N212-Safe Medication Administration and Dosage Test

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therapeutic blood levels for phenytoin

10-20mcg/ml Toxicity signs include nystagmis, ataxia, confusion, nasuea, slurred speech, and dizziness

What are examples of intermediate-acting insulins?

Commercially, intermediate-acting insulins are available as insulin isophane (Humulin N or Novolin N). (The "N" stands for NPH.)

How often can a patient take a sublingual dose of nitroglycerin during an acute attack?

Repeat q 5 min for 2 additional doses for acute attack.

Use cautiously in Nifedipine`

Severe hepatic impairment, ventricular arrythmias, Beers list for short acting

Use cautiously for hyroxyzine

Severe heptaic dysfunction , Beers list (decrease dosage), lethal in neonates

IV admin

50% solution must be diluted in NS, to a concentration of <20%, admin not to exceed 150mg/min Max concentration of 1.6meq/ml

What drug schedule is morphine sulfate?

Schedule II

Can hydromorphone cause orthostatic hypotension?

Yes

antacids and phenytoin

do not take antiacids within 2hrs of phenytoin

What is the PO dose range of hydromorphone?

PO (Adults > 50 kg): Immediate-release— 4-8 mg q 3-4 hr initially (some patients may respond to doses as small as 2 mg initially); or once 24-hr opioid requirement is determined, convert to extended-release by administering total daily oral dose once daily.

What are examples of long-acting insulins?

Products include Lantus (insulin glargine) and Levemir (insulin detemir).

Since prolonged use may lead to physical and psychological dependence, should patients be prevented from receiving higher doses of morphine sulfate?

Prolonged use may lead to physical and psychological dependence and tolerance. This should not prevent patient from receiving adequate analgesia. Most patients who receive morphine for pain do not develop psychological dependence. Progressively higher doses may be required to relieve pain with long-term therapy.

What is the indication for morphine sulfate?

Severe pain. Management of moderate to severe chronic pain in patients requiring use of a continuous around-the-clock opioid analgesic for an extended period of time (extended/ sustained-release). Pulmonary edema. Pain associated with MI.

When do rapid-acting insulins enter the bloodstream?

Within 15 minutes of subcutaneous injection.

contrindications for atorvastatin

increased LFT

Pharmacokinetics of phenytoin

distrubytes through CSF, breat milk, and crosses placenta. Protein binding 90%. Metabolized by the liver. Minimal amounts excreted by the kidneys

AE/SE ketorolac

euphoria, headache, asthma, dyspnea, edema, pallor, vasodilatio

What are side effects/adverse reactions for epidural agents?

*CNS*: SEIZURES, anxiety, dizziness, headache, irritability. *EENT*: blurred vision, tinnitus. *CV*: CARDIOVASCULAR COLLAPSE, arrhythmias, bradycardia, hypotension, tachycardia. *GI*: nausea, vomiting. *GU*: urinary retention. *Derm*: pruritus. *F and E*: metabolic acidosis. *Neuro*: circumoral tingling/numbness, tremor. *MS*: chondrolysis. *Misc*: allergic reactions, fever.

SL dosage for nitro

0.3-0.6mg may repeat x3

Half life of phenytoin

22hrs

When does oral morphine sulfate peak?

60 minutes

protein binding Nifedipine

92%

Classification of phenytoin

Arrhythmic/anticonvulsant

valsartan

ARB

SE/AE magnesium sulfate

Drowsiness, decreased respiratory rate, arrhythmia, bradycardia hypotension, diarrhea, muscle weakness, flushing, sweating, hypothermia

What are adverse reactions/side effects of hydromorphone?

*CNS*: confusion, sedation, dizziness, dysphoria, euphoria, floating feeling, hallucinations, headache, unusual dreams. *EENT*: blurred vision, diplopia, miosis. *Resp*: respiratory depression. *CV*: hypotension, bradycardia. *GI*: constipation, dry mouth, nausea, vomiting. *GU*: urinary retention. *Derm*: flushing, sweating. *Misc*: physical dependence, psychological dependence, tolerance.

What are the side effects/adverse reactions of nitroglycerin?

*CNS*: dizziness, headache, apprehension, restlessness, weakness. *EENT*: blurred vision. *CV*: hypotension, tachycardia, syncope. *GI*: abdominal pain, nausea, vomiting. *Derm*: contact dermatitis (transdermal). *Misc*: alcohol intoxication (large IV doses only), cross-tolerance, flushing, tolerance.

When is nitroglycerin contraindicated?

*Contraindicated in*: Hypersensitivity; Severe anemia; Pericardial tamponade; Constrictive pericarditis; Alcohol intolerance (large IV doses only); Concurrent use of PDE-5 inhibitor (sildenafil, tadalafil, vardenafil).

What are drug-drug interactions of nitroglycerin?

*Drug-Drug*: Concurrent use of nitrates in any form with sildenafil, tadalafil, and vardenafil increase risk of serious and potentially fatal hypotension; concurrent use is contraindicated. Additive hypotension with antihypertensives, acute ingestion of alcohol, beta blockers, calcium channel blockers, haloperidol, or phenothiazines. Agents having anticholinergic properties (tricyclic antidepressants, antihistamines, phenothiazines) may decrease absorption of translingual or sublingual nitroglycerin.

What are side effects/adverse reactions of insulin?

*Endo*: HYPOGLYCEMIA. *Local*: erythema, lipodystrophy, pruritis, swelling. *Misc*: allergic reactions including ANAPHYLAXIS.

When should nitroglycerin be used cautiously?

*Use Cautiously in*: Head trauma or cerebral hemorrhage; Glaucoma; Hypertrophic cardiomyopathy; Severe liver impairment; Malabsorption or hypermotility (PO); Hypovolemia (IV); Normal or pulmonary capillary wedge pressure (IV); Cardioversion (remove transdermal patch before procedure); OB: May compromise maternal/fetal circulation; Lactation, Pedi: Safety not established.

Lasix

*know a lot* Diuretic Slow IVP 10mg/min Hypokalmeia HF (monitor I&O) High ceeling (increased dose, increased output) Foley Hypomagnesemia Thiazide combined (not another loop) Dig toxicity

When should you re-assess the patient's pain after giving them morphine sulfate?

1 hr following PO, subcut, IM, and 20 min (peak) following IV administration

1 liter of fluid equals how many kilograms?

1 liter = 1 kilogram

Order: Isuprel (isoproterenol) 40 ml/hr IV Available: Isuprel 2mg in 500 mL D5W How many mcg/min is the patient receiving?

1 mg = 1000 mcg, so 2 mg = 2000 mcg. (40 mL / 500 mL) * 2000 mcg = 160 mcg in 1 hour. 160 mcg / 60 min = 2.67 mcg/min

Translingual spray Nitro dosage

1-2 sprays x3

What are the first two steps in the procedure taken in order to administer High Alert Medications?

1. First Check ( 6 rights ) 2. Second Check ( 6 rights) - different individual

Heparin 25,000 Units in 500mL D5W at 50mL/hr has been infusing for 8 hours and the drug is discontinued. 1. How many units of heparin was the patient receiving each hour? 2. How much total heparin was given?

1. How many units of heparin was the patient receiving each hour? 2, 500 units/hour 25000 units / 500 mL * 50 mL / 1 hour = 2500 units How much total heparin was given? 20,000 units 2,500 units * 8 hours = 20,000 units

Use the following sliding scale to determine the amount of insulin to give your patient: No coverage: Glucose less than 150 2 units: Glucose 150-200 4 units: Glucose 201-275 6 units: Glucose 276-350 8 units: Glucose 351-400 Glucose over 400 NHO stat 1. How much insulin would you give if you had a glucose of 140? 2. How much insulin would you give if the glucose was 280?

1. No coverage since the glucose is less than 150 2. 6 units using an insulin syringe.

Your patient has been diagnosed with Pregnancy Induced Hypertension. The physician orders, "Magnesium Sulfate 8 g, IVPB in 100 ml D5W over 20 minutes." The label states, "Magnesium Sulfate 20% solution." The drop factor of the tubing is listed as 10 gtt/ml. 1. What volume of Magnesium Sulfate will you add to the D5W? 2. What is the drip rate (gtt/min) of the Magnesium Sulfate IVPB?

1.) 40 ml 20% Magnesium Sulfate = 20 g / 100 mL. Since only 8 g are needed, 20 g / 100mL = 8 g / X. Solve for x = 40 mL. 2.) 70 gtt/min 40 mL from previous answer is added to the 100 mL of D5W, equaling 140 mL. 140 mL / 20 min * 10gtt/mL = 70 gtt/min

Put in order: D5W, NS, LR, D5LR, 2%NS, D5NS, D10W,1/2NS

1/2NS, D5W, D10W, LR, NS, D5LR, D5NS, 2%NS

What is the half-life of morphine sulfate?

2-4 hr

When does IV morphine peak?

20 minutes

The doctor has ordered 250mL Lactate Ringer's to run for 5 hours for a 5 year old child. The micro drip factor is 60 (60gtt/mL). Compute the flowrate.

250 mL / 300 min * 60 gtt / 1 mL = 50 gtts/ min

What is the duration of oral and IV morphine sulfate?

4-5 hours

1/2 life ketorolac

4.5hr

A nurse is caring for a 12 month old child who has been admitted to a pediatric unit for dehydration secondary to vomiting and diarrhea/ The toddler weighs 22 lb. The toddler is to receive D5 1/2 NS with 20 MEQ KCL at 4ml/kg/hr. The nurse should set the pump to deliver ___ ml per hr

40 *common question

Calculate the IV drip rate (gtt/min) for 400 ml of 0.9% NaCl over two hours. The drop factor is 20 gtt/ml.

400 mL / 120 min * 20 gtt/mL = 67 gtt/min

What is the maximum dose of hydromorphone for child and adults under 50 kg?

5 mg

Order: 1 Gm Ancef in 50ml of D5W q8h. Equipment available 20 gtts/mL To infuse in 30 minutes the nurse should regulate the infusion rate at what drop rate (gtts/min)__________________________

50 mL / 30 min * 20 gtts / mL = 33.3 = 33 gtts/min

The order reads, "800 ml D5W to infuse over 8 hours." The drop factor is 15 gtt/ml. Calculate the drip rate (gtt/min).

800 mL / 480 min * 15gtt/mL = 25 gtt/min

Pharmakokinetics furosemide

90% protein binding Mostly dealt with my the kidneys half life 30-60min

ketorolac protein bound

99%

Give dopamine 2mcg per kg per minute. Available is Dopamine 200mg in 250 mls of NS. The patient weighs 60kg. What flow rate will be set on the pump to the nearest tenth of a ml

9ml/hr

A client with type 1 diabetes mellitus is scheduled for a total hip replacement. In reviewing the client's orders the evening prior to surgery, a nurse notes that the physician did not write an order to change the client's daily insulin dose. Which nursing action is most appropriate? 1. Notify the physician who wrote the insulin order in the client's medical record. 2. Write an order to decrease the morning insulin dose by one-half of the prescribed morning dose. 3. Do nothing because the physician would want the client to receive the usual insulin dose prior to surgery. 4. Inform the day shift nurse to check the client's fingerstick glucose before surgery and hold the morning dose of insulin.

ANSWER: 1 Because the client will be NPO (nothing per mouth) for surgery, the nurse must ensure that the usual insulin dosage has been changed to prevent hypoglycemia. The change may include eliminating the rapid-acting insulin and giving a decreased amount of intermediate-acting NPH or Lente insulin. A registered nurse is unable to prescribe medications. The nurse could write the order based on standing orders, but this is not noted in the option. Doing nothing could cause a hypoglycemic reaction because the client will be NPO for surgery. Holding the morning dose of insulin can cause hyperglycemia leading to diabetic ketoacidosis. Even without food, glucose levels increase from hepatic glucose production. Clients with type 1 diabetes require insulin 24 hours a day. ➧ Test-taking Tip: Note the key words "most appropriate." Eliminate options 2 and 4 knowing that the nurse should neither write an order to change the dose nor hold the dose. Both require a physician order. Next, look at options 1 and 3. Eliminate option 3, recalling the effects of insulin when the client is NPO.

A nurse's client has requested an epidural for pain management during delivery. Which factor is associated with epidural anesthesia? 1. Need for medications to stimulate contractions 2. Decrease in incidence of vaginal operative deliveries 3. Decrease in second stage of labor 4. Increase in cesarean births

ANSWER: 1 Epidural anesthesia is associated with less pain during the intrapartum period. Women who receive epidural anesthesia are more likely to require stimulation of uterine contractions. There is an increase, not decrease, in incidence of a vaginal operative delivery, such as forceps or vacuum extraction. There is no association between cesarean births and epidural anesthesia. ➧ Test-taking Tip: Focus on the issue: risk associated with epidural anesthesia. Note that three options are similar (decrease and increase). Select the option that is different.

Which physician's order should the nurse question for a newly admitted client diagnosed with diabetic ketoacidosis (DKA)? 1. D5W at 125 mL per hour 2. KCL 10 mEq in 100 mL NaCl IV now 3. Stat arterial blood gases. Administer sodium bicarbonate if pH is less than 7.0. 4. Regular insulin infusion per protocol adjusting dose based on hourly glucose levels

ANSWER: 1 In DKA, the blood glucose level is above 300 mg/dL. Additional glucose will only increase the glucose level. Initially 0.45% or 0.9% sodium chloride (NaCl) is administered for fluid resuscitation. Glucose may be added when blood glucose levels approach 250 mg/dL. Insulin will drive potassium into the cells, so potassium chloride (KCL) is administered to prevent life-threatening hypokalemia. Normal pH is 7.35 to 7.45. Sodium bicarbonate will reverse the severe acidosis. Intravenous (IV) insulin will correct the hyperglycemia and hyperketonemia. Tight glucose control can be maintained by hourly glucose checks and adjusting the insulin infusion dose. ➧ Test-taking Tip: Note the key word "question." Select the option that would not be included in the treatment of the client with DKA.

A nurse who is initiating an intravenous infusion of lactated Ringer's (LR) for a client in shock recognizes that the purpose of LR for the client is to: 1. increase fluid volume and urinary output. 2. draw water from the cells into the blood vessels. 3. provide dextrose and nutrients to prevent cellular death. 4. replace electrolytes of sodium, potassium, calcium, and magnesium for cardiac stabilization.

ANSWER: 1 LR is an isotonic crystalloid solution containing multiple electrolytes in approximately the same concentration as plasma. It enters the cells from the blood, replacing fluids and increasing urinary output. A hypertonic solution draws fluid from the cells into the vascular compartment. LR alone does not contain dextrose. Formulations with dextrose are available. Magnesium is not a component of LR. ➧ Test-taking Tip: Apply knowledge of the components of LR and use the process of elimination. Eliminate options 3 and 4 because neither dextrose nor magnesium is a component of LR.

A nurse receives the following medication orders while caring for multiple clients. Which medication should the nurse plan to administer first? 1. Nitroglycerin (Nitrostat®) 0.4 mg sublingually (SL) stat for the client experiencing chest pain 2. Morphine sulfate 4 mg intravenously (IV) now for the client experiencing incisional pain 3. Lorazepam 2 mg IV now for the client experiencing restlessness and picking at tubing 4. One unit packed red blood cells stat for the client with a hemoglobin of 9.5 g

ANSWER: 1 Nitroglycerin increases coronary blood flow by dilating coronary arteries and improving collateral flow to ischemic areas of the heart. Increasing collateral blood flow reduces anginal pain and the potential of myocardial infarction. This action has the greatest potential of changing client outcomes and can be performed more quickly than the other actions. Both morphine and lorazepam are controlled substances, requiring the nurse to retrieve and sign these out from a secure location. Administering IV medications takes longer than SL medications. Obtaining blood from the blood bank will take longer than the time it takes to administer a SL medication. ➧ Test-taking Tip: Use the ABCs (airway, breathing, circulation) and the time it takes to implement each action to establish the priority. Because nitroglycerine affects the circulatory system, this action should be first.

A health-care provider prescribes for an 8-year-old child to receive 1 unit of aspart insulin for every 15 grams of carbohydrates consumed at mealtime. Additionally, the client is to receive insulin per the sliding scale insulin as noted below. The 8-year-old child's fingerstick blood glucose before breakfast is 82, and the child ate 30 grams of carbohydrates at breakfast. Based on this information and the sliding scale below, the nurse should administer ______ unit(s) to the child. 70-79.................. -2 and call 80-89.................. -1 90-180................. 0 181-200............... 1 201-250............... 2 251-300............... 3 More than 300... Call

ANSWER: 1 One unit of insulin aspart should be administered. The client should receive 2 units for the 30 grams of carbohydrates (CHO) minus 1 unit for the blood glucose of 82 mg/dL, for a total of 1 unit. ➧ Test-taking Tip: Carefully read what the question is asking. Be sure to note both the insulin "coverage dose" for the carbohydrate intake and the insulin "correction dose" for the blood sugar

A nurse is preparing to administer morphine sulfate intravenously for a 6-year-old child in severe pain. The child has an intravenous (IV) infusion of D5W at 50 mL/hr through a peripherally inserted central catheter (PICC). Which action is best for the nurse to take to administer the medication? 1. Dilute the morphine sulfate with 5 mL of sterile water and administer over 5 minutes into the existing IV tubing's medication port closest to the client. 2. Administer the morphine sulfate undiluted into the existing IV tubing's medication port closest to the client. 3. Question the prescribed medication because morphine sulfate cannot be administered through a central line. 4. Disconnect the infusion, inject 3 mL of normal saline, and administer the morphine sulfate undiluted.

ANSWER: 1 The nurse should dilute the morphine sulfate before administration to prevent too-rapid administration and adverse effects. A single dose should be given over 4 to 5 minutes. To avoid too-rapid administration, a syringe pump should be used. Administering undiluted morphine sulfate to a child increases the risk of adverse effects. Morphine sulfate can be administered into a PICC access device. Unnecessary IV disconnections increase the risk for infection. Morphine sulfate is compatible with D5W. ➧ Test-taking Tip: Select an option that is the most complete and the safest for the child.

A nurse is caring for a laboring client who is receiving bupivacaine (Marcaine®) per epidural route for analgesia. For which adverse effects, specific to the local anesthetic agent, should the nurse closely monitor? SELECT ALL THAT APPLY. 1. Hypotension 2. Elevated temperature 3. Slowing of the second stage of labor 4. Nausea 5. Urinary retention 6. Sedation

ANSWER: 1, 2, 3, 5 Bupivacaine is a local anesthetic agent. The medication blocks sympathetic nerve fibers in the epidural space, which causes decreased peripheral resistance. This, in turn, causes hypotension. Maternal temperature may be elevated to 100°F (37.8°C) or higher due to sympathetic blockage that may decrease sweat production and diminish heat loss. The use of epidural analgesia has been demonstrated to slow the second stage of labor. The descent of the presenting part is slowed because the medication decreases the woman's ability to push effectively. Also, relaxation of the levator ani muscle impedes internal rotation. Bupivacaine alters transmission of impulses to the bladder, thus causing urinary retention. Nausea and sedation are not side effects of bupivacaine. ➧ Test-taking Tip: Look at the suffix of the medication "-caine." This suffix is common for local anesthetic agents. Select options that would be related to this type of pain control.

A home-health nurse is planning the first home visit for a 60-year-old Hispanic client newly diagnosed with type 2 diabetes mellitus. The client has been instructed to take 70/30 combination insulin in the morning and at suppertime. Which interventions should be included in the client's plan of care? SELECT ALL THAT APPLY. 1. Instruct the client to inspect the feet daily. 2. Ensure that the client eats a bedtime snack. 3. Assess the client's ability to read small print. 4. Teach the client how to perform a hemoglobin A1c test. 5. Instruct the client on storing prefilled syringes in the refrigerator. 6. Teach the client to take one unit of 70/30 insulin after eating a snack.

