Pharmacology-- Palliative

Triamterene

A potassium-sparing diuretic, a serious potential adverse effect of triamterene is hyperkalemia. When excess potassium is present in the extracellular space, it will result in hydrogen being transferred from the intra to extracellular space, contributing to metabolic acidosis. Excessive diuresis would result in excess water loss via excessive urination and reduced plasma volume, elevating hematocrit (measures the ratio of mass of red blood cells to plasma volume). Therefore, the nurse expects results that support metabolic acidosis, hyperkalemia, and fluid volume deficit. A client accidentally takes double the prescribed dose of triamterene for several days. Which laboratory result does the nurse attribute to excess amounts of this medication? Select All That Apply Blood pH 7.31 This medication can cause metabolic acidosis, which would result in a low blood pH. Serum potassium 5.8 mEq/L (5.8 mmol/L) Triamterene is a potassium-sparing diuretic and can cause hyperkalemia. Hematocrit 55% (0.55 L/L) Because the client has been taking too much of a diuretic, the nurse would expect fluid volume deficit, which results in an elevated hematocrit. NOT: Blood bicarbonate (HCO3) 32 mEq/L (32 mmol/L) In metabolic acidosis, a low bicarbonate is expected. An elevated bicarbonate supports metabolic alkalosis. Blood glucose 270 mg/dL (15 mmol/L) The client is not necessarily diabetic, and this diuretic would not directly elevate blood glucose.

acute pancreatitis

Acute pancreatitis is a serious condition that must be identified and treated quickly. It can progress to a systemic inflammatory response and a form of hypovolemic shock. In addition to the quality of pain identified, other signs of severe pancreatitis include jaundice, abdominal rigidity, and absence of bowel sounds. Grey Turner sign may develop after about 24-48 hours. This is a discoloration of the flanks caused by the leaking of pancreatic enzymes. A client with a history of alcohol use reports abdominal pain. What qualities of pain does the nurse report as supporting possible acute pancreatitis? Select All That Apply The pain radiates to the left shoulder. Many types of visceral pain will create referred pain in other parts of the body. Typical areas for pancreatitis are the back, left flank, and left shoulder. Severity is 8/10 in the mid-epigastric area. Acute pancreatitis creates severe pain in the mid-epigastric area or left upper quadrant. Lying supine intensifies the pain. Lying supine increases acute pancreatic pain, and side-lying in a fetal position can palliate the pain. NOT: It developed over the past seven days. Pancreatic pain is associated with an acute/sudden onset. If associated with alcohol use, it may develop over a few days. It decreases when the client eats. Pain that is reduced with eating is associated with peptic ulcer, and pancreatitis is usually associated with nausea and vomiting and decreased food tolerance.

Albuterol

Albuterol is a β-2 agonist administered to create bronchodilation in clients with bronchoconstriction. Side effects include tachycardia, palpitations, tremors, dizziness, anxiety, headache, and dry mouth. The selectivity to β-2 receptors is dose-dependent, so the continuous administration via nebulizer increases the risk for side effects related to stimulation of β-1 as well as β-2 receptors. A client in severe respiratory distress is prescribed continuous albuterol nebulizers. For which side effect does the nurse monitor the client? Select All That Apply Tremors As part of the fight-or-flight response with sympathetic nervous system activation, the client feels nervous and may have tremors. Dizziness Due to stimulation of the sympathetic nervous system, the client may experience vertigo. NOT: Hyperkalemia Albuterol promotes increased amounts of available epinephrine, which promotes the movement of potassium into the intracellular space, reducing serum potassium. Excessive salivation The client is more likely to experience dry mouth with nebulizer treatments of albuterol. Wheezing Though the client may exhibit wheezing, this is related to the bronchoconstriction that the albuterol is being administered to treat, not to the albuterol itself.

Ropinirole (Requip)

Although the nurse should educate the client to monitor for a worsening of the common symptoms associated with dopaminergic medications (hypotension, dry mouth, and psychosis), ropinirole places the client at a greater risk for daytime drowsiness or sleep attacks compared to the other effects. Because this poses a serious safety risk, it is important for the nurse to address. A client who is currently taking levodopa receives a new prescription for ropinirole. The nurse educates the client about what adverse effect unique to ropinirole? Sleep attacks Although any dopaminergic medications can potentially result in daytime drowsiness, ropinirole and pramipexole are most associated with sleep attacks, or narcolepsy. NOT: Psychosis Psychosis can occur with any drug that increases dopamine levels, so it is not unique to ropinirole. Postural hypotension Levodopa and ropinirole can both cause hypotension; it is worse when first starting a medication or when dosing is increased. Dry mouth Dry mouth is common to both levodopa and ropinirole.

Furosemide (Lasix)

Although there are some good choices in each meal, the best option is one that provides good sources of potassium and minimizes sodium. Furosemide causes loss of potassium via the urine, and hypokalemia places the client at increased risk for cardiac dysrhythmias. High sodium promotes fluid retention, increasing preload, and risk for pulmonary edema. It is important for clients to be aware of sodium content of foods as exceeding recommended sodium intake (usually 2 g/day) because it is a common cause of complications. For example, a single serving of a common brand of canned tomato soup contains 790 mg of sodium. A client with stage 3 left-sided heart failure is prescribed furosemide. What meal choice by the client does the nurse identify as the best evidence of successful dietary teaching? Pork tenderloin with apricots and plain baked potato A potato provides 620 mg of potassium, and pork tenderloin is a lean meat. Apricots also provide potassium. None of the items are high in sodium. NOT: Bacon, lettuce, tomato sandwich, and green salad Bacon is high in sodium and fat. A medium tomato does provide a moderate amount of potassium—320 mg. Grilled ham and cheese sandwich and a banana Ham is high in sodium, as are most cheeses. A medium banana provides about 450 mg of potassium. Skinless chicken breast and canned tomato soup Skinless chicken breast is a good quality protein, but canned soups are high in sodium.

Enalapril (Vasotec)

Angiotensin-converting enzyme (ACE) inhibitors reduce the effects of the renin-angiotensin-aldosterone system and contributes to hypertension and heart failure. The reduction in circulating angiotensin II reduces the release of aldosterone, decreasing sodium and water reabsorption from renal tubules, but increasing the reabsorption of potassium. Increased amounts of bradykinins is thought to be responsible for angioedema, and the full mechanism behind the ACE inhibitor cough is not known. A client has newly been prescribed enalapril for hypertension. The nurse withholds the enalapril and notifies the health care provider for which findings? Select All That Apply Swelling of the lips without presence of a rash Though not a true allergic reaction, and it does not present with a rash, angioedema is a serious complication of angiotensin-converting enzyme inhibitors. A persistent, mild, nonproductive cough A dry, nonproductive cough may occur and is known as "angiotensin-converting enzyme inhibitor cough" and is an indicator that the client will not tolerate this chosen class of medication. An increase in urine output in the last 24 hours Due to the blocking of aldosterone by the angiotensin-converting enzyme inhibitor, the client may have some increase in urine output, which is a desired effect. An orthostatic drop of 20 mm HG in diastolic BP A drop in blood pressure is expected with early treatment with an angiotensin-converting enzyme inhibitor, but a drop of 20 mm Hg is an indication that this dose is too high and should be adjusted. Serum potassium level of 3.2 mmol/L (mEq/L) Angiotensin-converting enzyme inhibitors promote the retention of potassium and can increase potassium levels. Because the client's potassium level is below normal (<3.5), this is not a reason to hold the dose.

