Chapter 57: Drugs Affecting Gastrointestinal Secretions PREPU

An 86-year-old client has been prescribed ranitidine (Zantac). The nurse knows that an older adult who takes H2RAs may experience what adverse effect?

Agitation Rationale: With H2RAs, older adults are more likely to experience adverse effects, especially confusion, agitation, and disorientation, with cimetidine. In addition, older adults often have decreased renal function, and doses need to be reduced.

A common drug regimen for eradication of H. pylori includes a proton pump inhibitor (PPI) and two antibiotics. Which of the following is one of the preferred antibiotics?

Amoxicillin Rationale: The treatment of choice for H. pylori infection is a PPI and clarithromycin plus either amoxicillin or metronidazole.

A patient is in the intensive care unit and being administered ranitidine (Zantac) parenterally. How long will it take for ranitidine (Zantac) to reach peak blood levels?

15 minutes Rationale: Parenteral ranitidine reaches peak blood level in 15 minutes. Parenteral ranitidine reaches its peak prior to 30 minutes, 1 hour, and 2 hours.

The nursing instructor is discussing the use of histamine2 receptor antagonists in the treatment of peptic ulcer disease. According to the instructor, which of the following is a typical dosing schedule of famotidine during the first few weeks of treatment for gastric ulcer in patients with normal renal function?

20 mg bid Rationale: During the first few weeks of treatment for gastric ulcer, 40 mg of famotidine is administered at bedtime each day or 20 mg is administered twice daily. Thereafter, the typical maintenance dose is 20 mg at bedtime each day. Dosage is typically reduced in patients with impaired renal function.

The physician has prescribed ranitidine for a patient in your unit. Prior to administering the drug for the first time, which of the following adverse effects should you mention to the patient?

Headache Rationale: Adverse effects with H2RAs such as ranitidine are typically uncommon and mild with the usual doses and duration of treatment. However, effects can include diarrhea or constipation, headache, dizziness, muscle aches, and fatigue.

A client is taking an antacid that contains aluminum salts. The nurse would monitor the client for which of the following?

Hypophosphatemia Rationale: Aluminum binds dietary phosphates and causes hypophosphatemia, but they do not cause acid rebound like other antacids. Magnesium antacids cause diarrhea; calcium salts cause hypercalcemia.

You are caring for a 45-year-old client who has been prescribed sucralfate for treatment of peptic ulcer disease. Which of the following nursing diagnoses may relate specifically to administration of this medication?

Impaired Bowel Elimination: Constipation Rationale: Since sucralfate can cause constipation, Impaired Bowel Elimination: Constipation may be relevant to administration of the drug. Although the other diagnoses may be appropriate for the underlying disease, they do not relate to the use of sucralfate.

Which adverse reaction of proton pump inhibitors is specific to menopausal women with osteoporosis?

Increased fracture risk Rationale: An increase in fractures of the hip, wrist, and spine have been seen in clients taking high doses of PPIs and undergoing treatment of osteoporosis with bisphosphonates.

A 75-year-old client is diagnosed with type 2 diabetes mellitus, hypertension, osteoporosis, and gastric ulcer disease. She is prescribed PPIs. The nurse is aware that long-term (greater than 1 year) administration of PPIs may lead to what problem for this client?

Increased risk for hip fractures Rationale: Sucralfate is well tolerated by older adults. PPIs are also well tolerated, but long-term use (greater than 1 year) is associated with increased risk of hip fractures in adults older than 50 years of age. The risk of fractures increases the longer the medications are taken. The risk of hip fractures is also greater in those taking higher dosages of PPIs.

Which of the following would be the proton pump inhibitor of choice for a child with GERD?

Lansoprazole Rationale: Lansoprazole is the only proton pump inhibitor approved for use in children and would be the drug of choice.

Which agent would a nurse identify as the prototype histamine-2 receptor antagonist?

Cimetidine Rationale: Cimetidine is considered the prototype histamine-2 receptor antagonist.

The nurse should warn a patient taking aluminum and calcium containing antacids about which of the following adverse effects? (Choose one)

Constipation Rationale: The nurse should warn a patient taking aluminum and calcium containing antacids about constipation that can be associated with taking products containing either medication.