ANSWER: 1, 2, 3, 5 Diabetes, diabetic complications, and increased mortality have been reported to occur at a higher rate in Hispanics compared with non-Hispanic whites of the same age. Therefore, careful daily skin assessment is necessary. Neuropathy, peripheral vascular disease, and immunocompromise can result in diabetic foot ulcer and complications. The 70/30 insulin is a combination of NPH and regular insulin. The NPH insulin will peak 4 to 12 hours after administration. A bedtime snack will cover the insulin peak to prevent hypoglycemia. Magnifying devices are available if the client is unable to read small print to prevent dosing errors. Syringes may be prefilled but should be stored in the refrigerator with the needle up. Blood is drawn in the laboratory to check the A1c. Only short-acting (regular) or rapid-acting insulin (aspart or lispro), not 70/30 insulin, would be administered to cover for additional carbohydrates if the client were on a carbohydrate-counting regimen with insulin coverage. This would be prescribed by the physician. ➧ Test-taking Tip: Focus on the situation, an older adult client with type 2 diabetes taking 70/30 insulin. Apply knowledge of care of the diabetic client and insulin types to select the correct options.

A 12-year-old child's medication regimen for treating type 1 diabetes mellitus is changed from administering NPH and rapid-acting insulin to a basal-bolus insulin regimen. To achieve tight glucose control and for therapy to be effective, the nurse should instruct that the child and/or parent to: SELECT ALL THAT APPLY. 1. administer a once daily dose of a long-acting insulin such as glargine (Lantus®). 2. administer rapid-acting insulin such as aspart (NovoLog®) with each meal and snack based on the carbohydrate grams consumed. 3. administer extra rapid-acting insulin when the amount of the child's daily exercise increases. 4. consistently count the amount of carbohydrates the child consumes throughout the day. 5. monitor the child's blood glucose four to eight times a day. 6. monitor the child's blood glucose at midnight and 3 a.m. once a week.

ANSWER: 1, 2, 4, 5, 6 With basal-bolus insulin therapy, basal insulin is administered once a day using glargine, and then a bolus of rapid-acting insulin is administered with each meal and snack based on the number of carbohydrates eaten and the child's blood glucose level. Depending on the amounts of snacks eaten, blood glucose could be monitored up to eight times a day, and the child may get six to seven injections a day. Because of the potential for hypoglycemia at night, the child's blood glucose should be monitored at midnight and 3 a.m. once a week. Exercise increases the need for carbohydrates and not insulin. ➧ Test-taking Tip: Read each option carefully. The duration of glargine insulin is 24 hours. The onset of aspart insulin is 5 to 10 minutes. Recall that aspart administration can be either subcutaneously or through an insulin infusion pump.

Nurse A is documenting administration of morphine sulfate in a client's electronic medical record (EMR). The nurse is called away to talk with a physician and quickly leaves the computer. Seeing a free computer, Nurse B selects a different client for documentation. Nurse B is also called away. Nurse A returns to the computer and completes documentation on Nurse B's client's record. Which nursing actions should have prevented this incorrect medical record entry? SELECT ALL THAT APPLY. 1. Log out of the system before leaving the computer 2. Check that the correct client is selected before beginning documentation 3. Tell Nurse B to make sure to select the right client before documenting 4. Ask another nurse to complete the documentation 5. Always log in when accessing a record 6. Always use the assigned user ID and created password when documenting in an EMR

ANSWER: 1, 2, 5, 6 Nurses should always log in with their personal user ID and password before documenting on a medical record and always log out before leaving the computer. Never use another person's computer access. Always make sure the correct client is selected. Nurse B did select the correct client, however, did not log out. A nurse should never have another nurse complete incomplete documentation. ➧ Test-taking Tip: Read each option carefully and think about actions that would prevent inappropriate documentation in an EMR. Apply knowledge of using information technology for accurate documentation.

Which instructions should the nurse provide to a client regarding diabetes management during stress or illness? SELECT ALL THAT APPLY. 1. Notify the health-care provider if unable to keep fluids or foods down. 2. Test fingerstick glucose levels and urine ketones daily and keep a record. 3. Continue to take oral hypoglycemic medications and/or insulin as prescribed. 4. Supplement food intake with carbohydrate-containing fluids, such as juices or soups. 5. When on an oral agent, administer insulin in addition to the oral agent during the illness. 6. A minor illness, such as the flu, usually does not affect the blood glucose and insulin needs.

ANSWER: 1, 3 An acute or minor illness can evoke a counterregulatory hormone response resulting in hyperglycemia, thus the client should continue medications as prescribed. If the client is unable to eat due to nausea and vomiting, dehydration can occur from hyperglycemia and the lack of fluid intake. Blood glucose should be checked every 4 hours when ill and the ketones tested every 3 to 4 hours if the glucose is greater than 240 mg/dL. The client should supplement the diet with carbohydrate-containing fluids only if eating less than normal due to the illness. Insulin may or may not be necessary; it is based on the client's blood glucose level. ➧ Test-taking Tip: Focus on the counterregulatory hormone response during an illness that causes hyperglycemia.

An adult client experiencing diabetic ketoacidosis has been admitted to an emergency department. Which interventions should a nurse initiate immediately? SELECT ALL THAT APPLY. 1. Administer oxygen. 2. Administer D5W with 0.9% NaCl solution after establishing an intravenous (IV) access. 3. Initiate a regular insulin infusion. 4. Determine the time and amount of the last insulin injection. 5. Administer potassium and magnesium to correct electrolyte imbalances. 6. Assess the client's breath for the presence of ketones.

ANSWER: 1, 3, 4 Diabetic ketoacidosis is characterized by hyperglycemia (usually above 300 mg/dL), ketosis, acidosis, and dehydration. Airway management with oxygen administration is necessary. Regular insulin infusion is initiated to lower the client's blood glucose levels. Determining the time and amount of the last insulin injection is needed to ascertain the initial starting dose of the insulin infusion. The initial IV solution is 0.9% NaCl. Once glucose levels approach 250 mg/dL (13.9 mmol/L), 5% dextrose is added. Although electrolyte imbalances occur due to the loss of electrolytes from hyperglycemic diuresis, laboratory assessment of the client's serum values should be completed first. Assessing the breath odor is an assessment not an intervention. ➧ Test-taking Tip: Note the key words, "interventions" and "immediately." Eliminate options that are assessments and those that should not be initiated immediately.

A 5-year-old client is receiving dextrose 5% in water and half-normal saline (D5 0.45 NaCl) solution at 100 mL/hr. Which findings during a nursing assessment suggest excessive parenteral fluid intake? SELECT ALL THAT APPLY. 1. Dyspnea 2. Gastric distention 3. Crackles 4. Lethargy 5. Temperature of 102°F (38.9°C) 6. Dry mucous membranes

ANSWER: 1, 3, 4 Dyspnea, crackles, and other signs of respiratory distress indicate fluid volume overload and occurs from fluid rapidly shifting between the intracellular and extracellular compartments. Lethargy and change in level of consciousness can occur from fluid shifting in brain cells. Gastric distention can occur from excessive oral fluid intake or infection. An elevated temperature and dry mucous membranes are signs of fluid volume deficit, not excess. ➧ Test-taking Tip: Eliminate options that pertain to oral fluid intake or fluid volume deficit.

A laboring client is experiencing problems, and a nurse is concerned about possible side effects from the epidural anesthetic just administered. Which problems should the nurse attribute to the epidural anesthetic? SELECT ALL THAT APPLY. 1. Controlled pain 2. Postpartum hemorrhage 3. Period of inability to move lower extremities 4. Inability to urinate 5. Maternal fever

ANSWER: 1, 3, 4, 5 Epidural anesthesia is associated with less pain during the intrapartum period. Women who receive epidural anesthesia are more likely to experience an inability to move the lower extremities, inability to urinate, and maternal fever. Postpartum hemorrhage is not associated with epidural anesthesia. ➧ Test-taking Tip: Focus on the issue: side effects of epidural anesthesia. Select the option that is not a side effect.

A client requires intravenous vancomycin (Vancocin®) for antibiotic-resistant pneumonia. The order calls for 500 mg to be administered, and the medication is supplied in a 100 mL piggyback that contains 5 mg per 1 mL to run over 1 hour. In order to administer the correct dose, a nurse should set the infusion pump to run at a rate of _____ mL per hour.

ANSWER: 100 Use the formula for calculating intravenous flow rates. Formula: Infuse rate (in mL/hour) = Volume to be infused / Infusion time 100 mL/hr = 100 mL 1 hr ➧ Test-taking Tip: Identify the volume to be infused. The time over which it needs to be infused allows for quick and easy infusion rate calculations using the equation shown.

A nurse is caring for a client recovering from surgery. Intravenous (IV) therapy is initiated to help maintain normal fluid balance. A physician orders 1,000 mL lactated Ringer's solution to be delivered over 8 hours. In order to infuse the IV fluids over 8 hours, the nurse should set the hourly infusion rate at ____ mL/hr.

ANSWER: 125 1,000 mL divided by 8 hours equals 125 mL/hour. ➧ Test-taking Tip: Read the question carefully to determine what is being asked. Remember that to determine the milliliters per hour, divide the volume to be infused by the number of hours over which it should be infused.

A client diagnosed with diabetes mellitus is on an insulin infusion drip. The insulin bag indicates there are 100 units of insulin in 1,000 milliliters (mL) of normal saline. Based on the client's blood glucose reading, the client should receive 1.5 units per hour. To ensure that the client receives 1.5 units per hour, the nurse should set the pump at ______ mL/hr.

ANSWER: 15 100 units : 1,000 mL :: 1.5 units : X mL 100X = 1,500 X = 15 ➧ Test-taking Tip: Use a drug calculation formula and the on-screen calculator and double-check the answer if it seems unusually large.

Following a normal chest x-ray for a client who had cardiac surgery, a nurse receives an order to remove the chest tubes. Which intervention should the nurse plan to implement first? 1. Auscultate the client's lung sounds 2. Administer 4 mg morphine sulfate intravenously 3. Turn off the suction to the chest drainage system 4. Prepare the dressing supplies at the client's bedside

ANSWER: 2 Because the peak action of morphine sulfate is 10 to 15 minutes, this should be administered first. Auscultating the client's lungs before and after the procedure, turning off the suction, and assembling the dressing supplies are all necessary, but administering the analgesic should be first. ➧ Test-taking Tip: Recall that focusing on the client should be the priority.

A nurse is teaching a client who has been newly diagnosed with type 2 diabetes mellitus (DM). Which teaching point should the nurse emphasize? 1. Use the arm when self-administering NPH insulin. 2. Exercise for 30 minutes daily, preferably after a meal. 3. Consume 30% of the daily calorie intake from protein foods. 4. Eat a 30-gram carbohydrate snack prior to strenuous activity.

ANSWER: 2 Exercise increases insulin receptor sites in the tissue and can have a direct effect on lowering blood glucose levels. Exercise also contributes to weight loss, which also decreases insulin resistance. Usually type 2 DM is controlled with oral hypoglycemic agents. If insulin is needed, sites should be rotated. For those with DM, protein should contribute less than 10% of the total energy consumed. Strenuous activity can be perceived by the body as a stressor, causing a release of counterregulatory hormones that subsequently increases blood glucose. Hyperglycemia can result from the combination of strenuous activity and extra carbohydrates. ➧ Test-taking Tip:The key terms are "type 2" and "emphasize." Apply knowledge of type 2 DM and eliminate options 1, 3, and 4 because type 2 diabetics will produce some insulin, and often weight reduction, calorie reduction, and exercise will help to normalize glucose levels.

A nurse, who is working the evening shift, is planning to administer insulin subcutaneously to a hospitalized child. Which statement made by the nurse to the mother would be inappropriate? 1. "It is okay for your child to say 'ouch,' cry, or even scream when receiving an injection." 2. "I can give the injection while your child is sleeping; then the injection won't be noticed." 3. "I will apply lidocaine/prilocaine (EMLA®) cream, a topical analgesic, 1 hour before the injection to reduce pain." 4. "The child will need to be lying, but after the injection you can hold and comfort your child."

ANSWER: 2 Injections should never be administered to a sleeping child because the injection is painful and the child will wake up and be terrified. Giving approval for the child to vent his or her feelings provides the child with a better sense of control. EMLA® cream can reduce the pain with insertion, but pain may still be felt as the medication is injected. The child can be lying flat during the injection. ➧ Test-taking Tip:The key word is "inappropriate."

A client admitted with a diagnosis of acute coronary syndrome calls for a nurse after experiencing sharp chest pains that radiate to the left shoulder. The nurse notes, prior to entering the client's room, that the client's rhythm is sinus tachycardia with a 10-beat run of premature ventricular contractions (PVCs). Admitting orders included all of the following interventions for treating chest pain. Which should the nurse implement first? 1. Obtain a stat 12-lead electrocardiogram (ECG). 2. Administer oxygen by nasal cannula. 3. Administer sublingual nitroglycerin. 4. Administer morphine sulfate intravenously.

ANSWER: 2 Oxygen should be available in the room and should be initiated first to enhance oxygen flow to the myocardium. Though a stat 12-lead ECG is needed to identify ischemia or infarct location, the first action is to treat the client. Sublingual nitroglycerin dilates coronary arteries and will enhance blood flow to the myocardium. Once oxygen is in place and the vital signs known, nitroglycerin should be administered. Morphine sulfate is a narcotic analgesic used for pain control and anxiety reduction. Because it is a controlled substance, extra steps are needed to retrieve the medication from a secure source, so this is not the first action. ➧ Test-taking Tip: Use the ABCs (airway, breathing, circulation) to establish the priority action. Improving oxygen flow to the myocardium is priority.

A client diagnosed with hyperglycemia is receiving a continuous intravenous (IV) insulin drip. Blood glucose measures are being taken every 1 to 2 hours. A nurse checks the client's blood glucose, and the reading is 32 mg/dL. The client, who was previously alert, is now lethargic and does not respond to questions. The nurse administers 25 mL of D50W per protocol. The client begins to respond. Which additional risk-management action should be taken by the nurse? 1. Continue the insulin drip 2. Report the event to the nurse manager 3. Recheck the blood glucose measure in 1 hour 4. Administer a second dose of 25 mL of D50W

ANSWER: 2 Safety events must be reported to the nurse manager. Risk management seeks to identify and eliminate potential safety hazards. The monitoring and medication protocol may need revision based on changes in the client's status and correlating blood glucose results. Reporting the client's hypoglycemia to the nurse manager will result in the monitoring of patterns and trends, and possibly regulatory reporting. Some states require reporting of hypoglycemia that leads to client injury or death. To continue the insulin drip would result in client injury. Waiting 1 hour is too long to determine if the client is still hypoglycemic. A second dose of D50W should not be given without first assessing the client's response and taking another blood glucose measurement. ➧ Test-taking Tip:The key words "risk management action" include appropriate follow-up and reporting. Eliminate options that pertain only to the client.

A nurse is caring for a 5-year-old child from Italy. The child is crying and the interpreter is stating that the child has extreme pain. The nurse's first priority should be to: 1. have the child's mother who knows limited English ask the child what hurts. 2. assess the level of the child's pain using an appropriate FACES pain rating scale. 3. administer morphine sulfate 1 mg IV as prescribed. 4. call the health-care provider to request a change in pain medication dosage as it is not adequately controlling the child's pain.

ANSWER: 2 The FACES pain-rating scale has been translated to a variety of languages. The nurse's judgment regarding the choice of pain medication and dose should be based on the reported level of pain. If possible, the nurse should do an independent assessment because sometimes information can be misinterpreted if there is limited knowledge of the language. Assessment should be completed prior to a pain intervention. There is no information indicating the need for the pain medication to be changed. ➧ Test-taking Tip: Note the key word "priority." Use the nursing process. Assessment is the first step.

A health-care provider (HCP) writes the following orders for a client admitted in sickle cell crisis: "oxygen 2L/NC, one unit MS 4 mg IV now, one unit packed red blood cells, and hydroxyurea (Hydrea®) 250 mg oral daily." In response to these orders, what action should a nurse take? 1. Initiate all orders as prescribed 2. Call the HCP to clarify the MS order 3. Prepare 4 mg MS for administration after initiating the oxygen 4. Verify with another nurse that MS should be morphine sulfate based on this client's condition

ANSWER: 2 The abbreviation MS is on the "do not use" list of abbreviations by The Joint Commission (formerly the Joint Commission on Accreditation of Healthcare Organizations [JCAHO]). It could be interpreted as morphine sulfate or magnesium sulfate. Initiating all orders, preparing and administering MS, or verifying the abbreviations MS with another nurse are unsafe actions. ➧ Test-taking Tip: Carefully read each prescribed order, noting that all would be appropriate for a client in sickle cell crisis except MS. MS could be either morphine sulfate (which is appropriate) or magnesium sulfate (which would be inappropriate).

A nurse administers 15 units of glargine (Lantus®) insulin at 2100 hours to a Hispanic client when the client's fingerstick blood glucose reading was 110 mg/dL. At 2300 hours, a nursing assistant reports to the nurse that an evening snack was not given because the client was sleeping. Which instruction by the nurse is most appropriate? 1. "You will need to wake the client to check the blood glucose and then give a snack. All diabetics get a snack at bedtime." 2. "It is not necessary for this client to have a snack because glargine insulin is absorbed very slowly over 24 hours and doesn't have a peak." 3. "The next time the client wakes up, check a blood glucose level and then give a snack." 4. "I will need to notify the physician because a snack at this time will affect the client's blood glucose level

ANSWER: 2 The onset of glargine is 1 hour, it has no peak, and it lasts for 24 hours. Glargine lowers the blood glucose by increasing transport into cells and promoting the conversion of glucose to glycogen. Because it is peakless, a bedtime snack is unnecessary. Options 1 and 3 are unnecessary and option 4 is incorrect. Glargine is administered once daily, the same time each day, to maintain relatively constant concentrations over 24 hours. ➧ Test-taking Tip: Apply knowledge of the action of glargine insulin.

A nurse administers a usual morning dose of 4 units of regular insulin and 8 units of NPH insulin at 7:30 a.m. to a client with a blood glucose level of 110 mg/dL. Which statements regarding the client's insulin are correct? 1. The onset of the regular insulin will be at 7:45 a.m. and the peak at 1:00 p.m. 2. The onset of the regular insulin will be at 8:00 a.m. and the peak at 10:00 a.m. 3. The onset of the NPH insulin will be at 8:00 a.m. and the peak at 10:00 a.m. 4. The onset of the NPH insulin will be at 12:30 p.m. and the peak at 11:30 p.m.

ANSWER: 2 The onset of regular insulin (short-acting) is one-half to 1 hour, and the peak is 2 to 3 hours. The onset of NPH insulin (intermediate acting) is 2 to 4 hours, and the peak is 4 to 12 hours. All other options have incorrect medication onset and peak times. ➧ Test-taking Tip: Apply knowledge of insulin onset and peak times.

A nurse working on a telemetry unit is planning to complete noon assessments for four assigned clients with type 1 diabetes mellitus. All of the clients received subcutaneous insulin aspart (NovoLog®) at 0800 hours. In which order should the nurse assess the clients? Place each answer option into the correct order. _____ A 60-year-old client who is nauseous and has just vomited for the second time _____ A 45-year-old client who is dyspneic and has chest pressure and new onset atrial fibrillation _____ A 75-year-old client with a fingerstick blood glucose level of 300 mg/dL _____ A 50-year-old client with a fingerstick blood glucose level of 70 mg/dL

ANSWER: 2, 1, 3, 4 First, the nurse should assess the client with new onset atrial fibrillation and dyspnea. Diabetes increases the risk of coronary artery disease and myocardial infarction. Next, assess the client who just vomited. The client with a 300 mg/dL blood glucose level should then be assessed. This blood glucose level is not immediately life-threatening, but needs to be lowered as soon as possible. The client with the blood glucose level of 70 mg/dL can be assessed last because this is a normal blood glucose level. ➧ Test-taking Tip: Use the ABC's (airway, breathing, circulation) to establish the priority client. Then, look at the information provided for each client to determine the next priority. Consider that all clients received insulin at 0800 hours.

