Pharm HESI
A client is refusing to take lactulose (Heptalac) because of diarrhea. Which is the nurse's best response to this client?
"Diarrhea is expected; that's how your body gets rid of ammonia."; Lactulose draws water into bowel producing a laxative effect and thereby evacuating ammonia from bowel. Client must understand that this is an expected and therapeutic effect for him/her to remain compliant.
filgrastim [Neupogen] [side effects]
*- side effects: bone pain (all over), headache, injection site reaction, nausea, vomiting*; - indications: cancer-related neutropenia and severe chronic neutropenia; - desired effect: increased neutrophil counts and decreased risk of infection
The nurse is reviewing the use of the PCA pump with a client in the immediate post-operiod. The client will receive morphine 1 mg I.V hourly basal rate with 1 mg I.V every 15 min per PCA to toal 5 mg I.V max per hour. What assessment has the highest priority before initiating the PCA pump?
*Rate and depth of respiration*; - if respiratory depression, PCA pump should be stopped and HCP notified if respiratory rate falls below 12 breaths per minute; - nurse should anticipate adjustments in the client's dosage before the PCA pump is restarted
calcitriol [Rocaltrol] —active form of vitamin D3 [indications]
*hypocalcemia and resulting bone disease in patients on chronic renal dialysis*; secondary hyperparathyroidism and metabolic bone disease in pre-dialysis patients with moderate to severe chronic renal failure
Prednisone [moon face]
- "moon face" is swelling in cheeks and neck; - long-term high doses of prednisone causes water retention and redistribution of fat deposits, w/fat winding up in the face, abdomen, and back of neck; - facial roundness will typically decrease once steroid is tapered down and discontinued
Peptic ulcer disease [med timing]
- *H2 blockers [Tagamet, Zantac]*: h.s.; if B.I.D - 1st dose in a.m., 2nd at h.s.; - *PPI's [-azole's]*: before 1st meal; - *Cytoprotectives [sucralfate]*: 1 hr before meals; 30-120 min apart from other meds; - *H2 blockers w/antacids*: antacid 1 hr *after* H2 blocker; - *Antacids*: 1-3 hrs *after* meals and at h.s.
Nitroglycerin
- *I.V*: specific non-PVC plastic I.V bags and tubing must be used; - *patch*: can use *any non-hairy area* on body; - *topical*: remove old ointment before applying new ointment
baclofen [Lioresal]
- *class*: antispasmodic, central acting skeletal muscle relaxant; - *action*: stimulates GABA receptors; depresses afferent reflex activity at spinal cord level; - *indications*: muscle spasms; MGMT of spasticity in severe chronic disorders such as MS, spinal cord injury, and cerebral palsy
Nursing considerations for rapid acting insulin
- *color*: clear; - *onset*: 5-15 min; - *route*: subQ; - patient should eat immediately after administration - do not give unless meal is available; - *monitor for*: hypoglycemia and hypokalemia; - always have an oral carbohydrate available
baclofen [Lioresal] [continued]
- *desired effect*: reduction and/or relief of spasms, cramping, and tightness of muscles - *side effects*: drowsiness, dizziness, weakness, and nausea;
digoxin [Lanoxin] & furosemide [Lasix]
- *increased risk of digoxin toxicity* when used together; - therapeutic range: 0.5 to 1.5 [toxicity = 2.0]; - signs of toxicity: confusion, loss of appetite, nausea, vomiting, diarrhea, visual alterations e.g., seeing spots or halos; - antidote: DigiFab [Digoxin Immune Fab]
Ginkgo
- *side effects*: GI distress, headache, allergic skin reaction; - *adverse effects*: seizures; - *drug interactions*: interferes w/action of anticoagulants; - stimulates enzymes in liver that metabolize many drugs which *may diminish effects of drugs*
The patient's potassium level is 2.5. Which clinical findings does the nurse expect to see when assessing this patient? (Select all that apply.)
