NCLEX PN Prep: Pharmacology

A client with chronic kidney disease is admitted with pneumonia and pleurisy. The client's laboratory results are shown in the exhibit. Which prescription will the nurse question? Click on the exhibit button for additional information. Laboratory Results Hemoglobin: 9.0 g/dL (90 g/L) Platelets: 267,000/mm*3 (267 x 10*9/L) White Blood Cells: 14,500/mm*3 (14.5 x 10*9/L) Creatinine: 2.8 mg/dL (214 µmol/L) A. Acetaminophen 500 mg PO every 6 hours, as needed for fever B. Epoetin alfa 15,000 units subcutaneus injection, once weekly C. Epoetin alfa 15,000 units subcutaneus injection, once weekly D. Levofloxacin 500 mg IV, once daily

Correct Answer: C. Epoetin alfa 15,000 units subcutaneus injection, once weekly This client has chronic kidney disease with an elevated serum creatinine level. Ketorolac (Toradol) is a highly potent nonsteroidal anti-inflammatory drug (NSAID) often used for pain and available in intravenous form. However, NSAIDs (eg, indomethacin, ibuprofen, naproxen, ketorolac) are nephrotoxic and should be avoided in clients with kidney disease. Also, the client should not be given 2 types of NSAIDs simultaneously (eg, naproxen plus ibuprofen) as they can be toxic to the stomach and kidneys. Incorrect Answers: [A. Acetaminophen 500 mg PO every 6 hours, as needed for fever] Prescribing acetaminophen as needed is appropriate to treat fever. [B. Epoetin alfa 15,000 units subcutaneus injection, once weekly] Clients with chronic kidney disease often have anemia due to erythropoietin deficiency. Recombinant erythropoietin injections are often prescribed to treat anemia. [D. Levofloxacin 500 mg IV, once daily] Levofloxacin is an appropriate antibiotic to use for treating pneumonia. Educational objective:Nonsteroidal anti-inflammatory drugs (NSAIDs) (eg, indomethacin, ibuprofen, naproxen, ketorolac) are nephrotoxic and should be avoided in clients with kidney disease. In addition, clients taking a NSAID medication should not take a different NSAID medication at the same time.

The nurse reinforces education with a client starting isotretinoin for acne. Which statement indicates the client needs further instruction? A. "I should not donate blood while taking this medication." B. "I will stop taking my tetracycline prior to taking this medication." C. "I will take vitamin A supplements." D. "I will use condoms and birth control pills."

Correct Answers: C. "I will take vitamin A supplements." Isotretinoin is an oral acne medication derived from vitamin A. Due to teratogenic risk and severity of side effects (eg, Stevens-Johnson syndrome, suicide risk), isotretinoin is used to treat only severe and/or cystic acne not responding to other treatments. Exposure to any amount of this medication during pregnancy can cause birth defects. Clients are required to enter a Web-based risk management plan (iPLEDGE) and use 2 forms of contraception. Taking vitamin A supplements along with isotretinoin can cause vitamin A toxicity, which can cause increased intracranial pressure, gastrointestinal upset, liver damage, and changes in skin and nails. Therefore, clients should be instructed to avoid vitamin A supplements while taking this medication. Incorrect Answers: [A. "I should not donate blood while taking this medication."] Blood donation is also prohibited during the duration of treatment and up to a month after treatment ends due to the possibility of inadvertent transfusion to a pregnant woman. [B. "I will stop taking my tetracycline prior to taking this medication."] Isotretinoin should not be taken with tetracycline because the latter also increases the risk for intracranial hypertension. [D. "I will use condoms and birth control pills."] Clients are required to enter a Web-based risk management plan (iPLEDGE) and 2 forms of contraception. Educational objective:Isotretinoin is a vitamin A derivative prescribed to treat severe and/or cystic acne. Side effects include birth defects, skin changes (eg, dry skin, skin fragility, cutaneous atrophy), and risk for increased intracranial pressure. Clients need to be instructed to avoid tetracycline, excess sun and tanning, and vitamin A supplements. Women of child-bearing age should use 2 forms of contraception to prevent pregnancy.

The health care provider prescribes simvastatin for a client with hyperlipidemia. The nurse reinforces which teaching regarding correct timing of medication administration? A. At noon with a meal B. In the morning on an empty stomach C. In the morning with breakfast D. With the evening meal

Correct Answer: D. With the evening meal Statin drugs (eg, simvastatin, atorvastatin, rosuvastatin) are prescribed to lower cholesterol and reduce the risk of atherosclerosis and coronary artery disease. Most of the cholesterol in the body is synthesized by the liver during the fasting state, at night. Trials have found greater reductions in total and LDL cholesterol when statins (especially those that are short-acting; eg, simvastatin) are taken in the evening or at bedtime as opposed to during the day. Incorrect Answers: [A. At noon with a meal] Medications that can cause stomach upset (eg, nonsteroidal anti-inflammatory drugs) should be taken with food. [B. In the morning on an empty stomach] Levothyroxine should be taken on an empty stomach in the morning. Acid-suppressing medications (eg, proton pump inhibitors, H2 blockers) should be taken 30 minutes before a meal. [C. In the morning with breakfast] Medications that can cause stomach upset (eg, nonsteroidal anti-inflammatory drugs) should be taken with food. Educational objective:The client taking a statin drug such as simvastatin should be taught to take the medication with the evening meal or at bedtime to promote maximal effectiveness.

The client is brought to the emergency department in handcuffs by the police. Witnesses said that the client became violent and confused after consuming large amounts of alcohol at a party. The client is placed in 4-point restraints, and ziprasidone hydrochloride is administered. The client is sleeping 30 minutes later. What is a priority action for the nurse at this time? A. Check for a history of bipolar disease B. Determine if restraints can now be removed C. Monitor for ECG changes D. Obtain blood for the current blood alcohol level

Correct Answer: C. Monitor for ECG changes. Ziprasidone hydrochloride (Geodon) is an atypical antipsychotic drug used for acute bipolar mania and psychosis and agitation. Its use carries a risk for ECG changes, including torsades de pointes, a life-threatening dysrhythmia. A baseline ECG and potassium level are usually obtained. At a minimum, the client should be placed on a cardiac monitor. The client also should be monitored for hypotension and seizures, especially if the previous medical history is not known or obtainable. The risk for adverse effects is increased with the interaction of alcohol. Incorrect Answers: [A. Check for a history of bipolar disease] Although knowing past psychiatric history will assist in determining the cause of the episode, this knowledge is not essential to caring for this client's needs. Any physical reason for the behavior should be ruled out before focusing on psychiatric history. Risk for suicide also must be assessed after the client is alert and sober. [B. Determine if restraints can now be removed] The need for restraints should be reassessed after the drug has worn off, not before the medication peaks, as the client could suddenly wake up and become violent again. The client's physiological response is the priority. Performing restraint monitoring per protocol, including checks on circulation and hydration/elimination needs, is also a priority. [D. Obtain blood for the current blood alcohol level] It would be beneficial to know the current alcohol (ethanol) level to estimate the client's level of intoxication and when the client will be sober. The body normally clears alcohol at a rate of 15-35 mg/dL (3-8 mmol/L) per hour. However, there is a reliable history that the client had been drinking, and the presence of alcohol in the blood carries a risk for drug interaction. Therefore, it is more important to monitor the client for any negative effects (adverse physiological responses) from the drug than to quantify the current alcohol level. Educational objective:After ziprasidone hydrochloride (Geodon) administration, clients should be monitored for cardiac effects, hypotension, and/or seizure activity. Alcohol interacts with ziprasidone and increases the potential for an adverse effect from the drug.

A nurse is reinforcing teaching about herbal supplements to a group of clients in the local community center. Saw palmetto is one herbal medicine being discussed. Which audience participants would find this information beneficial? A. Clients diagnosed with heart failure B. Clients with benign prostatic hyperplasia C. Clients with major depressive disorder D. Perimenopausal clients experiencing hot flashes

Correct Answer: B. Clients with benign prostatic hyperplasia Herbal preparations are not regulated by government agencies and are generally classified as food or dietary supplements. Manufacturers are therefore able to avoid the scientific scrutiny exercised when prescription drugs are readied for the market. Saw palmetto is one such herbal preparation, and clients most often use it to treat benign prostatic hyperplasia. Incorrect Answers: [A. Clients diagnosed with heart failure] Hawthorn extract is used to treat heart failure and is an approved treatment for this condition in some countries (eg, Germany). [C. Clients with major depressive disorder] St John's wort has been used for centuries to treat depression but may cause hypertension and serotonin syndrome when used with other antidepressants. [D. Perimenopausal clients experiencing hot flashes] Black cohosh is an herbal supplement often used by perimenopausal clients experiencing hot flashes. Educational objective:Saw palmetto, a herbal preparation, is often used to treat benign prostatic hyperplasia. St John's wort has been used for centuries to treat depression.

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

Correct Answer: D. "I will rotate the site where I apply the patch." 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. Incorrect Answers: [A. "I can continue to take my prescription of sildenafil."] 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. [B. "I should take the patch off when I shower."] Patches may be worn in the shower. [C. "I will remove the patch if I develop a headache."] 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.

Which medication prescriptions should the nurse question? Select all that apply. A. Cephalexin for a client with severe allergy to penicillin B. Fexofenadine for a client with hives C. Ibuprofen for a client with asthma and nasal polyps D. Lisinopril for a client with diabetes mellitus E. Propranolol for a client with asthma

Correct Answers: A, C, and E Cephalexin is a cephalosporin, which is chemically similar to penicillin. If a client has had a severe allergic reaction to penicillin, there is a 1%-4% chance of an allergic reaction (cross-sensitivity) to a cephalosporin. Clients with nasal polyps often have sensitivity to nonsteroidal anti-inflammatory drugs (NSAIDS), including aspirin. In addition, NSAIDs can exacerbate asthma symptoms. Therefore, acetaminophen may be a better choice for these clients. The selective beta blockers (eg, metoprolol, atenolol, bisoprolol) are generally given for heart failure and hypertension control due to their beta1-blocking effect. The nonselective beta blockers (eg, propranolol, nadolol), in addition, have a beta2-blocking effect that results in bronchial smooth muscle constriction. Therefore, nonselective beta blockers are generally contraindicated in clients with asthma. Incorrect Answers: [B. Fexofenadine for a client with hives] H1 receptor antagonists (eg, fexofenadine, cetirizine, levocetirizine, loratadine) decrease the inflammatory response by blocking histamine receptors. Histamine is released from mast cells during a type I (immediate) hypersensitivity reaction (ie, allergic rhinitis, allergic conjunctivitis, and hives). [D. Lisinopril for a client with diabetes mellitus] Angiotensin-converting (ACE) inhibitors (ending in "pril") are the drugs of choice in diabetic clients with hypertension or proteinuria. This would be an appropriate administration. Educational objective:Clients with asthma and nasal polyps can have sensitivity to NSAIDs; those with an allergy to penicillin can have a cross-sensitivity to cephalosporins. Nonselective beta blockers are contraindicated in clients with asthma. H1 receptor antagonists block histamine in an allergic reaction. ACE inhibitors are protective for diabetic nephropathy.

The nurse reviews a client's medical record and notes the following PRN medication prescriptions: acetaminophen, haloperidol, and benztropine. The nurse would administer a dose of benztropine on assessing which client behavior? A. Muscle rigidity and shuffling gait B. Nihilistic delusions C. Tangentiality D. Waxy flexibility

Correct Answer: A. Muscle rigidity and shuffling gait Benztropine (Cogentin) is an anticholinergic medication used to treat some extrapyramidal symptoms, which are side effects of some antipsychotic medications. These side effects include: — Pseudoparkinsonism: Symptoms that resemble parkinsonism (eg, masklike face, shuffling gait, rigidity, resting tremor, psychomotor retardation [bradykinesia]) — Dystonia: Abnormal muscle movements of the face, neck, and trunk caused by sustained muscular contractions (eg, torticollis, oculogyric crisis, opisthotonos) Incorrect Answers: [B. Nihilistic delusions] Delusions are a symptom of schizophrenia; treated with antipsychotic medications. [C. Tangentiality ] Tangentiality (deviating from the original topic of discussion) is an abnormal thought process seen in schizophrenia; treated with antipsychotic medications. [D. Waxy flexibility] Waxy flexibility (tendency to remain in an immobile posture) is a motor disturbance seen in schizophrenia; treated with antipsychotic medications. Educational objective:Benztropine (Cogentin) is an anticholinergic drug used to treat extrapyramidal symptoms, which are side effects of some antipsychotic medications.

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? A. "It destroys tumor cells and helps shrink the tumor." B. "It prevents seizure development." C. "It prevents blood clots in legs." D. "It reduces swelling around the tumor."

Correct Answer: B. "It prevents seizure development." 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. Incorrect Answers: [A. "It destroys tumor cells and helps shrink the tumor."] Chemotherapy and radiation therapy would kill tumor cells and reduce tumor size. [C. "It prevents blood clots in legs."] Hospitalized clients and clients with malignancy are at higher risk for venous thromboembolism. These clients would benefit from anticoagulation (eg, heparin, enoxaparin, rivaroxaban, apixaban). [D. "It reduces swelling around the tumor."] 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.

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? A. Check renal function laboratory results B. Flush tube with normal saline, not water C. Stop the feeding for 1 to 2 hoursD. Take the blood pressure (BP)

Correct Answer: C. Stop the feeding for 1 to 2 hours 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. Incorrect Answers: [A. Check renal function laboratory results] 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. [B. Flush tube with normal saline, not water] 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. [D. Take the blood pressure (BP)] 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 is reinforcing teaching to a client with advanced chronic obstructive pulmonary disease who was prescribed oral theophylline. Which client statement indicates that additional teaching is required? A. "I need to avoid caffeinated products." B. "I need to get my blood drug levels checked periodically." C. "I need to report anorexia and sleeplessness." D. "I take cimetidine rather than omeprazole for heartburn."

Correct Answer: D. "I take cimetidine rather than omeprazole for heartburn." 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. Incorrect Answers: [A. "I need to avoid caffeinated products."] Caffeinated products (eg, coffee, cola, chocolate) should be avoided as they would intensify the adverse effects (eg, tachycardia, insomnia, restlessness) of theophylline. [B. "I need to get my blood drug levels checked periodically."] The best way to prevent toxicity is to monitor drug levels periodically and adjust the dose. [C. "I need to report anorexia and sleeplessness."] 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 nurse has received new medication prescriptions for a client admitted with hypertension and an exacerbation of chronic obstructive pulmonary disease. Which prescription should the nurse question? A. Amlodipine B. Codeine C. Ipratropium D. Methylprednisolone

Correct Answer: B. Codeine Codeine is a narcotic analgesic used for acute pain or as a cough suppressant. Depressing the cough reflex can cause an accumulation of secretions in the presence of chronic obstructive pulmonary disease (COPD), leading to respiratory difficulty. In general, sedatives (eg, narcotics, benzodiazepines) can also depress the respiratory center and effort; therefore, they should not be given to clients with respiratory diseases (eg, asthma, COPD). Incorrect Answers: [A. Amlodipine] Calcium channel blockers (eg, amlodipine, nifedipine) are used to treat hypertension and do not worsen bronchoconstriction, unlike beta blockers (eg, metoprolol, atenolol). [C. Ipratropium] Ipratropium (Atrovent) is a short-acting inhaled anticholinergic often used in combination with a short-acting beta-agonist (eg, albuterol) to promote bronchodilation and reduce bronchospasm. [D. Methylprednisolone] Methylprednisolone (Solu-Medrol) is a systemic glucocorticoid that improves respiratory symptoms and overall lung function in clients experiencing an exacerbation of COPD. Educational objective:Codeine is a narcotic medication with antitussive properties that can cause an accumulation of secretions in clients with chronic obstructive pulmonary disease and lead to respiratory distress. Caution is advised when sedatives are prescribed for clients with respiratory diseases.

A client with generalized anxiety disorder has received a new prescription for sertraline. The nurse should reinforce teaching to this client about which possible side effect? A. Constipation B. Sedation C. Sexual dysfunction D. Weight loss

Correct Answer: C. Sexual dysfunction Selective serotonin reuptake inhibitors (SSRIs) are commonly used to treat major depression and anxiety disorders. SSRIs (eg, fluoxetine, paroxetine, citalopram, escitalopram, sertraline) are generally well tolerated except for sexual dysfunction. Clients often underreport this side effect. However, when asked specifically, over 50% of clients taking SSRIs may be experiencing some type of sexual dysfunction. This can be a decrease in sexual desire, arousal, or orgasm and may vary by gender. The nurse should discuss this with the client. The side effect may decrease or cease after a 2- to 4-week waiting period for the therapeutic effect, or the client may be able to switch to a different antidepressant medication (eg, bupropion). Incorrect Answers: [A. Constipation] Constipation is uncommon with SSRIs. Drugs with anticholinergic activity (eg, tricyclic antidepressants such as amitriptyline) may result in constipation or urinary retention. [B. Sedation] Sedation is a common side effect of benzodiazepines (eg, alprazolam, lorazepam, diazepam, and chlordiazepoxide), first generation antihistamines, and narcotic medications. SSRIs may cause insomnia. [D. Weight loss] Weight gain is a common side effect of most SSRIs, especially with long-term therapy. Educational objective:Selective serotonin reuptake inhibitors (eg, fluoxetine, paroxetine, citalopram, escitalopram, sertraline) can cause sexual dysfunction. The client should be encouraged to report this to the health care provider if they are still present 2-4 weeks after treatment initiation.

A client with chronic kidney disease has received a continuous intravenous infusion of heparin for 5 days. The nurse reviews the coagulation studies and the medication administration record. Which prescription would the nurse question? A. Epoetin B. Sodium polystyrene sulfonate C. Vitamin K D. Warfarin

Correct Answer: C. Vitamin K Vitamin K (phytonadione) is a fat-soluble vitamin that is administered as an antidote for warfarin-related bleeding. This medication prescription should be questioned as vitamin K reverses the anticoagulant effect of warfarin, and the client's coagulation studies are in the therapeutic range (aPTT 46-70 sec, INR 2-3). Incorrect Answers: [A. Epoetin] Epoetin (Procrit) is a synthetic hormone that stimulates the production of erythropoietin and is used to treat anemia associated with chronic kidney disease. This is an appropriate prescription. [B. Sodium polystyrene sulfonate] Sodium polystyrene sulfonate (Kayexalate) is a sodium exchange resin administered to reduce elevated serum potassium levels in clients with chronic kidney disease and hyperkalemia. This is an appropriate prescription for this client. [D. Warfarin] Warfarin (Coumadin) is a vitamin K antagonist used for long-term anticoagulation that is started about 5 days before a continuous heparin infusion is discontinued. An overlap of the parenteral and oral anticoagulant is required for about 5 days as this is the time it takes warfarin to reach therapeutic level. This is an appropriate prescription for this client. Educational objective:Anticoagulants stop thrombus formation by interfering with the coagulation cascade. Parenteral heparin and oral warfarin affect the clotting cascade differently; therefore, a 5-day overlap for the 2 drugs is required. This allows warfarin to reach a therapeutic level before the continuous heparin infusion is stopped.

A nurse has reinforced teaching a client who is being discharged on lithium for a bipolar disorder. Which statement by the client indicates a need for further teaching? A. "I need to drink 1-2 liters of fluid daily." B. "I need to have my blood levels checked periodically." C. "I should not limit my sodium intake." D. "I should use ibuprofen for pain relief."

Correct Answer: D. "I should use ibuprofen for pain relief." Lithium is a mood stabilizer most often used to treat bipolar affective disorders. It has a very narrow therapeutic serum range of 0.6-1.2 mEq/L (0.6-1.2 mmol/L). Levels >1.5 mEq/L (1.5 mmol/L) are considered toxic. Lithium toxicity usually occurs with the following: 1. Dehydration 2. Decreased renal function (eg, elderly clients) 3. Diet low in sodium 4. Drug-drug interactions (nonsteroidal anti-inflammatory drugs [NSAIDs] and thiazide diuretics.) Lithium is cleared renally. Even a mild change in kidney function (as seen in elderly clients) can cause serious lithium toxicity. Therefore, drugs that decrease renal blood flow (eg, NSAIDs) should be avoided. Acetaminophen would be a better choice for pain relief. Incorrect Answers: [A. "I need to drink 1-2 liters of fluid daily."] Sodium, water, and lithium are normally filtered by the kidneys. Restriction of dietary sodium /water or dehydration signals renal sodium and water reabsorption which will also increase lithium absorption, resulting in toxicity. Therefore, clients should never restrict their sodium or water intake while taking lithium; instead, they should maintain a consistent sodium intake. [B. "I need to have my blood levels checked periodically."] Blood should be drawn frequently to monitor for therapeutic lithium levels and toxicity. [C. "I should not limit my sodium intake."] Sodium, water, and lithium are normally filtered by the kidneys. Restriction of dietary sodium /water or dehydration signals renal sodium and water reabsorption which will also increase lithium absorption, resulting in toxicity. Therefore, clients should never restrict their sodium or water intake while taking lithium; instead, they should maintain a consistent sodium intake. Educational objective:Dehydration, decreased renal function, diet low in sodium, and drug-drug interactions (eg, NSAIDs and thiazide diuretics) can cause lithium toxicity.

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? A. "I may experience flushing but will continue to take the medication as prescribed." B. "I should lie down before taking the medication." C. "I should not swallow the tablet." D. "I will wait to call 911 if I don't experience relief after the third tablet."

Correct Answer: D. "I will wait to call 911 if I don't experience relief after the third tablet." 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. 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. If using a spray, the client should not inhale it but direct it onto/under the tongue instead. Incorrect Answers: [A. "I may experience flushing but will continue to take the medication as prescribed."] Headache and flushing are common side effects of NTG due to systemic vasodilation. [B. "I should lie down before taking the medication."] The client should lie down before taking the pill as it can cause dizziness from possible orthostatic hypotension. [C. "I should not swallow the tablet."] Sublingual tablets should never be swallowed. 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 reinforcing teaching about trazodone to an elderly client with depression. Which statement by the client indicates that additional teaching is needed? A. "I will call the health care provider if I develop a prolonged erection." B. "I will get up slowly, in stages, from supine to standing." C. "I will take this medication at night to avoid daytime drowsiness." D. "It is okay to drink 2 glasses of wine at night."

Correct Answer: D. "It is okay to drink 2 glasses of wine at night." Trazodone (Oleptro), a serotonin modulator, is used to treat major depressive disorder. In addition to affecting serotonin levels, the drug blocks alpha and histamine (H1) receptors. Blockade of alpha receptors can cause orthostatic hypotension similar to that from other alpha blockers (eg, terazosin, tamsulosin) used to treat benign prostatic hyperplasia. Blockade of H1 receptors leads to sedation. Therefore, this drug is particularly effective in treating insomnia associated with depression. However, concurrent intake of other medications or substances that cause sedation can be detrimental; these include benzodiazepines (eg, alprazolam, lorazepam, diazepam), sedating antihistamines (eg, chlorpheniramine, hydroxyzine), and alcohol. Incorrect Answers: [A. "I will call the health care provider if I develop a prolonged erection."] Priapism is a known serious side effect of trazodone. A client with an erection lasting several hours should go to the hospital. [B. "I will get up slowly, in stages, from supine to standing."] Clients should be advised to rise from supine to standing slowly, in stages, due to the risk of orthostatic hypotension. [C. "I will take this medication at night to avoid daytime drowsiness."] The drug should be taken at bedtime to avoid daytime sedation. Educational objective:Trazodone modulates serotonin levels in the brain. It also blocks alpha and H1 receptors, leading to orthostatic hypotension and sedation, respectively. Priapism, although rare, is another serious side effect.

A client with chronic heart failure is being discharged home on furosemide and supplementary potassium chloride tablets. Which instructions related to the potassium supplement should the nurse reinforce to the client? A. "A diet rich in protein and vitamin D will help with absorption." B. "If the tablet is too large to swallow, crush and take it in applesauce or pudding." C. "Potassium tablets should be taken on an empty stomach." D. "Take it with plenty of water and sit upright for a period of time afterward."

Correct Answer: D. "Take it with plenty of water and sit upright for a period of time afterward." Furosemide is considered a "potassium-wasting" diuretic, meaning that a client could experience loss of potassium. A low potassium level in a client with heart failure could be dangerous due to possible life-threatening dysrhythmias and increased susceptibility to toxicity from digoxin (if taken). Therefore, potassium supplementation is needed for this client. Potassium should be taken with plenty of water (at least 4 ounces), and the client should sit upright for a period of time after ingestion. This prevents the tablet from lodging in the esophagus, which can cause erosion and pill-induced esophagitis. Pill-induced esophagitis is also common with tetracyclines (eg, doxycycline) and bisphosphonates ("dronates": alendronate, ibandronate, pamidronate, risedronate), and clients taking these medications should be given similar instructions. Incorrect Answers: [A. "A diet rich in protein and vitamin D will help with absorption."] A diet rich in protein and vitamin D will help with calcium supplement absorption. [B. "If the tablet is too large to swallow, crush and take it in applesauce or pudding."] Some potassium tablets are sustained-release and should not be crushed. The nurse would need to verify the type of tablet the client is taking before giving this instruction. [C. "Potassium tablets should be taken on an empty stomach."] Potassium should be taken with a meal or immediately following a meal to prevent gastric upset. Educational objective:The nurse should teach the client to take potassium tablets with plenty of water (at least 4 ounces) and to sit upright after ingestion to prevent pill-induced esophagitis. Potassium should also be taken with meals or immediately after a meal to prevent gastric upset. Sustained-release tablets should not be crushed.

A 21-year-old client is being evaluated in the outpatient psychiatric clinic after starting isocarboxazid 2 weeks ago. Which of the client's statements needs to be addressed first? A. "I am not sleeping well at night and would like a sleeping aid." B. "I do not know how well I will do on this restricted diet." C. "I have been having quite a bit of nausea and constipation." D. "This medicine is not working; I am so tired of being depressed."

Correct Answer: D. "This medicine is not working; I am so tired of being depressed." Commonly used monoamine oxidase inhibitors (MAOIs) include isocarboxazid, phenelzine, and tranylcypromine. These first-generation antidepressants are used only for resistant depression due to serious adverse affects. These medications inhibit the enzyme that breaks up norepinephrine, serotonin, and dopamine, thereby increasing their availability in the body. Clients taking MAOIs or other antidepressants are at increased risk for suicidal ideation, particularly children, adolescents, and young adults. The risk of suicidal thoughts can be more prevalent when starting the medication or with dose increases. Feelings of hopelessness or despair must be evaluated to assess if suicidal ideation or thoughts of self-harm are present Incorrect Answers: [A. "I am not sleeping well at night and would like a sleeping aid."] MAOIs should be administered in the morning, as sleep dysfunction is common. This client statement should prompt a discussion of current medication habits, but is not the priority. [B. "I do not know how well I will do on this restricted diet."] Clients taking MAOIs need to avoid tyramine-containing foods (eg, cheese, overripe fruit, liquor, beef/chicken liver, fermented products) due to risk of hypertensive crisis. A medication change might be considered if a client is unable to adhere to the restrictions, but would not be priority. [C. "I have been having quite a bit of nausea and constipation."] Nausea and constipation are adverse effects of MAOIs. Although strategies for management of adverse effects should be discussed, this is not priority. Educational objective:MAOIs and other antidepressants are associated with increased risk of suicidal ideation during the first few weeks of treatment. Clients taking MAOIs need to avoid tyramine-containing foods due to risk of hypertensive crisis.

The parent of a child diagnosed with attention-deficit hyperactivity disorder (ADHD), predominantly inattentive type, says to the nurse, "I hate the idea of my child taking a drug that's a stimulant. How will I know that the methylphenidate is even working?" Which is the best response by the nurse? A. "Methylphenidate is generally a safe and effective drug for children with ADHD." B. "Methylphenidate will increase the levels of neurotransmitters in your child's brain." C. "You should see your child's school grades improve." D. "Your child should be able to more easily complete school assignments and other tasks."

Correct Answer: D. "Your child should be able to more easily complete school assignments and other tasks." Although methylphenidate (eg, Ritalin, Concerta) is classified as a stimulant, in children with ADHD it improves attention, decreases distractibility, helps maintain focus on an activity, and improves listening skills. For many years, the effects of methylphenidate in children were labeled as paradoxical. Now, research has shown that methylphenidate significantly increases levels of dopamine in the central nervous system (CNS) that lead to stimulation of the inhibitory system of the CNS. Methylphenidate works quickly; symptom relief is often seen after the first dose. Incorrect Answers: [A. "Methylphenidate is generally a safe and effective drug for children with ADHD."] This is a true statement; methylphenidate is generally safe for most children, adolescents, and adults. Methylphenidate can cause adverse reactions, but these affect a very small percentage of users. However, this response does not address the parent's question about how the drug works. [B. "Methylphenidate will increase the levels of neurotransmitters in your child's brain."] This is a true statement but does not give the parent information about the benefits of methylphenidate. In addition, it contains language that most clients would not understand. [C. "You should see your child's school grades improve."] A child's school grades may improve due to the benefits of methylphenidate. This would be seen over time as a secondary benefit; the immediate therapeutic effects are often observed with the first dose. Educational objective:The therapeutic effects of methylphenidate can be observed very quickly in children with ADHD. Methylphenidate improves attention, decreases distractibility, helps maintain focus on an activity, and improves listening skills.

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

Correct Answer: D. Encourage client to report any fever or sore throat 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: 1. Oral care - use a small, soft-bristled toothbrush or a warm mouth wash 2. Use lukewarm water; avoid beverages or food that are too hot or cold 3. Room should be kept at an even and moderate temperature 4. Avoid rubbing or facial massage. Use cotton pads to wash the face if necessary. 5. Have a soft diet with high calorie content; avoid foods that are difficult to chew. Chew on the unaffected side of the mouth. Incorrect Answers: [A. Encourage client to drink cold beverages] Lukewarm water should be used; beverages that are too hot or too cold should be avoided. [B. Encourage client to eat a high-fiber diet] 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. [C. Encourage client to perform facial massage] 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.

A practical nurse in the cardiac intermediate care unit is assisting the registered nurse caring for a client with acute decompensated heart failure. The client also has a history of coronary artery disease and peripheral vascular disease. The practical nurse is preparing to administer medications. Based on the assessment data, the nurse should question which medication? Vital Signs Blood pressure: 110/60 mm Hg Heart rate: 80/min Respirations: 22/min O2 saturation of SpO2: 90% on room air Assessment Data Crackles in middle & lower lung fieldsModerate jugular venous distension3+ pedal edema Medications Aspirin: 81 mg by mouth, daily Metoprolol: 50 mg by mouth, twice a day Furosemide: 40 mg IV, daily Atorvastatin: 20 mg by mouth, daily A. Aspirin B. Atorvastatin C. Furosemide D. Metoprolol

Correct Answer: D. Metoprolol Beta blockers, or "lols" (metoprolol, carvedilol, bisoprolol, atenolol), are the mainstay of therapy for clients with chronic heart failure as they improve survival rates for both systolic and diastolic heart failure. Beta blockers work by decreasing the effects of renin and inhibiting the sympathetic nervous system response (increase in heart rate) that stresses the failing heart. However, in certain situations, beta blockers can worsen heart failure symptoms by decreasing normal compensatory sympathetic nervous system responses and myocardial contractility. In this client with acute decompensated heart failure (ADHF), marginally low blood pressure (BP), crackles in the lungs, low oxygen saturation, jugular venous distension (JVD), and peripheral edema, the administration of beta blockers can cause the client to further deteriorate. The client may be able to take beta blockers at low doses after the client is stabilized and ADHF is resolved with diuresis. Incorrect Answer: [A. Aspirin] Aspirin is contraindicated if the client has evidence of bleeding. Statins are contraindicated if there is evidence of severe liver or muscle injury. It is appropriate to administer both of these medications to this client who has coronary artery disease and peripheral vascular disease. [B. Atorvastatin] Aspirin is contraindicated if the client has evidence of bleeding. Statins are contraindicated if there is evidence of severe liver or muscle injury. It is appropriate to administer both of these medications to this client who has coronary artery disease and peripheral vascular disease. [C. Furosemide] This client has crackles, JVD, and peripheral edema, indicating the need for furosemide (Lasix). Therefore, the nurse should continue to monitor the client's BP when furosemide is administered as it can lower BP. When excess fluid is removed through diuresis, the heart will be able to pump more effectively, which will increase cardiac output and BP. Educational objective:The nurse should question the administration of beta blockers in a client with symptoms of acute decompensated heart failure due to the possibility of further clinical deterioration. Beta blockers are most useful for chronic heart failure.

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? 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 A. Bruising easily, especially on the arms B. Fatigue C. Feeling depressed D. Muscle cramps in the legs

Correct Answer: D. Muscle cramps in the legs 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. 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. Incorrect Answers: [A. Bruising easily, especially on the arms] 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). [B. Fatigue] 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. [C. Feeling depressed] 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 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? A. Bradycardia B. Hypokalemia C. Nephrotoxicity D. Ototoxicity

Correct Answer: D. Ototoxicity 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 Incorrect Answers: [A. Bradycardia] 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. [B. Hypokalemia] 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. [C. Nephrotoxicity] 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.

A client taking morphine sulfate for acute pain has not voided in 6 hours. The nurse suspects the client has developed urinary retention. What is the priority nursing intervention? A. Ask if the client needs to use the bedpan B. Assess the client's fluid intake C. Assess the client's skin turgor D. Palpate the client's suprapubic area

Correct Answer: D. Palpate the client's suprapubic area Opioids (eg, morphine sulfate), anticholinergic medications, and tricyclic antidepressants can cause urinary retention; they increase bladder sphincter tone and/or relax bladder muscle. The nurse should assess the client's suprapubic area to determine if the client has urinary retention. If the area is distended and dull to percussion, the nurse should proceed with interventions. Incorrect Answers: [A. Ask if the client needs to use the bedpan] While asking if a bedpan is needed is an important nursing intervention, it does not aid in the assessment of urinary retention. [B. Assess the client's fluid intake] Gathering assessment data indicating the presence of urinary retention is necessary prior to other interventions. The nurse should assess for fluid intake after assessing bladder distension. [C. Assess the client's skin turgor] The client's skin turgor is assessed after the nurse checks for urinary retention and fluid intake. There is no need to assess skin turgor until other indicators of adequate fluid intake are reviewed. Educational objective:Assessing the client's suprapubic area is the priority nursing action when urinary retention is suspected. Interventions are performed after a problem is identified and its cause is determined. Urinary retention is an expected side effect of opioid medications.

A client with a chronic kidney disease has blood laboratory values as shown in the exhibit. The nurse administers sodium polystyrene sulfonate by mouth per the health care provider's prescription. The nurse evaluates that the therapy is effective when which value is noted on the follow-up results? Laboratory Results Creatinine: 4.5 mg/dL (398 µmol/L) Potassium: 5.9 mEq/L (5.9 mmol/L) Calcium: 6.3 mg/dL (1.57 mmol/L) Phosphorous: 5.2 mg/dL (1.68 mmol/L) A. Calcium 7.4 mg/dL (1.85 mmol/L) B. Creatinine 4.0 mg/dL (353 µmol/L) C. Phosphorus 3.9 mg/dL (1.26 mmol/L) D. Potassium 4.9 mEq/L (4.9 mmol/L)

Correct Answer: D. Potassium 4.9 mEq/L (4.9 mmol/L) The client with kidney disease is at risk for both hyperkalemia (normal potassium 3.5-5.0 mEq/L [3.5-5.0 mmol/L]) and hyperphosphatemia due to reduced glomerular filtration rate. Untreated hyperkalemia may cause life-threatening cardiac arrhythmias. Sodium polystyrene sulfonate (Kayexalate) can be used to treat hyperkalemia. It works in the gastrointestinal tract to trade sodium for potassium, thereby eliminating excess potassium through the stool and reducing the serum potassium level. Incorrect Answers: [A. Calcium 7.4 mg/dL (1.85 mmol/L)] Serum calcium levels (normal 8.6-10.2 mg/dL [2.15-2.55 mmol/L]) may decrease with diminished renal function due to lower activation of vitamin D and subsequent impaired gut absorption of calcium. Calcium supplements are used to increase the serum calcium level. Sodium polystyrene sulfonate does not affect the serum calcium level. [B. Creatinine 4.0 mg/dL (353 µmol/L)] Sodium polystyrene sulfonate does not affect serum creatinine levels. Creatinine levels may decrease after dialysis. [C. Phosphorus 3.9 mg/dL (1.26 mmol/L)] Phosphorus is also not filtered with kidney injury and the levels increase in serum (normal 2.4-4.4 mg/dL [0.78-1.42 mmol/L]). Phosphate binders (calcium acetate/carbonate) administered orally eliminate phosphorus through stool. Sodium polystyrene sulfonate does not bind phosphorus. Educational objective:Clients with kidney disease are at risk for hyperkalemia. Sodium polystyrene sulfonate (Kayexalate) works in the gastrointestinal tract to trade sodium for potassium, thereby eliminating excess potassium through the stool and reducing the serum potassium level.

A nurse is discharging a client who is receiving lithium for treatment of a bipolar disorder. It is most important for the nurse to reinforce which instruction to the client? A. Avoid a high-potassium diet B. Exercise regularly and maintain a high-fiber diet C. Maintain oral hygiene D. Report excessive urination and increased thirst

Correct Answer: D. Report excessive urination and increased thirst Lithium is a mood stabilizer most often used to treat bipolar affective disorders. It has a narrow therapeutic index (0.6-1.2 mEq/L). Risk factors for lithium toxicity include dehydration, decreased renal function (in the elderly), diet low in sodium, and drug-drug interactions (eg, nonsteroidal anti-inflammatory drugs [NSAIDS] and thiazide diuretics). Chronic toxicity can result in: 1. Neurologic manifestations - ataxia, confusion or agitation, and neuromuscular excitability (tremor, myoclonic jerks) 2. Nephrogenic diabetes insipidus - polyuria and polydipsia (increased thirst) Clients should be educated about monitoring for these symptoms and obtaining serum lithium levels at regular intervals. Incorrect Answers: [A. Avoid a high-potassium diet] Dietary potassium should be avoided when taking drugs such as potassium-sparing diuretics (eg, spironolactone, triamterene, amiloride) and angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. [B. Exercise regularly and maintain a high-fiber diet] Regular exercise and a high-fiber diet can prevent constipation, which is not a known side effect of lithium. Opioids, anticholinergics, and iron supplements are medications that cause constipation. [C. Maintain oral hygiene] Good oral hygiene is ideal for every client but is not specially indicated for those taking lithium. Clients taking phenytoin should maintain oral hygiene to prevent gingival hyperplasia. Educational objective:Risk factors for lithium toxicity include dehydration, decreased renal function, low-sodium diet, and drug-drug interactions (eg, NSAIDs and thiazide diuretics). Chronic toxicity manifests with neurologic symptoms (ataxia, confusion or agitation, and neuromuscular excitability) and/or diabetes insipidus (polyuria and polydipsia).