A nurse in the Post-Anesthesia Care Unit (PACU) is caring for a client who received general anesthesia. Which interventions should the nurse implement when caring for this client? SELECT ALL THAT APPLY. 1. Teach the client how to use an incentive spirometer 2. Move the client into a lateral position to protect the airway 3. Administer morphine sulfate intravenously (IV) for pain control 4. Protect IV lines to prevent dislodgement during emergence delirium 5. Repeat orientation explanations until the amnesiac anesthesia wears of

ANSWER: 2, 3, 4, 5 Unless contraindicated, the side-lying position will prevent aspiration of secretions. Turning also will mobilize secretions. Analgesics are administered IV in the PACU for a rapid onset in controlling pain. Some clients emerge from anesthesia in an agitated state for a short period of time. This is termed emergence delirium. Amnesiac anesthesia causes a loss of memory. Repeat explanations such as "Mr. Brown, surgery is over; you are in the recovery room." The client would not be alert enough to be able to comprehend using the incentive spirometer and would not be ready to sit up to use it. ➧ Test-taking Tip: Visualize a client recovering from anesthesia and use the ABCs (airway, breathing, circulation) and Maslow's Hierarchy of Needs theory to assist in identifying appropriate interventions.

A nurse is teaching a client newly diagnosed with chronic stable angina. Which instructions should the nurse incorporate in the teaching session on measures to prevent future angina? SELECT ALL THAT APPLY. 1. Increase isometric arm exercises to build endurance. 2.Wear a face mask when outdoors in cold weather. 3. Take nitroglycerin before a stressful situation even though pain is not present. 4. Perform most exertional activities in the morning. 5. Avoid straining at stool. 6. Eliminate tobacco use.

ANSWER: 2, 3, 5, 6 Blood vessels constrict in response to cold and increase the workload of the heart. Sexual activity and straining at stool increases sympathetic stimulation and cardiac workload. Nitroglycerin produces vasodilation and improves blood flow to the coronary arteries; it can be used prophylactically to prevent angina. Nicotine stimulates catecholamine release, producing vasoconstriction and an increased heart rate. Isometric exercise of the arms can cause exertional angina. Exertional activity increases the heart rate, thus reducing the time the heart is in diastole, when blood flow to the coronary arteries is the greatest. A period of rest should occur between activities and activities should be spaced. ➧ Test-taking Tip:The key phrase is "measures to prevent future angina." Consider if each option could potentially increase myocardial oxygen demand or decrease available oxygen, either of which could precipitate angina.

A nurse is caring for a group of clients all in need of pain medication. The nurse has determined the most appropriate pain medication for each client based on the client's level of pain. Prioritize the order in which the nurse should plan to administer the pain medications beginning with the analgesic for the client with the most severe pain. ______ Ketorolac (Toradol®) 10 mg oral ______ Fentanyl (Sublimaze®) intravenously (IV) per patient-controlled analgesia (PCA) with a bolus dose ______ Hydromorphone (Dilaudid®) 5 mg oral ______ Morphine sulfate 4 mg IV ______ Propoxyphene (Darvon®) 65 mg oral

ANSWER: 2, 4, 3, 1, 5 The most potent of the medications is fentanyl (Sublimaze®), an opioid narcotic analgesic that binds to opiate receptors in the central nervous system (CNS), altering the response to and perception of pain. A dose of 0.1 to 0.2 mg is equivalent to 10 mg of morphine sulfate. Morphine sulfate is also an opioid analgesic. Hydromorphone, another opioid analgesic, would be third in priority. The oral dosing of this medication would indicate that the client's pain is less severe than the client receiving fentanyl or morphine sulfate. Hydromorphone 7.5 mg oral is an equianalgesic dose to 30 mg of oral morphine or 10 mg parenteral morphine. Ketorolac is a NSAID and nonopioid analgesic that inhibits prostaglandin synthesis, producing peripherally mediated analgesia. Propoxyphene is last in priority. It also binds to opiate receptors in the CNS but is used in treating mild to moderate pain. It has analgesic effects similar to acetaminophen. ➧ Test-taking Tip: Focus on ordering the medications starting with the most potent opioid analgesics and ending with the nonopioid analgesic.

A nurse is hanging an intravenous (IV) solution of D5NS with 20 mEq of KCL. The nurse notices the label from the pharmacy is correct as indicated; however, the solution is D5W. Which actions should be taken by the nurse to safely administer the IV infusion? SELECT ALL THAT APPLY. 1. Check for one unique client identifier before administration 2. Consult the supervisor 3. Administer the IV solution 4. Call the pharmacist 5. First, initiate the new stat orders for another client 6. Know the organization's policy for medication administration

ANSWER: 2, 4, 6 Safe medication practices include knowing the organization's policy for medication administration and knowing what actions to take in the event of a potential error. This includes consulting the supervisor or calling the pharmacist. Although it is important to always check for two unique identifiers, that action will not prevent the medication error. The IV solution should not be administered since it is not the correct solution. Distractions, such as the assignment of another client with stat orders, may result in forgetting to clarify the IV solution. ➧Test-taking Tip: Note that the IV solution is incorrect; identify actions to prevent the error.

A charge nurse is reviewing documentation completed by a registered nurse (RN) and evaluating delegation abilities to a licensed practical nurse (LPN) and nursing assistant (NA). Which medical record documentation should the charge nurse determine may have occurred because of inappropriate delegation? Client Narrative Notes 1 0800 BP elevated at 150/90 mm Hg (obtained per J. Brown, NA). Client rates right shoulder incisional pain at 10/10. Morphine sulfate given intravenously for pain control. __________________________ M. Drew, RN. 2 1000 Assisted up to the bathroom per J. Brown, NA. Voided cloudy, foul-smelling urine. Urine output 20 mL/hr for past 4 hr. Dr. Peters notified. __________________________ M. Drew, RN. 3 1200 Fingerstick blood glucose 55 mg/dL (taken per J. Brown, NA). Given 4 units lispro (Humalog®) insulin subcut as ordered before lunch. __________________________ A. Smith, LPN 4 1400 Ambulated 100 feet in hallway. Assisted with hygiene while sitting in chair per RN direction. Hygienic care refused earlier due to fatigue. __________________________ J. Brown, NA

ANSWER: 3 Appropriate delegation includes assessing the knowledge and skill of the delegate. A glucose level of 55 mg/dL is low (normal = 70-110 mg/dL) and rapid-acting lispro insulin should not have been administered. There is no indication that the LPN notified the RN of the abnormal findings. Taking a blood pressure and reporting the findings to the RN is evident in option 1. Administering intravenous medications is within the RN scope of practice. Assisting a client to the bathroom is an appropriate task for the NA, reporting to the RN the findings is evident, and the RN's role in calling the physician is appropriate. Assisting a client with activity and hygienic care is appropriate NA tasks and reporting of refused hygienic care is evident. Documenting completion of tasks is appropriate for the NA. The location of documentation of task completion may vary by facility and may include only a flowsheet or narrative documentation. ➧ Test-taking Tip: Carefully read each option. Consider the RN's responsibility in assessing the knowledge and skills of the delegate.

The parents of a 7-year-old child diagnosed with type 1 diabetes mellitus are planning to drive 1,200 miles for a vacation at the beach. They question the nurse about insulin storage for the trip. Which response by the nurse is most accurate? 1. "Because insulin must be refrigerated, you will need to obtain the medication from a pharmacy at your destination." 2. "Freeze the insulin before you leave home and take it in a cooler; it should be thawed by the time you get to the beach." 3. "Keep the insulin in a cooler with an ice pack and out of direct heat and sunlight for the trip. Store unopened insulin in the refrigerator at your destination." 4. "Because it is illegal to transport needles and syringes across most state lines, you will need to obtain a prescription from your doctor and purchase the insulin and the syringes at your destination."

ANSWER: 3 Because insulin should be kept out of direct sunlight and extreme heat, it should be transported in a cooler with an ice pack. Insulin is destroyed when frozen. Although it is not illegal to transport needles and syringes, the child should have a prescription to identify the medication and justify the syringes. The prescription also provides a means to obtain additional supplies if needed. ➧ Test-taking Tip: Focus on what the question is asking: insulin storage. Eliminate options 1 and 4 because these responses do not address insulin storage. Decide the best option, 2 or 3. Note that option 3 is more complete, thus eliminate option 2.

A registered nurse (RN) assesses that a client is pale, diaphoretic, dyspneic, and experiencing chest pain. Which actions are best for the nurse to take? 1. Stay with the client, call the charge nurse for help, and call the patient care assistant (PCA) to bring an automatic vital signs machine to the room immediately. 2. Call the PCA to take the client's vital signs while the RN leaves to obtain a narcotic analgesic for administration and notify the charge nurse. 3. Apply oxygen, call the PCA to bring an automatic vital signs machine, and call the charge nurse for help and ask to bring the chart and morphine sulfate noted on the medication record. 4. Activate the emergency system for a code to get immediate help, apply oxygen, and send responders for needed equipment and medication.

ANSWER: 3 Because the client is in distress, the RN should stay with the client, apply oxygen, and obtain help from other members of the health-care team. Asking the charge nurse to bring the chart and morphine sulfate, or other medications noted in the chart, will save time in responding to the situation. The charge nurse should delegate locating the chart and obtaining the medication to another nurse. In option 1 the charge nurse is responding, but then either the nurse or the charge nurse would need to leave the room to obtain needed medication, causing a loss of time in treating the client's pain. In option 2 the RN leaves the room but should have stayed, as the client is in distress. In option 4, the code system should only be activated if the client's pulse or respirations are absent because activation will bring members from multiple departments. Some facilities have an acute response team (ART), which has a different composition of personnel who can respond in emergency situations. ➧ Test-taking Tip: Read each option carefully and systematically. Eliminate any options that allow the nurse to leave the room. Use the ABCs (airway, breathing, circulation) to establish the priority intervention for the RN.

A nurse is caring for a client who has 0.9% NaCl infusing intravenously (IV). An order had been written the previous day to change the IV solutionto 0.9% NaCl with 10 mEq KCL. Which action should the nurse initiate first? 1. Notify the client's physician 2. Complete an incident report 3. Check the client's serum potassium level 4. Replace 0.9% NaCl with the ordered solution

ANSWER: 3 Because the order was written the previous day and not implemented, the nurse should first check the client's serum potassium level and then notify the physician. The nurse should determine if there are order changes before replacing the solution. The physician may change the amount of KCL in the IV solution based on the client's serum potassium level and other client data. An incident report should be completed by the nurse after caring for the client.

A 9-year-old child with a history of type 1 diabetes mellitus for the past 6 years is admitted with a diagnosis of diabetic ketoacidosis (DKA). In preparing for the child's arrival to the nursing unit, the nurse should prepare to: 1. add sodium bicarbonate to the current IV fluids. 2. add potassium chloride to the current IV fluids. 3. use either 0.9% or 0.45% saline for the base IV fluid. 4. administer insulin by subcutaneous injection

ANSWER: 3 Both water and sodium are depleted in DKA, thus the child will require intravenous saline. Research has shown no benefit to giving sodium bicarbonate to children with DKA to reverse metabolic acidosis. Potassium is added only after laboratory studies have confirmed that the plasma potassium is low. Usually there is not a drop in plasma potassium. Insulin is always given IV in DKA for rapid effect and close monitoring. Insulin onset by subcutaneous route is 15 to 30 minutes and can cause hypoglycemia from potential excessive dosing when attempting to reduce the hyperglycemia. ➧ Test-taking Tip: Recall that high blood glucose levels causes osmotic diuresis and the loss of fluids. DKA is a life-threatening condition, and the nurse needs to be ready to act when the child is admitted.

A clinic nurse is evaluating a client with type 1 diabetes who intends to enroll in a tennis class. Which statement made by the client indicates that the client understands the effects of exercise on insulin demand? 1. "I will carry a high-fat, high-calorie food, such as a cookie." 2. "I will administer 1 unit of lispro insulin prior to playing tennis." 3. "I will eat a 15-gram carbohydrate snack before playing tennis." 4. "I will decrease the meal prior to the class by 15-grams of carbohydrates."

ANSWER: 3 Excessive exercise without sufficient carbohydrates can result in unexpected hypoglycemia. The food should be a simple sugar food because the fat content of a high-fat food will delay the absorption of the glucose in the food. Taking insulin or decreasing the carbohydrate intake prior to activity will lower the blood glucose level such that hypoglycemia can occur. ➧ Test-taking Tip: Recall that type 1 diabetes mellitus requires daily insulin administration and that activity increases energy expenditure and the demand for glucose.

A nurse is evaluating a client's outcome. The client's nursing care plan includes the nursing diagnosis of fluid volume deficit related to hyperosmolar hyperglycemic nonketotic syndrome (HHNS) secondary to severe hyperglycemia. The nurse knows that the client has a positive outcome when which serum laboratory value has decreased to a normal range? 1. Glucose 2. Sodium 3. Osmolality 4. Potassium

ANSWER: 3 Extreme hyperglycemia produces severe osmotic diuresis; loss of sodium, potassium, and phosphorous; and profound dehydration. Consequently, hyperosmolality occurs. A normalizing of the serum osmolality indicates that the fluid volume deficit is resolving. A decrease in serum glucose indicates that the hyperglycemia is resolving, but not the fluid volume deficit. Serum sodium and potassium values should increase, not decrease, with treatment. ➧ Test-taking Tip: Focus on the issue: deficient fluid volume.

Two hours after taking a regular morning dose of Insulin Regular (Humulin R®), a client presents to a clinic with diaphoresis, tremors, palpitations, and tachycardia. Which nursing action is most appropriate for this client? 1. Check pulse oximetry and administer oxygen at 2 L per nasal cannula. 2. Administer a baby aspirin, one sublingual nitroglycerin tablet, and obtain an electrocardiogram (ECG). 3. Check blood glucose level and provide carbohydrates if less than 70 mg/dL (3.8 mmol/L). 4. Check vital signs and administer atenolol (Tenormin®) 25 mg orally if heart rate is greater than 120 beats per minute.

ANSWER: 3 Humulin R is regular insulin that peaks in 2 to 4 hours after administration. The client's symptoms suggest hypoglycemia, so a blood glucose level should be checked. The symptoms do not suggest a respiratory problem (option 1). Though diaphoresis, palpitations, and tachycardia are symptoms of both hypoglycemia and cardiac problems, the client had taken insulin 2 hours earlier. Treating the low blood sugar first will likely resolve the client's symptoms. ➧ Test-taking Tip: Focus on the effects of Humulin R and the client's symptoms.

A health-care provider's (HCPs) progress notes state a plan to initiate an oral NSAID for a child's pain. Based on this information, a nurse should consult with the HCP when noting that which medication was prescribed? 1. Acetaminophen (Tylenol®) 2. Tolmetin (Tolectin®) 3. Hydromorphone (Dilaudid®) 4. Naproxen (Naprosyn®)

ANSWER: 3 Hydromorphone is an opioid analgesic, not an NSAID. Acetaminophen, tolmetin, and naproxen are all NSAIDs. ➧ Test-taking Tip: This is a false-response item; select the medication that is not an NSAID.

The mother of a 12-year-old child diagnosed with type 1 diabetes mellitus asks a nurse what changes in the daily routine should be made during attendance at summer camp. The child will be at camp for 4 weeks. Which is the best response by the nurse? 1. "The child will have an increased need for insulin due to the high carbohydrate content of camp food." 2. "The child's food intake should be decreased by 10% while the insulin should be increased by 10%." 3. "The child's food intake should be increased as activity increases; monitor blood glucose levels three to four times a day to evaluate results." 4. "The child's insulin injection should be given before every meal and snack to ensure that the food being consumed at camp can be utilized by the body."

ANSWER: 3 Increases in muscle activity promote a more efficient utilization of glucose. School-aged children are more physically active in the summer months than during the school year. An increase of insulin with an increase in physical activity and/or a decrease in food consumption will result in profound hypoglycemia. Giving regular insulin before every meal and snack is an option for older individuals who are usually engaged in regular, high-intensity physical activity; it would not be recommended for a 12-year-old child attending 4 weeks of camp. ➧ Test-taking Tip: Knowledge of the physiological mechanism of insulin utilization by the body is needed, as well as the relationship of food to insulin needs and the metabolic needs of a 12-year-old child.

A nurse completes teaching insulin administration to the parent of a toddler newly diagnosed with type 1 diabetes mellitus. The nurse concludes that the teaching was successful when the parent states: 1. "NPH insulin (Humulin N®) is only given at night immediately before the bedtime snack." 2. "It is okay to use only the buttocks for the insulin injections until the child is older." 3. "Insulin lispro (Humalog®) acts within 15 minutes and peaks 30 to 90 minutes after injection." 4. "Insulin detemir (Levenir®) can be added to the insulin lispro (Humalog®) pen to reduce the number of injections."

ANSWER: 3 Lispro is rapid-acting insulin that peaks in 30 to 90 minutes and may last as long as 5 hours in the blood. NPH insulin can be given in the morning, but there is better glucose control if given at night. NPH peaks in 4 to 14 hours, so there is no need to make sure food is available immediately after administration. Insulin injections should always be rotated to prevent subcutaneous tissue damage from giving the injections in the same location. Detemir is long-acting and lispro is rapid-acting insulin. An insulin pen uses pre-filled, multiple-use insulin cartridges; adding other types of insulins should not be attempted.

A 76-year-old client, hospitalized for cancer treatment, has an emergency bowel resection for a bowel obstruction. Four hours postoperatively, the client is experiencing pain. A nurse has the choice of standing postoperative pain orders or standing orders for cancer clients (protocol orders) of which all medications are listed on the client's medication administration record. Which medication should the nurse initially select to treat the client's postoperative pain? 1. Meperidine (Demerol®) 75 mg IM 2. Fentanyl (Duragesic®) transdermal patch 50 mcg/hr 3. Morphine sulfate (Duramorph®) 4 mg IVP q3-4h prn 4. Hydromorphone (Dilaudid®) continuous infusion 15 to 30 mg/hr

ANSWER: 3 Morphine sulfate is recommended for severe, acute pain. It alters the client's perception and response to painful stimuli while producing generalized CNS depression. Meperidine has been reported to cause delirium in the elderly; older adults are at increased risk for meperidine toxicity. Fentanyl is recommended for moderate to severe chronic pain requiring continuous opioid analgesic therapy. Hydromorphone will take additional time to prepare; although it is a good option to obtain the medication for later dosing. Starting at the lowest dose (15 mg/hr) is recommended for older adult clients. ➧ Test-taking Tip: Knowledge of analgesics for older adults is necessary to answer this question. If unsure, use the process of elimination, eliminating options 2 and 4 because of the longer time of onset and the client is in acute pain.

A terminally ill, 46-year-old client has an order for morphine sulfate 2 mg to 6 mg intravenously (IV) every 2 hours prn for pain. A nurse administers 2 mg for the first dose, but after 20 minutes the client has no relief and experiences no side effects. What is the nurse's best action? 1.Wait until the 2 hours has elapsed from the time the 2 mg morphine sulfate was administered before giving additional medication, but implement complementary measures for pain control. 2. Call the physician to determine if additional medication can be administered now, since the client had inadequate pain relief. 3. Administer 4 mg of morphine sulfate at the peak effect of the first dose, which would be 20 minutes after the first dose. 4. Repeat the 2 mg of morphine sulfate now and, if not effective, administer the additional 2 mg in 15 minutes.