A clinic nurse is planning care for a 68-year-old man who has been on omeprazole (Prilosec) therapy for heartburn for some time. Regarding the patient's safety, which of the following would be a priority nursing action?

Coordinate bone density testing for the patient. Rationale: All of the options would be appropriate for this patient. However, with regard to the patient's safety and the fact that he is a 68-year-old man and has been on omeprazole therapy for some time, the nurse should be concerned about possible hip fractures. Therefore, the priority action by the nurse should be to coordinate bone density testing. Omeprazole decreases the dissolution and absorption of calcium, which may increase the risk of hip fracture. Men are more likely to have PPI-associated hip fractures than women.

After teaching a group of students about H-2 receptor antagonists, the instructor determines that the teaching was successful when the students identify which drug as most appropriate for a patient with hepatic dysfunction?

Nizatidine Rationale: Nizatidine is the drug of choice for patients with liver dysfunction because it does not undergo first pass metabolism in the liver like the other histamine-2 receptor antagonists.

A patient is diagnosed with peptic ulcer due to H. pylori. The nurse would anticipate administering which agent in conjunction with an antibiotic?

Omeprazole Rationale: Omeprazole is a proton pump inhibitor which is used as part of combination therapy to treat H. pylori infections. Magaldrate is an antacid that is used to relieve GI hyperacidity. Sucralfate is a GI protectant that is used as short-term treatment of duodenal ulcers. Cimetidine is a H-2 receptor antagonist used to treat duodenal and benign gastric ulcers.

After teaching a group of students about proton pump inhibitors, the instructor determines that the students have understood the information when they identify which agent as the prototype proton pump inhibitor?

Omeprazole Rationale: Omeprazole is considered the prototype proton pump inhibitor.

A patient reports chronic abdominal pain. The patient has a 40-pack year history but reports a decrease in smoking to approximately ½ pack/day. The physician, after thorough assessment and evaluation and labs, prescribes a treatment regimen for duodenal ulcer. What important teaching would the nurse include in relation to treatment?

Smoking's effects on healing Rationale: Duodenal ulcers are associated with cigarette smoking. The ulcers of smokers heal more slowly and recur more rapidly than do those of non-smokers.

Which of the following antacids is contraindicated in patients with congestive heart failure? (Choose one)

Sodium bicarbonate (Bellans) Rationale: Sodium bicarbonate is the antacid that is contraindicated in patients with cardiovascular problems, such as hypertension and congestive heart failure, and those on sodium-restricted diets, as sodium bicarbonate can alter the body's sodium-water balance and cause fluid retention.

The use of calcium carbonate is associated with the development of acid rebound.

True

The nursing instructor is teaching students about proper administration of sucralfate. According to the instructor, sucralfate should be administered

an hour before meals. Rationale: Sucralfate, a proton pump inhibitor, must be given time to act before significant gastric activity, and it requires an acidic environment to be effective. For these reasons, sucralfate should be given an hour before meals and antacids.

Misoprostol is a synthetic form of prostaglandin E prescribed to protect the gastric mucosa from erosion and ulceration. The drug is contraindicated in patients who

are pregnant. Rationale: Misoprostol is contraindicated during pregnancy because it may cause abortion, premature birth, or birth defects. It is also contraindicated in women of childbearing potential who are not using effective contraception.

Your 32-year-old patient tells you that he takes antacid tablets several times each day. Knowing that the brand of antacid he uses contains calcium carbonate, you caution the patient that overuse could place him at risk for

metabolic alkalosis. Rationale: Overuse of antacids containing calcium carbonate can cause alkalosis and raise urine pH.

A 52-year-old man is suffering from a deficiency of exocrine pancreatic secretions and is prescribed pancrelipase (Pancrease MT). Before the medication therapy begins, the nurse will assess for allergies related to

pork. Rationale: Pancrelipase is contraindicated in patients who are hypersensitive to pork protein or enzymes because the drug is derived from pork. Allergies to ragweed, pollen, and shellfish are not associated with the use of the drug.