The nurse reviews the analgesia prescriptions for assigned clients. The nurse should question the health care provider about which prescription? A. Lidocaine 5% patch over intact skin for a client with chronic postherpetic neuralgia who reports intolerable, persistent, burning pain B. 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 C. 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 D. Transdermal fentanyl patch for a client who is 1 day postoperative above-the-knee amputation and reports intermittent, throbbing stump pain

Correct Answer: D. Transdermal fentanyl patch for a client who is 1 day postoperative above-the-knee amputation and reports intermittent, throbbing stump pain 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. Incorrect Answers: [A. Lidocaine 5% patch over intact skin for a client with chronic postherpetic neuralgia who reports intolerable, persistent, burning pain] 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. [B. 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] 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. [C. 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] 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 24-year-old female client is prescribed isotretinoin for severe cystic acne. Which instruction is most important for the nurse to reinforce? A. Apply lubricating eye drops when wearing contacts B. Do not break, crush, or chew capsules C. Use sunscreen routinely during therapy D. Use two forms of contraception consistently

Correct Answer: D. Use two forms of contraception consistently Isotretinoin (Accutane, Amnesteem) is prescribed for severe, disfiguring nodular acne that has been unresponsive to other therapies (eg, antibiotics). It works by decreasing sebum secretion and shrinking sebaceous glands (often permanently); one course of isotretinoin is typically very effective. However, isotretinoin is a teratogenic medication known to cause serious harm to a fetus if taken during pregnancy. Females prescribed isotretinoin must participate in a risk management program. Requirements generally include two negative pregnancy tests before initiating isotretinoin and two forms of contraception (ie, use 1 month prior to starting isotretinoin, during treatment, and for 1 month after discontinuing isotretinoin). Refills can be only obtained after a negative pregnancy test (performed monthly during therapy). Blood donation is also discouraged for both males and females during therapy. Incorrect Answers: [A. Apply lubricating eye drops when wearing contacts] Dryness of the eyes, mouth, and skin are common side effects. Lubricating eye drops may be needed to wear contacts. Some clients are unable to wear contacts while taking isotretinoin. [B. Do not break, crush, or chew capsules] Capsules should be swallowed whole with ≥8 oz of water or other fluid. Capsules should not be broken, crushed, or chewed as the contents could irritate the esophagus. [C. Use sunscreen routinely during therapy] Isotretinoin sometimes causes photosensitivity. The nurse should teach the client to use sunscreen routinely. Educational objective:Isotretinoin is a teratogenic medication known to cause serious harm to a fetus if taken during pregnancy. The client must use two forms of contraception prior to, during, and after therapy. Negative pregnancy tests are required before initiating therapy and prior to refills.

A pediatric client is diagnosed with an acute asthma attack. Which immediate-acting medications should the nurse prepare to administer to this client? Select all that apply. A. Albuterol B. Ibuprofen C. Ipratropium D. Montelukast E. Tobramycin

Correct Answers: A and C Asthma is an inflammatory condition in which the smaller airways constrict and become filled with mucus. Breathing, especially on expiration, becomes more difficult. Pharmacologic treatment for acute asthma includes the following: 1. Oxygen to maintain saturation >90% 2. High-dose inhaled short-acting beta agonist (albuterol or levalbuterol) and anticholinergic agent (ipratropium) nebulizer treatments every 20 minutes 3. Systemic corticosteroids (Solu-Medrol) to control the underlying inflammation. These will take some time to show an effect. Incorrect Answers: [B. Ibuprofen] Nonsteroidal anti-inflammatory agents (eg, ibuprofen, naproxen, indomethacin) and aspirin can worsen asthma symptoms in some clients and are not indicated unless necessary. [D. Montelukast] Montelukast (Singulair) is a leukotriene (chemical mediator of inflammation) inhibitor and is not used to treat acute episodes. It is given orally in combination with beta agonists and corticosteroid inhalers (eg, fluticasone, budesonide) to provide long-term asthma control. [E. Tobramycin] Tobramycin is an aminoglycoside antibiotic. It is used in aerosolized form to treat cystic fibrosis exacerbation when Pseudomonas is the predominant organism causing lung infection. Educational objective:Inhaled corticosteroids and leukotriene inhibitors are typically used to achieve and maintain control of inflammation for long-term management of asthma. Quick-relief medications (eg, albuterol, ipratropium) are used to treat acute symptoms and exacerbations.

The nurse is caring for a postoperative client who is unresponsive to painful stimuli and is given naloxone. Within 5 minutes, the client can be roused and responds to verbal commands. One hour later, the client is again difficult to rouse, with minimal response to physical stimuli. Which actions does the nurse anticipate? Select all that apply. A. Administration of oxygen B. Administration of a 2nd dose of naloxone C. Discontinuation of pain medication D. Initiation of a rapid response or code teamE. Monitoring of respiratory rate

Correct Answers: A, B, and E A client in the postoperative period who is unresponsive to painful stimuli is likely still under the effects of opioid medications used during anesthesia. Naloxone (Narcan), an opioid antagonist, will temporarily reverse the effects of any opioid medications. However, the half-life of naloxone is shorter than that of most opioid medications (ie, the effect typically wears off in 1-2 hours), and a second dose may be required. The nurse should make frequent observations of the client's respiratory rate and administer prescribed oxygen for respiratory support. The registered nurse should be notified to fully assess the client and to administer a second dose of naloxone as prescribed (either a one-time dose or continuous drip). Incorrect Answers: [C. Discontinuation of pain medication] A postoperative client will likely still need pain medication due to the trauma from surgery. Pain should be managed with nonopioids (eg, acetaminophen, nonsteroidal anti-inflammatory drugs) if needed. [D. Initiation of a rapid response or code team] 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. Educational objective:Naloxone is usually prescribed as needed in postoperative clients for over-sedation related to opioid use. The nurse should monitor clients who are given naloxone with the understanding that the opioid antagonist has a shorter half-life than that of most of the opioids it is meant to counteract. As a result, a second dose of naloxone may be necessary.

The nurse prepares to reinforce teaching for a client with latent tuberculosis who is prescribed oral isoniazid. Which instructions should the nurse include? Select all that apply. A. Avoid drinking alcohol B. Expect body fluids to change color to red C. Report yellowing of skin or sclera D. Report numbness and tingling of extremities E. Take with aluminum hydroxide to prevent gastric irritation

Correct Answers: A, C, and D 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 · 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: o Hepatoxicity (eg, scleral and skin jaundice, vomiting, dark urine, fatigue) o Peripheral neuropathy (eg, numbness, tingling of extremities) Incorrect Answers: [B. Expect body fluids to change color to red] 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. [E. Take with aluminum hydroxide to prevent gastric irritation] 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 registered nurse and practical nurse are conducting a workshop on contraceptive methods for a group of outpatient clients. Which instructions should the nurses include when discussing combined estrogen-progestin oral contraceptives? Select all that apply. A. Consult the health care provider (HCP) if you experience leg pain or swelling B. Discontinue contraceptives if you experience spotting between menses C. Do not smoke while taking combined contraceptives D. Immediately report any breast tenderness to the HCP E. Seek immediate medical treatment if you experience vision loss

Correct Answers: A, C, and E The use of hormonal contraception (ie, estrogen with or without progestin) places women at a 2- to 4-fold increased risk for developing blood clots due to resulting hypercoagulability. Hormone levels vary among contraceptives, and higher levels of hormone content correlate to an increased risk of adverse thrombotic events (eg, stroke, myocardial infarction). Clients who are prescribed oral contraceptive pills (OCPs) containing estrogen should be educated on potential warning signs (eg, chest pain, vision loss, severe leg pain). In addition, clients should be instructed not to smoke while taking combined OCPs due to an increased risk of blood clots. Incorrect Answers: [B. Discontinue contraceptives if you experience spotting between menses] Irregular bleeding and spotting between menses are common side effects of combined OCPs. These side effects may be bothersome but are not serious and may improve within 3 months of initiation. If the client cannot tolerate side effects, a different OCP may be considered. [D. Immediately report any breast tenderness to the HCP] Clients should be counseled that breast tenderness is a common side effect of combined OCPs and does not warrant emergent reporting to the health care provider. Educational objective:Clients who are prescribed oral estrogen contraceptives (with or without progestin) have an increased risk for developing blood clots. Clients should be educated on warning signs to report to the health care provider (eg, severe leg pain, vision loss) versus common side effects (eg, breast tenderness, spotting).

A client with a history of degenerative arthritis is being discharged home following exacerbation of chronic obstructive pulmonary disease. After reviewing the discharge medications, the nurse should reinforce which of the following topics with the client? Discharge Medications Albuterol: 2 puffs every 4-6 hours as needed Prednisone: 40 mg PO daily Naproxen: 220 mg PO twice daily Tiotropium: 1 capsule inhaled daily A. Dryness of the mouth and throat may occur B. Ringing in the ears is an expected, transient side effect C. The albuterol canister should not be shaken before use D. The health care provider should be notified if stools are black and tarry E. Tiotropium capsules should not be swallowed

Correct Answers: A, D, and E A common side effect of tiotropium (Spiriva) and other anticholinergics (eg, ipratropium, benztropine) is xerostomia (dry mouth) due to the blockade of muscarinic receptors of the salivary glands, which inhibits salivation. Sugar-free candies or gum may be used to alleviate dry mouth and throat. Tiotropium capsules should not be swallowed. These capsules are placed inside the inhaler device, and the capsule is pierced, allowing the client to inhale its contents. Glucocorticoids (eg, prednisone), when taken in combination with aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs) such as naproxen, can increase the risk of gastrointestinal ulceration and bleeding. The client should report black, tarry stools (ie, melena) to the health care provider as they could indicate gastrointestinal bleeding. Incorrect Answers: [B. Ringing in the ears is an expected, transient side effect] Tinnitus (ie, ringing in the ears) is an uncommon side effect of NSAID (eg, naproxen) use. Tinnitus is commonly associated with toxicity related to salicylate-containing NSAIDs (eg, aspirin) or aminoglycosides (eg, gentamicin, neomycin, tobramycin); its onset should be reported by a client taking these medications. The medication may need to be discontinued to prevent permanent hearing loss. [C. The albuterol canister should not be shaken before use] The albuterol canister should be shaken prior to inhalation to ensure appropriate medication delivery. Educational objective:The nurse should teach the client taking glucocorticoids with aspirin or nonsteroidal anti-inflammatory drugs about the risk for gastrointestinal bleeding or ulceration. Xerostomia is a common side effect of anticholinergic drugs that can be alleviated with sugar-free candies or gum. Tiotropium capsules should not be swallowed.

The nurse is conducting intake interviews at the clinic. Which client situations would require the nurse to intervene? Select all that apply. A. Client with iron deficiency anemia takes iron supplements with milk B. Client takes levothyroxine early in the morning on an empty stomach C. Client taking phenazopyridine for urine infection states that the urine has turned orange D. Client taking metronidazole mentions going to a wine-tasting party tonight E. Client with closed-angle glaucoma takes over-the-counter diphenhydramine for a cold

Correct Answers: A, D, and E Iron is absorbed better on an empty stomach; ascorbic acid (vitamin C), such as found in citrus fruits and juices, increases the absorption of iron. However, milk products decrease iron absorption and should be avoided. Metronidazole (Flagyl) is used to treat trichomoniasis and amebiasis. Consuming alcohol while taking the medication may elicit a disulfiram (Antabuse)-like reaction. Alcohol should be avoided for at least 48 hours after treatment is completed. Many antihistamines also have anticholinergic effects. Anticholinergics have an antimuscarinic effect that can increase intraocular pressure and are therefore contraindicated in closed-angle glaucoma. Other contraindications include urinary retention (benign prostatic hyperplasia) and bowel obstruction related to the anticholinergic drug's effect on the smooth muscle in the urinary and gastrointestinal tract. Incorrect Answers: [B. Client takes levothyroxine early in the morning on an empty stomach] Enteral nutrition decreases levothyroxine absorption; as a result, it should be taken early in the morning on an empty stomach (at least 30 minutes before food intake). [C. Client taking phenazopyridine for urine infection states that the urine has turned orange] Phenazopyridine (Pyridium) is used as a local anesthetic in the treatment of urinary tract infection. The azo dye turns the urine an orange-red color. The client needs to be reassured that this is an expected result and could stain clothing. Educational objective:Clients taking metronidazole (Flagyl) should avoid alcohol. Those with glaucoma or urinary retention should avoid anticholinergic drugs. Oral iron is better absorbed on an empty stomach and with vitamin C. Phenazopyridine (Pyridium) will turn urine an orange-red color.

The health care provider has just prescribed tetracycline for an adolescent with acne vulgaris. The client takes oral contraceptive pills. The nurse should reinforce teaching about which topics? Select all that apply. A. Not taking tetracycline with dairy products B. Taking tetracycline at bedtime C. Taking tetracycline with food. D. Using additional contraceptive techniques E. Using sunblock

Correct Answers: A, D, and E The following should be taught to clients taking tetracyclines (eg, tetracycline, doxycycline, minocycline): 1. Take on an empty stomach - for optimum absorption, tetracyclines should be taken 1 hour before or 2 hours after meals. 2. Avoid antacids or dairy products - tetracyclines should not be taken with iron supplements, antacids, or dairy products as they bind with the drug and decrease its absorption. 3. Take with a full glass of water - tetracyclines can cause pill-induced esophagitis and gastritis; the risk can be reduced by taking with a full glass of water and remaining upright after pill ingestion 4. Photosensitivity - severe sunburn can occur with tetracycline. The client should use sunblock. Medications such as tetracycline and rifampin can decrease the effectiveness of oral contraceptives; additional contraceptive techniques will be needed. Tetracycline taken at bedtime has been associated with esophageal irritation and stricture development as it increases reflux of the gastric contents into the esophagus. This can be prevented by taking the medicine with plenty of water and during the day when upright. Educational objective:Tetracyclines should be taken 1 hour before or 2 hours after meals with plenty of water. They should not be taken with dairy products or within 2 hours of taking antacids. Clients should use sunblock due to photosensitivity and plan to use additional contraceptive techniques.

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

Correct Answers: A. "I am looking forward to our summer vacation at the beach." 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. Incorrect Answers [B. "I plan to eat more fruits and vegetables to prevent constipation."] Increasing dietary intake of fluids and bulk-forming foods (eg, fruits, vegetables) promotes normal bowel function and prevents constipation. [C. "I should not drive until I know how this drug affects me."] 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. [D. "I will drink at least 6-8 glasses of water daily."] Increasing dietary intake of fluids and bulk-forming foods (eg, fruits, vegetables) promotes normal bowel function and prevents constipation. 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 clinic nurse is preparing to administer an allergy immunotherapy injection to a client recently initiated on the therapy. Which statement by the client indicates a need for further teaching? A. "I can leave right after the shot as I didn't have a reaction last time." B. "I will be back in a week for my next allergy shot." C. "I will let the doctor know if I get any itchy hives tonight." D. "It is okay if I have some redness at the injection site tonight."

Correct Answers: A. "I can leave right after the shot as I didn't have a reaction last time." Allergy immunotherapy injections (allergy shots) trigger an increase in the body's production of specific immunoglobulins to reduce the client's allergy symptoms when exposed to specific allergens (eg, pollen, cat dander, dust mite). Small doses of the allergen(s) are injected subcutaneously on a client-specific schedule. Rarely, allergy shots may induce an immediate and potentially fatal anaphylactic reaction. The client must remain at the facility for 30 minutes after an injection so the nurse can monitor for severe systemic reactions (eg, respiratory failure, tongue and throat swelling). Incorrect Answers: [B. "I will be back in a week for my next allergy shot."] For the first few months, allergy shots are typically given every week, with a dose increase at every injection until the target maintenance dose is reached. The maintenance dose is then given every few weeks for 3-5 years. [C. "I will let the doctor know if I get any itchy hives tonight."] Although rare, the client may have a mild, systemic allergic reaction (eg, hives, itching, facial swelling, mild asthma) up to 24 hours after an allergy shot. The occurrence of any systemic reaction should be reported to the health care provider as the next dose increase may need to be delayed. [D. "It is okay if I have some redness at the injection site tonight."] It is common to have a localized reaction to an allergy shot. The nurse should reinforce teaching that some redness and swelling at the injection site is expected and not life-threatening. Educational objective:A client receiving an allergy shot is at risk for anaphylaxis immediately after the injection, so the client must remain at the facility and be monitored for 30 minutes after the injection.

The clinic nurse is reinforcing teaching to a client who has been 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. A. "Apply the patch when the ship starts moving and not before." B. "Dispose of the patch out of reach of children and pets." C. "Ensure that the old patch is removed before applying a new one." D. "Place the patch on a hairless, clean, dry area behind the ear." E. "Wash your hands with soap and water after handling the patch."

Correct Answers: B, C, D, and E 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. Clients should be instructed to: · Apply the patch ≥4 hours before travel to allow for absorption and medication onset. Transdermal patches have a slower onset but 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 overdose. · Dispose of the patch out of reach of children and pets to avoid accidental ingestion. · Wash hands with soap and water after handling the patch to avoid inadvertent drug absorption or contact with the eyes. 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.

An 80-year-old client is prescribed codeine for a severe cough. The home health nurse is reinforcing instructions on how to prevent the common adverse effects associated with codeine. Which client statements indicate an understanding of how to prevent them? Select all that apply. A. "I'll be sure to apply sunscreen if I go outside." B. "I'll drink at least 8 glasses of water a day." C. "I'll drink decaffeinated coffee so I can sleep at night." D. "I'll sit on the side of my bed for a few minutes before getting up." E. "I'll take my medicine with food."

Correct Answers: B, D, and E Codeine is an opioid drug prescribed as an analgesic to treat mild to moderate pain and as an antitussive to suppress the cough reflex. Although the antitussive dose (10-20 mg orally every 4-6 hours) is lower than the analgesic dose, clients can still experience the common adverse effects (eg, constipation, nausea, vomiting, orthostatic hypotension, dizziness) associated with the drug. Codeine decreases gastric motility, resulting in constipation. Increasing fluid intake and fiber in the diet and taking stool softeners or laxatives are effective measures to prevent constipation. Changing positions slowly is effective in preventing the orthostatic hypotension associated with codeine, especially in older clients. Taking the medication with food is effective in preventing the gastrointestinal irritation (eg, nausea, vomiting) associated with codeine. Incorrect Answers: [A. "I'll be sure to apply sunscreen if I go outside."] Wearing sunscreen while outside and avoiding caffeine are not indicated to prevent adverse effects related to codeine use. [C. "I'll drink decaffeinated coffee so I can sleep at night."] Wearing sunscreen while outside and avoiding caffeine are not indicated to prevent adverse effects related to codeine use. Educational objective:The common adverse effects of codeine, an opioid drug, include constipation, nausea, vomiting, orthostatic hypotension, and dizziness. Interventions to help prevent these include increasing fluid intake and bulk in the diet, laxatives, taking the medication with food, and changing position slowly.

A client at 9 weeks gestation arrives at the clinic for an initial obstetric appointment. The nurse reviews the client's medical history and obtains a list of current medications. The nurse recognizes that which of the following medications should be clarified with the health care provider immediately? Select all that apply. A. Albuterol B. Doxycycline C. Isulin aspart D. Isotretinoin E. Levothyroxine F. Lisinopril

Correct Answers: B, D, and F Clients with preexisting conditions (eg, asthma, hypertension, diabetes) may require changes to medication therapy if they become pregnant. In particular, teratogenic or unnecessary medications should be discontinued (before conception, when possible). The nurse should refer a client taking contraindicated medications to a health care provider immediately. For example: · Doxycycline, a tetracycline antibiotic, is avoided in pregnancy because it can impair bone mineralization and discolor permanent teeth in the fetus. · Isotretinoin (Accutane) has a black box warning for severe birth defects. Retinoids may not be prescribed to women of childbearing age without a formal agreement to participate in iPLEDGE (a prescription tracking program) and a commitment to use two forms of contraception. · ACE inhibitors such as lisinopril (Prinivil) have a black box warning for use in pregnancy because they can affect fetal renal function and lung development or cause fetal death. Incorrect Answers: [A. Albuterol] Albuterol, an inhaled beta agonist, has not been conclusively proved to be safe during pregnancy but should be continued when medically indicated (eg, severe asthma) to prevent the risks of asthma during pregnancy (eg, preterm birth, growth restriction). [C. Isulin aspart] Insulin is safe for use during pregnancy and is commonly used to treat pregestational or gestational diabetes. [E. Levothyroxine] Levothyroxine (Synthroid) for treatment of hypothyroidism is safe but should be monitored carefully to ensure an appropriate dose due to physiological changes in pregnancy. Educational objective:Commonly used medications that are absolutely contraindicated in pregnancy include doxycycline, isotretinoin, and ACE inhibitors.

One month ago, a client was prescribed phenytoin 100 mg orally 3 times daily. The client's current serum phenytoin level is 32 mcg/mL (127 µmol/L). Which action by the health care provider does the nurse anticipate? A. Administer phenytoin as prescribed B. Decrease phenytoin daily dose C. Increase phenytoin daily dose D. Repeat serum phenytoin level in 2 hours

Correct Answers: B. Decrease phenytoin daily dose Phenytoin (Dilantin), an anticonvulsant drug, is used to treat generalized tonic-clonic seizures. The therapeutic serum phenytoin reference range is 10-20 mcg/mL (40-79 µmol/L). In the presence of an elevated reference range (32 mcg/mL [127 µmol/L]), if no seizure activity is observed, the nurse would anticipate the health care provider prescribing a decreased daily dose. The nurse will continue to monitor for signs of toxicity (eg, ataxia, nystagmus, slurred speech, decreased mentation). Incorrect Answers: [A. Administer phenytoin as prescribed] The serum phenytoin level is elevated, so administering the prescribed dose or increasing the dose can raise the level and further increase the risk for drug-induced toxicity. [C. Increase phenytoin daily dose] The serum phenytoin level is elevated, so administering the prescribed dose or increasing the dose can raise the level and further increase the risk for drug-induced toxicity. [D. Repeat serum phenytoin level in 2 hours] Repeating the serum phenytoin level in 2 hours will not result in a significant change as 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-induced toxicity involve the central nervous system (eg, nystagmus, ataxia, slurred speech, decreased mentation) and can occur when phenytoin plasma levels exceed the therapeutic reference range (10-20 mcg/mL [40-79 µmol/L]).

The nurse is caring for a client admitted with serotonin syndrome after taking citalopram and tramadol. Which findings does the nurse expect to observe? Select all that apply. A. Absent deep tendon reflexes B. Cold, clammy skin C. Muscle rigidity D. Restlessness and agitation E. Sinus tachycardia

Correct Answers: C, D, and E Serotonin syndrome, a potentially life-threatening condition, develops when drugs affecting the body's serotonin levels are administered simultaneously or in overdose. Drugs, which may trigger this reaction, include selective serotonin reuptake inhibitors (SSRIs), monoamine oxidase inhibitors (MAOIs), dextromethorphan, ondansetron, St. John's wort, and tramadol. The diagnosis is primarily clinical and based on medication history and clinical findings. Symptoms may include mental status changes (eg, anxiety, agitation, disorientation), autonomic dysregulation (eg, hyperthermia, diaphoresis, tachycardia/hypertension), and neuromuscular hyperactivity (eg, tremor, muscle rigidity, clonus, hyperreflexia). Incorrect Answers: [A. Absent deep tendon reflexes] The client experiencing serotonin syndrome would exhibit hyperreflexia. [B. Cold, clammy skin] The client experiencing serotonin syndrome would exhibit warm moist skin and a fever. Educational objective:Clinical manifestations of serotonin syndrome include mental status changes (eg, anxiety, agitation, disorientation), autonomic dysregulation (eg, hyperthermia, diaphoresis, tachycardia/hypertension), and neuromuscular hyperactivity (eg, tremor, muscle rigidity, clonus, hyperreflexia).

The nurse reinforces teaching about methotrexate to a 28-year-old client with rheumatoid arthritis. Which client statement indicates the need for further instruction regarding this drug? A. "I should get a flu shot this year as my resistance to germs will be lower." B. "I should not get pregnant while taking this medicine." C. "I will make sure I have my eyes checked every 6 months." D. "It will be difficult, but I will not have wine with my dinner."

Correct Answers: C. "I will make sure I have my eyes checked every 6 months." Methotrexate (Rheumatrex) is classified as an antineoplastic immunosuppressant drug used to treat various malignancies and as a nonbiologic disease-modifying antirheumatic drug (DMARD) used to treat rheumatoid arthritis and psoriasis. The client's statement about getting an eye checkup every 6 months indicates that further teaching is necessary. Eye examinations every 6 months are not indicated for clients on methotrexate, whereas they are recommended for those who are prescribed hydroxychloroquine (Plaquenil), a nonbiological antimalarial DMARD that can cause retinal damage. Incorrect Answers: [A. "I should get a flu shot this year as my resistance to germs will be lower."] Methotrexate is an immunosuppressant and can cause bone marrow suppression. Clients are at risk for infection and should avoid crowded places and contact with individuals who have known infections. Clients on methotrexate should receive the recommended killed (inactivated) vaccines (eg, influenza, pneumococcal), but live vaccines (eg, herpes zoster) are contraindicated. [B. "I should not get pregnant while taking this medicine."] Methotrexate is teratogenic and can cause congenital abnormalities and fetal death; therefore, clients should not become pregnant while taking this drug and wait at least 3 months after it is discontinued to conceive. [D. "It will be difficult, but I will not have wine with my dinner."] Methotrexate is hepatotoxic; clients on this medication should avoid drinking alcohol as alcohol use increases the risk for hepatotoxicity. Educational objective:Methotrexate is a disease-modifying antirheumatic drug used to treat rheumatoid arthritis. The major adverse effects associated with methotrexate include bone marrow suppression, hepatotoxicity, congenital abnormalities, and fetal death.

The nurse is reinforcing discharge instructions for a client with degenerative joint disease and a new prescription for naproxen. What instructions regarding this drug does the nurse include? Select all that apply. A. Avoid driving while taking this medicine B. Change positions slowly C. Discontinue immediately if suicidal thoughts occur D. Notify the health care provider of tarry stools E. Take the medicine with food

Correct Answers: D and E Naproxen is a nonsteroidal anti-inflammatory drug (NSAID) commonly prescribed to decrease joint pain and inflammation. All NSAIDs (eg, indomethacin, ibuprofen) are associated with the following: 1. Gastrointestinal (GI) toxicity: Symptoms of GI bleeding, such as black, tarry stools, should be reported. Gastrointestinal upset (eg, dyspepsia, pain) can be reduced if the medicine is taken with food. 2. Kidney injury: Long-term use of NSAIDs is associated with kidney injury. 3. Hypertension and heart failure: NSAIDs can cause fluid retention, which can exacerbate conditions such as heart failure, cirrhosis/ascites, and hypertension. 4. Bleeding risk: Clients should notify the health care provider if NSAIDs are taken concurrently with aspirin, other NSAIDs, or anticoagulant/antiplatelet drugs as these can increase the risk of GI bleeding. Incorrect Answers: [A. Avoid driving while taking this medicine] Clients should not drive when taking sedating antihistamines or benzodiazepines. [B. Change positions slowly] Orthostatic hypotension is common with blood pressure medications (eg, ACE inhibitors, alpha blockers) but not with NSAIDS. [C. Discontinue immediately if suicidal thoughts occur] Suicidal thoughts are commonly associated with selective serotonin reuptake inhibitors (antidepressants) and varenicline (Chantix), a smoking cessation medication. Educational objective:All nonsteroidal anti-inflammatory drugs (eg, indomethacin, ibuprofen, naproxen) are associated with gastrointestinal toxicity, kidney injury, exacerbation of fluid overload/hypertension, and bleeding risk. They should be used at the lowest dose and for the shortest time possible.

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? A. Client reports burning during injection into the IV line B. Client reports dizziness when getting up to use the bathroom C. Client's blood pressure is 106/68 mm Hg D. Client's respiratory rate is 11/min

Correct Answers: D. Client's respiratory rate is 11/min 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. Incorrect Answers: [A. Client reports burning during injection into the IV line] 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. [B. Client reports dizziness when getting up to use the bathroom] 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. [C. Client's blood pressure is 106/68 mm Hg] 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.

After receiving shift report, the nurse is assessing a client started on trimethoprim-sulfamethoxazole 2 days ago for treatment of a urinary tract infection. The client reports itching, and the nurse notices a diffuse maculopapular rash on the client's face. What should the nurse do first? A. Administer diphenhydramine B. Administer injectable epinephrine C. Examine the client's trunk and limbs D. Reassess the client's allergy history

Correct Answers: D. Reassess the client's allergy history Clients may not know the signs and symptoms of allergies or not remember a past history of allergies, which causes underreporting of allergies. Therefore, reassessing client allergies is the first and oftentimes the quickest action. To ensure that the client report is accurate, the nurse should ask about specific signs and symptoms that would indicate an allergy (eg, hives, rash, diarrhea) as the client may not be aware of these indicators. A diffuse maculopapular rash is a typical manifestation of an allergic medication reaction that develops within the first 3 days of starting a new medication. The registered nurse (RN) should be notified and should ask the client about any signs and symptoms of anaphylaxis. The health care provider (HCP) should be notified to assess, diagnose, and treat the rash. If a medication allergy is diagnosed, the client's record should be updated and the pharmacist should be notified. Incorrect Answers: [A. Administer diphenhydramine] Diphenhydramine is an antihistamine used to treat mild allergic reactions. This would be appropriate to administer after an allergic reaction is confirmed by the HCP. Corticosteroids (eg, prednisone) have an anti-inflammatory action and may also be used to prevent or treat a mild allergic reaction. [B. Administer injectable epinephrine] A drug rash is a mild allergic reaction. Injectable epinephrine (Epi-pen) would only be used when the client is having a severe anaphylactic reaction, with swelling of the airway and/or cardiovascular collapse. [C. Examine the client's trunk and limbs] A drug rash is usually a systemic type of reaction with diffuse rash evident on the face, trunk, and limbs. Therefore, assessment of the client's trunk and limbs would be the second nursing action after reassessing allergy history. Educational objective:A client with signs of a potential allergic reaction should be assessed quickly, including allergy history and physical assessment (face, trunk, and limbs) with attention to signs of anaphylaxis. The health care provider should then be notified to assess the client, and the client's allergies should be updated in the medical record.

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. A. Inhaled albuterol nebulizer every 20 minutes B. Inhaled ipratropium nebulizer every 20 minutes C. Intravenous methylprednisolone D. Montelukast 10 mg by mouth STAT E. Salmeterol metered-dose inhaler every 20 minutes

Correct Answer: A, B, and C 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: 1. Oxygen to maintain saturation >90% 2. High-dose inhaled short-acting beta agonist (SABA) (albuterol) and anticholinergic agent (ipratropium) nebulizer treatments every 20 minutes. 3. Systemic corticosteroids (Solu-Medrol) Incorrect Answers: [D. Montelukast 10 mg by mouth STAT ] 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. [E. Salmeterol metered-dose inhaler every 20 minutes] 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 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 notification of the supervising registered nurse? A. "I am going for repeat testing to confirm glaucoma." B. "I am not able to exercise as much as I used to." C. "I started taking esomeprazole for heartburn." D. "My bowel movements are not regular."

Correct Answer: A. "I am going for repeat testing to confirm glaucoma." 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 PD, anticholinergic drugs can precipitate acute glaucoma (especially in the setting of benign prostatic hyperplasia). As a result, such medications are contraindicated in these clients. Incorrect Answers: [B. "I am not able to exercise as much as I used to."] 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 threaten sight and is the priority. [C. "I started taking esomeprazole for heartburn."] Esomeprazole is safe to take with benztropine and will not cause an adverse reaction. [D. "My bowel movements are not regular."] Constipation is a common side effect of benztropine. PD can also cause constipation due to the characteristic decreased mobility. 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 are therefore contraindicated.

The nurse is assessing a client with rheumatoid arthritis who is being considered for adalimumab therapy. Which statement made by the client needs further investigation? A. "I am taking an antibiotic for a urinary tract infection." B. "I had a negative tuberculosis skin test 2 weeks ago." C. "I just received my yearly flu shot a week ago." D. "I will continue taking naproxen at night to help with pain."

Correct Answer: A. "I am taking an antibiotic for a urinary tract infection." Infliximab, adalimumab, and etanercept are tumor necrosis factor (TNF) inhibitors that suppress the inflammatory response in autoimmune diseases such as rheumatoid arthritis, Crohn disease, and psoriasis. Due to the immunosuppressive action of TNF inhibitors, clients taking these drugs are at increased risk for infection. A client with current, recent, or chronic infection should not take a TNF inhibitor Incorrect Answers: [B. "I had a negative tuberculosis skin test 2 weeks ago."] The immunosuppressive action of TNF inhibitors can activate latent tuberculosis (TB). Therefore, a tuberculin skin test (TST) should be administered prior to beginning TNF inhibitor therapy, and clients who test positively for latent TB must also undergo treatment for TB before starting therapy. Clients should have a TST every year while receiving the drug. [C. "I just received my yearly flu shot a week ago."] Clients taking immunosuppressive TNF inhibitors (eg, adalimumab) should receive an annual inactivated (injectable) influenza vaccine to reduce the risk of contracting the flu virus. Clients taking TNF inhibitors or other immunosuppressants are at risk for infection and therefore should not receive live attenuated vaccines. [D. "I will continue taking naproxen at night to help with pain."] Many clients with rheumatoid arthritis use nonsteroidal anti-inflammatory medications (eg, celecoxib, naproxen) in conjunction with antirheumatic and/or targeted therapies (eg, methotrexate, adalimumab, etanercept) to effectively treat pain and minimize inflammation. Educational objective:Clients with infection should not take tumor necrosis factor (TNF) inhibitors (eg, infliximab, adalimumab, etanercept) as these suppress the immune response. Before starting drug therapy, clients should be tested for tuberculosis and receive the inactivated (injectable) influenza vaccine. Clients taking TNF inhibitors should avoid live vaccines.

The home health hospice nurse visits a client who is newly prescribed extended-release oxycodone 40 mg orally, scheduled every 12 hours to treat severe chronic cancer pain. Which information is most important to reinforce to the client's caregiver? A. Administer the medication around the clock even if the client denies having pain B. Avoid administering with immediate-release opioids to prevent respiratory depression C. Change the dosage and frequency to 20 mg every 6 hours if breakthrough pain occurs D. Request a tapered dose from the health care provider if pain decreases to prevent tolerance

Correct Answer: A. Administer the medication around the clock even if the client denies having pain Extended-release oxycodone (Oxycontin) is a long-acting opioid agonist prescribed to manage severe chronic pain when nonopioids and immediate-release opioids (eg, immediate-release oxycodone, hydrocodone) are inadequate. The nurse should teach the client's caregiver to administer extended-release oxycodone as scheduled, even if the client does not report pain. Administration twice daily is necessary to maintain a therapeutic level and provide continuous relief as the duration of the analgesic effect is 12 hours. Incorrect Answers: [B. Avoid administering with immediate-release opioids to prevent respiratory depression] Immediate-release opioids and nonopioids are coadministered with long-acting opioids for relief of breakthrough pain. Respiratory status should be monitored; however, clients who receive long-term therapy become opioid tolerant and are less likely to experience adverse effects. Because the goal of hospice care is comfort, this client should be relieved of breakthrough pain regardless of respiratory status. [C. Change the dosage and frequency to 20 mg every 6 hours if breakthrough pain occurs] The dose and frequency cannot be changed without a prescription. Also, breakthrough pain is best treated with short-acting opioids. [D. Request a tapered dose from the health care provider if pain decreases to prevent tolerance] Long-term opioid therapy leads to drug tolerance and physical dependence; higher doses are eventually required for therapeutic effect. In the dying client, it is not appropriate to taper the dose. Rather, it should be titrated upward for effective pain relief. Educational objective:Long-acting controlled-release opioid drugs for chronic pain require regularly scheduled dosing to maintain a therapeutic drug level. Immediate-release opioids may be required for breakthrough pain. Long-term opioid use leads to tolerance and physical dependence; higher doses are eventually required for therapeutic effect.

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? A. Atropine sublingual drops B. Lorazepam sublingual tablet C. Morphine sublingual liquid D. Ondansetron sublingual tablet

Correct Answer: A. Atropine sublingual drops 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. Incorrect Answers: [A. Atropine sublingual drops] 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"). [C. Morphine sublingual liquid] 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. [D. Ondansetron sublingual tablet] 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 client has increased intracranial pressure with cerebral edema, and mannitol is administered. Which assessment should the nurse make to evaluate if a complication from the mannitol is occurring? A. Auscultate breath sounds to assess for crackles B. Monitor for >50 mL/hr urine output C. Monitor Glasgow Coma Scale increasing from 8/15 to 9/15 D. Press over the tibia to assess for pitting edema

Correct Answer: A. Auscultate breath sounds to assess for crackles Mannitol (Osmitrol) is an osmotic diuretic used to treat cerebral edema (increased intracranial pressure) and acute glaucoma. When administered, mannitol causes an increase in plasma oncotic pressure (similar to excess glucose) that draws free water from the extravascular space into the intravascular space, creating a volume expansion. This fluid, along with the drug, is excreted through the kidneys, thereby reducing cerebral edema and intracranial pressure. However, if a higher dose of mannitol is given or it accumulates (as in kidney disease), fluid overload that may cause life-threatening pulmonary edema results. An early sensitive indicator of fluid overload is new onset of crackles auscultated in the lungs. To prevent these complications, clients require frequent monitoring of serum osmolarity, input and output, serum electrolytes, and kidney function. Incorrect Answers: [B. Monitor for >50 mL/hr urine output] Urine output would be expected to increase from the diuretic effect of mannitol. This is not a complication. [C. Monitor Glasgow Coma Scale increasing from 8/15 to 9/15] Glasgow Coma Scale scores range from 3-15. Improved mental status (orientation, alertness) is a desired effect of treatment. [D. Press over the tibia to assess for pitting edema] The presence of crackles is a more sensitive sign of fluid overload than pedal edema. Furthermore, in a bedridden client, the assessment should take place at a dependent part of the body, usually the sacral area. Educational objective:Mannitol is an osmotic diuretic used to treat cerebral edema and acute glaucoma. Normal kidney function and adequate urine output are crucial while administering this medication as mannitol accumulation can result in significant volume expansion, dilutional hyponatremia, and pulmonary edema.

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 A. Bleeding risk B. Bronchospasm C. Muscle injury D. Tinnitus

Correct Answer: A. Bleeding risk This client is on 3 different medications that increase bleeding risk (aspirin, clopidogrel, and rivaroxaban). The highest priority for the nurse is to reinforce client teaching on the signs/symptoms and risk reduction of bleeding. The client should be instructed 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. Incorrect Answers: [B. Bronchospasm] This client is on low-dose aspirin and metoprolol; bronchospasm rarely occurs with high doses of these medications. Although this should be a teaching topic for the client, bleeding is more likely to occur. [C. Muscle injury] 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. [D. Tinnitus] 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.