ANSWER: 3 The client has a range order for morphine sulfate. The total dose is 6 mg in a 2-hour period. Since the client had no relief after 15 minutes and no side effects, 4 mg should be administered to maximize pain control. The peak time for morphine sulfate administered IV is 20 minutes. Complementary measures can be used to distract the client from pain but should not replace analgesic medications for pain control. It is unnecessary to call the physician because the ordered dose is up to 6 mg in 2 hours. The initial dose of 2 mg did not relieve the client's pain; giving an additional 2 mg now and then waiting will only delay when the client can receive the next maximum dose of the medication for adequate pain control. ➧ Test-taking Tip: Recognize that the morphine sulfate has been ordered as a range order. Carefully consider the data in the situation.

An adolescent client is taught how to use a continuous subcutaneous insulin infusion pump for tight glucose control of type 1 diabetes mellitus. Which statement by the client indicates the need for additional teaching? 1. "I can put in the number of carbohydrates that I consume, and the insulin pump will calculate the bolus insulin dose that I will receive." 2. "I must still check my blood glucose levels with meals and snacks and calculate the amount of carbohydrates I consume to ensure I get the correct bolus dose of insulin." 3. "As my blood glucose control improves with the use of the insulin pump, I should see a drop in the weight that I have gained." 4. "Every 2 to 4 days, I will need to change the syringe, catheter, and site moving the site away at least 1 inch from the last site."

ANSWER: 3 Weight gain, and not weight loss, commonly occurs as blood glucose control improves. Newer pumps calculate bolus insulin dose to the carbohydrates consumed. Monitoring blood glucose levels and carbohydrates consumed is still necessary with an insulin pump. About every 2 to 4 days when a syringe is empty, a new syringe and tubing is attached to the pump along with a new skin setup. The site is also changed to prevent lipoatrophy. ➧ Test-taking Tip:The key phrase "need for additional teaching" indicates that this is a false-response question. Select the option that is incorrect. Note that options 1, 2, and 4 relate to the pump operation, whereas option 3 is different. Often the option that is different is the answer.

A nurse is planning the care of a 2-hour-old infant at 38 weeks gestation whose mother has type 1 diabetes mellitus. The nurse writes the following NANDA diagnosis: "Altered Nutrition: less than body requirements" and appropriately adds which "related to" statement? 1. Decreased amounts of red blood cells secondary to low erythropoietin levels 2. Decreased amounts of total body fat secondary to decreased growth hormone 3. Increased glucose metabolism secondary to hyperinsulinemia 4. Increased amounts of body water

ANSWER: 3 While in utero, the fetus of a diabetic mother is exposed to high levels of maternal glucose. Hyperplasia of the fetal pancreas occurs resulting in hyperinsulinemia. When the fetus is born, the glucose supply from the mother is disrupted and the neonate's blood sugar falls rapidly in response to the corresponding high levels of circulating insulin. The infant of an insulin-dependent mother (IDM) has increased amounts of red blood cells (RBCs) because hemoglobin A1c binds to oxygen, decreasing the oxygen available to the fetal tissues. This tissue hypoxia stimulates increased erythropoietin production, which stimulates RBC production. The IDM has increased amounts of body fat as a result of hyperinsulinemia, which converts glucose to adipose tissue and stimulates production of pituitary growth hormone. IDMs have decreased total body water, particularly in the extracellular spaces. ➧ Test-taking Tip: Recall the physiology of diabetes and the adaptations made by the IDM

A nurse is instructing a client diagnosed with coronary artery disease about care at home. The nurse determines that teaching is effective when the client states: SELECT ALL THAT APPLY. 1. "If I have chest pain, I should contact my physician immediately." 2. "I should carry my nitroglycerin in my front pants pocket so it is handy." 3. "If I have chest pain, I stop activity and place one nitroglycerin tablet under my tongue." 4. "I should always take three nitroglycerin tablets, 5 minutes apart." 5. "I plan to avoid being around people when they are smoking." 6. "I plan on walking on most days of the week for at least 30 minutes."

ANSWER: 3, 5, 6 Stopping activity decreases the body's demand for oxygen. One nitroglycerin tablet, taken sublingually, dilates the coronary arteries and increases oxygen to the myocardium. If pain is unrelieved, a second tablet should be taken 5 minutes later. Passive smoke can cause vasoconstriction and decrease blood flow velocity even in healthy young adults. The American Heart Association recommends exercising for 30 minutes on most days of the week. Medical attention is required only if pain persists and then the client should call 911 rather than the physician because emergency treatment may be necessary. Nitroglycerin loses its potency if stored in warm, moist areas, making the client's pants pocket an undesirable location for storage. If pain is relieved after one tablet, another tablet is not required. The standard dose for nitroglycerin is one tablet or spray 5 minutes apart until pain is relieved, to a maximum of three tablets. ➧ Test-taking Tip:The key words are "teaching is effective." Select the client statements that are correct.

A male client confides to a clinic nurse that he is no longer dyspneic after receiving his new St. Jude's heart valve. He wants to have a vasectomy so that he can enjoy sexual intercourse again without the fear of his wife becoming pregnant. What is the nurse's best response? 1. "That's probably a good idea. The life expectancy after heart valve replacement is 10 to 15 years." 2. "You seem relieved that the heart valve replacement was successful and that you can enjoy a normal life again." 3. "If you have cardiac symptoms such as dyspnea during sexual intercourse, you can take a nitroglycerin tablet before sexual activity to prevent symptoms." 4. "Be sure to inform the physician that you have an artificial heart valve so you are given antibiotics as a preventive measure before the procedure."

ANSWER: 4 A St. Jude's valve is an artificial heart valve. Antibiotics are required prior to invasive procedures to prevent complications such as endocarditis. The physician also needs to know that the client has an artificial heart valve because the client should be receiving anticoagulants and there is the risk of increased bleeding. As long as the person receives regular follow-up with a health-care provider, the person can expect a normal life expectancy. Although mechanical valves are durable, they may need replacement in 10 to 15 years. Although responding that the client seems relieved is a therapeutic response, it is not the best response, because the client needs teaching. Nitroglycerin is not prescribed for persons with valvular heart disease unless the person also has coronary artery disease; thus he would not have nitroglycerin available. ➧ Test-taking Tip:The key terms in the stem are "vasectomy" and "heart valve." Recall that antibiotics are prescribed prophylactically prior to invasive procedures.

A nurse assesses a client 6 hours postoperatively following a lumbar spinal fusion. The client is experiencing a headache rated at 8 out of 10 but denies nausea. The neurovascular status of the lower extremities is intact, and the vital signs are within the normal range. The client log rolls with assistance. The lungs have fine crackles in the left base. The back dressing has a dime-sized bloody spot surrounded by a moderate amount of clear yellowish drainage. Which nursing action demonstrates the nurse's best clinical judgment? 1. Administering morphine sulfate intravenously 2. Encouraging coughing and deep breathing 3. Reinforcing the incisional dressing 4. Notifying the client's physician

ANSWER: 4 A bloody area surrounded by clear yellowish fluid on the dressing and the client's headache suggest a cerebral spinal fluid leak, a complication following spinal fusion. The client may need to be kept on bedrest for a few days while the dural tear heals or may need a blood patch to seal the leak because the client is at risk for a central nervous system infection. All other actions are correct and should also be implemented. ➧ Test-taking Tip: Focus on the data and what the question is asking: "the best clinical judgment."

A client is being admitted to a postsurgical unit following anorectal surgery. A nurse reviews the following postoperative orders from the surgeon. Which order should the nurse question? 1. Administer morphine sulfate per intravenous bolus before the first defecation 2. Administer sitz bath after each defecation 3. Begin high-fiber diet as soon as client can tolerate oral intake 4. Position client in supine position with the head of the bed elevated to 30 degrees.

ANSWER: 4 After anorectal surgery, the client should be positioned in a side-lying position to decrease rectal edema and client discomfort. Pain medication is recommended before the first defecation, and a sitz bath is encouraged for rectal cleansing after defecation. Prevention of constipation with a high-fiber diet is also recommended.

A nurse is reviewing orders received for a newly admitted child with second- and third-degree burns over 10% of the total body surface area (TBSA). The child weighs 20 kg. The nurse should seek further clarification from a physician when the physician's order is: 1. Ringer's lactate (RL) at 50 mL per hour for the next 8 hours. 2. insert a urinary catheter. 3. elevate the extremities above the level of the heart. 4. morphine sulfate IV prn for pain control.

ANSWER: 4 Because the order for morphine sulfate does not state a dose, the order should be clarified with the physician. If the physician intended the dose to be based on the weight of the child, then this should be included in the order. In the first 24 hours, fluid resuscitation is 4 mL/kg body weight per percentage of burn TBSA, with half over the first 8 hours and the remaining over the next 16 hours (4 mL X 20 kg = 80 mL; 80 mL X 10 = 800 mL for 24 hours; half of this is 400 mL over 8 hours; 400 ÷ 8 = 50 mL). A Foley urinary catheter is inserted so that urine output can be closely monitored as a guide for volume status. During the resuscitation phase, edema formation can decrease perfusion. Elevating the limbs above the heart level promotes gravity-dependent drainage. ➧ Test-taking Tip: Carefully read each option. Avoid reading into any option choice.

A nurse is caring for a client with type 2 diabetes on a telemetry unit. The client is scheduled for cardiac rehabilitation exercises (cardiac rehab). The nurse notes that the client's blood glucose level is 300 mg/dL and the urine is positive for ketones. Which nursing action should be included in the nurse's plan of care? 1. Send the client to cardiac rehab because exercise will lower the client's blood glucose level. 2. Administer insulin and then send the client to cardiac rehab with a 15-gram carbohydrate snack. 3. Delay the cardiac rehab because blood glucose levels will decrease too much with exercise. 4. Cancel the cardiac rehab because blood glucose levels will increase further with exercise.

ANSWER: 4 Exercising with blood glucose levels exceeding 250 mg/dL and ketonuria increases the secretion of glucagon, growth hormone, and catecholamines, causing the liver to release more glucose. Exercise in the presence of hyperglycemia does not lower the blood glucose level (options 1 and 3). Administering insulin may be an option, but the blood glucose level should be known before sending the client to cardiac rehab (option 2). ➧ Test-taking Tip: Think about the physiological effects of stress on blood glucose levels. Then eliminate options 1 and 3 because these are incorrect. Of the remaining two options, decide which action is safest for the client.

A client calls a clinic to renew the prescription for insulin being administered subcutaneously via an insulin pump. Which insulin type, if prescribed by a physician, should the nurse question? 1. Insulin lispro (Humolog®) 2. Insulin aspart (Novolog®) 3. Insulin glulisine (Apidra®) 4. Insulin glargine (Lantus®)

ANSWER: 4 Glargine is long-duration insulin not suited to delivery by an infusion pump; the order should be questioned. Four types of insulin may be delivered through an insulin pump: regular, lispro, aspart, and glulisine. These are short-duration and short or rapid-acting types of insulin that can be administered at a basal rate for continuous infusion at a slow but steady rate. The pump can also be triggered manually to provide a bolus dose to accommodate insulin needs to match the caloric contents of a meal. ➧ Test-taking Tip: Recall that only short-duration and short- or rapid-acting types of insulin can be administered through an insulin pump. Thus, select the option with a long-duration insulin.

An elderly client with Alzheimer's dementia is being admitted from a postanesthesia unit following a hip hemiarthroplasty to treat a hip fracture. Which intervention should a nurse initially plan for the client's pain control? 1. Apply a fentanyl (Duragesic®) transdermal patch. 2. Initiate morphine sulfate per patient-controlled analgesia (PCA) with a basal rate. 3. Administer intravenous morphine sulfate based on the client's report of pain. 4. Administer scheduled doses of morphine sulfate intravenously around the clock.

ANSWER: 4 In addition to scheduling pain medication around the clock, supplemental NSAIDs can be administered to reduce inflammation and enhance the effects of the analgesic. A transdermal analgesic patch is used to treat chronic, not acute, pain. Usually a PCA affords the client better control over the pain and avoids the peaks and valleys associated with intermittent analgesics. However, the client with dementia would be unable to adequately use PCA. The client with dementia typically cannot report the level of pain accurately. ➧ Test-taking Tip: Note the client has Alzheimer's dementia. This influences the treatment choices.

A nurse is evaluating teaching for a client who has diabetes and is beginning insulin therapy using an insulin pen. Which behavior should best indicate to a nurse that teaching about the insulin therapy was effective? 1. The nurse showing the client a video that explains how to use the insulin pen 2. The client reading a handout that describes the different types of insulin and insulin pens 3. The nurse demonstrating the correct procedure for preparing the insulin pen for administration 4. The client preparing the insulin pen and self-injecting correctly on the first attempt

ANSWER: 4 The client correctly demonstrating withdrawing and administering insulin suggests that the teaching about medication was effective. Options 1 and 3 are teaching strategies. Option 2 does not demonstrate that learning has occurred. The client correctly demonstrating preparing the insulin pen and administering the insulin suggests that the teaching about insulin therapy was effective. Options 1 and 3 are nursing interventions using various teaching strategies. Option 2 is a client action but it does not demonstrate that learning has occurred. ➧ Test-taking Tip: Focus on what the question is asking, "indicates teaching . . . was effective" and the nursing process step of evaluation. Options that include nursing interventions should be eliminated as well as any options with client behaviors that do not demonstrate that learning has occurred.

A nurse instructs a client on safe disposal of insulin syringes and needles when at home. Which statement by the client indicates that additional teaching is needed? 1. "After I draw up my insulin, I scoop the cap to cover it while I cleanse my skin." 2. "I have a needle destruction device that breaks the needles from the syringes so that others won't get stuck by the needles." 3. "I plan to use this plastic milk container to discard my used needles and syringes and take it to the clinic for disposal." 4. "Because the needles are capped, the syringes are safe to dispose of with my household trash."

ANSWER: 4 Used needles and syringes should not be placed in the household trash because of the risk of needlestick injuries to waste management personnel. Scooping the cap to cover the needle protects others from needlestick injuries. The U.S. Environmental Protection Agency (2004) recommends that at-home syringes and needles be disposed of through use of needle destruction devices, sharps mail-back programs, community drop-off programs, or household hazardous waste facilities. ➧ Test-taking Tip:The key phrase is "additional teaching is needed." Select the statement that is incorrect.

An 8-year-old child with gastroenteritis is prescribed to receive 500 mL of lactated Ringer's (LR) solution over the next 10 hours. The rate in milliliters per hour that a nurse should infuse the solution is _______ mL.

ANSWER: 50 The 50 mL per hour is obtained by dividing 10 hours into 500 mL of LR. ➧ Test-taking Tip: Use a known formula and check your answer, especially if it seems unusually large.

A nurse is caring for a woman who was admitted at 25.2 weeks gestation in preterm labor. The woman received nifedipine (Procardia®) but continued having contractions. The nurse is now administering magnesium sulfate. Which assessment findings indicate that the woman is experiencing an adverse effect from the magnesium sulfate? SELECT ALL THAT APPLY. a. Shortness of breath b. Nausea c. Hypertension d. Dizziness e. Hypotension f. Insomnia

ANSWER: A, B, D, E Women receiving magnesium sulfate may encounter hypotension, shortness of breath, nausea, and dizziness. Hypertension and insomnia are not commonly associated with magnesium sulfate, and they also are not side effects of nifedipine. Hypotension is more common with nifedipine. Hold for decreased DTR ➧ Test-taking Tip:The key words are "adverse effects." Think about the effect of magnesium on cells. Note that options 3 and 5 are opposites; eliminate one of these

A nurse is assessing a client who is taking atorvastatin (Lipitor®). For which manifestations should the nurse specifically assess? a. Constipation and hemorrhoids b. Muscle pain and weakness c. Fatigue and dysrhythmias d. Flushing and postural hypotension

ANSWER: B Atorvastatin is a 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitor (statin) used to lower lipid levels. Statins can cause muscle tissue injury manifested by muscle ache or weakness. Muscle injury can progress to myositis (muscle inflammation) or rhabdomyolysis (muscle disintegration). Additional SE of statins is confusion and decreased UO. Bile acid sequestrants may cause constipation and hemorrhoids because they are not absorbed from the small intestine. Diarrhea, not constipation, is a side effect of statin medications. Side effects of niacin, a lipid-lowering agent, include flushing, dysrhythmias, and postural hypotension. ➧ Test-taking Tip:The key words are "specifically assess." The nurse should be monitoring for side effects. Select the option that includes the side effect for the HMG-CoA reductase inhibitors (statins).

Before a child's hospital discharge, a nurse is teaching the parents how to administer an oral medication to the child. Which nurse instruction would be most appropriate? a. Administer the medication and then follow it with a small glass of milk b. Give the child a flavored ice pop just before the medication (numb taste buds) c. Tell the child that the medication will taste good d. Open all capsules and mix the contents with applesauce

ANSWER: B The cold from the ice pop will help to numb the taste buds and weaken the taste of the medication. Options A, C, and D are incorrect. Essential foods, such as milk, should be avoided because the child may later refuse the food that he/she associates with the medicine. If the child is old enough, warn the child that the medication is objectionable, but then praise the child after the medication is swallowed. Some capsules are extended release and should not be opened. Milk can also decrease absorption. ➧ Test-taking Tip: Note the key words "most appropriate." Recall that cold has a numbing effect. Therefore, select option 2.

A nurse is administering multiple anticonvulsant medications to children. For which medication should a nurse teach the parents about ensuring that their child has good oral care to prevent gingival hyperplasia? a. Carbamazepine (Tegretol®) b. Valproic acid (Depakene®) c. Phenobarbital d. Phenytoin (Dilantin®)

ANSWER: D About 20% of people taking phenytoin have gingival hyperplasia. This can be minimized with thorough oral care. Gingival hyperplasia is unique to phenytoin among antiepileptic medications and is not a side effect of carbamazepine, valproic acid, or phenobarbital. ➧ Test-taking Tip: Apply knowledge of medication side effects to answer this question.

A clinic nurse is administering HepB (hepatitis B vaccine) intramuscularly to a newborn prior to hospital discharge. Which site is best for the nurse to plan to administer the injection? a. Deltoid b. Ventrogluteal c. Dorsogluteal d. Vastus lateralis

ANSWER: D The anterolateral thigh muscle is recommended as the site for HebB administration for neonates (age less than 1 month). The deltoid and dorsogluteal muscles are not well-developed in neonates. Although 0.5 mL of medication can be administered into the ventrogluteal muscle of neonates, it is not a recommended site. ➧ Test-taking Tip: Think about the largest muscle in neonates before reviewing the options. The key word is "best."

When does action occur with intermediate-acting insulins? When does peak activity occur? Duration?

Action starts between 2 and 4 hr after injecting. Peak activity occurs between 4 and 10 hr. Duration of action lasts 10-16 hr.

Action of hyroxyzine

Acts as a CNS depressant . Anticholinergic. Blocks histamine 1 receptros

What are the indications for nitroglycerin?

Acute (translingual, SL, ointment) and long-term prophylatic (oral, transdermal) management of angina pectoris. PO: Adjunct treatment of HF. IV: Adjunct treatment of acute MI. Production of controlled hypotension during surgical procedures. Treatment of HF associated with acute MI.

How should PO nitroglycerin be administered (e.g. taken with meals, or on an empty stomach)?

Administer dose 1 hr before or 2 hr after meals with a full glass of water for faster absorption. Sustained- release preparations should be swallowed whole; do not break, crush, or chew.

How is Bupivacaine (epidural agent) administered?

Administer in increments of 3-5 mL allowing sufficient time to detect toxic signs/symptoms of inadvertent IV or IT administration. A test dose of 2-3 mL of 0.5% with epinephrine solution is recommended prior to epidural blocks.

Where should insulin be injected?

Administer into abdominal wall, thigh, or upper arm subcutaneously.

What is the rate of IV administration of hydromorphone?