Saliva substitute is absorbed systemically.

False Rationale: Saliva substitute is not generally absorbed systemically.

If a patient is receiving sucralfate and omeprazole, the doses can be taken together.

False Rationale: Sucralfate is not absorbed well in the presence of proton pump inhibitors and doses should be spaced at least 30 minutes apart if both drugs are prescribed.

Pancrelipase would most likely be used to treat a patient with cystic fibrosis.

True

Ranitidine and cimetidine are both H2RAs used in the treatment of peptic ulcer disease. Of the two, ranitidine is preferred in critically ill clients because it is less likely to

interfere with the metabolism of other drugs. Rationale: Unlike cimetidine, ranitidine does not affect the cytochrome P450 drug-metabolizing system in the liver and therefore does not interfere with the metabolism of other drugs by that system.

In preparing a teaching plan for a patient who is to receive misoprostol, which of the following would the nurse include as possible adverse effects? Select all that apply.

• Flatulence • Dyspepsia • Excessive vaginal bleeding • Dysmenorrhea Rationale: Flatulence is a possible adverse effect. Excessive vaginal bleeding is a possible adverse effect of misoprostol. Dyspepsia is a possible adverse effect of misoprostol. Dysmenorrhea is a possible adverse effect of misoprostol. Dizziness is not associated with misoprostol. Vertigo is not associated with misoprostol.

A client is receiving sodium bicarbonate orally. Which of the following would lead the nurse to suspect that the client is developing systemic alkalosis? (Select all that apply.)

• Headache • Confusion • Irritability • Tetany Rationale: Indications of systemic alkalosis include headache, confusion, irritability, tetany, nausea, and weakness.

Which of the following drugs are commonly used in combination with certain antibiotics in the treatment of H. pylori? Select all that apply:

• Omeprazole (Prilosec) • Lansoprazole (Prevacid) Rationale: The proton pump inhibitors, like omeprazole (Prilosec) and lansoprazole (Prevacid), are commonly used in combination with certain antibiotics in the treatment of H. pylori.

Which statement by a patient receiving pancrelipase indicates that the patient has understood his instructions?

"I should take the drug with meals and snacks." Rationale: Pancrelipase is given with meals and snacks so that the enzyme is available when it is needed.

A nurse is reviewing information about proton pump inhibitors. The nurse recognizes that which of the following is available as an over-the-counter agent?

Omeprazole Rationale: Omeprazole is available over the counter; lansoprazole, rabeprazole, and esomeprazole are prescription medications.

Which of the following antacids may produce constipation and should be used cautiously in clients that have chronic constipation? Select all that apply:

• Calcium carbonate (Mylanta) • Aluminum hydroxide (ALternaGEL) Rationale: The aluminum and calcium containing antacids may produce constipation.

Which of the following reduce the secretion of gastric acid by inhibition of the hydrogen-potassium adenosine triphosphate (ATPase) enzyme system of the gastric parietal cells? (Select all that apply)

• Esomeprazole (Nexium) • Lansoprazole (Prevacid) Rationale: The proton pump inhibitors, like esomeprazole (Nexium) and lansoprazole (Prevacid) reduce the secretion of gastric acid by inhibition of the hydrogen-potassium adenosine triphosphate (ATPase) enzyme system of the gastric parietal cells.

You are teaching your 47-year-old client about omeprazole, which the physician has prescribed as part of a regimen to treat an H. pylori infection. What statement, made by the client, suggests that he understands proper use of the drug?

"I need to swallow the drug whole." Rationale: Omeprazole, a proton pump inhibitor, must be swallowed whole; it should not be cut, crushed or chewed. The drug should be taken approximately an hour before a meal, not after a meal. Concomitant use of antacids is common, though the physician may instruct the patient to take the two medications at different times during the day.

When describing proton pump inhibitors, which of the following would be appropriate to include?

Acid labile Rationale: Proton pump inhibitors are acid labile. Proton pump inhibitors are rapidly absorbed from the GI tract. Proton pump inhibitors are extensively metabolized by the liver. Proton pump inhibitors are excreted in the urine.