- General skeletal muscle weakness; - Lethargy; - Weak hand grasps
Hypokalemia [nursing considerations for administering potassium]
- Giving PO = GI upset so give w/food; - Never give via I.V push; - I.V admin: assess I&O before and during admin; give in diluted form; and mix well; - if infusion causes burning: can give w/lidocaine; may have to decrease infusion; - contraindicated if history of renal disease
NSAIDs [POC]
- NSAIDs can induce kidney injury including hemodynamically mediated acute kidney injury; electrolyte and acid-base disorders; acute interstitial nephritis, which may be accompanied by nephrotic syndrome; and papillary necrosis - NSAIDs = water retention = HTN which counteract diuretic effect
The nurse is teaching a patient with hypokalemia about foods high in potassium. Which food items does the nurse recommend to this patient? (Select all that apply.)
- Soybeans; - Cantaloupe; - Potatoes
Do NOT administer these types of meds via a feeding tube
- Sublingual tablets; - Enteric-coated (EC); - Sustained release (SR); - Extended release (XR); - Long acting (LA)
A client with a serum potassium level of 3.2 asks why she has to take potassium. What reasons should the nurse give her for taking this medication? (Select all that apply.)
- Your diuretic causes not only water and sodium to be excreted but also potassium; - Your serum potassium level is low, and Slow-K helps to prevent a potassium deficit; - The potassium supplement should maintain a normal potassium level in your body while you are taking the diuretic.
What to do AFTER administering meds via a NG tube?
- after all meds given, flush with 30-60 mL warm water; - keep patient in high Fowler's for at least 1 hr; - start enteral feeding after 1 hr
Advil and antacids [GI distress]
- can be taken at the same time; - example: Ibuprofen and Tums; - suggest taking medication with food to prevent GI upset
aliskiren [Tekturna] [teach] [continued]
- change positions slowly; - pregnancy category D = birth defects; - full therapeutic effect usually obtained by week 2 of therapy; - not as effective for older adults and African Americans
oxybutynin [Ditropan] [overview] indications: enuresis; bladder spasms; symptoms associated w/neurogenic or overactive bladder including: frequent urination, urgency, nocturia, urge incontinence, and frequency
- class: urinary tract antispasmodics; anticholinergic; - action: blocks cholinergic receptors in bladder to decrease urinary frequency and urgency; - desired effect: reduced pressure in bladder and increased tone of urinary sphincter; prevention of involuntary bladder contraction and increased bladder capacity
How to administer meds via a NG tube
- crush solid meds and mix with 30 mL warm water; - give one med at a time; - flush with 5-30 mL warm water between each med
Antiparkinson levodopa/carbidopa [Sinemet] Dopaminergic agent that increases dopamine in brain
- desired effect: Lessen tremors, lessen involuntary movements, decrease drooling; - do NOT to take w/high-protein meal because the high-protein will affect absorption; - adverse effects: dyskinesia and impaired voluntary movement may occur with high levodopa dosages
Aspirin caution [patient teaching]
- discontinue 2 weeks prior to surgical procedures; - take with food or milk to decrease GI upset; - do NOT take more than 1 drug from any class at same time
oxybutynin [Ditropan] [*side effects*]
- dizziness, drowsiness; - constipation, dry mouth, nausea; - urinary retention
baclofen [Lioresal] [patient teaching]
- do NOT double up doses; - do NOT take with alcohol or CNS depressants; - diabetics: may cause high blood glucose levels; - take with meals or milk; - do NOT drive until drowsiness factor is known; - do NOT stop med quickly
Clonazepam [Klonopin] [side effects] ----- Benzodiazepine used as an anticonvulsant
- drowsiness, unsteadiness, and clumsiness are expected effects during early therapy; they are dose related and usually diminish or disappear w/continued use; - caution against taking w/opioids; - take w/food to minimize GI upset; - initiate seizure precautions when drug 1st started
Best time to draw for a peak drug level
- drug and facility dependent; - doctor will order a "peak" level to be drawn x minutes after a dose; - usually for I.V meds - 30-60 min after completion of dose
Multiple sclerosis and ginkgo
- ginkgo is taken for memory and mental function - does not appear to improve cognitive function among people with MS; - ginkgo's anti-inflammatory and platelet-activating factor inhibiting properties may help treat MS but further research is needed