Administer slowly, at a rate not to exceed 2 mg over 3-5 min.

administration of ketorolac

Administer undiluted over 15 sec

IM admin of phenoytoin

Adminster only IM deep into well developed msucle - preferably with z-track. Injection is extremely painful. Do not use deltoid. Signifigant tissue damage, slouging, and necrosis can result from sub-q and IV. rotate injection sites frequently

Why should patients be advised to change positions slowly when on morphine sulfate?

Advise patient to change positions slowly to minimize orthostatic hypotension.

What should the nurse tell the patient at discharge to do if they develop dry mouth or blurred vision while taking nitroglycerin?

Advise patient to notify health care professional if dry mouth or blurred vision occurs.

contraindications for phenytoin

Alcohol intolerance, sinus bradycardia, AV block, concurrent use of delavirdine

All continuous infusions of high-alert medication must be administered how? How should it be labeled?

All continuous infusions of high-alert medication must be administered via IV pump. Label each infusion line with the name of the medication being infused at the distal ends of all tubing.

Where are neuromuscular blocking agents stored? Why?

All neuromuscular blocking agents are stored separated from other medications in the pharmacy in containers with the following: "Warning, This is a Muscle Paralyzing Agent." Separated storage and warnings for vials set up due to paralyzing effect and potential for death if injected into non-ventilated patients apart from a planned intubation.

AE/SE atorvastatin

Amnesia, confusion, dizziness, headache, insomnia, weakness, chest pain, peripheral edema, bronchitis, abdominal cramps, constipation, diarrhea, flatus, heartburn, hepatitis, pancreatitis, hyperglycemia, myalgia, myopahty

What do all high-alert medications require?

An independent second check.

What are symptoms of hypoglycemia?

Anxiety; restlessness; tingling in hands, feet, lips, or tongue; chills; cold sweats; confusion; cool, pale skin; difficulty in concentration; drowsiness; excessive hunger; headache; irritability; nightmares or trouble sleeping; nausea; nervousness; tachycardia; tremor; weakness; unsteady gait

Applying ointment for nitro paste

Apply ointment by using dose measuring application onto measyirng scale printed on paper. Use skin (chst, abdomen, thighs, avoid distal extremities), in a thin, even layer, covering 2-3in are. Donot rub in ointment, this will increase absorption, apply occlusive dressing if ordered

What should be assessed before and periodically during administration of hydromorphone?

Assess BP, pulse, and respirations before and periodically during administration.

How can constipation be prevented in patients taking opioids?

Assess bowel function routinely. Institute prevention of constipation with increased intake of fluids and bulk and with laxatives to minimize constipating effects. Administer stimulant laxatives routinely if opioid use exceeds 2-3 days, unless contraindicated.

What does the nurse need to keep in mind in regards to GI symptoms of the patient taking hydromorphone? How can this side effect be prevented?

Assess bowel function routinely. Institute prevention of constipation with increased intake of fluids and bulk, and laxatives to minimize constipating effects. Administer stimulant laxatives routinely if opioid use exceeds 2-3 days, unless contraindicated.

How often should the nurse assess the patient for sensory deficit in the patient undergoing an epidural? How is this assessed?

Assess for sensory deficit every shift. Ask patient to point to numb and tingling skin areas (numbness and tingling at the incision site is common and usually normal). Notify physician or other health care professional of unwanted motor and sensory deficits.

What should patients be assessed for when taking insulin?

Assess for symptoms of hypoglycemia and hyperglycemia periodically during therapy.

What should the nurse assess for in regards to systemic toxicity in the client who has an epidural?

Assess for systemic toxicity (circumoral tingling and numbness, ringing in ears, metallic taste, dizziness, blurred vision, tremors, slow speech, irritability, twitching, seizures, cardiac dysrhythmias) each shift. Report to health care professional.

When should pain level be assessed in the client taking hydromorphone

Assess type, location, and intensity of pain prior to and 1 hr following IM or PO and 5 min (peak) following IV administration. When titrating opioid doses, increases of 25-50% should be administered until there is either a 50% reduction in the patient's pain rating on a numerical or visual analogue scale or the patient reports satisfactory pain relief. When titrating doses of short-acting hydromorphone, a repeat dose can be safely administered at the time of the peak if previous dose is ineffective and side effects are minimal.

contraindications of Nifedipine

Av block, systolic BP <90, use of phenytoin (decreases effectivness)

IM phenytoin

Avoided due to pain and irradict absorption

What is the action of morphine sulfate?

Binds to opiate receptors in the CNS. Alters the perception of and response to painful stimuli while producing generalized CNS depression. Therapeutic Effects: Decrease in severity of pain.

What is the action and therapeutic effect of hydromorphone?

Binds to opiate receptors in the CNS. Alters the perception of and response to painful stimuli while producing generalized CNS depression. Suppresses the cough reflex via a direct central action. Therapeutic Effects: Decrease in moderate to severe pain. Suppression of cough.

What rapid-acting insulins can be given intravenously?

Both insulin aspart and insulin glulisine can be given intravenously in selected situations under medical supervision.

What are examples of combination insulin?

Brand names of these products include Humulin 70/30 (70% NPH, 30% regular), Humalog Mix 75/25 (75% insulin lispro protamine suspension and 25% insulin lispro), Humalog Mix 50/50 (50% insulin lispro protamine suspension and 50% insulin lispro), and Novolin 70/30 (70% NPH, 30% regular), or Novolog 70/30 (70% insulin aspart protamine suspension and 30% insulin aspart).

What is the half-life of epidural agents (bupivacaine and ropivacaine)?

Bupivacaine—1.5-5 hr (after epidural use); ropivacaine—4.2 hr (after epidural use).

pregnancy class furosemide

Epidural

Catherter hunch over Intrathecal space Punctured dura -- spinal headache Can convert to spinal block for c-section

Can patients drink alcohol on morphine sulfate?

Caution patient to avoid concurrent use of alcohol or other CNS depressants with this medication.

Why should the nurse caution patients to move slowly while on nitroglycerin?

Caution patient to change positions slowly to minimize orthostatic hypotension. First dose should be taken while in a sitting or reclining position, especially in geriatric patients.

Why should a diabetic patient's weight be monitored periodically?

Changes in weight may necessitate changes in insulin dose

What to know about nitroglycerin

Chest pain/hypertension Dark metal glass container (cool place) hypotension Headache common SE Check BP prior to admin Have to have line Titrated up to 200 (50-60 normal) CHF and HTN we start at 5mcg/min

Drug-drug interactions for hydroxyzine

Combined CNS effects

What drug natural products can cause CNS depression in patients taking hydromorphone?

Concomitant use of kava-kava, valerian, chamomile, or hops can increase CNS depression.

What are drug-natural product interactions of morphine sulfate?

Concomitant use of kava-kava, valerian, or chamomile can increase CNS depression.

When should an epidural be used cautiously?

Concurrent use of other local anesthetics; Liver disease; Concurrent use of anticoagulants (including low-dose heparin and low-molecular- weight heparins/heparinoids) increase the risk of spinal/epidural hematomas; *OB*: Bupivacaine and ropivacaine— both agents rapidly cross the placenta with obstetrical paracervical block anesthesia and can result in maternal, fetal, or neonatal toxicity with cardiac, central nervous system, or vascular tone abnormalities. May cause maternal hypotension; *Pedi*: Bupivacaine—safety not established in children < 12 yr. Ropivacaine—safety not established in children < 18 yr; *Geri*: May require lower doses due to increase risk of hypotension and/or increase risk of toxicity due to age-related decline in renal function.

How is information confirmed when doing a double check?

Confirmed using the MAR; and provider order if necessary

What are symptoms of hyperglycemia?

Confusion, drowsiness; flushed, dry skin; fruit-like breath odor; rapid, deep breathing, polyuria; loss of appetite; nausea; vomiting; unusual thirst

When is hydromorphone contraindicated?

Contraindicated in: Hypersensitivity; Some products contain bisulfites and should be avoided in patients with known hypersensitivity; Severe respiratory depression (in absence of resuscitative equipment) (extended-release only); Acute or severe bronchial asthma (extended-release only); Paralytic ileus (extended- release only); Acute, mild, intermittent, or postoperative pain (extended-release only); Prior GI surgery or narrowing of GI tract (extended-release only); Opioid non-tolerant patients (extended-release only); *OB, Lactation*: Avoid chronic use during pregnancy or lactation.

When is morphine contraindicated?

Contraindicated in: Hypersensitivity; Some products contain tartrazine, bisulfites, or alcohol and should be avoided in patients with known hypersensitivity.; Acute, mild, intermittent, or postoperative pain (extended/sustained-release); Significant respiratory depression (extended/sustained-release); Acute or severe bronchial asthma (extended/sustained-release); Paralytic ileus (extended/sustained release)

When is insulin contraindicated?

Contraindicated in: Hypoglycemia; Allergy or hypersensitivity to a particular type of insulin, preservatives, or other additives

What is the indication of insulin?

Control of hyperglycemia in patients with type 1 or type 2 diabetes mellitus.

Pregnancy category for phenytoin

Phenytoin brand name

Dilantin

For continuous infusion, what diluent should morphine sulfate be added to? What should the concentration be?

Diluent: May be added to D5W, D10W, 0.9% NaCl, 0.45% NaCl, Ringer's or LR, dextrose/saline solution, or dextrose/Ringer's or LR. Concentration: 0.1-1 mg/mL or greater for continuous infusion.

How should naloxone be diluted?

Dilute the 0.4-mg ampule of naloxone in 10 mL of 0.9% NaCl and administer 0.5 mL (0.02 mg) by direct IV push every 2 min. For children and patients weighing < 40 kg, dilute 0.1 mg of naloxone in 10 mL of 0.9% NaCl for a concentration of 10 mcg/mL and administer 0.5 mcg every 2 min. Titrate dose to avoid withdrawal, seizures, and severe pain.

How should direct IV morphine sulfate be diluted? What should the concentration be per mL? How long should it be administered?

Dilute with at least 5 mL of sterile water or 0.9% NaCl for injection. Concentration: 0.5-5 mg/mL. Rate: High Alert: Administer 2.5-15 mg over 5 min.

Implementation of furosemide

Do not admin past 5pm - can disrupt sleep due to output IV preferred over IM Admin undiluated 10mg/min Protect from light NTE 4mg/min for intermittent infusions

Why shouldn't nitroglycerin be discontinued abruptly?

Do not discontinue abruptly; gradual dose reduction may be necessary to prevent rebound angina.

Should PO morphine sulfate be administered with food or on an empty stomach? Why?

Doses may be administered with food or milk to minimize GI irritation.

AE/SE in hydroxyzine

Drowsiness, agitation, ataxia, dissiness, headache, weakness, wheezing, dry mouth, bitter taste, constipation, nausea, urinary retention, flsuing, pain at IM site, abcesses at IM site, chest tightness

What are drug-drug interactions of epidural agents?

Drug-Drug: Additive toxicity may occur with concurrent use of other amide local anesthetics (including lidocaine, mepivacaine, and prilocaine). Use of bupivacaine solution containing epinephrine with MAO inhibitors may cause hypertension. Fluvoxamine, amiodarone, ciprofloxacin, and propofol may increase effects of ropivacaine.

What are drug-drug interactions of insulin?

Drug-Drug: Beta blockers, clonidine, and reserpine may mask some of the signs and symptoms of hypoglycemia. Corticosteroids, thyroid supplements, estrogens, isoniazid, niacin, phenothiazines, and rifampin may increase insulin requirements. Alcohol, ACE inhibitors, MAO inhibitors, octreotide, oral hypoglycemic agents, and salicylates, may decreases insulin requirements. Concurrent use with pioglitazone or rosiglitazone may increase risk of fluid retention and worsening HF.

What are drug-drug interactions of hydromorphone?

Drug-Drug: Exercise extreme caution with MAO inhibitors (may produce severe, unpredictable reactions— reduce initial dose of hydromorphone to 25% of usual dose, discontinue MAO inhibitors 2 wk prior to hydromorphone). Increase risk of CNS depression with alcohol, antidepressants, antihistamines, and sedative/ hypnotics including benzodiazepines and phenothiazines. Administration of partial antagonists (buprenorphine, butorphanol, nalbuphine, or pentazocine) may precipitate opioid withdrawal in physically dependent patients. Nalbuphine or pentazocine may decrease analgesia.

What are drug-natural product interaction of insulin?

Drug-Natural Products: Glucosamine may worsen blood glucose control. Fenugreek, chromium, and coenzyme Q-10 may produce additive hypoglycemic effects.

time/action profile atorvastatin

Duration 20-30min

Indications furosemide

Edema due to HF, hepatic impairment, or renal disease. Hypertension.

Should morphine be diluted when given as an epidural? What are other considerations when morphine is given as an epidural?

Epidural: Administer undiluted. If a lidocaine test dose is administered, flush catheter with 0.9% NaCl and wait 15 min before administration of DepoDur. Do not use an in-line filter. Do not admix or administer other medications in epidural space for 48 hr after administration. Administer within 4 hr after removing from vial. Store in refrigerator; do not freeze.

What are some hypertonic solutions?

Examples of hypertonic solutions include 5% Dextrose in 0.45% sodium chloride (D5 0.45%NS, D5½NS), 5% dextrose in lactated Ringers (D5LR, D5RL) 3% sodium chloride, 10% dextrose in water (D10W), D20W, D50W and colloids (albumin 25%, plasma protein fraction, dextran and hetastarch). and D5NS

What are examples of hypotonic solutions?

Examples of hypotonic solutions include, one third normal saline (0.33% Sodium Chloride, 1/3 NS, 0.33%NS), half normal saline (0.45% Sodium Chloride, 0.45%NS, ½ NS) and 2.5% Dextrose in Water (D2.5W). and 1/4NS

What are examples of isotonic fluids?

Examples of isotonic solutions include Dextrose 5% in Water (D5W), normal saline (0.9% Sodium Chloride, NS), and Ringer's Lactate (RL, LR).

True or False NPH insulins should be used in the management of ketoacidosis.

FALSE NPH insulins should not be used in the management of ketoacidosis.

True or False Most patients develop a psychological dependence to hydromorphone.

FALSE Though prolonged use may lead to physical and psychological dependence and tolerance, this should not prevent patient from receiving adequate analgesia. Most patients who receive hydromorphone for pain do not develop psychological dependence. Progressively higher doses may be required to relieve pain with long-term therapy.

True or False The nurse should throw away Humulin N if it is cloudy.

False The addition of protamine causes the cloudy appearance of intermediate-acting insulins and results in the formulation being a suspension rather than a solution. This is why these insulins must be gently mixed before administering.

True or False Solutions greater than 500 mOsm/L can be infused through a peripheral line.

False Use a central line to infuse IV fluids with a mOsm/L >500.

True or False When cells are exposed to a hypertonic solution they will swell as fluid moves into the intracellular space.

False When cells are exposed to a *hypotonic* solution they will swell as fluid moves into the intracellular space.

What should the nurse keep in mind when administering hydromorphone to geriatric and pediatric clients?

Geri, Pedi: Assess geriatric and pediatric patients frequently; more sensitive to the effects of opioid analgesics and may experience side effects and respiratory complications more frequently.

dose adjusments/weaning of phenytoin

Gradually

atorvastatin class

HMG-Coa (statins)

What is the half-life of nitroglycerin?

Half-life: 1-4 min.

When should morphine be used cautiously?

Head trauma; increased intracranial pressure; Severe renal, hepatic, or pulmonary disease; Hypothyroidism; Seizure disorder; Adrenal insufficiency; History of substance abuse; Undiagnosed abdominal pain; Prostatic hyperplasia; Patients undergoing procedures that rapidly decreased pain (cordotomy, radiation); long-acting agents should be discontinued 24 hr before and replaced with short-acting agents Geri: Geriatric or debilitated patients (dose decrease suggested) OB, Lactation: Avoid chronic use; has been used during labor but may cause respiratory depression in the newborn; Pedi: Neonates and infants 3 mo (more susceptible to respiratory depression) Pedi: Neonates (oral solution contains sodium benzoate which can cause potentially fatal gasping syndrome).

SE/AE of Nifedipine

Headache, anxiety, abnormal dreams, confusion, dizziness, blurred vision, tinnitus, cough, dyspnea, SOB, Arrythmias, HF, peripheral edema, bradycardia, chest pain, hypotension, palpitations, tachycardia, dysuria, flushing, hyperglycemia, thrombocytopenia, muscle cramps, tremor, gingival hyperplasia

What should you assess patients for before and during administration of morphine sulfate?

High Alert: Assess level of consciousness, BP, pulse, and respirations before and periodically during administration.

The patient is to receive a transfusion of 3 units of packed cells. Each unit contains 250 ml. You begin the first transfusion at 0800 and by 1400 the third unit should be infused. Special blood administration tubing set delivers 10 gtts/ml/min. How many mL per hour will the blood need to run?________________________________ What is the drop rate (gtts/min)?________________________________

How many mL per hour will the blood need to run?125ml/hr What is the drop rate (gtts/min)? 20.83 21 gtts/min

What are examples of rapid-acting insulins?

Humalog (lispro), Apidra (glulisine), and Novolog (aspart) are rapid-acting insulin analogs. *Used for sliding scale before meals

What is the generic name for Dilaudid?

Hydromorphone

When is having an epidural contraindicated?

Hypersensitivity; cross-sensitivity with other amide local anesthetics may occur (lidocaine, mepivacaine, prilocaine); Bupivacaine contains bisulfites and should be avoided in patients with known intolerance; OB: Bupivacaine only—Do not use 0.75% concentration. Only 0.5% and 0.25% concentrations should be used for obstetrical anesthesia due to reports of cardiac arrest and difficult resuscitation with the 0.75% concentration; Lactation: Discontinue nursing.

Is 10% dextrose in water (D10W), D20W, D50W and colloids (albumin 25%, plasma protein fraction, dextran and hetastarch) isotonic, hypertonic, or hypotonic?

Hypertonic

Is 5% Dextrose in 0.45% sodium chloride (D5 0.45%NS, D5½NS) isotonic, hypotonic, or hypertonic?

Hypertonic

Is 5% dextrose in lactated Ringers (D5LR, D5RL) 3% sodium chloride isotonic, hypotonic, or hypertonic?

Hypertonic

What is often managed with hypotonic solutions?

Hypertonic dehydration, water replacement and diabetic ketoacidosis (after initial sodium chloride replacement) are often managed with hypotonic solutions. Precaution should be taken with patients who have hypotension as these fluids could further lower the blood pressure.

Hypertonic solutions are used for what?

Hypertonic solutions are used to replace electrolytes, to manage hypotonic dehydration (loss of fluid but a greater loss of sodium caused by vomiting, diarrhea, post operative loss, long term use of diuretics, burns), and short term treatment of shock. Caution should be taken because they can irritate blood vessels and may cause circulatory overload if too much fluid shifts from the interstitial space to the intravascular space. Hypertonic solutions should be given slowly.

Hypertonic solutions have what concentration?

Hypertonic solutions have a concentration that is higher than the concentration of plasma (300 mOsm/L or more).

Is 2.5% Dextrose in Water (D2.5W) isotonic, hypotonic, or hypertonic?

Hypotonic

Is half normal saline (0.45% Sodium Chloride, 0.45%NS, ½ NS) isotonic, hypotonic, or hypertonic?

Hypotonic

Is one third normal saline (0.33% Sodium Chloride, 1/3 NS, 0.33%NS) isotonic, hypotonic, or hypertonic?

Hypotonic

What is the concentration of hypotonic solutions?

Hypotonic solutions have a concentration that is less than the concentration of plasma (less than 270 mOsm/L).

Time action/profile for magnesium sulfate

IM - onset 60 duration 3-4hr IV onset immediate duration 30 min

What is the dosage for IM, IV, Subcut of morphine sulfate?

IM, IV, Subcut (Adults > 50 kg): Usual starting dose for moderate to severe pain in opioid-naive patients—4-10 mg q 3-4 hr. MI—8-15 mg, for very severe pain additional smaller doses may be given every 3-4 hr.