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

Correct Answer: A. Change positions slowly when going from lying to standing Terazosin is an alpha-adrenergic blocker that can relieve urinary retention in clients with benign prostatic hyperplasia (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). Incorrect Answers: [B. Do not drink grapefruit juice when taking this drug] 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. [C. Take this medication first thing in the morning, before breakfast] Alpha-1-adrenergic antagonists (eg, terazosin, doxazosin, tamsulosin, alfuzosin) should be taken at bedtime, not in the morning, to avoid orthostatic hypotension. [D. Your stool may become darker and that's normal] 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 benign prostatic hyperplasia. 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.

A client has a follow-up checkup in the urology clinic. Six months ago, the client started taking tolterodine. What data collected from the client should the nurse report to the health care provider? A. Client excitedly reports being able to go an entire work day without having to urinate B. Client is using an over-the-counter artificial saliva product for dry mouth C. Client reports occasional dizziness in the morning and when changing positions D. Client reports symptoms of constipation

Correct Answer: A. Client excitedly reports being able to go an entire work day without having to urinate Tolterodine (Detrol LA), oxybutynin (Ditropan), and solifenacin (Vesicare) are antimuscarinic/anticholinergic medications used for overactive bladder and urge urinary incontinence. They decrease urinary urgency and frequency. The most common side effects are anticholinergic (eg, dry mouth, constipation, cognitive dysfunction). The client's report of not urinating the entire day while at work may indicate that the dosage is too high and is causing urinary retention. Urinary retention can lead to bladder infections and distension. This information should be reported to the health care provider (HCP). Incorrect Answers: [B. Client is using an over-the-counter artificial saliva product for dry mouth] Artificial saliva products and sugar-free hard candy and gum are acceptable ways to manage dry mouth caused by anticholinergic medications. [C. Client reports occasional dizziness in the morning and when changing positions] Occasional dizziness is a side effect of tolterodine. The client should rise and change positions slowly. However, if this client is receiving too high a dose, reduction of the dose may alleviate the dizziness. Severe dizziness should be reported to the HCP. [D. Client reports symptoms of constipation] Constipation can be managed with increased fiber in the diet, fluids, stool softeners, or laxatives. Educational objective:Anticholinergic medications (eg, tolterodine, oxybutynin, solifenacin) are commonly used for overactive bladder. The client should experience a reduction in the number of times needed to urinate, but the number should not decrease below typical urination frequency. The nurse should also teach the client how to manage the common side effects of dry mouth, constipation, and mild dizziness.

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

Correct Answer: A. Client who is receiving tube feedings and has a phenytoin level of 8 mcg/mL (32 mcmol/L) 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. Incorrect Answers: [B. Client with a heart rate of 62/min who has a digoxin level of 1.3 ng/mL (1.7 nmol/L)] 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). [C. Client with a new prosthetic aortic valve who has an INR of 3.0] The therapeutic INR for a client with a mechanical heart valve is 2.5-3.5. [D. Client with a poor appetite and a lithium level of 0.8 mEq/L (0.8 mmol/L)] 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 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? A. Client with bronchospasm who is due to receive nebulized acetylcysteine B. Client with chronic obstructive pulmonary disease due to receive PO prednisone C. Client with cystic fibrosis who is due to receive PO pancrelipase with breakfast D. Client with suspected bacterial pneumonia due to receive IV levofloxacin

Correct Answer: A. Client with bronchospasm who is due to receive nebulized acetylcysteine 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. Incorrect Answers: [B. Client with chronic obstructive pulmonary disease due to receive PO prednisone] 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. [C. Client with cystic fibrosis who is due to receive PO pancrelipase with breakfast] 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. [D. Client with suspected bacterial pneumonia due to receive IV levofloxacin] 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.

The postoperative client on hydromorphone becomes hypoxic, and naloxone is administered per protocol. What is most important for the nurse to consider in the follow-up care of this client? A. Client's respiratory status 60 minutes later B. Documenting the client's hypoxic event C. Obtaining an order for a different analgesic D. Potential for drug-drug interaction now

Correct Answer: A. Client's respiratory status 60 minutes later Hydromorphone duration of action is 3-4 hours. The effects of naloxone (Narcan) start to wane at 20-40 minutes after administration, and its duration of action is approximately 90 minutes. Therefore, depending on the hydromorphone dose, its duration of action can continue beyond the duration of the naloxone. Repeat naloxone doses may be necessary. Incorrect Answers: [B. Documenting the client's hypoxic event] Documentation is essential, but client care is more important than paperwork. [C. Obtaining an order for a different analgesic] Naloxone will reverse the effects of the narcotic in the body and, as long as it is in the body, will reverse the effects of any additional narcotic administered. This client will need a different class of analgesic at this time. However, adequate respiration/oxygenation as the naloxone wears off is more important. [D. Potential for drug-drug interaction now] Naloxone is the reversal agent for narcotics, and a drug-drug interaction is not a concern. Educational objective:The half-life of naloxone (Narcan) is shorter than most narcotics. When naloxone is used to reverse the effects of narcotics, the nurse must monitor the client to ensure that the client does not fall again into excessive sedation and/or respiratory depression.

A client is receiving lithium carbonate 900 mg/day for a schizoaffective disorder. The laboratory notifies the nurse that the client's lithium level is 1.0 mEq/L (1.0 mmol/L). Based on this result, which prescription does the nurse anticipate receiving from the health care provider? A. Continue at the current dosage B. Decrease the dosage C. Discontinue the medication D. Increase the dosage

Correct Answer: A. Continue at the current dosage Lithium carbonate is used as a mood stabilizer in clients with schizoaffective disorder (combination of schizophrenia and a mood disorder) and bipolar disorders. Lithium has a very narrow therapeutic index (0.6-1.2 mEq/L [0.6-1.2 mmol/L]); levels >1.5 mEq/L (1.5 mmol/L) are considered toxic. Lithium toxicity can be acute (eg, ingesting a bottle of lithium tablets in a suicide attempt) or chronic (eg, slow accumulation due to decreased renal function or drug-drug interactions). Acute or acute-on-chronic toxicity presents predominantly with gastrointestinal symptoms (eg, nausea, vomiting, diarrhea); neurologic manifestations occur later. However, neurologic manifestations occur early in chronic toxicity. Common neurologic manifestations include ataxia, confusion, or agitation, and neuromuscular excitability (eg, tremor, myoclonic jerks). Chronic toxicity also manifests as diabetes insipidus (eg, polyuria, polydipsia). Incorrect Answers: [B. Decrease the dosage] No dose adjustment is needed as this client's lithium level is therapeutic. [C. Discontinue the medication] No dose adjustment is needed as this client's lithium level is therapeutic. [D. Increase the dosage] No dose adjustment is needed as this client's lithium level is therapeutic. Educational objective:Lithium levels should be checked frequently given the narrow therapeutic index (0.6-1.2 mEq/L [0.6-1.2 mmol/L]). A level >1.5 mEq/L (1.5 mmol/L) is considered toxic. Chronic toxicity manifests with neurologic symptoms (eg, confusion, tremor, ataxia) and/or diabetes insipidus (eg, polyuria, polydipsia).

A client has been on lithium carbonate therapy for 7 days. Which of the following findings would be most important to report to the health care provider? A. Diarrhea, vomiting, and mild tremor B. Dry mouth and mild thirst C. Hyperactivity and auditory hallucinations D. Lithium level of 1.3 mEq/L (1.3 mmol/L)

Correct Answer: A. Diarrhea, vomiting, and mild tremor Lithium carbonate is used for the initial and maintenance treatment of bipolar mania. Typical symptoms of mania include extreme hyperactivity, delusions and hallucinations, grandiosity, elation, poor judgment, aggressiveness, impulsivity, pressure of speech, insomnia, flight of ideas, and sometimes hostility. Acute lithium toxicity presents primarily with gastrointestinal side effects such as persistent nausea and vomiting and diarrhea. Neurologic symptoms typically manifest later and include tremor, confusion, ataxia, and sluggishness. Severe toxicity results in seizures and encephalopathy. Serum lithium levels and clinical condition must be monitored before medication administration. Serum levels ≥1.5 mEq/L (1.5 mmol/L) and/or even the mildest symptoms of lithium toxicity must be reported to the health care provider. Incorrect Answers: [B. Dry mouth and mild thirst] Dry mouth and thirst are common and expected side effects of lithium when treatment is initiated. They will resolve spontaneously and lithium need not be discontinued. [C. Hyperactivity and auditory hallucinations] Hyperactivity and auditory hallucinations are clinical findings associated with bipolar mania. Because lithium may take up to 3 weeks to become effective, it would not be unusual for a client to experience these symptoms after only 7 days of treatment. [D. Lithium level of 1.3 mEq/L (1.3 mmol/L)] Lithium has a very narrow range of therapeutic serum levels; the usual ranges are 1.0-1.5 mEq/L (1.0-1.5 mmol/L) for treatment of acute mania and 0.6-1.2 mEq/L (0.6-1.2 mmol/L) for maintenance therapy. Educational objective:Acute lithium toxicity (>1.5 mEq/L [1.5 mmol/L]) presents primarily with gastrointestinal side effects such as persistent nausea and vomiting and diarrhea. Neurological symptoms typically manifest later and include tremor, confusion, ataxia, and sluggishness. The health care provider must be notified at the earliest indication of lithium toxicity.

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? Time | 0600 Wednesday | 0600 Thursday Blood Pressure: 148/84 mm Hg | 98/60 mm Hg 24-hour intake/output: 1000/3000 mL | ------ Serum Sodium: 140 mEq/L (140 mmol/L) | 150 mEq/L (150 mmol/L) Serum Potassium: 4.2 mEq/L (140 mmol/L) | 150 mEq/L (150 mmol/L) Serum Glucose: 90 mg/dL (5 mmol/L) | 99 mg/dL (5.5 mmol/L) Medications | Thursday Furosemide: 40 mg IVP, once daily | 0700 Levofloxacin: 500 mg IV, once daily | 0700 Glipizide: 5 mg orally, twice daily | 0700 - 1700 Potassium Chloride: 20 mEq/L orally, once daily | 0700 A. Furosemide B. Glipizide C. Levofloxacin D. Potassium chloride

Correct Answer: A. Furosemide 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. Incorrect Answer: [B. Glipizide] 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. [C. Levofloxacin ] 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. [D. Potassium chloride] 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 client with asthma was recently prescribed fluticasone/salmeterol. After the client has received instructions about this medication, which statement would require further teaching by the nurse? A. "After taking this medication, I will rinse my mouth with water." B. "At the first sign of an asthma attack, I will take this medication." C. "I have been smoking for 12 years, but I just quit a month ago." D. "I received the pneumococcal vaccine about a month ago."

Correct Answer: B. "At the first sign of an asthma attack, I will take this medication." Fluticasone/salmeterol (Advair) is a combination drug containing a corticosteroid (fluticasone) and a bronchodilator (salmeterol). Salmeterol is a long-acting inhaled β2-adrenergic agonist that promotes relaxation of the bronchial smooth muscles over 12 hours. Fluticasone decreases inflammation. This medication is used as part of the treatment plan for prevention and long-term control of asthma. Client instructions include: — After inhalation, rinse the mouth with water without swallowing to reduce the risk of oral/esophageal candidiasis. — Avoid smoking and using tobacco products — Receive the pneumococcal and influenza vaccines if there is a risk for infection Fluticasone/salmeterol is not a rescue inhaler and does not treat acute exacerbations of asthma. The client should always have a rescue inhaler (eg, albuterol [short-acting β2-adrenergic agonist] or ipratropium [Atrovent]) for sudden changes in breathing and call 911 if the rescue inhaler does not relieve the breathing problem. Educational objective:Fluticasone/salmeterol (Advair) is a long-acting inhaled β2-adrenergic agonist combination drug containing a corticosteroid (fluticasone) and a bronchodilator (salmeterol). It is used for long-term control of asthma but not for acute attacks.

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? A. "Drowsiness is a common side effect of this medication and will improve over time." B. "I can begin driving again after I have been on this medication for a few weeks." C. "I need to immediately report any new or increased anxiety when on this medication." D. "I need to immediately report any new rash when on this medication."

Correct Answer: B. "I can begin driving again after I have been on this medication for a few weeks." 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. 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. 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 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 behavioral health clinic nurse assesses a 23-year-old client who started taking paroxetine 3 weeks ago. Which statement made by the client is most important for the nurse to investigate? A. "I don't have much of an appetite since starting this medication." B. "I have a lot more energy, but I'm feeling just as depressed." C. "I have been feeling dizzy when I walk around at home." D. "I have experienced frequent headaches lately."

Correct Answer: B. "I have a lot more energy, but I'm feeling just as depressed." Selective serotonin reuptake inhibitors (SSRIs) (eg, fluoxetine, paroxetine, sertraline, citalopram) are used to treat a number of psychiatric conditions (eg, major depressive disorder, generalized anxiety disorder). Clients usually see therapeutic effects in 1-4 weeks. SSRIs may increase the risk of suicide, especially in young adults (age 18-24) during initial therapy or after a dosage increase. A client who reports increased energy without a change in depressive feelings needs to be assessed and monitored for suicidal ideation or actions as the client may now have the energy to execute the suicide plan. Common, expected side effects of SSRIs include: · Loss of appetite; weight loss or weight gain · Gastrointestinal disturbances (nausea, vomiting, diarrhea) · Headaches, dizziness, drowsiness, insomnia · Sexual dysfunction Side effects should gradually diminish over 3 months, although some may persist. If symptoms are intolerable or a particular SSRI is ineffective, the client may be switched to a different antidepressant. Educational objective:Selective serotonin reuptake inhibitors (eg, fluoxetine, paroxetine, sertraline, citalopram) are used to treat psychiatric conditions (eg, major depressive disorder, generalized anxiety disorder). A client reporting increased energy with little or no reduction of depression needs immediate assessment for suicide risk.

The health care provider (HCP) prescribes paroxetine to a client with depression. What statement by the client indicates proper understanding of the medication? A. "I can discontinue the medication if my symptoms improve." B. "I need a healthy diet and regular exercise to combat weight gain." C. If I don't feel better in 1-2 weeks, then the medication is not working." D. "This medication might increase my sexual performance."

Correct Answer: B. "I need a healthy diet and regular exercise to combat weight gain." Paroxetine (Paxil) is a selective serotonin reuptake inhibitor (SSRI) often prescribed for major depression and anxiety disorders. Other SSRIs include citalopram (Celexa), escitalopram (Lexapro), fluoxetine (Prozac), and sertraline (Zoloft). Weight gain is a common side effect of long-term SSRI use. The nurse should teach the client to eat a healthy diet and engage in regular exercise to combat the weight gain. Other major side effects of SSRIs include increased suicide risk (at the beginning of therapy), sexual dysfunction, and serotonin syndrome when taken in excess doses. Incorrect Answers: [A. "I can discontinue the medication if my symptoms improve."] SSRIs should not be stopped abruptly without discussion with the HCP. Dosages should be gradually tapered before discontinuation to avoid withdrawal symptoms. [C. If I don't feel better in 1-2 weeks, then the medication is not working."] Most clients will start to see symptom improvement in 1-2 weeks. However, some may take several weeks and require dose adjustments. Clients should continue to take the medication and discuss it with the HCP. [D. "This medication might increase my sexual performance."] SSRIs can cause sexual dysfunction. Clients should notify the HCP for a change of medication or to add medications to increase sexual performance. Educational objective:The major side effects of SSRIs include increased suicide risk (at the beginning of therapy), sexual dysfunction, weight gain, and serotonin syndrome (excess doses). It may take several weeks for the therapeutic effects of SSRIs to begin; they should never be discontinued abruptly.

During a routine office visit, the nurse documents the list of current medications of a client with a history of hypertension. Which statement by the client would cause the most concern? A. "I periodically take docusate sodium for constipation." B. "I regularly take ibuprofen for chronic low back pain." C. "I take hydrochlorothiazide to prevent swelling around my ankles." D. "I take omeprazole daily to prevent heartburn."

Correct Answer: B. "I regularly take ibuprofen for chronic low back pain." Over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen can cause cardiovascular side effects, including heart attack, stroke, high blood pressure, and heart failure from fluid retention. These drugs also decrease the effectiveness of diuretics and other blood pressure medications. The risks can be even higher in the client who already has cardiovascular disease or takes NSAIDs routinely or for a long time. In addition, long-term use of NSAIDs is associated with peptic ulcers and chronic kidney disease. These clients should use NSAIDs cautiously, at the lowest dose necessary and for a short time. The nurse should notify the health care provider that this client is routinely taking ibuprofen. Incorrect Answers: [A. "I periodically take docusate sodium for constipation."] Taking docusate sodium occasionally for constipation is appropriate. [C. "I take hydrochlorothiazide to prevent swelling around my ankles."] Hydrochlorothiazide is a weak diuretic and is commonly used to treat hypertension. [D. "I take omeprazole daily to prevent heartburn."] Omeprazole for heartburn is appropriate for this client. Educational objective:NSAIDs may cause heart attack, stroke, high blood pressure, and possible heart failure after long-term use. NSAIDs decrease the effectiveness of diuretic and blood pressure medications. Long-term use is also associated with chronic kidney disease and peptic ulcers.

The nurse in an ambulatory care center is reinforcing teaching to a client with a diagnosis of persistent depressive disorder (dysthymia) about the appropriate use of bupropion hydrochloride SR. Which statement made by the client indicates a need for further teaching? A. "If I have a sudden change in my mood, I should call my physician immediately." B. "If I have trouble swallowing the tablet, I can cut it in half." C. "If I miss a dose, I should not double the next dose to catch up." D. "It may take several weeks before I get better."

Correct Answer: B. "If I have trouble swallowing the tablet, I can cut it in half." Bupropion hydrochloride (Wellbutrin) is an atypical antidepressant used to treat depressive disorders, including major depressive disorder, seasonal affective disorder, and persistent depressive disorder (dysthymia). Preparations of bupropion hydrochloride include immediate-release, sustained release (SR), and extended-release (XL) tablets. Any medication marked SR or XL should not be chewed, cut, or crushed due to the risk of adverse effects from too rapid absorption of the drug. No form of bupropion hydrochloride should be altered; tablets should be swallowed whole, with or without food. Seizures are of particular concern if a client takes a high or toxic dose of bupropion hydrochloride. Clients on any kind of antidepressant need to be monitored closely for worsening depression, sudden or unusual behavior or mood changes, and the emergence of suicidal thoughts and behaviors. Clients with a diagnosis of depression and/or their family members need education and information on the increased risk of suicide. Additional instructions to a client about the use of bupropion hydrochloride include the following: · Limit alcohol; inform the health care provider if you are used to consuming large amounts of alcohol · Do not double up on the medication if a scheduled dose is missed · Take the medication at the same time each day · It may take several weeks to feel the effects of bupropion hydrochloride · Weight loss may occur when taking this medication Educational objective:No form of bupropion hydrochloride should be crushed, chewed, or cut due to the risk of seizures and other adverse effects caused by the more rapid absorption and resulting higher serum levels of the drug. No medications labeled SR or XL should be altered before they are administered. This type of medication preparation should be swallowed whole.

A client with fibromyalgia refuses to take the prescribed drug duloxetine. When the nurse asks, why, the client responds, "Because I'm not depressed!" What is the nurse's most appropriate response? A. "Depression is common with fibromyalgia, but a low dose of this drug can prevent it." B. "It can relieve your chronic pain and help you sleep better at night." C. "It helps to relieve the adverse effects of your other prescribed drugs." D. "You have the right to refuse. I will notify your health care provider (HCP)."

Correct Answer: B. "It can relieve your chronic pain and help you sleep better at night." Fibromyalgia (FM) results from abnormal central nervous system pain transmission and processing. It is characterized by chronic, bilateral musculoskeletal axial pain (above and below the waist), multiple tender points, fatigue, and sleep/cognitive disturbances. Duloxetine (Cymbalta) is a serotonin-norepinephrine reuptake inhibitor that has both antidepressant and pain-relieving effects. It is used to relieve chronic pain that interferes with normal sleep patterns in clients with FM. With the restoration of normal sleep patterns, fatigue often improves as well. Other effective drugs to treat the chronic pain associated with FM include pregabalin and amitriptyline (Elavil), an older tricyclic antidepressant drug. Incorrect Answers: [A. "Depression is common with fibromyalgia, but a low dose of this drug can prevent it."] Although depression often accompanies chronic pain, duloxetine can be prescribed specifically to treat the chronic pain associated with FM. [C. "It helps to relieve the adverse effects of your other prescribed drugs."] Duloxetine is prescribed for major depressive disorder and to relieve pain associated with diabetic neuropathy and FM. It is not given to relieve the adverse effects of other drugs. [D. "You have the right to refuse. I will notify your health care provider (HCP)."] A client has the right to refuse any drug. However, the nurse should first explain the purpose of the drug to the client before notifying the HCP. Educational objective:Medications such as duloxetine, pregabalin, and amitriptyline have neuropathic pain-relieving effects. They are commonly used for treating pain associated with diabetic neuropathy and FM. Duloxetine is particularly effective for treating both depression and pain.

A client is taking morphine sulfate for acute pain. The client stands, is immediately "lightheaded," and calls for the nurse. What is the nurse's priority action? A. Assess the client's orthostatic blood pressure B. Assist the client to a sitting position C. Hold and walk with the client D. Keep the client on bed rest

Correct Answer: B. Assist the client to a sitting position Opioids, including morphine sulfate, dilate peripheral blood vessels and can cause hypotension. The side effect is not as noticeable when the client is lying down; however, once the client attempts to stand, it can cause orthostatic hypotension. It is more common in clients who have some underlying volume depletion (eg, opioid-induced nausea/vomiting). Due to the safety risk, clients must be taught to rise slowly from a sitting to a standing position. The nurse should first assist the client to sit if the client feels lightheaded in a standing position. Safety is the client's priority. If orthostasis is evident, fluid bolus may be needed and should be communicated to the health care provider. Incorrect Answer: [A. Assess the client's orthostatic blood pressure] Assessing the client's orthostatic vital signs and recommending bed rest until the lightheadedness resolves are important but not first-priority actions. [C. Hold and walk with the client] Walking with the client is not recommended when the client is symptomatic on standing. [D. Keep the client on bed rest] Assessing the client's orthostatic vital signs and recommending bed rest until the lightheadedness resolves are important but not first-priority actions. Educational objective:Client safety is the priority action in any situation. The nurse should assist the client to a safe position prior to proceeding with other interventions.

A client reports 7 of 10 on the pain scale at 2300 and asks if it is too soon to receive "another pain pill." The nurse reviews the medication administration record. Which intervention should the nurse implement? Vital Signs Temperature: 99.2 F (37.3 C) Blood Pressure: 134/89 mm Hg Heart Rate: 98/min Respirations: 19/min O2 saturation: 99% Sedation: Awake, alert Medication Administration Record Allergies: None PRN Medications | Administration History Acetaminophen 650 mg: 1 suppository rectally every 6 hours as needed for fever | 0900 Hydrocodone 5mg/acetaminophen 325 mg: 2 tablets orally every 4 hours as needed for moderate pain | 0300 (2 tablets) - 0700 (2 tablets) - 1100 (2 tablets) - 1500 (2 tablets) - 1900 (2 tablets) Ondansetron 4mp | 0900 IV every 4 hours as needed for nausea | 1300 A. Administer the hydrocodone/acetaminophen as prescribed B. Call the health care provider to request a prescription for a different analgesic C. Decrease the dose of hydrocodone/acetaminophen from 2 tablets to 1 D. Prepare to administer naloxone

Correct Answer: B. Call the health care provider to request a prescription for a different analgesic The nurse must be aware of the amount of acetaminophen a client receives from all sources (eg, suppository for fever, oral medication for pain). If the client regularly receives more than one acetaminophen product, the nurse should alert the health care provider (HCP) and pharmacist. The safest action is for the HCP to suspend additional acetaminophen products until the client no longer regularly receives acetaminophen. The nurse should communicate the administration history during the hand-off report so that the nurses on subsequent shifts are aware and the client is not harmed by hepatotoxicity from acetaminophen overdose. On review of the medication administration record, the nurse should hold the requested dose of hydrocodone/acetaminophen as it would exceed the 24-hour limit of 4 g. To address the client's pain, the nurse should ask the HCP for an analgesic without acetaminophen (eg, hydrocodone/ibuprofen, oxycodone). The nurse should also report the earlier administration of acetaminophen via rectal suppository to the HCP. Incorrect Answers: [A. Administer the hydrocodone/acetaminophen as prescribed] The medication should be held. In addition, the nurse cannot change the dose without a prescription from the HCP. [C. Decrease the dose of hydrocodone/acetaminophen from 2 tablets to 1] The medication should be held. In addition, the nurse cannot change the dose without a prescription from the HCP. [D. Prepare to administer naloxone] Vital signs and sedation level do not show that naloxone is indicated at this time. If the client's respirations are ≤12/min, the nurse should hold the medication and contact the HCP. Educational objective:The nurse should closely monitor the medication administration record of clients receiving acetaminophen to ensure that the total 24-hour dose from all sources does not exceed 4 g. Hepatotoxicity may develop with >4 g/day.

A client suffering from chronic kidney disease is scheduled to receive recombinant human erythropoietin and iron sucrose. The client's hemoglobin is 9.7 g/dL (97 g/L) and hematocrit is 29% (0.29). What is the appropriate nursing action? A. Administer the erythropoietin in the client's ventrogluteal muscle B. Check blood pressure prior to administering the erythropoietin C. Hold the client's next scheduled iron sucrose dose D. Hold the erythropoietin and inform the health care provider

Correct Answer: B. Check blood pressure prior to administering the erythropoietin Anemia associated with chronic kidney disease is treated with recombinant human erythropoietin (Epogen/Procrit, epoetin). Therapy is initiated when hemoglobin is <10 g/dL (100 g/L) to alleviate the symptoms of anemia (eg, fatigue) and the need for blood transfusions. Therapy should be discontinued or the dose reduced for hemoglobin >11 g/dL (110 g/L) to prevent venous thromboembolism and adverse cardiovascular outcomes from blood thickened by high concentrations of RBCs. Hypertension is a major adverse effect of erythropoietin administration. Therefore, uncontrolled hypertension is a contraindication to recombinant erythropoietin therapy. Blood pressure should be well controlled prior to administering erythropoietin Incorrect Answers: [A. Administer the erythropoietin in the client's ventrogluteal muscle] Erythropoietin is administered intravenously or in any subcutaneous area (not intramuscularly). [C. Hold the client's next scheduled iron sucrose dose] Iron in the form of iron sucrose (Venofer) or ferric gluconate (Ferrlecit) may be prescribed to promote an adequate response to erythropoietin. Adequate stores of iron, vitamin B12, and folic acid are required for the erythropoietin to work. [D. Hold the erythropoietin and inform the health care provider] The dose should be held if the client has a hemoglobin level >11 g/dL (110 g/L) or uncontrolled hypertension. Educational objective:Anemia of chronic kidney disease is treated with recombinant human erythropoietin for hemoglobin <10 g/dL (100 g/L). Hemoglobin levels >11 g/dL (110 g/L) are associated with thromboembolic and cardiovascular events. Uncontrolled hypertension is a contraindication to recombinant human erythropoietin therapy.

The nurse completes the following drug administrations. Which would require an incident report? A. Client with chronic stable angina and blood pressure of 84/52 mm Hg; isosorbide mononitrate held B. Client with depression stopped phenelzine yesterday; escitalopram given today C. Client with diabetes and morning glucose of 90 mg/dL (5.0 mmol/L); the daily NPH insulin 20 units given at 8:00 AM D. Client with pulmonary embolism and International Normalized Ratio (INR) of 2.5; warfarin given

Correct Answer: B. Client with depression stopped phenelzine yesterday; escitalopram given today Selective serotonin reuptake inhibitors (SSRIs) (eg, escitalopram) cannot be combined with monoamine oxidase inhibitors (MAOIs) (eg, phenelzine) as there is a risk of serotonin syndrome. MAOI effects persist long after dosing stops. An MAOI should be withdrawn at least 14 days before starting an SSRI. Incorrect Answers: [A. Client with chronic stable angina and blood pressure of 84/52 mm Hg; isosorbide mononitrate held] The isosorbide has actions identical to nitroglycerin and can cause hypotension from vasodilation. It should be held when the systolic blood pressure is <90 mm Hg. Perfusion to the kidneys is inadequate if the systolic blood pressure is <80 mm Hg. Because the pressure is so low, the nurse does not want to lower it further by giving the drug. [C. Client with diabetes and morning glucose of 90 mg/dL (5.0 mmol/L); the daily NPH insulin 20 units given at 8:00 AM] Insulin is given to control diabetes. A "normal" fasting glucose level (70-99 mg/dL [3.9-5.5 mmol/L]) indicates that the dosing is correct and should be given to continue control of blood glucose. [D. Client with pulmonary embolism and International Normalized Ratio (INR) of 2.5; warfarin given] The effect of warfarin (Coumadin) is monitored by the INR. The therapeutic range of INR is 2-3. This result indicates that the current dosing is achieving the desired effect. Educational objective:There must be a minimum of 14 days between the administration of MAOIs and SSRIs to avoid serotonin syndrome; these medications cannot be administered concurrently.

The practical nurse is conducting a hospital admission history and assessment in collaboration with the registered nurse. The client reports taking the herb black cohosh (Actaea racemosa) daily. What is the best nursing response? A. Ask the client about menopausal symptoms B. Contact the pharmacy to see if the herb interferes with the client's medications C. Facilitate a prescription for use of the herb during hospitalization D. Tell the client to stop taking the herb

Correct Answer: B. Contact the pharmacy to see if the herb interferes with the client's medications The nurse should follow up regarding the quantity of the herb and how it is used. Black cohosh is used by some clients for menopausal hot flashes. The main side effects are thickening of the uterine lining and potential liver toxicity. Herbs can cause harmful reactions when taken in combination with other drugs. It is most important to determine that an herb does not interfere with other medications. Herbal therapy is usually stopped 2-3 weeks before any surgery. Incorrect Answers: [A. Ask the client about menopausal symptoms] The client may be experiencing menopausal symptoms, but the nurse's priority is to determine whether black cohosh interferes or interacts with other prescribed medications. [C. Facilitate a prescription for use of the herb during hospitalization] Herbs are not routinely continued during a short hospitalization, especially when they are used for comfort and symptomatic relief. [D. Tell the client to stop taking the herb] There is no established contraindication to the client continuing to take the herb. Some herbs, such as those starting with the letter g (eg, garlic, ginger, Ginkgo biloba, ginseng) lead to an increased bleeding risk. St. John's wort interferes with the metabolism of other drugs. It is important to know about potential interactions and the necessary response (eg, delay surgery, change medication or dosing). Educational objective:The nurse should contact the pharmacy to determine possible drug-drug interaction in a client using herbal therapy.

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

Correct Answer: B. Dizziness 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, 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. Incorrect Answers: [A. Erectile dysfunction] Adverse effects of beta-blockers include bradycardia, bronchospasm, depression, and decreased libido with erectile dysfunction. [C. Dry cough] 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. 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.

The nurse is monitoring a client who has overdosed on alprazolam and alcohol. 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? A. Benztropine B. Flumazenil C. Naloxone D. Phentolamine

Correct Answer: B. Flumazenil Alprazolam (Xanax) is a benzodiazepine commonly used to treat anxiety disorders and panic attacks. Side effects include drowsiness, depression, diarrhea, and constipation. Concurrent use with alcohol increases central nervous system depression. An overdose of alprazolam and alcohol can produce clinical manifestations of airway occlusion, apnea, hypotension, and oxygen desaturation with resultant respiratory arrest. Flumazenil (Romazicon) is the antidote used to reverse the sedative effects of benzodiazepines. Incorrect Answers: [A. Benztropine ] Benztropine (Cogentin) is used in the treatment of extrapyramidal side effects associated with antipsychotic medications or metoclopramide. [C. Naloxone] Naloxone (Narcan) is the antidote used to reverse the effects of opioids. [D. Phentolamine] Phentolamine (Regitine) is the antidote used to treat a norepinephrine (Levophed) extravasation. Educational objective:Flumazenil is an antidote used to reverse the sedative effects of benzodiazepines such as alprazolam.

A client with seizure disorder is prescribed a moderately high dose of phenytoin. Which teaching topic should the nurse reinforce with this client? A. Diet high in iron B. Good oral care and dental follow-up C. Shaving with an electric razor D. Use of sunglasses for eye protection

Correct Answer: B. Good oral care and dental follow-up The nurse should discuss the need to perform good oral hygiene with a soft-bristle toothbrush and to visit the dentist regularly as phenytoin can cause gingival hyperplasia (overgrowth of the gum tissues or reddened gums that bleed easily), especially in high doses. Folic acid supplementation can also reduce this side effect. The other major side effects of phenytoin use are an increase in body hair, rash, folic acid depletion, and decreased bone density (osteoporosis). Incorrect Answers: [A. Diet high in iron] Long-term use of phenytoin can cause folic acid deficiency and decreased bone density. Therefore, a diet high in folic acid and calcium should be recommended. [C. Shaving with an electric razor] Clients who use anticoagulants (eg, warfarin, rivaroxaban, apixaban) should avoid cuts and preferably use an electric razor for shaving. [D. Use of sunglasses for eye protection] Exposure of the eyes to ultraviolet light and use of corticosteroids are risk factors for cataract development. Educational objective:The nurse should encourage the client taking phenytoin to perform good oral hygiene and visit the dentist regularly to prevent gingival hyperplasia. The other major side effects of phenytoin use are an increase in body hair, rash, folic acid depletion, and decreased bone density (osteoporosis).

A client with cancer pain is prescribed oxycodone. Which information is most essential to reinforce in order to help prevent long-term complications? A. How to assess blood pressure daily B. How to prevent constipation C. How to prevent itching D. How to prevent nausea

Correct Answer: B. How to prevent constipation Oxycodone is a morphine-like opioid medication. Opioid medications bind to opioid receptors in the intestine, which slows peristalsis and increases water absorption, leading to constipation. Constipation is an almost universally expected side effect from opioid medications. Clients will not develop tolerance to this side effect. Although clients with idiopathic chronic constipation are not commonly advised to take laxatives, opioid-induced constipation is treated with simultaneous use of senna (stimulant) and docusate (stool softener). Incorrect Answers: [A. How to assess blood pressure daily] Opioids cause the release of histamine, a vasodilator, which is responsible for pruritus and flushing. Opioids can also cause peripheral vasodilation and nervous system depression; both can lead to hypotension. These develop in some clients when the treatment is initiated but usually resolve over time. Antihistamines (eg, diphenhydramine) can prevent the pruritus. Lifestyle changes (eg, rising slowly from a seated position) and adequate hydration can prevent hypotension. [C. How to prevent itching] Opioids cause the release of histamine, a vasodilator, which is responsible for pruritus and flushing. Opioids can also cause peripheral vasodilation and nervous system depression; both can lead to hypotension. These develop in some clients when the treatment is initiated but usually resolve over time. Antihistamines (eg, diphenhydramine) can prevent the pruritus. Lifestyle changes (eg, rising slowly from a seated position) and adequate hydration can prevent hypotension. [D. How to prevent nausea] Opioids stimulate the opioid receptors in the gastrointestinal tract and the chemoreceptor trigger zone in the brain, producing nausea. This is also not seen with long-term use. Antiemetics (eg, ondansetron) can be helpful. Educational objective:Constipation is an expected long-term side effect of opioid use; clients will not develop tolerance to this side effect. It is important to teach aggressive preventive measures (eg, defecate when the urge is felt, drink 2-3 L of fluid/day, high-fiber diet, exercise) and simultaneous use of a stool softener and a stimulant.

A client with asthma and sinusitis has increased wheezing and decreased peak flow readings. The nurse recognizes that which of the following over-the-counter home medications taken by the client could be contributing to increased asthma symptoms? A. Guaifenesin 600 mg orally twice a day as needed B. Ibuprofen 400 mg orally every 6 hours for pain as needed C. Loratadine 1 tablet orally every day as needed D. Vitamin D 2,000 units orally every day

Correct Answer: B. Ibuprofen 400 mg orally every 6 hours for pain as needed Two groups of commonly used drugs, nonsteroidal anti-inflammatory drugs and beta-adrenergic antagonists (beta blockers), have the potential to cause problems for clients with asthma. Ibuprofen (Motrin) and aspirin are common over-the-counter anti-inflammatory drugs that are effective in relieving pain, discomfort, and fever. About 10%-20% of asthmatics are sensitive to these medications and can experience severe bronchospasm after ingestion. This is prevalent in clients with nasal polyposis. Incorrect Answers: [A. Guaifenesin 600 mg orally twice a day as needed] Guaifenesin (Mucinex) is an expectorant used to thin respiratory secretions and should not have the potential to exacerbate asthma or cause an attack. [C. Loratadine 1 tablet orally every day as needed] Loratadine (Claritin) is an antihistamine and should not have the potential to exacerbate asthma or cause an attack. [D. Vitamin D 2,000 units orally every day] Vitamin D is used to help maintain bone density and should not have the potential to exacerbate asthma or cause an attack. Educational objective:Ibuprofen and aspirin are common over-the-counter anti-inflammatory drugs that can cause bronchospasm in some clients with asthma.

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

Correct Answer: B. Improvement in spontaneous activity 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. Incorrect Answers: [A. Improvement in short-term memory] 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. [C. Reduction in number of visual hallucinations] 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. [D. Reduction of dizziness with standing] 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).

A client is in the cardiovascular clinic for a 3-month follow-up visit. At the first visit, the client was prescribed hydrochlorothiazide and amlodipine for hypertension. Which statement by the client would be concerning and should be reported to the registered nurse? A. "I like to have a banana every morning with breakfast." B. "I occasionally experience slight dizziness when I get up in the morning." C. "I started taking licorice root for occasional heartburn." D. "I usually take my hydrochlorothiazide first thing in the morning."