Atenolol (Tenormin)

Atenolol is a β-1-selective antagonist that works to decrease blood pressure by reducing myocardial response to epinephrine. This results in a slowing of heart rate and a decrease in the strength of contraction to reduce stroke volume, thereby reducing cardiac output and blood pressure. This also results in the desired effect of reduction in myocardial oxygen consumption, but these medications can also cause excessive bradycardia and eventual heart block, making heart rate an important assessment. A client is prescribed atenolol. The nurse assesses what parameter as most relevant to the mechanism of action of atenolol? Heart rate By blocking β-1 receptors in the myocardium, atenolol lowers heart rate and reduces the strength of myocardial contraction. NOT: Breath sounds Although bronchoconstriction can be a side effect with beta blockers, this is less of a concern with those like atenolol, which are β-1-selective. Heart sounds Heart rate, not heart sounds, are affected by beta blockers. Blood pressure The mechanism of action of atenolol is the reduction in heart rate and contractility, and this results in a lowering of BP, making heart rate more relevant.

Atropine

Atropine is an anticholinergic medication, so the nurse should alert the healthcare provider (HCP) of any conditions where anticholinergic effects would be contraindicated. Note that the HCP may still choose to administer the medication to treat the client's bradycardia depending on the client's individual situation based on degree of risk versus benefit to the client. A client has been prescribed atropine for symptomatic bradycardia. The nurse alerts the healthcare provider that the client has which condition? Select All That Apply Myasthenia gravis Myasthenia gravis involves the autoimmune destruction of acetylcholine receptors, so anticholinergic medication would be contraindicated. Glaucoma Blocking of parasympathetic receptors in the eye will promote pupil dilation, which can impede the drainage of aqueous humor, increasing intraocular pressures. Prostatic hyperplasia Anticholinergic medication can worsen urinary retention associated with prostatic hyperplasia by preventing urinary sphincter relaxation. NOT: Otitis media There is no contraindication for use of atropine if a client has otitis media. Right-sided heart failure Anticholinergic medication will not have negative effects on right-sided heart failure.

Benztropine (Cogentin)

Benztropine is an anticholinergic medication that may cause side effects, such as urinary retention, tachycardia, dry mouth, dry eyes, constipation, and blurred vision. The nurse should monitor the client's voiding pattern to best identify urinary retention before it causes any complications, such as acute kidney injury (AKI). If AKI were to develop, the client could exhibit fluid retention and a rise in creatinine level. A client is prescribed benztropine. The nurse monitors which parameter to identify an adverse effect of this medication? Urine output Determining frequency and quantity of the voiding pattern is the best indicator of urinary retention. NOT: Creatinine level Creatinine level will not be affected unless urinary retention was prolonged, leading to post-renal acute kidney injury. Daily weight Urinary retention would not make a significant difference to the client's daily weight. Peripheral edema Peripheral edema is not an expected finding with anticholinergic medication.

Bismuth subsalicylate (Pepto-Bismol)

Bismuth subsalicylate is an absorbent antidiarrheal that is a salicylate. The nurse should recognize the risk for allergic reaction and the effect of tinnitus associated with this class of medication. A harmless side effect is temporary darkening of stools and tongue that occurs due to the bismuth reacting with sulfur in the saliva of the digestive tract. A client is prescribed bismuth subsalicylate. The nurse includes what teaching points for the client? Select All That Apply "Your stools may become very dark, and your tongue may darken." A harmless side effect is temporary darkening of stools and tongue. "Do not take this medication if you are allergic to aspirin." This medication is a salicylate, and clients with aspirin allergy (also a salicylate) may suffer an allergic reaction. "Contact your healthcare provider if you have ringing in your ears." As with other salicylates, tinnitus can happen with this medication, especially at higher doses. NOT: "Dependence can develop, so limit use to no more than three days." There is no risk for dependence with this medication. "Take this medication with meals to reduce the risk of gastrointestinal upset." This medication may be taken regardless of meals.

Calcium Carbonate (Tums)

Calcium carbonate has several indications including as an antacid, a calcium supplement, and phosphate binder. Since this client is taking the medication for dyspepsia, this would be an over-the-counter preparation sold under commercial names, such as Tums. Following the package directions, avoiding taking the product with milk or within two hours of other medications, and being aware of the risk for constipation are universal recommendations for other-the-counter antacids. A client is taking chewable calcium carbonate tablets for dyspepsia. The nurse includes which points when educating the client? Select All That Apply "This medication can lead to constipation." Antacids can lead to constipation, especially with frequent use. "Do not take it within two hours of other medications." Calcium carbonate and other antacids interfere with the absorption of medications. "Avoid taking calcium carbonate with milk." A rare condition known as milk-alkali syndrome can develop. Risk increases with duration and dose and decreased renal function. NOT: "Do not exceed three doses throughout the day." Calcium carbonate can be taken four or more times a day, as directed on the product package. "Take this medication on an empty stomach." Calcium carbonate can be taken with or without food.

Chronic cancer pain

Chronic cancer pain requires a comprehensive management plan with frequent assessment and adjustment based on response. Principles, such as ensuring ongoing, rather than PRN dosing and use of concurrent non-pharmacological interventions, are relatively universal. Side effects of opioid use also must be assessed for and managed including the common effects of constipation, hypotension, altered level of consciousness, and respiratory depression. Constipation is the only side effect of narcotics to which the body cannot build a tolerance, meaning the client must be on a bowel regimen. Clients at the end of life who have decreased renal function or who are on high doses of opioids are also at increased risk for opioid-related neurotoxicity. The nurse cares for a client with advanced cancer pain. What pain management interventions does the nurse include? Select All That Apply Notify healthcare provider if the pain is escalating, despite use of opioids. Increasing pain despite the administration of opioids is a sign of either a new, acute complication contributing to pain or of opioid neurotoxicity; healthcare provider should be notified of this change. Employ non-pharmacological interventions for pain control. At all times in pain management, non-pharmacological interventions should be employed to increase pain control and reduce the need for medications. Ensure long-acting and short-acting medications are available. For ongoing chronic cancer pain, regular dosing of long-acting and immediate release PRN medication for breakthrough pain is recommended. NOT: Assess the client's level of pain control three times per day. The nurse should assess pain control every four hours, after being medicated, and as indicated. Advocate for parenteral administration of all analgesics. The desired route for medication is oral as long as this route is effective and the medication is available in oral form. Parenteral routes are invasive, require additional resources, and carry greater risks.

Preoperative Fractured Hip

Clients with a fractured hip will have extreme pain from muscle spasm and edema, requiring opioids for pain control. The primary purpose of traction is to decrease painful muscle spasms and also help immobilize the fracture, reducing the risk for additional complications from bone movement, including increased tissue damage, hemorrhage, and pain. The nurse cares for a client with a fractured hip awaiting surgical correction. What interventions does the nurse include to reduce pain preoperatively? Traction is used to immobilize the affected limb and reduce pain. NOT: Performs passive range of motion of lower legs The affected limb should be immobilized. Maintains traction to affected limb. Positions the client on the affected side The client should remain supine with traction is applied. Administers ibuprofen regularly A client with acute hip fracture will require opioids for pain control, rather than ibuprofen.