Coumadin lab

INR (1 without blood thinners) 2 for blood thinners artificial values/a-fib--> 3.5

What is the IV dosage for nitroglycerin? What is the max dose?

IV (Adults): 5 mcg/min; increase by 5 mcg/min q 3-5 min to 20 mcg/min; if no response, increase by 10-20 mcg/min q 3-5 min (dosing determined by hemodynamic parameters; max: 200 mcg/min).

How many mg/hr can be given in an continuous infusion of hydromorphone? Can a bolus of hydromorphone be given, and if so, how much?

IV (Adults): Continuous infusion (unlabeled)— 0.2-30 mg/hr depending on previous opioid use. An initial bolus of twice the hourly rate in mg may be given with subsequent breakthrough boluses of 50-100% of the hourly rate in mg.

What is the safe dose range for giving hydromorphone IV, IM, or Subcut??

IV, IM, Subcut (Adults > 50 kg): 1.5 mg q 3-4 hr as needed initially; may be increased. IV, IM, Subcut (Adults and Children < 50 kg): 0.015 mg/kg mg q 3-4 hr as needed initially; may be increased.

Dosing for antiarrythmic effects for phenytoin

IV- 50-100mg q10-15 until arrytmia abolished or at 15mg/kg (max) PO- Loading dose 250mg 4times daily for 1 day, than 250mg x2, than maintiance 300-400mg/day in divided doses

Should IV nitroglycerin be diluted? Can regular tubing be used?

IV: Doses must be diluted and administered as an infusion. Standard infusion sets made of polyvinyl chloride (PVC) plastic may absorb up to 80% of the nitroglycerin in solution. Use glass bottles only and special tubing provided by manufacturer

What drug reverses respiratory depression in the patient taking an opioid agonist?

If an opioid antagonist is required to reverse respiratory depression or coma, naloxone (Narcan) is the antidote.

What is the antidote for opioid toxicity? How is it administered?

If an opioid antagonist is required to reverse respiratory depression or coma, naloxone is the antidote. Dilute the 0.4-mg ampule of naloxone in 10 mL of 0.9% NaCl and administer 0.5 mL (0.02 mg) by direct IV push every 2 min.

assessment of atorvastatin

If muscle tenderness develops, monitor CK levels. if CK levels are >10 times the supper limit of normal, D/C. Treat with immunosuppresant agents

What should the nurse do if the respiratory rate falls below 10/min in the patient taking hydromorphone?

If respiratory rate is 10/min, assess level of sedation. Dose may need to be decreased by 25-50%. Initial drowsiness will diminish with continued use.

What should you do if the respiratory rate of a patient on morphine sulfate is less than 10/min?

If respiratory rate is 10/min, assess level of sedation. Physical stimulation may be sufficient to prevent significant hypoventilation. Subsequent doses may need to be decreased by 25- 50%. Initial drowsiness will diminish with continued use.

What are critical steps/specific information for Chemotherapy Agents/Cytotoxic Agents?

If the IV cytotoxic agent is being administered for the treatment of cancer, an oncology-trained nurse must be present for administration. Oncology nurses must be consulted for the initial dose of PO chemo agents when used for the treatment of cancer. Only oncology trained nurses may administer Cytotax (Cyclophosphamide) PO or IV, even if the indication is not for cancer. Methotrexate is a high risk agent. Usual dose is 1-3 times per week. Daily dosing must be verified with the prescriber due to risk of neutropenia.

When should reconstitution be done in agents with no antibacterial preservatives?

Immediately before use

Why doesn't insulin glargine have real peak action?

In fact, insulin glargine has no real peak action because it forms slowly dissolving crystals in the subcutaneous tissue.

What drugs can increase the risk of CNS depression in the patient taking hydromorphone?

Increase risk of CNS depression with alcohol, antidepressants, antihistamines, and sedative/ hypnotics including benzodiazepines and phenothiazines.

Assessment furosemide

Increased risk for falls in elderly Assess for hypokalmia (N/V, paresthesia, muscle crmaps, confusion) May need to add potassium spairing diuretic hearing loss/tinitis can occur after prolonged high dose therapy or rapid infusion

What is the action and therapeutic effect of nitroglycerin?

Increases coronary blood flow by dilating coronary arteries and improving collateral flow to ischemic regions. Produces vasodilation (venous greater than arterial). Decreases left ventricular end-diastolic pressure and left ventricular end-diastolic volume (preload). Reduces myocardial oxygen consumption. Therapeutic Effects: Relief or prevention of anginal attacks. Increased cardiac output. Reduction of BP.

What should the nurse do if the client complains of a headache during the use of nitroglycerin?

Inform patient that headache is a common side effect that should decrease with continuing therapy. Aspirin or acetaminophen may be ordered to treat headache. Notify health care professional if headache is persistent or severe.

How should sublingual nitroglycerin be stored?

Inform patient that tablets should be kept in original glass container or in specially made metal containers, with cotton removed to prevent absorption. Tablets lose potency in containers made of plastic or cardboard or when mixed with other capsules or tablets. Exposure to air, heat, and moisture also causes loss of potency. Instruct patient not to open bottle frequently, handle tablets, or keep bottle of tablets next to body (i.e., shirt pocket) or in automobile glove compartment. Advise patient that tablets should be replaced 6 mo after opening to maintain potency.

action furosemide

Inhibits the re absorption of sodium and chloride from the loop of henel and distal renal tubule. Increases renal excretion of water, sodium, chloride, magnesium, potassium, and calcium

Why is insulin a high-alert drug?

Insulin-related medication errors have resulted in patient harm and death. Clarify ambiguous orders; do not accept orders using the abbreviation "u" for units, (can be misread as a zero or the numeral 4; has resulted in tenfold overdoses).

What are intermediate-acting insulins?

Intermediate-acting insulin contains protamine, which delays onset, peak, and duration of action to provide basal insulin coverage. Basal insulins are given to control blood glucose levels throughout the day when not eating.

Is Ringer's Lactate (RL, LR) isotonic, hypotonic, or hypertonic?

Isotonic

Is dextrose 5% in Water (D5W) isotonic, hypotonic, or hypertonic?

Isotonic

What do isotonic solutions treat?

Isotonic solutions can be used to treat dehydration and hypernatremia.

What concentration is isotonic fluid?

Isotonic solutions have a concentration of 270 to 300 mOsm/L.

Where does the isotonic solution remain?

Isotonic solutions remain in the intravascular space and there are no real shifts of fluids between the intracellular and extracellular spaces.

Is it safe for pregnant women to use hydromorphone?

It is Pregnancy Category C. This means: Risk not ruled out: Animal studies have shown an adverse effect and there are no adequate and well-controlled studies in pregnant women, or no animal studies have been conducted and there are no adequate and well-controlled studies in pregnant women.

Is morphine sulfate safe for pregnant women to take?

Is nitroglycerin safe for pregnant women?

What does intrathecal mean?

It is a route of administration for drugs via an injection into the spinal canal, more specifically into the subarachnoid space so that it reaches the cerebrospinal fluid (CSF).

What is pediatric dosing based on?

It is based on weight which should always be obtained and recorded in metric weights.

Should the PO medication of hydromorphone be given on an empty stomach?

It may be administered with food or milk to minimize GI irritation.

Who is considered an authorized staff when doing an Independent Second Check?

Licensed nurse, pharmacist, licensed provider

Action of phenytoin

Limits seizure propagation by altering transport. shortens action potential and decreasing automaticity.

What are the actions and therapeutic effect of epidural agents?

Local anesthetics inhibit initiation and conduction of sensory nerve impulses by altering the influx of sodium and efflux of potassium in neurons, slowing or stopping pain transmission. Epidural administration allows action to take place at the level of the spinal nerve roots immediately adjacent to the site of administration. The catheter is placed as close as possible to the dermatomes (skin surface areas innervated by a single spinal nerve or group of spinal nerves) that, when blocked, will produce the most effective spread of analgesia for the site of injury. *Therapeutic Effects*: Decreased pain or induction of anesthesia; low doses have minimal effect on sensory or motor function; higher doses may produce complete motor blockade.

What is the indication for having an epidural?

Local or regional anesthesia or analgesia for surgical, obstetric, or diagnostic procedures.

What is the action of insulin? What is the therapeutic effect?

Lower blood glucose by: stimulating glucose uptake in skeletal muscle and fat, inhibiting hepatic glucose production. Other actions: inhibition of lipolysis and proteolysis, enhanced protein synthesis. Therapeutic Effects: Control of hyperglycemia in diabetic patients.

What should the nurse assess for in regards to unwanted motor and sensory deficit?

Many factors, including location of the epidural catheter, local anesthetic dose, and variability in patient response, can result in patients experiencing unwanted motor and sensory deficits. Pain is the first sensation lost, followed by temperature, touch, proprioception, and skeletal muscle tone.

Can nitroglycerin be used prophylactically?

May also be used prophylactically 5-10 min before activities that may precipitate an acute attack.

Can regular insulin be used IV?

May be administered IV undiluted directly into vein or through Y-site. Rate: Administer up to 50 units over 1 min.

For continuous infusions, what can regular insulin be diluted in?

May be diluted in 0.9% NaCl using polyvinyl chloride infusion bags. Concentration: 0.1 unit/mL to 1 unit/mL in infusion systems with the infusion fluids. Rate: Rate should be ordered by health care professional, and infusion placed on an IV pump for accurate administration. Rate of administration should be decreased when serum glucose level reaches 250 mg/dL.

What are lab test considerations for nitroglycerin?

May cause increase urine catecholamine and urine vanillylmandelic acid concentrations. ● Excessive doses may cause increase methemoglobin concentrations. ● May cause falsely increase serum cholesterol levels.

Assessment for ketorolac

May incease LFT, creatinine, or potassium Increasing dose my not increase pain relief but may increase SE Oral therapy only as a continuation of parenteral therapy - use IM or IV

use caution with phenytoin in

May increase SI, hepatic and renal disease, severe cardiac or respiratory disease. If used chronically in pregnancy, harm may come to fetus. Safety not estbalished in lactation. Fatal if given to neonates. Geri: if used IV, increased chance of AE USe extreme caution in patients with HLA-B*1502

What are lab considerations for hydromorphone?

May increase plasma amylase and lipase concentrations.

drug-drug interactions magnesium sulfate

May potentiate CCB or nerumuscular blocking agents

Why should hydromorphone be discontinued gradually after long-term use?

Medication should be discontinued gradually after long-term use to prevent withdrawal symptoms.

Where is insulin metabolized?

Metabolized by liver, spleen, kidney, and muscle.

pharmakokinetics ketorolac

Metabolized by the liver, excreted mainly by the kidneys

intermittent infusion of phenytoin

Mix with no more than 50ml of NS with it Not to exceed 50mg/min Pts with cardiac diseae, hypotension, or geri - no more than 25mg/min Do not mix with dextrose containing solutions

What is the indication for hydromorphone?

Moderate to severe pain (alone and in combination with non-opioid analgesics); extended release product for opioid-tolerant patients requiring around-the-clock management of persistent moderate-to-severe pain. Antitussive (lower doses).

What are critical steps when administering anticoagulant medication, such as argatroban, bivalirudin, and heparin (therapeutic doses as drips or boluses)?

Monitor Anti-Xa/PTT/PT/INR per provider order.

Assmessment for Nifedipine

Monitor BP and pulse and EKG, can cause dig toxicity,

What should the nurse monitor before and after nitroglycerin administration?

Monitor BP and pulse before and after administration. Patients receiving IV nitroglycerin require continuous ECG and BP monitoring. Additional hemodynamic parameters may be monitored.

What should the nurse assess for in regards to orthostatic hypotension? How is unresolved hypotension treated?

Monitor BP, heart rate, and respiratory rate continuously while patient is receiving this medication. Mild hypotension is common because of the effect of local anesthetic block of nerve fibers on the sympathetic nervous system, causing vasodilation. Significant hypotension and bradycardia may occur, especially when rising from a prone position or following large dose increases or boluses. Treatment of unresolved hypotension may include hydration, decreasing the epidural infusion rate, and/or removal of local anesthetic from analgesic solution. *1000ml fluid bolus before an epidural

How often should blood glucose and A1C be monitored?

Monitor blood glucose every 6 hr during therapy, more frequently in ketoacidosis and times of stress. Hemoglobin A1C may also be monitored every 3-6 mo to determine effectiveness.

What should the nurse monitor during and after the epidural procedure?

Monitor for sensation during procedure and return of sensation after procedure

ketorolac (toradol)

NSAID (moderate to severe pain)

Are peaks prominent in long-acting insulins?

Is nitroglycerin a high-alert medication?

Is hydromorphone and morphine the same medication?

No. Do not confuse with morphine; fatalities have occurred.

Can long-acting insulins be mixed or diluted with other insulins or solutions?

No. Even though insulin glargine and insulin detemir are clear solutions, neither can be diluted or mixed with any other insulin or solution. Mixing insulin glargine or insulin detemir with other insulin products can alter the onset of action and time to peak effect. If bolus insulin is to be given at the same time as insulin glargine or insulin detemir, two separate syringes and injection sites must be used.

Should nitroglycerin be placed on the same skin site daily?

No. Sites of topical application should be rotated to prevent skin irritation. Remove patch or ointment from previous site before application.

Can the nurse use any syringe to draw up insulin?

No. Use only insulin syringes to draw up dose. The unit markings on the insulin syringe must match the insulin's units/mL.

ketorolac uses

Not to exceed 5 days total for all routes

Y site compatiaibty phenytoin

ONLY compatable with cisplattin - NOTHING else

Trasndermal parch nitro dosage

Ointment 1-2in q6-8hrs Trasndermal patch 0.2-0.4 mg/hr, may titrate up to 0.4-0.8mg/hr. Patch should be worn 12-14hrs than taken off for 10-12hr/day

Why should geriatric patients be assessed more frequently when on morphine sulfate?

Older adults are more sensitive to the effects of opioid analgesics and may experience side effects and respiratory complications more frequently.

What is the onset, peak, and duration of IV hydromorphone?

Onset: 10-15 min Peak: 15-30 min Duration: 2-3 hr

What is the onset and duration of epidural agents?

Onset: 10-30 min Duration: 2-8 hr

What is the half-life of hydromorphone?

Oral (immediate-release), or injection— 2-4 hr; Oral (extended-release)—8-15 hr.

What is osmolality?

Osmolality describes the concentration in a one kilogram of water. Osmolality refers to fluids inside the body.

osmolarity over 500

PICC/central line

How much hydromorphone should be given to children?

PO (Adults and Children < 50 kg): 0.06 mg/kg q 3-4 hr initially, younger children may require smaller initial doses of 0.03 mg/kg.

In order to have an antitussive effect, how much hydromorphone should be given?

PO (Adults and Children > 12 yr): 1 mg q 3-4 hr. PO (Children 6-12 yr): 0.5 mg q 3-4 hr.

What is the PO dosage for nitroglycerin?

PO (Adults): 2.5-9 mg q 8-12 hr.

dose atorvastatin

PO 10-20mg x1 NTE 40mg/day

Route/dosage ketorolac

PO 10mg q4-6hrs IV 30mg q6hrs (geri 15mg)

Route/dosgae furosemide

PO 20-80mg/day, may repeat Q6-8hrs IV/IM 20-40mg, may repeat 1-2hrs and increase by 20mg Continous 0.1mg/kg/hr up to 0.4mg/kg/hr

time/action profile furosemide

PO 30-60 min onset, peak 1-2hr, duration 6-8hrs IV 5 min, 30 min, 2hr

Time/action profile ketorolac

PO peak 2-3hr, duration 4-6hr IM/IV onset 10min, peak 1-2hr, duration 6hrs+

What is the dosage for po/rectal of morphine sulfate?

PO, Rect (Adults > 50 kg): Usual starting dose for moderate to severe pain in opioid-naive patients— 30 mg q 3-4 hr initially.

Onset, peak, duration of hyroxyzine

PO- 15-30, 2-4hr, 4-6hrs Same for IM

dosage for hydroxyzine

PO- antianxiety (25-100mg x4) preop sedation (50-100mg) antipruertic (25mg x4) IM- preop (25-100mg single) Antiemetic (25-100mg q4hrs)

Why should nitroglycerin patch be removed at night?

Patch may be worn for 12-14 hr and removed for 10-12 hr at night to prevent development of tolerance.

How long should a nitroglycerin transdermal patch be worn?

Patch should be worn 12-14 hr/day and then taken off for 10-12 hr/ day.

How often should a client on a continuous infusion of hydromorphone have boluses?

Patients on a continuous infusion should have additional bolus doses provided every 15-30 min, as needed, for breakthrough pain. The bolus dose is usually set to the amount of drug infused each hour by continuous infusion.

Action of magnesium sulfate

Plays in important role in neuro transmission and muscular excitability

Dosing for anticonvulsant effects of phenytoin

Po - loading 15-20mg/kg in 3 divided doses. Maintenance 5-6mg/kg/day IV- 15-20mg/mg/kg - maintence SAA

Onset, peak, duration of phenytoin

Po - onset 2-24hrs, peak 1.5-3hrs, duration 6-12hr IV - 0.5-1hr onset, rapid peak, duration 12-24hrs

Contraindications for hyroxyzine

Potential for congenital defects if taken during pregnancy

Why shouldn't direct IV morphine be rapidly administered?

Rapid administration may lead to increased respiratory depression, hypotension, and circulatory collapse.

What are rapid-acting insulin?

Rapid-acting insulins are analogs of regular insulin. An analog is a chemical structure very similar to another but differing in one component. The amino acid sequences of these analogs are nearly identical to human insulin. They differ in the positioning of certain proteins, which allow them to enter the bloodstream rapidly— within 15 min of subcutaneous injection. This closely mimics the body's own insulin response and allows greater flexibility in eating schedules for diabetic patients.

What are the five types of insulin?

Rapid-acting, short-acting, intermediate-acting, long-acting, and combination insulins.

What are examples of short-acting insulin?

Regular insulin is short-acting insulin and is available commercially as Humulin R or Novolin R.

What is more effective? PRN administration or regularly administering morphine sulfate?

Regularly administered doses may be more effective than prn administration. Analgesic is more effective if given before pain becomes severe.

Why should transdermal nitroglycerin patches be removed before MRI, cardioversion, or defibrillation?

Remove patches before MRI, cardioversion or defibrillation to prevent patient burns.

AE/SE of phenytoin

SI, ataxia, agiitation, confusion, dizziness, dysarthria, headache, insomnia, weakness, diplopia, nystagmus, hypotension, tachycardia, gingival hyperplasia, constipation, rash, aplastic anemia, thrombocytopenia, osteoprosis, fever

Onset of SL, PO, Oint, Patch, IV nitro

SL - 1 to 3min PO - 40-60 min Oint - 20-60 Patch - 40-60 min IV -- immediate

What drug schedule is hydromorphone? What does that schedule mean?

Schedule II High potential for abuse and extreme liability for physical and psychological dependence (amphetamines, opioid analgesics, dronabinol, certain barbiturates). Outpatient prescriptions must be in writing. In emergencies, telephone orders may be acceptable if a written prescription is provided within 72 hr. No refills are allowed.

Therapuetic effects of hyroxyzine

Sedation, decreased anxiety, decreased N/V, decrease in allergic symptoms

How is severe hypoglycemia treated?

Severe hypoglycemia is a life-threatening emergency; treatment consists of IV glucose, glucagon, or epinephrine.

caution furosemide

Severe liver disease, electrolyte depletion, DM, hypoproteinia (increased risk for toxicity), severe renal impairment, Geri increase SE

What to know about morphine sulfate

Slow IVP Respiratory depression IVP --> dilute NS Naloxone - reversal hypotension increased fall risk N/V Itching

How are epidural agents metabolized and excreted?

