health record. Documentation related to care provided is recorded in nursing progress notes. Diagnostics completed as ordered. A client with hypertension is prescribed an angiotensin II receptor blocker (ARB). Which instruction will the nurse provide about this medication? Select all that apply. One, some, or all responses may be correct. 1. "Monitor the blood pressure often." 2. "Discontinue treatment if a cough develops." 3. "Stop the medication if swelling of the mouth, lips, or face develops." 4. "Have blood drawn for potassium levels 2 weeks after starting the medication." 5. "Do not take nonsteroidal anti-inflammatory drugs (NSAIDs) concurrently with this medication." 6. "Notify other prescribers of new ARB prescription." 7. "Report lightheadedness or dizziness upon standing to the provider." 8. "Serum levels will be drawn at least once a month to ensure therapeutic levels."

1, 3, 4, 6, 7, Rationale: The risk for hypotension is increased with ARB use, therefore the client should be educated on the signs and symptoms of a low blood pressure and the need to monitor blood pressure often. The medication should be stopped if angioedema occurs, and the health care provider should be notified. Electrolyte levels of potassium, sodium, and chloride should be obtained 2 weeks after the start of therapy and then periodically thereafter. ARBs may increase the effects of other medications such as antihypertensives and lithium, dosages may need to be adjusted accordingly. A dry cough may occur during treatment with ARBs; however, it is not necessary to discontinue the medication because the cough usually resolves. There is no need to avoid the use of NSAIDs while taking an ARB. Serum levels are not monitored with ARB use.

The nurse reviews the electronic health record and documents visit-related care in the nursing progress notes. Labs drawn and imaging completed per provider orders. Digoxin is prescribed for a client with heart failure. The nurse will assess for which clinical manifestation that indicates digoxin toxicity? Select all that apply. One, some, or all responses may be correct. 1. Confusion 2. Headache 3. Nausea 4. Yellow vision 5. Dizziness 6. Irregular pulse 7. Increased urine output 8. Decreased respiratory rate

1-6 Rationale: Signs and symptoms of digoxin toxicity include confusion, headache, nausea, bradycardia, visual disturbances (blurred vision or yellow vision), and dizziness. In addition, electrocardiogram (ECG) findings may include heart block, atrial tachycardia with block, or ventricular dysrhythmias, all causing an irregular pulse. Increased urine output is an expected effect of improved cardiac output. Changes in respiratory rate, slow or fast, are not associated with digoxin toxicity.

Click to highlight the 3 orders the nurse would perform right away.- 1. Administer diltiazem 0.25 mg/kg IV 2. Apply and titrate oxygen to maintain oxygen saturation =92% 3. Bed rest with bathroom privileges 4. Continuous cardiac monitoring 5. Initiate IV access 6. Insert indwelling urinary catheter

1. Administer diltiazem 0.25 mg/kg IV 4. Continuous cardiac monitoring 5. Initiate IV access Rationale: Resolving the client's inadequate cardiac output and inadequate tissue perfusion are priorities for the nurse. The nurse would initiate continuous cardiac monitoring, initiate IV access, and administer diltiazem to normalize (decrease) the client's heart rate. The client's oxygen saturation is >92%, negating the need to apply supplemental oxygen. The client's "bed rest with bathroom privileges" order only requires the nurse to ensure the client ambulates only to the bathroom, which does not address the client's needs for increased tissue perfusion. Inserting an indwelling urinary catheter may reduce the risk for falls but it is not as important as increasing tissue perfusion for the client.

The nurse has performed the interventions as ordered by the health care provider. For each client finding, click to specify if the assessment finding demonstrates diltiazem administration was effective, ineffective, or unrelated. Assessment finding 1. Heart rate 82 beats per minute 2. Irregular 2+ pulse 3. Cough 4. Capillary refill 3 seconds 5. Oxygen saturation 98% on room air

1. Effective 2. Ineffective 3. Unrelated 4. Ineffective 5. Effective Rationale: Diltiazem is a calcium channel blocker indicated for angina, hypertension, and atrial fibrillation; this drug slows the calcium channel influx into cardiac muscle, which decreases cardiac contractility and sinoatrial-atrioventricular (SA-AV) node impulse conductivity. Calcium channel blockers decrease chronotropic action (lowering heart rate), decrease blood pressure (decreasing vascular resistance), and decrease electrical conduction in the cardiac cycle (functioning as an antidysrhythmic). Diltiazem therapy should elicit therapeutic responses including decreased heart rate, decreased blood pressure, and normalization of cardiac rhythm. The effects of diltiazem normalizing electrical conductivity, heart rate, and cardiac output include normalizing heart rate and improving oxygen saturation. Diltiazem will not always correct cardiac dysrhythmias and cardiac output, so an irregular pulse and/or diminished capillary refill after diltiazem therapy indicate an ineffective result. A cough related to cardiac dysfunction may not be resolved with diltiazem therapy, but cough and pulmonary sequelae are not indications for a calcium channel blocker.