Clonidine (Catapres)

Clonidine, a centrally-acting α-2 agonist, results in inhibition and reduced sympathetic outflow from the central nervous system. The reduction in norepinephrine effects results in a decrease in peripheral resistance, heart rate, and blood pressure. These lipid-soluble drugs cross the blood-brain barrier and can affect central nervous system functioning. They have been used in conditions such as attention deficit disorder due to these effects. A client is prescribed clonidine. The nurse monitors the client for which side effect? Select All That Apply Drowsiness Clonidine crosses the blood-brain barrier and has a high incidence of causing lethargy and drowsiness. Behavioral changes Clonidine can cause various behavioral changes, including agitation and delirium. Dry mouth Dry mouth is one of the most common side effects of clonidine (incidence ~40%) and is caused by blocking norepinephrine release. NOT: Neutropenia Clonidine has not been linked to neutropenia. Be careful with sound-alikes. Clozapine, an atypical antipsychotic, is associated with neutropenia. Hypertension Clonidine, used as an antihypertensive, results in hypotension, but if abruptly stopped, it can result in rebound hypertension.

Colchicine (Colcrys)

Colchicine is an anti-gout medication used for prevention and to treat acute flares. When treating an acute flare, it is common for the client to experience gastrointestinal symptoms with colchicine, especially diarrhea, for which the nurse should monitor. There is a risk for toxicity when the client has a decreased glomerular filtration rate and is why the nurse should know the client's creatinine level and encourage fluid intake. A client is prescribed colchicine for gout. What actions does the nurse take when caring for the client? Select All That Apply Encourage fluid intake To promote adequate renal clearance, the client should be instructed to take the medication with water and to maintain good hydration. Assess serum creatinine level Colchicine is contraindicated in renal impairment. Assess bowel movements Diarrhea is a common side effect of colchicine and can be quite severe, requiring dose adjustment. NOT: Administer with food Colchicine can be taken regardless of meals, but it is thought to be best absorbed on an empty stomach. Monitor blood pressure closely Colchicine has no known effects on blood pressure.

methylprednisoone

Corticosteroids, such as methylprednisolone, possess glucocorticoid and mineralocorticoid properties. The most abundant endogenous mineralocorticoid is aldosterone; it is helpful to think of how the body responds to aldosterone when thinking about the side effects of these medications. Aldosterone causes the retention of sodium and water and loss of potassium leading to fluid retention and possible hypokalemia. Another effect of corticosteroids is the increase in bone resorption and reduction of bone formation, leading to osteoporosis. Abruptly stopping corticosteroids can cause adrenal insufficiency, so these medications should be slowly tapered down.

Diltiazem (Cardizem)

Diltiazem is a non-dihydropyridine calcium channel blocker used in the treatment of arrhythmias or hypertension. It inhibits calcium ions from entering vascular smooth muscle and myocardial cells during depolarization, resulting in vasodilation and slowing of myocardial conduction. It can lead to atrioventricular block, hypotension, and peripheral edema. A client is prescribed diltiazem. The nurse assesses which parameter related to the effects of diltiazem? Select All That Apply Blood pressure Diltiazem is used to treat hypertension, so blood pressure should be monitored for treatment response because it can cause significant hypotension. Peripheral edema Due to preventing vasoconstriction of precapillary sphincters, diltiazem increases capillary hydrostatic pressure and can cause peripheral edema. Heart rhythm Diltiazem is used to treat arrhythmias, so rhythm should be monitored for treatment response. It also can result in bradycardia. NOT: Calcium level Although it is a calcium channel blocker, diltiazem has no effect on serum calcium levels. Temperature Diltiazem is not associated with changes in temperature.

Documentation

Documentation should be factual, accurate, complete, relevant, current, and organized. Of the options listed, the best choice represents these characteristics most closely. A client reports sudden onset chest pain that is unrelieved after two doses of sublingual nitroglycerin. How does the nurse best document the outcome of the interventions? "At 1705 pain rated as 3/10 and BP is 110/85 mm Hg; Second dose of 0.3 mg nitroglycerin administered at 1706 and Dr. S. Jones notified via telephone at 1707; indicates they will assess client immediately." This example of documentation includes the pertinent details without excessive or irrelevant data included. Times, relevant assessment findings, actions taken, and the name of the healthcare provider contacted are all included. NOT: "Client reported reduced pain to 3/10 and vital signs are stable, but due to continued pain, another spray of nitroglycerin was given and the healthcare provider was informed. The healthcare provider will be in to assess the client." This record is incomplete, as the client's reaction to treatment should include the time the actions were taken. The name of the healthcare provider contacted should also be included. "Reassessed the pain at 1705; this time, it is rated as 3/10. At this time, vital signs were BP 110/85 mm Hg, heart rate 77 beats/min radially, respiratory rate 22 breaths/min, and temperature of 99ºF (37.2°C). Snother spray of nitroglycerin was given, and called the attending healthcare provider to let them know. They stated they will be up to assess the client immediately." This account contains a casual tone and is unnecessarily long. Some irrelevant information is included, such as the client's temperature. "Reassessed pain at 1705, which was rated as 3/10; vital signs stable; second dose of nitro given. Attending healthcare provider informed. Awaiting new orders when healthcare provider arrives." Time of assessment and client rating included, but the name of the healthcare provider who was contacted should also be included.

Droperidol (Inapsine)

Droperidol (Inapsine) is a typical antipsychotic that is used as a sedative and antiemetic perioperatively. As with other similar atypical antipsychotics, such as haloperidol, it can cause long QT and torsade de pointes arrhythmias, which have been fatal in some cases. If the client has a history of this abnormal rhythm, this medication is contraindicated. A client is prescribed droperidol for postoperative nausea. The nurse prioritizes notifying the healthcare provider about which condition in the client's history? Long QT syndrome Droperidol is contraindicated in clients with long QT syndrome. NOT: Malignant hyperthermia Malignant hyperthermia is a complication related to general anesthetic in clients who have a genetic susceptibility, and it is not relevant to droperidol. Schizophrenia As a typical antipsychotic, this medication is safe to administer to a client with a history of schizophrenia. Seizure disorder There is no contraindication with this medication and a seizure disorder.

Pentobarbital (Nembutal)

Due to the potential for serious side effects with pentobarbital, it is reserved for elevations in intracranial pressure from traumatic brain injury that are unresponsive to first-line treatment, such as osmotic diuretics and glucocorticosteroids. Pentobarbital has a high degree of interaction with other medications and can cause serious arrhythmias and hypotension, which is why other medications would be chosen if the client only required sedation or seizure prevention. A client with severe brain trauma has been prescribed pentobarbital. How does the nurse best explain the purpose of administering the medication to this client? "Pentobarbital slows cerebral blood flow and metabolism, reducing intracranial pressure." Because it decreases cerebral blood flow, stabilizes cell membranes, and reduces vasogenic edema, pentobarbital creates a more uniform blood supply and reduces intracranial pressure (ICP). NOT: "This barbiturate creates sedation and reduces the overall basal metabolic rate, inducing a coma." Although pentobarbital is sedating and used to induce coma, the primary goal for this client is to reduce intracranial pressures. "Pentobarbital sedates the client to prevent complications during mechanical ventilation." Other medications can be used that have a better safety profile than pentobarbital for the purpose of sedation for mechanical ventilation. "Barbiturates like pentobarbital are prescribed to prevent seizure activity related to brain injury." If preventing seizures were the primary goal, other anti-seizure medications with a better safety profile than pentobarbital would be used.