Small amounts that may reach systemic circulation are mostly metabolized by the liver. Very little excreted unchanged in the urine.

Other interactions with phenytoin

St johns wart may decrease levels, decreases folic acid absorption

When should insulin be used cautiously?

Stress and infection (may temporarily increase insulin requirements); Renal/hepatic impairment (may decrease insulin requirements); Concomitant use with pioglitazone or rosiglitazone (increase risk of fluid retention and worsening HF); OB: Pregnancy may temporarily increase insulin requirements

What is the common dose range of insulin:

Subcut (Adults and Children): 0.5-1 unit/kg/day. Adolescents during rapid growth—0.8-1.2 units/kg/day.

action of Nifedipine

Systemic vasodilation

When teaching parents of a pediatric patient how to administer hydromorphone, what should the nurse teach about the measuring device?

Teach parents or caregivers how to accurately measure liquid medication and to use only the measuring device dispensed with the medication.

Is the goal of epidural for pain management to provide analgesia or anesthesia?

The goal of adding low-dose local anesthetics to epidural opioids for pain management is to provide analgesia, not to produce anesthesia. Patients should be able to ambulate if their condition allows, and epidural analgesic should not hamper this important recovery activity.

When is the high-alert medication process exempted?

The high-alert medication process is exempted in an emergency situation when the delivering of immediate treatments to the patient outweighs the process. The nurse shall use extra caution in administering those high-alert medications during the emergency situation.

High osmolality causes what to move where from where?

The higher osmolality causes water to move out of the intracellular space into the intravascular space. This causes cells to shrink.

What is the nurse responsible for when the patient that is on high-alert medications is transferred?

The licensed caregiver conducting the transferring (aka "giving") of patient will perform an independent check of all the high-alert medications that the patient is currently receiving, and the caregiver will document in the EHR (select 'handoff' in the eMAR form for each high alert medication).

What is the onset of action of insulin glargine? What about full activity?

The onset of action of insulin glargine is 3-4 hr after subcutaneous injection. Full activity occurs within 3-10 hr and remains constant for 24 hr

What is the onset of regular insulin (short-acting)? What is its peak activity and duration?

The onset of regular insulin is 0.5-1 hr; its peak activity occurs 2-4 hr after subcutaneous injection and its duration of action is 5-7 hr. This time/action profile makes rigid meal scheduling necessary, as the patient must estimate that a meal will occur within 45 min of injection.

What is the osmolality of the intravascular?

The osmolality of the intravascular is 285 - 295 mOsm/kg.

What is the peak time for rapid-acting insulins? What is the duration?

The peak time for rapid-acting insulins is 1-2 hr and the duration is 3-4 hr.

What are the classifications for hydromorphone?

Therapeutic: allergy, cold, and cough remedies (antitussives), opioid analgesics Pharmacologic: opioid agonists

What are the therapeutic and pharmacologic classifications for nitroglycerin?

Therapeutic: antianginals Pharmacologic: nitrates

Why do cells shrink when exposed to hypertonic solutions?

They shrink since water is pulled out of the cells.

Why do cells get bigger when they are exposed to hypotonic solutions?

They swell since fluid moves into the intracellular space.

metolazone

Thiazide like diuretic

How are High Alert Medications determined?

This determination is made through the Pharmacy and Therapeutics (P&T) Committee utilizing references such as the Institute for Safe Medical Practices (ISMP) publications.

What therpeutic class of medications is alteplase and retaplase?

Thrombolytic Agents - For stroke pts ensure tpa checklist has been completed

Why is nitroglycerin used during surgical procedures?

To put the patient in controlled hypotension.

indications of hyroxyzine

Treatment of anxiety, preoperative sedation, anti-emetic, anti-pruritic

Indications for magnesium sulfate

Treatment of hypertension, seizures associated with severe eclampsia, pre-eclampsia, or acute nephritis Unlabeled use: Preterm labor, torsade de pointes.

Indications for phenytoin

Treatment/prevention of tonic clonic seizures and complex partial seizures Or unlabed use as an antiarrythmic for ventriuclar arrythmias. Management of neuropahtic pain

True or False Regular insulin can be given intravenously.

True

True or False When cells are exposed to a hypertonic solution they will shrink because water is pulled out of the cells.

True

True or False When cells are exposed to an isotonic solution, they do not get larger or smaller.

True

True or False Where possible, a reminder message appears on the automated dispensing machine's display terminal and on the eMAR to alert the caregiver to the high-alert status of the medication.

True

True or False Absence of medication from the high-alert medication chart should not be perceived as a determination of lower risk to the patient.

True Many other medications in use offer equal or greater risk of harm when misused.

How many authorized staff are required for an Independent Second Check?

Two

When a high-alert medication is administered by a student nurse, how many nurses must conduct the independent second check process, along with the student?

Two *licensed* nurses

Do not use list

U (mistaken for 0 or 4) IU (mistaken for IV or 10) Q.d, QOD Trailing zero (decimal point may be missed - except to indicate measuring with precision) MS, MSO4, MgSO4

How is nitroglycerin metabolized?

Undergoes rapid and almost complete metabolism by the liver; also metabolized by enzymes in bloodstream.

How can unwanted motor and sensory deficits during epidural administration be corrected with simple treatment?

Unwanted motor and sensory deficits often can be corrected with simple treatment. For example, a change in position may relieve temporary sensory loss in an extremity. Minor extremity muscle weakness is often treated by decreasing the epidural infusion rate and keeping the patient in bed until the weakness resolves. Sometimes removing the local anesthetic from the analgesic solution is necessary, such as when signs of local anesthetic toxicity are detected or when simple treatment of motor and sensory deficits has been unsuccessful.

When should hydromorphone be used cautiously?

Use Cautiously in: Head trauma; increased intracranial pressure; Severe renal, hepatic, or pulmonary disease; Hypothyroidism; Seizure disorder; Adrenal insufficiency; Alcoholism; Undiagnosed abdominal pain; Prostatic hypertrophy; Biliary tract disease (including pancreatitis); *Geri*: Geriatric and debilitated patients may be more susceptible side effects; dose decrease recommended.

What are drug-drug interactions of morphine sulfate?

Use with extreme caution in patients receiving MAO inhibitors within 14 days prior (may result in unpredictable, severe reactions—decrease initial dose of morphine to 25% of usual dose). Decreased CNS depression with alcohol, sedative/hypnotics, clomipramine, barbiturates, tricyclic antidepressants, and antihistamines. Administration of partial-antagonist opioid analgesics may precipitate opioid withdrawal in physically dependent patients. Buprenorphine, nalbuphine, butorphanol, or pentazocine may decrease analgesia. May increase the anticoagulant effect of warfarin. Cimetidine decrease metabolism and may increase effects.

What insulins are usually mixed together in combination insulin?

Usually a short- and an intermediate-acting insulin. Typically the intermediate-acting insulin makes up 70-75% of the mixture, with rapid- or short- acting insulin making up the remainder.

What are combination insulins?

Various combinations of premixed insulins are available, containing fixed proportions of two different insulins.

For continuous infusions, what can nitroglycerin be diluted with (the diluent)? What is the maximum concentration?

Vials must be diluted in D5W or 0.9% NaCl. Concentration: Should not exceed 400 mcg/mL.

Pharmacokinetics of hyroxyzine

Well absorbed in PO/IM routes, completely metabolized by the liver, eliminated in feces

What happens to fluid in the intravascular space when serum osmolality is reduced?

When the serum osmolality is reduced there is a shift of fluids from the intravascular space and into the intracellular and interstitial spaces. This causes cells to swell. Hypotonic solutions can deplete the intravascular space as fluid moves into the interstitial space.

How should morphine sulfate be titrated?

When titrating opioid doses, increases of 25-50% should be administered until there is either a 50% reduction in the patient's pain rating on a numerical or visual analogue scale or the patient reports satisfactory pain relief. When titrating doses of short-acting morphine, a repeat dose can be safely administered at the time of the peak if previous dose is ineffective and side effects are minimal.

Is hydromorphone and morphine Y site compatible?

Yes

Is hydromorphone and nitroglycerin Y site compatible?

Yes

Is insulin a high-alert drug?

Yes

Should insulin injection sites be rotated?

Yes

Should morphine sulfate be diluted?

Yes

Are morphine and nitroglycerin Y site compatible? What about nitroglycerin and hydromorphone (Dilaudid)?

Yes to both questions

Does hydromorphone cross the placenta or enters breast milk?

Yes, it does

Is hydromorphone a high-alert medication?

Yes-It is an opioid analgesic.

Should hydromorphone be diluted? If not, why? If so, how much and with what diluent?

Yes. Dilute with at least 5 mL of sterile water or 0.9% NaCl for injection.

Can intermediate-acting insulins be mixed?

Yes. Intermediate-acting insulins can be mixed with short- or rapid-acting insulins to provide both basal and bolus coverage.

Does the independent second check need to be documented?

Yes. Must be documented in the eMAR or any other approved documentation system.

Coadministration of hydromorphone with nonopioid analgesics may have ________ analgesic effects and permit _____ opioid doses.

additive lower

Direct Iv phenytoin

admin undiluted 50mg/1min Rapid admin can lead to hypotension and CNs depression

Contrindications furosemide

alcohol intolerance, sulfa/thiazide sensitivites

hyroxyzine classification

antianxiety, antihistamine, sedative/hyponotics

How to apply transdermal patch

applied to any hairless site. Apply firm pressure over site. Waterproof. Do not cut or trim to adjust dosage

Heparin Lab

aptt or ptt or anti-xa

Drug -drug interactions for phenytoin

atorvastatin - decreases absorption CNS depressants - combined effect

SE/AE furosemide

blurred vision, dizziness, headache, vertigo, hearing loss, tinnitis, hypotnesion, constopation, dirrhea, dry mouth, increase LFt, N/V, pancreatitis, hypercholestremia, hyperglycemia, hyperurcemia, hypokalemia, hypomagnesiemia, hyponatremia, hypovolemia, metaolic alkilosis, thrombocytopneaia, muscle cramps

What are the generic names for epidural agents?

bupivacaine ropivacaine

Nifedipine

can be used for tocolysis in preterm labor

Long-acting insulins have the most _______ onset and the _______ duration of all insulins.

delayed longest

Isotonic fluids will lead to expansion of the ______ fluids.

extracellular

IV admin of phenytoin

follow infusion with NS, avoid extravastation - vesicant - cant cause purple glove syndrome

contraindications for magnesium sulfate

hypocalcemia, anemia, heart block, avoid using for more thn 7 days for preterm labor, avoid using within 2hrs of delivery

Investigational agents

infusions and non-infusions Consult research protocol. Consult pharmacists as needed. *clinical trials

bumetanide

loop diuretic

furosemide (Lasix) class

loop diuretic

Every medication administration poses ____ and every administration should include a complete assessment of the ___ Rights.

risk Six

hyroxyzine brand name

vistarill

phenytoin admin

with or immediatly after meals Have pt take sip of water, take med, than swallow more water

Fluids in order of osmolarity

0.45% NS, D5W, D10W, LR, 0.9% NS, D5LR, D5 0.9%, 2%

Order for Nitro

0.4mg SL x3 per 5 min until pain stops What if order is 1/150th of a grain 60mg = 1grain

half life of hyroxyzine

3hrs

How should you draw up insulin?

Only use insulin syringes to draw up insulin. Do not use TB syringes.

Assessment prior to magnesium sulfate

Monitro P, BP, RR, and EKG, Respirations should be at least 16 before each dose If DTR hypoactive, no additional doses UO should be at least 100ml/4hr

Why shouldn't morphine be stopped suddenly after long-term use?

Morphine should be discontinued gradually to prevent withdrawal symptoms after long-term use.

Where is morphine sulfate metabolized and excreted?

Mostly metabolized by the liver. Active metabolites excreted renally.

Where is hydromorphone metabolized?

Mostly metabolized the liver.

metabolism of Nifedipine

Mostly the liver

When are thrombolytic agents considered high-alert medications?

Non-infusions and bolus doses

What is the onset, peak, and duration of PO-IR (immediate release) hydromorphone?

Onset: 30 min Peak: 30-90 min Duration: 4-5 hr

Half life of Nifedipine

2-5hrs

What are the policies and procedures for Chemotherapy/Cytotoxic medications that *ARE NOT* based on weight?

-Initial dose requires double check by 2 RNs. If oncology patient, one must be chemo certified RN or pharmacist. -Recalculates BSA for initial dose and each dose change.

What should the nurse teach the patient at discharge to do with his nitroglycerin if the patient develops an acute anginal attack in the future?

Advise patient to sit down and use medication at first sign of attack. Relief usually occurs within 5 min. Dose may be repeated if pain is not relieved in 5-10 min. Call health care professional or go to nearest emergency room if anginal pain is not relieved by 3 tablets in 15 min.

A laboring client, who has epidural analgesia, reports itching. A nurse informs a health-care practitioner who orders nalbuphine hydrochloride (Nubain®) 3 mg subcutaneously. The pharmacy supplies nalbuphine hydrochloride as 10 mg/mL. To provide the correct dose, the nurse should plan to administer _____ mL to the client.

ANSWER: 0.3 Use a proportion to determine the amount in milliliters. Multiply the extremes, then the means, and solve for X. 10 mg : 1 mL :: 3 mg : X mL 10 X 3 X 0.3. ➧ Test-taking Tip: Since the ordered dose is less than 10 mg, the amount to give should be less than 1 mL. Use the formula dose needed/dose on hand or a proportion formula.

A nurse prepares to administer naloxone (Narcan®) 0.4 mg intravenously (IV) to a client experiencing respiratory depression from morphine sulfate administered by patient-controlled analgesia (PCA). Naloxone is supplied in a 1 mg/mL vial. In order to give the correct dose, the nurse should administer ____ mL to the client.

ANSWER: 0.4 Use a proportion formula to calculate the correct amount: 1 mg : 1 mL :: 0.4 mg : X mL Multiply the extremes and then the means and solve for X. X = 0.4 mL ➧ Test-taking Tip: Use a medication formula to calculate the correct dosage. Double-check answers that seem unusually large.

What class of drug is argatroban?

Anticoagulant

What class of drug is bivalirudin?

Anticoagulant

Monitoring before Iv phenytoin

BP, EKG, respiratory function, CBC, calcium, albumin, hepatic function, glucose (increased)

Osmolality is primarily determined by what?

Because sodium is the most common extracellular electrolyte, osmolality is primarily determined by the sodium level.

Why is the risk of hypolgycemic episodes lessened in patients taking rapid-acting insulin?

Because these insulins leave the bloodstream quickly, the risk of hypoglycemic episodes several hours after the meal is lessened.

beers list

Beers criteria list 34 potentially inappropriate medications and classes to avoid in older adults.

Dilaudid

Beers list NArcan Slow IVP --> ringing in ears N/V

Nifedipine classification

CCB, antianginal, andtihypertensive

What are side-effects of morphine sulfate?

CNS: confusion, sedation, dizziness, dysphoria, euphoria, floating feeling, hallucinations, headache, unusual dreams. EENT: blurred vision, diplopia, miosis. Resp: RESPIRATORY DEPRESSION. CV: hypotension, bradycardia. GI: constipation, nausea, vomiting. GU: urinary retention. Derm: flushing, itching, sweating. Misc: physical dependence, psychological dependence, tolerance.

What solution is hydromorphone compatible in?

D5W, D5/0.45% NaCl, D5/0.9% NaCl, D5/LR, D5/Ringer's solution, 0.45% NaCl, 0.9% NaCl, Ringer's , LR.

Would insulin potentially cause an increase or decrease in serum phosphate, magnesium, and potassium levels?

Decrease

What isotonic solution is often used to manage dehydration? Why?

Dehydration is often managed by infusion of D5W. The reason for this is that the solution does not alter the interstitial and intracellular spaces, rather it replaces fluid volume in the intravascular space.

What is included in an initial review?

Depending upon the medication, this may include checking the lab value associated with therapeutic effect of the specific medication.

lab for warfarin/comadin

INR

What therapeutic class of drug is Methotrexate?

Cytotoxic agent Methotrexate is a high risk agent. Usual dose is 1-3 times per week. Daily dosing must be verified with the prescriber due to risk of neutropenia.

A client is to receive a systemic cephalosporin, cephalexin (Keflex®) 500 mg in 50 mL of normal saline intravenous piggyback (IVPB). The medication is to be infused over 20 minutes. To correctly infuse the medication, the nurse should set the pump rate at_______ mL/hr.

ANSWER: 150 50 mL : 20 min :: X mL/hr: 60 min/hr Multiple the means (inside values) and then the extremes (outside values) to solve for X. 20X = 3,000 X = 150 mL/hr ➧ Test-taking Tip: Use a formula to calculate the correct dose and verify the answer if it seems unusually large.

A child diagnosed with leukemia is to receive a unit of platelets. The child's weight is 33 lbs. The ordered rate for the platelets is 10 mL/kg/hr. A nurse should plan to transfuse the platelets at a rate of _______ mL/hr.

ANSWER: 150 First convert pounds to kilograms using a proportion formula (2.2 lbs = 1 kg). 2.2 lbs : 1 kg :: 33 lbs : X kg Multiply the extremes and then the means and solve for X. 2.2 X = 33 X = 15 kg. The child weighs 15 kilograms. Next determine the rate: Milliliter per hour at 10 mL/kg/hr. 10 mL : 1 kg :: X mL : 15 kg X = 150 mL/hr. The commonly accepted rate for transfusions in a child is 10 mL/kg/hr. ➧ Test-taking Tip: Read the question carefully to determine what is being asked. Recall that 2.2 pounds equals 1 kg.

A client is to receive esomeprazole (Nexium®) 40 mg oral daily. The medication is supplied in 20-mg capsules. In order to give the correct dose, a nurse should administer ____ capsules to the client.

ANSWER: 2 20 mg : 1 capsule :: 40 mg : X capsules 20X = 40 X = 2 capsules ➧ Test-taking Tip: Use a formula to calculate the correct dose and verify the answer if it seems unusually large.

A nurse is recording intake for a child hospitalized with diarrhea who has now begun to eat. The nurse should document ____ mL for the 3 ounces of popsicle that the child consumed.

ANSWER: 90 One ounce is equal to 30 mL. Using the proportion formula: 1 oz : 30 mL :: 3 oz : X mL Multiply the means and the extremes. X 90 mL. ➧ Test-taking Tip: Recall that 1 ounce is equal to 30 mL. Visualize a medicine cup, which is 1 ounce or 30 mL.

What are the policies and procedures for Chemotherapy/Cytotoxic medications *requiring dose adjustments based on weight*?

Chemotherapy/Cytotoxic medications that require dose adjustments based on weight: -Required double check by 2 Chemo-certified RNs or Pharmacist -Recalculates BSA and each individual medication dose independently

When an infusion device is used, what does the double check include?

Double check must also verify infusion pump settings, including rate and concentration.

What should the nurse ensure before beginning the procedure for administering High Alert Medications.

Ensure environment is free of distraction to allow for uninterrupted process.

Most neonatal medications are considered high-alert. What medications are exceptions?

Erythromycin eye ointment, Vitamin K, oral sucrose solution, Hepatitis B vaccine, and diaper area topical products.

When should alteplase and reteplase be reconstituted?

Immediately before use since they have no antibacterial preservatives.

When should pediatric medications be verified with another source?

In any situation where the parent or adult accompanying the patient has concerns with dosing.

What is applied to the neck of every neuromuscular blocking agent (and with what language) before the vial is stocked in an anesthesia tray or unit-based cabinet?

Shrink wrap is applied to the neck. It should say: "Warning Paralyzing Agent. Causes Respiratory Arrest-Use in Intubated Patients Only!"

Is morphine sulfate a high-alert medication?

Yes

When should the procedure and policies for high-alert medications be followed for Epidural class of therapeutic medications?

Initial settings, all dosing and program changes, every bag change.

When is the double check (Independent Second Check) initiated?

