Pharmacology-Exam 3

Meds to slow Heart Rate

1. Beta Adrenergic Blockers 2. Calcium Channel Blockers

The nurse would be especially cautious to avoid extravasation of which drug that is commonly administered intravenously? 1. Phenobarbital (Luminal) 2. Phenytoin (Dilantin) 3. Ethosuximide (Zarontin) 4. Clonazepam (Klonopin)

2 Rationale: Dilantin is frequently administered IV due to slow and variable absorption rates when given orally. If Dilantin extravasates, serious soft tissue damage can result. Phenobarbital would be more likely to be administered orally and is infrequently given intravenously. Zarontin and Klonopin are oral medications.

Which drug is the primary agent for paroxysmal supraventricular tachycardia (PSVT)? 1. Flecainide (Tambocor) 2. Adenosine (Adenocard) 3. Lidocaine (Xylocaine) 4. Procainamide (Pronestyl)

2. Adenosine (Adenocard)

The nurse is managing care for a group of patients receiving antidysrhythmic medication. Which assessment data will the nurse discuss with the prescriber as adverse effects of these medications? 1. Depression, irritability, fatigue, and nausea 2. Anorexia, insomnia, confusion, and 2+ pitting peripheral edema 3. Low-grade fever, diaphoresis, weakness, and dry mucous membranes 4. Palpitations, chest pain, weakness, and fatigue

4

The mechanism of action of the antidiarrheal atropine (Lomotil) is to 1. promote stool passage. 2. block dopamine receptors in the brain. 3. increase stool formation. 4. slow peristalsis.

4 Rationale: Antidiarrheals such as atropine slow peristalsis and allow water reabsorption. Laxatives promote stool passage and increase size of stool. Antiemetics block dopamine and inhibit vomiting centers. Laxatives increase stool passage.

Prediabetes

- AIC 5.7 to 6.5, FBG-100-125

Nursing Implications for the patient with peptic ulcers, GERD

- Assessment --- H & P, V/S, wt., med list, caffeine, alcohol, smoking use --- CBC, gastric pain?, monitor for GI bleed - Interventions --- Monitor lab (renal/hepatic functions), CBC, v/s, need for supplements?; monitor for URI, - Reassessment --- Improvement in pain,? Diarrhea --- Experiencing adverse effect

therapeutic goals of Pharmacotherapy for Alzheimer's

- Goal of therapy is to improve function in ADLS, behavior and cognition, - Therapy is begun soon after diagnosis - Acetylcholinesterase Inhibitors

Food groups to treat Folic Acid Deficiency

- Increase fresh green veggies, dried beans, wheat products

teaching points: psyllium mucilloid (Metamucil)

- Mix the product in a full glass of water and drink another glassful after taking the drug.

Nursing intervention

- Monitor rhythm - worsening of HF symptoms - blood pressure, - bronchospasm - (goal at least 25mg twice daily)

Peptic Ulcer Disease

- Ulcer: erosion of the mucosa layer of the GI tract --- Gastric ulcer (stomach) --- Duodenal ulcer (duodenum)-small intestine

Lubiprostone (Amitiza)

- treat chronic constipation and IBS (Irritable bowel syndrome) - help stimulate the colon, so there is more regularity

what the suffix for H2 receptor blocker?

-tidine Ranitidine (Zantac) Cimetidine (Tagamet)

From a pharmacology standpoint, which statement best explains why levodopa is superior to dopamine? 1. It crosses the blood-brain barrier. 2. It has fewer adverse effects. 3. It has less risk for addiction. 4. It can be administered orally.

1 Rationale: Levodopa can cross the blood-brain barrier, but dopamine cannot. Levodopa administration leads directly to dopamine synthesis. Levodopa does not have fewer side effects. There is no risk for addiction from either substance. Route of administration is not a factor.

Spasticity is most commonly caused by damage to what area of the body? 1. Cerebral cortex 2. Peripheral nerves 3. Brainstem 4. Spinal cord

1 Rationale: Spasticity usually results from damage to the motor area of the cerebral cortex. Spasticity is not likely to occur with damage to peripheral nerves, the brainstem, or the spinal cord.

Nursing interventions: Lidocaine

Absorption of lidocaine in the general circulation causes systemic toxicity and may cause respiratory depression. Ensure resuscitation equipment is available nearby.

what is the drug of choice for PSVT (paroxysmal supraventricular tachycardia)

Adenosine

Which anti-dysrhythmics drugs have 10 second half life?

Adenosine adverse effects are generally self-limiting because of its 10-second half life.

Hemostatics

Aminocaproic acid (Amicar) (IV or PO) - Given after surgery to reduce post op bleeding. Given to patients with hemophilia血友病 after dental procedures.

Risks of ARNI

Angioedema Hyperkalemia-monitor K+ level Renal- monitor serum creatinine

Nursing interventions: Thiazide Diuretics

Blood pressure, monitor electrolytes and renal labs

Identify the first line treatment for dysrhythmias.

Correction of electrolytes imbalances

Side Effects of ACE Inhibitors

Cough- "Ace Cough"-20% of patients-dry non-productive cough --- From inhibiting kininase and bradykinin

Angiotensin Converting Enzyme Inhibitors (ACE)

Enalapril, Fosinopril, Lisinopril, Ramipril, Captopril - FIRST LINE TREATMENT - ↓ fluid volume and ↓ BP peripheral resistance and inhibit aldosterone secretion, so also ↓ preload - Reduces mortality and morbidity - Any patient with a reduced EF <40% regardless of symptoms unless contraindicated - Heart Failure Quality Core Measure

Example drugs to treat Folic Acid Deficiency

Folic Acid

therapeutic goals of Parkinson's pharmacotherapy

Goal is to increase the patient ability to perform ADL's

Nursing implications for constipation drugs

Increase fluid intake for constipation patients

Contraindications with aldosterone antagonists

Life threatening hyperkalemia or renal insufficiency

Nursing interventions: ARB blockers

Monitor K+ and renal labs, blood pressure

what drug treat for Zollinger-Ellison syndrome

Omeprazole (Prilosec)- proton pump inhibitor

what drugs cause blue men syndrome?

Potassium Channel Blockers - Amiodarone (Cordarone)

A client with a diagnosis of cancer is receiving epoetin alfa (Epogen, Procrit) as part of the treatment regimen. Select important assessments by the nurse. a. Assessing the client's energy level. b. Monitoring the hematocrit and hemoglobin levels. c. Monitoring the client's blood pressure. d. Assessing for neurologic changes e. Assessing for the presence of infections

a,b,c,d

Side effects/Adverse effects: eltrombopag (Promacta)

arthralgia, myalgia, and paresthesia, HA, flu like sx (more serious-bone marrow fibrosis, thromboembolism, hematologic malignancy & hepato toxicity. Cataract formation)

Thrombin time

assesses for fibrinogen deficiency

Side effects: Dexamethasone (Decadron)

hyperglycemia, fluid retention, increase B/P

Prothrombin time (PT)

monitors warfarin therapy

Nursing implications: Phenobarbital (Luminal)

- ** may take several weeks to be effective, not used for absence seizures; serum blood levels to monitor therapeutic level - Pregnancy Category D and is contraindicated in pregnancy.

Side effects/Adverse effects: ferrous sulfate (Feosol)

- Adverse effects-nausea, heartburn, constipation, diarrhea, dark stools, hypotension - More serious adverse effects-cardiac collapse, aggravation of peptic ulcers or ulcerative colitis, hepatic necrosis - Iron dextran (IV only) can cause anaphylaxis - There are slow release preparations that are tolerated better and cause less GI distress (more expensive)

Example drugs to treat Pernicious Anemia

- Cyanocobalamin (Nascobal) - form of Vitamin B12 - Given deep SubQ or IM initially and then PO - There is a nasal spray available (for maintenance therapy)

Diagnosis of Diabetes- Type 2 Diabetes:

- FBS >126 (8-hour fast) - A1C>6.5 % (do not need to be fasting) - Oral glucose tolerance test-OGTT->200 (do not have to fasting) - Random plasma glucose >200 with symptoms that indicate diabetes (polyuria, polydipsia or weight loss) - Patient may have risk factors (weight gain, obesity, sedentary lifestyle, genetics, poor diet) - signs or symptoms that indicate diabetes-fatigue, blurred vision, thirst, yeast infections, skin infections, UTIs, nocturia, unintentional weight loss, acanthosis nigricans (also associated with obesity) - Prediabetes- AIC 5.7 to 6.5, FBG-100-125

Teaching points: Ethosuximide (Zarontin)

- Ginkgo may reduce the therapeutic effects of ethosuximide (Zarontin).

senna (Ex-Lax)

- Herbal agents - Herb that irritates bowel, increases peristalsis

Ivabradine (Corlanor)- no generic

- Selectively inhibits the SA node-decreases HR - Useful when maximum does of beta blocker reached or beta blocker contraindicated - Reduce hospitalizations and death in HFrEF (<35%) patients NYHA class II-III - Maximum doses of medical treatment, sinus rhythm with HR >70 - Contraindicated in decompensated state - cost (expansive)

Side Effects/Adverse Effects: Lidocaine

- Side Effects: dizziness, N/V, lethargy, bradycardia, - Adverse effects: CNS toxicity: confusion, seizures, slurred speech, paresthesia-a numbing sensation associated with nerve endings, respiratory depression

Side effects/Adverse effects: Memantine (Namenda)

- Side effect: dizziness, fatigue, HA, - Adverse effects: hypertension, sedation, anemia

Side effects/Adverse effects: Diazepam (Valium)

- Side effect: drowsiness, sedation - Adverse effects: respiratory depression, hypotension, muscular weakness

Side effects/Adverse effects: Phenobarbital (Luminal)

- Side effect: sedation - Adverse effects: respiratory depression, CNS depression, blood dyscrasias体液不调

Emetics

- Stimulate vomiting Uses - Ingestion of poisons, overdoses of oral drugs ** must know what is been ingested (poison, toxin, or medication) prior to initiating vomiting - sometimes, we don't want to the vomit back up because it will cause esophageal burns significantly.

docusate (Colace)

- Stool softeners - Water and fat is absorbed into the stool - Prevent constipation

Benztropine (Cogentin)

- Therapeutic class: antiparkinson drug - Pharmacologic class: centrally acting cholinergic receptor blocker (anticholinergic) - Mechanism of action: blocks excess cholinergic stimulation of neurons - Indication: suppresses tremors

Side Effects of Phosphodieterase Inhibitors

- Ventricular arrhythmias (1 in every 10 patients) including torsades de pointes - Shortens AV conduction time - Hypotension

which drugs can use for bowel preps?

- bisacodyl (Dulcolax) - polyethylene glycol (MiraLax) - Sodium phosphate (Fleet Phospho-Soda)

Miscellaneous drugs for diarrhea

- bismuth subsalicylate (Pepto -Bismol) - Be alert - has salicylate (tinnitus) - Lactobacillus acidophilus

Platelet Enhancers--romiplostin (Nplate)

- given Sub Q and eltrombopag (Promacta) given PO- used in chronic immune idiopathic thrombocytopenia purpura (ITP)n(this disorder results low production of platelets or increased destruction of platelets). Patient with ITP increased risk for bleeding & bruising anywhere in body.

Nursing interventions: Phosphodieterase Inhibitors

- monitor BP - monitor for arrhythmias - check potassium, magnesium - measure QT interval

Nursing interventions: Digoxin

- monitor for visual disturbance - bradycardia - check apical pulse - digoxin levels - K+ level - Mg+ level

Administration: Promethazine (Phenergan)

- oral, IV (very cautious must be given in smallest dose possible and be diluted, and in a large IV-slow IV push), IM, suppository - This medication can cause severe respiratory depression and should not be used in children under the age of two. - When given via IV push, patients receiving promethazine should be closely monitored for signs of tissue necrosis.