methadone [Dolophine] [break through pain]
- give short-acting analgesics, PRN for "Breakthrough" pain; - immediate release pain meds: Morphine, Dilaudid, Percocet, Codeine; - augment patient's regimen w/other pharmaceutical and non-pharmaceutical pain relief measures for breakthrough pain - half-life = 15-30 hrs
fluconazole [Diflucan] [liver studies]
- hepatotoxic; - monitor LFTs - drug may cause elevation of following serum labs: ALT, AST, alkaline, phosphatase, bilirubin; - monitor for signs of hepatotoxicity such as fatigue, weakness, abdominal pain, loss of appetite, itching, easy bruising, or yellowing of the eyes or skin
Key steps to take BEFORE administering meds via NG tube
- high Fowler's; - check for placement; - check residual - if < 150 mL return residual to patient and prepare to admin med; - stop enteral feeding; - flush tube with 30-60 mL warm water;
Peak drug level
- highest concentration of a drug in patient's bloodstream; - indicates rate of absorption; - if peak level too high - drug toxicity could occur
orlistat [Xenical] [weight MGMT] [nursing considerations] indications: obesity MGMT
- highly toxic for liver - can become jaundice; - blocks absorption of fat-soluble vitamins, may not receive adequate vitamin K, resulting in decreased clotting factor - patient would be pale and have many bruises - report this finding to the HCP
Cephalosporins [penicillin allergy]
- if allergic to penicillin *may* also be allergic to cephalosporins; - if *mild* penicillin reaction can use cephalosporins w/minimal risk; - do NOT give if history of *severe* reactions to penicillins; - treat anaphylaxis w/epi
aliskiren [Tekturna] [teach] indications: hypertension [usually reserved for those who don't respond to ACE inhibitors or ARBs]
- immediately report signs of angioedema such as swelling of face, lips, tongue; difficulty breathing or swallowing; swelling of hands or feet; - do NOT take drug following high fat meal - will interfere w/absorption of drug; - do NOT use salt substitutes or potassium supplements w/o consulting HCP;
Myasthenia gravis [tensilon effectiveness] [continued]
- increase in muscle strength would be seen in 1 to 3 min; - if no response occurs, another dose is given over next 2 min, and muscle strength is again tested; - if no increase in muscle strength occurs w/this higher dose, the muscle weakness is not caused by MG
liraglutide [Victoza] [type 2 diabetes mellitus]
- indication: type 2 diabetes; - route: subQ, once daily; - side effects: hypoglycemia, nausea, vomiting, diarrhea, constipation, headache; - contraindications: patient or family history of Thyroid C-cell tumors or Multiple Endocrine Neoplasm Syndrome type 2
pentoxifylline [Trental] [ischemic pain] Enhances RBC flexibility, which reduces blood viscosity, providing better oxygenation to muscle tissues to stop intermittent claudication
- indications: intermittent claudication related to peripheral vascular disease; - intermittent claudication is leg pain produced upon increased activity and ischemia to tissues, includes numbness and paresthesias; pain is reduced w/rest; - condition due to obstruction of arteries
Vitamin B12 injections
- intrinsic factor helps body absorb B12 in intestine; - lack of intrinsic factor results from loss of stomach cells that produce intrinsic factor; - can be caused by: celiac disease, *advancing age*, drugs that lower stomach acid; gastric surgery; - *treated w/life-long, monthly I.M injections*
Aspirin caution [nursing considerations]
- labs to monitor liver, renal, and clotting functions; - tinnitus indicates *toxicity*, other symptoms of toxicity: dizziness, hyperpnea, and psychological disturbances; - AVOID aspirin or any aspirin-containing product when taking antiplatelet agents, or meds that precipitate or aggravate bleeding
orlistat [Xenical] [weight MGMT] [patient teaching]
- limit dietary fat to <30% of daily calories to reduce GI side effects associated w/increased fat content in stool e.g., flatulence, oily spotting, and fecal urgency - take w/all meals containing fat; - take a daily multivitamin supplement 2 hours before or after taking orlistat
Common rapid acting insulin drugs
- lispro [Humalog]; - aspart [Novolog]; - glulisine [Apidra]
Trough drug level
- lowest concentration of a drug in patient's bloodstream; - usually drawn just before next scheduled dose