Correct Answer: C. "I started taking licorice root for occasional heartburn." Licorice root is an herbal remedy sometimes used for gastrointestinal disorders such as stomach ulcers, heartburn, colitis, and chronic gastritis. Clients with heart disease or hypertension should be cautious about using licorice root. When used in combination with a diuretic such as hydrochlorothiazide, it can increase potassium loss, leading to hypokalemia. Hypokalemia can cause dangerous cardiac dysrhythmias. Thiazide diuretics are considered "potassium-wasting" diuretics, so this client is already at risk for hypokalemia. The addition of licorice root could potentiate the potassium loss. The nurse should report this finding to the registered nurse (RN), and the client should be discouraged from using this herbal remedy. The primary health care provider (PHCP) should also be informed. Incorrect Answers: [A. "I like to have a banana every morning with breakfast."] Bananas are rich in potassium. Eating one each morning is beneficial. [B. "I occasionally experience slight dizziness when I get up in the morning."] Diuretics and calcium channel blockers (eg, nifedipine, amlodipine, felodipine) commonly cause postural hypotension or dizziness on rising. The nurse should reinforce the importance of rising slowly and sitting on the side of the bed for a few minutes before standing up. Persistent dizziness should be reported to the RN and PHCP. [D. "I usually take my hydrochlorothiazide first thing in the morning."] Diuretics should be taken in the morning as nighttime dosing will cause nocturia and interrupted sleep. Educational objective:Licorice root can potentiate potassium loss and increase the risk for hypokalemia in a client taking thiazide diuretics. Use of licorice root should be reported to the registered nurse and primary health care provider, and the client should be discouraged from continued use.

The clinic nurse evaluates a client who was prescribed lithium therapy a month ago for bipolar disorder. Which client statement would cause the most concern? A. "I've felt the need for an afternoon nap most days this week." B. "I've gained 3 lb (1.36 kg) since I began taking this medication." C. "I've had the stomach flu for the past couple of days." D. "My mouth seems to be drier than usual lately."

Correct Answer: C. "I've had the stomach flu for the past couple of days." Lithium is often used in the treatment of bipolar disorder. It has expected, mild side effects as well as potentially serious ones related to drug toxicity. Drowsiness, weight gain, dry mouth, and gastrointestinal upset are expected, mild side effects. Lithium toxicity occurs with dehydration, hyponatremia, decreased renal function, and drug-drug interactions (eg, nonsteroidal anti-inflammatory drugs, thiazide diuretics). Lithium and sodium are closely related in the body. Acute viral gastroenteritis (stomach flu) presents with abrupt onset of diarrhea, nausea, vomiting, and abdominal pain. Clients with vomiting and diarrhea are at risk of developing dehydration and/or low serum sodium, increasing the risk for lithium toxicity. Incorrect Answers: [A. "I've felt the need for an afternoon nap most days this week."] Drowsiness is an expected side effect. The nurse should advise the client to avoid hazardous activities and driving until the effects of lithium are known or this side effect subsides. [B. "I've gained 3 lb (1.36 kg) since I began taking this medication."] Weight gain is an expected side effect. The nurse should provide client education about healthy food choices and proper exercise and/or provide for a dietary consult. [D. "My mouth seems to be drier than usual lately."] Dry mouth is an expected side effect. The nurse should provide client teaching about measures to counteract this side effect (eg, ice chips, sugarless gum or candy, drinking plenty of water). However, excessive urination and polydipsia indicate nephrogenic diabetes insipidus from lithium toxicity. Educational objective:Dehydration and sodium loss from vomiting and diarrhea can lead to toxic lithium levels in clients receiving lithium therapy.

The nurse is reviewing teaching about newly prescribed clonazepam with a client who is receiving palliative care for cancer. Which client statement shows a correct understanding of the nurse's teaching? A. "I am glad that I can continue to take my kava supplement each morning." B. "If I can't sleep, I will take some melatonin with my evening dose of clonazepam." C. "If I feel restless, I can put some drops of lavender essential oil in a diffuser to calm myself." D. "When my anxiety is getting really intense, I will drink some valerian tea to help me relax."

Correct Answer: C. "If I feel restless, I can put some drops of lavender essential oil in a diffuser to calm myself." Lavender aromatherapy is a safe, low-risk intervention to implement in conjunction with anxiolytic medications (Option 3). The nurse must evaluate the client's use of all complementary and alternative therapies to ensure that there are no potential interactions with prescribed medications and therapies. The active compounds in lavender essential oil promote relaxation and sleep without interacting with prescription medications. Essential oils can be inhaled directly as a vapor, diffused via a mist, or dropped onto linens. Incorrect Answer: [A. "I am glad that I can continue to take my kava supplement each morning."] The herbal supplements kava and valerian root—both used for anxiety, insomnia, and depression—may increase central nervous system (CNS) depression when used with benzodiazepines (eg, clonazepam). Kava should not be combined with benzodiazepines because this increases the risk of hepatotoxicity. [B. "If I can't sleep, I will take some melatonin with my evening dose of clonazepam."] Melatonin is a hormone supplement used at bedtime to promote sleep and may increase drowsiness and CNS depression when taken with clonazepam. Combining melatonin with benzodiazepine medications can exaggerate side effects of the benzodiazepine (eg, dizziness, impaired concentration, daytime sleepiness). [D. "When my anxiety is getting really intense, I will drink some valerian tea to help me relax."] The herbal supplements kava and valerian root—both used for anxiety, insomnia, and depression—may increase central nervous system (CNS) depression when used with benzodiazepines (eg, clonazepam). Kava should not be combined with benzodiazepines because this increases the risk of hepatotoxicity. Educational objective:Lavender aromatherapy is a safe, low-risk, complementary intervention for clients experiencing anxiety. Valerian root, kava, and melatonin may potentiate the adverse effects of clonazepam or other benzodiazepines, and should not be combined with them.

The nurse reinforces teaching for a client newly prescribed buspirone for generalized anxiety disorder. Which client statement indicates that teaching has been effective? A. "Driving is not recommended until I stop taking this medication." B. "If I experience a panic attack I should take an extra dose of medication." C. "It will be 2-4 weeks before I feel the full effect of this medication." D. "Withdrawal symptoms will occur if I abruptly stop taking this medication."

Correct Answer: C. "It will be 2-4 weeks before I feel the full effect of this medication." Buspirone (Buspar) is an anxiolytic medication that differs from other medications used to manage anxiety disorders (eg, benzodiazepines) because it typically lacks central nervous system depressant effects and has a low abuse potential. Therefore, buspirone has a favorable side-effect profile because it usually does not produce withdrawal symptoms, dependence, or psychomotor slowing (eg, slowing of thought, impaired movement). However, unlike other anxiolytic medications, buspirone does not work immediately. Onset of symptom relief occurs after 1 week of therapy, with full effects occurring between 2 and 4 weeks. Incorrect Answers: [A. "Driving is not recommended until I stop taking this medication."] As with any medication, the nurse should advise clients to avoid driving until individual effects are known. However, it is unlikely that buspirone will cause psychomotor impairment and require cessation of driving or operating machinery for the duration of treatment. [B. "If I experience a panic attack I should take an extra dose of medication."] Buspirone should be taken as prescribed and is not indicated for relief of acute anxiety or panic attacks. The health care provider may prescribe an additional medication with a fast-acting effect for panic attacks. [D. "Withdrawal symptoms will occur if I abruptly stop taking this medication."] Buspirone does not cause physical dependence or tolerance, and withdrawal symptoms do not occur with discontinuation of use. Educational objective:Buspirone is an anxiolytic medication that does not have central nervous system depressant effects; therefore, it does not cause dependence, tolerance, psychomotor slowing, or withdrawal symptoms. Full therapeutic effects occur between 2 and 4 weeks of therapy.

The nurse reinforces education to the parent of a child who was diagnosed with attention-deficit hyperactivity disorder and received a prescription of methylphenidate. Which statement by the parent best demonstrates that teaching has been effective? A. "An additive-free, low-sugar diet will reduce my child's symptoms." B. "I can now manage my child's condition on my own." C. "My child should take the last daily dose of methylphenidate before 6:00 PM." D. "Once the medication is started, I will not have to monitor my child anymore."

Correct Answer: C. "My child should take the last daily dose of methylphenidate before 6:00 PM." Stimulants (eg, methylphenidate, dextroamphetamine, lisdexamfetamine) are first-line agents in the treatment of attention-deficit hyperactivity disorder (ADHD). Methylphenidate (Ritalin) is administered in divided doses 2 or 3 times daily, usually 30-45 minutes before meals. As a stimulant, methylphenidate may interfere with sleep and should be given no later than around 6:00 PM. The sustained-release preparation should be given in the morning. The dosage in children is usually started low and titrated to the desired response. Children should be monitored closely during initial treatment for development of tics and continuously for adherence and response to therapy. Incorrect Answers: [A. "An additive-free, low-sugar diet will reduce my child's symptoms."] Contrary to popular myth, sugar does not increase hyperactivity; although an additive-free diet may be a healthy approach for children, eliminating additives or food colorings does not decrease the symptoms of ADHD. [B. "I can now manage my child's condition on my own."] A team approach (parents, teachers, and health care providers) is the most effective way to help a child with ADHD. School-based interventions may include specific classroom modifications or accommodations to be incorporated into the treatment plan. [D. "Once the medication is started, I will not have to monitor my child anymore."] Children should be monitored closely during initial treatment for development of tics and continuously for adherence and response to therapy Educational objective:Methylphenidate is a stimulant drug with the potential to cause insomnia. Parents are instructed to administer the last dose no later than 6:00 PM to prevent sleep disruption.

The nurse is preparing to administer a sodium polystyrene sulfonate retention enema. Which explanation by the nurse best describes the purpose of this type of enema? A. "A contrast medium is administered rectally to visualize the colon via x-ray." B. "Bedridden clients receive this enema to stimulate defecation and relieve constipation." C. "This enema assists the large intestines in removing excess potassium from the body." D. "This enema is administered before bowel surgery to decrease bacteria in the colon."

Correct Answer: C. "This enema assists the large intestines in removing excess potassium from the body." Sodium polystyrene sulfonate (Kayexalate) retention enema is a medicated enema administered to clients with high serum potassium levels. The resin in Kayexalate replaces sodium ions for potassium ions in the large intestine and promotes evacuation of potassium-rich waste from the body, thereby lowering the serum potassium level. Kayexalate can also be given orally and is much more effective. Kayexalate can rarely be associated with intestinal necrosis. Incorrect Answers: [A. "A contrast medium is administered rectally to visualize the colon via x-ray."] A barium enema uses contrast medium (barium) administered rectally to visualize the colon using fluoroscopic x-ray. [B. "Bedridden clients receive this enema to stimulate defecation and relieve constipation."] A fleet enema relieves constipation by infusing a hypertonic solution into the bowel, pulling fluid into the colon and causing distension and then defecation. [D. "This enema is administered before bowel surgery to decrease bacteria in the colon."] A neomycin enema is a medicated enema that reduces the number of bacteria in the intestine in preparation for colon surgery. Educational objective:Kayexalate retention enemas are medicated enemas administered to clients with high serum potassium levels. The resin in Kayexalate replaces sodium ions for potassium ions in the large intestine and promotes evacuation of potassium-rich waste from the body, thereby lowering the serum potassium level.

The nurse administers the prescribed dose of hydromorphone 2 mg to a client who is 2 days postoperative from a colostomy. Which assessment finding is most important for the nurse to follow-up? A. Client has 1 emesis of green fluid B. Client has had no bowel movement for 2 days C. Client falls asleep while talking to the nurse D. Client reports experiencing pruritus

Correct Answer: C. Client falls asleep while talking to the nurse Respiratory depression is the most serious side effect of narcotic medication. Sedation precedes respiratory depression. Falling asleep during a conversation scores "3" on the Pasero Opioid-Induced Sedation Scale (POSS); no additional narcotics should be given to the client. Other classes of drugs (eg, non-steroidal anti-inflammatory medications) can be given if the client is still in pain. The client will also be at increased risk for respiratory depression if the pain is completely relieved and/or it is night time. No additional narcotics should be given until the client is at level 2 sedation on POSS (eg, slightly drowsy, easily aroused). Incorrect Answers: [A. Client has 1 emesis of green fluid] Nausea or vomiting is a typical side-effect of narcotic administration, especially when it is given in a larger dose or to the opioid-naïve client. It usually lessens with time and repeat administration. Nausea or vomiting would not be a concern unless it is excessive or severe. The nurse should ensure that the client receives adequate hydration (eg, intravenous fluids, clear liquids, antiemetics). [B. Client has had no bowel movement for 2 days] Constipation is a known side effect of opioid administration and does not lessen with long-term administration. Proactive measures are needed as long as the client is on narcotics. However, large intestine peristalsis does not usually start until 2-3 days after surgery. [D. Client reports experiencing pruritus] Pruritus (itching) is a known side effect of narcotic administration. It is usually treated with diphenhydramine (Benadryl) or some other antihistamine. Educational objective:Sedation precedes respiratory depression in narcotic administration. A client (especially if on high doses) should be assessed for sedation level. Level 3 sedation on POSS requires that no additional narcotics be administered to the client.

The health care provider prescribes phenazopyridine hydrochloride for a client with a urinary tract infection. What would the office nurse remind the client to expect while taking this medication? A. Constipation B. Difficulty sleeping C. Discoloration of urine D. Dry mouth

Correct Answer: C. Discoloration of urine 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. Incorrect Answers: [A. Constipation] Constipation, difficulty sleeping, and dry mouth are not common adverse effects of phenazopyridine hydrochloride. [B. Difficulty sleeping] Constipation, difficulty sleeping, and dry mouth are not common adverse effects of phenazopyridine hydrochloride. [D. Dry mouth] 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 practical nurse is assisting the registered nurse in assessing a child with attention-deficit hyperactivity disorder at the clinic for a well-child visit. The client has been taking methylphenidate for a year. What are the priority nursing assessments? A. Attention span and activity level B. Dental health and mouth dryness C. Height/weight and blood pressure D. Progress with schoolwork and in making friends

Correct Answer: C. Height/weight and blood pressure Methylphenidate (Ritalin, Concerta) is a central nervous system stimulant used to treat attention-deficit hyperactivity disorder (ADHD) and narcolepsy. It affects neurotransmitters (dopamine and norepinephrine) in the brain that contribute to hyperactivity and lack of impulse control. A common side effect of methylphenidate is loss of appetite with resulting weight loss. Parents and caregivers should be instructed to weigh the child with ADHD at least weekly due to the risk of temporary interruption of growth and development. It is very important to compare weight/height measures from one well-child checkup to the next. If weight loss becomes a serious problem, methylphenidate can be given after meals; however, before meals is preferable. Another side effect of methylphenidate is increased blood pressure and tachycardia. These should be monitored before and after starting treatment with stimulants. Incorrect Answers: [A. Attention span and activity level] Therapeutic effects of methylphenidate include increased attention span and decreased hyperactivity. These would be important components of a well-child assessment, but not the priority. [B. Dental health and mouth dryness] Evaluating dental health is part of any well-child assessment. Dry mouth is not a common side effect of methylphenidate. [D. Progress with schoolwork and in making friends] Expected outcomes of methylphenidate therapy include improvement in schoolwork and social relationships. These would be important components of a well-child assessment, but not the priority. Educational objective:Side effects of methylphenidate therapy that require ongoing monitoring are loss of appetite leading to delayed growth and development and increased blood pressure. Children with attention-deficit hyperactivity disorder should be weighed regularly at home or school. Any weight loss trend should be discussed with the health care provider. Also, weight/height measures from one well-child checkup to the next need to be compared. Blood pressure and cardiac function should also be monitored on an ongoing basis.

The women's health nurse is caring for a 30-year-old client who wants to use the ethinyl estradiol and norelgestromin patch for contraception. Regarding this method of birth control, which finding should be most concerning to the nurse? A. Client reports heavy menstrual cycles B. History of breast cancer in maternal aunt C. History of deep venous thrombosis D. Weight is 186 lb (84.4 kg) and BMI is 31.0 kg/m*2

Correct Answer: C. History of deep venous thrombosis The transdermal contraceptive patch (ethinyl estradiol and norelgestromin) is a combined hormonal contraceptive (CHC) that is absorbed through the skin. The client applies a patch weekly for 3 weeks, then removes it for 1 hormone-free week. The patch has similar contraindications as other CHCs, and some research shows that the patch may have an increased risk of thromboembolism (compared with oral contraception) due to higher serum concentrations of estrogen. A history of deep venous thrombosis (DVT) is the most concerning finding because of the additional risk of thromboembolic events when using CHCs. Incorrect Answers: [A. Client reports heavy menstrual cycles] CHCs help regulate menstrual cycles, typically reducing the amount of bleeding during menses; therefore, heavy menses is not as concerning as the client's history of DVT. [B. History of breast cancer in maternal aunt] A personal history of breast cancer or the breast cancer susceptibility gene (BRCA) is concerning because contraceptives may stimulate hormone-dependent tumor growth. The nurse should report the family history to the health care provider, but it is not more concerning than a personal history of DVT or breast cancer. [D. Weight is 186 lb (84.4 kg) and BMI is 31.0 kg/m*2] The patch may have a higher failure rate in obese clients who are approximately >200 lb (90.7 kg) and should be avoided. The nurse should counsel the client about diet and exercise, but this is not more important than the client's history of DVT. Educational objective:The transdermal contraceptive patch (ethinyl estradiol and norelgestromin) is a combined hormonal contraceptive (CHC). As with all CHCs, a client history of thromboembolic events should concern the nurse because it may increase the risk of thromboembolic events while using the patch.

The nurse working on the inpatient psychiatric unit is preparing to administer 9:00 AM medications to a client. The medication administration record is shown in the exhibit. On assessment, the client is tremulous, exhibits muscle rigidity, and has a temperature of 101.1 F (38.4 C). Which action should the nurse take? A. Give all medications, including acetaminophen, and reassess in 30 minutes B. Hold the haloperidol, give acetaminophen, and reassess in 30 minutes C. Hold the haloperidol and notify the health care provider (HCP) immediately D. Hold the hydrochlorothiazide and notify the HCP immediately

Correct Answer: C. Hold the haloperidol and notify the health care provider (HCP) immediately This client is exhibiting signs and symptoms of neuroleptic malignant syndrome (NMS), a rare but potentially life-threatening reaction. NMS is most often seen with the "typical" antipsychotics (eg, haloperidol, fluphenazine). However, even the newer "atypical" antipsychotic drugs (eg, clozapine, risperidone, olanzapine) can cause the syndrome. NMS is characterized by fever, muscular rigidity, altered mental status, and autonomic dysfunction (eg, sweating, hypertension, tachycardia). Treatment is supportive and is directed at reducing fever and muscle rigidity and preventing complications. Treatment in an intensive care unit (ICU) may be required. The most important intervention is to immediately discontinue the antipsychotic medication and notify the HCP for further assessment. Incorrect Answers: [A. Give all medications, including acetaminophen, and reassess in 30 minutes] Administering acetaminophen may be appropriate, but it is more important to discontinue the haloperidol and notify the HCP immediately. [B. Hold the haloperidol, give acetaminophen, and reassess in 30 minutes] Due to the life-threatening nature of NMS, the HCP should be informed immediately. The HCP may order muscle enzymes, administer IV fluids/medications, and move the client for close monitoring (eg, to the ICU). [D. Hold the hydrochlorothiazide and notify the HCP immediately] Hydrochlorothiazide is a diuretic commonly used for hypertension. It does not cause NMS symptoms. Educational objective:NMS is characterized by fever, muscle rigidity, altered mental status, and autonomic dysfunction. The most important intervention is to discontinue the antipsychotic medication.

The practical nurse on the neurosurgery step-down unit is assisting the registered nurse in the care of a stable client with a closed-head injury who is 1 day post craniotomy. The practical nurse prepares to administer the 7:00 AM medications and reviews the client's medication administration record. Which prescription prompts the practical nurse to contact the prescribing health care provider for clarification? Allergies: None Medications | Time Gabapentin: 300 mg orally, every 8 hours | 0700, 1500, and 2300 Hydrocodone/acetaminophen: (5 mg/325 mg) orally, every 4 hours | Every 4 hours prn Acetamnophen: 1,000 mg IV, every 6 hours | 0600, 1200, 1800, and 2400 Phenytoin: 100 mg orally, every 12 hours | 0700 and 1900 A. Acetaminophen 1,000 mg IV, every 6 hours B. Gabapentin 300 mg orally, every 8 hours C. Hydrocodone/acetaminophen (5 mg/325 mg) orally, every 4 hours prn D. Phenytoin 100 mg orally, every 12 hours

Correct Answer: C. Hydrocodone/acetaminophen (5 mg/325 mg) orally, every 4 hours prn The recommended dose for acetaminophen should not exceed 4 g in 24 hours as excessive intake can lead to liver injury. The nurse should contact the health care provider (HCP) to question the prescription for the prn opioid analgesic hydrocodone/acetaminophen (5 mg/325 mg) (Vicodin). This client is already receiving acetaminophen 1,000 mg IV every 6 hours (4,000 mg). If the client needed and received the maximum possible dosage of 6 tablets of hydrocodone/acetaminophen (5 mg/325 mg), the total dose of acetaminophen (4,000 mg + 1,950 mg [6 tablets] = 5,950 mg) would exceed the recommended daily dosage. Incorrect Answers: [A. Acetaminophen 1,000 mg IV, every 6 hours] Acetaminophen (Tylenol) is an antipyretic and nonopioid analgesic. The HCP may prescribe this drug to manage mild to moderate pain and fever in the initial postoperative period. Its antipyretic effects can mask fever in clients medicated for postoperative pain. The nurse would not question this prescription. [B. Gabapentin 300 mg orally, every 8 hours] Gabapentin (Neurontin) is an analgesic adjunct and anticonvulsant drug prescribed to promote comfort and decrease the incidence of seizures. The nurse would not question this prescription. [D. Phenytoin 100 mg orally, every 12 hours] Phenytoin (Dilantin) is an anticonvulsant prescribed to prevent and/or treat post-traumatic seizure activity in clients following a head injury. The nurse would not question this prescription. Educational objective:Taking higher than recommended doses of acetaminophen can lead to hepatotoxicity. The nurse should monitor the total amount of acetaminophen administered to a client in a 24-hour period, including the amount combined with opioid drugs (eg, hydrocodone/acetaminophen [Vicodin]). The nurse would notify the health care provider if the combined dose exceeds the recommended dosage of 4 g in 24 hours.

The nurse reinforces discharge teaching for the parent of a child newly prescribed methylphenidate for attention-deficit hyperactivity disorder. The nurse advises the parent that the child might experience which side effects? A. Decreased blood pressure and growth delays B. Heart palpitations and weight gain C. Loss of appetite and restlessness D. Trouble sleeping and a dry cough

Correct Answer: C. Loss of appetite and restlessness Stimulant medications are commonly used to treat attention-deficit hyperactivity disorder (ADHD) in children and adults. Methylphenidate (Ritalin) and amphetamines (eg, dextroamphetamine, lisdexamfetamine) are the most commonly used stimulants. The major problems with stimulant medications include: 1. Decreased appetite and weight loss - can lead to growth delays 2. Cardiovascular effects - hypertension and tachycardia (particularly in adults) 3. Appearance of new or exacerbation of vocal/motor tics 4. Excess brain stimulation - restlessness, insomnia 5. Abuse potential - misuse, diversion, addiction Incorrect Answers: [A. Decreased blood pressure and growth delays] Growth delays are a common side effect. The medications may cause hypertension, not hypotension. [B. Heart palpitations and weight gain] Heart palpitations are a common side effect; weight loss, not weight gain, can be a problem. [D. Trouble sleeping and a dry cough] Trouble sleeping is a common side effect, but the medications do not cause a dry cough. Educational objective:Methylphenidate (Ritalin), a central nervous system stimulant used to treat attention-deficit hyperactivity disorder, has the following potential side effects: anorexia and weight loss/growth delays, restlessness and insomnia, hypertension and tachycardia, vocal or motor tics, and abuse potential.

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? A. Evening primrose B. Ginseng C. Melatonin D. St. John's Wort

Correct Answer: C. Melatonin 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. Incorrect Answer: [A. Evening primrose] Evening primrose may be used for eczema or skin irritations. [B. Ginseng] Ginseng is used to promote mental alertness and enhance the immune system. [D. St. John's Wort] 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 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? A. Blood urea nitrogen of 12 mg/dL (4.28 mmol/L) B. BMI of 34 kg/m2 recorded during today's examination C. Past medical history of uncontrolled hypertension D. Takes alprazolam as prescribed for anxiety

Correct Answer: C. Past medical history of uncontrolled hypertension 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. Incorrect Answers: [A. Blood urea nitrogen of 12 mg/dL (4.28 mmol/L)] 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]). [B. BMI of 34 kg/m2 recorded during today's examination] Sumatriptan is not contraindicated for underweight or overweight clients. [D. Takes alprazolam as prescribed for anxiety] 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.

The health care provider 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? A. Encourage increased fluid intake B. Provide frequent rest periods C. Remind the client to get up slowly from the bed or a sitting position D. Remind the client to wear sunglasses when outdoors

Correct Answer: C. Remind the client to get up slowly from the bed or a sitting position Tricyclic antidepressants (eg, amitriptyline, nortriptyline, desipramine, imipramine) are commonly used for neuropathic pain. Side effects are especially common in elderly clients. 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. Incorrect Answers: [A. Encourage increased fluid intake] These are important instructions but not priority ones. [B. Provide frequent rest periods] These are important instructions but not priority ones. [C. Remind the client to get up slowly from the bed or a sitting position] 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.

The nurse is caring for a client with asthma exacerbation. Blood pressure is 146/86 mm Hg, pulse is 110/min, and respirations are 32/min. The respiratory therapist administers nebulized albuterol as prescribed. One hour after the treatment, the nurse assesses which finding that indicates the drug is producing the therapeutic effect? A. Constricted pupils B. Heart rate of 120/min C. Respirations of 24/min D. Tremor

Correct Answer: C. Respirations of 24/min Albuterol (Proventil) is a short-acting inhaled beta-2 agonist used to control airway obstruction caused by chronic obstructive pulmonary disease, asthma, or bronchitis. It also is used to prevent exercise-induced asthma. The therapeutic effect is relaxation of the smooth muscles of the airways, which results in immediate bronchodilation. Bronchodilation decreases airway resistance, facilitates mucus drainage (expectorates mucus plugs), decreases the work of breathing, and increases oxygenation. As a result of these actions, the respiratory rate will decrease and peak flow will be increased (if tested). However, short-acting beta-2 agonists are associated with the following side effects (not therapeutic effects): tremor (most frequent), tachycardia and palpitations, restlessness, and hypokalemia. These side effects are due to the oral deposition of medication (subsequent systemic absorption) and can be reduced with the use of a spacer or chamber device. The presence of constricted pupils is neither a side effect nor therapeutic effect of the drug. Constricted pupils are often seen with opioid medications (eg, morphine, oxycodone). Educational objective:Albuterol (Proventil) is a short-acting beta-2 agonist that produces immediate bronchodilation by relaxing smooth muscles. Bronchodilation decreases airway resistance, facilitates mucus drainage, decreases the work of breathing, and increases oxygenation. Peak flow will improve. The most frequent side effects are tremor, tachycardia, restlessness, and hypokalemia.

The nurse is reinforcing discharge teaching to several clients with new prescriptions. Which instructions by the nurse about medication administration are correct? Select all that apply. A. Avoid salt substitutes when taking valsartan for hypertension B. Take levofloxacin with an aluminum antacid to avoid gastric irritation C. Take sucralfate (for a gastric ulcer) after meals to minimize gastric irritation D. When taking ethambutol, notify the health care provider (HCP) for changes in vision E. When taking rifampin, notify the HCP if the urine turns red-orange in color

Correct Answer: A and D Both angiotensin-converting enzyme (ACE) inhibitors ("prils" - captopril, enalapril, lisinopril, ramipril) and angiotensin receptor blockers ("sartans" - valsartan, losartan, telmisartan) can cause hyperkalemia. Salt substitutes contain high potassium and must not be taken without consulting the health care provider (HCP). Ethambutol (Myambutol) is used to treat tuberculosis but can result in an ocular toxicity that causes loss of vision and red-green color discrimination. Vision acuity and color discrimination must be monitored regularly Incorrect Answers: [B. Take levofloxacin with an aluminum antacid to avoid gastric irritation] Levofloxacin (Levaquin) is a quinolone antibiotic. For this class of antibiotics, 2 hours should pass between the drug ingestion and taking aluminum/magnesium antacids, iron supplements, multivitamins with zinc, or sucralfate. In addition, these substances can bind up to 98% of the drug, making it ineffective. [C. Take sucralfate (for a gastric ulcer) after meals to minimize gastric irritation] Sucralfate (Carafate) should be administered before meals (ac) to coat the mucosa to prevent irritation from acid during meals. It should also be administered at least 30 minutes to 2 hours before or after other medications to prevent these medications from binding with sucralfate, rendering the medications less effective. [E. When taking rifampin, notify the HCP if the urine turns red-orange in color] Rifampin (Rifadin) normally causes red-orange discoloration of all body fluids. The client should be alerted about this possible change, but it does not require the client to notify the HCP. In addition, most antituberculosis medications (eg, rifampin, isoniazid, pyrazinamide) can cause hepatitis. Educational objective:Watch for vision changes with ethambutol. Do not give potassium supplements or salt substitutes to a client taking an angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker. Sucralfate must be given before meals to coat the gastric ulcer mucosa. Quinolone antibiotics should not be given with antacids or supplements that will bind with the drug.

A client with obesity has just started taking orlistat. Which statement by the client indicates a need for further teaching? A. "I have started taking a daily multivitamin with my dinner-time dose of medication." B. "I may have oily stools and fecal incontinence when taking this medication." C. "I will consume a low-fat diet in which no more than 30% of my calories are from fat." D. "I will take my medication with, or within 1 hour of, meals that contain fat."

Correct Answer: A. "I have started taking a daily multivitamin with my dinner-time dose of medication." Orlistat is a lipase inhibitor that prevents the breakdown and absorption of fats from the intestine. This medication is prescribed to clients with obesity who have difficulty losing weight or a comorbidity that makes weight loss therapeutically essential (eg, diabetes, heart disease). Orlistat should always be used with diet modification and an exercise regimen. Because orlistat blocks the absorption of fats, it also interferes with fat-soluble vitamin uptake. Clients should offset this effect by taking a multivitamin that contains vitamins A, D, E, and K. To be most effective, multivitamins should be taken >2 hours after taking orlistat. Incorrect Answers: [B. "I may have oily stools and fecal incontinence when taking this medication."] Clients may experience fecal incontinence, flatulence, oily stools, and oily spotting because unabsorbed fat is eliminated through defecation. [C. "I will consume a low-fat diet in which no more than 30% of my calories are from fat."] A low-fat diet is an essential component of weight loss when a lipase inhibitor has been prescribed. [D. "I will take my medication with, or within 1 hour of, meals that contain fat."] The nurse should teach the client to take orlistat with, or within 1 hour of, meals that contain fat. If the client selects foods that do not contain fat, the dose may be skipped. Educational objective:Orlistat, a lipase inhibitor, prevents the absorption of fat from the gastrointestinal tract and is used with diet (eg, low-fat) and exercise to promote weight loss. Because orlistat blocks the absorption of fats, it also interferes with the uptake of fat-soluble vitamins. Clients should take a daily multivitamin with vitamins A, D, E, and K >2 hours after taking orlistat to prevent nutrient deficiencies.

A nurse is caring for a client with type 2 diabetes mellitus who was recently started on pioglitazone. Which client data obtained by the nurse is most important to report to the registered nurse? A. Bilateral pitting edema in ankles B. Blood pressure is 140/88 mm Hg C. Most recent HbA1c is 6.7% D. Retinal photocoagulation in right eye

Correct Answer: A. Bilateral pitting edema in ankles Thiazolidinediones (also called glitazones; 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. Incorrect Answers: [B. Blood pressure is 140/88 mm Hg] The target blood pressure for a client with diabetes is <140/90 mm Hg. [C. Most recent HbA1c is 6.7%] The goal HbA1c for a client with diabetes is <7%. [D. Retinal photocoagulation in right eye] 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 increases insulin sensitivity but carries a low risk for hypoglycemia (similar to metformin).

Which client finding would be a contraindication for the nurse to administer dicyclomine hydrochloride for irritable bowel syndrome? A. Bladder scan showing 500 mL urine B. Hemoglobin of 11 g/dL (110 g/L) C. History of cataracts D. Reporting frequent diarrhea today

Correct Answer: A. Bladder scan showing 500 mL urine Dicyclomine hydrochloride (Bentyl) is an anticholinergic medication. Anticholinergics are used to relax smooth muscle and dry secretions. Anticholinergic side effects include pupillary dilation, dry mouth, urinary retention, and constipation. Therefore, the classic contraindications are closed-angle glaucoma, bowel ileus, and urinary retention. The urge to urinate is normally present at 300 mL; pain is usually felt around 500 mL. This client has urinary retention and should not have the bladder smooth muscle further relaxed. Incorrect Answers: [B. Hemoglobin of 11 g/dL (110 g/L)] Anticholinergic drugs do not affect the blood count. The normal reference range for hemoglobin is 11.7-15.5 g/dL (117-155 g/L) for females and 13.2-17.3 g/dL (132-173 g/L) for males. [C. History of cataracts] The common eye contraindication is narrow-angle glaucoma as it could worsen the condition. Cataracts are a clouding of the lens and are not related to drainage flow. [D. Reporting frequent diarrhea today] Diarrhea is an expected finding with irritable bowel syndrome or other increased peristalsis and is a common reason for the drug to be prescribed. Anticholinergic drugs are contraindicated in the presence of a bowel ileus or atony as constipation is a side effect and further relaxation of the intestines could worsen these conditions. Educational objective:Anticholinergic drugs are contraindicated when smooth muscle relaxation is already a concern. Commonly cited contraindications include narrow-angle glaucoma, urinary retention (including benign prostatic hyperplasia), and bowel ileus/obstruction.

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 to reinforce for this client? 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 A. Bleeding Risk B. Bronchospasm C. Muscle injury D. Tinnitus

Correct Answer: A. Bleeding Risk This client is on 3 different medications that increase bleeding risk (aspirin, clopidogrel, and rivaroxaban). The highest priority for the nurse is to reinforce client teaching on the signs/symptoms and risk reduction of bleeding. The client should be instructed 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. Incorrect Answer: [B. Bronchospasm] This client is on low-dose aspirin and metoprolol; bronchospasm rarely occurs with high doses of these medications. Although this should be a teaching topic for the client, bleeding is more likely to occur. [C. Muscle injury ] 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. [D. Tinnitus] 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 client is prescribed long-term pharmacologic therapy with hydroxychloroquine to treat systemic lupus erythematosus. The nurse should reinforce teaching about which intervention related to the drug's adverse effects? A. Have an ophthalmologic examination every 6 months B. Take the medication on an empty stomach C. Take vitamin D and calcium supplements D. Wear a MedicAlert bracelet

Correct Answer: A. Have an ophthalmologic examination every 6 months Hydroxychloroquine (Plaquenil) is an antimalarial drug, but it is more commonly prescribed to reduce fatigue and treat the skin and arthritic (eg, joint inflammation, pain) manifestations of systemic lupus erythematosus (SLE). Hydroxychloroquine can also help to reduce lupus exacerbations in clients with inactive to mild disease, but several months can pass before its therapeutic effects become apparent. Although rare, serious adverse drug reactions such as retinal toxicity and visual disturbances can occur with hydroxychloroquine. Therefore, clients are instructed to undergo regular ophthalmologic examination every 6-12 months. Incorrect Answer: [B. Take the medication on an empty stomach] Hydroxychloroquine should be taken with food to decrease gastrointestinal upset (common side effect). [C. Take vitamin D and calcium supplements] Some clients with severe SLE are prescribed long-term corticosteroid (prednisone) therapy to prevent organ damage and are at risk for adverse reactions, such as accelerated osteoporosis. Osteoporosis is not an adverse reaction of hydroxychloroquine, and vitamin D and calcium supplementation is not required. [D. Wear a MedicAlert bracelet] There are no effects of hydroxychloroquine that would require wearing a MedicAlert bracelet. Educational objective:Hydroxychloroquine (Plaquenil) is used to treat the skin and arthritic manifestations of systemic lupus erythematosus. Taking the medication with food can help alleviate gastrointestinal upset. Serious adverse drug reactions include retinopathy and visual disturbances; therefore, regular ophthalmologic examination every 6-12 months is required.

The nurse reinforces medication instructions to a client with primary adrenal insufficiency (Addison disease) who is prescribed hydrocortisone 10 mg orally 3 times a day. Which instructions should be included? Select all that apply. A. Discontinue hydrocortisone if you have mood changes or disruptions in behavior B. Make an appointment with an optometrist yearly to assess for cataracts C. Report even a low-grade fever to the health care provider immediately D. Report signs of hyperglycemia, including increased urine, hunger, and thirst E. Take the medication on an empty stomach F. The dose of hydrocortisone may need to be decreased during times of stress

Correct Answer: B, C, and D 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. 2. Report any signs and symptoms of infection to the health care provider (HCP) immediately. Corticosteroid use can cause immunosuppression, and infection can develop quickly and spread rapidly. The anti-inflammatory effects of corticosteroids may also mask signs of infection, such as inflammation, redness, tenderness, heat, fever, and edema. 3. Stay attuned to signs and symptoms of stress, which may require an increased dose of corticosteroid. A stress response (surgery, trauma) can cause a sudden decrease in cortisol levels, triggering addisonian crisis. 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. 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. 7. Corticosteroid medications can cause gastric irritation and should not be taken on an empty stomach. 8. Recognize signs and symptoms of Cushing syndrome and report them to the HCP. 9. Develop a regular HCP-approved exercise program. Educational objective:Corticosteroids are the primary drugs used to treat Addison disease. It is imperative that the nurse teach the client about this medication, including to never stop it abruptly, notify the health care provider of signs and symptoms of infection, and monitor blood glucose closely if diabetes is a comorbid condition.

The nurse reinforces medication teaching to a client prescribed metronidazole. Which client statement indicates a need for further education? A. "I might have a metallic taste in my mouth when I'm taking this medicine." B. "I need to decrease the amount of alcohol I drink while taking this medicine." C. "I should not worry if my urine turns a dark color while taking this medication." D. "I will immediately call the clinic if I get a new rash or have skin peeling."

Correct Answer: B. "I need to decrease the amount of alcohol I drink while taking this medicine." Metronidazole is an antibiotic medication used to treat bacterial, parasitic, and protozoal infections. Nurses educating clients about metronidazole should ensure that the client is aware of drug interactions and side effects to watch for and report. The client should be instructed to abstain completely from consuming food, drinks, or products containing alcohol during, and for 3 days after, therapy. The combination of alcohol and metronidazole may cause clients to experience facial flushing, headaches, nausea, vomiting, and abdominal cramping. Incorrect Answers: [A. "I might have a metallic taste in my mouth when I'm taking this medicine."] Metronidazole commonly causes a harmless but unpleasant metallic taste in the mouth and darkening of urine (eg, brown, rust-colored). [C. "I should not worry if my urine turns a dark color while taking this medication."] Metronidazole commonly causes a harmless but unpleasant metallic taste in the mouth and darkening of urine (eg, brown, rust-colored). [D. "I will immediately call the clinic if I get a new rash or have skin peeling."] Although it is rare, metronidazole may cause Stevens-Johnson syndrome (SJS), a life-threatening complication characterized by necrosis and sloughing of the skin and mucous membranes. Clients should be educated to immediately report signs of SJS (eg, rash, skin peeling). Educational objective:Clients prescribed metronidazole are instructed to abstain from using alcohol during, and for 3 days after, therapy, as it may cause flushing, headaches, nausea, vomiting, and abdominal cramping. Metronidazole may cause a harmless metallic taste and darkened urine. Clients should immediately report any new rashes, as Stevens-Johnson syndrome can occur.