Enoxaparin (Lovenox)

Enoxaparin is a low-molecular-weight heparin given for anticoagulation. The primary risk to the client is bleeding, so the nurse's assessments should focus on parameters that indicate the client is experiencing blood loss and that the client is being anticoagulated effectively. Remember that although the hemoglobin level can show if the client has experienced blood loss, it does not correlate with the risk for bleeding (a client with a low hemoglobin is not at increased risk for bleeding). Conversely, although aPTT and INR levels can indicate the degree of risk for bleeding, they cannot confirm that blood loss has actually occurred. A client is prescribed enoxaparin. The nurse monitors which parameter? Select All That Apply Hemoglobin level Hemoglobin should be followed, as a drop is indicative of blood loss. Activity tolerance A subjective sign of anemia due to blood loss is decreased activity tolerance or fatigue. The client may feel dyspnea on exertion. Bowel movements The most common site of blood loss while on an anticoagulant is the gastrointestinal tract, so the nurse should monitor bowel movements for signs of melena. NOT: Activated partial thromboplastin time (aPTT) Low-molecular-weight heparin does not require aPTT monitoring. This is used with unfractionated intravenous heparin. International normalized ratio (INR) INR measures the effectiveness of warfarin and is not related to low-molecular-weight heparin.

Bisacodyl (Dulcolax)

Enteric-coated medications need to be taken whole. With many medications, alterations in the pH of the gastrointestinal tract can alter the absorption of the medication. In the case of bisacodyl, elevating the gastric pH and making it less acidic will cause the medication to come in contact with upper GI mucosa and will result in nausea and GI upset. A client is prescribed oral bisacodyl to be used as needed at home. The nurse includes which teaching point about this medication? Select All That Apply "The tablets must be swallowed whole." Tablets should be swallowed whole to protect the enteric coating. "Avoid milk products within two hours of a dose." Milk can prematurely remove the enteric coating, so it should be avoided. "Take this medication on an empty stomach." Taking it on an empty stomach improves the efficacy of bisacodyl. NOT: "This medication is used to soften stools." Bisacodyl is a stimulant laxative, not a stool softener. "Seek medical attention if abdominal cramps occur." Abdominal cramping is a typical side effect, as peristalsis is stimulated.

Fentanyl (transdermal)

Fentanyl is a potent opioid used for moderate to severe pain in clients who are opioid-tolerant. When first switching to a new opioid preparation, the nurse should be more vigilant about both inadequate pain control and the risk for overdose. Signs of overdose include decreased level of consciousness and respiratory depression. Naloxone should be available to reverse these effects as needed. The topical form of fentanyl, or patch, takes about 12 hours to offer pain control; the nurse should ensure the client has another form of immediate-release pain medication when the patch is first applied. Once applied, it should be changed every 72 hours to a clean, relatively hair-free body site. A client is newly prescribed transdermal fentanyl. The nurse includes which action in the plan of care? Select All That Apply Determine the client's past use of opioids. Fentanyl is not recommended for clients who are opioid naive. If the client has not had opioids in the past, the risk for adverse effects is greater. Assess the client's level of consciousness. A decreased level of consciousness is a sign of opioid overdose and should be assessed regularly. Ensure naloxone is available as needed. Naloxone, an opioid antagonist, is required should the client show signs of opioid overdose. NOT: Clean application area with alcohol. The patch should be applied to clean, dry skin that is free of large amounts of hair, but there is no need to clean the area with alcohol. Date the patch and change it every 24 hours. Fentanyl patches are changed every 72 hours.

Fluconazole (Diflucan)

Fluconazole is an antifungal medication that potentiates the action of warfarin by reducing its metabolism (breakdown) in the liver. This interaction means warfarin will be in the client's system longer, and when they take a subsequent dose, they are essentially overdosing on the medication. If the client must receive fluconazole, the healthcare provider would likely reduce the dose of warfarin for the client to offset the risk of bleeding. A client has just been prescribed fluconazole. The nurse notifies the healthcare provider when noting the client also takes which medication? Warfarin Fluconazole has been shown to significantly inhibit the metabolism of warfarin. NOT: Enoxaparin There is no risk for interaction with this medication. Ranitidine There is no risk for interaction with this medication. Ramipril There is no risk for interaction with this medication.

Hydrocholorothiazide (HCTZ)

Hydrochlorothiazide is a thiazide diuretic that is used to treat hypertension and earlier stages of heart failure. It blocks the reabsorption of water and sodium in the renal tubules for the desired effect of increased urine output and reduction in plasma water volume, reducing preload. Side effects include hypokalemia, hyperuricemia, glucose intolerance, hypotension, hyperlipidemia, and increased calcium levels. A client diagnosed with type 2 diabetes, hypertension, and heart failure is prescribed hydrochlorothiazide. The nurse instructs the client to take what actions while on this medication? Select All That Apply Increase the frequency of blood glucose monitoring. Thiazide diuretics are associated with poorer glycemic control in clients with diabetes. Monitor weight each morning in the same clothes after voiding. The client has heart failure and is on a diuretic. Monitoring daily weight helps indicate total body water. Increase daily intake of foods high in potassium, like avocados. Thiazide diuretics can increase loss of potassium, which the client should replace through increased dietary intake. NOT: Increase daily intake of foods high in calcium, like yogurt. Thiazides have been associated with increased retention of calcium leading to elevated levels; this electrolyte should not be increased in their diet. Notify the healthcare provider if heart rate is under 65 beats/min. A heart rate less than 65 beats/min is desirable in most clients with heart failure, and bradycardia is not directly associated with thiazide use.

Antihypertensives and hemodialysis

In the past, it was common practice to withhold all antihypertensives for clients prior to hemodialysis treatments due to fear of causing hypotension when undergoing the procedure. Current guidelines recommend a more tailored approach, and the nurse should consult the nephrologist or healthcare provider to determine if antihypertensive drugs should be given before a scheduled dialysis treatment. The decision will be made based on the client's history, the mechanism of action, and pharmacokinetics of the medications in question. A client is to be newly started on hemodialysis. Which action does the nurse take related to the client's prescribed antihypertensive medication? Asks the healthcare provider to clarify the timing of administration Treatment decisions are made on a case-by-case basis, so asking for clarification about the plan for this client is the best choice. NOT: Administers the antihypertensive medication as prescribed Due to the new hemodialysis treatments, the nurse should recognize a possible interaction with the client's medications, such as the antihypertensives, and seek clarification. Administers the client's antihypertensives after the hemodialysis treatment This may be what is decided, but until seeking clarification from the healthcare provider, the nurse cannot be certain this is the best choice for this client. Determines if the antihypertensive is removed by hemodialysis This will be a factor that is considered when making a decision about whether or not to administer the medications, but other information will also need to be considered.

Beclomethasone (inhaled)

Inhaled corticosteroids (ICS) present fewer adverse effects compared to systemically administered corticosteroids due to the local action and relatively low bioavailability of the inhaled route. The local effects involve immunosuppression of the respiratory tract, including the oral cavity (increasing the risk for opportunistic infections like oral candida) and the airways (increasing the risk for respiratory infections with prolonged use). The effects of an ICS will not be as immediately evident as with a bronchodilator, but client response should include increase in airway diameter and decrease in dyspnea. A client with chronic obstructive pulmonary disease (COPD) is newly prescribed inhaled beclomethasone. What actions does the nurse include in the plan of care? Select All That Apply Frequent mouth care Inhaled corticosteroids can increase the risk for oral candida, so mouth care should be done, and the client should rinse after inhaler use. Monitor temperature Being on an inhaled corticosteroid increases the risk for respiratory infections, but this risk is related to prolonged use rather than when first starting the medication. The nurse should monitor temperature in the client with COPD due to the increased risk for respiratory infections associated with this condition. Assess breath sounds Assessing breath sounds is routine when caring for a client with COPD to monitor response to treatment. Although the inhaled corticosteroid will not result in an immediate change in breath sounds, the client's response to treatment as a whole should be monitored. NOT: Restrict fluids to two liters per day Although corticosteroids can lead to fluid retention, this is more an issue for systemic doses, and restricting fluids can thicken respiratory secretions, making them harder to clear, so it is not an appropriate action. Monitor serum cortisol Serum cortisol levels would not be measured related to an inhaled corticosteroid.

