PHARM Quiz 4

The nurse is preparing to discharge a patient who is receiving acebutolol HCl (Sectral). Which instruction will the nurse include in the medication teaching plan for this patient?

"If you take your pulse and it is less than 60, hold your medicine and call your health care provider for instructions." : Acebutolol HCl (Sectral), a beta blocker, has negative chronotropic effects and could cause symptomatic bradycardia and/or heart block. The health care provider should be consulted before acebutolol is administered to a patient with bradycardia (heart rate less than 60 beats/min). The patient should not stop taking the medication abruptly and should notify the provider if dizziness occurs. Patients who have hypertension should avoid caffeine. Bleeding disorders are not a side effect of acebutolol.

The nurse is caring for a patient who has acute pancreatitis. The health care provider has prescribed an anticholinergic drug. The patient asks, "How will this drug help me?" What is the nurse's best response?

"It will decrease the gastric secretions.": Anticholinergic drugs are helpful in reducing gastric secretions in patients with acute pancreatitis. The heart rate is decreased when low doses of anticholinergic drugs are administered. Cholinergic blockers aid in intubation by reducing salivary secretions. In patients with Parkinson's disease, these drugs are prescribed as they reduce muscle rigidity and tremors.

The nurse is caring for a patient who is receiving anticholinergic drug therapy. The patient states, "I feel hot but have not been able to sweat." What advice does the nurse give to the patient?

"Stay out of the heat and humidity.": As the patient does not sweat, there is impaired thermoregulation. The nurse should ask the patient to stay out of hot and humid weather, as the patient is at a high risk of developing heat stroke. Inclusion of fiber in the diet may reduce the other effects of anticholinergic drugs such as constipation. The medications should be taken before bedtime, if the anticholinergics produce sedation. Drinking 6 to 8 glasses of water daily helps in minimizing the effects such as dry mouth.

The primary health care provider instructs the nurse to administer 1 milligram (mg) of medicine to a patient. How many grams of medicine would the nurse administer?

0.001 g: A milligram is three degrees of magnitude less than a gram. Therefore, the decimal point moves three places to the left to convert milligrams (mg) into grams. One milligram (mg) is equal to 0.001 g. One kilogram (kg) is equal to 1000 g. One microgram (mcg) is equal to 0.000001 g. One nanogram (ng) is equal to 0.000000001 g.

A patient is prescribed ampicillin (Ampi) 250 mg IM. The medicine is available in a 250 mg vial. The drug label says to add 1mL of diluent to make 1 mL of drug solution. How many milliliters should the patient receive?

1 ml: For ampicillin (Ampi) reconstitution, the drug label indicates that 1 mL of sterile water should be added to the vial containing 250 mg of the drug. The total volume would be 1 mL. The basic formula for this calculation is D/H × V = A, where D is the desired dose, H is the on-hand dose, V is the vehicle, and A is the amount calculated to be given to the patient. A= (250/250) × 1 = 1 mL. The patient should receive 1 mL of the drug. According to the formula, 4 mL and 5 mL doses of ampicillin (Ampi) are too high, and may cause toxicity. A dose of 0.5 mL of ampicillin (Ampi) is too low for a therapeutic effect.

The nurse is preparing to administer penicillin 400,000 units. The pharmacy sends penicillin 300,000 units/mL. How many milliliters will the nurse administer? Round your answer to the nearest hundredth.

1.3 mL: Dividing what should be given (400,000 units) by what is available (300,000 units/mL) gives the answer of 1.33 mL.

The order is for Synthroid 0.075 mg daily for the patient. The pharmacy sends Synthroid 0.05-mg scored tablets. How many tablets will the nurse give?

1.5: Dividing what should be given (0.075 mg) by what is available (0.05 mg/tablet) gives an answer of 1.5 tablets.

The primary health care provider prescribes 0.01 g of prochlorperazine (Compazine) to a patient who reports nausea and vomiting. The available dose is 5 mg/5 mL. What dose should be given to the patient? Record your answer using a whole number. ________ mL

10ml: According to the ratio and proportion method, H: V :: D : x H- Medication dose on label V- Vehicle D- Desired dose x- Unknown amount In the case above, D and H are in different units. To convert grams (g) to milligrams (mg), the decimal point should be moved one space to the right for each degree of change in magnitude. Grams are three degrees greater than milligrams; therefore, the decimal point should be moved three spaces to the right. D is 0.01 g = 10 mg x= V × D/H = 5 mL × (10 mg/5 mg) = 10 mL

The nurse is to administer nitroglycerin 0.4 mg sublingually. The tablets are dispensed as 200-mcg tablets. How many tablets will the nurse administer per dose?