Scopolamine (Transerm-Scop)

- patch - Anticholinergic; inhibits muscarinic activity of acetylcholine

Recognize laboratory testing used to monitor anticoagulation therapy.

- patients on warfarin must have regular follow up to check their INR - patients on heparin in the hospital we check their aPTT - Patients on apixaban(Eliquis), rivaroxaban (Xarelto), dabigatran (Pradaxa) do not have labs that are monitored - However, all of these meds create a significant risk for bleeding.

what the suffix for proton pump inhibitor?

- prazole esomeprazole (Nexium) lansoprazole (Prevacid) omeprazole (Prilosec)

Platelet Enhancers--Oprelvekin (Neumega)

- produced through recombinant DNA technology and stimulates production of megakaryocytes and thrombopoietin. - Indications-used for patients at risk for thrombocytopenia during chemo. Given subQ - Higher risk for causing heart failure, fluid retention

Side Effects: Epinephrine

- restlessness, - angina, - HTN, - tachycardia

signs and symptoms of Type 1 diabetes

- sustained hyperglycemia, BG >126 fasting, more abrupt onset, polyuria, polyphagia, polydipsia, glycosuria, weight loss -if pts. have lack of insulin, fatigue, weakness. Some present with ketoacidosis. (Occurs over days to several weeks) - Can result in body using lipids for energy source (ketolysis) because no insulin means no glucose can enter cell. Results in ketonuria can lead to ketoacidosis.

The nurse teaches the patient with a neuromuscular disorder about nonpharmacological treatment of muscle spasms. What will the best information include? 1. Application of heat or cold 2. Ultrasound 3. Massage 4. Relaxation techniques 5. Guided imagery

1,2,3 Rationale: Nonpharmacological treatment of muscle spasms includes application of heat or cold, ultrasound, and massage. Guided imagery is not a nonpharmacological treatment for muscle spasms. Relaxation techniques are not a type of nonpharmacological treatment for muscle spasms.

Which drug would be indicated for treating ventricular tachycardia? 1. Lidocaine (Xylocaine) 2. Verapamil (Calan) 3. Diltiazem (Cardizem) 4. Atropine (Atropair)

1. Lidocaine (Xylocaine) Rationale: Lidocaine is a sodium channel blocker and is indicated for ventricular dysrhythmias. Verapamil and diltiazem are calcium channel blockers indicated for atrial dysrhythmias. Atropine is a cholinergic-blocking agent and causes an increase in heart rate.

Meds that Stabilize Rhythm

1. Potassium Channel Blockers 2. Sodium Channel Blockers

The nurse is aware that antacids containing aluminum can cause 1. low iron levels. 2. abdominal pain. 3. constipation. 4. indigestion.

1 Rationale: Aluminum compounds can inhibit the absorption of dietary iron. Antacids do not cause abdominal pain. Calcium-based products, such as Tums, cause constipation. Antacids would help the indigestion.

The nurse is assisting the older adult diagnosed with a gastric ulcer to schedule her medication administration. What would be the most appropriate time for this patient to take her lansoprazole (Prevacid)? 1. About 30 minutes before her morning meal 2. At night before bed 3. After fasting at least 2 hours 4. 30 minutes after each meal

1 Rationale:PPIs such as lansoprazole(Prevacid) should be taken before the first meal of the day. The proton pump is activated by food intake. The administration of a PPI 20 to 30 minutes before the first major meal of the day will allow peak serum levels to coincide with the occurrence of maximum acidity from the proton pump activity. Options 2, 3, and 4 are incorrect. PPIs should be taken before the first major meal of the day, not at night or after meals. Fasting is not required for this drug.

Side Effects: Digoxin (Lanoxin)

Bradycardia, anorexia, N/V, visual disturbances such as seeing halos, a yellow-green tinge, or blurring.

Angiotensin II Receptor Blockers (ARB)

Candesartan, Valsartan - ARBs are recommended in patients with HF with reduced EF with current or prior symptoms - If they are ACE inhibitor intolerant (cough, angioedema) unless contraindicated - Reduce morbidity and mortality

The nurse notes that a patient who has Parkinson's disease often has twitching of the eye and increased tremors when medications are being administered. The nurse discusses which changes in therapy with the provider? 1. Increasing the dose of medications 2. Changing the interval between doses of medication 3. Using a liquid form of the medication 4. Scheduling a drug holiday 5. Adding an adjunctive drug

Correct Answer: 1,2,5 Rationale: These findings may indicate a wearing-off time has occurred. The dose of medication may need to be increased, the timing of drug administration may need to be changed, or an adjunctive drug may need to be added. There is no indication that a liquid form of the medication is indicated. The patient needs to remain on the medication.

What will the nurse include when teaching a caregivers' support group about Alzheimer's disease? 1. Glutamergic inhibitors are the most common class of drugs for treating Alzheimer's disease. 2. Depression and aggressive behavior are common with the disease. 3. Memory difficulties are an early symptom of the disease. 4. Chronic inflammation of the brain can be a cause of the disease. 5. Pharmacologic therapies are given to help improve memory in Alzheimer's disease.

Correct Answer: 2,3,4,5 Rationale: Depression and aggressive behavior are common symptoms of the disease. Memory difficulties are an early symptom of Alzheimer's disease. It is suspected that chronic inflammation and excess free radicals can cause neuron damage and contribute to the disease. The acetylcholinesterase inhibitors are the most widely used class of drugs for treating the disease. These drugs work by increasing the availability of acetylcholine. Acetylcholine is involved in cognition, memory, and learning. Glutamergic inhibitors are not the most common class of drugs for treating Alzheimer's disease.

The patient receives warfarin (Coumadin). The nurse notes that the patient's morning international normalized ratio (INR) is 7-. What are the priority nursing interventions at this time? 1. Hold the next dose of warfarin (Coumadin) and repeat the international normalized ratio (INR). 2. Administer protamine sulfate and hold the next dose of warfarin (Coumadin). 3. Hold the next dose of warfarin (Coumadin) and contact the physician. 4. Administer vitamin K and hold the next dose of warfarin (Coumadin).

Correct Answer: 4 Rationale: Vitamin K is the antidote for warfarin (Coumadin) overdose, and its administration is warranted with an international normalized ratio (INR) of 7-. Repeating the international normalized ratio (INR) is appropriate, but the patient must receive vitamin K immediately. Protamine sulfate is the antidote for heparin, not warfarin. Consulting the physician is appropriate, but the patient must receive vitamin K immediately.

Dexamethasone (Decadron)

Corticosteroid, anti-inflammatory,

Cardiac glycoside

Digoxin (Lanoxin) - ↑ contractility/strength of the contraction= ↑ CO - Can be beneficial in patients with HF with reduced EF, unless contraindicated - Can decrease hospitalizations for HF - Can improve symptoms, quality of life, and exercise tolerance in patients with mild to moderate HF

Naloxegol (Movantik)

treat chronic constipation in pt. taking Opioids (block Mu receptors)

Side Effects of Aldosterone Antagonists

Hyperkalemia - hyperkalemia increases when serum creatinine is >1.6 mg/dL. - Baseline serum K+ needs to be <5.0 mEq/L - Monitor for arrhythmias due to ↑K+ - Teach patient to avoid K+ rich foods (bananas, citrus fruits, tomatoes and using salt substitutes) - Worsening Renal Function -BUN, Cr, GFR

Nursing implication: Metoclopramide (Reglan)

IV, orally, slow IV push

Nursing interventions: Potassium Sparing Diuretics

Monitor K+, BUN, monitor for arrhythmias

Nursing interventions: vasodilators

Monitor all vital signs, monitor for arrhythmias

Potassium Sparing Diuretics

Spironolactone, Triamterene, Amiloride, Eplerenone - Limited Use- not as effective - Exception-Spironlactone (more later) - Inhibits aldosterone at the distal renal tubules - Promotes Na and H2O excretion and K retention - Diuretic effect can be delayed 2-3 days when used alone

Platelet count

a part of CBC, assesses for adequate or deficient platelets

what drugs decrease preload (volume) and antagonize aldosterone

aldosterone antagonists- Spironolactone (Aldoctone)

The nurse explains to the client that the development of pernicious anemia is caused by: a. Bone marrow depression. b. Vitamin B12 deficiency. c. Iron deficiency. d. Blood loss.

b. Vitamin B12 deficiency.

what drugs block sympathetic stimulation?

beta adrenergic blockers - Carbedilol (Coreg) - Bisoprolol (Zebeta) - Metoprolol (Lopressor)

The client receiving chemotherapy is prescribed oprelvekin (Neumega) as part of the treatment regimen. The nurse explains that the function of this drug is to: a. Stimulate white blood cell production. b. Reverse bone marrow suppression. c. Stimulate platelet production. d. Reduce excessive immature white cells.

c. Stimulate platelet production.

what drugs increase contractility (positive inotropic)?

cardiac glycoside - Digoxin (Lanoxin)

Beta Adrenergic Blockers

carvedilol (Coreg), Bisoprolol (Zebeta), and metoprolol (Lopressor) - Decrease workload by slowing HR and decrease BP - Only 3 beta blockers proven to reduce mortality in HF - Recommended for all patients with current or prior symptoms of HF with reduced EF unless contraindicated - Reduce morbidity and morality - Reverse ventricular remodeling - Start at a low dose and gradually increase

Side effects/Adverse effects: Sucralfate (Carafate)

constipation

Bleeding time

diagnosis of coagulation disorders

Side effects: Scopolamine (Transerm-Scop)

drowsiness, dry mouth, urinary retention

Side effect: Adenosine (Adenocard)

dyspnea, facial flushing, dizziness

Identify acute and chronic complications of diabetes

heart disease, PAD, MI, CVA, blindness, kidney failure, neuropathies, amputations, sexual dysfunction, depression, increased risk for infections, poor wound healing

Which antidysrhythmic agent also dilates coronary arteries and is frequently used to treat angina? 1. Verapamil (Calan) 2. Amiodarone (Cordarone) 3. Procainamide (Pronestyl) 4. Lidocaine (Xylocaine)

1. Verapamil (Calan) Rationale: Verapamil is a calcium channel blocker that is often used to treat angina by dilating coronary arteries. Amiodarone is a potassium channel blocker that prolongs the action potential and decreases automaticity. Procainamide is a sodium channel blocker that reduces automaticity and slows conduction of the action potential across the myocardium. Lidocaine is a sodium channel blocker and is indicated for ventricular dysrhythmias.

In monitoring clients receiving erythropoiesis-stimulating agents, it is most important for the nurse to monitor for 1. thromboembolus. 2. TIA (transient ischemic attack). 3. MI (myocardial infarction). 4. stroke.

1. thromboembolus. Rationale: Clients are at greater risk for thrombolytic disease, which can result in MI, stroke, and TIA. Transient ischemic attack can occur as a result of thromboembolic disease. Myocardial infarction can occur as a result of thromboembolic disease. Stroke can occur as a result of thromboembolic disease.

Heparin anti-Xa

monitors heparin or LMWHs in patients with heparin resistance

Activated partial thromboplastin time (aPTT)

monitors heparin therapy

Activated clotting time (ACT)

monitors high dose heparin therapy

International normalized ratio (INR)

monitors warfarin therapy

Lisinopril (Prinivil) is often used to treat heart failure because it lowers blood volume. Which statement best explains how lisinopril lowers blood volume? 1. It has an antagonistic effect on angiotensin-converting enzyme. 2. It lowers aldosterone secretion, a hormone that increases sodium reabsorption. 3. It causes hypernatremia and increased renal tubule permeability, resulting in a diuretic effect. 4. It causes a diuretic effect by lowering the amount of sodium lost in the urine.