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? A. "I won't need a bolus dose of insulin before my meals anymore." B. "I'm glad my blood sugars won't go way up and way down, like they did before." C. "I'm so glad I don't have to stick my finger 4 times a day to test my sugar anymore." D. "It'll finally be easier for me to lose some weight."

Correct Answer: B. "I'm glad my blood sugars won't go way up and way down, like they did before." 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. Incorrect Answers: [A. "I won't need a bolus dose of insulin before my meals anymore."] 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. [C. "I'm so glad I don't have to stick my finger 4 times a day to test my sugar anymore."] 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. [D. "It'll finally be easier for me to lose some weight."] 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.

The nurse is reinforcing teaching to a client being discharged on enoxaparin therapy following total knee replacement surgery. Which statement made by the nurse is most appropriate? A. "Eliminate green, leafy, vitamin K-rich vegetables from your diet." B. "Mild bruising or redness may occur at the injection site." C. "You can take over-the-counter drugs such as ibuprofen to relieve mild discomfort." D. "You will need PT/INR assessments at regular intervals while on enoxaparin therapy."

Correct Answer: B. "Mild bruising or redness may occur at the injection site." Enoxaparin (Lovenox) is a low molecular weight heparin (LMWH) that may be prescribed for up to 10-14 days following hip and knee surgery to prevent deep venous thrombosis. Teaching for the client discharged on enoxaparin therapy includes the following: 1. Pinch 1 inch of skin upward and insert the needle at a 90-degree angle into the skinfold. 2. Continue to hold the skin fold throughout the injection process and then remove the needle at a 90-degree angle. 3. Mild pain, bruising, irritation, or redness of the skin at the injection site is common. Do not rub the site with the hand. Using an ice cube on the injection site can provide relief. 4. Avoid taking aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), and herbal supplements (eg, Ginkgo biloba, vitamin E) without health care provider approval as these can increase bleeding risk. 5. Monitor complete blood count (CBC) to assess for thrombocytopenia. Incorrect Answers: [A. "Eliminate green, leafy, vitamin K-rich vegetables from your diet."] Vitamin K-rich foods do not need to be eliminated from the diet during enoxaparin therapy; prothrombin time (PT) and International Normalized Ratio (INR) are not affected. However, PT and INR are decreased when a vitamin K antagonist (eg, warfarin [Coumadin]) is taken with vitamin K-rich foods. [C. "You can take over-the-counter drugs such as ibuprofen to relieve mild discomfort."] Avoid taking aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), and herbal supplements (eg, Ginkgo biloba, vitamin E) without health care provider approval as these can increase bleeding risk. [D. "You will need PT/INR assessments at regular intervals while on enoxaparin therapy."] Routine coagulation studies (eg, PT, INR, partial thromboplastin time [PTT]) do not need to be monitored in a client who is taking enoxaparin. However, periodic assessment of CBC is usually required to monitor for hidden bleeding and thrombocytopenia, especially in older clients with renal insufficiency. Educational objective:Enoxaparin is a low molecular weight heparin that requires monitoring of complete blood count (thrombocytopenia) but not coagulation studies. Administration of unfractionated heparin requires monitoring of partial thromboplastin time, whereas warfarin requires monitoring of prothrombin time/International Normalized Ratio. Clients on these medications should avoid aspirin and nonsteroidal anti-inflammatory drugs.

The nurse is caring for a client who had surgery yesterday. When administering omeprazole, the client asks "What is that for? I don't take it at home." Which reply by the nurse is most appropriate? A. "Omeprazole helps prevent nausea by making your stomach empty faster." B. "Omeprazole helps prevent you from developing an ulcer due to the stress of surgery." C. "Omeprazole protects you from getting an infection while on antibiotics." D. "This medication will treat your gastroesophageal reflux disease (GERD)."

Correct Answer: B. "Omeprazole helps prevent you from developing an ulcer due to the stress of surgery." Omeprazole is a proton pump inhibitor (PPI) that suppresses the production of gastric acid by inhibiting the proton pump in the parietal cells of the stomach. In most hospitalized clients without a history of GERD or ulcers, PPIs are prescribed to prevent stress ulcers from developing during surgery or a major illness. Although evidence has shown that two-thirds of clients who receive PPIs do not need them, these medications are still widely prescribed in hospitalized clients. PPIs can be identified by their "-prazole" ending (eg, pantoprazole, lansoprazole, esomeprazole). Incorrect Answers: [A. "Omeprazole helps prevent nausea by making your stomach empty faster."] Metoclopramide (Reglan) is not a PPI. It decreases postoperative nausea by promoting gastric emptying. [C. "Omeprazole protects you from getting an infection while on antibiotics."] PPIs may be associated with an increased risk of Clostridium difficile infection with antibiotic use. [D. "This medication will treat your gastroesophageal reflux disease (GERD)."] The client does not take this medication at home. The nurse is assuming that the client has a history of GERD rather than assessing for this condition first. Educational objective:PPIs such as omeprazole are often prescribed to hospitalized clients without GERD or ulcers to prevent stress ulcers from developing during surgery or a major illness.

A parent calls the clinic about a 3-year-old who is sick with the flu. Which report by the parent would necessitate intervention by the nurse? A. Acetaminophen being given every 4 hours for fever B. Bismuth subsalicylate being used for nausea C. Ibuprofen being given every 6 hours for body aches D. Popsicles and gelatin desserts being used for hydration

Correct Answer: B. Bismuth subsalicylate being used for nausea The nurse should tell the parent to discontinue the use of bismuth subsalicylate (Pepto-Bismol) as it contains a salicylate (same class as aspirin) and could possibly cause Reye syndrome. Reye syndrome can develop in children with a recent viral illness such as varicella or influenza. It can cause acute encephalopathy and hepatic dysfunction. Children with viral infections should not be given aspirin or products containing salicylates. Incorrect Answers: [A. Acetaminophen being given every 4 hours for fever] Acetaminophen and ibuprofen are being used appropriately. [C. Ibuprofen being given every 6 hours for body aches] Acetaminophen and ibuprofen are being used appropriately. [D. Popsicles and gelatin desserts being used for hydration] Sufficient fluids are important to maintain hydration in the child with influenza. Water and fluids should be offered frequently; popsicles and gelatin desserts (eg, Jell-O) provide a palatable means of getting children to ingest fluids. Educational objective:The nurse should tell the parent not to administer any product containing aspirin or salicylates to a child with a viral infection (eg, influenza, varicella) to prevent Reye syndrome.

A nurse receives an electrocardiogram of a client with type 2 diabetes, heart failure, and hypothyroidism. Based on the findings [pictured: EKG strip of sinus bradycardia], which of the following medications should the nurse suspect as the most likely cause? A. Captopril B. Carvedilol C. Glimepiride D. Levothyroxine

Correct Answer: B. Carvedilol 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. Incorrect Answers: [A. Captopril] The side effects of these drugs include tachycardia [C. Glimepiride] The side effects of these drugs include tachycardia [D. Levothyroxine] The side effects of these drugs include tachycardia 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 nurse caring for a client reports a critical laboratory value of 120,000/mm3 (120 x 109/L) platelets, decreased from 300,000/mm3 (300 x 109/L) on admission. The health care provider says this is normal. The client is receiving heparin injections. Which nursing action would be the most appropriate? A. Contact the appropriate certification and licensing board B. Document the exchange in the chart C. Report the incident to the hospital's legal team D. Report the incident to the state medical board

Correct Answer: B. Document the exchange in the chart There are 2 forms of heparin-induced thrombocytopenia. The first form (platelets >100,000/mm3 [100 x 109/L]) normalizes within a few days. The second form (platelets <40,000/mm3 [40 x 109/L]) is a life-threatening autoimmune process that requires immediate heparin discontinuation. When in doubt of a clinician's judgment, the nurse should document these objections and report to the nursing supervisor. Incorrect Answers: [A. Contact the appropriate certification and licensing board] It is important to first refer up the nursing hierarchy. [C. Report the incident to the hospital's legal team] It is important to first refer up the nursing hierarchy. [D. Report the incident to the state medical board] It is important to first refer up the nursing hierarchy. Educational objective:The nurse should document and then report objections about a clinician's judgment to the nursing supervisor.

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 practical nurse (PN) to contact the supervising registered nurse (RN)? A. Client reports numbness bilaterally since the surgery B. Fondaparinux is prescribed for STAT administration C. Lower-extremity muscle strength is 3/5 bilaterally D. Postoperative laboratory results show hemoglobin of 9.9 g/dL

Correct Answer: B. Fondaparinux is prescribed for STAT administration Fondaparinux (Arixtra), unfractionated heparin, and low molecular weight heparin (eg, enoxaparin, dalteparin) are anticoagulants commonly used for prevention of deep vein thrombosis and pulmonary embolism 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 due to bleeding risk. The supervising registered nurse should be contacted for direction regarding holding or administering this medication in collaboration with the healthcare provider (HCP). 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. Incorrect Answers: [A. Client reports numbness bilaterally since the surgery] Paresthesia (numbness and tingling) 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 if present beyond this time frame. [C. Lower-extremity muscle strength is 3/5 bilaterally] 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. [D. Postoperative laboratory results show hemoglobin of 9.9 g/dL] 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 (reference range 11.7-16.0 g/dL for females; 13.2-17.3 g/dL in males). Blood loss should be monitored over time; transfusion usually is not indicated unless hemoglobin is <7-8 g/dL. 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 male client admitted with a traumatic open fracture of the femur, hematocrit of 36% (0.36), and hemoglobin of 12 g/dL (120 g/L) is being prepared for surgery. Which prescription should the practical nurse validate with the registered nurse before administration? A. Cefazolin B. Enoxaparin C. Morphine D. Tetanus toxoid

Correct Answer: B. Enoxaparin The Joint Commission Surgical Improvement Project CORE measure set has shown that preventive medications (eg, heparin, enoxaparin, aspirin) in select surgical procedures, given 24 hours before and after surgery, reduce the risk of venous thromboembolism. However, the estimated blood loss in a client with a fracture can be significant depending on the site (eg, 250-1200 mL). Although this client's admission hematocrit (36% [0.36]) and hemoglobin (12 g/dL [120 g/L]) are only slightly low for an adult male (normal: 39%-50% [0.39-0.50], 13.2-17.3 g/dL [132-173 g/L]), the blood loss may not yet be evident. Therefore, the nurse would validate the prescription for enoxaparin (Lovenox) before administration. Medications commonly prescribed for a client with an open fracture include: · Cefazolin (Ancef), a bone-penetrating cephalosporin antibiotic that is active against skin flora (Staphylococcus aureus); it is given prophylactically before and after surgery to prevent infection. · Cyclobenzaprine (Flexeril), a central and peripheral muscle relaxant given to treat pain associated with muscle spasm; carisoprodol (Soma) or methocarbamol (Robaxin) can also be prescribed. · Tetanus and diphtheria toxoid, an immunization given prophylactically to prevent infection (Clostridium tetani) if immunizations are not up to date (>10 years), unavailable, or unknown · Ketorolac (Toradol), a nonsteroidal anti-inflammatory drug given to decrease inflammation and pain · Opioids (eg, morphine, hydrocodone [Vicodin]), given for analgesia Educational objective:Medications commonly prescribed for a client with an open fracture to prevent infection and treat pain and muscle spasm include cefazolin (Ancef), tetanus toxoid, ketorolac (Toradol), opioids, and cyclobenzaprine (Flexeril).

A child with cystic fibrosis is to receive a dose of pancrelipase at 12:00 PM. The client states that he is not hungry and will eat his lunch in an hour. Which action is appropriate for the nurse to take? A. Administer the prescribed pancrelipase B. Hold the pancrelipase until the client eats C. Notify the health care provider D. Skip this dose of the pancrelipase

Correct Answer: B. Hold the pancrelipase until the client eats Cystic fibrosis affects the pancreatic excretion of digestive enzymes. Without these enzymes, the client is unable to absorb fats, starches, and some proteins from the diet. Pancrelipase provides these enzymes to the client and must be given with every snack and meal so that the client can digest and absorb the nutrients eaten. If the client is not eating when the medication is scheduled, there are no nutrients to digest. Therefore, the dose should be held until the client eats. Educational objective:Pancrelipase is a medication containing lipase, protease, and amylase. In cystic fibrosis, the client's pancreas does not excrete these necessary enzymes. To prevent malabsorption syndrome, the enzymes must be taken with every snack and every meal.

A client with coronary artery disease is being seen in the clinic for a follow-up examination. During medication reconciliation, the nurse identifies which reported medication as requiring further investigation? A. 10 mg isosorbide dinitrate twice daily B. 20 mg atorvastatin once daily C. 500 mg naproxen twice daily D. 2,000 mg fish oil once daily

Correct Answer: C. 500 mg naproxen twice daily Nonsteroidal anti-inflammatory drugs (NSAIDs) (eg, naproxen, ibuprofen) are common medications used for their analgesic, antipyretic, and anti-inflammatory properties. However, the use of NSAIDs increases the risk of thrombotic events (eg, heart attack, stroke) in clients with cardiovascular disease (eg, coronary artery disease [CAD]), especially with long-term use. The nurse should investigate the reason a client with cardiovascular disease is taking an NSAID and alert the health care provider of the medication usage. Incorrect Answers: [A. 10 mg isosorbide dinitrate twice daily] Isosorbide dinitrate (Isordil) is a long-acting nitrate medication prescribed to prevent angina in clients with CAD. Nitrate medications prevent angina by causing vasodilation of the peripheral vessels (decreasing cardiac workload) and the coronary arteries (improving coronary artery perfusion). [B. 20 mg atorvastatin once daily] Atorvastatin (Lipitor) is a statin drug prescribed to lower cholesterol, which can reduce the risk of atherosclerosis and coronary artery disease. [D. 2,000 mg fish oil once daily] Fish oil is an over-the-counter nutritional supplement often taken by clients with heart disease or individuals at risk. Fish oil contains omega-3 fatty acids, which may decrease blood triglyceride levels with consistent use. Educational objective:Clients with cardiovascular disease (eg, coronary artery disease) are cautioned against taking nonsteroidal anti-inflammatory drugs (NSAIDs) (eg, naproxen), which increase the risk of thrombotic events (eg, heart attack, stroke). Nurses who identify clients with cardiovascular disease taking NSAIDs should investigate the reasons for use and notify the health care provider.

The nurse is reviewing new prescriptions from the health care provider. Which prescription would require further clarification? A. Atorvastatin for hyperlipidemia in a client with angina pectoris B. Bupropion for smoking cessation in a client with emphysema C. Cyclobenzaprine for muscle spasms in a client with hepatitis D. Metronidazole for trichomoniasis in a client with Crohn disease

Correct Answer: C. Cyclobenzaprine for muscle spasms in a client with hepatitis Cyclobenzaprine (Flexeril) is a common, centrally acting skeletal muscle relaxant prescribed for muscle spasticity, muscle rigidity, and acute or chronic muscle pain/injury. Centrally acting muscle relaxants interfere with reflexes within the central nervous system (CNS) to decrease muscle spasm and rigidity. Like many medications, muscle relaxants are metabolized by the liver. The presence of liver disease (eg, hepatitis) decreases hepatic metabolism and can cause a buildup of medication, leading to medication toxicity and increased CNS depression (eg, weakness, confusion, drowsiness, lethargy). The prescription for a muscle relaxant would need to be clarified in a client with liver disease. Incorrect Answers: [A. Atorvastatin for hyperlipidemia in a client with angina pectoris] Atorvastatin (Lipitor) is a statin prescribed for hyperlipidemia. It is used for primary and secondary prevention of cardiovascular disease and would not warrant further clarification when used in a client with angina pectoris. [B. Bupropion for smoking cessation in a client with emphysema] Bupropion (Wellbutrin, Zyban) and varenicline (Chantix, Champix) are commonly prescribed for smoking cessation. Both bupropion and varenicline can cause serious neuropsychiatric effects (eg, depression, suicide); however, there is no contraindication for clients with emphysema. [D. Metronidazole for trichomoniasis in a client with Crohn disease] Metronidazole (Flagyl) is an antibiotic that can be used to treat a Trichomonas infection. There is no contraindication for its use in clients with Crohn disease. Educational objective:Like many medications, skeletal muscle relaxants (eg, cyclobenzaprine) are metabolized hepatically. In the presence of hepatic impairment (eg, hepatitis), drug metabolism is reduced and results in the accumulation of medication in the body, which leads to toxicity and serious adverse effects.

The nurse is preparing to administer the fourth dose of vancomycin IVPB to a client with infective endocarditis. Which intervention does the nurse anticipate? A. Administering PRN antiemetic prior to the infusion B. Administering via an infusion pump over at least 30 minutes C. Drawing a trough level just prior to administration of the vancomycin D. Starting a new IV line before administration

Correct Answer: C. Drawing a trough level just prior to administration of the vancomycin Vancomycin is a very potent antibiotic that can cause nephrotoxicity and ototoxicity. Measuring for serum concentrations is a way to monitor for risk of nephrotoxicity as well as for therapeutic response. Trough serum vancomycin concentrations are the most accurate and practical method for monitoring efficacy. A trough should be obtained just prior (about 15-30 minutes) to administration of the next dose. Incorrect Answers: [A. Administering PRN antiemetic prior to the infusion] Unlike some chemotherapy medications, vancomycin does not commonly cause nausea or vomiting. Premedication with antiemetics is not required. However, premedication with antihistamines (diphenhydramine) is recommended if the client had developed red man syndrome, also known as red neck syndrome, with prior vancomycin infusion. This syndrome is characterized by red blotching of the face, neck, and chest due to too rapid administration. [B. Administering via an infusion pump over at least 30 minutes] Vancomycin should be administered over a minimum of 60 minutes. Too rapid administration can cause red man syndrome, considered a toxic effect rather than an allergic reaction. [D. Starting a new IV line before administration] The nurse would want to verify patency of the IV line prior to administration as thrombophlebitis is a possibility with vancomycin; however, a new IV line is not necessarily required. Educational objective:To measure for efficacy and risk of nephrotoxicity with vancomycin, the nurse should draw periodic trough levels just prior to administration of the next IV dose.

The nurse is preparing to administer IV cefazolin to a client who is newly admitted with cellulitis. The client's allergies include amoxicillin, ciprofloxacin, and sulfa drugs. What should the nurse do first? A. Administer the medication as ordered B. Clarify the order with the supervising registered nurse C. Get more information from the client about the client's allergies D. Notify the pharmacy that the drug is inappropriate for this client

Correct Answer: C. Get more information from the client about the client's allergies The nurse should find out more about this client's allergies before giving the medication. Specifically, the nurse must learn what type of reaction the client had to amoxicillin, a penicillin antibiotic. With a history of anaphylaxis to penicillin, cephalosporins (eg, cefazolin) are contraindicated. Penicillin-cephalosporin cross-sensitivity occurs due to the structural similarity between the cephalosporin and penicillin molecules. If this client's reaction to amoxicillin was only a rash or other mild reaction that was not life-threatening, the cephalosporin can be safely administered. However, if the client had an anaphylactic reaction to penicillin, the health care provider (HCP) will need to prescribe a different antibiotic. Incorrect Answer: [A. Administer the medication as ordered] The nurse should hold the medication until more is known about the client's reaction to amoxicillin. [B. Clarify the order with the supervising registered nurse] The nurse does not have enough information to determine whether the supervising registered nurse or the HCP needs to be notified. [D. Notify the pharmacy that the drug is inappropriate for this client] The nurse does not have enough information to determine whether the medication is appropriate. Educational objective:A client with a penicillin allergy may be allergic to cephalosporin antibiotics. Cephalosporins may be safely administered to clients with a history of mild allergic reaction, such as rash, but they are contraindicated in clients with a history of penicillin anaphylaxis.

The nurse is caring for a client who started receiving chemotherapy 10 days ago. Today, the health care provider prescribes filgrastim. Which of the following is an expected outcome of this medication? A. Decrease in serum uric acid B. Increase in hemoglobin level C. Increase in neutrophil count D. Increase in platelet count

Correct Answer: C. Increase in neutrophil count Chemotherapy can cause suppression of rapidly reproducing cells, including bone marrow suppression. This can result in decreased red blood cells, white blood cells, and platelets, all manufactured in the bone marrow. It is most likely to be seen with chemotherapy (versus radiation), with the lowest counts (the nadir) usually at 7-10 days after therapy initiation. Leukopenia is a decrease in total circulating white blood cell count (<4,000/mm3) and neutropenia is a decrease in circulating neutrophils (usually <1500/mm3). Filgrastim (Neupogen) and pegfilgrastim (Neulasta) stimulate neutrophil production and are given prophylactically or if the client has an infection and more neutrophils are needed to fight it. Incorrect Answers: [A. Decrease in serum uric acid] Cancer chemotherapy causes cell lysis, which results in tumor lysis syndrome due to massive release of nucleic acid and its metabolic product, uric acid. Uric acid deposition leads to acute kidney injury. Medications such as allopurinol or rasburicase and aggressive IV hydration are used to prevent this complication. [B. Increase in hemoglobin level] Anemia is also common with chemotherapy. Epoetin (Procrit), a form of erythropoietin, stimulates the body to make additional red blood cells. [D. Increase in platelet count] Low platelet count is not considered an urgent need until it is at <50,000/mm3. Usually, platelet transfusions are given. Educational objective:Bone marrow suppression from chemotherapy can cause decreased red blood cells, white blood cells, and platelets. Erythropoietin is used to increase red blood cell production, and filgrastim is administered to stimulate neutrophil production.

The nurse should monitor for which potential complication in a client receiving IV vancomycin and gentamicin? A. Blood in nasogastric tube drainage B. Decrease in red blood cell count C. Increase in serum creatinine level D. Onset of muscle aches and cramping

Correct Answer: C. Increase in serum creatinine level Vancomycin and aminoglycosides (eg, gentamicin, amikacin, tobramycin) are strong antibiotics that can cause nephrotoxicity and ototoxicity. The client receiving these medications simultaneously would be at even greater risk for these adverse reactions; therefore, ongoing monitoring of hearing and renal function (blood urea nitrogen [BUN], creatinine levels, urinary output) is imperative. Increased levels of BUN and creatinine may indicate kidney damage and should be reported to the registered nurse before continuing these medications. Incorrect Answers: [A. Blood in nasogastric tube drainage] Blood in the nasogastric tube could be a complication of peptic ulcer disease and the use of nonsteroidal anti-inflammatory drugs and corticosteroids. [B. Decrease in red blood cell count] A decreased red blood cell count may be evidence of bone marrow suppression that can occur with use of certain cancer drugs (eg, methotrexate). [D. Onset of muscle aches and cramping] Muscle cramping can occur occasionally with use of gentamicin but is not an indication to stop the infusion. Muscle aching and cramping may signify a complication with the use of statins (eg, atorvastatin, rosuvastatin) and fibrates (eg, gemfibrozil, fenofibrate). Educational objective:The nurse should recognize that the risk of nephrotoxicity and ototoxicity is greater when vancomycin and aminoglycosides (eg, gentamicin) are administered together. Kidney and hearing functions should be closely monitored in these clients.

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? A. Close monitoring for hypotension B. Gradually increasing the prednisone dose C. Increasing the insulin dose D. Monitoring and recording intake and output

Correct Answer: C. Increasing the insulin dose 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. Incorrect Answers: [A. Close monitoring for hypotension] Most glucocorticoids have some mineralocorticoid activity, causing fluid retention and worsening hypertension. [B. Gradually increasing the prednisone dose] 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. [D. Monitoring and recording intake and output] 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 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? A. Also takes ibuprofen for pain B. Frequency of urination has increased C. Mild red rash has developed over torso D. Nausea occurs after each dose

Correct Answer: C. Mild red rash has developed over torso 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. Incorrect Answers: [A. Also takes ibuprofen for pain] 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. [B. Frequency of urination has increased] 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. [D. Nausea occurs after each dose] 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 practical nurse is collecting data on a client receiving methotrexate to treat rheumatoid arthritis. Which finding associated with this drug is most important for the nurse to report to the registered nurse? A. Hair loss B. Nausea C. Petechiae D. Stomatitis

Correct Answer: C. Petechiae Methotrexate (Rheumatrex) is a nonbiologic disease-modifying antirheumatic drug prescribed to treat rheumatoid arthritis. Adverse effects associated with this medication include bone marrow suppression, hepatotoxicity, and gastrointestinal irritation (eg, nausea, vomiting, diarrhea). Bone marrow suppression can lead to anemia, leukopenia, and thrombocytopenia. Anemia manifests as fatigue, dyspnea on exertion, and pallor. Leukopenia increases the risk for infection. Thrombocytopenia presents as petechiae, purpura, or bleeding. Petechiae are small, purplish hemorrhagic skin spots that occur when the platelet count is <150,000/mm*3 (150x10*9/L). Bone marrow suppression is managed with dose reduction or discontinuation of the medication. Incorrect Answers: [A. Hair loss] Mild temporary alopecia, although uncommon, is an expected adverse effect of methotrexate. It does not require intermediate intervention and is not the most important finding to report. [B. Nausea] Nausea and vomiting are the most common side effects (25%-60%) associated with methotrexate. Although the registered nurse should be notified to request a prescription for an antiemetic, nausea is not the most important finding to report. [D. Stomatitis] Stomatitis (inflammation of the mouth, oral ulcers) is a common side effect associated with methotrexate. It can be prevented with folic acid supplementation. Although the condition is uncomfortable, it would not require immediate intervention and is not the most important finding to report. Educational objective:Methotrexate (Rheumatrex) is a nonbiologic disease-modifying antirheumatic drug prescribed to treat rheumatoid arthritis. Major adverse effects include bone marrow suppression and hepatotoxicity. Most common side effects can be prevented by folic acid supplementation.

The nurse reinforces teaching about methotrexate to a client with rheumatoid arthritis. It is most important to address which topic regarding this drug? A. Need for an eye examination B. Need for sunblock C. Risk for infection D. Risk for kidney injury

Correct Answer: C. Risk for infection Methotrexate (Rheumatrex) is classified as an antineoplastic, immunosuppressant drug used to treat various malignancies and as a nonbiologic disease-modifying antirheumatic drug (DMARD) used to treat rheumatoid arthritis and psoriasis. Methotrexate can cause bone marrow suppression resulting in anemia, leukopenia, and thrombocytopenia. Leukopenia and its immunosuppressant effects can increase susceptibility to infection. Clients should be educated about obtaining routine killed (inactivated) vaccines (eg, influenza, pneumococcal) and avoiding crowds and persons with known infections. Live vaccines (eg, herpes zoster) are contraindicated in clients receiving immunosuppressants, such as methotrexate. Alcohol should be avoided in clients taking methotrexate as it is hepatotoxic and drinking alcohol increases the client's risk for hepatotoxicity. Incorrect Answers: [A. Need for an eye examination] Regular eye examinations every 6 months are indicated for clients prescribed the nonbiological DMARD antimalarial hydroxychloroquine (Plaquenil) as it can cause retinal damage. Ethambutol, used to treat tuberculosis, also requires frequent eye examinations. [B. Need for sunblock] Photosensitivity (common with tetracycline, thiazide diuretics, and sulfonamides) and nephrotoxicity (common with aminoglycosides, vancomycin, and nonsteroidal anti-inflammatory drugs) can occur, but immunosuppression is more likely and potentially fatal. [D. Risk for kidney injury] Photosensitivity (common with tetracycline, thiazide diuretics, and sulfonamides) and nephrotoxicity (common with aminoglycosides, vancomycin, and nonsteroidal anti-inflammatory drugs) can occur, but immunosuppression is more likely and potentially fatal. Educational objective:Methotrexate is a nonbiologic disease-modifying antirheumatic drug used to treat rheumatoid arthritis. The major adverse effects associated with its use include bone marrow suppression, hepatotoxicity, and gastrointestinal irritation.

The nurse reinforces teaching to a client prescribed isoniazid, rifampin, ethambutol, and pyrazinamide to treat active tuberculosis. Which of the following instructions associated with the adverse effects of rifampin is most important for the nurse to include? A. Notify the health care provider if your urine is red B. Take acetaminophen every 6 hours for drug-associated joint pain while taking this medication C. Wear eyeglasses instead of soft contact lenses while taking this medication D. You can stop taking the medications as soon as one sputum culture comes back normal

Correct Answer: C. Wear eyeglasses instead of soft contact lenses while taking this medication Active tuberculosis (TB) is treated with combination drug therapy. Isoniazid causes hepatotoxicity and peripheral neuropathy. Rifampin (Rifadin) also causes hepatotoxicity. Therefore, baseline liver function tests should be obtained. Clients should be advised to watch for signs and symptoms of hepatotoxicity (eg, jaundice, anorexia). Ethambutol causes ocular toxicity, and clients will need frequent eye examinations. A teaching plan for a client prescribed rifampin includes these additional instructions: · Rifampin changes the color of body fluids (eg, urine, sweat) due to its body-wide distribution. Tears can turn red, making contact lenses appear discolored. Client should wear eyeglasses instead of soft contact lenses while taking this medication. · Women should use nonhormonal birth control methods while taking this drug as it can decrease the effectiveness of oral contraceptives. Incorrect Answers: [A. Notify the health care provider if your urine is red] Red urine is an expected finding with rifampin use; clients should not be concerned. [B. Take acetaminophen every 6 hours for drug-associated joint pain while taking this medication] Clients should be advised to not consume alcohol and drugs that can increase the risk for hepatotoxicity (eg, acetaminophen) during long-term use of this drug. [D. You can stop taking the medications as soon as one sputum culture comes back normal] The effectiveness of treatment for active TB is determined by 3 negative sputum cultures and chest x-ray. If the entire course of therapy (6-9 months) is not completed, reinfection, spread to others, and development of resistant strains of TB bacteria can result. Educational objective:Common potential side effects of rifampin include hepatotoxicity, red-orange discoloration of body fluids, and increased metabolism of some drugs (eg, oral contraceptives, hypoglycemics, warfarin).

An African American client comes to the clinic for a follow-up visit 2 months after starting enalapril for hypertension. Which client statement should be reported to the health care provider immediately? A. "Is there anything I can take for my dry, hacking cough?" B. "My blood pressure this morning was 158/84 mm Hg." C. "Sometimes I feel a little dizzy when I stand up." D. "Will you look at my tongue? It feels thicker than normal."

Correct Answer: D. "Will you look at my tongue? It feels thicker than normal." Angioedema is swelling that usually affects areas of the face (lips, tongue), larynx, extremities, gastrointestinal tract, and genitalia. It often starts in the face and can quickly become life-threatening as it progresses to the airways. Angioedema is an adverse effect of ACE inhibitors (eg, enalapril, lisinopril, captopril) and occurs more commonly in African Americans clients. Unlike other typical drug allergies, this side effect can occur anytime after starting the medication. The nurse should carefully monitor the client and report the angioedema to the health care provider immediately. Incorrect Answer: [A. "Is there anything I can take for my dry, hacking cough?"] A persistent, dry, hacking cough is a common side effect of ACE inhibitors. It is not life-threatening, but the medication should be discontinued/changed to resolve the cough. [B. "My blood pressure this morning was 158/84 mm Hg."] The nurse should review the client's blood pressure readings from the past month since enalapril was started. The client may need a dosage change or an additional medication. This should be reported to the health care provider but it is not the priority in this situation. [C. "Sometimes I feel a little dizzy when I stand up."] Occasional dizziness upon rising (ie, orthostatic hypotension) is a common side effect of most antihypertensives. The client should be taught to rise slowly and sit on the side of the bed for a few minutes before standing. Educational objective:Swelling of the tongue can be a sign of angioedema in clients taking ACE inhibitors; this can be potentially life-threatening if the airway becomes compromised. The nurse should report this to the health care provider immediately. Angioedema is more common in African Americans.

The nurse is reading the revised medication prescriptions for a client recently admitted with type 1 diabetes mellitus. Which prescription should the nurse question and report to the health care provider? A. 10 units regular insulin IV push for blood glucose >250 mg/dL (13.9 mmol/L) B. 14 units glargine insulin subcutaneous injection every night at 8:00 PM C. 18 units aspart insulin subcutaneous injection 15 minutes before breakfast D. 20 units NPH insulin IV push administered every morning at 7:00 AM

Correct Answer: D. 20 units NPH insulin IV push administered every morning at 7:00 AM Subcutaneous injection is the only indicated route for NPH insulin administration; it should never be administered via IV push. Regular insulin and certain rapid-acting insulins are the only forms of insulin that can be administered via IV push; this is typically performed only in an acute care facility under close observation by a registered nurse. Incorrect Answers: [A. 10 units regular insulin IV push for blood glucose >250 mg/dL (13.9 mmol/L)] Administration of 10 units regular insulin IV push for blood glucose >250 mg/dL (13.9 mmol/L) is appropriate and does not need to be reported to the health care provider. [B. 14 units glargine insulin subcutaneous injection every night at 8:00 PM] Administration of 14 units glargine insulin subcutaneous injection every night at 8:00 PM is appropriate, and a new prescription is not required. [C. 18 units aspart insulin subcutaneous injection 15 minutes before breakfast] 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 only indicated route for NPH insulin administration; it should never be administered via IV push.

A student nurse is caring for a client with iron deficiency anemia who is newly prescribed ferrous sulfate. Which action by the student nurse requires the supervising nurse to intervene? A. Encourages the client to drink extra fluids while taking ferrous sulfate B. Offers the client orange juice for administration of ferrous sulfate C. Plans to administer ferrous sulfate one hour before breakfast D. Prepares to administer a prescribed calcium supplement with ferrous sulfate

Correct Answer: D. Prepares to administer a prescribed calcium supplement with ferrous sulfate Ferrous sulfate is an oral iron supplement prescribed to prevent or treat iron deficiency anemia, which occurs when the body lacks sufficient iron, an essential mineral in the formation of new RBCs. Low iron levels may result from malabsorption, insufficient intake, increased requirements (eg, pregnancy), or blood loss. The nurse should avoid administering calcium supplements or antacids with or within 1 hour of ferrous sulfate because calcium decreases iron absorption. Incorrect Answers: [A. Encourages the client to drink extra fluids while taking ferrous sulfate] Taking an iron supplement increases the client's risk for constipation. Instructing the client to increase fluid intake during therapy may help prevent hard stools. [B. Offers the client orange juice for administration of ferrous sulfate] Taking an iron supplement with vitamin C (eg, orange juice) further enhances duodenal acidity and increases absorption. An acid-rich environment enhances iron absorption, so oral supplements should be taken 1 hour before or 2 hours after meals. [C. Plans to administer ferrous sulfate one hour before breakfast] Taking an iron supplement with vitamin C (eg, orange juice) further enhances duodenal acidity and increases absorption. An acid-rich environment enhances iron absorption, so oral supplements should be taken 1 hour before or 2 hours after meals. Educational objective:Ferrous sulfate is an oral iron supplement prescribed to prevent or treat iron deficiency anemia. The nurse should administer the medication 1 hour before or 2 hours after meals because it is best absorbed in an acidic environment. Antacids or calcium supplements decrease absorption of iron if administered with or within 1 hour of ferrous sulfate.

An elderly client with depression, diabetes mellitus, and heart failure has received a new digoxin prescription for daily use. Which client assessment indicates that the nurse should follow up on serum digoxin levels frequently? A. Apical heart rate is 62/min B. Blood sugar level is 240 mg/dL (13.3 mmol/L) C. Client is taking 20 mg fluoxetine daily D. Serum creatinine is 2.3 mg/dL (203 µmol/L)

Correct Answer: D. Serum creatinine is 2.3 mg/dL (203 µmol/L) Digoxin (Lanoxin) is a cardiac glycoside that increases cardiac contractility but slows the heart rate and conduction. It is used in heart failure (to increase cardiac output) and atrial fibrillation (to reduce the heart rate). The drug is excreted almost exclusively by the kidney. BUN and creatinine levels are measurements of kidney function. The normal range for creatinine is 0.6-1.3 mg/dL (53-115 µmol/L). Elderly clients tend to develop age-related decrease in glomerular filtration rate (GFR). These clients and those with obvious kidney injury (possibly due to diabetes in this client) can accumulate digoxin. The early symptoms of toxicity are nausea and vomiting. Later signs of toxicity are arrhythmias, including heart blocks. Therefore, clients at risk for digoxin toxicity require frequent drug level monitoring and dose adjustment. Incorrect Answers: [A. Apical heart rate is 62/min] An apical heart rate is taken for a full minute prior to administration. It is safe to administer the drug when the apical heart rate is ≥60/min. [B. Blood sugar level is 240 mg/dL (13.3 mmol/L)] An elevated blood sugar level requires attention but is unrelated to digoxin toxicity. However, hypokalemia can increase the risk of digoxin toxicity. [C. Client is taking 20 mg fluoxetine daily] Fluoxetine (Prozac) is an antidepressant drug that is a selective serotonin reuptake inhibitor. It does not usually interact with digoxin and its use is unaltered by cardiac disease. This is a normal dose. Educational objective:Digoxin (Lanoxin) is excreted almost exclusively by the kidneys. Decreased kidney function usually requires decreased digoxin dosage and frequent drug level monitoring. BUN and creatinine are measurements of kidney function.

A client with chronic heart failure developed an intractable cough and an incident of angioedema after starting enalapril. Which prescription does the nurse anticipate for this client? A. Alprazolam B. Dextromethorphan C. Lisinopril D. Valsartan

Correct Answer: D. Valsartan Major side effects of angiotensin-converting enzyme (ACE) inhibitors include: · Symptomatic hypotension · Intractable cough · Hyperkalemia · Angioedema (allergic reaction involving edema of the face and airways) · Temporary increase in serum creatinine For clients unable to tolerate ACE inhibitors, angiotensin II receptor blockers (ARBs) such as valsartan or losartan are recommended. ARBs prevent the vasoconstrictor and aldosterone-secreting effects of angiotensin II by binding to the angiotensin II receptor sites. Incorrect Answers: [A. Alprazolam] Alprazolam is an anxiolytic. It is not used in the treatment of heart failure. [B. Dextromethorphan] Dextromethorphan is a cough suppressant. A cough caused by an ACE inhibitor will not be improved by a cough suppressant. [C. Lisinopril] Lisinopril is an ACE inhibitor. This client has been unable to tolerate this class of drug. Educational objective:ARBs are recommended for clients unable to tolerate ACE inhibitors.

