uworld pharmacology

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

3. Methotrexate is an antirheumatic drug prescribed to treat rheumatoid arthritis. It acts by interfering with folic acid metabolism, which inhibits DNA synthesis and cell reproduction. Adverse effects associated with methotrexate include bone marrow suppression, hepatotoxicity (ie, drug-induced liver injury), and gastrointestinal irritation (eg, nausea, vomiting, diarrhea).

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

1,4

A diabetic client is prescribed metoclopramide. Which of the following side effects must the nurse teach the client to report immediately to the health care provider? Select all that apply. 1. Excess blinking of eyes 2. Dry mouth 3. Dull headache 4. Lip smacking 5. Puffing of cheeks

1,4,5 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) (Options 2 and 3) 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 teach the client the importance of immediately communicating these to the health care provider.

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? 1. "I can restart my paroxetine once I get back home." 2. "I can take acetaminophen for headaches." 3. "I will avoid foods and drinks that contain tyramine." 4. "I will report any increased fever or diarrhea."

1. 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 (Option 1). Due to this risk, SSRIs are contraindicated while on linezolid therapy. SSRIs can be resumed 24 hours after linezolid therapy has been discontinued. (Option 2) Headaches may be a side effect of linezolid therapy. Acetaminophen is not contraindicated. (Option 3) 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). (Option 4) 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:

The nurse prepares to administer morning medications to assigned clients. Which prescription should the nurse clarify with the health care provider? 1. Clopidogrel for client with history of stroke and platelet count of 154,000/mm3 (154 × 109/L) 2. Losartan for client with hypertension who is 8 weeks pregnant 3. Prednisone for client with herpes simplex lesions and Bell palsy 4. Tiotropium for client with pneumonia and chronic obstructive pulmonary disease

2 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 (Option 2). 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). (Option 1) 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/mm3 [150-400 × 109/L]) (Option 3) 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. (Option 4) 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.

The nurse is caring for a client who will have a copper intrauterine device (IUD) inserted. When reinforcing teaching related to the copper IUD, which of the following nurse statements are appropriate? Select all that apply. 1. "Backup contraception is needed for 2 days until the IUD is effective." 2. "Heavier menses and more menstrual cramping are common in clients using a copper IUD." 3. "Missing a period while using a copper IUD is normal and no reason for concern." 4. "You may have cramping and vaginal spotting for a short time after IUD insertion." 5. "You should check for the IUD strings at least once a month after menses." I

2,4,5 A copper intrauterine device (IUD) is a form of long-acting, reversible contraception that causes an intrauterine inflammatory effect that impairs sperm mobility and prevents implantation of a fertilized egg. It is a highly effective contraceptive and is also used for emergency contraception. IUD insertion commonly causes mild discomfort, cramping, and/or light vaginal bleeding (Option 4). Ibuprofen is recommended before and after insertion for relief of cramping/pain. Menstrual changes are also common among IUD users. For clients with copper IUDs, heavier bleeding and increased cramping during menses are the most common and expected side effects (Option 2). The client should check for the strings at least monthly to ensure that the IUD has not been expelled (Option 5). (Option 1) Unlike levonorgestrel IUDs, copper IUDs have an immediate contraceptive effect; backup contraception is not required. Condoms are recommended for clients who are at risk for sexually transmitted infections. (Option 3) Although pregnancy risk is low (<1%) when using the copper IUD, pregnancy is possible (eg, device expelled). Ovulation and menses still occur when using the copper IUD because the device does not contain hormones. A pregnancy test is necessary if a period is missed. Educational objective:A copper intrauterine device (IUD) is a form of long-acting, reversible contraception that has an immediate contraceptive effect upon placement. Mild discomfort (eg, cramping, spotting) is associated with IUD insertion, and clients should anticipate heavier bleeding and increased cramping during menses. IUD strings should be checked at least every month to ensure that the IUD has not been expelled. Additional Information Pharmacological and Parenteral Therapies NCSBN Client Need

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

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

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

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

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

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

A client with deep vein thrombosis (DVT) is receiving a continuous infusion of unfractionated heparin. The client asks the nurse what the heparin is for. How should the nurse respond? 1. "Heparin is a blood thinner that will help to dissolve the clot in your leg." [27%] 2. "Heparin will help stabilize the clot in your leg and prevent it from breaking off and traveling to your lungs." [6%] 3. "Heparin will keep the current clot from getting bigger and help prevent new clots from forming." [65%] 4. "I'm sorry. This is something that your health care provider (HCP) can answer better upon arriving." [0%]

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

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

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

The nurse provides teaching about methotrexate to a client with rheumatoid arthritis. It is most important to address which topic regarding this drug? 1. Need for an eye examination 2. Need for sunblock 3. Risk for infection 4. Risk for kidney injury

3. Methotrexate (Rheumatrex) is classified as a folate antimetabolite, 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. (Option 1) 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. (Options 2 and 4) 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.