2 Rationale: ACE inhibitors lower blood volume by lowering the secretion of aldosterone from the adrenal cortex. ACE inhibitors have an antagonistic effect on angiotensin-converting enzyme, but this action lowers blood pressure by reducing peripheral vascular resistance, not by lowering blood volume. Increasing sodium in the blood will not lower blood volume. Aldosterone is a hormone that increases the reabsorption of sodium and water.

A client has developed nausea and vomiting. What is the nurse's primary treatment? 1. Replacing fluids 2. Identifying and eliminating the cause 3. Encouraging the client to lie still 4. Providing the client with soft foods

2 Rationale: Nausea and vomiting are often due to modifiable conditions. Eliminating the conditions is the primary treatment. Replacement of fluids is essential but not the primary treatment. If the client is vomiting, lying still is difficult and may be dangerous if aspiration occurs. The client should not eat while nauseated and vomiting.

The patient tells the nurse that she awakens frequently during the night because of leg and foot cramps. What is the best response by the nurse? 1. "Ask your physician for a muscle relaxant." 2. "Increase your intake of vitamin B6." 3. "Take a warm bath before going to bed." 4. "Apply heat to relieve the cramping."

2 Rationale: Oral therapy with vitamin B6 may reduce the intensity and duration of leg muscle cramping. It is premature to ask the physician for a muscle relaxant. Applying heat will relax the muscles but will not prevent cramping. Taking a warm bath will relax the muscles but will not prevent cramping.

The patient is scheduled to receive rimabotulinum- toxinB (Myobloc) for treatment of muscle spasticity. Which of the following will the nurse teach the patient to report immediately? 1. Fever, aches, or chills 2. Difficulty swallowing, ptosis, blurred vision 3. Continuous spasms and pain on the affected side 4. Moderate levels of muscle weakness on the affected side

2 Rationale:Dysphagia,ptosis,and blurred vision are all symptoms of possible botulinum toxin B toxicity and must be reported immediately. Options 1, 3, and 4 are incorrect. Fever, aches, and chills are not anticipated side effects. Moderate levels of muscle weakness may occur after the drug is administered, and strengthening exercises may be needed on the affected side. Continuous muscle spasms and pain should not occur because the drug blocks muscle contraction.

The nurse discusses the disease process of multiple sclerosis with the patient and caregiver. The patient will begin taking glatiramer (Copaxone), and the nurse is teaching the patient about the drug. Which of the following points should be included? 1. Drink extra fluids while this drug is given. 2. Local injection site irritation is a common effect. 3. Take the drug with plenty of water and remain in an upright position for at least 30 minutes. 4. The drug causes a loss of vitamin C so include extra citrus and foods containing vitamin C in the diet.

2 Rationale:Glatiramer(Copaxone)isgivenby injection and often causes injection site irritation. Options 1, 3, and 4 are incorrect. Extra fluids do not need to be included and the drug is not given orally. It does not deplete vitamin C from the body.

A patient being treated for GERD has increased risk for development of infection with Clostridium difficile. The nurse would include which information in this patient's teaching? 1. Report any episode of diarrhea. 2. Treat diarrhea with over-the-counter antidiarrheal drugs. 3. Increase intake of active culture yogurt. 4. Avoid fatty foods. 5. Increase fluid intake.

2,3 Rationale: Antidiarrheal drugs may cause retention of harmful bacteria. Dairy products containing live active cultures help restore normal flora. The patient does not need to report each episode of diarrhea but should report if the amount increases or is frequent, or if the stool includes mucus, blood, or pus. Avoidance of fatty foods and increasing fluids are not specifically prescribed to treat this condition.

A patient says, "Ever since I changed jobs I just don't feel as good. I think my heart medicine is not working." What nursing assessment questions are priority? 1. "How well are you sleeping?" 2. "How did your new job change your work schedule?" 3. "How did your new job change your insurance coverage?" 4. "How has your job change affected your home life?" 5. "In what way do you not feel as well?"

2,3,5 Rationale: The nurse's first question should clarify what the patient means by not feeling as well. If the patient has had a change in work schedule, it may be that medications are being taken at a different time or at various times during the week. This would affect their efficacy. If a change in insurance coverage has occurred, it may be that the brand of medication covered is changed. The patient who is doing well on one brand of medication should not change brands. Sleeping is always of concern but is not the highest priority in this assessment. While this question may reveal information about stressors at home, it is not of the highest priority in this conversation.

The client is scheduled for bowel surgery. What medications are appropriate for cleansing the bowel, or "bowel prep," prior to this procedure? 1. Docusate sodium (Colace) 2. Bisacodyl (Dulcolax) 3. Methylcellulose (Citrucel) 4. Sodium phosphate (Fleet Phospho-Soda) 5. Mineral oil

2,4 Rationale: Bisacodyl (Dulcolax) is a stimulant laxative and appropriate for a "bowel prep." Sodium phosphate (Fleet Phospho-Soda) is an osmotic saline laxative and appropriate for a "bowel prep." Docusate sodium (Colace) is a stool softener and is not appropriate for a "bowel prep." Methylcellulose (Citrucel) is a bulk-forming laxative and is not appropriate for a "bowel prep." Mineral oil is not appropriate for a "bowel prep."

A client asks if he could use an over-the-counter bulk-type laxative. Which assessment finding would cause the nurse to tell the client not to use this drug? 1. The client is over age 60. 2. The client takes warfarin every other day. 3. The client has type 2 diabetes. 4. The client has a history of fecal impaction. 5. The client is allergic to penicillin.

2,4 Rationale: Bulk-type laxatives may decrease the absorption and effects of warfarin. If there is a chance that the client has a fecal impaction, bulk-type laxatives should not be used. There is no contraindication for use of this laxative class in clients over 60. Bulk-type laxatives may decrease the absorption and effects of warfarin. Allergy to penicillin is not a contraindication for use of bulk-type laxatives.

The nurse is presenting community education regarding self-treatment of heartburn with antacids. As part of this discussion, the nurse advises people with which conditions to avoid antacids? 1. People with low calcium levels. 2. Those with diminished renal function. 3. Women who are perimenopausal. 4. People who are on sodium-restricted diets. 5. People with coronary artery disease.

2,4 Rationale: Diminished renal function is a reason to avoid self-directed antacid use. Many over-the-counter antacids contain significant amounts of sodium. Calcium antacids are often used as calcium supplements. There is no reason for perimenopausal women to avoid antacids. There is no reason for those with coronary artery disease to avoid antacids.

The patient being treated for GERD says, "I seem to have so many colds and coughs now." How should the nurse respond to this statement? 1. "Be sure to get your flu shot." 2. "The medicine you are on for GERD changes your gastric pH." 3. "You need to avoid crowds until your GERD is under control." 4. "You may be more susceptible to respiratory infection while taking this medication." 5. "You may be having an allergic reaction to your medicine."

2,4 Rationale: The medications for GERD change gastric pH, which increases risk for respiratory illnesses. The patient's normal defense mechanisms are impaired by this drug, increasing susceptibility to respiratory infection. Getting immunized against influenza is a wise choice but is not specifically associated with this report. There is no reason to avoid crowds. This is not an allergic reaction.

The nurse reviews laboratory studies of a patient receiving digoxin (Lanoxin). Intervention by the nurse is required if the results include which of the following laboratory values? 1. Serum digoxin level of 1.2 ng/dL 2. Serum potassium level of 3 mEq/L 3. Hemoglobin of 14.4 g/dL 4. Serum sodium level of 140 mEq/L

2. Serum potassium level of 3 mEq/L Rationale: Normal serum potassium level is 3.5 to 5 mEq/L. Hypokalemia may predispose the patient to digitalis toxicity. Options 1, 3, and 4 are incorrect. A digoxin level of 1.2 ng/dL is within therapeutic range. A hemoglobin of 14.4 g/dL and a serum sodium of 140 mEq/L are also within normal range.

A patient with severe diarrhea has an order for diphenoxylate with atropine (Lomotil). When assessing for therapeutic effects, which of the following will the nurse expect to find? 1. Increased bowel sounds 2. Decreased belching and flatus 3. Decrease in loose, watery stools 4. Decreased abdominal cramping

3 Rationale: A decrease in the number and consistency of stools is a therapeutic effect of diphenoxylate with atropine (Lomotil). Options 1, 2, and 4 are incorrect. A decrease in bowel sounds rather than an increase would be noted if the drug is having therapeutic effects. The drug has no direct effect on the causes of belching or flatus. Although reduction in abdominal cramping may occur due to decreased peristalsis, it is not the therapeutic indication for the drug.

The client has been vomiting for several days. The nurse would assess the client for which acid-base disturbance? 1. Metabolic acidosis 2. Respiratory alkalosis 3. Metabolic alkalosis 4. Respiratory acidosis

3 Rationale: Metabolic alkalosis will result from excessive loss of hydrochloric acid from the stomach brought on by prolonged vomiting. Respiratory alkalosis will not occur as a result of vomiting. Metabolic and respiratory acidosis will not occur as a result of vomiting.

Stool softeners 1. break up fecal material. 2. decrease peristalsis. 3. promote water absorption in the intestine. 4. increase peristalsis.

3 Rationale: Stool softeners cause more water and fat to be absorbed. Stimulant laxatives break up fecal material. Stimulant laxatives increase peristalsis. No laxatives cause decrease in peristalsis.

After a client begins pancreatic enzyme replacement therapy, the nurse will assess for 1. headache. 2. dry mouth. 3. nausea and vomiting. 4. falls.

3 Rationale: The most frequent adverse effects are GI symptoms of nausea, vomiting, and diarrhea. Some anorexiants can cause headache. Antidiarrheal therapy can cause dry mouth. Antiemetic therapy can cause sedation and falls.

Which statement is the most accurate regarding acetylcholinesterase inhibitors when used for Alzheimer's disease? 1. They reverse the structural damage within the brain. 2. They increase synthesis of acetylcholine. 3. They increase enzymatic breakdown, leading to increased neuronal production. 4. They intensify the effect of acetylcholine at the receptor.

4 Rationale: Acetylcholinesterase inhibitors intensify the effect of acetylcholine at the receptor. They do not increase acetylcholine synthesis or enzymatic breakdown. Currently no drugs can reverse the structural damages associated with Alzheimer's disease.

Which statement is accurate regarding the use of beta-adrenergic blockers for use in patients with heart failure? 1. Higher doses are used initially until optimal vital signs are achieved. 2. Dosage changes are done on a daily basis for the first 2 weeks. 3. This drug class does not have an effect on the bronchioles of the lungs. 4. They are generally used in combination with other heart-failure drugs.

4 Rationale: Beta-adrenergic blockers are rarely used to treat heart failure alone. They are commonly used in combination with ACE inhibitors. Initial doses are small, and are doubled every 2 weeks until the optimal dose is achieved. Beta-adrenergic blockers can be selective to beta1 receptors or non-selective. Non-selective blockers block beta1 and beta2 receptors. The blockage of beta2 receptors can affect the bronchioles of the lungs.

The nurse teaches the patient about digoxin (Lanoxin) toxicity and determines that learning has occurred when the patient makes which statements? 1. "I should limit my fluids while taking this medication." 2. "It is okay to keep taking my ginseng." 3. "If I have nausea, it means I must stop the medication." 4. "I can drink orange juice every morning." 5. "I must check my pulse and not take the medication if it is less than 60."