The nurse reviews the electronic health record system for client information and documents care in the nursing progress notes. Client care implemented per provider orders and emergency department protocols. A client receiving morphine is being monitored by the nurse for adverse effects of the medication. Which clinical finding warrants immediate action by the nurse? Select all that apply. One, some, or all responses may be correct. 1. Polyuria 2. Unconsciousness 3. Bradycardia 4. Dilated pupils 5. Bradypnea 6. Hypertension 7. Yawning 8. Lacrimation

2, 3, 5 Rationale: The effect of morphine, if severe, can cause unconsciousness. The CNS depressant effect of morphine causes bradycardia and bradypnea. Morphine does not increase urine output. Morphine causes constriction of pupils. Along with bradycardia, morphine is associated with hypotension, not hypertension. Yawning, lacrimation, and rhinorrhea are symptoms associated with withdrawal from morphine or other opioids.

The nurse reviews the electronic health record system for client information and documents care in the nursing progress notes. Labs drawn and diagnostics completed per provider orders. A client receiving chemotherapy develops bone marrow suppression. The nurse will monitor for which thrombocytopenic effect? Select all that apply. One, some, or all responses may be correct. 1. Fatigue 2. Pale skin 3. Deep vein thrombosis 4. Dizziness 5. Melena 6. Purpura 7. Emboli 8. Hematuria

5,6 & 8 Rationale: Bone marrow suppression results in a reduced number of circulating white and red blood cells, as well as platelets. Black tarry feces caused by the action of intestinal secretions on blood are associated with bleeding in the gastrointestinal tract; bleeding is related to a reduced number of thrombocytes, which are part of the coagulation process. Hemorrhages into the skin and mucous membranes (purpura) may occur with reduced numbers of thrombocytes, which are part of the coagulation process. Blood in the urine (hematuria) may occur with a reduced number of thrombocytes, which are part of the coagulation process. Signs of reduced red blood cells, not platelets, include fatigue, pale skin, and dizziness. Deep vein thrombosis and emboli are effects of thrombocytosis.

1537 70-year-old male client presents in Emergency Department with shortness of breath while tree trimming an hour ago. The client states, "my heart feels like it's flip flopping." Client has a past medical history of hypertension, for which he takes metoprolol 50 mg daily. Client additionally states he has been urinating more frequently through the night and he has had a dry cough for the past week. Vital Signs: heart rate (HR) 118 beats per minute, blood pressure (BP) 138/88 mmHg, oxygen saturation (SpO2) 92% on room air, by mouth (PO) temperature 98°F (36.7°C). Clear lung sounds in all lung fields. Pulse irregular and +2. Capillary refill 2 seconds. Skin warm and dry. Alert and oriented. Which problem would the nurse consider the client to be at risk for after reviewing the Nurses' Note? Select all that apply. Ischemic stroke Hemorrhagic stroke Angina Myocardial infarction Heart block Myxedema crisis Acute kidney failure Risk for falls

Ischemic stroke Angina Myocardial infarction Risk for falls Rationale: A rapid heart rate and irregular pulse can contribute to blood stasis, increasing the risk of developing a blood clot in the atria, which may result in an ischemic stroke. A rapid heart rate and irregular pulse can also cause decreased cardiac output, which may decrease perfusion and oxygen supply to the heart; this may result in chest pain (angina) or myocardial infarction. Decreased cardiac output may result in decreased blood flow to the brain, which may cause disorientation or dizziness, increasing the client's risk for falls. A hemorrhagic stroke is bleeding in the brain, and there is nothing in the client's presentation or history that places him at an increased risk for this condition. Heart block is a dysrhythmia most frequently resulting from a prior heart attack or heart disease, neither of which apply to this client. This client does not exhibit signs or symptoms of myxedema crisis, a form of hypothyroidism, which include confusion, hypothermia, weakness, etc. Acute kidney failure is a sudden loss of kidney function, which would result in decreased urinary output, not nocturia.

Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 areas of medication education the nurse should provide.

Rationale: Correct: Levothyroxine is a synthetic hormone replacement indicated for low thyroxine (T4) levels; an order for this drug indicates the client has hypothyroidism. The nurse would review the client's TSH level to confirm the cause of the client's symptoms (a normal or high TSH combined with a low T4 level confirms primary hypothyroidism). Levothyroxine therapy may result in a dangerously high heart rate, as the drug raises metabolism and cardiac output. The drug should be taken on an empty stomach, 30-60 minutes before breakfast, for maximum absorption and to simulate the body's rise of thyroid activity upon waking. Switching brands of a thyroid drug is generally not suggested without guidance from the provider because potency between brands may vary. Incorrect: An order for a beta blocker such as metoprolol would be contraindicated for a client with hypothyroidism, as it would further decrease cardiac output. There is no indication the client has an inflammatory or infectious disease, so a WBC is not indicated for this client. There is no indication in the client's presentation that urinary output monitoring is required. Fibromyalgia is a disease characterized by generalized musculoskeletal pain that would likely not be resolved with levothyroxine therapy. Lyme disease is an infection caused by a tick bite resulting in a rash and joint pain. Mononucleosis is an infection caused by the Epstein-Barr virus (EBV) resulting in fatigue and fever. Levothyroxine therapy raises thyroid activity, raising metabolic activity and cardiac output, including elevation (not decrease) of heart rate and blood pressure. Taking an antacid with levothyroxine, and most other drugs, decreases absorption of the drug; if stomach upset occurs with levothyroxine therapy, the client should notify the prescriber.

1537 70-year-old male client presents in Emergency Department with shortness of breath while tree trimming an hour ago. The client states, "my heart feels like it's flip flopping." Client has a past medical history of hypertension, for which he takes metoprolol 50 mg daily. Client additionally states he has been urinating more frequently through the night and he has had a dry cough for the past week. Vital Signs: heart rate (HR) 118 beats per minute, blood pressure (BP) 138/88 mmHg, oxygen saturation (SpO2) 92% on room air, by mouth (PO) temperature 98°F (36.7°C). Clear lung sounds in all lung fields. Pulse irregular and +2. Capillary refill 2 seconds. Skin warm and dry. Alert and oriented.

Shortness of breath my heart feels like it is flip-flopping HR of 118 and an irregular pulse Rationale: Shortness of breath is an abnormal assessment that suggests a cardiac or respiratory disorder, possibly contributing to an oxygenation or perfusion complication. A "flip flopping" sensation in the heart suggests cardiac palpitations, possibly a cardiac dysrhythmia. Barring an explained situation (exercising, etc.), an elevated heart rate, particularly tachycardia, suggests a cardiac disorder, possibly an imbalance of oxygen demand and supply, hypovolemia, etc. An irregular pulse suggests a cardiac dysrhythmia, possibly resulting in decreased cardiac output and decreased tissue perfusion. An increase in nocturnal urination and a recent dry cough require additional assessment, but are not as important as focused cardiac and respiratory assessments. A blood pressure reading of 138/88 mmHg, while slightly elevated, may be a result of client fear or anxiety, and may be further confirmed following up with a second reading later in the client's stay. An oxygen saturation level of 92% on room air is slightly lower than normal, but oxygen therapy is generally not initiated unless it drops below 92%. Capillary refill is generally 2 seconds or less in healthy adults, but may take up to 3 seconds in older clients.

thrombocytopenic effect

Thrombocytopenia signs and symptoms may include: Easy or excessive bruising (purpura) Superficial bleeding into the skin that appears as a rash of pinpoint-sized reddish-purple spots (petechiae), usually on the lower legs. Prolonged bleeding from cuts. Bleeding from your gums or nose

Complete the following sentence by using the list of options. The client is experiencing _____ and _____ , caused by _______

decreased cardiac output lightheadedness atrial fibrillation Rationale: The client's stated "lightheadedness" is caused by decreased cardiac output and its subsequent decreased tissue perfusion. Atrial fibrillation with tachycardia does not allow adequate ventricular filling time, which reduces stroke volume and perfusion to the heart and brain. The client is not exhibiting signs of pneumonia, which may include fever, productive cough, and difficulty breathing. The client is not exhibiting signs of stroke, which may include facial droop, arm drift, and slurred speech. The client is not exhibiting signs of pulmonary edema, which may include chest pain, fatigue, and abnormal breath sounds.