Initiated after the administering provider has completed an initial review.

How are epidural medications administered?

Intrathecal and Epidural infusions and PCEA

What is considered a high-alert medication?

-Anticoagulants (Heparin, therapeutic doses as drips or boluses, argatroban, bivalirudin) -Epidural (Intrathecal and Epidural inusions and PCEA) -Chemotherapy Agents/Cytotoxic Agents -Insulin (infusions, IV push, subcutaneous) -Investigational Agents (infusions & non-infusions) -Magnesium Sulfate (Family Birth Center Only - infusions and boluses) -PCA Opiates and Narcotics -Neonates -Neuromuscular Blocking Agents -Pediatric Medications (under 15 years of age)-All intravenous medications -Thrombolytic Agents-Non-infusions and bolus doses

What aren't considered high-alert medications, but Harrison has deemed them to be?

-Intravenous Potassium given as electrolyte replacement -Enoxaparin -Sodium chloride IV solutions greater than 0.9% -Narcotic infusions (not on PCA or PCEA)

What are the Six Rights of Medication Administration?

-Right Medication/Solution -Right Patient -Right Time -Right Amount/Dose/Concentration - including lab values if applicable -Right Route/Method of Administration -Right Documentation only after the medication has been given

Procedure for High alert medications

1. Ensure environment is free of distractions to allow for uninterrupted processes 2. An authorized clinician will perform the first 6 rights of verification of the ISC. A second authorized clinician will perform his or her own ISC. Six rights of verification without collaborating answers (such as calculations) with the first clinician 3. Both clinicians agree on the correct six rights of verification and each person independently derived calculations must match. This also includes the verification of correct programming of the IV pump, correct infusion set up and correct drug admin technique 4. Perform BCMA verification at bedside 5. Document med admin in eMAR

A client admitted with unstable angina is started on intravenous heparin and nitroglycerin. The client's chest pain resolves, and the client is weaned from the nitroglycerin. Noting that the client had a synthetic valve replacement for aortic stenosis 2 years ago, a physician writes an order to restart the oral warfarin (Coumadin®) 5 mg at 1900 hours. Which is the nurse's best action? a. Administer the warfarin as prescribed. b. Call the physician to question the warfarin order. c. Discontinue the heparin drip and then administer the warfarin. d. Hold the dose of warfarin until the heparin has been discontinued.

ANSWER: A Both heparin and warfarin are anticoagulants, but their actions are different. Oral warfarin requires 3 to 5 days to reach effective levels. It is usually begun while the client is still on heparin. Calling the physician is unnecessary. The nurse's scope of practice does not permit altering medication orders. The nurse should neither discontinue the heparin nor hold the warfarin without a written order. ➧ Test-taking Tip: Use the process of elimination to eliminate options 3 and 4, which alter medication orders, because these are not within the nurse's scope of practice. Of the two remaining options, focus on the action of heparin and warfarin. Recall that warfarin takes 3 to 5 days to reach therapeutic effectiveness, during which time the client will continue to require anticoagulation.

A health-care provider (HCP) adds a second medication for blood pressure control for a client whose blood pressure has not been well-controlled with one antihypertensive medication. If the HCP orders the following medication combinations, which combination should the nurse question? a. Atenolol (Tenormin®) and metoprolol (Lopressor®) b. Metolazone (Zaroxolyn®) and valsartan (Diovan®) c. Captopril (Capoten®) and furosemide (Lasix®) d. Bumetanide (BUmex®) and diltiazem (Cardizem®)

ANSWER: A When two medications are used to treat hypertension, each medication should be from different drug classifications. Atenolol and metroprolol are both beta-adrenergic blockers and would essentially have the same mechanism of action. Metolazone is a thiazide-like diuretic, and valsartan is an angiotensin II receptor blocker (ARB). Captopril is an angiotensinconverting enzyme (ACE) inhibitor, and furosemide is a loop diuretic. Bumetanide is a loop diuretic, and diltiazem is a calcium channel blocker. ➧ Test-taking Tip: Recall that beta blockers end in "lol." Use this as a cue to identify the two medications that are within the same drug classification and would be inappropriately prescribed.

A nurse is evaluating whether a client on multiple oral medications is taking the medications correctly. Which finding should be most concerning to the nurse because the absorption rate of medications can be increased? a. Taking afternoon oral medications with a carbonated soft drink b. Drinking a glass of milk with the tetracycline antibiotic oral medication c. Taking morning oral medications with water and consuming 2,500 mL of water daily d. Taking mealtime oral medication with a meal low in fiber and high in fatty foods

ANSWER: A Carbonated beverages can cause oral medications to dissolve faster, be neutralized, or experience a change in absorption rate in the stomach. When dairy products are taken with an antibiotic, such as tetracycline, there is decreased drug absorption in the stomach. Medications should be taken with a full glass of water. Foods low in fiber and high in fat will delay stomach emptying and medication absorption by up to 2 hours. ➧ Test-taking Tip: Focus on key words "most concerning" and the focus of the question: increases rate of absorption. Then use the process of elimination to select option 1. Although options 2 and 4 are concerning, these do not increase medication absorption rate.

A nurse receives the following medication orders while caring for multiple clients. Which medication should the nurse plan to administer first? a. Nitroglycerin (Nitrostat®) 0.4 mg sublingually (SL) stat for the client experiencing chest pain b. Morphine sulfate 4 mg intravenously (IV) now for the client experiencing incisional pain c. Lorazepam 2 mg IV now for the client experiencing restlessness and picking at tubing d. One unit packed red blood cells stat for the client with a hemoglobin of 9.5 g

ANSWER: A Nitroglycerin increases coronary blood flow by dilating coronary arteries and improving collateral flow to ischemic areas of the heart. Increasing collateral blood flow reduces anginal pain and the potential of myocardial infarction. This action has the greatest potential of changing client outcomes and can be performed more quickly than the other actions. Both morphine and lorazepam are controlled substances, requiring the nurse to retrieve and sign these out from a secure location. Administering IV medications takes longer than SL medications. Obtaining blood from the blood bank will take longer than the time it takes to administer a SL medication. Blood usually only if hgb <7 ➧ Test-taking Tip: Use the ABCs (airway, breathing, circulation) and the time it takes to implement each action to establish the priority. Because nitroglycerine affects the circulatory system, this action should be first.

A nurse is to administer vancomycin to a client diagnosed with sepsis. The client is to have a peak and trough level completed on this dose of the medication. Which action should the nurse initiate first? a. Determine if the trough level has been drawn on the client. b. Determine medication compatibilities before infusing into an existing intravenous line. c. Check the client's culture and sensitivity report. d. Check the amount of time over which the medication dose should infuse.

ANSWER: A The trough level is the lowest concentration so it needs to be collected just before the next administration. The peak level is the highest concentration - draw this 1-2hrs after completion of IV vanco. Determining medication compatibilities and checking C&S reports and the infusion duration are important actions before administering vancomycin. However, these actions can be done while the laboratory is obtaining the trough level or after knowing that the level has been drawn. ➧ Test-taking Tip: Note the key word "first" and focus on the situation "a peak and trough level." Eliminate options that do not pertain to obtaining a peak and trough level.

A nurse, checking newly written physician orders, determines that which orders require the nurse to contact the physician to clarify the order? SELECT ALL THAT APPLY. a. Aspirin 325 mg orally qd b. MS 4 mg IV q2hr prn c. Furosemide (Lasix®) 40 mg IV now d. D5W with 20 mEq KCL IV at 124 mL/hr (volume) e. Heparin 5,000 u subcutaneously bid

ANSWER: A, B, D, E The abbreviations "qd," "MS," and "u" are disallowed by the Joint Commission (formerly the Joint Commission on Accreditation of Healthcare Organizations [JCAHO]). Responses C and D are incorrect choices because these responses have the essential components of a medication order—medication name, dose, frequency, and route—and use of acceptable abbreviations. D is missing amount of fluid to give. ➧ Test-taking Tip: Read each order carefully to identify the disallowed abbreviations. Make sure each medication was the drug name, route, quantity, and time

Which instructions should the nurse provide to a client regarding diabetes management during stress or illness? SELECT ALL THAT APPLY. a. Notify the health-care provider if unable to keep fluids or foods down. b. Test finger stick glucose levels and urine ketones daily and keep a record. c. Continue to take oral hyperglycemic medication and/or insulin as prescribed. d. Supplement food intake with carbohydrate containing fluids, such as juices or soups. e. When on an oral agent, administer insulin in addition to the oral agent during the illness. f. A minor illness, such as the flu, usually does not affect the blood glucose and insulin needs.

ANSWER: A, C An acute or minor illness can evoke a counterregulatory hormone response resulting in hyperglycemia, thus the client should continue medications as prescribed. If the client is unable to eat due to nausea and vomiting, dehydration can occur from hyperglycemia and the lack of fluid intake. Blood glucose should be checked every 4 hours when ill and the ketones tested every 3 to 4 hours if the glucose is greater than 240 mg/dL. The client should supplement the diet with carbohydrate-containing fluids only if eating less than normal due to the illness. Insulin may or may not be necessary; it is based on the client's blood glucose level. ➧ Test-taking Tip: Focus on the counterregulatory hormone response during an illness that causes hyperglycemia.

An experienced nurse is supervising a new nurse caring for a hospitalized child who is receiving intravenous (IV) therapy. Which action should indicate to the experienced nurse that the new nurse needs additional orientation regarding IV therapy for children? a. Determines that the current solution has been infusing for 24 hours and should be changed b. Selects a 1,000 mL bag of the prescribed IV solution and checks it against the orders c. Prepares new tubing and the prescribed IV solution 1 hour before it is due to be changed d. Removes the plastic cover, spikes the bag with the tubing spike, and squeezes the drip chamber

ANSWER: B IV solutions in 250- and 500-mL containers should be selected to guard against circulatory overload. IV solutions are considered medications and errors in administration can have negative consequences. IV solutions open longer than 24 hours are no longer considered sterile. Tubing is changed every 72 to 96 hours, depending on agency policy. The procedure for spiking the bag is correct. The bag could be either hung first or after being spiked. IV can be spiked up to 1hr before administration. ➧ Test-taking Tip:The key words are "needs additional orientation." Read each option carefully to determine which option has the greatest potential for producing harm.

A nurse administers a usual morning dose of 4 units of regular insulin and 8 units of NPH insulin at 0730 to a client with a blood glucose level of 110 mg/dL. Which statements regarding the client's insulin are correct? a. The onset of the regular insulin will be at 0745 and the peak at 1300. b. The onset of the regular insulin will be at 0800 and the peak at 1000. c. The onset of the NPH insulin will be at 0800 and the peak at 1000. d. The onset of the NPH insulin will be at 1230 and the peak at 2330.

ANSWER: B The onset of regular insulin (short-acting) is one-half to 1 hour, and the peak is 2 to 4 hours. The onset of NPH insulin (intermediate acting) is 1 to 2 hours, and the peak is 6 to 10 hours. All other options have incorrect medication onset and peak times. ➧ Test-taking Tip: Apply knowledge of insulin onset and peak times.

A nurse applies a fentanyl (Sublimaze®) transdermal patch to a client for the first time. Shortly after application, the client is experiencing pain. Which nursing action is most appropriate? a. Remove the transdermal patch and apply a new one. b. Administer a short-acting opioid analgesic. c. Rub the transdermal patch to enhance absorption of the medication. d. Call the physician to request a fentanyl transdermal patch with a higher dosage.

ANSWER: B When the first fentanyl transdermal patch is applied, effective analgesia may take 12 to 24 (6) hours to develop because absorption is slow. Removing the patch is unnecessary. Transdermal patches should not be rubbed to enhance absorption because it can cause the delivery of the medication to fluctuate. It is premature to request a higher dose of fentanyl. ➧ Test-taking Tip: Focus on that fact that absorption from a fentanyl transdermal patch is slow.

A nurse receives an order to administer hydroxyzine (Vistaril®) 25 mg intramuscularly (IM) to a client. Before injecting the medication, which statements should the nurse make to the client? SELECT ALL THAT APPLY. a. "You will feel minimal pain at the injection site." b. "Expect to experience relief from nausea within about 10 minutes." c. "You will feel me pull the skin to the side at the site before I inject the medication." d. "Tense your muscle as I make the injection to avoid focusing on the injection itself." e. "I will select your deltoid muscle because use of the muscles with turning increases absorption." f. "You will feel a cold sensation as I cleanse your skin with the alcohol swab."

ANSWER: C, F Hydroxyzine is an antiemetic and sedative/hypnotic. The injection can be extremely painful, so it is administered by the Z-track IM method. In the Z-track method, the skin is pulled away from the injection site, the injection made, the medication is administered, and the nurse waits 10 seconds before the needle is withdrawn and the skin is released. The skin is disinfected with alcohol prior to administration, which will feel cool when applied. Medications administered by the IM route generally take 15 to 30 minutes to become effective. Tensing muscles increase pain. A large muscle such as the ventrogluteal, not the deltoid muscle, should be used for the injection. Literature suggests the ventrogluteal site is safer than the dorsogluteal site for intramuscular injections. ➧ Test-taking Tip: Note the issue of the question, an IM injection of hydroxyzine. Apply knowledge of IM injections and hydroxyzine to answer this question

A nurse gives a medication without checking the medication administration record (MAR) When the nurse documents the medication given, the nurse notices that the medication was also given 15 minutes earlier by another nurse, resulting in the client receiving a double dose. The nurse notifies a supervisor and a physician of the event. Which action should the nurse who administered the second medication dose expect? a. Assignment of fewer clients at one time b. Disciplinary action to the first nurse for giving the first dose c. Disciplinary action possibly including suspension or termination d. Completion of a variance (incident) report that would be reviewed by management

ANSWER: D The nurse who made the error should expect the completion of a variance report with review by management. A complete review of the situation needs to occur, including the type of medication, dose, outcome of the client, and steps of medication administration, including documentation. The nurse should not expect a change in client assignments. Although disciplinary action varies by organization, generally a pattern of incompetent actions must be demonstrated for suspension or termination. ➧Test-taking Tip: Use the process of elimination. Focus on the professional responsibility of the nurse. Look for the strategic words "variance" and "reviewed."

What is the second check? Who can do it?

Another licensed nurse, pharmacist, licensed provider (different from the one who did the first check and will administer the medication) will perform and independent *second check* that will include the following steps: -Perform 6 rights verification -Document dual sign-off on MAR to indicated that "independent second check" was completed according to requirements for each high alert medication.

Where aren't concentrated electrolytes stocked? What is the exception?

Concentrated electrolytes are not stocked in general patient care areas. Exception is only given to areas that perform high acuity, high intensity procedures (e.g., cardiac surgery) and in emergency drug boxes (Code Blue).

What therapeutic class of drug is Cyclophosphamide?

Cytotoxic agent Only oncology trained nurses may administer Cytotax (Cyclophosphamide) PO or IV, even if the indication is not for cancer.

True or False A double check is required for a tPA infusion?

False No double check is required for a tPA infusion.

For PCA/PCEA, what does the double check also include?

For PCA or PCEA double check must include infusion rate, bolus rate, bolus interval and hourly limit.

What does the double check include with initial infusion set-up and bag changes?

For initial infusion set-up and bag changes, verification must also include connection to correct infusion line and appropriate pump.

What is the first check? Who can do it?

Licensed nurse, pharmacist, licensed provider administering medication will perform a *first check* that will include the following steps: -Perform 6 rights verification -Label syringe with barcoded label provided by pharmacy if using stock bottle. -Document initial sign-off on MAR to indicate that the "first check" was completed according to requirements for each high alert medication.

What are High Alert Medications?

Medications that have been identified through national literature as having the greatest frequency of misuse, coupled with the highest severity of harm when administered improperly.

What should the nurse do if they suspect the pediatric dose is incorrect?

Nursing staff should also check with a pharmacist with any questions and the prescriber if the dose seems incorrect.

When should high-alert medications policies and procedures be done for PCA Opiates and Narcotics?

PCA-initial settings, all program changes, and medication cartridge changes.

What is PCEA?

Patient-controlled epidural analgesia (PCEA).

When is the independent double check process performed?

Performed immediately before administration of a High Alert medication.

How should high-alert medications be dispensed?

Pharmacy dispenses certain high-alert medications with additional auxiliary warning labels.

Why does the pharmacy limit the use of auxiliary labels?

Pharmacy limits the use of auxiliary labels so that there is not an overabundance of warning labels which diminishes the overall effect of warning label.

What does an Independent Second Check require?

Requires two authorized staff (licensed nurse, pharmacist, licensed provider) to perform independent checks on medications identified as "high alert" using the 6 rights. The independent process requires the first clinician to complete the six rights by him or herself, and than the second clinician completes the same verification again without collaborating answers. The med can be given once they both have agreed that their separate answers match. Check must be performed and documented in the eMAR - all administered via IV pump

The Licensed Care Provider administering the medication and Licensed Care Provider performing the independent second check should sign-off what on the MAR?

Sign-off on the MAR that they verified patient assessment (including appropriateness of ordered medication), patient name, drug name, dose, quantity or volume, strength and pharmacy supplied syringe label from stock bottle/multi-dose vial (if used) of the medication to be administered.

Every medication administration should include a complete assessment of what?

Six Rights

What should the nurse receiving a patient with high-alert medications do?

The nurse receiving the patient will perform an independent check of all high-alert medications that the patient is currently receiving, and will document in the EHR (select 'Handoff' in the eMAR form for each high alert medication.

What is the therapeutic classification of morphine sulfate? What is the pharmacologic classification?

Therapeutic: opioid analgesics Pharmacologic: opioid agonists

How should alteplase and retaplase be reconstituted?

They should be reconstituted with Sterile Water for Injection, USP, without preservatives. Do not use Bacteriostatic Water for Injection, USP.

How to perform second check with student RN

Two other licensed clinicians must perform the ISC processes with the student. In the comments field in the epic system the names of the two licensed clinicians who performed the ISC must be documented

What would you look up if you were unsure of the medication?

What it is Safe dose/route What does it do Why are they taking it Interactions SE How do you know if its working

A nurse is caring for a group of clients all in need of pain medication. The nurse has determined the most appropriate pain medication for each client based on the client's level of pain. Prioritize the order in which the nurse should plan to administer the pain medication beginning with the analgesic for the client with the most severe pain. a. ___ Ketorolac (Toradol) 10 mg oral b. ___Fentanyl (Sublimaze®) intravenously per patient-controlled analgesia with a bolus dose c. ___Hydromorphone (Dilaudid®) 5mg oral d. ___Morphine sulfate 4 mg IV

a. _4__ Ketorolac (Toradol) 10 mg oral b. _1__Fentanyl (Sublimaze®) intravenously per patient-controlled analgesia with a bolus dose c. _3__Hydromorphone (Dilaudid®) 5mg oral d. _2__Morphine sulfate 4 mg IV The most potent of the medications is fentanyl (Sublimaze®), an opioid narcotic analgesic that binds to opiate receptors in the central nervous system (CNS), altering the response to and perception of pain. A dose of 0.1 to 0.2 mg is equivalent to 10 mg of morphine sulfate. Morphine sulfate is also an opioid analgesic. Hydromorphone, another opioid analgesic, would be third in priority. The oral dosing of this medication would indicate that the client's pain is less severe than the client receiving fentanyl or morphine sulfate. Hydromorphone 7.5 mg oral is an equianalgesic dose to 30 mg of oral morphine or 10 mg parenteral morphine. Ketorolac is a NSAID and nonopioid analgesic that inhibits prostaglandin synthesis, producing peripherally mediated analgesia. Propoxyphene is last in priority. It also binds to opiate receptors in the CNS but is used in treating mild to moderate pain. It has analgesic effects similar to acetaminophen. ➧ Test-taking Tip: Focus on ordering the medications starting with the most potent opioid analgesics and ending with the nonopioid analgesic.

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