4,5 Rationale: Orange juice is a source of potassium, which will minimize the risk for digoxin (Lanoxin) toxicity. Sixty beats per minute is the generally accepted limit for withholding digoxin (Lanoxin). Nausea, by itself, may be a side effect, but it is not necessarily indicative of digoxin (Lanoxin) toxicity. Ginseng may increase the risk of digoxin (Lanoxin) toxicity. Dehydration can increase the risk for digoxin (Lanoxin) toxicity; the patient must not limit fluids.

A woman brings her husband to the emergency department and tells the nurse that her husband just had a stroke. The physician verifies a thrombotic stroke occurred and plans to use alteplase (Activase). What priority assessment question will the nurse ask the wife? 1. "What other medications does your husband take?" 2. "Does your husband have hypertension?" 3. "What other medical illnesses does your husband have?" 4. "What time did your husband have the stroke?"

4. "What time did your husband have the stroke?" Alteplase (Activase) must be given within 3 hours of a thrombotic stroke for maximum effectiveness. Asking about hypertension is a good question but is not the priority. Asking about medications is a good question but is not the priority. Asking about illnesses is a good question but is not the priority.

Which adverse effect is shared among all antidysrhythmic drugs? 1. Edema 2. Impotence 3. Photosensitivity 4. Prodysrhythmic effects

4. Prodysrhythmic effects Rationale: All antidysrhythmic agents can worsen existing dysrhythmias or create new ones

A patient with type 1 diabetes on insulin therapy reports that he takes propranolol (Inderal) for hypertension. The nurse will teach the patient to check glucose levels more frequently because of what concern? 1. The propranolol can produce insulin resistance. 2. The two drugs used together will increase the risk of ketoacidosis. 3. Propranolol will increase insulin requirements by antagonizing the effects at the receptors. 4. The propranolol may mask symptoms of hypo- glycemia.

4. The propranolol may mask symptoms of hypoglycemia. Rationale: Beta blockers such as propranolol decrease the body's adrenergic "fight-or-flight" responses and may diminish or mask the symptoms and signals of hypoglycemia that a patient with diabetes normally perceives as blood glucose drops. Options 1, 2, and 3 are incorrect. Beta blockers may inhibit glycogenolysis, resulting in hypoglycemia, and have no effect on the development of insulin resistance.

The patient receiving heparin therapy asks how the "blood thinner" works. What is the best response by the nurse? 1. "Heparin makes the blood less thick." 2. "Heparin does not thin the blood but prevents clots from forming as easily in the blood vessels." 3. "Heparin decreases the number of platelets so that blood clots more slowly." 4. "Heparin dissolves the clot."

Answer: 2 Rationale: Anticoagulants do not change the viscosity (thickness) of the blood. Instead, anticoagulants modify the mechanisms by which clotting occurs. Options 1, 3, and 4 are incorrect. Heparin does not make the blood less viscous or actually thinner and does not decrease the number of platelets or dissolve existing clots.

A patient with deep vein thrombosis is receiving an infusion of heparin and will be started on warfarin (Coumadin) soon. While the patient is receiving heparin, what laboratory test will provide the nurse with information about its therapeutic effects? 1. Prothrombin time (PT) 2. International Normalized Ratio (INR) 3. Activated partial thromboplastin time (aPTT) 4. Platelet count

Answer: 3 Rationale: Therapeutic effects of heparin are monitored by the aPTT. While the patient is receiving heparin, the aPTT should be 1.5 to 2 times the patient's baseline, or 60 to 80 seconds. Options 1, 2, and 4 are incorrect. A PT or INR is used to monitor the effectiveness of warfarin (Coumadin). Platelets are not affected by anticoagulant therapy and are not useful in monitoring the therapeutic effects of the drug.

A patient has started clopidogrel (Plavix) after experiencing a transient ischemic attack. What is the desired therapeutic effect of this drug? 1. Anti-inflammatory and antipyretic effects 2. To reduce the risk of a stroke from a blood clot 3. Analgesic as well as clot-dissolving effects 4. To stop clots from becoming emboli

Answer:2 Rationale:Antiplatelet drugs such as clopidogrel are given to inhibit platelet aggregation and, thus, reduce the risk of thrombus formation. Options 1, 3, and 4 are incorrect. Antiplatelet drugs do not exert anti- inflammatory, antipyretic, or analgesic effects. The anti- platelet and anticoagulant drugs do not prevent emboli formation. Thrombolytics dissolve existing blood clots.

Nursing implications: antidiarrheal

Assessment - H & P; current medications, labs, abdominal assessment (bowel sounds, last BM) - Ask about normal bowel habits, find cause - Need to know what cause the diarrhea Intervention - Administer medications, - Avoid Antidiarrheals when suspect poisoning or infection by toxin- producing organism Reassessment - Monitor for response to medications, monitor hepatic, renal, and electrolytes Teaching - Healthy lifestyle, correct self administration of meds

Nursing implications: nausea and vomiting drugs

Assessment - H & P; medication, V/S, wt (ask about recent wt loss; labs; cause - ?? Traveling, last eaten, bowel assessment; blood in emesis Interventions - Give fluids, monitor emesis-always report emesis and describe it, it is output; V/S - ??Dehydration? - hypotension, tachycardia - Treat cause; give antiemetics (preemptive if possible) Reassessment - Response to intervention Teaching - Healthy eating, take before activity that cause N & V

Meds to increase heart rate

Atropine and EPI

Donepezil (Aricept)

- Therapeutic class: Alzheimer's - Pharmacologic class: acetylcholinesterase inhibitor-can delays worsening dementia for 6-12 months - Mechanism of action: inhibits the breakdown of acetylcholinesterase - thus increases the amount and effect of acetylcholine in neurons - Indication: improve memory

Atropine

- Therapeutic class: Anti-arrhythmic - Pharmacologic class: Cholinergic receptor blocker - Mechanism of action: increases HR - Indication: treatment of sinus bradycardia and heart blocks

Adenosine (Adenocard)

- Therapeutic class: Anti-arrhythmics - Pharmacologic class: nucleoside - Mechanism of action: slow conduction and decrease automaticity of SA node - Indication: primary agent for PSVT (Paroxysmal supraventricular tachycardia)

Propanolol (Inderal)

- Therapeutic class: anti- arrhythmic - Pharmacologic class: non selective Beta adrenergic blocker (Beta 1 and 2) - Mechanism of action: block sympathetic stimulation (sympatholytic)→ ↓ HR, ↓BP, ↓ conduction velocity速率 - Indication: HTN, angina, a-flutter, a-fib

Memantine (Namenda)

- Therapeutic class: anti-Alzheimer's - Pharmacologic class: N-Methyl-D-aspartate antagonist - Mechanism of action: binds to CNS N-Methyl-D-aspartate (NMDA) receptor sites, preventing binding of glutamate -an excitatory neurotransmitter - Indication: decrease symptoms of dementia, cognitive enhancement

diltiazem (Cardizem)

- Therapeutic class: anti-arrhythmic - Pharmacologic class: Calcium Channel Blocker - Mechanism of action: ↓ automaticity in SA node, ↓conduction velocity through AV node, prolongs the refractory period - Indication: angina, HTN, afib, a flutter, SVTs (supraventricular tachycardia)

Side effects/Adverse effects: filgrastin (Neupogen)

- flu like syndrome, fever, - dyspnea, nausea, vomiting, fatigue, - flushing, - bone pain, - arthralgia, alopecia, thrombocytopenia, cutaneous vasculitis, pericardial effusion, hypersensitivity reactions, tachycardia/dysrhythmias

Side effects: folic acid

- flushing, rash, hypersensitivity

State the A1C goal per the ADA for adults

- 7 more less - Prediabetes- AIC 5.7 to 6.5

Side effects/Adverse effects: romiplostin (Nplate)

-Arthralgia, dizziness, insomnia, myalgia, abdominal pain, dyspepsia, paresthesia, HA, fatigue. (more serious-thromboembolism, bone marrow fibrosis, hypersensitivity reactions)

etiology of Type 2 diabetes

- 90-95 % of all patient with diabetes - Patho-Insulin resistance-lack of sensitivity of insulin receptors at target cells. Pancreas tries to produce more insulin but eventually the cells burnout resulting in a deficiency in insulin secretion --- Patients often are obese with dyslipidemia --- Pts often asymptomatic with T2DM for years before dx --- Affects persons in middle age but seeing increased incidence in children & adolescents due to obesity and sedentary lifestyle --- Environmental (western diet) & genetic contributions --- If treated with healthy diet and exercise, insulin resistance can be reversed - If untreated, results in same chronic conditions as Type 1 DM (micro and macrovascular complications)

Seizure/epilepsy

- A disturbance of electrical activity in the brain that may affect consciousness, motor activity, and sensation - Caused by abnormal or uncontrolled neuronal discharges - A result of underlying disorder - Infectious disease, trauma, metabolic disorder, vascular diseases, pediatric disorders, - Can result from medications, high dose of local anesthetic, withdrawal from alcohol or medications - Triggers include sleep deprivation缺觉, flickering闪烁的 lights, fluid/electrolyte imbalance - Epilepsy is a disorder - seizures occur chronically

what drugs decrease afterload (lower resistance)

- ACE inhibitor - ARB inhibitor - ARNI inhibitor

Gastroesophageal Reflux Disease (GERD)

- Acidic content of stomach moves upward into esophagus - "heartburn" or dyspepsia消化不良,dysphagia - Esophageal (cardiac) sphincter weakens ** occurs in infants - Often self treated with OTC - C/O: esophagitis, esophageal ulcers, or strictures, Barrett's esophagus - Often with lifestyle changes: Avoid fatty or acidic food, don't go to bed with full stomach, elevate head of the bed, eliminate tobacco and alcohol.

Pramlintide (Symlin)

- Adjunct for treatment of Type 1 diabetes when post prandial hyperglycemia occurs even with pre-meal insulin - Antihyperglycemic drug - Used with insulin in type 1 and type 2 - Synthetic analog of amylin - Slows gastric emptying - Increases satiety - Leading to decreased calorie intake - Administered Subq just prior to meal - Reduce rapid or short acting insulin when start Symlin

Side effects/Adverse effects: Erythropoietin Stimulating Drugs- epoetin alfa (Epogen, Procrit), darbepoetin (Aranesp)

- Adverse effects-HA, fever, N/D, insomnia, cough, URI, edema, more serious include HTN, seizures, heart failure, DVT, MI, stroke, tumor progression in higher doses. Overdose can cause polycythemia (too many RBCs) - Contraindicated in uncontrolled HTN (pt. may also need an antihypertensive drug), caution when used with androgen therapy (increased blood viscosity, increased risk for clot formation) - Not effective if patient has iron deficiency or other vitamin deficiency-patients often given iron supplements with this med due to increase production of RBCs

Side effects/Adverse effects: Oprelvekin (Neumega)

- Adverse effects-fluid retention/edema, use very cautiously in patients with heart failure or renal disease. HA, visual disturbance, dizziness, dyspnea, fatigue, rash, nausea, vomiting (more serious-tachycardia, febrile neutropenia, pleural effusion, anaphylaxis, dysrhythmia, yeast infections)

Adverse effects/black box warning:

- Adverse effects: N/V, abd. Pain, HA, dizziness, fatigue, coughing, allergic rxn., arthralgia - Black box warning: potential for severe hypoglycemia

Role of the Nurse: Thrombolytics

- Alteplase (Activase) must be given within 3 hours of a thrombotic stroke for maximum effectiveness. - Assess for exclusions to therapy! Given in ER and ICU setting - Monitor patient's VS, O2 sat., heart rhythm, LOC, for CP, for S/S of TIA or CVA - Monitor puncture sites during and after infusion-hold manual pressure for minimum of 30 minutes for bleeding - Monitor baseline coagulation studies - Monitor level of consciousness for symptoms of cerebral hemorrhage - Observe for reperfusion arrhythmias - Teach patient about increased risk of bleeding - Monitor for shock-internal bleeding may cause hypovolemic shock in the patient receiving alteplase. Significant intravasculature fluid loss prevents the heart from pumping an adequate supply of blood and oxygen to the organs. It is important to frequently monitor the patient for symptoms of shock. Be alert for changing vital signs such as deceased blood pressure, increase heart rate, and decreased body temperature. Assess the patient for increasing anxiety, confusion, shallow breathing, profuse sweating, and weak pulse.