2 tablets: 0.4 mg is equivalent to 400 mcg. The nurse must administer two 200-mcg tablets to achieve a dose of 400 mcg.

The primary health care provider prescribes 5 mg of diphenoxylate and atropine (Lomotil) tablets to a patient with diarrhea. The nurse observes that the medication dosage on the label is 2.5 mg. What should be the dosage of this medication for the patient? Record your answer using a whole number. ________ tablets/day

2.5 tabs/day: The basic formula is used to calculate the dosage of medications. It is A= D/H × V. A- Amount of medication to be given to the patient D- Desired dose H- Medication dose on label V- Vehicle In the case above, D is 5 mg, H is 2.5 mg, and V is 1 tablet; therefore, A= (5 mg/2.5 mg) × 1 tablet A= 2 tablets/day

The primary health care provider prescribes 50 mg of clarithromycin (Biaxin) to a patient. The available dose is 125 mg/5 mL. Which dose of the medication should be given to the patient?

2ml: According to the basic formula, x = V ×D/H, where H is medication dose on the label, V is vehicle, D is desired dose, and x is unknown amount. In this case, x = (50 mg/125 mg) × 5 mL = 2 mL. Based on the basic formula, 1mL, 3 mL, and 4 mL are not the correct doses of the medication to be given to the patient.

The primary health care provider has recommended 0.75 g of ciprofloxacin (Cipro) orally b.i.d. The available dosage form is 250 mg tablets. How many tablets of ciprofloxacin (Cipro) should be given to the patient? Record your answer using a whole number. ______ tablets

3: The first step is to convert the unit of measurement of the prescribed medication to the same unit of measurement, according to the tablet label. To convert grams to milligrams, the decimal has to be moved three spaces to the right, so 0.75 g = 750 mg. The basic formula for this calculation is 222529895 × V = A, where, D is the desired dose, H is the on-hand dose, V is the vehicle, and A is the amount calculated to be given to the patient. Therefore,222529895 × V =222529895 × 1 tablet = 3 tablets. Therefore, the patient should be given 3 tablets.

Which patient is an unsuitable candidate for a sympathomimetic agent?

A patient who has hypertension: A patient who has hypertension is an unsuitable candidate for the administration of a sympathomimetic agent. Administration of a sympathomimetic agent in a hypertensive patient may cause further increase in blood pressure. Administering them in a patient who has hypertension increases chances of heart failure. Patients who have insomnia, glaucoma, or a common cold are suitable candidates for administration of a sympathomimetic agent.

Which is the highest priority intervention for a patient admitted with glaucoma?

Administer pilocarpine.: Pilocarpine is a direct-acting cholinergic agonist that constricts the pupils and opens the canal of Schlemm to promote drainage of aqueous humor. This drug is used to treat glaucoma by relieving fluid pressure in the eye and to promote miosis. Teaching the patient to wear glasses will not help glaucoma, nor will keeping the lights very low or staying out of sunlight.

The nurse is preparing to administer bethanechol (Urecholine) to a patient. Which information in the patient's history prompts the nurse to collaborate with the primary health care provider before giving the drug?

Asthma: Muscarinic agonists induce bronchospasm, which would cause problems for a client with a history of asthma. Constipation is an adverse effect of cholinergic-blocking drugs. Hypotension is an adverse effect of bethanechol. Psoriasis is a common skin condition where skin becomes thick; it is not directly related to the side effects of bethanechol (Urecholine).

A patient who is scheduled for an endoscopy is administered atropine prior to the procedure. What is the reason for giving atropine to the patient?

Atropine reduces salivation in the mouth.: Atropine is administered prior to endoscopy in order to reduce salivation which may aid in inserting the endoscope. Atropine is used in the treatment of bradycardia and ventricular systole as it increases heart rate. Atropine increases intraocular pressure in glaucoma patients which may result in loss of vision. Overdose of atropine increases frequency of urination.

Before administering an adrenergic agonist, what is the most important assessment for the nurse to complete?