When describing the possible adverse effects associated with omeprazole therapy, which of the following would the nurse identify as least common?

Alopecia Rationale: Alopecia can occur with proton pump therapy, but it is not a common adverse effect. Common adverse effects include dizziness, headache, and cough.

Which of the following adverse effects is more likely to be caused by cimetidine than by other H2RAs?

Gynecomastia Rationale: Cimetidine is more likely to cause gynecomastia and mental confusion than other H2RAs.

The nurse should explain that metoclopramide (Reglan) decreases nausea and vomiting by which of the following actions?

Inhibiting stimulation of the vomiting center in the brain Rationale: Reglan inhibits stimulation of the vomiting center in the brain. This medication also increases the amplitude of gastric contractions and gastric motility while decreasing gastric emptying time.

A client is diagnosed with Helicobacter pylori infection. The physician will order amoxicillin and what other type of medication?

Proton pump inhibitors Rationale: The treatment of choice for Helicobacter pylori infection is a PPI and clarithromycin plus either amoxicillin or metronidazole.

When caring for an older adult client taking an antacid, the nurse should institute which safety precautions? Select all that apply.

• Fall risk • Bed alarm • Strict intake and output Rationale: The older adult should be monitored closely for fluid and electrolyte disturbances while taking antacids. Signs of dehydration include decreased urine output, restlessness, dizziness, and confusion. These symptoms increase the risk of falls. The client should be assisted when ambulating. A bed alarm can alert the nurse to restlessness and attempts to get out of bed alone. Contact precautions are transmission-based precautions and are not necessary. Fluid and electrolyte imbalance are not transmitted from one client to another. Strict intake and output measurements are necessary to assess for decreased urinary output.

An antacid has been added to the treatment regimen for a client on multiple medications. When is the best time for the nurse to administer the antacid?

At bedtime Rationale: Antacids are best administered one to two hours after meals and at bedtime. No oral drugs should be administered within one to two hours of an antacid.

A nurse is caring for an elderly patient who has been administered cimetidine. Which intervention should the nurse perform?

Closely monitor the patient for confusion and dizziness. Rationale: The nurse should closely monitor the elderly patient who has been administered cimetidine for confusion and dizziness. When the patient is receiving an antiemetic, the nurse monitors the patient frequently for continued reports of pain, sour taste, spitting blood, or coffee-ground-colored emesis. When antacids are given to the patient, the nurse should observe the patient for concentrated urine and restlessness. When the patient is administered prolonged doses of metoclopramide, the nurse reports any sign of tardive dyskinesia or extrapyramidal symptoms to the PHCP.

A male patient is taking cimetidine (Tagamet). Which adverse effect is more likely to occur with cimetidine than with other histamine2 receptor antagonists?

Gynecomastia Rationale: Gynecomastia is an adverse effect that is more likely to occur with cimetidine than with other histamine2 antagonists. Hypoxia, hypertension, and seizures are not adverse effects of cimetidine. (less)

A patient is taking nonsteroidal anti-inflammatory agents for arthritis of the knees and hips. Which of the following diseases is a result of cellular destruction of the gastrointestinal tract from this medication?

Peptic ulcer disease Rationale: Cell destruction will occur from the ingestion of NSAIDs, which can lead to the development of peptic ulcer disease. Nonsteroidal anti-inflammatory agents do not cause esophageal cancer, bowel obstruction, or liver cancer.

In treating Helicobacter pylori infection, a physician prescribes two antimicrobials. Why two?

Two are needed to prevent the emergence of drug-resistant H. pylori organisms. Rationale: Effective combinations include two antimicrobials. For the antimicrobial component, two of the following drugs—amoxicillin, clarithromycin, metronidazole, or tetracycline—are used. A single antimicrobial agent is not used because of concern about emergence of drug-resistant H. pylori organisms.

A 60-year-old man has scheduled a follow-up appointment with his primary care provider stating that the omeprazole (Prilosec) which he was recently prescribed is ineffective. The patient states, "I take it as soon as I feel heartburn coming on, but it doesn't seem to help at all." How should the nurse best respond to this patient's statement?