Nursing Implications: pharmacotherapy for muscle spasms or spasticity

- Assessment --- H & P, medication hx, baseline level of V/S, injury, pain; assess muscle tone, labs - Implementation --- Monitor muscle tone, ROM, V/S; pain level (before and after ROM); monitor labs for hepatic and renal function; - Evaluation --- Increased ability to do ADL's, decreased pain; - Teaching --- Correct administration; Safety while using - risk for falls, increase fluids; increase fiber, avoid alcohol --- No driving --- May take with food if GI distress (nausea, heartburn, etc.) occurs.

Nursing Implications: anti-Parkinson's, anti-Alzheimer's, antiMS

- Assessment --- H & P; medication hx, baseline evaluation- ADL's, etc.; thought processes; (is this a flair? Exacerbation?) - Implementation --- V/S, watch for hypotension; lab tests, provide for patient safety; monitor for behavioral changes - Evaluation --- Therapeutic effects: is the medicine working? improved self-care; monitor for side effects (increased twitching - PD; agitation, etc.), labs - toxicity, - Teaching --- Safety-take routinely and don't miss a dose, correct administration (???PD drugs on empty stomach or avoided with high-protein meal; may cause urine and sweat to darken); (MS - report redness, pain at injection sites-many of these meds are injectable meds-IM, subcu) --- Support the caregiver; have very difficult role

Nursing Implications: antiseizure drugs

- Assessment --- Seizure history, medication history, lab values (CBC, lytes, hepatic/renal fxn), wt.; - Implementation --- Monitoring - neurological status, lab values, V/S --- Provide care of pt. during seizure - Evaluation --- Pt response, drug interaction?? - Teaching --- Medication regimen, restrictions as to driving (seizure); avoid abrupt withdrawal of medication; counsel regarding pregnancy --- Lifestyle and dietary changes: caffeine and smoking alter effectiveness of benzodiazepines, barbiturates affect absorption of Vit, alcohol and other CNS depressants increase adverse effects of antiseizure medications; depression risk --- GABA antagonist???

Nursing considerations: ARNI

- Available in 3 doses - cost (expansive) - history of angioedema - last dose of ACE inhibitors --- Do not administer within 36 hours of switching from or to an ACE inhibitor

Nursing consideration: Sucralfate (Carafate)

- Avoid other medications 2hrs pre/post; must be taken 4 times/day given on empty stomach, oral suspension available because this medication is large and may be difficult to swallow, especially for elderly patients. Surcralfate should be given two hours before or after other medications, as it may decrease absorption of other medications, especially phenytoin, digoxin, warfarin, and fluoroquinolone antibiotics.

Compare and contrast the different types of insulin and how it is dosed (basal, burst, corrective).

- Basal: Controls blood glucose (BG) between meals and over-night --- Typically, about 50% of patient's insulin needs --- Keeps liver from releasing glucose when it is not needed --- Handles minor amounts of BG from fat and protein hours after meal --- 0.2-0.4 units/kg daily for adults - Bolus: 'BURST' of insulin to cover a meal or a snack. --- Quickly 'corrects' a high blood glucose level - Correction Insulin- "sliding scale" based on pre meal glucose level

Nursing Implications: anti-dysrhythmia drugs

- Baseline Assessment --- BP (maybe in both arms), HR, EKG, pulse for 1 min, Apical pulse, height, electrolytes lab values - Nursing Diagnosis-decrease heart output, anxiety, fatigue related to drug effects-beta blocker, sexual dysfunction-beta blocker - Administration/ongoing assessment - Ensuring therapeutic response - Minimizing adverse effects - Patient understanding of therapy - Patient procurement and self -administration of therapy

Side Effects

- Block sympathetic stimulation of the heart, so: --- Bradycardia or heart block --- Hypotension --- Fatigue, insomnia, drowsiness --- Impotence or decreased libido - Can make HF worse- --- Caution during decompensated phase- fluid retention and worsening HF; fatigue; bradycardia or heart block; and hypotension - If abruptly withdrawn Palpitations, rebound HTN, life threatening arrhythmias, or MI

Nursing implications: Phenytoin (Dilantin)

- Blood tests for therapeutic level, - Phenytoin (Dilantin) has a very narrow range between a therapeutic dose and a toxic dose; blood levels must be monitored to ensure a therapeutic level and to prevent toxicity.

Review the major steps of hemostasis and fibrinolysis.

- Blood vessel injury causes vessel spasm (constriction) - Reduces blood flow through vessel - Platelets become sticky and are attracted (aggregation) to each other and adhere to injured area. This is facilitated by adenosine diphosphate (ADP), thrombin, thromboxane A2 and receptor sites (glycoprotein IIb/IIIa & von Willebrand's factor) - Aggregation of platelets forms plug - Formation of insoluble fibrin strand and coagulation (coagulation cascade) - Normal clotting occurs in 6 minutes

Irritable Bowel Syndrome

- Bowel habits are altered with diarrhea alternating with constipation, mucus noted - Drug therapy is targeted at symptoms - Find out what causes the symptoms and try to avoid it.

psyllium mucilloid (Metamucil)

- Bulk -forming agents - Absorbs water and add size to fecal mass - Used for chronic constipation - Promote normal bowel movements

Side Effects of Digoxin

- Cardiac arrhythmias-heart block - GI symptoms - Visual issues (yellow/green halo), disorientation, & confusion - Digoxin toxicity levels >2 ng/mL- fine line between therapeutic and toxic --- Risk increases with: --- hypokalemia, hypomagnesemia, or hypothyroidism --- Watch if patient on diuretic-need potassium replacement - Ideal HR >60 to administer --- Check apical pulse for 1 minute --- Notify provider if HR <60 before giving* --- Could be an early sign of toxicity --- Some providers do not agree with holding the dose, but ask

ACE Inhibitors and Renal Issues

- Common practice is to not begin ACE inhibitors in renal insufficiency or to stop or decrease ACE if creatinine rises - May be related to diuresis and not ACE - Research now shows this increase is likely temporary and renal status will stabilize in 2-3 days - ACE's are life saving to HF patients and should not be stopped

Nursing Implications: Thrombolytic drugs

- Complete H&P, vitals, labs, med list-very thorough history important! - Monitor for adverse effects, therapeutic effects (CP eliminated, EKG returns to normal) - Establish continuous EKG monitoring, all IV access lines, arterial line, Foley catheter before begin infusion - Monitor Vital signs a minimum of every 15 minutes first hour of infusion and then every 30 minutes remainder of infusion and next 8 hours - Assess for abnormal bleeding: pallor, hypotension, tachycardia, dizziness, sudden severe HA, lumbar pain, decreased LOC, assess IV sites, invasive lines. Avoid new invasive lines during and up to 8 hours after infusion. If patient must undergo a new stick hold manual pressure a minimum of 30 minutes. - Limit patient activity: bedrest during infusion - Assess for reperfusion arrhythmias, hypotension, neurologic symptoms - Teach patient why they are receiving this medication, adverse effects, anticoagulant or antiplatelet meds prescribed after therapy and need for close follow up. - Teach about LSM to reduce risk for recurrent MI or stroke. - Minimize bleeding- avoiding needles and pressure on bleeding. Since alteplase increases the risk of bleeding, precautions should be taken to avoid complications. Avoid administering anticoagulant and antiplatelet since they increase the risk of bleeding. Maintain tissue integrity by avoiding invasive procedures and needle punctures related to subcutaneous or intramuscular injections. - Antidote is Aminocaproic Acid. If excessive bleeding is suspected, stop thrombolytic therapy and administer aminocaproic acid (Amicar) as an antidote to prevent further bleeding. This antifibrinolytic drug prevents the conversion of plasminogen to plasmin and avoids fibrinolytic activity that results in bleeding.

Colony-Stimulating Factors

- Examples-filgrastin (Neupogen) (similar to G-CSF and used for patients with neutropenia associated with chemo), pegfilgrastin (Neulasta) (has a sustained action), sargramostim (Leukine) (similar to GM-CSF and used in AML, bone marrow transplant) - Colony-stimulating factors (CSFs) are named according to the types of blood cells that they stimulate. Granulocyte colony-stimulating factor (G-CSF) increases the production of neutrophils, the most common type of granulocyte. - Indications include patients: --- Undergoing chemotherapy --- Receiving bone marrow stem cell transplants --- With certain malignancies - By raising neutrophil counts, CSFs can assist in keeping antineoplastic dosing regimens on schedule (and thus more effective). - Patients undergoing chemo for breast cancer have risk for developing acute myeloid leukemia while on CSFs

Nursing Implications for patients receiving drugs for anemia

- Complete Health History, labs, meds, drug allergies, VS, baseline ht. and weight. Assess fatigue level. - Assess for therapeutic effects (improved H&H, RBC, activity level, less fatigue, pallor, SOB, sense of well-being) this is ongoing - Assess for adverse effects: itching, skin rash, hypokalemia, nausea, vomiting, heartburn, constipation, black stools (iron meds), allergic reactions - RBC and HCT counts rise slowly over 3-6 months-continue to assess patient - Encourage proper nutrition -increase foods with iron, folic acid, Vitamin B12 - What are these foods? - Teach patient proper administration to enhance absorption - Folic acid may be taken on empty stomach or with food - Vitamin B12- must be given IM/deep SubQ initially, then nasal spray and then oral for maintenance (take with food) - Iron-take on empty stomach, liquid preps take thru straw to avoid staining teeth, increasing Vitamin C rich foods may increase absorption - ***To increase VitB12- fish, meat, poultry, mil/milk products, fortified cereals - Folic acid-leafy green veggies, citrus fruits, dried beans & peas - Iron-meats, fish, poultry, lentils & beans - Teach patient to report immediately S/S hypokalemia (muscle weakness, cramping, palpitations, dysrhythmias) (with Vitamin B12) - Increase fluid and fiber intake-prevent constipation with iron - Can dilute liquid prep of iron-place straw back of mouth to prevent staining of teeth - Space activities, frequent rest periods - Teach patient and family proper dosing/administration, adverse effects, length of therapy, what to report - Keep all vitamins, and iron preps out of reach of children (iron poisoning can be fatal to children) - Nursing diagnosis for the patient with anemia?