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? 1. Alprazolam 2. Dextromethorphan 3. Lisinopril 4. Valsartan

4 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. (Option 1) Alprazolam is an anxiolytic. It is not used in the treatment of heart failure. (Option 2) Dextromethorphan is a cough suppressant. A cough caused by an ACE inhibitor will not be improved by a cough suppressant. (Option 3) Lisinopril is an ACE inhibitor. This client has been unable to tolerate this class of drug.

An elderly client with depression is given trazodone. Which statement by the client indicates that additional teaching is needed? 1. "I will call the health care provider if I develop a prolonged erection." [3%] 2. "I will get up slowly, in stages, from supine to standing." [2%] 3. "I will take this medication at night to avoid daytime drowsiness." [3%] 4. "It is okay to drink 2 glasses of wine at night." [90%]

4 Trazodone (Oleptro), a serotonin modulator, is used to treat major depressive disorders. 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 (Option 4). (Option 1) Priapism is a known serious side effect of trazodone. A client with an erection lasting several hours should go to the hospital. (Option 2) Clients should be advised to rise from supine to standing slowly, in stages, due to the risk of orthostatic hypotension. (Option 3) The drug should be taken at bedtime to avoid daytime sedation. Educational objective:Trazodone modulates serotonin levels in the brain. In addition, it blocks alpha and H1 receptors, leading to orthostatic hypotension and sedation, respectively. Priapism is another serious side effect, though rare.

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? 1. C-reactive protein (CRP) 2. Prothrombin time (PT) 3. Serum LDL cholesterol 4. Tuberculin skin test (TST)

4 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 (Option 4). (Option 1) 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. (Options 2 and 3) 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.

What intervention is essential prior to starting a client on atorvastatin therapy? 1. Assessing for muscle strength [16%] 2. Assessing the client's dietary intake [9%] 3. Determining if the client is on digoxin therapy [11%] 4. Monitoring liver function tests [61%]

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

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. 1. Blood pressure of 140/84 mm Hg 2. Heart rate of 98/min 3. Platelet count of 200,000/mm3 (200 x 109/L) 4. Report of Ginkgo biloba use 5. Report of peptic ulcer disease

4,5 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

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

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

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? 1. Encourages the client to drink extra fluids while taking ferrous sulfate 2. Offers the client orange juice for administration of ferrous sulfate 3. Plans to administer ferrous sulfate one hour before breakfast 4. Prepares to administer a prescribed calcium supplement with ferrous sulfate

4. 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 (Option 4).

nitro does what

causes vasodilation and lowers blood pressure causes vasodilation and can lower blood pressure. Systolic blood pressure should be >90 mm Hg to ensure renal perfusion (Option 3).

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. 1. Amitriptyline 2. Chlorpheniramine 3. Docusate 4. Donepezil 5. Lorazepam

1,2,5 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 (Option 1). 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 (Option 2). Lorazepam (Ativan) is a benzodiazepine with a long half-life (10-17 hours). Side effects include drowsiness, dizziness, ataxia, and confusion (Option 5). (Option 3) Docusate is a stool softener and does not increase risk of injury in the elderly. (Option 4) 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.

The nurse prepares to administer 9:00 AM medications to a client. Which data should the nurse evaluate prior to administration? Select all that apply. Click the exhibit button for additional information. 1. Blood pressure 2. Blood sugar 3. Heart rate 4. International Normalized Ratio 5. Potassium level

1,3,5

Which medication prescriptions should the nurse question? Select all that apply. 1. Cephalexin for a client with severe allergy to penicillin 2. Fexofenadine for a client with hives 3. Ibuprofen for a client with asthma and nasal polyps 4. Lisinopril for a client with diabetes mellitus 5. Propranolol for a client with asthma

1,3,5 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 (Option 1). 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 (Option 3). 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 (Option 5). (Option 2) 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). (Option 4) 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 office nurse, while reviewing a client's health information, notices that the client has recently started taking St. John's wort for symptoms of depression. What additional information is most important for the nurse to obtain? 1. Ask if the client is currently taking any prescription antidepressant medications 2. Ask if the client has been diagnosed with depression by a mental health care provider (HCP) 3. Ask if the client takes a multivitamin with iron 4. Ask if the client uses tanning beds

1. St. John's wort interferes with many prescription medications. It is a priority for the nurse to assess for concomitant use of St. John's wort with prescription SSRIs, MAOIs, or tricyclic antidepressants as such combinations can cause serotonin syndrome. Additional Information Pharmacological and Parenteral Therapies NCSBN Client Need

therapeutic aPTT?