"Prilosec will help your heartburn but it's not designed to provide immediate relief of specific episodes of heartburn." Rationale: Optimal efficacy requires that omeprazole is taken daily, not just when the patient is symptomatic. A lack of immediate symptomatic relief does not necessarily indicate that the drug is ineffective.

Ms. Law has been taking omeprazole for the last 10 years. What is the risk to the patient from long-term use of omeprazole?

Increased risk of gastric cancer Rationale: Long-term PPI administration in rats has demonstrated an increased rate of gastric cancer. This finding has not been replicated in humans. PPIs do cause hypergastrinemia, which in turn causes diffuse, linear, or micronodular hyperplasia and atrophic gastritis. These changes occur most frequently in patients with Helicobacter pylori infection and markedly increased gastrin levels. Gastric hyperplasia and atrophic gastritis in combination with H. pylori infection increase the risk of gastric cancer, but there are no studies that show a direct correlation between PPI administration and gastric cancer.

Carter, age 2, is diagnosed with cystic fibrosis; the physician places him on pancrelipase. What would be the most appropriate diagnosis for Carter related to his medication regimen?

Imbalanced nutrition: less than body requirements, related to impaired digestion secondary to insufficient pancreatic enzymes Rationale: Pancrelipase is administered as enzymatic replacement therapy for patients with deficient exocrine pancreatic secretions; cystic fibrosis; chronic pancreatitis; ductal obstructions caused by cancer of the pancreas or common bile duct; pancreatic insufficiency; or steatorrhea from malabsorption syndrome and after pancreatectomy, gastrectomy, or post-GI surgery, such as Billroth II gastroenterostomy. Caution must be used with large doses because they may cause nausea, abdominal cramps, and diarrhea. Hyperuricosuria and hyperuricemia have occurred with extremely high doses. Less often, allergic reactions have occurred.

Which of the following best reflects the rationale for using histamine-2 receptor antagonists for stress ulcer prophylaxis?

Protects the stomach lining via acid blockage Rationale: Histamine-2 receptor antagonists are used for stress ulcer prophylaxis because the drugs block the production of acid thereby protecting the stomach lining, which is at risk because of decreased mucus production. Reducing the overall acid level is the rationale for use as short-term treatment of active duodenal ulcer. Blocking the overproduction of hydrochloric acid is the rationale for treatment of pathologic hypersecretory conditions. Decreasing the acid being regurgitated into the esophagus is the rationale for treatment of erosive gastroesophageal reflux.

A 30-year-old nonpregnant patient is prescribed misoprostol. Which of the following should the nurse instruct the patient as part of the teaching plan?

Use a reliable contraceptive. Rationale: The nurse should instruct the patient to use a reliable contraceptive to avoid pregnancy during the course of treatment as it can cause birth defects. The nurse should instruct the patient taking proton pump inhibitors not to chew, open, or crush the tablet but to swallow the tablet whole at least one hour before eating. The nurse needs to inform the patient to take the drug for motion sickness about one hour before travel.

A patient has GERD and is taking ranitidine (Zantac). She continues to have gastric discomfort and asks whether she can take an antacid. Which of the following is an appropriate response by the nurse?

"Yes, but be sure to wait at least 2 hours to take the antacid after you take the ranitidine." Rationale: If both ranitidine and antacids are prescribed, give them at least 2 hours apart to prevent decreased absorption of ranitidine. The nurse should advise the patient to wait at least 2 hours between doses and to take the antacid after the ranitidine. The other three statements are not true.

A patient is taking cimetidine (Tagamet) for increased gastric pain and hypersecretion. Nurses should use caution when administering cimetidine to patients with which of the following conditions?

Hepatic disease Rationale: No contraindications exist, but the use of cimetidine should be used cautiously in patients with impaired hepatic and renal function. The patient with cancer, hypertension, and diabetes mellitus can take cimetidine safely.

A female client presents to the physician's office with increasing stomach acidity. She self-administers calcium antacids. She notes that she seems to be having more issues with stomach acid, so she has been taking the calcium antacids more frequently. The nurse suspects that this may have caused what to occur in this client?