Blood pressure: An adrenergic agonist causes vasoconstriction, leading to high blood pressure. Temperature, skin integrity, and respiratory rate are not directly affected by adrenergic agonists. Blood pressure is the most important assessment because of the detrimental effects of high blood pressure, such as stroke, which can be life threatening.

The nurse is caring for a patient diagnosed with heart failure and chronic obstructive pulmonary disease (COPD). The patient is ordered carvedilol (Coreg). What is the nurse's primary intervention?

Call the health care provider to request a different medication.: Carvedilol (Coreg) is a nonselective beta blocker used primarily in the treatment of heart failure but is also beneficial for hypertension and angina. Patients with a history of asthma, emphysema, bronchitis, or any condition with increased airway resistance or bronchoconstriction cannot take nonselective or beta2-blocking drugs without experiencing further bronchoconstriction and negative effects on their underlying disease condition. The patient could receive a selective beta blocker instead. The nurse should make the health care provider aware of the patient's history of respiratory disease.

The nurse administers pilocarpine (Pilocar) ophthalmic drops to a patient. For which clinical indicator does the nurse monitor as a means of evaluating the therapeutic effectiveness of the ophthalmic treatment?

Constricted pupils: A parasympathomimetic agent such as pilocarpine causes activation of muscarinic receptors in the eye, producing miosis, or pupillary constriction, and contraction of the ciliary muscle, which results in accommodation for near vision. Administration of a cholinergic agonist is more likely to cause lacrimation and myopia than dry eyes and hyperopia (farsightedness).

The nurse monitors a patient prescribed dicyclomine (Bentyl) for which therapeutic effect? Decrease in GI motility Decrease in urinary frequency Increase in heart rate Increase in blood pressure

Decrease in GI motility: Dicyclomine (Bentyl) is an antispasmodic cholinergic blocker used to decrease GI motility in patients with functional GI disorders such as irritable bowel syndrome. The other findings would not indicate therapeutic effects to the administration of this medication.

An elderly patient with an overactive bladder is treated with anticholinergic drugs. Which clinical presentations are suggestive of complications of anticholinergic drugs? Select all that apply. Diarrhea Dry mouth Tachycardia Blurred vision Bronchospasm

Dry mouth Tachycardia Blurred vision: The patient is at risk of complications of anticholinergic drugs. These include dry mouth, tachycardia, and blurred vision. These complications occur due to blockage of cholinergic receptors. Diarrhea and bronchospasm are not complications of anticholinergic drugs.

During a cardiopulmonary resuscitation emergency, the nurse expects to administer which injectable, fast-acting medication?

Epinephrine (Adrenalin): Epinephrine is administered in emergency situations and is one of the primary vasoactive drugs used in many advanced cardiac life support protocols. Naphazoline and oxymetazoline are administerd intranasally to ease congestion. Naphazoline may also be used as an ophthalmic medication. Salmeterol is given via the respiratory tract because of its affinity for beta2 receptors that act on the lungs.

A patient diagnosed with asthma just completed an albuterol nebulizer treatment. The patient tells the nurse, "I feel like my heart is fluttering, and my hands are very shaky." What is the nurse's most appropriate action?

Explain this sensation as a side effect.: Albuterol is a beta2 agonist that predominantly acts on beta2 receptors in the lungs to cause bronchodilation. Side effects include tachycardia and jitteriness, because the medication is not 100% selective on beta2 receptors. It is not necessary to notify the health care provider, because the patient is describing side effects of the medication. The next treatment should not be held, because the patient's breathing takes priority over side effects. A decreased dose of albuterol is not necessary.

The health care provider's prescription reads: Administer hydralazine (Apresoline) 1.25 mg/kg/day. The child weighs 22 pounds. How many mg/kg/day should the nurse plan to administer? Record your answer using one decimal place. _________________ mg/kg/day

First step: Convert pounds to kilograms first. 2.2 pounds = 1 kilogram 2.2 lb :: 22 lb 1 kg x kg 2.2 l (x kg) = 22 lb (1 kg) x = 10 kg Second step: 1.25 mg :: x mg 1 kg 10 kg 1 kg (x mg) = 1.25 mg (10 kg) x = 12.5 mg/kg/day

The nurse is reviewing a patient's medical history and recognizes which conditions as usual contraindications to the use of adrenergic medications? Select all that apply. Pregnancy Hypertension Drug allergy Migraines Diverticulitis

Hypertension Drug allergy: The only usual contraindications to the use of adrenergic drugs are known drug allergy and severe hypertension.