46 to 70 seconds

when can clients start recieving influenza vaccine

above 6 months

what medication is contraindicated in acute decompensated heart failure (ADHF) who has JVD, low O2

beta blockers better used for chronic heart failure

adverse reaction for streptomycin

difficulty hearing

what med to give for a fib

diltiazem (calcium channel blocker)

ace inhibitors during pregnancy can cause what

fetal renal hemodynamics resulting in low fetal urine output(oligohydramnios) and fetal growth restriction.

2 side effects of statins

hepatic dysfunction (increased AST) muscle injury

regular eye examinations every 6 months with what drug

hydroxychlorquine

arbs and aces can cause what

hyperkalemia

2 things to be monitored on statin therapy

liver and muscles aches

black cahosh is used for

menopausal symptoms

if a client is prescribed clopidorgel the nurse should be concerned about what 2 things

peptic ulcer disease ginko biloba use

photosensitivity is common with what three drugs

tetracyclines thiazide diuretics sulfonamides

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?

vitamin b6

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? 1. Administer the medication around the clock even if the client denies having pain 2. Avoid administering with immediate-release opioids to prevent respiratory depression 3. Change the dosage and frequency to 20 mg every 6 hours if breakthrough pain occurs 4. Request a tapered dose from the health care provider if pain decreases to prevent tolerance

1

The nurse has provided education about proper use of an epinephrine auto-injector to a client with a history of a severe hypersensitivity reaction to bee stings. Which of the following client statements indicate that teaching has been effective? Select all that apply. 1. "I may have a rapid heartbeat and palpitations after injecting the medication." 2. "I must call an ambulance or go to the nearest hospital following an injection." 3. "I should avoid storing my device in extremely hot or cold temperatures." 4. "The area to be injected should be cleansed with alcohol or soap and water." 5. "The medication is injected at a 90-degree angle into the outer thigh."

1 Administer injection at a 90-degree angle into the outer thigh at the first sign of an allergic reaction (Option 5) Hold the auto-injector in place for 10 seconds to ensure delivery of the entire dose Seek immediate medical care after an injection because anaphylactic reactions may resume when the effects of the epinephrine subside (ie, 10-20 minutes) (Option 2) Expect to experience tachycardia, palpitations, and/or dizziness after administration (Option 1) Store EAIs at room temperature in a dark place to prevent inactivation by heat or light, or device failure from cold (Option 3)

in which scenarios should the nurse hold the prescribed medication and question its administration? Select all that apply. 1. Client on IV heparin and the platelet count is 50,000/mm3 (50 x 109/L) 2. Client on newly prescribed lisinopril and is at 8 weeks gestation 3. Client on nitroglycerine patch for heart failure and blood pressure is 84/56 mm Hg 4. Client on phenytoin for epilepsy and the nurse notes gingival hyperplasia 5. Client on warfarin and prothrombin time/International Normalized Ratio is 1.5 times control value

1,2,3

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. 1. 4-month-old client who is receiving scheduled vaccinations 2. 3-year-old client who is afraid of needles 3. 24-year-old client who is 6 weeks postpartum 4. 32-year-old client who is pregnant at 12 weeks gestation 5. 45-year-old client with a history of HIV

2,3

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

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

The health care provider prescribes amoxicillin/clavulanate (liquid) twice a day for a child with acute sinusitis. What instructions are most important for the parents? Select all that apply. 1. Administer it with food if nausea or diarrhea develops 2. Complete the medication course even if the child is better 3. Expect a rash, which is normal, as a side effect 4. Shake the medicine well before use 5. Use a household spoon to measure the dose

1,2,4 Amoxicillin/clavulanate belongs to aminopenicillin group and is often used to treat respiratory infections. Instructions for parents about amoxicillin include: 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 (Option 1). Shake the liquid well prior to administration. Administer at evenly spaced intervals throughout the day to maintain therapeutic blood levels (Option 4). 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 (Option 2).

The nurse is reviewing the medication administration record of a client with atrial fibrillation. Which of the following should the nurse monitor before giving these medications? Select all that apply. Click the exhibit button for more information. 1. Digoxin level 2. Glucose 3. INR 4. Platelet count 5. Serum potassium

1,2,4,5 he nurse should routinely monitor laboratory values prior to administering medications. A complete blood count should be assessed periodically in clients receiving enoxaparin to monitor for bleeding and thrombocytopenia. Digoxin and potassium levels should be assessed with the administration of digoxin. Glucose levels should be monitored in the client receiving glucocorticoids.

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

1,2,5 Antiplatelet therapy (eg, aspirin, clopidogrel, prasugrel, ticagrelor) is initiated to prevent platelet aggregation in clients at risk for myocardial infarction, stroke, or other thrombotic events. This therapy increases bleeding risk, so clients should be assessed for bruising, tarry stools, and other signs of bleeding (eg, hematuria, bleeding gums, epistaxis) (Options 1 and 2). Clients should be taught to self-monitor for these signs. In addition, clopidogrel may cause thrombotic thrombocytopenic purpura, so platelets should be monitored periodically (Option 5).