Rebound acidity Rationale: Calcium antacids have high neutralizing capacity and rapid onset. They may cause rebound acidity and hypercalcemia.

Which of the following reduce the secretion of gastric acid by inhibiting the action of histamine at H2 receptors in the stomach? (Select all that apply)

• Famotidine (Pepcid) • Ranitidine (Zantac) Rationale: Ranitidine and famotidine are drugs that reduce the secretion of gastric acid by inhibiting the action of histamine at H2 receptors in the stomach.

Which of the following would a nurse expect as most likely to be used in combination with antibiotics for treatment of Helicobacter pylori infection?

Omeprazole Rationale: Proton pump inhibitors such as omeprazole are used as part of combination therapy with antibiotics for treatment of Helicobacter pylori infection.

A 32-year-old female executive comes to the clinic with severe heartburn. The physician prescribes omeprazole (Prilosec). The patient asks the nurse when the pain will go away. What is an appropriate response by the nurse?

Recommended time for therapy is usually between 2 and 8 weeks. Rationale: Even though heartburn pain will decrease within a couple days of therapy and some patients are on long-term therapy for as long as 5 years, the most important response by the nurse should include that the patient should take the medication at the recommended time. Optimal efficacy requires that omeprazole is taken daily, not just when the patient is symptomatic. The nurse must stress that the patient take the medication as recommended, which could be between 2 and 8 weeks. Usually, it takes longer than a few minutes after the first dose for the pain to subside.

The patient has Maalox ordered for administration before meals. Which of the following conditions is contraindicated with the administration of Maalox?

Renal dysfunction Rationale: Magnesium-based antacids are contraindicated in patients with renal failure. Magnesium-based antacids are not contraindicated with hypertension, regular heart rate, or stress ulcer.

A nurse is planning care for a 59-year-old woman who is on ranitidine therapy. The nurse is concerned for the patient's safety. Which of the following would be an appropriate nursing diagnosis?

Risk for Injury related to drug-induced somnolence, dizziness, confusion, or hallucinations Rationale: The appropriate nursing diagnosis related to safety would be Risk for Injury related to drug-induced somnolence, dizziness, confusion, or hallucinations. Diarrhea related to adverse effects of drug therapy and Acute Pain related to adverse drug effects, headache are appropriate nursing diagnosis for a patient taking ranitidine, but are not related to safety. Potential Complication: Electrolyte Imbalance related to hypophosphatemia, secondary to drug therapy would be appropriate for a patient taking an aluminum hydroxide with magnesium hydroxide antacid (Maalox, Mylanta).

A 75-year-old client is treating his ulcer with antacids. Based on the client's age, the nurse expects the physician to prescribe a dose of antacid that compares with the average prescribed dose in what way?

Smaller than the average prescribed dose Rationale: Smaller doses of antacids may be effective in older adults, because they usually secrete less gastric acid than younger adults do.

A 23-year-old female patient is prescribed misoprostol (Cytotec). Which of the following patient teaching interventions is most important?

Use effective contraceptive measures Rationale: Misoprostol (Cytotec) is used to prevent NSAID gastric ulcer development. The medication can cause spontaneous abortion; thus, the medication should be administered with a good form of birth control. It should not be administered with magnesium antacids. It is not necessary for a patient aged 23 years to report postmenopausal bleeding. The medication should be administered two to four times per day.

A female client comes to the clinic with reports of burning pain in the stomach. She states that she thinks she had a virus 48 hours ago and she vomited many times. She hasn't vomited in 24 hours. She asks the physician to give her a prescription for omeprazole because she saw an ad on TV that said it would heal stomach pain. The nurse assists the client in understanding that PPIs are considered drugs of choice for treatment of what conditions? (Select all that apply.)

• Duodenal ulcers • Zollinger-Ellison syndrome • Gastric ulcers Rationale: PPIs are considered drugs of choice for treatment of heartburn, gastric and duodenal ulcers, GERD, esophagitis, and hypersecretory syndromes such as Zollinger-Ellison syndrome. It is not used in the treatment of anaphylaxis.