Myasthenia gravis [tensilon effectiveness] Tensilon test is performed to confirm diagnosis of MG; Edrophonium is a short-acting acetylcholinesterase inhibitor used as a diagnostic agent
- med inhibits breakdown of an enzyme so more acetylcholine binds to receptors; - increased muscle *strength* for 3-5 min after injection = increased severity of MG and myasthenic crisis; - increased muscle *weakness* = cholinergic crisis and patient is reacting to an overdose of medication
Positive inotrope [assess] Positive inotropes affect *contractility* - *increase force of ventricular contraction* and *cardiac output*; Examples: - phosphodiesterase inhibitors: inamrinone [Inocor] and milrinone [Primacor]; - cardiac glycosides: digoxin [Lanoxin]; - beta androgenic agonists: epi, dopamine, dobutamine
- monitor BP - before inotrope has a chance to correct the low BP, the RAAS system may be triggered; - once aldosterone is secreted, it will: 1. increase reabsorption of sodium [and where sodium goes, water will follow]; and 2. cause vasoconstriction in the arterioles; both of which will increase BP
Positive inotrope [assess] [continued]
- monitor BUN and creatinine to assess renal function; - monitor for hypokalemia; - thyroid meds decrease digoxin levels
liraglutide [Victoza] [type 2 diabetes mellitus] [nursing considerations] - dosed independent of meals - may be taken with or without food; - half-life: 13 hrs
- monitor for hypoglycemia and always have oral carbohydrate available; - monitor for pancreatitis; - nausea will decrease over time when his/her body gets use to med; - risk of thyroid C-cell tumors including medullary thyroid cancer
baclofen [Lioresal] [nursing considerations]
- monitor: BP, I&O; - watch for: sensitivity reactions such as fever, skin eruptions, and respiratory complications; - increased risk of seizures in epilepsy patients - supervise ambulation
Hypokalemia [clinical manifestations]
- muscle weakness is *early sign*; - muscle cramps, paresthesias; weak peripheral pulses; - decreased deep tendon reflexes; shallow respirations; - PVCs, u waves, v-tach; - confusion, anorexia, nausea, vomiting;
calcitonin-salmon [Miacalcin] [rhinitis] Indicated for osteoporosis
- route: *intranasal spray* or injection; - make sure patient has healthy nares before starting; - teach patient: alternate nares everyday; report rash, itching, or nasal irritation; before 1st use, allow bottle to reach room temp, then prime pump by releasing 5 sprays until full spray is produced
Antihypertensives [low potassium]
- some antihypertensives lower potassium levels; - hypokalemia affects myocardial contractility, which places patient at greatest risk for dysrhythmias that may be unresponsive to drug therapy
oxybutynin [Ditropan] [patient teaching]
- stop taking and notify HCP immediately if signs of angioedema and/or anaphylaxis such as swelling of face, tongue, or throat; rash; dyspnea; - before taking Ditropan, empty the bladder, to minimize urinary retention
Hypokalemia [causes]
- vomiting, prolonged diarrhea, NG suction; - non-potassium sparing diuretics and steroids, - inadequate dietary intake of potassium; - Cushing's syndrome; - alkalosis; - uncontrolled diabetes
Upon admission to the emergency center, an adult client with acute status asthmaticus is prescribed this series of medications. In which order should the nurse administer the prescribed medications? (Arrange from first to last.)
1. Albuterol (Proventil) puffs; 2. Salmeterol (Serevent Diskus); 3. Prednisone (Deltasone) orally; 4. Gentamicin (Garamycin) IM.
When administering potassium orally, the nurse knows that it must be taken with at least how many ounces of water or juice?
4
NASAL INHALER: Steps 1. Gently blow your nose to clear it of mucus 2. Make sure the canister fits, shake the canister several times just before using it. 3. Keep your head upright. Breathe out slowly.
4. Use your finger to close the nostril on side not receiving med. 5. Press down on canister as you begin to breathe in slowly through nose. Repeat steps for other nostril. If you are using more than one spray in each nostril, follow all these steps again. 6. Try not to sneeze or blow your nose just after using spray.
A patient has a low potassium level and the physician has ordered an I.V infusion. Before starting an I.V potassium infusion, what does the nurse assess?
Adequate urine output
The nurse is assessing a client who is taking furosemide [Lasix]. The client's potassium level is 3.4, chloride is 90, and sodium is 140. What is the nurse's primary intervention?