The nurse is caring for a client diagnosed with endometrial cancer who is receiving brachytherapy. Which interventions should the nurse implement while caring for this client? Select all that apply. 1. Cluster care to limit each staff member's time in the room to 30 minutes a shift 2. Instruct the client to be up and around in the room but not to leave the room 3. Keep the door to the room closed as radiation is emitting constantly from the client 4. Teach family members and visitors to stay at least 6 feet away from the client 5. Use a lead apron when providing direct client care to reduce exposure to radiation 6. Wear a radiation film-badge while in the client's room to monitor radiation exposure

1,3,4,5,6 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 exposure to radiation. Time spent near the radiation source is restricted. The guideline is to limit staff time spent in the room to 30 minutes per shift.Cluster nursing care to minimize exposure to the radiation sourceRotate daily staff responsibilities to limit time spent in the client roomAll staff must wear a dosimeter film badge when assigned to care for a client receiving internal radiationNo individuals who are pregnant or under age 18 may be in the room All staff and visitors must keep the maximum distance possible from the radiation source. Maintaining a distance of at least 6 feet is an established standard.Assign the client to a private room with a private bathKeep the door to the room closedEnsure that a sign stating, "Caution, Radioactive Material" is affixed to the doorInstruct the client to remain on bedrest to prevent dislodgement of the implant Shielding with lead diminishes exposure to radiation. All staff providing nursing care that requires physical contact must wear a lead apron. (Option 2) 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 is never touched with the hands; instead, long-handled forceps are 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 internal radiation emissions. Staff should spend no more than 30 minutes in a client's room; should remain at least 6 feet away from the radiation source; and should wear lead aprons when providing direct client care.

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 to the nurse and should be reported to the primary health care provider (PHCP)? 1. "I like to have a banana every morning with my breakfast." 2. "I occasionally experience slight dizziness when I get up in the morning." 3. "I started taking licorice root for my occasional heartburn." 4. "I usually take my hydrochlorothiazide first thing in the morning."

3. The nurse should discourage the client from using the herbal remedy licorice root when taking thiazide diuretics. Licorice root can potentiate potassium loss and increase the client's risk for hypokalemia. Use of licorice root should be reported to the PCHP.

The nurse reinforces teaching to a female client about taking misoprostol to prevent stomach ulcers. Which statement by the client would prompt further instruction? 1. "I can take this medication with food if it hurts my stomach." 2. "I must use a reliable form of birth control while taking this medication." 3. "I should continue to take my ibuprofen as prescribed." 4. "I will take this medicine with an antacid to decrease stomach upset."

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

4. Desmopressin is a medication often used to treat central diabetes insipidus, a disease characterized by reduced antidiuretic hormone (ADH) levels that may result in dehydration and hypernatremia. Desmopressin mimics the effects of naturally occurring ADH, which increases renal water resorption and concentrates urine. However, this effect also increases the risk for water intoxication from decreased urine output. Clients receiving desmopressin must have their fluid and electrolyte status closely monitored for symptoms of water intoxication/hyponatremia (eg, headache, mental status changes, weakness). The nurse should immediately notify the health care provider (HCP) of client reports of water intoxication symptoms, as severe hyponatremia may progress to seizure, neurologic damage, or death (Option 4)

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

4. NPH insulin SHOULD NEVER be given through IV only regular insulin.

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? 1. "I periodically take docusate sodium for constipation." [12%] 2. "I regularly take ibuprofen for chronic low back pain." [41%] 3. "I take hydrochlorothiazide to prevent swelling around my ankles." [29%] 4. "I take omeprazole daily to prevent heartburn." [17%]

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.

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? 1. Continue at the current dosage 2. Decrease the dosage 3. Discontinue the medication 4. Increase the dosage

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

1,2,5 Parkinson disease (PD) is characterized by decreased dopamine levels, uncontrolled acetylcholine, and formation of abnormal protein clusters (Lewy bodies) in the brain. PD causes both physical and neurological (eg, mood alterations, dementia) symptoms.

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

1. Thrombolytic therapy aims to stop the infarction process, dissolve the thrombus in the coronary artery, and reperfuse the myocardium. This treatment is used when facilities do not have an interventional cardiac catheterization laboratory or when such a facility is too far away to transfer the client safely. Client selection is important because all thrombolytics lyse the pathologic clot but may also lyse other clots (eg, at a postoperative site). Minor or major bleeding can be a complication. Inclusion criteria for thrombolytic therapy in clients with acute myocardial infarction include chest pain lasting ≤12 hours, 12-lead ECG findings indicating acute ST-elevation myocardial infarction, and no absolute contraindications (eg, history of cerebral arteriovenous malformation) (Option 1

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? 1. Amlodipine 2. Codeine 3. Ipratropium 4. Methylprednisolone