Nursing Implications for all coagulation modifiers

- Complete health history (previous history of MI, PAD, Stroke, MI, valve disease, DVT, PE, bleeding disorder, malignancy, CVD. Thorough exam, vitals, complete med list, pregnancy status, allergies - Assess heart, lungs, assess extremities, assess for presence of cardiac, and peripheral vascular risk factors. S/S of MI, PE, CVD, PAD, DVT, bleeding/bruising - Evaluate labs-aPTT, PT, INR, CBC, renal and kidney function, lipid profile, CMP - Assess for risks for DVT, arterial disease (i.e. prolonged travel, venous stasis, smoking) - Assess for adverse effects of anticoagulation, antiplatelet therapy - Assess for therapeutic effects (for example improving thrombophlebitis, improved perfusion to extremity, improved pedal pulses, no recurrent MI or TIA) - Encourage early ambulation post op, active ROM if bedrest, passive ROM for patient's that are immobile/weak - Anticoagulant use is a high risk safety concern and is one of the Joint Commission's National Patient Safety Goals - Continuously monitor for S/S of excessive bleeding or occult bleeding - Monitor ethnically diverse patients for therapeutic or undesirable effects - Teach patient and family members S/S of excessive/occult bleeding - If external bleeding occurs, teach to hold firm manual pressure x 15 minutes, if bleeding continues, is excessive, cannot control, feel dizzy/faint, call 911 - Women of menstrual age should report heavy excessive bleeding (pad count) - Continue to monitor CBC, H&H, RBCs and platelets, should stay in normal range - Monitor clotting times: (aPTT goal is 1.5-2.5 times normal for heparin. INR goal for warfarin (Coumadin) is usually 2-3.5 during therapy. - Teach patient to report new symptoms (CP, SOB, pain in claves, legs) and to carry wallet ID card or wear medic alert bracelet - Teach patient the need to return for labs and also let the lab person know they are on anticoagulation meds - Minimize risk for bleeding during care of patient - Teach patient ways to reduce risk for bleeding at home: switch to soft toothbrush, inspect gums for bleeding, use an electric razor, cut food cautiously when using a knife, avoid contact sports, and handle older adults with care! They have fragile skin! - Teach patient to report new meds that may interact with anticoagulant and increase risk for bleeding (aspirin, NSAIDS contraindicated)

Management of Type 2 diabetes:

- Controlled through lifestyle changes (weight loss, regular exercise, healthy diet) - Management of BP, lipids, smoking cessation, foot care and yearly eye exams - Treated with oral hypoglycemic drugs - May need insulin therapy - Also injectable drugs that mimic incretins to maintain glucose levels

Side effects: bisacodyl (Dulcolax)

- Cramping, to be used occasionally, can result in laxative dependence, deplete F & E

State the proper technique for administration of insulin, including preparation and mixing

- Current evidence supports as first line management the use of intensive insulin therapy to mimic physiologic insulin release by combining basal insulin (long acting, i.e. insulin glargine or detemir) or intermediate insulin (NPH) with bolus dosing (regular or rapid such as lispro, aspart, glulisine) at mealtime. The patient receives multiple daily injections (MDI). - Some patients may have been managed in the past with twice daily injections -Mixing a rapid acting with an intermediate acting insulin. No longer recommended as first line unless patient unable to manage the MDI. - The short acting insulin must be drawn up first when mixing insulins (if the 2 insulins are compatible). - Insulin glargine and insulin detemir should not be mixed with any other insulin. - Always use correct insulin syringe (U100, U500), rotate sites, give at 90 degrees subcu, do not massage after injection - Only regular insulin can be given IV (used for meal coverage, correction, during treatment of DKA and HHS) - Teach patient about proper administration technique, mixing and rotating sites (may cause scar tissue-insulin will be absorbed (not enough dose) if do not rotate the sites) - Patient's on insulin will be advised to monitor glucose at home-usually before each meal and more often if ill, of if insulin is being adjusted, or on new meds that increase BS (i.e. steroids)

Parkinson's disease

- Degeneration and destruction of dopamine-producing neurons in the subtantia nigra portion of the brain - Progressive loss of dopamine in the CNS causing tremor, muscle rigidity, and abnormal movement and posture - Absence of dopamine allows more acetylcholine to stimulate this area of brain - resulting in Parkinson symptoms

Recall the pathophysiology and stroke volume of heart failure

- Dependent on 3 factors: Preload- passive stretch Contractility- Force of the "squeeze" out of the ventricle (strength of the contraction) Afterload- Pressure the ventricle must overcome to eject blood into the circulation

Metoclopramide (Reglan)

- Dopamine antagonist - Used for those with GERD/esophageal reflux; causes stomach to empty, nausea as well

***Erythropoietin Stimulating Drugs

- Example- epoetin alfa (Epogen, Procrit), darbepoetin (Aranesp) (this one longer acting allowing for a 1 per week or every 2-week injection and also given in CKD-chronic kidney disease) Given SubQ or IV. - Erythropoietin- this hormone stimulates RBC production, it is secreted by kidney - Secreted when kidneys sense reduction in oxygen-hypoxia (COPD, anemia, high altitudes) or hemorrhage. - The drug epoeitin alfa identical to the natural hormone - Indications: Anemia - These meds are given for the anemia caused by the chemotherapy used to treat the cancer not for the anemia caused by the cancer itself. - Darbepoetin alfa (Aranesp) stimulates production of red blood cells, which carry oxygen. Getting additional oxygen to the tissues helps the client feel better.

S/S of hyperglycemia

- Fasting blood glucose greater than 126 mg/dL - Polyuria, polydipsia, polyphagia - Glucosuria糖尿, weight loss/gain, fatigue, blurred vision, abdominal pain

Nursing Implications: Oprelvekin (Neumega)

- Fluid retention (DOE/edema/ascites) - Monitor CBC (dilutional anemia) & platelet count, and electrolytes esp. K+ level (goal for plt. Count is usually >50,000) - Monitor for arrhythmias, dizziness, HA, SOB, chest congestion, bone pain, myalgia, chills, fever, infection, blurred vision, anorexia, N/V/D. Caution patient about driving. - Teach patient about proper dosing, adverse effects, necessary f/u, and what to report

Pharmacotherapy for MS

- Goal is to provide symptom relief - Place MS in remission by modifying associated symptoms and slow progression of disease - Relapse-remitting MS - Secondary-progressive MS --- Progressive-relapsing MS --- Primary - progressive MS - Disease-modifying Drugs - Immune modulators -Beta Interferons - Immunosuppressants-corticosteroid (hormone release by adrenal glands above the kidney)

***Nursing Implications for patients receiving erythropoiesis-stimulating drugs

- H&P, med list, labs (CBC, aPTT, INR, Iron studies, renal and liver function), baseline vitals, ht., weight. - Know baseline BP- The most serious adverse effect of epoetin alfa (Epogen) is hypertension, which can raise blood pressure to dangerous levels, and which occurs in as many as 30% of clients receiving the drug. - Continue to monitor vital signs, labs, patient's symptoms (do they feel better? S/S of adverse effects of the drug?) - Assess for adverse effects-HTN, HA, neurologic changes (change in LOC), S/S of impending seizure activity, angina, signs of thrombosis in peripheral extremities (can develop cerebral or coronary emboli) - Continue to monitor CBC, Hct/Hgb, aPTT, INR, iron studies, renal/liver studies, BP and pulse frequently esp. 1st 2 weeks - Teach patient to drink adequate fluids, frequent rest periods, return for labs, do not drive first few weeks due to increased risk for seizure due to rapid rise in RBC and possible HTN/seizure activity. - Teach patient/family about proper administration, adverse effects, S/S of MI, Stroke, aura/seizure activity, peripheral artery thrombosis or DVT, report severe HA immediately - Obtain a dietary consult-encourage good nutrition- rec. foods high in iron, folic acid, Vitamin B12 (green leafy veggies, meats, dairy, eggs, fortified cereals and breads, citrus fruits, dried beans and peas) - Evaluate the effectiveness of therapy-increase in activity, less fatigue and SOB - Nursing Diagnosis? --- Risk for fall-esp. for pts. have headache, neurologic symptoms --- Activity intolerance --- Fatigue --- Risk for coronary perfusion

Side Effects of Vasodilators

- Headache, dizziness, and GI complaints - Tachycardia - Orthostatic hypotension - Side Effects of nesiritide --- Severe hypotension --- Arrhythmias --- Approved for decompensated HF only

Side Effects of ACE/ARB Inhibitors

- Headache, dizziness, orthostatic hypotension - Renal disturbances - Angioedema <1% --- More common in women and blacks - Monitor B/P closely- know prior to administration - Monitor electrolytes especially BUN, CR - NSAIDS-decrease drug effects

teaching points for the patient with peptic ulcers, GERD

- Healthy lifestyle - Acidophilus乳酸菌-containing foods - stop smoking/alcohol - Correct timing of medications

Side Effects: Potassium Sparing Diuretics

- Hyperkalemia- Monitor K+ level closely and know the latest level before administering --- Monitor for arrhythmias due to ↑K+ --- Teach patient to avoid K+ rich foods (bananas, citrus fruits, tomatoes and using salt substitutes) --- Outpatient monitoring -Check K+ at 1 week, 1 month and every 3 months - Increased BUN- know the latest BUN before administering - Gynecomastia- enlarged breasts-about 10%

Serious complication of Type 2 diabetes

- Hyperosmolar Hyperglycemic State (HHS)-acute complication associated with Type 2 (due to not enough circulating insulin)

Side Effects of Loop and Thiazide Diuretics

- Hypotension-Always know the B/P - Hypokalemia, hypomagnesemia, hyponatremia, hypocalcemia - Renal insufficiency - Electrolyte monitoring always - Always know latest electrolytes before administering - Weakness/Dizziness - Dry Mouth - Cardiac arrhythmias - Ototoxicity (loop)

Vasodilators-Nesiritide (Natrecor)- IV only

- Identical to human beta-type natriuretic peptide (BNP) --- ventricles secrete BNP when stressed-aids in diuresis and sodium excretion - Reduces LV filling pressure - No symptomatic hypotension? --- IV nitroglycerin, nitroprusside, or nesiritide may be considered with diuretic therapy for relief of dyspnea in patients admitted with acutely decompensated HF, but not promising (2013 AHA Heart Failure Guidelines) --- No impact on mortality, re-hospitalization, or renal function, --- Research has shown a small but statistically significant impact on dyspnea, but also an increased risk of hypotension

Role of Nurse

- Important to know the onset, peak, and duration of action of the prescribed insulin - Monitor for and recognize signs and symptoms of hypoglycemia and hyperglycemia know how to treat - Educate patient & family about insulin therapy, oral antidiabetic meds and proper administration and adverse effects. Healthy diet, carb counting, lifestyle changes, importance of regular exercise, self-monitoring of glucose, advise smoking cessation, referral to nutritionist and appropriate support services (Multidisciplinary approach for best outcomes) - Patient will need regular follow up, labs, foot exams and yearly eye exams

Diuretics

- Increase cardiac output by decease fluid volume and B/P= increase urine output - Diuretics are recommended in patients with HF with reduced EF who have evidence of fluid retention, unless contraindicated, to improve symptoms - Start with low dose and adjust PRN- urine output increase and weight decrease - Low sodium diet combination ideal - May use "pill on pocket"

Example drugs to treat IDA

- More severe need iron supplements --- ferrous sulfate, --- ferrous gluconate, --- ferrous fumarate, --- iron dextran (IV form)

Nursing implications: anticoagulants

- Most serious side effect-minor and major bleeding - Assessment for internal bleeding- --- Monitor CBC, platelets, assess for bleeding, hematoma, assess for lumbar pain, abdominal bulging, guaiac tests on stool, assess coagulation studies, increased bruising - Bleeding risk increases during transition from heparin to warfarin --- Do not give warfarin to pregnant patients --- Heparin, low-molecular weight heparin can be given to pregnant patients --- Oral anticoagulants, anti-platelets- aspirin, ibuprofen, indomethacin can potentiate the action of heparin and increase risk for adverse bleeding --- Heparin-limit intake of garlic, ginger, green tea, ginkgo which may increase risk for bleeding --- If serious bleeding occurs-antidote for heparin is Protamine sulfate given IV-onset within 5 minutes --- Antidote for warfarin is Vitamin K

Explain how insulin and glucagon maintain glucose homeostasis

- Insulin and Glucagon have significant impact on glucose metabolism (there are other mechanisms but these 2 hormones have a key role in maintaining normal glucose levels). - Amylin is a protein co-secreted with insulin by beta cells. Acts to decrease post prandial glucose levels by prolonging gastric emptying time, reducing postprandial glucagon secretion & reduces food intake through centrally mediated appetite suppression. - Glucose essential molecule used by the body's cells as a primary source for energy/fuel and brain uses glucose exclusively for energy. But it is too big to simply diffuse into the cells by itself. Instead, it needs to be transported into the cells. Insulin is a hormone produced by the pancreas that facilitates glucose transport into cells - Insulin has a hypoglycemic effect - Insulin is like a key that opens the cells to allow glucose inside the cell to use as energy. It allows glucose to be taken up from the blood and absorbed into fat, skeletal and liver cells. - Anabolic (build up) hormone -to build up muscle, - No insulin means glucose cannot be transported into cells so glucose levels in the blood stream rise and the body must look for other sources for energy- this leads to symptoms and complications (the body starts to breakdown fat and skeletal muscle for fuel source) - Insulin is the carrier for glucose

Muscle spasms

- Involuntary contraction of muscle or groups of muscles - Muscles -tightened and fixed, causing intense pain

Emetics Medications

- Ipecac syrup - orally - Apomorphine (dopamine agonists) given subcutaneously - Induces vomiting within 15 minutes

Identify adverse effects of drugs for coagulation disorders and be able to develop a teaching plan for the patient receiving coagulation modifier.