Labetalol (Trandate)

Labetalol is a beta and alpha blocker that inhibits the release of epinephrine and norepinephrine. The result is hypotension that can lead to sexual dysfunction and impotence. Side effects that directly alter quality of life are more likely to lead to non-adherence to treatment. By properly educating the client about the relatively low risk for developing erectile dysfunction and strategies to reduce this side effect, the nurse can help increase adherence to treatment. A middle-aged male client is newly prescribed labetalol. To reduce the risk for nonadherence to treatment, the nurse teaches the client coping strategies for what adverse effect of labetalol? Sexual dysfunction Blocking of α and β receptors results in possible erectile dysfunction, which affects quality of life and may lead to the client not taking the medication. NOT: Weight gain Though some clients have cited mild weight gain on beta blocking medications, this is not a common adverse effect nor a common reason for non-adherence to treatment. Increased anxiety Due to a decreased activation of the adrenergic receptors, the client should have a reduction in the sensation of nervousness and anxiety. Sleep disturbance Sleep disturbance is not a known side effect of labetalol.

Levodopa (L-dopa)

Levodopa is a dopaminergic medication used to increase the low dopamine levels that contribute to Parkinson symptoms. If dopamine is in excess, it can lead to psychosis, as is seen in clients with schizophrenia. Because antipsychotics generally reduce dopamine levels in the brain, these medications often lead to parkinsonian symptoms. Other side effects of dopaminergic medications include psychosis, nausea, dizziness, postural hypotension, constipation, and dry mouth. A client is prescribed levodopa for Parkinson disease. The nurse monitors the client for what adverse effects of this medication? Select All That Apply Psychosis Due to increased levels of dopamine, the client can experience schizophrenia-like symptoms, including psychosis. Dizziness Orthostatic (postural) hypotension is a side effect that is more pronounced when the medication is first started or dosage is increased. NOT: Fever Fever is a symptom of neuroleptic malignant syndrome that can develop if the client abruptly stops taking levodopa. This is not a side effect of the medication itself, but rather of the dropping of dopamine levels when it is stopped. Diarrhea Constipation is a common effect, not diarrhea. Tremor This medication should reduce tremors associated with Parkinson disease.

Prednisone (Deltasone)

Long-term use of corticosteroids carries many metabolic effects that can affect most body systems. Teaching the client specific dietary modifications can help offset these effects, including weight gain, osteoporosis, hyperglycemia, dyslipidemia, sodium and fluid retention, and potassium loss. A client is prescribed prednisone for long-term use. The nurse instructs the client to incorporate which dietary modification while taking prednisone? Select All That Apply Increased intake of calcium-rich foods Prednisone is associated with osteoporosis with long-term use, and the client should increase intake of both calcium and vitamin D to help offset these effects. Increased intake of lean protein A diet high in lean protein can reduce dyslipidemia and control the weight gain associated with taking corticosteroids. Limiting intake of high-sodium foods The mineralocorticoid effects of prednisone lead to increased retention of sodium and water at the renal tubules, so sodium should be restricted. NOT: Avoidance of foods high in potassium The increase in mineralocorticoid effects increases the loss of potassium via urine, so the client should increase the intake of potassium-rich foods. Increased intake of complex carbohydrates The diet should be low in carbohydrates, as corticosteroids cause elevation of blood glucose.

Losartan (Cozaar)

Losartan is an angiotensin II receptor blocker (ARB) used to treat hypertension. They have a similar safety profile to angiotensin-converting enzyme (ACE) inhibitors. Both classes are associated with injury or death to a fetus, making them contraindicated in pregnancy. Both reduce the effects of aldosterone, leading to a decrease in sodium and water retention and an increase in potassium retention. They must also be used with caution in clients at risk for pre-renal acute kidney injury. A client has been prescribed losartan. What does the nurse assess related to this medication? Select All That Apply Last normal menstrual period Angiotensin II receptor blockers are contraindicated in pregnancy, so if the client is a woman of childbearing age, this question should be asked prior to administering the medication. Serum potassium level By reducing the amount of aldosterone, angiotensin II receptor blockers can increase potassium retention in renal tubules, putting client at risk for hyperkalemia. Serum creatinine level Both angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers have the potential to decrease glomerular filtration rate, especially in clients with poor renal blood flow due to blocking vasoconstriction of the efferent glomerular arterioles. NOT: Post-void residual urine Angiotensin II receptor blockers are not linked to urinary retention, which would be the only indication for checking residual urine levels. Apical heart rate Angiotensin II receptor blockers do not have a direct effect on heart rate or rhythm.

Metoprolol

Metoprolol, a beta blocker, lowers blood pressure and heart rate by inhibiting neurotransmitters from binding with β adrenergic receptors in the heart. A rise in blood pressure and heart rate occurs if the client builds tolerance and the medication effectiveness decreases. A client who has been taking 25 mg metoprolol twice daily for the past two years receives a checkup to monitor the drug's effectiveness. The nurse monitors the client for what symptom indicating a possible drug tolerance? Hypertension Beta blockers decrease blood pressure. A steady increase in baseline blood pressure may indicate the client is developing a tolerance to metoprolol. NOT: Oliguria Metoprolol, a beta blocker, does not typically affect urination. Oliguria in this client requires further evaluation by the healthcare provider. Weight gain Metoprolol, a beta blocker, is not typically associated with weight gain or weight loss. Weight gain in this client requires further evaluation by the healthcare provider. Bradycardia A client develops a drug tolerance when the response of the body to the same dose is decreased. Beta blockers typically decrease heart rate, so the nurse would monitor for increased baseline heart rate or tachycardia if suspecting an increased drug tolerance.

Morphine Sulfate (immediate release)

Morphine, when administered orally, has an onset of about 30 minutes, a peak of about 60 minutes, and a duration of 4-6 hours. The time will vary between clients based on factors, such as rate of absorption and elimination with clients who have poor renal clearance and having prolonged duration time. The nurse should be aware of the approximate pharmacokinetics for as needed medications, especially since the nurse decides when to administer and conduct follow-up assessments for these medications. A client is administered immediate-release morphine orally. How long after administration does the nurse reassess if wanting to time the evaluation for when morphine is at its peak therapeutic effect? 60 minutes Oral immediate-release morphine peaks in about one hour. Assessing at this time will give the nurse the best information as to the effectiveness of this dose. NOT: 15 minutes This would be too early to assess the peak effectiveness. 120 minutes The nurse would likely have missed the medication's peak effect if waiting two hours to assess. 30 minutes Effects will be felt within 30 minutes, but this will not reflect peak analgesia.