2 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). (Option 1) Calcium channel blockers (eg, amlodipine, nifedipine) are used to treat hypertension and do not worsen bronchoconstriction, unlike beta blockers (eg, metoprolol, atenolol). (Option 3) 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. (Option 4) Methylprednisolone (Solu-Medrol) is a systemic glucocorticoid that improves respiratory symptoms and overall lung function in clients experiencing an exacerbation of COPD. Educational objective:

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? 1. Assess the client's orthostatic blood pressure 2. Assist the client to a sitting position 3. Hold and walk with the client 4. Keep the client on bed rest

2 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. (Options 1 and 4) Assessing the client's orthostatic vital signs and recommending bed rest until the lightheadedness resolves are important but not first-priority actions. (Option 3) Walking with the client is not recommended when the client is symptomatic on standing. 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 parent calls the after-hours triage nurse about a 3-year-old who is sick with the flu. Which report by the parent would necessitate intervention by the nurse? 1. Acetaminophen being given every 4 hours for fever 2. Bismuth subsalicylate being used for nausea 3. Ibuprofen being given every 6 hours for body aches 4. Popsicles and gelatin desserts being used for hydration

2 could cause reye syndrome

Which herbal supplements pose an increased risk for bleeding in surgical clients and should be discontinued prior to major surgery? Select all that apply. 1. Black cohosh 2. Garlic 3. Ginger 4. Ginkgo biloba 5. Hawthorn

2,3,4 Herbal supplements that can increase risk for bleeding include: Gingko biloba Garlic Ginseng Ginger Feverfew

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

2,3,4 never disconiue gluccorticoid apruplty. this could cause addisonian cirisis corticosteroid can cause immunosupression and infection can develop quickly and rapidly can mask signs of infection increase dose during times of stress cataracts are side effect of corticosteroids, make an appointment yearly with optometrist to assess for cataracts recocnize s/s of cushiings syndrome and report to the phcp should have diet high in calcium and protein but low in fat hyperglycemia is another side effect do not take on empty stomach

A client diagnosed with vaginal candidiasis is instructed on self-care management techniques and proper administration of the prescribed miconazole vaginal cream. Which statement by the client indicates that further teaching is needed? 1. "Each time I use the bathroom, I will wipe myself from the front to the back." [2%] 2. "I should choose loose-fitting cotton underwear instead of nylon undergarments." [6%] 3. "I will refrain from having sex until my partner is also tested and treated for the infection." [67%] 4. "Prior to going to bed at night, I will apply miconazole cream using the vaginal applicator." [23%]

3 Candida albicans (yeast) can colonize and cause infections of the vulvovaginal region. Vaginal candidiasis often causes itching and painful urination due to urine stinging the inflamed areas of the vulva. Assessment shows a thick, white, curd-like vaginal discharge and reddened vulvar lesions. Miconazole (Monistat), an antifungal cream commonly prescribed to treat vaginal candidiasis, is inserted high into the vagina using an applicator. It is best applied at bedtime so that it will remain in the vagina for an extended period (Option 4). Sexual intercourse is avoided until the inflammation is resolved, typically for the duration of treatment, approximately 3-7 days (Option 3). However, sexual activity is not a significant cause of infection or reinfection of candida, and partner evaluation is not needed. Trichomoniasis, syphilis, gonorrhea, and HIV are mainly sexually transmitted; therefore, partners should be evaluated and treated. Other teaching points for this client should include: Ensuring proper hygiene of the perineum - cleansing from anterior to posterior (front to back) to prevent accidental introduction of fecal organisms (Option 1) Wearing loosely fitted cotton underwear and avoiding synthetic undergarments to promote ventilation, decrease friction, and reduce moisture (Option 2) Refraining from douching, which can introduce organisms higher up into the vaginal canal and cervix Educational objective:Miconazole cream is commonly prescribed to treat vaginal candidiasis. Miconazole is best applied at bedtime so that it will remain in the vagina longer. Clients being treated for vaginal candidiasis should wear loose-fitting cotton underwear and refrain from sexual intercourse for the duration of treatment. Additional Information Pharmacological and Parenteral Therapies NCSBN Client Need

A client in the intensive care unit is receiving IV vancomycin and gentamicin. The nurse should monitor for which potential complication with the administration of these medications? 1. Blood in nasogastric tube drainage 2. Decrease in red blood cell (RBC) count 3. Increase in serum creatinine level 4. Onset of muscle aches and cramping

3. 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 an even higher risk for these adverse reactions. The nurse should monitor the client's renal function by assessing blood urea nitrogen (BUN) and creatinine levels and measuring urinary output. Increased levels of BUN and creatinine may indicate kidney damage. The health care provider should be notified before continuing these medications (Option 1) Blood in the nasogastric tube could be a complication of peptic ulcer disease and the use of nonsteroidal anti-inflammatory drugs and corticosteroids. (Option 2) A decrease in the RBC count may be evidence of bone marrow suppression that can occur with use of certain cancer drugs (eg, methotrexate). (Option 4) Muscle cramping can occur occasionally with use of gentamicin but is not an indication to stop the infusion. Muscle aching and cramping that may signify a complication occur with the use of statins (eg, atorvastatin, rosuvastatin) and fibrates (eg, gemfibrozil, fenofibrate).