Which outcome would be most appropriate to establish for patients taking beta1 agonists?

Increased contractility of myocardium: Stimulation of beta1 receptors in the "fight-or-flight" response results in stronger ventricular contraction owing to increased contractility of myocardium. Beta2 agonist stimulation results in vasodilation and decreased resistance of peripheral vessels. Beta1 agonists act most specifically on the heart; relaxation of uterine smooth muscle is a result of taking alpha1 antagonists. Bronchial smooth muscle is affected by beta2 agonists.

The nurse is caring for a patient who is taking a cholinergic (parasympathomimetic) drug. Which assessment will indicate that the medication is having a desired effect? Increased gastrointestinal (GI) motility Mydriasis Urinary retention Vasoconstriction

Increased gastrointestinal (GI) motility: Cholinergic effects mimic the parasympathetic nervous system (rest and digest) as opposed to the sympathetic nervous system (fight or flight). Increasing GI motility helps the digestive process. This medication should not cause mydriasis, urinary retention or vasoconstriction because these are not effects of the parasympathetic nervous system when it is stimulated.

The nurse is caring for a patient who is receiving intravenous epinephrine (Adrenalin). Which assessment will indicate the patient is having the expected therapeutic effect of this medication?

Increased heart rate and strong pulse: Epinephrine (Adrenalin) causes sympathomimetic actions, including increased heart rate and contractility. Epinephrine causes bronchial dilation, not constriction. Epinephrine does not decrease blood pressure; at high doses, intravenous epinephrine increases blood pressure.

Which finding is a therapeutic effect of atropine (generic)? Miosis Lethargy Hypertension Increased heart rate

Increased heart rate: Atropine, a muscarinic antagonist, works primarily on the heart, exocrine glands, smooth muscle, and eyes; it produces an increased heart rate. Atropine is likely to cause mydriasis. Lethargy is not a therapeutic effect of atropine. Because there is no parasympathetic innervation to muscarinic receptors in blood vessels, atropine has no effect on vascular smooth muscle tone and therefore no effect on blood pressure. The nurse does not anticipate sinus tachycardia because this medication is indicated for the use of bradycardia.

The patient is prescribed a beta blocker medication and is also taking a diuretic as part of his treatment regimen. The nurse anticipates that this interaction will result in which of the following?

Increased hypotension: The interaction of both a beta blocker and a diuretic is likely to result in increased hypotension for the patient.

The nurse is caring for a patient who is undergoing treatment with an alpha-adrenergic drug. The nurse is monitoring daily laboratory test results on the patient. Because of the patient's treatment with the alpha-adrenergic drug, the nurse anticipates that the laboratory tests will show which result?

Increased level of glucose: The alpha-adrenergic drugs can cause an increase in serum levels of glucose.

The nurse is monitoring a patient's vital signs on each visit that he makes to a health clinic. The patient has started treatment with an adrenergic blocking drug. What is the nurse's highest priority?

Measure both supine and standing blood pressures.: When the patient is taking an adrenergic blocking drug, blood pressure should be monitored both supine and standing because of the tendency toward orthostatic hypotension. Also, the apical pulse should be counted for one full minute. Assessment of temperature and respiratory rate, although important, is not as paramount in this case.

Which adverse reaction will the nurse monitor for in a patient taking bethanechol (Urecholine) for treatment of urinary retention? Constipation Hypertension Muscle weakness Tachycardia

Muscle weakness: is an indication of a potential adverse reaction to bethanechol. Other assessments that may indicate an adverse reaction to this medication include abdominal cramps, diarrhea, orthostatic hypotension, and bradycardia.

The nurse is caring for a patient who has been ordered an adrenergic drug to treat asthma. When assessing the patient prior to administering the first dose of the drug, the nurse finds that the patient's blood pressure is 160/90 mm Hg. What is the nurse's highest priority action?

Notify the health care provider of the patient's elevated blood pressure reading.: Adrenergic drugs are contraindicated in the case of severe hypertension, so the health care provider should be notified of the finding.