A nurse is reinforcing teaching to a client who is being discharged on warfarin for atrial fibrillation. Which client statements indicate that teaching has been effective? Select all that apply. A. "Antibiotics can affect my INR value." B. "I am going to eat more leafy greens." C. "I will shoot for my INR value to be between 4 and 5." D. "I will take warfarin at the same time daily." E. "If I miss a dose, I can double it on the following day."

Correct Answers: A and D Intestinal bacteria produce vitamin K; most antibiotics kill these bacteria, leading to vitamin K deficiency. Warfarin is a vitamin K antagonist; therefore, INR would overshoot in the setting of vitamin K deficiency, placing the client at risk for bleeding. It is important to take warfarin at the same time daily to maintain a consistent therapeutic drug level. Incorrect Answers: [B. "I am going to eat more leafy greens."] Leafy-green vegetables contain a high amount of vitamin K, which may lower a client's INR and make it difficult to maintain a therapeutic INR. Clients do not have to avoid consumption of leafy-green vegetables, but they should eat a consistent quantity and have their INR checked periodically [C. "I will shoot for my INR value to be between 4 and 5."] A therapeutic INR for most conditions is 2-3 but can be up to 3.5 for heart valve disease. However, it is never between 4 and 5 [E. "If I miss a dose, I can double it on the following day."] Clients should call their health care provider if they miss or forget to take a warfarin dose. Double dosing is contraindicated. Educational objective:Warfarin must be taken at the same time daily to reach a therapeutic INR of 2-3. A diet high in vitamin K may decrease warfarin's anticoagulant effect. Most antibiotics will increase INR by causing a vitamin K deficiency.

In which scenarios should the nurse hold the prescribed medication and question its administration? Select all that apply. A. Client on IV heparin and the platelet count is 50,000/mm*3 (50 x 10*9/L) B. Client on newly prescribed lisinopril and is at 8 weeks gestation C. Client on nitroglycerin patch for heart failure and blood pressure is 84/56 mm Hg D. Client on phenytoin for epilepsy and the nurse notes gingival hyperplasia E. Client on warfarin and prothrombin time/International Normalized Ratio is 1.5 times control value

Correct Answers: A, B, and C Heparin is a natural anticoagulant. Its risk is heparin-induced thrombocytopenia (HIT), also known as heparin-associated thrombocytopenia. Normal platelet range is 150,000-400,000/mm*3 (150-400 x 10*9/L). A mild lowering of platelets may occur and resolve spontaneously around the 4th day of administration. The danger is type II HIT, a more severe form in which there is an acute drop in the number of platelets (more than 50% from baseline), which requires discontinuing heparin. Angiotensin-converting enzyme (ACE) inhibitors such as lisinopril are teratogenic. Lisinopril can cause embryonic/fetal developmental abnormalities (cardiovascular and central nervous system) if taken during pregnancy, especially during the first 13 weeks of gestation. During the 2nd and 3rd trimesters, ACE inhibitors interfere with fetal renal hemodynamics, resulting in low fetal urine output (oligohydramnios) and fetal growth restriction. Nitroglycerin causes vasodilation and can lower blood pressure. Systolic blood pressure should be >90 mm Hg to ensure renal perfusion. Incorrect Answers: [D. Client on phenytoin for epilepsy and the nurse notes gingival hyperplasia] Gingival hyperplasia or hypertrophy is a known side effect of phenytoin (Dilantin) and is not a reason to stop the drug. Vigorous dental hygiene beginning within 10 days of initiation of phenytoin therapy can help control it. Signs and symptoms that require discontinuation include toxic levels or phenytoin hypersensitivity syndrome (fever, skin rash, and lymphadenopathy). [E. Client on warfarin and prothrombin time/International Normalized Ratio is 1.5 times control value] Warfarin (Coumadin) is used to prolong clotting so that the desired result is a "therapeutic" range rather than the client's "normal" control value when not on the drug. Therapeutic range is considered roughly 1.5-2.5 times the control (International Normalized Ratio [INR] of 2-3), but up to 3-4 times the control (INR of 2.5-3.5) in high-risk situations such as an artificial heart valve. Educational objective:Heparin should be held when there is significant thrombocytopenia. Angiotensin-converting enzyme inhibitors are not administered to pregnant women, and nitrates are not administered when a client is hypotensive. Prothrombin time/International Normalized Ratio is expected to be 1.5-2.5 (up to 4) times the control value when therapeutic effects are reached. Gingival hyperplasia is a side effect of phenytoin (Dilantin) administration and is not a reason to stop the drug.

The nurse is caring for a client who was recently prescribed methadone for chronic, severe back pain. The client indicates taking extra tablets in the last 6 hours when the pain recurred. Which findings during discharge require the client to be monitored longer in the hospital setting? Select all that apply. A. Falls asleep when the nurse is talking B. Frequently scratches from pruritus C. Has third emesis since taking medication D. Monitor shows occasional premature ventricular contractions E. Pulse oximetry reading is 92%

Correct Answers: A, B, and E Methadone is a potent narcotic with a unique, long half-life (up to 50+ hours) due to its lipophilic properties (combines with lipids). However, its analgesic effect lasts only 6-8 hours. Thereafter, a large amount of the drug is still being released from the fat cells due to the long half-life, which creates a risk of overdose in clients who inadvertently self-medicate for additional pain relief. Early signs of toxicity are nausea/vomiting and lethargy. Falling asleep with stimulation is classified as obtunded and requires additional observation/monitoring. Sedation precedes respiratory depression, a life-threatening complication of severe toxicity. A normal, healthy, nonsmoking adult should have a pulse oximetry reading of 97%-100%; 95%-100% is considered acceptable. The low pulse oximetry reading indicates inadequate depth or rate of respiration. Incorrect Answers [B. Frequently scratches from pruritus] Itching sensation (pruritus) is an expected finding with narcotic use, especially in the opiate naïve, and can be managed with an antihistamine. [D. Monitor shows occasional premature ventricular contractions] Occasional premature ventricular contractions are a common finding in most adults. With methadone use, there is a risk of electrocardiogram changes and dysrhythmias, including ventricular tachycardia; therefore, the client should have cardiac monitoring. Educational objective:Methadone is a potent narcotic with a long half-life. Early signs of toxicity are nausea/vomiting and lethargy. Clients should have pulse oximetry and electrocardiogram monitoring. Ventricular tachycardia is a potential life-threatening complication.

The nurse is reinforcing information to a diabetic client with a new prescription for metoclopramide. Which of the following side effects must the nurse remind the client to report immediately to the health care provider? Select all that apply. A. Excess blinking of eyes B. Dry mouth C. Dull headache D. Lip smacking E. Puffing of cheeks

Correct Answers: A, D, and E Metoclopramide (Reglan) is prescribed for the treatment of delayed gastric emptying, gastroesophageal reflux (GERD), and as an antiemetic. Similar to antipsychotic drugs, metoclopramide use is associated with extrapyramidal adverse effects, including tardive dyskinesia (TD). This is especially common in older adults with long-term use. The client should call the health care provider immediately if TD symptoms develop, including uncontrollable movements such as: · Protruding and twisting of the tongue · Lip smacking · Puffing of cheeks · Chewing movements · Frowning or blinking of eyes · Twisting fingers · Twisted or rotated neck (torticollis) Incorrect Answers: [B. Dry mouth] Common side effects of metoclopramide such as sedation, fatigue, restlessness, headache, sleeplessness, dry mouth, constipation, and diarrhea need not be reported to the health care provider. [C. Dull headache] Common side effects of metoclopramide such as sedation, fatigue, restlessness, headache, sleeplessness, dry mouth, constipation, and diarrhea need not be reported to the health care provider. Educational objective:Both antipsychotic medication and metoclopramide use can be associated with significant extrapyramidal side effects (eg, tardive dyskinesia). The nurse should reinforce to the client the importance of immediately communicating these to the health care provider.

Which herbal supplements pose an increased risk for bleeding in surgical clients and should be discontinued prior to major surgery? Select all that apply. A. Black cohosh B. Garlic C. Ginger D. Ginkgo biloba E. Hawthorn

Correct Answers: B, C, and D Clients are often aware of the need to discontinue prescription medications such as aspirin and anticoagulants prior to elective surgery, but they may not know that some herbal supplements can increase bleeding risk. The nurse should question the client specifically about the use of herbal supplements. Herbal supplements that can increase risk for bleeding include: · Gingko biloba · Garlic · Ginseng · Ginger · Feverfew Incorrect Answers: [A. Black cohosh] Black cohosh is used for treatment of menopausal symptoms. The main side effect is liver injury. [E. Hawthorn] Hawthorn extract is used to control hypertension and mild to moderate heart failure. Hawthorn use does not increase the risk of bleeding. Educational objective:Use of herbal supplements such as ginkgo biloba, garlic, ginseng, ginger, and feverfew should be reported to the health care provider before surgery as they may increase the risk of bleeding.

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. A. Alanine aminotransferase from 20 U/L (0.33 µkat/L) to 80 U/L (1.34 µkat/L) B. High-density lipoprotein cholesterol from 48 mg/dL (1.24 mmol/L) to 30 mg/dL (0.78 mmol/L) C. Low-density lipoprotein cholesterol from 176 mg/dL (4.61 mol/L) to 98 mg/dL (2.54 mmol/L) D. Total cholesterol from 250 mg/dL (6.47 mmol/L) to 180 mg/dL (4.66 mmol/L) E. Triglycerides from 180 mg/dL (2.03 mmol/L) to 149 mg/dL (1.68 mmol/L)

Correct Answers: C, D, and E 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. Incorrect Answers: [A. Alanine aminotransferase from 20 U/L (0.33 µkat/L) to 80 U/L (1.34 µkat/L)] 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. [B. High-density lipoprotein cholesterol from 48 mg/dL (1.24 mmol/L) to 30 mg/dL (0.78 mmol/L)] 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.

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? A. "Heparin is a blood thinner that will help to dissolve the clot in your leg." B. "Heparin will help stabilize the clot in your leg and prevent it from breaking off and traveling to your lungs." C. "Heparin will keep the current clot from getting bigger and help prevent new clots from forming." D. "I'm sorry. This is something that your health care provider (HCP) can answer better upon arriving."

Correct Answers: C. "Heparin will keep the current clot from getting bigger and help prevent new clots from forming." 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. Incorrect Answers: [A. "Heparin is a blood thinner that will help to dissolve the clot in your leg."] 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. [B. "Heparin will help stabilize the clot in your leg and prevent it from breaking off and traveling to your lungs."] Heparin does not prevent the clot from breaking off but will deter the clot from growing larger. [D. "I'm sorry. This is something that your health care provider (HCP) can answer better upon arriving."] 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.

Which prescriptions for these clients does the nurse question? Select all that apply. A. Client with Clostridium difficile colitis, prescribed vancomycin 125 mg PO B. Client with diabetes and elevated mealtime glucose, prescribed lispro insulin scale 6 units subcutaneously C. Client with gastrointestinal bleed and nasogastric tube, prescribed pantoprazole 40 mg intravenous D. Client with hypertension and blood pressure (BP) 94/40 mm Hg, prescribed metoprolol succinate SR 50 mg PO E. Client with otitis media and penicillin allergy, prescribed ampicillin 500 mg PO

Correct Answers: D and E The nurse would question the prescriptions for the following clients: · Client with hypertension and BP 94/40 mm Hg, prescribed metoprolol succinate SR (Toprol-XL) 50 mg PO: This client's mean arterial pressure (MAP) is only 58 mm Hg ({[2x diastolic] + systolic} ÷ 3). A MAP >60-65 mm Hg is necessary to perfuse the vital organs (eg, brain, coronary arteries, kidneys). Toprol-XL is a long-acting beta blocker and will continue to drop the client's BP over a 24-hour period. · Client with otitis media and penicillin allergy prescribed ampicillin 500 mg PO: Ampicillin is classified as a penicillin antibiotic and is contraindicated in clients with a penicillin allergy. Incorrect Answers: [A. Client with Clostridium difficile colitis, prescribed vancomycin 125 mg PO] C difficile colitis is treated with metronidazole or vancomycin, depending on severity and number of relapses. Vancomycin is typically given orally in this situation, unlike other nonintestinal infections in which IV is the standard route. There is no reason to question this prescription. [B. Client with diabetes and elevated mealtime glucose, prescribed lispro insulin scale 6 units subcutaneously] A sliding insulin (correction) scale is used to prescribe rapid-acting lispro (Humalog) to control postprandial hyperglycemia. The nurse would not question this prescription. [C. Client with gastrointestinal bleed and nasogastric tube, prescribed pantoprazole 40 mg intravenous] Proton pump inhibitors (eg, pantoprazole, omeprazole) are prescribed for gastroesophageal reflux disease, and ulcer treatment and prophylaxis. The IV preparation is administered when the oral route is contraindicated. The nurse would not question this prescription. Educational objective:IV proton pump inhibitors are used for gastric ulcer bleeding. Oral vancomycin can be used for C difficile colitis. Ampicillin or amoxicillin are contraindicated in clients with a penicillin allergy. Antihypertensives are held if the client has borderline low BP.

The nurse is caring for a client who has been started on sulfamethoxazole/trimethoprim for a urinary tract infection. It is most important for the nurse to follow up on which client statement? A. "I go to the bathroom a lot more than usual." B. "It burns when I pee." C. "My urine is cloudy." D. "There is a red rash on my abdomen."

Correct Answers: D. "There is a red rash on my abdomen." Sulfamethoxazole/trimethoprim (Bactrim, sulfa) is a common cause of allergic reactions that often present as delayed cutaneous reactions. Allergic reactions frequently begin with fever, followed by a flat, red rash (looks like measles) and itching. The priority is to identify the allergy and take appropriate measures. Incorrect Answers: [A. "I go to the bathroom a lot more than usual."] Frequent urination, more than 8 times in 24 hours or more often than every 2 hours, is an expected symptom of urinary tract infection (UTI). In addition, if the client is forcing fluids as recommended for this diagnosis, increased voiding could result. The UTI is already being treated with the antibiotic, and this symptom is not a priority. [B. "It burns when I pee."] Dysuria, painful urination, is an expected symptom of UTI and does not require urgent intervention. The nurse could advocate for phenazopyridine hydrochloride (Pyridium), a urinary tract analgesic, for comfort, but stopping the drug to which the client is allergic is a priority. [C. "My urine is cloudy."] Blood or sediment (making the urine cloudy) can be present with a UTI. Treatment has been started, and identifying the allergy and taking appropriate measures are the priority. Educational object:Sulfa is a common cause of drug allergy that manifests as fever, rash, and itching. Identifying and treating a potential rash are the priority over management of expected symptoms for a known diagnosis.

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 supervisory registered nurse? A. "I am feeling unsteady when I walk." B. "I am getting up to urinate about 4 times during the night." C. "I have a metallic taste in my mouth when I eat." D. "My gums are getting so puffy and red."

Correct Answer: A. "I am feeling unsteady when I walk." 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. Incorrect Answers: [B. "I am getting up to urinate about 4 times during the night."] Nocturia is an expected side effect of diuretics but not phenytoin. Nocturia is also seen with diabetes mellitus and benign prostatic hyperplasia. [C. "I have a metallic taste in my mouth when I eat."] Metallic taste in the mouth is often seen with metronidazole but not with phenytoin. [D. "My gums are getting so puffy and red."] 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 nurse is reinforcing medication instructions for the parents of a child prescribed amoxicillin/clavulanate (liquid) twice a day for acute sinusitis. Which instructions are most important for the parents to remember? Select all that apply. A. Administer the medication with food if nausea or diarrhea develops B. Complete the medication course even if the child is better C. Rash is a normal, expected side effect D. Shake the medicine well before use E. Use a household spoon to measure the dose

Correct Answer: A, B, and D Amoxicillin/clavulanate belongs to the aminopenicillin group and is often used to treat respiratory infections. Instructions for parents about amoxicillin use include the following: · The medication may be taken with or without food as food does not affect absorption. · The most common side effects of this medication are nausea, vomiting, and diarrhea. If nausea or diarrhea develops, the medicine may be administered with food to decrease the gastrointestinal side effects. · Shake the liquid well prior to administration. Administer at evenly spaced intervals throughout the day to maintain therapeutic blood levels. · Ensure that the child receives the full course of therapy; do not discontinue the medication if the child is feeling better or symptoms have resolved. Incorrect Answer: [C. Rash is a normal, expected side effect] Rash, itching, dyspnea, and/or facial/laryngeal edema may indicate an allergic reaction. If any of these occur, the medication should be discontinued. [E. Use a household spoon to measure the dose] Pediatric liquid medications are often dispensed with a measuring device designed to administer the exact dose prescribed. A dropper, oral syringe, plastic measuring cup, or measuring spoon is an example of a calibrated dispensing device that may be included with the medication. Educational objective:Amoxicillin/clavulanate in liquid form should be shaken well prior to administration; the correct dose is administered using a calibrated measuring device. The medication is taken with or without food, at evenly spaced intervals, and until the prescribed dose is consumed. If nausea or diarrhea develops, the medication may be administered with food.

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? A. "Are you taking any over-the-counter medicines for your cold?" B. "Are you taking extra vitamin C?" C. "Did you babysit your granddaughter this past week?" D. "Did you get a flu shot in the past week?"

Correct Answer: A. "Are you taking any over-the-counter medicines for your cold?" 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. Incorrect Answers: [B. "Are you taking extra vitamin C?"] Taking extra vitamin C may offer some protection for the immune system, but it does not cause an increase in blood pressure. [C. "Did you babysit your granddaughter this past week?"] Exposure to young children increases the risk for contracting a contagious respiratory illness, but it does not directly increase blood pressure. [D. "Did you get a flu shot in the past week?"] 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 reinforcing discharge instructions for the parents of a 4-year-old with heart failure. Which statement by one of the parents indicates the need for further teaching related to digoxin administration? A. "We will hold the dose if our child's heart rate is above 90/min." B. "We will not give a second dose if our child vomits after the first dose." C. "We will not mix the medication with other foods or liquids." D. "We will report symptoms of nausea and vomiting to our health care provider."

Correct Answer: A. "We will hold the dose if our child's heart rate is above 90/min." Digoxin is a cardiac glycoside given to infants and children with 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 be able to demonstrate appropriate administration procedures for this medication. Parent teaching for digoxin administration includes the following: · Know the pulse rate at which to hold the medication based on the health care provider's (HCP's) prescription (this instruction should be reinforced by the nurse). In general, digoxin is held if pulse is <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 child's refusal to ingest these would result in inaccurate medication dose intake. · If a dose is missed, do not give an extra dose or increase the dosage. Maintain the same schedule. · If >2 doses are missed, notify the HCP. · If the child vomits after the first dose, do not give a second dose. Nausea, vomiting, or slow pulse rate could indicate toxicity. Notify the HCP. · Give water or brush the child's teeth after administration to remove the sweetened liquid. Educational objective:Digoxin has a narrow margin of safety in dosage; therefore, nausea, vomiting, or slow pulse rate can indicate toxicity. General guidelines are to hold digoxin for pulse <90-110/min in infants and young children and <70/min in older children.

A parent rushes a 4-year-old to the emergency department after finding the child sitting on the kitchen floor holding an empty bottle of aspirin. The parent has no idea how many tablets were left in the container. The child is sniffling and crying quietly. The practical nurse anticipates initially assisting with the implementation of which treatment? A. Activated charcoal B. Gastric lavage C. Sodium bicarbonate D. Syrup of ipecac

Correct Answer: A. Activated charcoal Activated charcoal is an important treatment in early acetylsalicylic acid (ASA) toxicity; it is recommended for gastrointestinal decontamination in clients with clinical signs of ASA poisoning (disorientation, vomiting, hyperpnea, diaphoresis, restlessness) as well as in those who are asymptomatic. Activated charcoal binds to available salicylates, thereby limiting further absorption in the small intestine and enhancing elimination. Incorrect Answers: [B. Gastric lavage] Similar to syrup of ipecac, gastric lavage is associated with risk of aspiration. In addition, there is no convincing evidence that it decreases morbidity. Gastric lavage is not routinely recommended but may be performed for the ingestion of a massive or life-threatening amount of drug. If necessary, it should be administered within 1 hour of ASA ingestion; administration requires a protected airway and possible sedation. [C. Sodium bicarbonate] The practical nurse may anticipate the administration of IV sodium bicarbonate as it is an appropriate treatment for aspirin toxicity after the administration of activated charcoal. It is given to make the blood and urine more alkaline, thereby promoting urinary excretion of salicylate. [D. Syrup of ipecac] Syrup of ipecac has been shown to have minimal benefit in treating aspirin overdose; in addition, it is not recommended due to the risk of aspiration pneumonia secondary to induced vomiting. Educational objective:Activated charcoal is used as the initial treatment for aspirin overdose in clients with clinical signs of salicylate toxicity as well as in those who are asymptomatic. Activated charcoal binds with salicylate and therefore inhibits absorption by the small intestine. IV sodium bicarbonate may be used for treating aspirin overdose after treatment with activated charcoal has been initiated.

A client with active pulmonary tuberculosis is prescribed 4-drug therapy with ethambutol. The nurse reinforces previous teaching to notify the health care provider immediately if which adverse effect associated with ethambutol occurs? A. Blurred vision B. Dark-colored urine C. Difficulty hearing D. Yellow skin

Correct Answer: A. Blurred vision Ethambutol (Myambutol) is used in combination with other antitubercular drugs (eg, isoniazid, rifampin, pyrazinamide) to treat active tuberculosis. The client must have baseline and periodic eye examinations during therapy as optic neuritis is a possible although potentially reversible adverse effect. The client is instructed to report any signs of decreased visual acuity or loss of color (red-green) discrimination. Incorrect Answer: [B. Dark-colored urine] Dark-colored urine and yellow skin can indicate the presence of hepatotoxicity, which is associated with many drugs used to treat tuberculosis (eg, isoniazid, pyrazinamide, rifampin). However, hepatotoxicity is not common with ethambutol. [C. Difficulty hearing] Difficulty hearing (tinnitus, subjective hearing loss) is an adverse reaction to streptomycin. Streptomycin, an aminoglycoside antibiotic, is a second-line drug sometimes used to treat multidrug-resistant tuberculosis and has ototoxic and nephrotoxic adverse effects. [D. Yellow skin] Dark-colored urine and yellow skin can indicate the presence of hepatotoxicity, which is associated with many drugs used to treat tuberculosis (eg, isoniazid, pyrazinamide, rifampin). However, hepatotoxicity is not common with ethambutol. Educational objective:Clients taking ethambutol must have a baseline eye examination and periodic checkups during therapy as optic neuritis is a possible although potentially reversible adverse effect.

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? A. Bumetanide B. Candesartan C. Carvedilol D. Isosorbide

Correct Answer: A. Bumetanide 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). Incorrect Answer: [B. Candesartan] 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. [C. Carvedilol] 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. [D. Isosorbide] 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 is reinforcing discharge teaching with a client who has been prescribed warfarin for chronic atrial fibrillation. The client should avoid excess or inconsistent intake of which foods? Select all that apply. A. Bananas B. Broccoli C. Grapefruit juice D. Red meat E. Spinach

Correct Answer: B, C, and E Large amounts of vitamin K-rich foods can decrease the anticoagulant effects of warfarin therapy. Clients are not instructed to remove such foods from their diet but are encouraged to be consistent in the intake of foods high in vitamin K, including leafy green vegetables, asparagus, broccoli, kale, Brussels sprout, and spinach. Several beverages also affect warfarin therapy. Green tea, grapefruit juice, and cranberry juice may alter the drug's anticoagulant effects. Incorrect Answers: [A. Bananas] Certain fruits (eg, bananas, oranges) are rich in potassium and may increase the risk for hyperkalemia with the use of potassium-sparing diuretics (eg, spironolactone, triamterene, eplerenone). However, bananas and oranges are low in vitamin K and are not known to interact with warfarin. [D. Red meat] Eating less red meat and reducing sodium intake are part of a heart-healthy diet but are not specific to a warfarin regimen. Educational objective:The nurse should teach the client receiving warfarin therapy to be consistent with intake of foods high in vitamin K (eg, leafy green vegetables, asparagus, kale, spinach). Clients do not need to restrict vitamin K-rich foods completely. Green tea, cranberry juice, and grapefruit juice may alter the anticoagulant effects of warfarin.

A client with methicillin-resistant Staphylococcus aureus (MRSA) bacteremia has been receiving IV vancomycin for the last 3 days. Which blood test trend is most important for the nurse to review when preparing to administer this medication? A. Blood cultures B. Creatinine levels C. Magnesium levels D. White blood cell (WBC) count

Correct Answer: B. Creatinine levels Vancomycin can cause nephrotoxicity, which occurs most often in clients who already have some degree of renal impairment. Serum creatinine levels should be monitored daily during IV vancomycin treatment to look for an increase in level over a few days. If an increasing trend is identified, the nurse should consult with the health care provider (HCP) and/or pharmacist before administering the dose. Incorrect Answers: [A. Blood cultures] Blood cultures may be checked periodically during vancomycin therapy, but they are not likely to change this quickly. [C. Magnesium levels] Magnesium levels are typically not affected by vancomycin therapy. [D. White blood cell (WBC) count] The WBC count may be helpful in determining the effectiveness of vancomycin therapy in treating infection. However, this laboratory result is unlikely to influence the nurse's decision on whether to administer the dose. Therefore, it is not the highest priority. Educational objective:Creatinine levels should be closely monitored for signs of nephrotoxicity in the client receiving IV vancomycin. If increasing creatinine is identified, the nurse should hold the dose and consult with the HCP and/or pharmacist before administration.

A client has been on long-term therapy with esomeprazole. What is essential for the nurse to ask the client? A. "Are you drinking plenty of water with the medication?" B. "Are you taking the medication after meals?" C. "Have you had a bone density test recently?" D. "Have you had your blood pressure taken regularly?"

Correct Answer: C. "Have you had a bone density test recently?" Long-term therapy with a proton pump inhibitor (PPI) (eg, omeprazole, pantoprazole, esomeprazole) may decrease the absorption of calcium and promote osteoporosis. A bone density test can assess if the client already has osteoporosis. Hospitalized clients also have an increased risk of diarrhea caused by Clostridium difficile. PPIs cause suppression of acid that otherwise would have prevented pathogens from more easily colonizing the upper gastrointestinal tract. This leads to increased risk of pneumonias. Incorrect Answers: [A. "Are you drinking plenty of water with the medication?"] Drinking extra water and being upright for 30 minutes after taking bisphosphonates (eg, risedronate, alendronate) is necessary to prevent esophagitis. However, this is not necessary with PPI use. [B. "Are you taking the medication after meals?"] The medication should be taken prior to meals [D. "Have you had your blood pressure taken regularly?"] PPIs do not affect blood pressure Educational objective:Long-term use of PPIs (eg, omeprazole, pantoprazole, esomeprazole) is associated with osteoporosis, C difficile infection, and pneumonias. Clients should be encouraged to increase calcium and vitamin D intake to help prevent osteoporosis.

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

Correct Answer: C. "I will place capsules in my pill box so I will not forget to take a dose." 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. Incorrect Answers: [A. "I will call my health care provider if I notice red urine or blood in my stool."] 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. [B. "I will not stop taking dabigatran even if I get a stomachache."] 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). [D. "I will swallow the capsule whole with a full glass of water."] 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.

The nurse is caring for a client taking tamoxifen for breast cancer. Which client statement is most concerning and a priority to report to the health care provider? A. "I don't have much interest in sex lately." B. "I feel like I might be getting a cold." C. "My periods have been heavy lately." D. "These hot flashes are occurring a lot."

Correct Answer: C. "My periods have been heavy lately." Selective estrogen receptor modulators (eg, tamoxifen) have differential action in different tissues (mixed agonist/antagonist). In the breast, they block estrogen (antagonist) and are therefore helpful in inhibiting the growth of estrogen-receptive breast cancer cells. However, tamoxifen has estrogen-stimulating (agonist) activity in the uterus, resulting in excessive endometrial proliferation (endometrial hyperplasia). This hyperplasia can eventually lead to cancer. Irregular or excessive menstrual bleeding in premenopausal woman or any bleeding in postmenopausal women can be a sign of endometrial cancer. Due to its estrogen-agonist actions, tamoxifen also poses a risk for thromboembolic events (eg, stroke, pulmonary embolism, deep vein thrombosis). Clients with breast cancer take tamoxifen for several (5-10) years to prevent recurrence. Therefore, monitoring for life-threatening side effects is very important. Incorrect Answers: [A. "I don't have much interest in sex lately."] Because tamoxifen blocks estrogen receptors, it can cause symptoms of menopause. Vaginal dryness, hot flashes, and decreased libido (sexual dysfunction) are common and would be discussed after addressing more concerning symptoms. [B. "I feel like I might be getting a cold."] Tamoxifen is not associated with significant immunosuppression although it may rarely cause leukopenia. [D. "These hot flashes are occurring a lot."] Because tamoxifen blocks estrogen receptors, it can cause symptoms of menopause. Vaginal dryness, hot flashes, and decreased libido (sexual dysfunction) are common and would be discussed after addressing more concerning symptoms. Educational objective:Tamoxifen has mixed agonist and antagonist activity on estrogen receptors in various tissues. It is used for several years in estrogen-responsive breast cancer. However, it is associated with increased risk of endometrial cancer and venous thromboembolism. Menopausal symptoms (eg, vaginal dryness, hot flashes) are the most common side effect.

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? A. Client eats a vegetarian diet B. Client has chronic atrial fibrillation C. Client takes indomethacin for osteoarthritis D. Client's platelet count is 176 x10*3/mm*3 (176 x10*9/L)

Correct Answer: C. Client takes indomethacin for osteoarthritis 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 Incorrect Answers: [A. Client eats a vegetarian diet] 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. [B. Client has chronic atrial fibrillation] Chronic atrial fibrillation increases the risk for thromboembolic events and would be an indication for anticoagulant therapy, such as apixaban. [D. Client's platelet count is 176 x10*3/mm*3 (176 x10*9/L)] The current platelet count is within a normal range (150-400 x10*3/mm*3 [150-400 x10*9/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 receives an injection of botulinum toxin type A for facial and neck rejuvenation. The nurse should monitor for which complication of this procedure? A. Abdominal rigidity and diarrhea B. Back pain and urge incontinence C. Difficulty swallowing and breathing D. Difficulty walking and hand tremor

Correct Answer: C. Difficulty swallowing and breathing Botulinum toxin type A (Botox) blocks neuromuscular transmission by inhibiting acetylcholine release from nerve endings. The drug is used for treating wrinkles, blepharospasm, and cervical dystonia. Complications are uncommon when Botox is used for cosmetic purposes but can be life-threatening if they occur. The toxin can also relax the muscles used for swallowing and breathing, resulting in dysphagia (aspiration risk) and respiratory paralysis. Incorrect Answers: [A. Abdominal rigidity and diarrhea] Botulism can be associated with constipation and urinary retention due to relaxation of smooth muscle. Unlike in Clostridium tetani infection (tetanus), the painful rigidity and spasms of the neck, back, and abdominal muscles are absent in botulism. [B. Back pain and urge incontinence] Botulism can be associated with constipation and urinary retention due to relaxation of smooth muscle. Unlike in Clostridium tetani infection (tetanus), the painful rigidity and spasms of the neck, back, and abdominal muscles are absent in botulism. [D. Difficulty walking and hand tremor] Ataxia and hand tremor usually indicate drug toxicity (eg, phenytoin, lithium). Educational objective:Botulinum toxin type A (Botox) inhibits the release of acetylcholine from nerve endings and causes relaxation of skeletal/smooth muscles. On occasion, surrounding muscle weakness can lead to dysphagia and respiratory paralysis.

The nurse reinforces teaching for a client taking atorvastatin to call the health care provider if experiencing which symptom associated with a serious, adverse effect of the medication? A. Diarrhea B. Headache C. Muscle aches D. Numbness in the feet

Correct Answer: C. Muscle aches 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. Myopathy with ongoing generalized muscle aches and weakness is a serious adverse effect of statins such as atorvastatin and rosuvastatin (Crestor). A client who develops muscle aches while on a statin drug should call the health care provider, who will then obtain a blood sample to assess the creatinine kinase (CK) level. If myopathy is present, CK will be significantly elevated (≥10x normal), and the drug should be discontinued. Incorrect Answers: [A. Diarrhea] 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. [B. Headache] 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. [D. Numbness in the feet] 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 drug such as atorvastatin or rosuvastatin should be taught to call the health care provider if generalized muscle aches develop as this may be a symptom of myopathy, a serious adverse effect of this type of medication.

The nurse is administering medications to a client who is being evaluated for a brain malignancy. The client is scheduled for a CT scan with IV iodinated contrast the next morning. Which medication should the nurse clarify with the health care provider? A. Amlodipine B. Gabapentin C. Metformin D. Phenytoin

Correct Answer: C. Metformin A computed tomography (CT) scan is a noninvasive procedure that provides detailed x-ray images of the body. In some cases, iodinated contrast (eg, IV, PO) is administered during the CT scan to enhance visualization of blood vessels or certain organs. For clients with renal impairment, a potential complication of IV iodinated contrast is acute kidney injury (ie, contrast-induced nephropathy). Lactic acidosis is a severe complication of metformin, an antidiabetic medication. Administration of IV iodinated contrast to a client who takes metformin can cause an accumulation of metformin in the bloodstream, which increases the risk for lactic acidosis. As a result, many health care providers will discontinue metformin 24-48 hours before administration of IV contrast and restart the medication after 48 hours, when stable renal function is confirmed. Incorrect Answers: [A. Amlodipine] Amlodipine is a calcium channel blocker commonly used to treat hypertension. Gabapentin is an anticonvulsant that is also used for neuropathic pain. Phenytoin is an anticonvulsant. None of these medications are known to interact with the iodinated contrast or worsen kidney injury. Therefore, these medications can be safely administered to the client who is scheduled to receive IV iodinated contrast. [B. Gabapentin] Amlodipine is a calcium channel blocker commonly used to treat hypertension. Gabapentin is an anticonvulsant that is also used for neuropathic pain. Phenytoin is an anticonvulsant. None of these medications are known to interact with the iodinated contrast or worsen kidney injury. Therefore, these medications can be safely administered to the client who is scheduled to receive IV iodinated contrast. [D. Phenytoin] Amlodipine is a calcium channel blocker commonly used to treat hypertension. Gabapentin is an anticonvulsant that is also used for neuropathic pain. Phenytoin is an anticonvulsant. None of these medications are known to interact with the iodinated contrast or worsen kidney injury. Therefore, these medications can be safely administered to the client who is scheduled to receive IV iodinated contrast. Educational objective:Iodinated contrast is commonly administered during computed tomography (CT) scans to enhance visualization of certain body structures. Clients who receive IV iodinated contrast while taking metformin are at increased risk for lactic acidosis; therefore, the health care provider may discontinue metformin 24-48 hours before administration of IV contrast and restart the medication after 48 hours.

A 64-year-old client is prescribed ciprofloxacin for a urinary tract infection. The nurse reminds the client to observe for and notify the health care provider immediately about which of the following? A. Brown-colored urine B. Hearing and balance problems C. Pain in the Achilles tendon area D. Sunburn

Correct Answer: C. Pain in the Achilles tendon area Use of fluoroquinolones (ciprofloxacin, levofloxacin, moxifloxacin, norfloxacin, ofloxacin), especially ciprofloxacin, places clients at increased risk for tendinitis and tendon rupture that most often occur in the Achilles tendon. This class of antibiotics carries a black box warning about this risk. The Food and Drug Administration recommends that at the first sign of tendon pain or swelling, clients should stop taking the fluoroquinolone, abstain from moving the affected area, and contact their health care provider promptly for further evaluation and a change of antibiotic. Incorrect Answer: [A. Brown-colored urine] Turning urine into a harmless brown color is a common side effect of nitrofurantoin, another antibiotic commonly prescribed for urinary tract infections. [B. Hearing and balance problems] Hearing and balance problems (vertigo) result from aminoglycoside ototoxicity (eg, gentamicin). [D. Sunburn] Ciprofloxacin can cause photosensitivity. The client should be instructed to avoid sun exposure and use sunscreen while taking the medication. Educational objective:Fluoroquinolones (ciprofloxacin) carry a black box warning citing an increased risk of tendinitis and rupture, especially of the Achilles tendon.

The nurse reinforces teaching to a female client about taking misoprostol to prevent stomach ulcers. Which statement by the client would prompt further instruction? A. "I can take this medication with food if it hurts my stomach." B. "I must use a reliable form of birth control while taking this medication." C. "I should continue to take my ibuprofen as prescribed." D. "I will take this medicine with an antacid to decrease stomach upset."

Correct Answer: D. "I will take this medicine with an antacid to decrease stomach upset." Misoprostol (Cytotec) is a synthetic prostaglandin that protects against gastric ulcers by reducing stomach acid and promoting mucus production and cell regeneration. It is often prescribed to prevent gastric ulcers in clients receiving long-term nonsteroidal anti-inflammatory drug (NSAID) therapy. Antacids, especially those that contain magnesium (eg, Gaviscon), can increase the adverse effects of misoprostol (eg, diarrhea, dehydration). If clients require therapy with antacids, they should choose one that does not contain magnesium (eg, calcium carbonate [Tums]) and contact the health care provider if adverse effects occur. Incorrect Answers: [A. "I can take this medication with food if it hurts my stomach."] Taking misoprostol with food can help decrease gastrointestinal side effects (eg, abdominal pain, cramping, diarrhea). [B. "I must use a reliable form of birth control while taking this medication."] Misoprostol is also used for labor induction and is classified as a pregnancy category X drug. Women of childbearing age must be educated on using reliable birth control and the possible sensation of uterine cramping while taking misoprostol. Clients who suspect they are pregnant must stop taking the medication and contact their health care provider immediately. [C. "I should continue to take my ibuprofen as prescribed."] The client can continue taking ibuprofen (an NSAID) with misoprostol because misoprostol is designed to reduce side effects of ibuprofen. Educational objective:Misoprostol prevents gastric ulcers in clients receiving long-term nonsteroidal anti-inflammatory drug therapy. It should not be taken with antacids but can be taken with food to reduce gastrointestinal upset. Women of childbearing age should be educated on using reliable birth control methods as misoprostol can induce labor.

The nurse is reinforcing teaching about home administration of sublingual nitroglycerin (NTG) tablets to a client with stable angina. Which statement by the client indicates the need for further teaching? A. "I will call 911 if my chest pain isn't relieved by NTG." B. "If I have chest pain, I can take up to 3 pills 5 minutes apart." C. "I'll call my doctor if I start having chest pain at night." D. "I'll keep one bottle in the house and one in the car."