Mupirocin (topical)

Mupirocin is an antibacterial product available by prescription for treatment of impetigo. It is also used topically and intranasally to treat nasal colonization with Methicillin-resistant Staphylococcus aureus. The usual directions are to apply to the affected area three times daily and to re-evaluate after three to five days if there is no clinical response. A client is prescribed mupirocin topical cream for the treatment of impetigo. What information does the nurse include for the client about this medication? Select All That Apply Notify the provider if there is no improvement in five days. The client should see improvement in this amount of time. Failure to respond could indicate the lesions are not related to impetigo, and the client should be reassessed. Avoid contact with mucous membranes. The topical preparation for impetigo is different from the ointment used for intranasal application for Methicillin-resistant Staphylococcus aureus. The topical preparation is irritating to mucous membranes, and eyes and should be rinsed immediately if contact occurs. Wash hands before and after application. This should be done for the application of most topical medications for promotion of asepsis and to avoid accidental ingestion and increased exposure to the drug. NOT: Warm the cream before application. The cream should be applied at room temperature. Cover the treatment area with a dressing. There is no need to cover the areas of impetigo being treated.

Non-Rebreather Mask (NRB)

Non-rebreather masks are used when a client requires higher amounts of oxygen than can be delivered via nasal prongs or other masks. It can deliver an Fio2 greater than 90%. The mask is attached to a reservoir bag that should be fully inflated with oxygen. There is a one-way valve between the mask and the reservoir, so the client draws in the oxygen without rebreathing any of the exhaled or room air. A client requires treatment with a non-rebreather oxygen mask. Which does the nurse do to optimize this treatment? Select All That Apply Positions in semi-Fowler Placing a client with the head of bed elevated lowers the diaphragm and decreases work of breathing. Ensures reservoir bag is inflated The reservoir bag should be inflated with oxygen for the client to inhale. Sets flow meter at 10 liters per minute Flow rates of 10 liters or greater should be used with these masks. NOT: Sets up a humidifier bottle Humidity should not be used with the non-rebreather. This action can decrease the oxygen delivered. Encourages pursed lip breathing With a full face mask, there is no need for the client to use this breathing method.

Ramipril (Altace)

Nurses do not monitor all clients on the same medications with the same level of vigilance, but should prioritize the level of assessment based on risk for adverse effects. In this case, the African American client has two reasons to be prioritized—the known decreased effectiveness of angiotensin-converting-enzyme inhibitors in this population and the increased risk for adverse effects. Ramipril (ACE inhibitors) are racist A group of clients have all recently been prescribed ramipril. Which client does the nurse monitor most closely related to this medication? 55-year-old African American male with heart failure African American clients do not respond as effectively to angiotensin-converting-enzyme inhibitor treatment and are at increased risk for the serious side effect of angioedema, so the nurse should monitor this client most closely. NOT: 75-year-old Caucasian female with heart failure This client would be the next priority after the African American male client, given the diagnosis of heart failure and older age that increases the risk for renal-related adverse effects with the angiotensin-converting-enzyme inhibitor. 60-year-old Asian female with diabetes This client would be third most important to assess closely. Adding new medications for the client with diabetes warrants monitoring for alterations in blood glucose levels. 42-year-old Hispanic male with diabetes There is no increased risk for this client compared to the others and could be assessed routinely. Explanation Nurses do not monitor all clients on the same medications with the same level of vigilance, but should prioritize the level of assessment based on risk for adverse effects. In this case, the African American client has two reasons to be prioritized—the known decreased effectiveness of angiotensin-converting-enzyme inhibitors in this population and the increased risk for adverse effects.

Ondansetron (Zofran)

Ondansetron is a serotonin blocker antiemetic often administered for chemotherapy-induced nausea. It blocks serotonin, peripherally at the vagus nerve and centrally in the chemoreceptor trigger zone to reduce nausea. A client is prescribed ondansetron. The nurse assesses the client for which common side effect(s)? Select All That Apply Headache Headache is one of the most common complaints, with up to 27% of clients experiencing this side effect. This effect is more common if given too quickly intravenously. Constipation Constipation occurs in 6-11% of clients who take this medication. NOT: Hyperkalemia Ondansetron is not known to cause hyperkalemia. Bradycardia Ondansetron is not known to cause bradycardia. Hypertension Ondansetron is not known to cause hypertension.

Oxybutynin (Ditropan)

Oxybutynin is an anticholinergic medication commonly used to treat overactive bladder. As an anticholinergic, it has the potential to block acetylcholine receptors in the parasympathetic nervous system, producing a number of side effects including urinary retention, dry mouth, dry eyes, tachycardia, dilated pupils, blurred vision, and constipation. A client is prescribed oxybutynin. The nurse monitors for which side effect? Select All That Apply Constipation Anticholinergic medications reduce gastrointestinal secretions and motility, leading to constipation. Dry mouth Saliva secretion is stimulated by acetylcholine receptors in the parasympathetic nervous system; therefore, anticholinergics reduce saliva production. Urinary retention Anticholinergics, and especially drugs for overactive bladder, such as oxybutynin, reduce bladder contraction and can lead to urinary retention. Tachycardia By blocking the effects of the parasympathetic nervous system, heart rate can increase. NOT: Constricted pupils Anticholinergics lead to pupil dilation, reducing the drainage of aqueous humor. This is why they are contraindicated for clients with glaucoma.

Promethazine (Phenergan)

Promethazine can cause severe chemical damage to tissues regardless of the route of administration and has resulted in gangrenous injury requiring amputation. Due to the risks, the preferred route is deep intramuscular (IM) injection rather than intravenous, but intravenous is still commonly used in clinical settings, usually in a small bag of saline rather than IV push. Subcutaneous injection is contraindicated. A client is receiving a dose of promethazine intravenously and reports a burning sensation at the site. The nurse takes which action? Discontinues the infusion and removes the intravenous catheter Due to the high risk for chemical damage to tissues with promethazine, any complaint of burning should alert the nurse to discontinue the medication. NOT: Assesses the site and, if no swelling is noted, restart the infusion The nurse should not allow the medication to continue to infuse due to the risk for tissue injury. Dilutes the medication by adding additional saline to the medication bag This medication should be diluted prior to administration, but once evidence of extravasation is present, the nurse should not allow the medication to continue to infuse due to the risk for tissue injury. Slows the infusion rate and reassess within in minutes The nurse should not allow the medication to continue to infuse due to the risk for tissue injury.

Propofol (Diprivan)

Propofol infusion syndrome (PRIS) is a rare but extremely dangerous complication associated with high doses and prolonged use ( more than 48 hours). In order to reduce the risk for PRIS, the lowest dose of propofol for the shortest duration should be used. Additional manifestations include lipidemia, rhabdomyolysis, hepatomegaly, and acute kidney injury. A client on mechanical ventilation receives high-dose propofol. The nurse monitors the client for which adverse effect? Select All That Apply Bradycardia The arrhythmia most commonly associated with propofol infusion syndrome is bradycardia and may be due, in part, to the presence of hyperkalemia. Metabolic acidosis Metabolic acidosis is an early manifestation of propofol infusion syndrome. Though the mechanism is not fully understood, is thought to involve propofol interference with mitochondrial processes. Hyperkalemia Hyperkalemia is associated with both metabolic acidosis and acute kidney injury that can occur with propofol infusion syndrome. NOT: Hypercapnia It is more likely for a client to have lower paCO2 levels in compensation for the metabolic acidosis that occurs with propofol infusion syndrome. Hypercalcemia Hypercalcemia is not associated with propofol infusion syndrome.