A community health nurse evaluates several clients' vaccination status. Which clients would the nurse recommend receive the influenza vaccine injection? Select all that apply. 1. 9-month-old with no known medical conditions 2. 5-year-old with congenital heart defect 3. 23-year-old recently diagnosed with HIV 4. 45-year-old caretaker of elderly parent 5. 75-year-old with end-stage renal failure

all of the above Special emphasis should be placed on vaccinating the following high-risk individuals: Clients with chronic conditions (eg, asthma, heart failure, cancer) may experience exacerbation of symptoms if infected (Options 2 and 5). Immunocompromised clients (eg, HIV) have decreased ability to fight infection (Option 3). Health care workers and caretakers are at greater risk for acquiring and transmitting infection to other clients (Option 4). Healthy children age 6-23 months and clients age ≥65 are at greatest risk for serious, flu-related complications (eg, pneumonia, dehydration) (Option 1). Pregnant clients are at increased risk for premature labor/delivery or influenza complications due to pregnancy-related physiologic changes.

A home health nurse is preparing to start a milrinone infusion via a peripherally inserted central catheter for a client with end-stage heart failure. What equipment is most important to be present in the home? Select all that apply. 1. Bathroom scale for daily weights 2. Blood pressure cuff 3. Central line dressing change kits 4. Infusion pump 5. Intermittent urinary catheterization kits

1,2,3,4 Milrinone (Primacor) is a phosphodiesterase-3 inhibitor given via IV infusion to increase contractility and promote vasodilation. Milrinone, an inotropic agent, is often prescribed to clients with heart failure unresponsive to other pharmacologic therapies. The medication is usually infused over 48-72 hours in a hospital setting; however, home infusion through a central line is becoming more common as a palliative measure for end-stage heart failure. Milrinone infusion requires central venous access (eg, peripherally inserted central catheter) as the medication is a vesicant and can cause extravasation if infused through a peripheral IV line. The home health nurse should perform the following: Ensure that an infusion pump is used to control the rate, and instruct the family on basic troubleshooting (Option 4). Evaluate medication effectiveness and possible side effects. Monitor the central line insertion site for infection. Change the central line dressing as prescribed (Option 3). Monitor daily weight (Option 1). Monitor blood pressure for possible hypotension (Option 2). Implement safety precautions as hypotension increases the client's risk of falling. (Option 5) Milrinone causes vasodilation, which may result in increased urinary output; however, intermittent catheterization is not indicated. Educational objective:A client may receive a milrinone infusion in the home for palliative treatment of end-stage heart failure. The infusion is set up via an infusion pump and infused through a central line. The client and family should be instructed on basic pump troubleshooting as well as the importance of measuring daily weight and blood pressure.

A client with a history of degenerative arthritis is being discharged home following an exacerbation of chronic obstructive pulmonary disease. After reviewing the discharge medications, the nurse should educate the client about which topics? Select all that apply. Click on the exhibit button for additional information. 1. Dryness of the mouth and throat may occur 2. Ringing in the ears is an expected, transient side effect 3. The albuterol canister should not be shaken before use 4. The health care provider should be notified if stools are black and tarry 5. Tiotropium capsules should not be swallowed

1,4,5 side effect of tiotroprium and other anticholinergics can cause xerostomia(dry mouth) give sugar free candies mes that end in tropium are anticholinergics tiotropium capsules should not be swallowed tinnitus is an uncommon side effects of nsaids.

A client with obesity has just started taking orlistat. Which statement by the client indicates a need for further teaching? 1. "I have started taking a daily multivitamin with my dinner-time dose of medication." 2. "I may have oily stools and fecal incontinence when taking this medication." 3. "I will consume a low-fat diet in which no more than 30% of my calories are from fat." 4. "I will take my medication with, or within 1 hour of, meals that contain fat."

1. 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 (Option 1).

A client with active pulmonary tuberculosis is prescribed 4-drug therapy with ethambutol. The community health nurse instructs the client to notify the health care provider immediately if which adverse effect associated with ethambutol occurs? 1. Blurred vision [46%] 2. Dark-colored urine [4%] 3. Difficulty hearing [25%] 4. Yellow skin [23%]

1. 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 potentially reversible adverse effect. The client is instructed to report signs of decreased visual acuity and loss of color (red-green) discrimination. (Options 2 and 4) 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. (Option 3) 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 multi-drug-resistant tuberculosis, with ototoxic and nephrotoxic adverse effects.