Correct Answer: D. "I'll keep one bottle in the house and one in the car." NTG is a vasodilator used to treat stable angina. It is a sublingual tablet or spray that is placed under the client's tongue. It usually relieves pain in about 3 minutes and lasts 30-40 minutes. The recommended dose is 1 tablet or 1 spray taken sublingually for angina every 5 minutes for a maximum of 3 doses. If symptoms are unchanged or worse 5 minutes after the first dose, emergency medical services (EMS) should be contacted. Previously, clients were taught to call EMS after the third dose was taken, but newer studies suggest that this leads to a significant delay in treatment. The NTG should be easily accessible at all times. Tablets are packaged in a light-resistant bottle with a metal cap. They should be stored away from light and heat sources, including body heat, to protect from degradation. Clients should be instructed to keep the tablets in the original container. Once opened, the tablets lose potency and should be replaced every 6 months. The car is not a good place to store NTG due to heat. Waking up at night with chest pain can signify that angina is occurring at rest and is no longer considered stable angina. This should be reported to the health care provider. Educational objective:Education about sublingual NTG should include placing the tablet or spray under the tongue; repeating the dose every 5 minutes, with up to 3 total doses if angina is not relieved; notifying EMS if the first dose does not improve the symptoms; keeping the tablets in the original container away from light and heat; and replacing the bottle every 6 months once opened.

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? A. "I should avoid alcohol intake with this new medication." B. "I should call my primary health care provider if my morning blood glucose is below 60 mg/dL (3.3 mmol/L)." C. "I should read the labels on all foods I eat, including those that say 'sugarless'." D. "This medication will help me lose weight."

Correct Answer: D. "This medication will help me lose weight." 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. Incorrect Answers: [A. "I should avoid alcohol intake with this new medication."] Clients taking sulfonylureas should avoid alcohol as it lowers blood glucose and can lead to severe hypoglycemia. [B. "I should call my primary health care provider if my morning blood glucose is below 60 mg/dL (3.3 mmol/L)."] 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. [C. "I should read the labels on all foods I eat, including those that say 'sugarless'."] 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 practical nurse reviews the laboratory results for 4 clients. Which laboratory value is most important for the practical nurse to report to the registered nurse for evaluation? A. Client with Clostridium difficile infection receiving metronidazole has a white blood cell count of 15,000/mm*3 (15.0 x 10*9/L) B. Client with liver cirrhosis has a prothrombin time of 18 seconds C. Client with mild asthma exacerbation receiving prednisone has a blood glucose of 250 mg/dL (13.9 mmol/L) D. Client with rheumatoid arthritis taking adalimumab has a white blood cell count of 14,000/mm*3 (14.0 x 10*9/L)

Correct Answer: D. Client with rheumatoid arthritis taking adalimumab has a white blood cell count of 14,000/mm*3 (14.0 x 10*9/L) Adalimumab (Humira), a tumor necrosis factor (TNF) inhibitor, is a biologic disease-modifying antirheumatic drug (DMARD) classified as a monoclonal antibody. Its major adverse effects are similar to those of other TNF inhibitor drugs (eg, etanercept [Enbrel], infliximab [Remicade]) and include immunosuppression and infection (eg, current, reactivated). An elevated white blood cell count in this client can indicate underlying infection and should be reported immediately. Incorrect Answers: [A. Client with Clostridium difficile infection receiving metronidazole has a white blood cell count of 15,000/mm*3 (15.0 x 10*9/L)] This client with Clostridium difficile infection will have an elevated white blood cell (WBC) count. The client is receiving appropriate therapy (eg, metronidazole, oral vancomycin). The nurse will need to monitor the WBC count and report it if it keeps increasing. [B. Client with liver cirrhosis has a prothrombin time of 18 seconds] The liver produces most blood clotting factors. Clients with liver cirrhosis will lose this ability and are at risk for bleeding. This client's prothrombin time is mildly elevated (normal 11-16 seconds), which is expected with cirrhosis. [C. Client with mild asthma exacerbation receiving prednisone has a blood glucose of 250 mg/dL (13.9 mmol/L)] Corticosteroids increase blood glucose. This is expected, and the client may need treatment if the glucose levels are markedly increased for a prolonged period. Most clients with asthma exacerbation are expected to take a 5- to 7-day course of steroids. Educational objective:Adalimumab (Humira), etanercept (Enbrel), and infliximab (Remicade) are common tumor necrosis factor inhibitors and biologic disease-modifying antirheumatic drugs. Major adverse effects associated with their use include immunosuppression and infection.

A client recently diagnosed with heart failure is being discharged on the angiotensin-converting enzyme inhibitor lisinopril. Which information related to this new medication is important for the nurse to reinforce at discharge? A. Instruct client to report for monthly blood work to monitor drug levels B. Review foods high in potassium that client should include in diet C. Teach client to check own pulse for 1 minute; hold medication if heart rate is <60/min D. Teach client to rise slowly and sit on side of bed for several minutes before rising

Correct Answer: D. Teach client to rise slowly and sit on side of bed for several minutes before rising Angiotensin-converting enzyme (ACE) inhibitors 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 the 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 their 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. Incorrect Answers: [A. Instruct client to report for monthly blood work to monitor drug levels] 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. [B. Review foods high in potassium that client should include in diet] A common side effect of ACE inhibitors 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. [C. Teach client to check own pulse for 1 minute; hold medication if heart rate is <60/min] 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 ACE 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.

The nurse is preparing to administer the fourth dose of IV vancomycin to a client. Which set of laboratory values would alert the nurse to hold the vancomycin and notify the health care provider? A. Vancomycin trough 10 mg/L (6.9 µmol/L), creatinine 1.1 mg/dL (97.2 µmol/L), BUN 6 mg/dL (2.1 mmol/L) B. Vancomycin trough 14 mg/L (9.7 µmol/L), creatinine 1.2 mg/dL (106.1 µmol/L), BUN 10 mg/dL (3.6 mmol/L) C. Vancomycin trough 18 mg/L (12.4 µmol/L), creatinine 0.6 mg/dL (53 µmol/L), BUN 18 mg/dL (6.4 mmol/L) D. Vancomycin trough 23 mg/L (15.9 µmol/L), creatinine 1.5 mg/dL (132.6 µmol/L), BUN 24 mg/dL (8.6 mmol/L)

Correct Answer: D. Vancomycin trough 23 mg/L (15.9 µmol/L), creatinine 1.5 mg/dL (132.6 µmol/L), BUN 24 mg/dL (8.6 mmol/L) Vancomycin (Vancocin) is a potent antibiotic used to treat gram-positive bacterial infections (eg, Staphylococcus aureus, Clostridium difficile). To lower the risk of dose-related nephrotoxicity, especially in clients with renal impairment and those who are >60 years of age, serum vancomycin trough levels should be monitored to assess for therapeutic range (10-20 mg/L [6.9-13.8 µmol/L]). A vancomycin trough level above the normal range and/or elevated creatinine and blood urea nitrogen (BUN) values should be reported to the health care provider (HCP) as this may indicate nephrotoxicity. Incorrect Answers: [A. Vancomycin trough 10 mg/L (6.9 µmol/L), creatinine 1.1 mg/dL (97.2 µmol/L), BUN 6 mg/dL (2.1 mmol/L)] Normal laboratory values do not need to be reported to the HCP. Baseline and ongoing monitoring for normal levels of creatinine (0.6-1.3 mg/dL [53-115 µmol/L]) and BUN (6-20 mg/dL [2.1-7.1 mmol/L]) are necessary in clients receiving vancomycin. [B. Vancomycin trough 14 mg/L (9.7 µmol/L), creatinine 1.2 mg/dL (106.1 µmol/L), BUN 10 mg/dL (3.6 mmol/L)] Normal laboratory values do not need to be reported to the HCP. Baseline and ongoing monitoring for normal levels of creatinine (0.6-1.3 mg/dL [53-115 µmol/L]) and BUN (6-20 mg/dL [2.1-7.1 mmol/L]) are necessary in clients receiving vancomycin. [C. Vancomycin trough 18 mg/L (12.4 µmol/L), creatinine 0.6 mg/dL (53 µmol/L), BUN 18 mg/dL (6.4 mmol/L)] Normal laboratory values do not need to be reported to the HCP. Baseline and ongoing monitoring for normal levels of creatinine (0.6-1.3 mg/dL [53-115 µmol/L]) and BUN (6-20 mg/dL [2.1-7.1 mmol/L]) are necessary in clients receiving vancomycin. Educational objective:The normal therapeutic level of vancomycin is 10-20 mg/L (6.9-13.8 µmol/L). Elevated vancomycin trough levels (>20 mg/L [>13.8 µmol/L]), creatinine (>1.3 mg/dL [>115 µmol/L]), and blood urea nitrogen (>20 mg/dL [>7.1 mmol/L]) are associated with nephrotoxicity and should be reported to the health care provider.

The nurse cares for a client who has oral candidiasis. The health care provider has prescribed nystatin oral suspension. Which of the following nursing actions are appropriate? Select all that apply. A. Assist the client in removing dentures and soaking them in nystatin B. Inspect the oral mucous membranes thoroughly before administering nystatin C. Instruct the client to discontinue the medication as soon as symptoms subside D. Instruct the client to swish the suspension in the mouth for several minutes E. Shake the bottle of suspension thoroughly before measuring the dose

Correct Answers: A, B, D, and E Nystatin is an antifungal medication commonly used to treat mucocutaneous candidal infections (ie, oral, intestinal, vaginal, skin). When caring for a client prescribed nystatin, the nurse should: · Assist clients with oral candida who wear dentures in removing them and soaking them in nystatin suspension because dentures often become a reservoir for reinfection. · Assess the appearance of the affected area (eg, oral cavity, skin lesions) frequently throughout nystatin therapy (eg, before administration, during routine assessments) to monitor treatment efficacy and identify potential side effects (eg, mucous membrane irritation). · Instruct clients prescribed nystatin liquid suspension for oral thrush to swish the suspension in the mouth for several minutes and then swallow the medication to allow treatment of any esophageal candida. · Ensure that liquid suspension forms of nystatin are shaken well before being measured for dosing because medication precipitates and causes unequal concentrations within the liquid. Incorrect Answers: [C. Instruct the client to discontinue the medication as soon as symptoms subside] Clients receiving nystatin should be educated to take the medication as prescribed each day and avoid missing doses; nystatin therapy is continued for at least 48 hours after symptoms subside to prevent recurrence of the infection. Educational objective:Oral nystatin suspension is an antifungal medication used to treat oral thrush caused by candidal infections. Nurses administering nystatin should assist the client in removing and soaking dentures, if present; assess the affected area frequently; educate the client to swish the medication in the mouth before swallowing; and ensure that the suspension is well shaken before dosing.

A client who has been on long-term omeprazole therapy for gastroesophageal reflux disease is admitted to the hospital for a urinary tract infection. The nurse recognizes that this client is at highest risk for which complication due to omeprazole use? A. Clostridium difficile infection B. Gait disturbance C. Jaw necrosis D. Tremor

Correct Answers: A. Clostridium difficile infection Long-term use of proton pump inhibitors (PPIs) is common as these medications are available over the counter. PPIs impair intestinal calcium absorption and therefore are associated with decreased bone density, which increases the possibility of fractures of the spine, hip, and wrist. PPIs cause acid suppression that otherwise would have prevented pathogens from more easily colonizing the upper gastrointestinal tract. This leads to increased risk of pneumonias. PPI use may also increase the risk for clostridium difficile-associated diarrhea (CDAD); currently the cause is unclear. A safety alert has been issued by the US Food and Drug Administration (FDA) advising health care providers to consider CDAD for unresolved diarrhea in PPI users. This client would be receiving antibiotics for a urinary tract infection, further increasing the risk for C difficile infection. Incorrect Answers: [B. Gait disturbance] Gait disturbance (ataxia) is commonly seen with phenytoin toxicity. [C. Jaw necrosis] Jaw necrosis is associated with long-term bisphosphonate (eg, alendronate, risedronate) therapy. [D. Tremor] Tremor is seen with lithium toxicity and albuterol (short-acting beta agonist) use. Educational objective:Long-term use of PPIs (Prazoles - omeprazole, lansoprazole, pantoprazole, rebeprazole) has been associated with decreased bone density (calcium malabsorption) and increased risk for C difficile-associated diarrhea and pneumonia.

The nurse reinforces instructions to a client discharged on warfarin, after being treated for a pulmonary embolism following surgery. Which statements made by the client indicate the need for further teaching? Select all that apply. A. "I will need to take my blood thinner for about 3-6 months." B. "I will place small rugs on my wood floors to cushion a fall." C. "I will take a baby aspirin if I have mild chest pain." D. "I will use a soft-bristled toothbrush to clean my teeth." E. "I will wear a blood thinner MedicAlert tag."

Correct Answers: B and C Clients discharged on warfarin (Coumadin) are taught interventions to prevent injury, such as removing scatter rugs in the home to reduce the risk of tripping and falling (especially in elderly). Clients are educated to avoid aspirin, drugs containing aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), and alcohol when taking warfarin due to an increased risk for bleeding. Incorrect Answers: [A. "I will need to take my blood thinner for about 3-6 months."] Warfarin is usually administered for 3-6 months following pulmonary embolism (PE) to prevent further thrombus formation. A longer duration (lifelong) of anticoagulation is recommended in clients with recurrent PE. Prothrombin time and INR must be monitored regularly to adjust the dose and maintain a therapeutic anticoagulant level. [D. "I will use a soft-bristled toothbrush to clean my teeth."] Clients should be taught to avoid trauma or injury to decrease the risk for bleeding. Preventive measures include gently brushing teeth with a soft-bristled toothbrush, avoiding use of alcohol-based mouthwash, avoiding contact sports or rollerblading, and using a straight razor. Flossing should also be avoided in general, but waxed dental floss may be used with care in some clients. [E. "I will wear a blood thinner MedicAlert tag."] Clients are instructed to wear a MedicAlert tag (eg, necklace, bracelet) when taking anticoagulants (eg, warfarin, heparin). Educational objective:Clients on warfarin or heparin should avoid using aspirin or nonsteroidal anti-inflammatory drugs, wear a MedicAlert device, avoid activities that increase the risk for bleeding, and limit alcohol intake.

The nurse is preparing to administer medications to a client admitted with atrial fibrillation. The nurse notes the vital signs shown in the exhibit. Which medications due at this time are safe to administer? Select all that apply. Vital Signs: Temperature: 98.4 (36.9 C) Blood Pressure: 124/78 Heart Rate: 46/min and irregularly irregular Respirations: 22/min A. Diltiazem extended-release PO B. Heparin subcutaneous injection C. Lisinopril PO D. Metoprolol PO E. Timolol ophthalmic

Correct Answers: B and C Clients with atrial fibrillation can have either bradycardia (slow ventricular response) or tachycardia (rapid ventricular response). This client's vital signs are significant for bradycardia (heart rate [HR] <60/min). Therefore, medications that can decrease HR should be held and the health care provider (HCP) notified. The reason for holding the medication (HR 46/min) and an HCP contact note should be documented. Heparin is an anticoagulant; the subcutaneous injection is most commonly used to prevent deep venous thrombosis in hospitalized clients on bed rest. This medication will not affect the vital signs and is safe to administer. Lisinopril, an ACE inhibitor, does not lower HR and is not contraindicated in clients with bradycardia. The client is not hypotensive; therefore, lisinopril is safe to administer. Incorrect Answers: [A. Diltiazem extended-release PO] Non-dihydropyridine calcium channel blockers (eg, diltiazem, verapamil) can decrease HR and should be held in clients with bradycardia. [D. Metoprolol PO] All beta blockers (eg, metoprolol, timolol, atenolol), including eye drops that can be absorbed systemically, can decrease the HR and should be held until the prescriptions can be clarified by the HCP. [E. Timolol ophthalmic] All beta blockers (eg, metoprolol, timolol, atenolol), including eye drops that can be absorbed systemically, can decrease the HR and should be held until the prescriptions can be clarified by the HCP. Educational objective:Medications that decrease the heart rate should be held in clients with bradycardia. These include beta blockers such as metoprolol and timolol (including eye drops) and some types of calcium channel blockers (eg, diltiazem, verapamil).

A community health nurse is preparing to administer influenza vaccines. Which clients can safely receive the live-attenuated, intranasal influenza vaccine? Select all that apply. A. 4-month-old client who is receiving scheduled vaccinations B. 3-year-old client who is afraid of needles C. 24-year-old client who is 6 weeks postpartum D. 32-year-old client who is pregnant at 12 weeks gestation E. 45-year-old client with a history of HIV

Correct Answers: B and C Influenza (flu) is a viral, respiratory illness common during the winter months. Each year, a new influenza vaccine is created to help protect against specific viral strains. The Centers for Disease Control and Prevention and the Public Health Agency of Canada recommend that all clients age ≥6 months receive the influenza vaccine annually. The influenza vaccine is available as an inactivated vaccine (intramuscular/intradermal injection) or as a live-attenuated influenza vaccine (LAIV; intranasal spray) that contains a weakened form of the live flu virus. The LAIV is safe and effective for most healthy individuals age 2-49 years to receive, including breastfeeding women. Incorrect Answers: [A. 4-month-old client who is receiving scheduled vaccinations] There is a remote chance the LAIV may become infectious; therefore, the LAIV is contraindicated in susceptible populations (eg, immunocompromised; children age <2) and populations with severe potential complications (eg, pregnancy). For these individuals, the inactivated vaccine is safest. [D. 32-year-old client who is pregnant at 12 weeks gestation] There is a remote chance the LAIV may become infectious; therefore, the LAIV is contraindicated in susceptible populations (eg, immunocompromised; children age <2) and populations with severe potential complications (eg, pregnancy). For these individuals, the inactivated vaccine is safest. [E. 45-year-old client with a history of HIV] There is a remote chance the LAIV may become infectious; therefore, the LAIV is contraindicated in susceptible populations (eg, immunocompromised; children age <2) and populations with severe potential complications (eg, pregnancy). For these individuals, the inactivated vaccine is safest. Educational objective:The live-attenuated, intranasal influenza vaccine is a safe and effective choice for many healthy clients age 2-49 years but should not be given to clients who are immunocompromised, pregnant, or age <2 years.

The nurse is passing prescribed medications to assigned clients. The nurse should hold and seek clarification for which scheduled administrations? Select all that apply. A. Client diagnosed with cirrhosis had 2 stools today; lactulose prescribed daily B. Client is receiving IV vancomycin; mild facial flushing noted after 30 minutes C. Client is scheduled for abdominal surgery tomorrow; vitamin E PO prescribed daily D. Client with diabetes has insulin glargine and aspart prescribed; AM glucose is 100 mg/dL (5.6 mmol/L) E. Lisinopril PO is prescribed daily; serum potassium level is 5.6 mEq/L (5.6 mmol/L)

Correct Answers: C and E ACE inhibitors ("-prils") and angiotensin II receptor blockers (ARBs) ("-sartans") create a risk for hyperkalemia. ACE inhibitors decrease the excretion of aldosterone. Ordinarily, aldosterone would increase sodium and decrease potassium. However, when the ACE inhibitor suppresses aldosterone, potassium rises, placing clients at risk for hyperkalemia, especially in the presence of impaired renal function. The nurse should question the administration of an ACE inhibitor in a client who is hyperkalemic. In general, certain herbs (garlic, gingko), vitamin E, and anticoagulation medications (eg, warfarin) are held prior to surgery as they can increase bleeding risk. Incorrect Answers: [A. Client diagnosed with cirrhosis had 2 stools today; lactulose prescribed daily] Lactulose is administered to excrete ammonia in cirrhosis with hepatic encephalopathy and not solely to treat constipation. The dose is adjusted to achieve 2-3 soft stools each day. [B. Client is receiving IV vancomycin; mild facial flushing noted after 30 minutes] Vancomycin should be infused over at least 60 minutes (100 minutes if infusing ≥1 g). When the medication is given too fast, the client may develop red man syndrome, which is characterized by facial and upper body flushing. If this occurs, the infusion needs to be slowed or stopped and restarted after a certain amount of time elapses, depending on flushing severity. However, it is not an anaphylactic rash and not a true allergy. This client is experiencing only a mild reaction; therefore, by slowing the infusion rate, the nurse can manage this side effect independently. [D. Client with diabetes has insulin glargine and aspart prescribed; AM glucose is 100 mg/dL (5.6 mmol/L)] Basal insulin glargine (Lantus) and the rapid-acting insulin aspart (NovoLOG) are used for glucose control in diabetic clients. The insulin is given at mealtime to prevent postprandial hyperglycemia. The client should receive the prescribed insulin prior to the meal even if blood glucose is within normal limits. Educational objective: · Clients receiving ACE inhibitors should be monitored for hyperkalemia, especially in the presence of renal insufficiency. · Certain herbs (garlic, gingko) and vitamin E can increase the risk for bleeding. · A scheduled insulin regimen is used to maintain glycemic control even if the blood glucose is within normal limits.

The nurse is reviewing discharge instructions with a client going home on linezolid therapy for a vancomycin-resistant enterococcus infection. Which client statement requires further teaching? A. "I can restart my paroxetine once I get back home." B. "I can take acetaminophen for headaches." C. "I will avoid foods and drinks that contain tyramine." D. "I will report any increased fever or diarrhea."

Correct Answer: A. "I can restart my paroxetine once I get back home." Linezolid (Zyvox) is an oxazolidinone antibiotic prescribed for vancomycin- and methicillin-resistant bacteria, pneumonia, and skin infections. Linezolid has monoamine oxidase inhibitor (MAOI)-type properties; concurrent use with selective serotonin reuptake inhibitors (SSRIs) (eg, paroxetine, fluoxetine, sertraline) increases the risk of serotonin syndrome, a potentially fatal accumulation of serotonin. Due to this risk, SSRIs are contraindicated while on linezolid therapy. SSRIs can be resumed 24 hours after linezolid therapy has been discontinued. Incorrect Answers: [B. "I can take acetaminophen for headaches."] Headaches may be a side effect of linezolid therapy. Acetaminophen is not contraindicated. [C. "I will avoid foods and drinks that contain tyramine."] Due to the MAOI-like properties of linezolid, clients should not consume foods or beverages containing tyramine during therapy to avoid adverse effects (eg, severe hypertension). [D. "I will report any increased fever or diarrhea."] Diarrhea is a common adverse effect of linezolid therapy. However, increased diarrhea or fever may indicate a complication from the regimen (eg, serotonin syndrome, Clostridium difficile infection) and should be reported promptly. Educational objective:Linezolid is an antibiotic with monoamine oxidase inhibitor-type properties that is prescribed to treat vancomycin- and methicillin-resistant bacterial infections. Selective serotonin reuptake inhibitors are contraindicated during therapy due to the increased risk of serotonin syndrome.

The nurse is reviewing prescriptions for the assigned clients. Which prescription should the nurse question? A. Allopurinol for a client who developed tumor lysis syndrome from chemotherapy for acute leukemia B. Dicyclomine for a client with a history of irritable bowel syndrome who develops a postoperative paralytic ileus C. IV morphine for a client after percutaneous nephrolithotripsy who reports the last bowel movement was 2 days ago D. Levofloxacin for a client with a urinary tract infection who has a history of anaphylaxis to penicillin drugs

Correct Answer: B. Dicyclomine for a client with a history of irritable bowel syndrome who develops a postoperative paralytic ileus Dicyclomine (Bentyl) is an anticholinergic/antispasmodic drug prescribed to manage symptoms of intestinal hypermotility in clients with irritable bowel syndrome. Dicyclomine is contraindicated in clients with paralytic ileus as it decreases intestinal motility and would exacerbate the condition. The nurse should question this prescription and contact the health care provider. Incorrect Answers: [A. Allopurinol for a client who developed tumor lysis syndrome from chemotherapy for acute leukemia] Tumor lysis syndrome occurs due to rapid lysis of cells and the resulting release of intracellular potassium and phosphorus into serum. Phosphorus binds to calcium, leading to hypocalcemia. The breakdown of cellular nucleic acids causes severe hyperuricemia. IV hydration and hypouricemic medications (eg, allopurinol) are prescribed to promote purine excretion and prevent acute kidney injury. [C. IV morphine for a client after percutaneous nephrolithotripsy who reports the last bowel movement was 2 days ago] Although opioids (eg, morphine) can cause constipation, symptoms can be managed with pharmacologic (eg, docusate sodium, sennoside) and nonpharmacologic interventions (eg, increased activity, increased fiber and fluid intake). Percutaneous nephrolithotripsy breaks and removes kidney stones, and can lead to severe pain. Therefore, pain medication is appropriate. [D. Levofloxacin for a client with a urinary tract infection who has a history of anaphylaxis to penicillin drugs] Levofloxacin, a fluoroquinolone antibiotic prescribed to treat urinary tract infections, has no known cross-sensitivity to penicillin. However, cross-sensitivity with other fluoroquinolones can occur. Educational objective:Dicyclomine is an antispasmodic drug that decreases intestinal motility and is contraindicated in clients with paralytic ileus.

A client with latent tuberculosis has been taking oral isoniazid (INH) 300 mg daily for 2 months. The client tells the nurse that for the past week she has had numbness, a burning sensation, and tingling in her hands and feet. Additional intake of which of the following would most likely have prevented this? A. Folic Acid B. Vitamin B6 C. Vitamin B12 D. Vitamin D

Correct Answer: B. Vitamin B6 INH interferes with the action of vitamin B6 (pyridoxine), resulting in peripheral neuropathy; it manifests as ataxia and paresthesia. Individuals who are most predisposed to becoming neurotoxic from taking INH include older adults, those who are malnourished, diabetic clients, pregnant or breastfeeding clients, alcoholics, children, those with liver or renal disease, and HIV-positive individuals. To prevent these complications, a vitamin B6 supplement at a dose of 25-50 mg/day is recommended for those at high risk. Incorrect Answers: [A. Folic Acid] Folic acid deficiency does not cause peripheral neuropathy. It is associated with macrocytic anemia and neural tube defects in children. [C. Vitamin B12] Vitamin B12 deficiency can cause peripheral neuropathy; however, it is not seen with INH therapy. [D. Vitamin D] Vitamin D deficiency causes osteomalacia but not peripheral neuropathy. Educational objective:High-risk clients on isoniazid therapy for treatment of tuberculosis may experience neurological side effects due to a decrease in the body's ability to utilize vitamin B6 (pyridoxine). A vitamin B supplement will prevent these effects.

The nurse is reinforcing education to a client with a venous thromboembolism who is prescribed rivaroxaban. Which statement by the client indicates the medication teaching has been effective? A. "I need to continue to avoid eating spinach and kale." B. "I probably will have some weakness in my legs when I take this medicine." C. "I should avoid taking aspirin while receiving this medication." D. "I will have to get blood drawn routinely to check my clotting levels."

Correct Answer: C. "I should avoid taking aspirin while receiving this medication." Factor Xa inhibitors (eg, rivaroxaban [Xarelto], edoxaban, apixaban) are anticoagulants used to prevent and treat venous thromboembolism. Factor Xa inhibitors are being prescribed more frequently than other oral anticoagulants (eg, warfarin), as they have a lower risk of bleeding and require less ongoing monitoring (eg, PT/INR). Clients prescribed rivaroxaban should be educated to avoid taking over-the-counter medications or supplements that increase bleeding risk, such as NSAIDs (eg, aspirin), garlic, and ginger. The combined effects of rivaroxaban and other anticoagulants may greatly increase the risk of uncontrolled bleeding (eg, epidural, intracranial, gastrointestinal) and hemorrhage Incorrect Answers: [A. "I need to continue to avoid eating spinach and kale."] Unlike warfarin, factor Xa inhibitors are not affected by vitamin K, which is found in many green, leafy vegetables (eg, spinach, kale). [B. "I probably will have some weakness in my legs when I take this medicine."] Anticoagulants, particularly factor Xa inhibitors, increase the risk for spontaneous intracranial bleeding or formation of epidural hematomas. Clients taking factor Xa inhibitors should be instructed to immediately contact their health care provider for symptoms of neurological impairment (eg, extremity weakness, altered sensation, numbness). [D. "I will have to get blood drawn routinely to check my clotting levels."] Routine monitoring of clotting times (eg, PT/INR, PTT) is unnecessary for clients prescribed factor Xa inhibitors. Educational objective:The nurse should instruct clients receiving factor Xa inhibitors (eg, rivaroxaban, edoxaban, apixaban), which are anticoagulants, to avoid taking additional medications or supplements with anticoagulant effects (eg, NSAIDs, garlic, ginger). The combined anticoagulant effects increase the risk for uncontrolled bleeding and hemorrhage.

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? A. "Have your blood sugars been in the desired range when you skip doses?" B. Take half of the evening dose to prevent a low blood sugar level." C. "The risk of low blood sugar is minimal when metformin is taken without food." D. "Why are you skipping meals? That is not a healthy weight loss strategy."

Correct Answer: C. "The risk of low blood sugar is minimal when metformin is taken without food." 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. Although skipping meals would cause a drop in blood glucose, metformin would not cause further hypoglycemia. Incorrect Answer: [A. "Have your blood sugars been in the desired range when you skip doses?"] 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. [B. Take half of the evening dose to prevent a low blood sugar level."] 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. [D. "Why are you skipping meals? That is not a healthy weight loss strategy."] 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.

A client with atrial fibrillation has just been placed on warfarin therapy. The nurse preceptor overhears the student nurse reinforcing teaching to the client about potential food-drug interactions. Which statement made by the student nurse requires the nurse preceptor to intervene? A. "Do you take any nutritional supplements?" B. "You will need to monitor your intake of foods containing vitamin K." C. "You will not be able to eat green leafy vegetables while taking warfarin." D. "Your blood will be tested at regular intervals."

Correct Answer: C. "You will not be able to eat green leafy vegetables while taking warfarin." Warfarin (Coumadin) works by blocking the availability of vitamin K, which is essential for blood clotting. As a result, the clotting mechanism is disrupted, reducing the risk of stroke, venous thrombosis, and pulmonary embolism. Clients who are on warfarin therapy must monitor their dietary intake of vitamin K. Rather than avoid vitamin K-rich foods, the client should maintain consistent vitamin K intake (eg, kale, broccoli, spinach, Brussels sprout) to keep prothrombin time (PT) and International Normalized Ratio (INR) stabilized within the recommended therapeutic range. Sudden changes in consumption of vitamin K-rich foods should be avoided as they alter the effectiveness of warfarin. An increase in vitamin K levels places the client at increased risk of blood clot formation, whereas a decrease places the client at increased risk for bleeding. There is some recent evidence that a very low intake of vitamin K may decrease the overall effectiveness of warfarin. Incorrect Answers: [A. "Do you take any nutritional supplements?"] Many medications can interfere with warfarin metabolism. Nutritional supplements may contain vitamin K, and any new medication or nutritional supplement should first be approved by the health care provider. Cranberry juice, grapefruit, green tea, and alcohol may also interfere with the effectiveness of warfarin. [B. "You will need to monitor your intake of foods containing vitamin K."] Clients who are on warfarin therapy must monitor their dietary intake of vitamin K. Rather than avoid vitamin K-rich foods, the client should maintain consistent vitamin K intake (eg, kale, broccoli, spinach, Brussels sprout) to keep prothrombin time (PT) and International Normalized Ratio (INR) stabilized within the recommended therapeutic range. [D. "Your blood will be tested at regular intervals."] PT/INR is monitored on an ongoing basis to determine the safest, most therapeutic warfarin dosage. Educational objective:A sudden increase or decrease in consumption of vitamin K-rich foods (green leafy vegetables) alters the effectiveness of warfarin. Rather than avoid vitamin K-rich foods, the client should maintain consistent daily vitamin K intake to keep PT/INR stable and within the recommended therapeutic range. PT/INR is monitored at regular intervals.

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

Correct Answer: C. Don't stop taking this medication abruptly 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. Incorrect Answers: [A. Avoid consuming high-sodium foods] 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. [B. Change positions slowly to prevent dizziness] Dizziness is a side effect of clonidine. The nurse should remind 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. [D. Use an oral moisturizer to relieve dry mouth] 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 client with hypertension and type 2 diabetes has recently started taking chlorthalidone. Which report by the client is most concerning to the nurse? A. Dizziness on standing B. Fasting blood glucose of 160 mg/dL (8.9 mmol/L) C. Presence of muscle cramps D. Sunburn on both arms

Correct Answer: C. Presence of muscle cramps Thiazide diuretics (eg, hydrochlorothiazide, chlorthalidone) are prescribed to treat hypertension and edema. The major side effects of thiazide diuretics include: · Hypokalemia - manifests as muscle cramps · Hyponatremia - manifests as altered mental status and seizures · Hyperuricemia - may precipitate or worsen gout attacks · Hyperglycemia - may require adjustment of diabetic medications Hypokalemia is the most serious side effect of thiazide diuretics as it can lead to life-threatening cardiac dysrhythmias. Incorrect Answers: [A. Dizziness on standing] Orthostatic hypotension may be a side effect of any diuretic. The nurse should teach the client to sit for a few minutes before standing and rise slowly. The nurse should also check that the client's blood pressure is not too low. [B. Fasting blood glucose of 160 mg/dL (8.9 mmol/L)] Mild to moderate hyperglycemia is common with thiazides and needs to be addressed. However, it is not life-threatening and therefore not a priority. [D. Sunburn on both arms] Most thiazide diuretics are sulfa derivatives and can therefore cause photosensitivity. The nurse should encourage the client to use sunscreen and wear protective clothing. Educational objective:The nurse should suspect hypokalemia in the presence of muscle cramps in a client taking diuretics. Hypokalemia can lead to dangerous ventricular dysrhythmias.

The nurse is preparing to administer a scheduled dose of metoclopramide IV to a client with diabetic gastroparesis. Which clinical finding causes the nurse to question the prescription? A. Diarrhea B. Frequent burping C. Headache D. Sucking lip motions

Correct Answer: D. Sucking lip motions Metoclopramide is a commonly used antiemetic medication that treats nausea, vomiting, and gastroparesis by increasing gastrointestinal motility and promoting stomach emptying. With extended use and/or high doses, metoclopramide may lead to the development of tardive dyskinesia (TD), a movement disorder that is characterized by uncontrollable motions (eg, sucking/smacking lip motions) and is often irreversible. The movement alterations of TD may impact a client's essential activities of daily living (eg, eating, dressing) and overall quality of life. The nurse should question the administration of a medication associated with TD in clients experiencing movement alterations. Incorrect Answers: [A. Diarrhea] Metoclopramide increases gastrointestinal motility, which may result in diarrhea in some clients. This symptom is reversible and usually easily managed. [B. Frequent burping] Burping is not a typical side effect associated with metoclopramide. [C. Headache] Headache is a common adverse effect of metoclopramide that typically improves spontaneously. Educational objective:Clients receiving metoclopramide at high doses and/or for extended periods are at risk for developing tardive dyskinesia (TD), an often irreversible movement disorder. The nurse should question a prescription for metoclopramide if symptoms of TD (eg, uncontrollable lip smacking, hand wringing, rocking) are present.

The clinic nurse reviews the medical record of a client who was prescribed etanercept, a tumor necrosis factor (TNF) inhibitor. Which test result is most important for the nurse to check before initiating this treatment? A. C-reactive protein (CRP) B. Prothrombin time (PT) C. Serum LDL cholesterol D. Tuberculin skin test (TST)

Correct Answer: D. Tuberculin skin test (TST) TNF inhibitor drugs (eg, etanercept [Enbrel], infliximab [Remicade], adalimumab [Humira]) block the action of TNF, a mediator that triggers a cell-mediated inflammatory response in the body. These drugs reduce the manifestations of rheumatoid arthritis (RA) and slow the progression of joint damage by inhibiting the inflammatory response. The medication causes immunosuppression and increased susceptibility for infection and malignancies. Clients should have a baseline TST before initiating therapy and yearly skin tests thereafter. Those with latent tuberculosis (TB) must be treated with antitubercular agents before initiating treatment with these drugs. Otherwise, TB reactivation would occur. Incorrect Answers: [A. C-reactive protein (CRP)] CRP is a non-specific test used to detect acute or chronic inflammation in the body. CRP can be used to evaluate the effectiveness of medications that decrease inflammation. An elevation would be expected in clients with RA, especially during a flare, but it is not the most important test result to check before initiating therapy. [B. Prothrombin time (PT)] LDL cholesterol and PT are unrelated to the administration of these medications. [C. Serum LDL cholesterol] LDL cholesterol and PT are unrelated to the administration of these medications. Educational objective:Major adverse effects of biologic disease-modifying TNF inhibitor drugs (eg, etanercept, infliximab, adalimumab) include severe infections and bone marrow suppression. TB reactivation is a major concern. Therefore, all clients must receive a TST to rule out latent TB.

A 45-year-old client with atrial fibrillation has been prescribed diltiazem. Which client outcome would best indicate that the medication has had its intended effect? A. Atrial fibrillation is converted to sinus rhythm B. Blood pressure is 126/78 mm Hg C. No signs or symptoms of stroke D. Ventricular rate decreased from 158/min to 88/min

Correct Answer: D. Ventricular rate decreased from 158/min to 88/min Atrial fibrillation is characterized by disorganized electrical activity in the atria due to multiple ectopic foci. It leads to loss of effective atrial contraction and places the client at risk for embolic stroke as a result of the thrombi formed in the atria. During atrial fibrillation, the atrial rate may be increased to 350-600/min. The ventricular response can vary. The higher the ventricular rate, the more likely the client will have symptoms of decreased cardiac output (ie, hypotension). The treatment goals are to reduce the ventricular rate to <100/min and prevent stroke. Ventricular rate control is the priority. Medications used for rate control include calcium channel blockers (ie, diltiazem), beta blockers (ie, metoprolol), and digoxin. Incorrect Answers: [A. Atrial fibrillation is converted to sinus rhythm] Diltiazem is unlikely to convert atrial fibrillation to sinus rhythm. Antiarrhythmic medications such as amiodarone or ibutilide will be used for conversion of the rhythm. [B. Blood pressure is 126/78 mm Hg] Calcium channel blockers such as diltiazem may reduce blood pressure, but the nurse is not evaluating this client in atrial fibrillation for this outcome. In this case, diltiazem is being used for ventricular rate reduction. [C. No signs or symptoms of stroke] Having no signs or symptom of stroke is a positive outcome in this client; however, it is not a specific outcome of diltiazem. Anticoagulants (eg, warfarin, dabigatran, rivaroxaban, apixaban) are used for this purpose. Educational objective:The nurse should monitor for a reduction in ventricular rate in the client with atrial fibrillation who is receiving diltiazem, metoprolol, or digoxin. Anticoagulants are used to prevent embolic complications.