Salicylate overdose (aspirine OD)

Salicylate overdose is associated with tinnitus, and if this condition appears, the drug is usually stopped. Hearing loss can also occur, but it is usually not permanent. All clients who take higher doses of aspirin regularly should be taught about this adverse effect. A client is prescribed a high dose of aspirin for osteoarthritis. The nurse instructs the client to contact the healthcare provider when which symptom develops? Tinnitus Tinnitus is a dose-related adverse effect of salicylates, such as aspirin, and should be reported immediately. NOT: Cold extremities Cool extremities are a sign of decreased perfusion, such as with peripheral artery disease, and are not associated with taking aspirin. Diarrhea Diarrhea is not a known effect of aspirin, but if the client were to have dark stools, this should be reported due to risk for gastrointestinal bleeding. Constipation Constipation is not a known effect of aspirin.

Spironolactone (Aldactone)

Spironolactone is a potassium-sparing diuretic that can cause hyperkalemia, potentially resulting in the relatively early manifestation of peaked T waves on an ECG. The nurse should not administer a medication that could further elevate potassium, such as spironolactone, until potassium level is known and this finding is investigated. If hyperkalemia progresses, it could cause heart block and eventual cardiac arrest (asystole). Peaked T waves are present on a client's electrocardiogram (ECG). What medication does the nurse withhold from the client until this finding is investigated? Spironolactone Spironolactone, a potassium-sparing diuretic, can contribute to hyperkalemia and can cause peaked T waves. NOT: Hydrochlorothiazide A thiazide diuretic is associated with potassium loss and is associated with flattened T waves and a U wave. Calcium carbonate Calcium carbonate could contribute to hypercalcemia and is associated with a shortened QT interval, not peaked T waves. Furosemide Furosemide could contribute to hypokalemia and is associated with flattened T waves and a U wave.

Estradiol

Systemic estrogen therapy increases the risk for endometrial cancer, breast cancer, and thromboembolic events. There is also increased risk for osteoporosis and dementia. Risk can be reduced for hormone-related cancers by using systemic preparation with progestin. Also, use of topical preparations has been shown to reduce the risk for most estrogen-associated adverse effects, but not eliminate them. The use of hormone replacement therapy for menopause is considered safer for women who are younger and in the early phases of menopause. A client is prescribed estradiol for the treatment of perimenopausal symptoms. The nurse informs the client that this medication increases the risk for what conditions? Select All That Apply Stroke Thromboembolic events, such as stroke, are increased when taking estrogen preparations. Breast cancer Breast cancer risk increases with use of systemic estrogens, and these are contraindicated in women with past history of breast cancer. Endometrial cancer The increased risk for endometrial cancer is a black box warning on systemic estrogen medications. NOT: Leukemia Estrogen therapy has not been shown to increase the risk for leukemia. Liver cancer Estrogen therapy has not been shown to increase the risk for liver cancer.

Diazepam (Valium)

The benzodiazepine, diazepam, has the potential to cause adverse effects related to all of the parameters listed, but the fact that the client is unconscious and receiving mechanical ventilation causes the nurse to identify hypotension as the priority. Note that the risk for these adverse effects is greater if the client is also receiving opioids or other central nervous system depressants. An unconscious client on mechanical ventilation is prescribed intravenous diazepam. The nurse monitors what parameter as a priority when administering this medication? Blood pressure Intravenous diazepam causes significant hypotension, especially if administered quickly. This should be the nurse's priority in this client. NOT: Urine output Diazepam has anticholinergic properties and can contribute to urinary retention, but given that the client is unconscious, an indwelling catheter should be in place. Level of consciousness The client has altered consciousness due to medications for rest during the period of mechanical ventilation, so this is not a relevant assessment. Respiratory depression Intravenous diazepam can cause respiratory depression, but because the client is receiving mechanical ventilation, this is not a priority.

Strength order of pain meds

The effects of epidural analgesia will vary depending on the medications being infused but common side-effects include respiratory depression, urinary retention, hypotension, and headache. If a headache does develop, the nurse should assess to determine any associated symptoms with a headache as it could be the result of spinal fluid leakage or meningitis. Lowering the head of the bed and increasing fluid intake can help with a spinal headache. Respiratory depression is possible related to infusion of opioids for analgesia affecting the respiratory muscles so the nurse should monitor oxygen saturation and respiratory rate, but oxygen should only be given if the saturation falls below the ordered parameters. Correct order: Codeine is a weak opioid with 200 mg being approximately equivalent to 30 mg of oral morphine. Morphine is the prototype opioid used as the comparison for potency on equianalgesic tables. For this comparison, 30 mg of oral morphine is used. Hydromorphone (Dilaudid) is more potent than morphine with 7.5 mg of oral hydromorphone offering similar analgesia to 30 mg of oral morphine. Fentanyl is not available in oral formulations. The parenteral dose of fentanyl equivalent to 30 mg of oral morphine is 0.1 mg, or 100 mcg, making it far more potent than morphine or hydromorphone. Sufentanil is the most potent opioid available with 10-40 mcg being equivalent to 30 mg of morphine, making it about one thousand times more potent than morphine and about three times more potent than fentanyl.

epidural analgesia

The effects of epidural analgesia will vary depending on the medications being infused, but common side effects include respiratory depression, urinary retention, hypotension, and headache. If a headache does develop, the nurse should assess to determine any associated symptoms with the headache, as it could be the result of spinal fluid leakage or meningitis. Lowering the head of the bed and increasing fluid intake can help with a spinal headache. Respiratory depression is possible related to infusion of opioids for analgesia affecting the respiratory muscles, so the nurse should monitor oxygen saturation and respiratory rate, but oxygen should only be given if the saturation falls below the prescribed parameters. The client receives epidural analgesia after a total knee replacement. Which action does the nurse include in client care? Monitor voiding pattern Epidural analgesia can lead to urinary retention, so the nurse should monitor the client's voiding pattern. NOT: Maintain head of bed at 90-degrees Epidural analgesia increases the risk for hypotension from peripheral vasodilation, and having the head of bed elevated may also precipitate a spinal-related headache; 30-45-degrees is usually recommended. Stop infusion if headache develops Headache may be related to a spinal fluid leak, but this needs to be reported to the healthcare provider for further instruction, and the nurse should not stop the infusion without a prescription. Administer high-flow oxygen There is no need for oxygen therapy simply because the client is receiving epidural analgesia.

Constipation risk

The nurse recognizes the postoperative client as having the greatest risk for constipation. Even if this client was not taking opioids postoperatively, the restriction to mobility from bilateral hip arthroplasty will place this client at the greatest risk for constipation compared to the other clients on this list. Most clients will be on opioids and have a regular stool softener, such as docusate, prescribed in addition to PRN stimulant laxatives such as bisacodyl. The nurse cares for a group of clients. Which client is most at risk for constipation? 55-year-old postoperative day two for bilateral total hip arthroplasty The client who is postoperative for hip arthroplasty will have multiple risk factors, including the use of opioid analgesia and immobility. NOT: 40-year-old who has nothing per mouth for an abdominal CT Not eating can increase the risk for decreased gastrointestinal motility, but fasting for a CT will be short-lived, making this client at low risk for constipation. 85-year-old prescribed antibiotics for a urinary tract infection Although the client's age is a risk factor, taking antibiotics is more likely to make the client prone to diarrhea. 65-year-old with rheumatoid arthritis prescribed corticosteroids Corticosteroids are not associated with an increased risk for constipation. This client likely takes nonsteroidal anti-inflammatory drugs for routine pain relief, rather than constipating opioids.