Administer 2 m.E.q potassium chloride per kilogram per day I.V
calcitriol [Rocaltrol] [nursing considerations]
Check serum phosphate before admin to patient w/CKD; If serum phosphate is elevated, calcium and phosphate can cause soft tissue calcification. Calcitriol should not be given until phosphate level is lowered.
The client has been vomiting and has weak, flabby muscles. The client's pulse is irregular. The nurse would correctly suspect what type of imbalance?
Hypokalemia
The client is taking digoxin and also taking a diuretic that decreases her potassium level. The nurse expects that a low potassium level (hypokalemia) could have what effect on the digoxin?
Increase the serum digoxin sensitivity level
Inhaled meds ------ Why take a deep breath and completely exhale before inhaling aerosolized medication?
Instruct patients to take a deep breath and exhale completely prior to closing their mouth around the end of the inhaler to empty the lungs and prepare the airway for receiving the medication. This is an essential part of the process of using a metered-dose inhaler.
The client is receiving potassium supplements. What is the most important nursing implication when administering this drug?
It must be diluted
ADH desired outcome
Its two primary functions are to retain water in the body and to constrict blood vessels, and it is also potassium sparing.
The client with end-stage cirrhosis presents with GI bleeding, combativeness, and confusion. The nurse anticipates an order to administer which medication?
Lactulose because it helps rid the body of ammonia. Excess ammonia leads to encephalopathy, which this client is manifesting
lactulose [Cephulac] [cirrhosis] Treats constipation and liver complications
Lactulose is administered to reduce blood ammonia by excretion of ammonia through the stool. Two to three soft stools a day indicate that lactulose is performing as intended; Diarrhea = too much lactulose
Safety precaution with regard to codeine and ambulation
Patient should not ambulate without assistance after receiving codeine
oxybutynin [Ditropan] [toxicity]
Toxicity produces CNS excitation, such as nervousness, restlessness, hallucinations, and irritability. Other signs of toxicity include hypotension or hypertension, confusion, tachycardia, flushed or red face, and signs of respiratory depression.
A patient's potassium level is low. What change in the cardiovascular system does the nurse expect to see related to hypokalemia?
Weak, thready pulse
calcitriol [Rocaltrol] [side effects]
Weakness, Nausea & Vomiting, dry mouth, constipation, bone pain, polyuria, polydipsia, weight loss, elevated BUN, AST, & ALT, cardiac arrhythmias, hypertension, and dehydration
The nurse is teaching the patient about hypokalemia. Which statement by the patient indicates a correct understanding of the treatment of hypokalemia?
When I take the liquid potassium in the evening, I'll eat a snack beforehand.
St. John's wort
can interfere with kidney transplant and cause rejection
A 43-year-old client is taking Slow-K. She is taking hydrochlorothiazide 50 mg daily to control her hypertension. The client's serum potassium level is 3.2. What clinical manifestations would the nurse expect to assess in this client?
confusion
Why do some patients have a spacer attached to their metered-dose inhaler?
device breaks up and slows down medication particles released from inhaler, trapping med in chamber of spacer thus allowing patient to inhale med from chamber; allows larger droplets emitted from aerosol spray to be retained in chamber while smaller, particles are inhaled, thus improving drug's absorption
A physician orders lactulose (Cephulac), 30 mL three times daily, when a client with cirrhosis develops an increased serum ammonia level. To evaluate the effectiveness of lactulose, the nurse should monitor:
level of consciousness (LOC)
Adverse reaction
non-therapeutic unintended effect of a drug that occurs within a therapeutic range
Bioavailability Percentage of administered drug that reaches the systemic circulation.
oral drugs: 20-40% of dose reaches systemic circulation; I.V: usually 100% reaches systemic circulation; - factors that alter bioavailability: drug form, route, GI mucosa/motility, foods/drugs, changes in liver metabolism [dysfunction or inadequate blood flow] → only if drug is metabolized by liver
How is the majority of potassium excreted?
through the kidneys
The nurse administers lactulose (Cephulac) to the client with cirrhosis for which purpose?
to reduce serum ammonia levels by promoting gastrointestinal excretion of ammonia through the GI tract.