What is the most accurate outcome criteria for the nurse to use when determining if a patient is responding appropriately to use of an adrenergic drug?

Patient's respiratory rate is 16 breaths/minute and blood pressure is 130/72 mm Hg.: The blood pressure and respiratory readings will give the most accurate information for outcomes criteria; the other information is vague and subjective.

The nurse advises a patient who is taking cholinergic drugs to avoid standing immediately and to take an upright position slowly. Which complication associated with the drug is the nurse trying to prevent?

Postural hypotension The main adverse effect of cholinergic drugs in the patient is postural hypotension, which results in dizziness and fainting. This effect can be decreased by changing positions slowly when taking an upright position. These drugs do not affect muscular function, gastrointestinal function, or respiratory function. Therefore, muscle cramps, nausea or vomiting, and dyspnea are not adverse effects related to cholinergic drugs.

Which drug is classified as an adrenergic antagonist?

Propranolol (Inderal): Propranolol is an adrenergic antagonist. Propofol comes under the class of anesthetic agents. Milrinone is classified under inotropic drugs. Epinephrine comes under the class of adrenergic agonists.

The nurse should expect which assessment finding for a client taking a selective beta 1 receptor blocker?

Pulse 62 Blocking of selective beta 1 receptors results in a decrease in heart rate, conduction, and contractility with no bronchoconstriction, which results in a lowered pulse. Wheezing is not expected, because this sign indicates bronchoconstriction. A bounding pulse is not expected if contractility is decreased, and the pulse is expected to be regular.

When teaching an 83-year-old patient about the effects of adrenergic agonists, the nurse will advise the patient to avoid which activity?

Slow jog in summer: If unusual demands are placed on the aging heart, problems and complications may arise. Examples of unusual demands include strenuous activities, excess stress, heat, and medication use. The stress heat from slow jogging may lead to significant increases in blood pressure and pulse rate. The older adult may then react negatively with a diminished ability to compensate adequately for these changes. A short daily walk and visiting a family member are not considered strenuous activities. Older adults are already at risk for polypharmacy and should not take any over-the-counter medications or herbal supplements without a prescription from the health care provider.

What is a clinical indicator of parasympathetic nervous system stimulation?

Slowing of the heart rate: The parasympathetic nervous system performs seven regulatory functions: slowing the heart rate, increasing gastric secretions, emptying the bladder, emptying the bowel, focusing the eye for near vision, constricting the pupil, and contracting bronchial smooth muscle. Alpha stimulation leads to dilation of pupil. Parasympathetic nervous system stimulation helps in relaxation of the bladder, allowing emptying of the bowels. Cholinergic drugs help the bronchi to contract rather than dilate.

Which adverse reaction will the nurse monitor for in a patient taking bethanechol (Urecholine) for treatment of urinary retention?

Syncope: Adverse effects include syncope(faint), hypotension with reflex tachycardia, headache, seizure, gastrointestinal upset(diarrhea), and asthmatic attacks. Miosis may result from use of bethanechol, not mydriasis.

The primary health care provider prescribes 500 mL of 5% dextrose in water with 10 mEq potassium chloride (KCl) over 10 hours. The available dosage is 500 mL of 5% dextrose in water with 20 mEq/10 mL potassium chloride (KCl). The drop factor of the intravenous IV set is 15 gtt/mL. What is the amount of drug to be used and the infusion flow rate?

The nurse calculates the drug dosage using the ratio and proportion method. The formula for the ratio and proportion method is, H: V :: D : X, where, H is the drug in hand (available), V is the vehicle or drug form (tablet, capsule, liquid), D is the desired dose (as ordered), x is the unknown amount to give, and :: stands for "as" or "equal to." 20 mEq: 10 ml :: 10 mEq: x ml 20x = 100 x= 100/20 x= 5 mL of KCl Therefore, the patient should receive 5 mL of KCl. The infusion flow rate is calculated as follows: Drops/minute (gtt/min) = amounts of fluids × Drops per milliliter (IV set)/hours to administer × minutes per hour (60) Drops/minute (gtt/min) = 500 ml × 15gtt/mL/10 × 60 Drops/minute (gtt/min) = 12 gtt/min Therefore, the drip rate should be 12 gtt/min. According to the above dosage calculation, 10, 15, or 20 mL of KCl is too high a dose for the patient, and may lead to toxicity. According to the above the flow rate calculation, an infusion rate of 14, 16, or 17 gtt/min is too fast, and may cause fluid overload.