A client diagnosed with endometrial cancer is receiving brachytherapy. Which interventions does the nurse anticipate for this client? Select all that apply. A. Cluster care to limit each staff member's time in the room to 30 minutes a shift B. Instruct the client to be up and around in the room but not to leave the room C. Place a sign on the client's door stating "Caution, Radioactive Material" D. Remind family members and visitors to stay at least 6 ft (1.82 m) away from the client E. Use a lead apron when providing direct client care to reduce exposure to radiation F. Wear a radiation film badge while in the client's room to monitor radiation exposure

Correct Answers: A, C, D, E, and F Internal radiation (brachytherapy) involves direct application of a radioactive implant to the cancerous site or tumor for a short time, usually 24-72 hours. This technique is used to treat cervical and endometrial cancer and delivers a high dose of radiation to the cancerous tissues with a limited dose to adjacent normal tissues. Implementation of the following nursing measures is vital as the client receiving brachytherapy emits radiation. Following the principles of time, distance, and shielding provides staff and visitors protection from radiation exposure. 1. Time spent near the radiation source is restricted. The guideline is to limit staff time spent in the room to 30 minutes per shift. o Cluster nursing care to minimize exposure to the radiation source o Rotate daily staff responsibilities to limit time spent in the client's room o All staff must wear a dosimeter film badge when assigned to care for a client receiving internal radiation o No individuals who are pregnant or under age 18 may be in the room 2. All staff and visitors must keep the maximum distance possible from the radiation source. Maintaining a distance of at least 6 ft (1.82 m) is an established standard. o Assign the client to a private room with a private bath o Keep the door to the room closed o Ensure that a sign stating, "Caution, Radioactive Material" is affixed to the door o Instruct the client to remain on bedrest to prevent dislodgement of the implant 3. Shielding with lead diminishes radiation exposure. All staff providing nursing care that requires physical contact must wear a lead apron. Incorrect Answers: [B. Instruct the client to be up and around in the room but not to leave the room] The client receiving brachytherapy for endometrial cancer is instructed to remain on bedrest while the radiation implant is in place. If the implant dislodges from the vaginal cavity, the implant should never be touched with the hands; instead, long-handled forceps should be used to pick it up for placement in a lead container. Educational objective:Following the principles of time, distance, and shielding provides staff protection from exposure to radiation when treating a client undergoing internal radiation. Staff should spend no more than 30 minutes in the client's room, should remain at least 6 ft (1.82 m) away from the radiation source, and should wear lead aprons when providing direct client care.

A client is being discharged after having a stent placed in the left anterior descending coronary artery. The client is prescribed clopidogrel. Which client data obtained by the nurse would be concerning in relation to this new medication? Select all that apply. A. Blood pressure of 140/84 mm Hg B. Heart rate of 98/min C. Platelet count of 200,000/mm*3 (200 x 10*9/L) D. Report of Ginkgo biloba use E. Report of peptic ulcer disease

Correct Answers: D and E Antiplatelet agents (eg, clopidogrel, ticagrelor, prasugrel, aspirin) prevent platelet aggregation and are given to clients to prevent stent re-occlusion. They prolong bleeding time and should not be taken by clients with a bleeding peptic ulcer, active bleeding, or intracranial hemorrhage. Ginkgo biloba also interferes with platelet aggregation and can cause increased bleeding time. Antiplatelet agents and Ginkgo biloba should not be taken together. If this were to occur, this client would be at an increased risk for bleeding. This information should be reported to the prescribing health care provider before the client is discharged. Incorrect Answers[A. Blood pressure of 140/84 mm Hg] This blood pressure is slightly elevated, but is unaffected by antiplatelet agents. [B. Heart rate of 98/min] Normal heart rate is between 60/min-100/min. [C. Platelet count of 200,000/mm*3 (200 x 10*9/L)] This is a normal platelet count (150,000/mm*3-400,000/mm*3 [150-400 x 10*9/L]). Educational objective:If a client is prescribed clopidogrel, the nurse should be concerned about a history of peptic ulcer disease and Ginkgo biloba use. In this situation, the client would be at increased risk for bleeding. This data should be reported to the prescribing health care provider before the client is discharged.

The clinic nurse is reinforcing teaching to 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? A. "I will need to get my blood drawn to see if I'm taking the right dose." B. "I will probably need to take this the rest of my life." C. "I will take this once a day in the morning." D. "If this makes my stomach upset, I will take it with an antacid."

Correct Answers: D. "If this makes my stomach upset, I will take it with an antacid." 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). Incorrect Answers: [A. "I will need to get my blood drawn to see if I'm taking the right dose."] 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. [B. "I will probably need to take this the rest of my life."] Thyroid supplementation with levothyroxine usually requires lifelong therapy. [C. "I will take this once a day in the morning."] 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 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? A. "I am tired of restricting my fluids but know I need to." B. "I feel like I am beginning to get sick with a bad cold." C. "I have been getting a lot of nasal pain with this spray." D. "I have recently started to experience frequent headaches."

Correct Answers: D. "I have recently started to experience frequent headaches." 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. Incorrect Answers: [A. "I am tired of restricting my fluids but know I need to."] Clients on desmopressin are often on fluid restriction as part of therapy. Frequent reinforcement may be necessary. [B. "I feel like I am beginning to get sick with a bad cold." ] 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. [C. "I have been getting a lot of nasal pain with this spray."] 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.

The nurse has reinforced education for a client newly prescribed alprazolam for generalized anxiety disorder. Which client statement indicates that teaching has been effective? A. "Eliminating aged cheeses and processed meats from my diet is essential." B. "I can skip doses on days that I am not feeling anxious." C. "I will take my daily dose at bedtime." D. "Using sunscreen is important as this drug will make me sensitive to sunlight."

Correct Answer: C. "I will take my daily dose at bedtime." Benzodiazepines (eg, alprazolam [Xanax], lorazepam [Ativan], clonazepam, diazepam) are commonly used antianxiety drugs. They work by potentiating endogenous GABA, a neurotransmitter that decreases excitability of nerve cells, particularly in the limbic system of the brain, which controls emotions. Benzodiazepines may cause sedation, which can interfere with daytime activities. Giving the dose at bedtime will help the client sleep. Incorrect Answers: [A. "Eliminating aged cheeses and processed meats from my diet is essential."] Eliminating aged cheeses and processed meats, which contain tyramine, is necessary with monoamine oxidase inhibitors (eg, tranylcypromine, phenelzine), which are used for depressive disorders. It is not necessary with benzodiazepines. [B. "I can skip doses on days that I am not feeling anxious."] A benzodiazepine should never be stopped abruptly. Instead, it should be tapered gradually to prevent rebound anxiety and a withdrawal reaction characterized by increased anxiety, confusion, and more. [D. "Using sunscreen is important as this drug will make me sensitive to sunlight."] Photosensitivity is a problem with most antipsychotics and many antidepressants, but not with benzodiazepines. Educational objective:Benzodiazepines have a sedative effect and should be administered at bedtime when possible. Benzodiazepines should never be stopped abruptly in long-term users as this can precipitate withdrawal symptoms.

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. A. Apical heart rate of 88/min B. Elevation of mood C. Improved energy levels D. Skin is cool and dry E. Slight weight gain

Correct Answer: A, B, and C 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, higher energy levels, and a heart rate that is within normal limits. 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. Incorrect Answers: [D. Skin is cool and dry] 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. [E. Slight weight gain] 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 in the emergency department is being discharged with a prescription for trimethoprim-sulfamethoxazole. Which statement by the client would indicate a need for further evaluation? A. "I developed a whole-body rash while on glyburide." B. "I drink at least 5 large bottles of water daily." C. "I had to stop using lisinopril due to a bad cough." D. "I have a birth control implant in place."

Correct Answer: A. "I developed a whole-body rash while on glyburide." Trimethoprim-sulfamethoxazole (Bactrim) is a sulfonamide antibiotic, commonly referred to as a sulfa drug. These antibiotics are prescribed to treat bacterial infections (eg, urinary tract infections). Contraindications include hypersensitivity to sulfa drugs, and pregnancy or breastfeeding. Glyburide is a sulfonylurea and has the potential to cause a sulfa cross-sensitivity reaction. Commonly used diuretics (eg, thiazides, furosemide) are also sulfa derivatives and can cause cross-sensitivity reaction. Although this reaction is uncommon, an alternate antibiotic, if possible, can be prescribed by the health care provider. Incorrect Answers: [B. "I drink at least 5 large bottles of water daily."] Crystalluria is a potential adverse effect of sulfa medications. Clients should drink at least 2-3 L of water daily to prevent crystalluria. [C. "I had to stop using lisinopril due to a bad cough."] Angiotensin-converting enzyme inhibitors (eg, lisinopril) can produce an intractable cough. The only way to relieve this adverse effect is to discontinue the medication. There is no cross-reactivity with sulfa medications. [D. "I have a birth control implant in place."] Birth control implants (eg, IMPLANON, NEXPLANON) are progestin rods placed subdermally in the upper arm that provide contraception for up to 3 years. They are not contraindicated with concurrent trimethoprim-sulfamethoxazole use. Educational objective:Clients prescribed sulfa antibiotics (eg, trimethoprim-sulfamethoxazole [Bactrim]) should be assessed for allergies to sulfa drugs and sulfonylurea medications, such as glyburide, due to potential cross-sensitivity reactions.

A client with long-term hypertension and hypercholesterolemia comes to the clinic for an annual checkup. The client takes nifedipine, simvastatin, and spironolactone and reports some occasional dizziness. Which statement by the client would warrant intervention by the nurse? A. "I've been better about walking for 20 minutes 3 days a week on my treadmill." B. "I've been trying to eat more fruits and vegetables. I discovered that I really like grapefruit." C. "I've heard that having a glass of red wine with dinner every night is good for my heart." D. "We no longer add salt when preparing meals. It has really been hard to get used to that."

Correct Answer: B. "I've been trying to eat more fruits and vegetables. I discovered that I really like grapefruit." The nurse should intervene when the client talks about eating grapefruit. Grapefruit inhibits enzyme CYP3A4. The drugs that are metabolized by the same pathway would not be metabolized, resulting in higher drug levels and serious side effects. Calcium channel blocker (eg, nifedipine) use with grapefruit juice can cause severe hypotension; some statins (eg, simvastatin) may result in myopathy. Incorrect Answers: [A. "I've been better about walking for 20 minutes 3 days a week on my treadmill."] The nurse should praise and encourage the client to continue exercising and possibly increase the amount. This is a positive lifestyle change. The client should engage in moderate-intensity aerobic exercise for at least 30 minutes most days of the week or vigorous-intensity aerobic exercise for 20 minutes 3 days a week. [C. "I've heard that having a glass of red wine with dinner every night is good for my heart."] It is thought that red wine in moderation has some beneficial effects on the heart. The nurse would not encourage a client to start drinking red wine if the client didn't already. Excessive alcohol consumption is strongly associated with hypertension. The nurse should encourage the client to discuss alcohol consumption with the health care provider (HCP). [D. "We no longer add salt when preparing meals. It has really been hard to get used to that."] Sodium restriction is important in the management of hypertension. This teaching should be reinforced and the client should be encouraged to restrict the use of salt. Educational objective:The nurse should tell the client not to eat grapefruit or drink grapefruit juice while taking calcium channel blockers due to the possible development of severe hypotension. The nurse should report this client's statement to the HCP.

A nurse is observing a nursing student reinforce teaching to a client on how to take sucralfate. Which statement made by the student would require intervention by the nurse? A. "Take this in the morning 1 hour before breakfast." B. "Take this with your other stomach medications." C. "Take your heart medication 2 hours after sucralfate." D. "You might experience constipation while taking this."

Correct Answer: B. "Take this with your other stomach medications." Sucralfate is an oral medication that forms a protective layer in the gastrointestinal mucosa, which provides a physical barrier against stomach acids and enzymes. It does not neutralize or reduce acid production but is prescribed to treat and prevent both stomach and duodenal ulcers. Sucralfate is generally prescribed 1 hour before meals and at bedtime and, for effective results, is taken on an empty stomach with a glass of water. Sucralfate forms a better protective layer at a low pH level. Therefore, antacids or other acid-reducing medications (eg, proton pump inhibitors, H2 blockers) should be avoided within 30 minutes of taking sucralfate to prevent altered absorption Incorrect Answers: [A. "Take this in the morning 1 hour before breakfast." ] Sucralfate should be taken 1 hour before meals to protect the stomach. [C. "Take your heart medication 2 hours after sucralfate."] Sucralfate binds with many medications (eg, digoxin, warfarin, phenytoin), reducing their bioavailability and effectiveness. Therefore, all other medications are generally taken ≥1-2 hours before or after taking sucralfate. [D. "You might experience constipation while taking this."] Constipation is a common side effect of sucralfate. Educational objective:Sucralfate should be taken on an empty stomach with a glass of water because it forms a better protective layer at a low pH level. Therefore, acid-reducing agents (eg, antacids, proton pump inhibitors, H2 blockers) should be avoided within 30 minutes of taking sucralfate, and all other medications should be taken ≥1-2 hours before or after sucralfate.

The nurse prepares to draw up regular and NPH insulins into one syringe. Place in order the steps the nurse should take when mixing the insulins. All options must be used. 1. Clean the vial tops with alcohol swabs 2. Draw up the NPH insulin vial 3. Draw up the regular insulin solution 4. Inject air into the NPH insulin vial 5. Inject air into the regular insulin vial A. 1, 5, 3, 4, 2 B. 1, 4, 5, 3, 2 C. 1, 5, 4, 2, 3 D. 1, 5, 4, 3, 2

Correct Answer: B. 1, 4, 5, 3, 2 Mixing insulins allows multiple insulin preparations to be delivered in a single subcutaneous injection, thereby sparing the client from multiple injections. Intermediate-acting insulins (eg, NPH) can be mixed with short-acting (eg, regular) or rapid-acting (eg, aspart, lispro) insulins. Most long-acting insulins (eg, glargine, detemir) are not suitable for mixing and are typically packaged in prefilled syringes. When drawing up multiple insulins, there is a risk for contaminating the shorter-acting vials with the longer-acting insulin, which would slow the action of later doses withdrawn from the shorter-acting insulin vial. Multidose vials of regular insulin that have been contaminated with other insulins are unsafe for IV administration. When drawing up multiple insulins, the nurse should: 1. Clean both vial tops with alcohol swabs. 2. Inject air into the NPH insulin vial without touching the needle to the solution. 3. Withdraw the needle from the NPH insulin vial and inject air into the regular insulin vial. 4. Invert the regular vial and withdraw the regular solution into the syringe. 5. Insert the needle into the NPH insulin vial and withdraw the solution. The nurse can recall the mnemonic RN (Regular before NPH). Educational objective:When drawing up multiple insulins, there is a risk for contaminating the shorter-acting insulin vial with longer-acting insulin and slowing the action of later doses withdrawn from the shorter-acting insulin vial. The nurse should withdraw the shorter-acting insulin first, and then use the same syringe to withdraw the intermediate-acting insulin.

The nurse reviews the medication administration records and laboratory results for assigned clients prior to drug administration. Which medication administration should the nurse question? A. Calcium acetate for a client with a phosphate level of 8.5 mg/dL (2.75 mmol/L) B. Clopidogrel for a client with a platelet count of 70,000/mm*3 (70 × 10*9/L) C. Magnesium sulfate for a client with a magnesium level of 1.0 mEq/L (0.5 mmol/L) D. Metformin for a client with a glycosylated hemoglobin level of 11%

Correct Answer: B. Clopidogrel for a client with a platelet count of 70,000/mm*3 (70 × 10*9/L) Clopidogrel (Plavix) is a platelet aggregation inhibitor used to prevent blood clot formation in clients with recent myocardial infarction, acute coronary syndrome, cardiac stents, stroke, or peripheral vascular disease. It can cause thrombocytopenia and increase the risk for bleeding; therefore, the nurse should notify the supervising registered nurse of the low platelet count (normal: 150,000-400,000/mm3 [150-400 × 109/L]) before administering clopidogrel. Incorrect Answers: [A. Calcium acetate for a client with a phosphate level of 8.5 mg/dL (2.75 mmol/L)] Calcium acetate (PhosLo) is used to control hyperphosphatemia (normal adult: 2.4-4.4 mg/dL [0.78-1.42 mmol/L]) in clients with end-stage kidney disease by binding to phosphate in the intestines that is then excreted in the stool. [C. Magnesium sulfate for a client with a magnesium level of 1.0 mEq/L (0.5 mmol/L) ] Magnesium sulfate is used to correct hypomagnesemia (normal adult: 1.5-2.5 mEq/L [0.75-1.25 mmol/L]) and treat torsades de pointes and seizures associated with eclampsia. [D. Metformin for a client with a glycosylated hemoglobin level of 11%] Metformin (Glucophage) is a first-line drug used to control blood sugar in clients with type 2 diabetes mellitus. Glycosylated hemoglobin (A1C) measures the total hemoglobin that has glucose attached to it, expressed as a percentage. Glucose remains attached to the red blood cell for the life of the cell (about 120 days) and reflects glycemic control over an extended period. The recommended A1C level for a client with diabetes is <7%. Although the A1C level is elevated, the medication would still be administered, unless the client is hypoglycemic. Educational objective:Clopidogrel (Plavix) can cause thrombocytopenia (platelet count <150,000/mm3 [150 × 109/L]) and increase a client's risk for bleeding.

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? Medication Administration Record Medications | Time Insulin NPH: 75 units subcutaneously, twice daily | 0800 & 2000 Insulin lispro: Sliding scale dosing, before meals and at bedtime | 0800, 1130, 1730, 2100 Laboratory Results Serum glucose | 328 mg/dL (18.20 mmol/L) Serum sodium | 141 mEq/L (141 mmol/L) Serum potassium | 3.0 mEq/L (3.0 mmol/L) A. Administer insulin lispro per protocol and 75 units NPH B. Contact the health care provider C. Obtain a urine specimen to check for ketonuria D. Recheck the client's blood glucose

Correct Answer: B. Contact the health care provider 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. Incorrect Answers: [A. Administer insulin lispro per protocol and 75 units NPH] 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. [C. Obtain a urine specimen to check for ketonuria] 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. [D. Recheck the client's blood glucose] 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 prepares to administer morning medications to assigned clients. Which prescription should the nurse clarify with the health care provider? A. Clopidogrel for client with history of stroke and platelet count of 154,000/mm*3 (154 × 10*9/L) B. Losartan for client with hypertension who is 8 weeks pregnant C. Prednisone for client with herpes simplex lesions and Bell palsy D. Tiotropium for client with pneumonia and chronic obstructive pulmonary disease

Correct Answer: B. Losartan for client with hypertension who is 8 weeks pregnant Losartan is an angiotensin II receptor blocker (ARB) prescribed to treat hypertension. ACE inhibitors (eg, lisinopril, enalapril) and ARBs are teratogenic, causing renal and cardiac defects or death of the fetus. ARBs and ACE inhibitors have black box warnings that indicate contraindication in pregnancy. The nurse should not give an ARB to a pregnant client. The health care provider should be notified so that an alternate antihypertensive may be prescribed that is safe to take during pregnancy (eg, labetalol, methyldopa). Incorrect Answers: [A. Clopidogrel for client with history of stroke and platelet count of 154,000/mm*3 (154 × 10*9/L)] Antiplatelet agents (eg, clopidogrel) are prescribed to prevent thromboembolic events in clients with increased risk for stroke or myocardial infarction. Laboratory values are monitored periodically as these drugs increase bleeding time (normal, 2-7 minutes [120-420 seconds]) and, rarely, may lower platelet count (normal, 150,000-400,000/mm*3 [150-400 × 10*9/L]) [C. Prednisone for client with herpes simplex lesions and Bell palsy] Bell palsy presents as acute onset of unilateral facial paralysis related to inflammation of the facial nerve (ie, cranial nerve VII) that may be triggered by a viral illness (eg, herpes simplex virus). Standard treatment includes corticosteroids (eg, prednisone) within 72 hours of symptom onset. [D. Tiotropium for client with pneumonia and chronic obstructive pulmonary disease] Tiotropium is an inhaled anticholinergic drug that inhibits receptors in the smooth muscles of the airways. It is prescribed daily for the long-term management of bronchospasm in clients with chronic obstructive pulmonary disease. Educational objective:Angiotensin II receptor blockers and ACE inhibitors are teratogenic, causing fetal injury or death, and are contraindicated in pregnancy.

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? A. Blood glucose of 95 mg/dL (5.3 mmol/L) B. Potassium level of 4.2 mEq/L (4.2 mmol/L) C. Reduction in dizziness D. Sodium level of 138 mEq/L (138 mmol/L)

Correct Answer: B. Potassium level of 4.2 mEq/L (4.2 mmol/L) 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). Incorrect Answers: [A. Blood glucose of 95 mg/dL (5.3 mmol/L)] Blood glucose levels can be increased by thiazide diuretics but are not affected by potassium-sparing diuretics. [C. Reduction in dizziness] All diuretics, including spironolactone, have the potential to cause dizziness. The nurse should monitor the client for orthostatic hypotension and implement safety precautions. [D. Sodium level of 138 mEq/L (138 mmol/L)] 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.

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

Correct Answer: C. "I can take up to 3 pills in a 15-minute period if I am experiencing chest pain." 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. · 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. · 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. · Headache may occur: Headache and flushing are common side effects of NTG due to systemic vasodilation and do not warrant medication discontinuation. 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.

An 80-year-old client is receiving amikacin, an aminoglycoside antibiotic, IVPB every 12 hours. Which data obtained by the practical nurse is most important to report to the registered nurse before the client receives the next dose? A. Blood pressure of 104/62 mm Hg B. Blood urea nitrogen of 20 mg/dL (7.1 mmol/L) C. Client report of tinnitus D. Urine output of 400 mL since last dose

Correct Answer: C. Client report of tinnitus Serious adverse reactions to aminoglycosides (eg, gentamicin, tobramycin, amikacin) include ototoxicity and nephrotoxicity and are affected by age, renal function, and drug dose. Careful dosing is especially important for older clients. Tinnitus and vertigo are early signs of ototoxicity. The nurse should monitor the client carefully and report any changes in the client's hearing, balance, or urinary output. Incorrect Answers: [A. Blood pressure of 104/62 mm Hg] This client's blood pressure is low, and so the nurse should compare it to previous readings. Blood pressure is generally not affected by IV antibiotics. The client may be taking antibiotics for sepsis. [B. Blood urea nitrogen of 20 mg/dL (7.1 mmol/L)] This client's blood urea nitrogen is within normal range (6-20 mg/dL [2.1-7.1 mmol/L]) but is at the high end of normal and should continue to be monitored. [D. Urine output of 400 mL since last dose] Urine output in this client is adequate (>30 mL/hr) but should be monitored closely. Educational objective:The nurse should closely monitor renal function and assess for any changes in hearing or balance in a client receiving aminoglycoside antibiotics. Ototoxicity and nephrotoxicity are serious adverse reactions related to this type of medication.

The home health nurse is reinforcing teaching for a client with atrial fibrillation who is prescribed digoxin 0.25 mg orally on even-numbered days. Which client statement will require further teaching about digoxin? A. "I will call the health care provider if I don't feel like eating." B. "I will call the health care provider if I feel dizzy and lightheaded." C. "I will call the health care provider if I have trouble reading." D. "I will take my blood pressure before taking my medicine."

Correct Answer: D. "I will take my blood pressure before taking my medicine." Digoxin (Lanoxin) is a cardiac glycoside that increases contractility (positive inotropic effects) and decreases heart rate (negative chronotropic effects). It is used to treat atrial fibrillation because, at therapeutic levels (0.5-2.0 ng/mL), it decreases conduction through the sinoatrial node (SA) and ventricular heart rate. However, drug toxicity is common due to digoxin's narrow therapeutic range. Clients are instructed to recognize and report signs and symptoms of toxicity to the health care provider (HCP), including the following: 1. Gastrointestinal symptoms, including anorexia, nausea, vomiting, and abdominal pain, are frequently the earliest symptoms. 2. Neurologic manifestations include lethargy, fatigue, weakness, and confusion. 3. Visual symptoms are characteristic and include alterations in color vision, scotomas, and blindness. 4. Cardiac arrhythmia is the most dangerous symptom. Digoxin toxicity can result in bradycardia and heart block, which can cause dizziness or lightheadedness. Clients are instructed to check the pulse and tell the HCP if it is low or has skipped beats. There is no need to routinely check blood pressure before taking the medicine. This client should be instructed to check the pulse and withhold digoxin if the heart rate is <60/min. Educational objective:Clients receiving digoxin are instructed to measure their pulse before taking the medication and withhold digoxin if their heart rate is <60/min. Clients should also be taught to recognize and report signs and symptoms of digoxin toxicity (eg, anorexia, nausea, diarrhea, lethargy, confusion, cardiac arrhythmias, visual changes) to the health care provider.

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

Correct Answer: D. "I will use the sliding scale to determine my NPH dose 4 times a day." 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. Incorrect Answer: [A. "I will always check my blood glucose prior to using the sliding scale."] These are correct statements and indicate the teaching objective was completed successfully. [B. "I will eat breakfast 30 minutes after taking my morning NPH and regular insulin."] These are correct statements and indicate the teaching objective was completed successfully. [D. "I will use the sliding scale to determine my NPH dose 4 times a day."] 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 diagnosed with stable angina is being discharged home on the cholesterol-lowering drug rosuvastatin. The nurse should reinforce instructions for the client to report which side effect to the health care provider immediately? A. Abdominal discomfort B. Insomnia C. Morning headache D. Muscle aches or weakness

Correct Answer: D. Muscle aches or weakness Rosuvastatin (Crestor) is a strong statin drug that can cut LDL drastically and reduce total cholesterol and triglycerides. It also increases HDL. A serious complication associated with statin medication is rhabdomyolysis (muscle toxicity). Rhabdomyolysis is the breakdown of muscle tissue that leads to the release of muscle fiber contents into the blood. These substances can be harmful to the kidney and often cause kidney damage. The client should immediately report any signs of muscle aches or weakness to the health care provider. These could be early signs of rhabdomyolysis, which can be fatal. Incorrect Answers: [A. Abdominal discomfort] These can also be considered side effects of rosuvastatin, but they are minor and do not need to be reported to the HCP immediately. If they persist, the client should consider reporting them. [B. Insomnia] These can also be considered side effects of rosuvastatin, but they are minor and do not need to be reported to the HCP immediately. If they persist, the client should consider reporting them. [C. Morning headache] These can also be considered side effects of rosuvastatin, but they are minor and do not need to be reported to the HCP immediately. If they persist, the client should consider reporting them. Educational objective:Clients taking statin drugs (eg, atorvastatin, rosuvastatin) should immediately report any muscle aches or weakness, as these may be early signs of rhabdomyolysis, a muscle disintegration that can cause serious kidney injury.

The nurse is collecting data on a client with hypertension and essential tremor who received the first dose of propranolol 2 hours ago. Which assessment is most concerning to the nurse? A. Client reports a headache B. Current blood pressure is 160/88 mm Hg C. Heart rate has decreased from 70/min to 60/min D. Slight wheezes auscultated during inspiration

Correct Answer: D. Slight wheezes auscultated during inspiration Propranolol is a nonselective beta blocker that inhibits β1 (heart) and β2 (bronchial) adrenergic receptors. It is used for many indications (eg, essential tremor) in addition to blood pressure control. Blood pressure decreases secondary to a decline in heart rate. Bronchoconstriction may occur due to the effect on the β2 adrenergic receptors. The presence of wheezing in a client taking propranolol may indicate bronchoconstriction or bronchospasm. The nurse should assess for history of asthma or respiratory problems in this client and notify the health care provider. Incorrect Answer: [A. Client reports a headache] A headache is a common occurrence with hypertension. The nurse may administer an analgesic as needed. [B. Current blood pressure is 160/88 mm Hg] This is the first dose of propranolol that the client has received. It may take several days of treatment for the blood pressure to reduce to a more normal reading. [C. Heart rate has decreased from 70/min to 60/min] A reduction in heart rate is expected with a beta blocker, and the nurse should continue monitoring it for further reduction. Educational objective:The nurse should be concerned about the presence of wheezing in a client taking a nonselective beta blocker such as propranolol. Wheezing may indicate bronchoconstriction or bronchospasm. The nurse should assess the client for history of asthma or other respiratory problems and notify the health care provider.

The health care provider has told a client to take over-the-counter supplemental calcium carbonate 1000 mg/day for treatment of osteoporosis. Which instruction should the clinic nurse reinforce with the client? A. Monthly calcium levels will need to be drawn B. Stop vitamin D supplements when taking calcium C. Take calcium at bedtime D. Take calcium in divided doses with food

Correct Answer: D. Take calcium in divided doses with food Calcium and vitamin D are essential for bone strength. Calcium carbonate (Caltrate) has the most available elemental calcium of over-the-counter products and is inexpensive; it is therefore the preferred calcium supplement for most clients with osteoporosis. Calcium absorption is impaired when taken in excess of 500 mg per dose. Therefore, most clients should take supplements in divided doses (<500 mg per dose). These should be taken within an hour of meals as food increases calcium absorption. Constipation is a frequent side effect of calcium supplements, so clients should be advised to take appropriate precautions. Calcium carbonate and calcium acetate (PhosLo) are used to reduce serum phosphorous levels in clients with chronic kidney disease. In such cases, calcium should remain in the intestine and bind the phosphorous present in food; the calcium phosphorus product would then be excreted in stool. Therefore, these clients should take calcium supplements before meals. Incorrect Answers: [A. Monthly calcium levels will need to be drawn] Calcium levels may need to be checked periodically, but it is not necessary to do so monthly. [B. Stop vitamin D supplements when taking calcium] Vitamin D also increases calcium absorption and is important for treatment of osteoporosis. There is no need to stop it. [C. Take calcium at bedtime] Calcium does not need to be taken at any particular time of day. Educational objective:The nurse should encourage the client with osteoporosis to take supplemental calcium with food to increase its absorption. Vitamin D will also enhance absorption. Multiple daily doses are recommended as calcium absorption is impaired when taken in excess of 500 mg per dose. Constipation is a frequent side effect of calcium supplementation.

A client has just been prescribed allopurinol for chronic gout. Which instruction is most important for the nurse to reinforce to the client? A. Report for periodic laboratory tests for kidney, liver, and blood functions B. Store the medication in a cool, dry place away from direct heat and light C. Take the medication after a meal to prevent gastric distress D. Take the medication with a full glass of water and increase fluids during the day

Correct Answer: D. Take the medication with a full glass of water and increase fluids during the day Allopurinol is prescribed to prevent gout attacks (pain and inflammation in joints caused by uric acid deposits). It inhibits uric acid production and improves solubility. Allopurinol should be taken with a full glass of water, and it is very important for the nurse to educate the client about fluid intake with this medication. The client should also increase daily fluid intake as this will help prevent the formation of renal stones and promote diuresis (increase drug and uric acid excretion). Incorrect Answers: [A. Report for periodic laboratory tests for kidney, liver, and blood functions] Biosynthesis of uric acid occurs in the liver, and antigout medications are excreted via the kidneys; therefore, liver and renal function should be checked periodically. In addition, blood counts should be monitored as some antigout medications can cause blood dyscrasias. This is important but does not have priority over the daily need for increased fluids. [B. Store the medication in a cool, dry place away from direct heat and light] This is a common instruction given about the storage of many medications. It helps to ensure potency of the medication and prevent deterioration. [C. Take the medication after a meal to prevent gastric distress] Taking allopurinol with food or after a meal can help to prevent gastric upset. Educational objective:It is important for the nurse to educate the client taking allopurinol about drinking a full glass of water with each dose and increasing overall fluid intake. Increased fluids help to prevent renal stones and promote diuresis and uric acid excretion.

A client just diagnosed with methicillin-resistant Staphylococcus aureus septic arthritis is receiving the first dose of IV vancomycin. Which finding is most concerning to the nurse? A. Diffuse muscle pain B. Flushing and pruritus C. Low blood pressure D. Wheezing and hives

Correct Answer: D. Wheezing and hives Red man syndrome (RMS) is a condition that can occur with rapid IV vancomycin administration. It is characterized by flushing, erythema, and pruritus, typically on the face, neck, and chest. Muscle pain, spasms, dyspnea, and hypotension may also occur. RMS is usually a rate-related infusion reaction and not an allergic reaction. It can be reduced by infusing vancomycin over a minimum of 60 minutes. It can be difficult to differentiate severe RMS from anaphylaxis as flushing and hypotension can occur in both conditions. However, hives, angioedema (lip swelling), wheezing, and respiratory distress are more suggestive of anaphylaxis. The client exhibiting signs and symptoms suggestive of anaphylaxis should have the vancomycin infusion stopped immediately and be treated with intramuscular (IM) epinephrine. The infusion must not be restarted if anaphylaxis is suspected. A slowed infusion rate or pre-medications will not prevent a future anaphylactic response. Incorrect Answers: [A. Diffuse muscle pain] Muscle pain and spasms may be symptoms of RMS. The nurse should also assess for other medications the client may be taking that could cause these symptoms (ie, statins). [B. Flushing and pruritus] Flushing and pruritus may also be symptoms of RMS. The nurse should further assess the client's airway for possible anaphylaxis. [C. Low blood pressure] Low blood pressure (BP) can have many causes, RMS being one of them. If low BP is due to RMS, stopping or reducing the rate of vancomycin (depending on severity) would solve this. If low BP is due to anaphylaxis, IM epinephrine must be given in addition to stopping the vancomycin infusion. Educational objective:The development of hives, angioedema, wheezing, and respiratory distress in a client receiving IV vancomycin indicates anaphylaxis. The infusion must be stopped immediately and IM epinephrine administered. RMS is a rate-related infusion reaction to IV vancomycin that is characterized by flushing, erythema, and pruritus, typically on the face, neck, and chest.

The nurse is caring for a client with cirrhosis who has hepatic encephalopathy. The client is prescribed lactulose. Which assessment by the nurse will most likely indicate that the medication has achieved the desired therapeutic effect? A. Higher potassium level B. Improved mental status C. Looser stool consistency D. Reduced abdominal distension

Correct Answers: B. Improved mental status Hepatic encephalopathy in cirrhosis results from higher serum ammonia levels that cause neurotoxic effects, including mental confusion. Oral lactulose is given to reduce the ammonia by trapping it in the gut and then expelling it with a laxative effect. Improved mental status implies reduction of ammonia levels. Incorrect Answers: [A. Higher potassium level] Clients with cirrhosis typically have hypokalemia due to hyperaldosteronism (as aldosterone is not metabolized by the damaged liver). Hypokalemia can also result from diuretics used to treat the fluid retention and ascites. Lactulose is not intended to treat this pathology. [C. Looser stool consistency] Lactulose is a laxative. In cirrhosis, constipation (which allows more ammonia to be absorbed) and hard stool (which irritates hemorrhoids) are to be avoided. However, the main purpose of lactulose is expelling the ammonia, with resulting benefits. [D. Reduced abdominal distension] Abdominal distension (ascites) in cirrhosis is treated with diuretics (eg, furosemide, spironolactone) and paracentesis. Lactulose does not influence this pathology or symptom. Educational objective:Lactulose is a laxative used to trap and expel ammonia in clients with cirrhosis who have hepatic encephalopathy. Elevated ammonia levels cause mental confusion.

A newly admitted client describes symptoms of dizziness and feeling faint on standing. The client has a history of type 2 diabetes, coronary artery disease, and bipolar disorder. Which medications may be contributing to the client's symptoms? Select all that apply. A. Atorvastatin B. Metformin C. Metoprolol D. Olanzapine E. Omeprazole

Correct Answers: C and D Drugs commonly associated with orthostatic hypotension include: 1. Most antihypertensive medications, particularly sympathetic blockers such as beta blockers (eg, metoprolol) and alpha blockers (eg, terazosin) 2. Antipsychotic medications (eg, olanzapine, risperidone) and antidepressants (eg, selective serotonin reuptake inhibitors) 3. Volume-depleting medications such as diuretics (eg, furosemide, hydrochlorothiazide) 4. Vasodilator medications (eg, nitroglycerine, hydralazine) 5. Narcotics (eg, morphine) Clients at risk for developing orthostatic hypotension should be instructed to: 1. Take medications at bedtime, if approved by the health care provider 2. Rise slowly from a supine to standing position, in stages (especially in the morning) 3. Avoid activities that reduce venous return and worsen orthostatic hypotension (eg, straining, coughing, walking in hot weather) 4. Maintain adequate hydration Incorrect Answers: [A. Atorvastatin] Muscle cramps and liver injury, not orthostatic hypotension, are the major adverse effects of statin medications (eg, atorvastatin) [B. Metformin] Major side effects of metformin are lactic acidosis and gastrointestinal disturbances (metallic taste in the mouth, nausea, and diarrhea). Unlike insulin, metformin does not usually cause hypoglycemia. Orthostatic hypotension is not a common side effect. [E. Omeprazole] Proton pump inhibitors (eg, omeprazole) are associated with increased risk of pneumonia, Clostridium difficile diarrhea, and calcium malabsorption (osteoporosis), but not orthostatic hypotension. Educational objective:Medications commonly associated with orthostatic hypotension include most antihypertensives, most antipsychotics and antidepressants, and volume-depleting agents. Clients are instructed to rise slowly when standing to prevent a drop in blood pressure.

Tumor Lysis Syndrome

is a group of metabolic abnormalities that can occur as a complication during the treatment of cancer, where large amounts of tumor cells are killed off (lysed) at the same time by the treatment, releasing their contents into the bloodstream.

The nurse reviews an elderly client's medication administration record and identifies which prescriptions as having the potential for injury in the elderly? Select all that apply. A. Amitriptyline B. Chlorpheniramine C. Docusate D. Donepezil E. Lorazepam

Correct Answers: A, B, and E Polypharmacy and physiologic changes associated with aging (eg, decreased renal and hepatic function, orthostatic hypotension, decreased visual acuity, balance and gait problems) place the elderly at increased risk of adverse drug effects. The Beers criteria provide a list that classifies potentially harmful drugs to avoid or administer with caution in the elderly due to the high incidence of drug-induced toxicity, cognitive dysfunction, and falls. Some commonly used medications in this list include antipsychotics, anticholinergics, antihistamines, antihypertensives, benzodiazepines, diuretics, opioids, and sliding insulin scales. Amitriptyline (Elavil) is a tricyclic antidepressant used to treat depression and neuropathic pain; its anticholinergic properties may cause dry mouth, constipation, blurred vision, and dysrhythmias. Chlorpheniramine (ChlorTrimeton) is a sedating histamine H1 antagonist used to treat allergy symptoms. Increased central nervous system effects (eg, drowsiness, dizziness) may occur due to its reduced clearance in the elderly. Lorazepam (Ativan) is a benzodiazepine with a long half-life (10-17 hours). Side effects include drowsiness, dizziness, ataxia, and confusion. Incorrect Answers: [C. Docusate] Docusate is a stool softener and does not increase risk of injury in the elderly. [D. Donepezil] Donepezil (Aricept) is an acetylcholinesterase inhibitor used to treat Alzheimer dementia. It does not place the elderly at increased risk of adverse effects. Educational objective:The Beers criteria provide a list that classifies potentially harmful drugs to avoid or administer with caution in the elderly due to the high incidence of adverse effects and potential for injury. The list includes antipsychotics, anticholinergics, antihistamines, antihypertensives, benzodiazepines, diuretics, opioids, and sliding insulin scales.