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? 1. "I don't have much of an appetite since starting this medication." 2. "I have a lot more energy, but I'm feeling just as depressed." 3. "I have been feeling dizzy when I walk around at home." 4. "I have experienced frequent headaches lately."

2. 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 (Option 2). Common, expected side effects of SSRIs include: Loss of appetite; weight loss or weight gain (Option 1) Gastrointestinal disturbances (nausea, vomiting, diarrhea) Headaches, dizziness, drowsiness, insomnia (Options 3 and 4) Sexual dysfunction

A client with an asthma exacerbation has been using her albuterol rescue inhaler 10-12 times a day because she cannot take a full breath. What possible side effects of albuterol does the nurse anticipate the client will report? Select all that apply. 1. Constipation 2. Difficulty sleeping 3. Hives with pruritus 4. Palpitations 5. Tremor

2,4,5

The nurse completes the following drug administrations. Which would require an incident report? 1. Client with chronic stable angina and blood pressure of 84/52 mm Hg; isosorbide mononitrate held 2. Client with depression stopped phenelzine yesterday; escitalopram given today 3. 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 4. Client with pulmonary embolism and International Normalized Ratio (INR) of 2.5; warfarin given

2. elective 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. (Option 1) 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. (Option 3) 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. (Option 4) 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.

A client has nausea, abdominal cramping, and persistent mucus-like, watery diarrhea that is positive for Clostridium difficile. The nurse anticipates the client will be prescribed which medication to treat this condition? 1. Ceftriaxone 2. Fluconazole 3. Metronidazole 4. Pantoprazole

3. C difficile is often associated with antibiotic therapy but can also be a nosocomial hospital-acquired infection. Antibiotics, especially broad-spectrum, reduce normal bacteria in the body. This allows other bacteria, such as C difficile, to take over and cause a superinfection. It grows in the intestinal tract and causes antibiotic-associated diarrhea. Metronidazole (Flagyl) is an anti-infective drug commonly used to treat C difficile. For severe C difficile infection, oral vancomycin may be used; intravenous vancomycin is ineffective. (Option 1) Ceftriaxone (Rocephin) is a cephalosporin antibiotic; its use could cause C difficile infection. (Option 2) Fluconazole (Diflucan) is a broad-spectrum antifungal agent; it is not indicated to treat C difficile. (Option 4) Pantoprazole (Protonix) is a proton pump inhibitor agent; its use has been associated with development of C difficile infection.

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? 1. "A contrast medium is administered rectally to visualize the colon via x-ray." 2. "Bedridden clients receive this enema to stimulate defecation and relieve constipation." 3. "This enema assists the large intestines in removing excess potassium from the body." 4. "This enema is administered before bowel surgery to decrease bacteria in the colon."

3. 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.

The nurse provides instructions to a client discharged on warfarin, after being treated for a pulmonary embolism (PE) following surgery. Which statements made by the client indicate the need for further teaching? Select all that apply. 1. "I will need to take my blood thinner for about 3-6 months." 2. "I will place small rugs on my wood floors to cushion a fall." 3. "I will take a baby aspirin if I have mild chest pain." 4. "I will use a soft-bristled toothbrush to clean my teeth." 5. "I will wear a blood thinner MedicAlert tag."

2,3 remove scatter rugs to reduce risk of tripping and faliing avoid aspirin and alcohol when taking warfarin usually given for 3 to 6 months

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

2,3,5

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? 1. "I developed a whole-body rash while on glyburide." 2. "I drink at least 5 large bottles of water daily." 3. "I had to stop using lisinopril due to a bad cough." 4. "I have a birth control implant in place."

1. 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.

A client has a serum potassium level of 2.8 mEq/L, and the health care provider (HCP) prescribes intravenous (IV) potassium chloride (KCL). The nurse administers 10 mEq KCL/100 mL 5% dextrose in water at 100 mL/hr through the client's peripheral IV line using an infusion pump. Shortly after initiation of the infusion, the client reports feeling burning and discomfort at the IV site. What is the nurse's priority action? 1. Notify HCP to request a peripherally inserted central catheter (PICC) 2. Notify HCP to request an oral preparation of KCL 3. Slow the rate of the KCL infusion 4. Stop the infusion of KCL immediately