The nurse is caring for a patient who is prescribed propranolol (Inderal). Which assessment finding will reveal if the medication is having a therapeutic effect?

The patient's blood pressure is 130/75 mm Hg. : Propranolol (Inderal) is nonselective—it blocks both beta1 and beta2 receptors at therapeutic doses. The medication is administered to treat hypertension. The patient's blood pressure is within normal limits, which indicates therapeutic effect. Clear lung sounds indicate the patient is not having respiratory side effects. Strong peripheral pulses is an indication that circulation and cardiac output may be strong; however, is not related to drug action. Nonselective beta blockers are not typically given for cardiac dysrhythmias.

Which medication is used in the treatment of hypertension?

Toprol-XL (metoprolol): The Food and Drug Administration has reported errors in prescribing and dispensing involving a mix-up between Topamax (topiramate), which is indicated for the treatment of epilepsy and prophylaxis of migraines, and Toprol-XL (metoprolol succinate), which is used for the treatment of hypertension and heart failure as well as the long-term treatment of angina pectoris. Other errors have occurred when Toprol-XL and Tegretol (carbamazepine), a drug used for various types of seizures and trigeminal neuralgia, have been confused. Tapazole (methimazole) is used to treat hyperthyroidism.

What system should the nurse assess to determine if bethanechol has had a therapeutic effect?

Urinary assessment: This medication increases the tone of the detrusor muscle and causes the patient to void. There would be no reason to perform a neurological, muscular or gastric assessment.

Which condition is treated with bethanechol (Urecholine) in a postoperative patient? Postoperative hypotension Urinary atony Respiratory atelectasis Postoperative ischemic colitis

Urinary atony: Bethanechol is a direct-acting cholinergic agonist that stimulates the cholinergic receptors on the smooth muscle of the bladder, leading to bladder contraction and emptying, leading to urinary atony. Postoperative hypotension is the contraindication to cholinergic drugs. Antihistamines are used to treat respiratory atelectasis in postoperative patients.

The nurse administers atropine (generic), 0.5 mg IV push to a patient with sinus bradycardia. Which instruction will the nurse include in patient teaching? Use ice chips to relieve dry mouth. Report blurred vision immediately. Expect minor urinary incontinence. Anticipate lethargy and sleepiness

Use ice chips to relieve dry mouth.: Blockade of muscarinic receptors in salivary glands can inhibit salivation, leading to xerostomia (dry mouth). Ice chips are one means of managing dry mouth. The nurse instructs the patient to eat ice chips rather than chewing gum or hard candy because the patient's heart rate has slowed enough to warrant the administration of atropine; until the patient's condition is stable, ice chips are a reasonable method of managing xerostomia. Blurred vision is an adverse effect of atropine; however, it does not necessitate immediate attention because its effect is usually mild. Atropine is likely to cause urinary retention and central nervous system (CNS) excitation. Lethargy is not a therapeutic effect of atropine.

The nurse assesses a patient receiving an adrenergic (sympathomimetic) agent. Which finding will be of greatest concern to the nurse?

Weak peripheral pulses and decreased heart rate: Adrenergic agents stimulate the sympathetic nervous system, which increases heart rate (positive chronotropic effect), contractility (positive inotropic effect), and conductivity (positive dromotropic effect). The nurse would be most concerned that the pulses remain weak and heart rate decreased after receiving this drug, as the therapeutic effect is not being achieved.

A client with a new prescription for propranolol (Inderal) tells the nurse he has a history of asthma. The nurse's priority action is to:

notify the client's health care provider.: Inderal is a nonselective beta blocker which can result in bronchoconstriction. The health care provider (HCP) needs to be notified about the client's history of asthma. Teaching the client how to take the blood pressure, teaching to change positions slowly, and informing the client to carry a rescue inhaler are all important; but notifying the HCP is priority to ensure safety and prevent bronchoconstriction first.

The patient is taking a beta blocker and begins to experience episodes of dizziness. In response to this the patient should:

notify the provider: Some of the beta blocker medications are known to produce dizziness as a side effect. However, the primary health care provider should be notified of this to ensure that the symptom is only a harmless side effect and not indicative of a worsening of the cardiac condition.