- Maintain a normal diet-avoid decreasing or increasing foods high in vitamin K (asparagus, broccoli, cabbage, cauliflower, kale). Vitamin K increase or decrease can affect oral warfarin therapy. - Avoid excessive alcohol-increases bleeding risk - Assess for S/S of hepatitis-dark urine, light clay color stools, jaundice, abdominal pain esp. in RUQ, itchy skin. Hepatitis possible complication of oral anticoagulant therapy - Teach patient/family proper administration (take meds same time each day) and dosing of meds-use teach back method - Injections of LMWH -into fatty layers of abdomen-just above iliac crest, avoid periumbilical area by 2 inches, draw up skin (lightly pinch), insert needles at 90-degree angle, do not aspirate for blood return. Release skin and hold slight pressure at site, do not rub or massage site

Side effects/Adverse effects: Aminocaproic acid (Amicar)

- May cause hyper coagulation with concurrent use of estrogen and oral contraceptives, - bradycardia and hypotension with IV administration. - Can cause headache, - allergic skin reactions.

Platelet Enhancers

- Megakaryocytes stimulated by the hormone thrombopoeitin (produced in liver) - Increases production of platelets - Drugs are used to enhance platelet production - Thrombopoeitin not available as a drug

Explain how hematopoiesis is regulated.

- Messages from hormones and other regulatory substances control this process - Control substances include Erythropoietin and chemicals secreted by leukocytes called Colony-stimulating factors (CSFs) - Recombinant DNA technology has allowed researchers to develop medications that simulate these substances to treat blood disorders

Teaching points: Valproic Acid (Depakene)

- Mixing valproic acid (Depakene) syrup with carbonated beverages will trigger immediate release of the drug, which causes severe mouth and throat irritation. - may cause life-threatening pancreatitis, and any severe or increasing abdominal pain should be reported immediately.

Identify the importance of knowing the onset and peak action of different types of insulin

- Modified forms for more rapid onset [insulin lispro (humulog)] - more prolonged duration [insulin glargine (Lantus)]

Nursing intervention: ACE inhibitors

- Monitor K+ and renal labs, blood pressure - slowly change position to prevent drop in blood pressure and feeling dizzy-orthostatic hypotension can occur - do not stop abruptly

Nursing Implications: romiplostin (Nplate)

- Monitor for CBc, platelets, liver studies and bleeding/bruising - Monitor for S/S of hepatotoxicity-yellow skin, RUQ abdominal pain, anorexia, clay color stools, dark urine - Monitor for vision problems, dizziness, insomnia, headache, bone or muscle pain, S/S of a blood clot, angioedema or allergic reactions - Teach patient about adverse effects, proper dosing, what to report

Role of the Nurse: Hemostatic drugs

- Monitor for clotting, monitor VS frequently if given IV - If administered intravenously, monitor IV site closely, patient should be on a cardiac monitor - Contraindicated if client has history of thromboembolic events or severe renal impairment

Nursing interventions: Aldosterone Antagonists

- Monitor for hyperkalemia, - monitor renal lab-BUN, Cr, and GFR, - monitor for arrhythmias

Nursing interventions: Amiodarone (Cordarone)

- Monitor liver enzyme - avoid grapefruit juice - onset of action may take 1-2 weeks before they see a difference, when they stop this med it will take 4-8 weeks to leave system because it has a long half life. - May have increased bleeding if they are taking Coumadin, digoxin - Drug-Drug: Amiodarone can increase serum digoxin levels by as much as 70%. Amiodarone can block the metabolism of warfarin, thus requiring lower doses of the anticoagulant. Use with beta-adrenergic blockers or CCBs may cause or worsen sinus bradycardia, sinus arrest, or AV block. - Contraindications: Amiodarone is contraindicated in patients with severe bradycardia, cardiogenic shock, sick sinus syndrome, severe sinus node dysfunction, or third- degree AV block.

Nursing intervention: loop diuretics

- Monitor renal lab, K+, Na+, - monitor blood pressure - monitor ototoxicity - measure I/O - weight daily

Teaching points: Benztropine (Cogentin)

- Teach to increase fluids for dry mouth, take with food

Spasticity

- Muscle groups remain in a continuous state of contraction (often result from CNS damage) - Muscles become stiff with increase muscle tone, pain, fixed joints can result - Dystonia肌张力障碍- chronic neurological disorder-need to inject something to stop the contraction --- Cerebral palsy, severe head injury, spinal cord injury/lesions, stroke

Nursing implications: anti-Alzheimer's

- Need to monitor VS if pt. has CAD; - can take if the symptoms are moderate - Behavior therapy will be involved with Alzheimer pts. with NSAID use...possible positive side effects - Educate family about condition will not cure, just help the pts. to be more alert and aware to take care of themselves - Suggest legal and finance support necessarily - Dietary restriction with dysphasia and restlessness. They may have problems like swallowing and chewing - Safe environment-changes in routine occurs can sometimes negatively affect them.

Nursing implications: Memantine (Namenda)

- Need to monitor VS if pt. has CAD; can take if the symptoms is moderate - Behavior therapy will be involved with Alzheimer pts. with NSAID use...possible positive side effects - Educate family about condition will not cure, change in routine can sometimes negatively affect them.

Parkinson's

- No medications to stop or reverse the disease progression, the loss of dopamine neurons in the brain that is causing pt.'s movement symptoms. So we only can manage the symptoms. - Dopaminergic --- Restores dopamine function or stimulates dopamine receptors located within the brain --- SE: N/V, dark urine, contraindicated with narrow glaucoma, muscle tickles and mood changes are signs of toxicity - Anticholinergic drugs --- Inhibits action of acetylcholine in brain; inhibits the overactivity of acetylcholine in corpus striatum --- SE: drowsiness, urinary retention

Nursing implications for patients receiving CSFs

- Obtain Complete health history, meds, baseline vitals, weight, height, assess fatigue, evaluate baseline lab results- CBC, WBC, ANC, CMP, EKG, - Ongoing assessments to evaluate effectiveness and for adverse effects & S/S of infection - Adverse effects-bone pain, fever, nausea, anorexia, hyperuricemia, anemia, ST depression, angina, respiratory distress, allergic reactions - Assess for fatigue r/t chemo - Teach proper dosing & encourage frequent rest periods, adequate fluid intake, space activities throughout day - Continue to monitor for therapeutic effects (rise in WBC, ANC). Stop CSF when WBC reach level ordered per provider. - Bone pain occurs 2-3 days prior to rise in WBCs, be alert for respiratory distress (SOB, congestion) esp. with sargramostin, and also EKG changes (ST depression), CP, palpitations, dizziness, dysrhythmias, hypotension, tachycardia - Monitor for S/S of allergic reactions-rash, wheezing, dyspnea. Monitor for RUQ or LUQ abdominal pain. - Assess for liver dysfunction (Filgrastim) (yellow skin, clay stools, dark urine, skin itching). - Report sx of gout-warmth, redness, painful swelling of joint - Patient will need to return for labs. - Maintain strict infection control measures. What will you teach patient? - Avoid crowds, good handwashing, avoid persons with infection and young children who are more likely to have an infection. - Cook food thoroughly, teach patient not to consume raw fruits or veggies. - Report immediately any fever, S/S of infection- purulent drainage from a wound, as well as redness, pain, warmth, new cough, UTI symptoms, vaginal itching or drainage, thrush, sores in mouth, itchy blisters/vesicles on the skin. - Nursing diagnosis?

Cause of constipation

- Opioids-NO. 1 cause - anticholinergics - antihistamines - iron supplements - Certain foods - Lifestyle-low dietary fiber, not enough fluid, high fat diet can increase risk of constipation

Dantrolene Sodium (Dantrium)

- PO - Therapeutic: skeletal muscle relaxant - Pharmacologic: direct acting antispasmodic, calcium release blocker - Mechanism of action: interferes with release of calcium ions with skeletal muscle cell - Indication: muscle spasms due to spinal cord injury, stroke, cerebral palsy or MS; also used for MH

Epinephrine

- Pharmacologic class: Adrenergic - Mechanism of action: ↑sympathetic reactions - Indication: cardiac arrest, also treat allergic reaction

Inflammatory Bowel Disease

- Presence of ulcers in the small intestine (Crohn's disease) or mucosal erosions large intestine (Ulcerative Colitis) - Cause unknown - suspect autoimmune disorder - Drug therapy is targeted to reduce symptoms, place disease in remission, and slow progression **** do not need to know specific drugs, but know use anti-inflammatory drugs to those, such as corticosteroids, these diseases are risk for infection.

Nursing interventions: Propanolol (Inderal)

- Prior to administration, the nurse should check BP and HR. if BP and HR is low, medication should stop. - Because this medication blocks normal signs of hypoglycemia, such as diaphoresis or tachycardia, diabetic patients should be cautioned to monitor their blood glucose regularly. - don't stop it abruptly, it can have rebound tachycardia - can mask hyperglycemic affects so need to check blood sugar regularly - beta blockers can reduce their chance of MI, also can used in PTSD, panic attacks, and college students can take it for anxiety

describe the process of hematopoiesis.

- Process of blood-cell formation - Occurs primarily in red bone marrow & requires B vitamins, vitamin C, copper, iron and other nutrients - Begins with stem cell in bone marrow --- Orders of the development of white blood cells, platelets, and red blood cells --- Stem cell—Proerythroblast—Reticulocyte—Action of erythropoietin—Erythrocyte - Homeostatic control maintained by hormones and growth factors - Most common condition can cause bone marrow suppression is cancer-pts. undergoing chemotherapy

Nursing implication: Omeprazole (Prilosec)

- Proton pumps are activated by food intake so should be taken 20-30 min prior to food intake; PPI heal peptic ulcers within 6-8 wks - Long term use increase risk of gastric CA in lab animals. - May see use of proton pump with antibiotics to tx H. pylori; - Interfere with Ca absorption so recommend taking Ca supplements.