Midazolam (Versed)

The nurse should recognize amnesia as an expected finding after conscious sedation with midazolam, which prevents the creation of new memories. Midazolam onset is 1-5 minutes, and its therapeutic effect is 2-6 hours, making it a good option for use in procedures, such as a colonoscopy. After undergoing colonoscopy, a client tells the nurse they have no memory of the procedure. How does the nurse respond? "Midazolam, a drug you received for sedation, results in this type of memory loss." Midazolam creates amnesia and is commonly used for conscious sedation in endoscopic procedures. NOT: "Diazepam was given, and it is known to affect your memory for a few hours." Diazepam is a benzodiazepine that does not result in memory loss. Valium is not often used as a solitary medication for procedures requiring conscious sedation. "This is concerning. May I conduct a brief neurological exam with you now?" Not remembering the procedure is an expected effect of conscious sedation for endoscopy procedures, so a neurological assessment is not indicated. "You were given general anesthetic, and it is normal to not remember the procedure." The client would not have been given a general anesthetic for a colonoscopy.

Nitroglycerin

The primary risk with nitroglycerin is hypotension. Nitrates are contraindicated with the use of the erectile dysfunction drugs, such as sildenafil, due to an exaggerated vasodilatory effect. Also, in the case of sildenafil, it is highly protein-bound, with a long half-life; therefore, nitrate doses should not be given within at least 24 hours of sildenafil. Note that, though rare, women can take sildenafil or another phosphodiesterase-5 enzyme inhibitor (PDE5-I) for conditions such as pulmonary hypertension or Raynaud phenomenon. So for clients with unknown history and who have not had nitroglycerin in the past, use of a PDE5-I should be ruled out regardless of gender. A client with no previous cardiac history reports central chest pain. Which data does the nurse gather prior to administering the immediate prescription for sublingual nitroglycerin? Select All That Apply Medications in past 24 hours If the client has taken an erectile dysfunction drug in the past 24 hours, nitroglycerin is contraindicated. Current blood pressure Nitroglycerin is contraindicated if the client has a systolic BP under 90 mm Hg. NOT: Oxygen saturation Whether the client is hypoxic or not, the client can receive nitroglycerin. Time of last oral intake Oral intake is not relevant to administering this medication. Current heart rate The client can receive nitroglycerin regardless of heart rate. The nurse should establish cardiac monitoring and obtain baseline measurements of vital signs prior to beginning the ordered infusion. Because nitroglycerin can be absorbed into regular intravenous bag and tubing materials that contain PVC, the nurse knows not to prepare the solution and to use the pre-prepared solutions and equipment from the manufacturer. A client is prescribed nitroglycerin continuous intravenous infusion. Which action does the nurse include when administering this drug? Select All That Apply Administers only ready-to-use preparations Due to interaction with plastics, intravenous nitroglycerin is supplied as ready-to-use in a non-polyvinyl chloride (PVC) plastic bag (or glass bottle) and tubing. Establishes continuous cardiac monitoring IV nitroglycerin is reserved for emergency situations where blood pressure, pulse, and continuous cardiac monitoring can be performed. NOT: Has intubation equipment at the bedside The client's airway is not specifically compromised by nitroglycerin infusion. Discards unused bags within 24 hours IV nitroglycerin is stable for about 96 hours. Once accessed, facility policy may require changing the bag within 24 hours. Holds all other forms of antihypertensives The client may or may not require other classes of antihypertensives, and they are not contraindicated unless the client's blood pressure drops below a safe level. The nurse should ensure there is a prescription to administer acetaminophen as needed in anticipation of nitroglycerin-induced headache. Other common side effects of nitroglycerin include flushing, dizziness, hypotension, and edema. None of the other medications would be necessary to have prescribed in relation to a nitroglycerin infusion. A client has been prescribed a nitroglycerin infusion. Which medication does the nurse ensure is available related to common side effects of nitroglycerin? Acetaminophen Headache is a common side effect of nitroglycerin due to cerebral vessel vasodilation. NOT: Morphine Morphine is an opioid and would not be used to treat side effects of nitroglycerin, but it should be available to treat chest pain unresponsive to nitroglycerin. Epinephrine Epinephrine is reserved for emergent situations and not for expected adverse effects of nitroglycerin. Diphenhydramine Allergic reaction is not a common finding with nitroglycerin and would be the reason for prescribing diphenhydramine. Nitroglycerin causes vasodilation and is most effective in the venous system. This venous dilation leads to venous pooling and a rapid decrease in preload and drop in blood pressure. The nurse must ensure the client is safe from a syncope-related fall prior to interviewing about pain and assessing other vital signs. In addition, the nurse seats the client to reduce myocardial oxygen demand to reduce the imbalance between oxygen supply and demand that leads to angina pain. While ambulating, a client takes a dose of nitroglycerin spray for angina. What does the nurse do first? Has the client sit down in a chair Nitroglycerin can result in a rapid drop in blood pressure, so the client should sit to reduce risk for a fall from syncope. NOT: Interviews the client about the pain Once the client is safely seated, the nurse can interview about the pain. Takes the client's blood pressure Blood pressure would be measured if the client is still experiencing angina and needs to take a second dose of nitroglycerin. Requests an electrocardiogram An electrocardiogram is not indicated unless the client does not respond to the nitroglycerin and acute coronary syndrome is suspected.

Warfarin (Coumadin)

Warfarin for atrial fibrillation should be administered to maintain an INR between 2-3 (normal is 0.9-1.2) to reduce the risk of cardiac emboli formation. The INR is calculated as a standard unit of measure based on the PT level that measures the vitamin K-dependent clotting factors II, VII, IX, and X. These are the clotting factors affected by warfarin. The aPTT test examines factors II, X, and IX that are affected by unfractionated heparin sodium. A client is prescribed warfarin for atrial fibrillation. What result does the nurse report to the health care provider as an indicator of effective treatment? International normalized ratio (INR) 2.5 For a client with atrial fibrillation, a therapeutic INR is generally between 2-3. NOT: Platelet count 100,000/mL (20x 10⁹/L) Warfarin does not have a direct effect on platelet level. This client's result is lower than normal range and would contribute to a mild increase in risk for bleeding. Prothrombin time (PT) 25 seconds Although the international normalized ratio (INR) is based on the PT level, the value used in clinical practice for warfarin monitoring is the INR. Activated partial thromboplastin time (aPTT) 70 seconds The aPTT is used to monitor the effectiveness of heparin infusion; it affects different clotting factors compared to warfarin. Foods high in vitamin K can decrease the effectiveness of warfarin and place the client at risk for cardioembolism. If the client were to have the warfarin dosing increased due to a resulting decrease in international normalized ratio (INR), abruptly reducing the intake of vitamin K could lead to supratherapeutic levels and an increased risk for bleeding. To avoid these possible fluctuations, the nurse should advise the client to be consistent with the intake of vitamin K-rich foods. A client diagnosed with atrial fibrillation is prescribed warfarin. The nurse cautions the client regarding dietary changes which would alter the intake of which food group? Dark green, leafy vegetables Dark green, leafy vegetables are high in vitamin K, which can reduce the effects of warfarin. NOT: Milk and dairy products There is no interaction between this food group and warfarin. Sodium-rich foods Although the client may be advised to reduce sodium intake for other reasons, this would not be related to warfarin. Legumes and lentils There is no interaction between this food group and warfarin.

Docusate sodium (Colace)

When addressing a client's questions about prescribed medications, the nurse needs to ensure the question being asked is being answered. In this case, the client is concerned about taking a laxative, so the best response is to first clarify that docusate is not a stimulant and is given to prevent straining. After making this statement, the nurse will go on to explain why this is important after having had a heart attack.