3. The nurse's priority action is to slow the infusion rate if the client feels a burning discomfort at the IV site shortly after initiation of the infusion. KCL irritates the vein, and irritation and discomfort at the site is expected. Slowing the infusion rate is effective in alleviating discomfort. (Option 1) KCL in concentrations 20-40 mEq/100 mL at a maximum rate of 40 mEq/hr should be administered through a central venous access device (CVAD) (eg, PICC, centrally inserted catheter) to prevent postinfusion phlebitis. A concentration of 10 mEq KCL/100 mL can be administered through a peripheral vein at the recommended infusion rate. (Option 2) The IV infusion is preferred over the oral preparation to decrease the risk for dysrhythmias when hypokalemia must be corrected quickly. Some clients may need both oral and IV forms if the serum potassium levels are markedly low. However, this action is not a priority. (Option 4) Rapid correction of this client's hypokalemia (2.8 mEq/L) is necessary due to risk for hypokalemia-associated dysrhythmias. Stopping the infusion when not necessary further increases risk. The nurse assesses the site at least every hour for adverse reactions (eg, redness, pain, swelling, phlebitis, thrombosis, extravasation or infiltration), and stops the infusion if any occur. Educational objective:Potassium chloride (KCL) administered by the IV route is prescribed for rapid correction of hypokalemia (<3.5 mEq/L). It is irritating to the vein but can be administered slowly through a peripheral vein at recommended infusion rates (5-10 mEq/hr). KCL concentrations 20-40 mEq/100 mL at a maximum rate of 40 mEq/hr should be administered through a CVAD to prevent postinfusion phlebitis or infiltration.

A client comes to the emergency department following a bee sting. The client has a diffuse rash, hypotension, and throat tightness. One injection of IM epinephrine does not improve the client's condition. What action should the nurse take next? 1. Administer IV fluid bolus 2. Administer methylprednisolone 3. Prepare for emergency cricothyrotomy 4. Repeat IM epinephrine injection

4. Anaphylactic shock has an acute onset, and manifestations usually develop quickly (20-30 minutes). Circulatory failure and respiratory manifestations, including laryngeal edema (from inflammation) and bronchoconstriction (primarily from release of histamine), can lead to cardiac/respiratory arrest. The management of anaphylactic shock includes: Ensure patent airway, administer oxygen Remove insect stinger if present IM epinephrine is the drug of choice and should be given to this client. Epinephrine stimulates both alpha- and beta-adrenergic receptors and dilates bronchial smooth muscle (beta 2) and provides vasoconstriction (alpha 1). The IM route (mid anterior lateral thigh) is better than the subcutaneous route. Repeat dose every 5-15 minutes. Place in recumbent position and elevate legs Maintain blood pressure with IV fluids, volume expanders or vasopressors Bronchodilator (inhaled beta agonist) such as albuterol is administered to dilate the small airways and reverse bronchoconstriction Antihistamine (diphenhydramine) is administered to modify the hypersensitivity reaction and relieve pruritus Corticosteroids (methylprednisolone [Solu-Medrol]) are administered to decrease airway inflammation and swelling associated with the allergic reaction Anticipate cricothyrotomy or tracheostomy with severe laryngeal edema

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

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

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? 1. Higher potassium level [2%] 2. Improved mental status [70%] 3. Looser stool consistency [13%] 4. Reduced abdominal distension [13%]

2

The nurse is reviewing prescriptions for the assigned clients. Which prescription should the nurse question? 1. Allopurinol for a client who developed tumor lysis syndrome from chemotherapy for acute leukemia 2. Dicyclomine for a client with a history of irritable bowel syndrome who develops a postoperative paralytic ileus 3. IV morphine for a client after percutaneous nephrolithotripsy who reports the last bowel movement was 2 days ago 4. Levofloxacin for a client with a urinary tract infection who has a history of anaphylaxis to penicillin drugs

2. 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 (Option 2). The nurse should question this prescription and contact the health care provider. (Option 1) 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. (Option 3) 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. (Option 4) 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.

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

3. hold if below 90 to 110 in infants and below 70 in older child

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

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

The health care provider (HCP) has told a client to take over-the-counter (OTC) supplemental calcium carbonate 1000 mg/day for treatment of osteoporosis. Which instruction should the clinic nurse give the client? 1. Monthly calcium levels will need to be drawn 2. Stop vitamin D supplements when taking calcium 3. Take calcium at bedtime 4. Take calcium in divided doses with food

4. Calcium and vitamin D are essential for bone strength. Calcium carbonate (Caltrate) has the most available elemental calcium of OTC 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. (Option 1) Calcium levels may need to be checked periodically, but it is not necessary to do so monthly. (Option 2) Vitamin D also increases calcium absorption and is important for treatment of osteoporosis. There is no need to stop it. (Option 3) Calcium does not need to be taken at any particular time of day.

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? 1. "Is there anything I can take for my dry, hacking cough?" 2. "My blood pressure this morning was 158/84 mm Hg." 3. "Sometimes I feel somewhat dizzy when I stand up." 4. "Will you look at my tongue? It feels thicker than normal."

4. Angioedema is swelling that usually affects areas of the face (lips, tongue), larynx, extremities, gastrointestinal tract, and genitalia. The swelling 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 American clients. Unlike other typical drug allergies, this side effect can occur any time after starting the medication. The nurse should immediately report angioedema to the health care provider and carefully monitor the client (Option 4).