Diuretics Summary

- Purpose: reduce preload-volume - Specific action: decrease swelling and fluid - Combination of diuretics may be necessary (loop, thiazide, aldosterone antagonist)-diuretic resistance

Digoxin (Lanoxin)

- Therapeutic Class: anti-arrhythmic, inotropic - Pharmacologic class: cardiac glycoside - Indication: a fib, aflutter, PSVT, increase inotropy (Digoxin inhibits Na+/K+/ATPase pump. By inhibiting this pump, digoxin increases the force of ventricular contraction, aka inotropy.) increases cardiac output, by increasing stroke volume per beat. - Mechanism of action: decrease automaticity of SA node, slow conduction through AV node, ↑vagal tone-vagus nerve -slows thing down (parasympathetic)

Explain the functions of colony-stimulating factors.

- Regulate WBCs (leukopoiesis) Also called leukopoietic growth factors - Comprise a small group of drugs that stimulate the growth and differentiation of one or more types of leukocytes - Goal: produce rapid increase of neutrophils in patients with depressed immune systems --- Reduce duration of neutropenia associated with chemotherapy or organ transplant --- CSF therapy shortens the length of time patients are susceptible to life- threatening infections due to low numbers of neutrophils (neutropenia). --- CSFs named according to the type of blood cells they stimulate. i.e.-granulocyte colony stimulating factor-(G-CSF) or (GM-CSF)

Treatment of Type I Diabetes

- Requires Insulin therapy. Basal, - meal coverage, correction, - healthy diet choices, - regular exercise (at least150 minutes/week), - weight management, - maintain normal BP, lipids and weight, - smoking cessation, - foot care. Regular exams by providers, labs and yearly dilated eye exams

Diagnosis of Diabetes- Type 1 Diabetes

- S/S (3 P's), fatigue, weight loss, random glucose >200, FBS >126, >200 after a OGTT, A1C >6.5%

Contraindications with ACE inhibitors

- SBP < 80 mm/Hg - Increased serum creatinine >3mg/Dl - Bil. Renal stenosis - Elevated K+ >5.0 meQ/L - Previous life threatening reactions (angioedema), etc. - Pregnancy

Side effects/Adverse effects: OnabotulinumtoxinA (Botox)

- Side Effect: fatigue, HA, dysphagia, ptosis, discomfort at injection site; local muscle weakness - Adverse effect: allergic reactions, anaphylaxis, respiratory distress

Side effects/Adverse effects: Promethazine (Phenergan)

- Side Effect: sedation, dry mouth, urinary retention-anticholinergic effects. - Adverse effects: neuroleptic malignant syndrome (severe confusion/disorientation), bradycardia, decrease in B/P

Side effects/Adverse effects: Ondansetron (Zofran)

- Side Effects: HA, fatigue, constipation, - Adverse effects: Prolonged QT interval (avoid in those with hypokalemia, hypomagnesemia, HF, bradyarrhythmias or those taking other meds that prolong QT interval (chance that we could precipitate QT interval problems such as PVCs- Premature ventricular contraction)

Side effects/Adverse effects: Levodopa, carbidopa, entacapone (Stalevo)

- Side effect: dizziness, involuntary movements, constipation, avoid foods and meds high in Vit B6, orthostatic hypotension - Adverse effects: hallucinations, depression, extrapyramidal effects (more twitching) and mood changes = toxicity, gradually withdrawal if the meds aren't working, can narrow angle glaucoma

Side effects/Adverse effects: Cyclobenzaprine (Flexeril)

- Side effect: drowsiness, dizziness, dry mouth, sedated with narcotic-should avoid drive - Adverse effect: respiratory depression, swelling of tongue, avoid use in those with CAD

Side effects/Adverse effects: Phenytoin (Dilantin)

- Side effect: drowsiness, dizziness, gingival hyperplasia - Adverse effects: Narrow Therapeutic range; agranulocytosis, cardiovascular issues (dysrhythmias), severe skin reactions, blood dyscrasias, increase serum glucose levels

Side effects/Adverse effects: Benztropine (Cogentin)

- Side effect: dry mouth, constipation, increased HR (anticholinergic effects); urinary retention - Adverse effects: paralytic ileus麻痹性肠梗阻, loss of balance, confusion, delusions, hallucinations,

Side effects/Adverse effects: Ethosuximide (Zarontin)

- Side effect: mood swings, drowsiness, HA, fatigue, gingival hypertrophy, wt. loss, GI distress - Adverse effects: psychosis, bone marrow suppression, blood dyscrasias, blood testing for therapeutic level

Side effects/Adverse effects: Dantrolene Sodium (Dantrium)

- Side effect: muscle weakness, drowsiness, dry mouth dizziness, photosensitivity - Adverse effect: urinary retention, tachycardia, erratic blood pressure, hepatotoxicity

Side effects/Adverse effects: Valproic Acid (Depakene)

- Side effect: sedation, drowsiness, GI upset and prolonged bleeding - Adverse effects: muscle weakness, bone marrow suppression, wt. gain, hepatotoxicity; monitor blood levels for therapeutic level.

Side effects/Adverse effects: Donepezil (Aricept)

- Side effect: vomiting, diarrhea, **dark urine, insomnia, irritability - Adverse effects: monitor closely those with CAD, asthma, PUD, depression

Side effects/Adverse effects: Metoclopramide (Reglan)

- Side effects: constipation, dry mouth, drowsiness - Adverse effects: Neuroleptic malignant syndrome, tardive dyskinesia

Side effects/Adverse effects: Aluminum hydroxide (AlternaGEL)

- Side effects: constipation, nausea - Adverse effects: decreased phosphate because of Calcium

side effects/Adverse effects: Omeprazole (Prilosec)

- Side effects: minimal; HA, nausea, diarrhea - Adverse effects: risk for osteoporosis, rash, blood disorders; decrease absorption of Vitamin B 12; increase risk for gastric CA (cancer) (in lab animals), pneumonia

Side effects/Adverse effects: Ranitidine (Zantac)

- Side effects: minimal; HA; Pneumonia-when the pH is increased, bacteria are able to colonize the stomach and may migrate up to the respiratory tract. CNS changes (hallucination, confusion, and CNS depression or excitation). Antiandrogen effects - Adverse effects: blood disorders; if taking high doses or those with renal/hepatic disease may exhibit confusion. *** B 12 absorption is reduced - avoid use in the elderly

bisacodyl (Dulcolax)

- Simulant laxatives - take orally - Promote peristalsis by irritating bowel mucosa, - Used for bowel prep, constipation

Sulfonylureas

- Stimulate release of insulin from pancreatic islet cells - Increase sensitivity of insulin receptors on target cells - Most common adverse effect is hypoglycemia ¥ Usually caused by taking too much medication or not eating enough food λ Other side effects: ¥ Weight gain, nausea, headache, drowsiness hepatotoxicity, photosensitivity, blood dyscrasias λ How taken: Right before a meal and skip if no meal λ Glimepiride (Amaryl), glipizide (Glucotrol), glyburide (DiaBeta)

Classes of Oral Hypoglycemic Drugs

- Sulfonylureas - Biguanides - Thiazolidinediones - Alpha-glucosidase inhibitors - Meglitinides - Increntin enhancers and miscellaneous agents

Amiodarone (Cordarone)

- Therapeutic class: anti-arrhythmic - Pharmacologic class: Potassium Channel Blocker - Mechanism of action: prolong repolarization, ↑ the absolute refractory period, and ↓ automaticity - Indication: Ventricular tachycardia, paroxysmal supraventricular tachycardia (PSVT). FIRST LINE for A trial fibrillation and HF

Lidocaine

- Therapeutic class: anti-arrhythmic - Pharmacologic class: Sodium Channel Blocker - Mechanism of action: block Na Ch. Preventing depolarization→ ↓ conduction velocity & suppressing ectopic pacer activity - Ectopic: in an abnormal place or position. Start somewhere not suppose to. - Indication: PVCs, VT, Vfib, ventricular dysrhythmias

Levodopa, carbidopa, entacapone (Stalevo)

- Therapeutic class: antiparkinson drug - Pharmacologic class: dopamine precursor, enhances dopamine - Mechanism of action: restores functional balance of dopamine and acetylcholine in corpus stratum of brain (crosses blood brain barrier) - Indication: parkinsonism

***Valproic Acid (Depakene)

- Therapeutic class: antiseizure drug - Pharmacologic class: Valproate, phenytoin-related drug, - Mechanism of action: increase levels of GABA - Indication: absence seizure, mixed seizure, migraines

Ethosuximide (Zarontin)

- Therapeutic class: antiseizure drug - Pharmacologic class: succinimide - Mechanism of action: depresses the activity of neurons in motor cortex - Indication: absence seizures - Pregnancy Category C.

***Phenytoin (Dilantin)

- Therapeutic class: antiseizure drug, - Pharmacologic class: Hydantoin, Sodium influx-suppressing drug - Mechanism of action: desensitizing Na channels in the CNS responsible for neuronal responsivity - Indication: seizure activity

***Phenobarbital (Luminal)

- Therapeutic class: antiseizure drug, sedative - Pharmacologic class: Barbiturate, GABA receptor agonist - Mechanism of action: enhance GABA neurotransmitter, suppressing abnormal neuronal discharges - Indication: decrease seizure activity

Aluminum hydroxide (AlternaGEL)

- Therapeutic: anti-heartburn drug - Pharmacologic: antacid-release symptom for short term use - Mechanism of Action: alkaline substances that neutralize the stomach acid - Indication: heartburn, indigestion, not as frequently recommended for ulcers

Promethazine (Phenergan)

- Therapeutic: antiemetic - Pharmacologic: Phenothiazine - Mechanism of Action: blocks effects of histamine, inhibitory effect on CTZ, anticholinergic activity, weak Dopamine antagonist - Indication: Treatment of motion sickness, N & V; motion sickness

Metoclopramide (Reglan)

- Therapeutic: antiemetic - Pharmacologic: inhibits dopaminergic receptors, stimulates motility of upper GI tract - Mechanism of action: blocks dopamine receptors in CTZ, stimulated motility of upper GI tract - Indication: decrease N & V, gastroparesis

Ranitidine (Zantac)

- Therapeutic: antiulcer drug - Pharmacologic: H2-receptor antagonist - Mechanism of Action: blocks the H2 receptors in stomach, reducing gastric acid production - Indication: peptic ulcers, gastric ulcers, Zollinger-Ellison, erosive esophagitis

Omeprazole (Prilosec)

- Therapeutic: antiulcer drug - Pharmacologic: proton pump inhibitor-short term use - Mechanism of Action: reduce acid production by binding to enzyme H+, K+-ATPase - Indication: peptic ulcers, GERD, Zollinger-Ellison syndrome-caused by a gastrin-secreting tumor of the pancreas that stimulates the acid-secreting cells of the stomach to maximal activity. Often, this syndrome results in GI mucosal ulceration.

Cyclobenzaprine (Flexeril)

- Therapeutic: centrally acting skeletal muscle relaxant - Pharmacologic: catecholamine reuptake inhibitor - Mechanism of action: depresses motor activity in the brainstem, increase levels of norepinephrine -block presynaptic uptake - Indication: acute muscle spasms

Nursing Implications: antiplatelet agents

- These meds contraindicated if patient having active bleeding (i.e. GI bleed, recent stroke, recent trauma, going to surgery). --- Aspirin, ticlodipine and clopidogrel (Plavix) are held 5-7 days prior to surgery unless it is minor surgery (due to the increased risk of bleeding from decreased formation of platelets) and they have a high cardiac risk (MI)-always check with the provider if patient scheduled for invasive procedure or surgery! - Monitor for bleeding --- Risk increases if given with anticoagulants or aspirin --- Monitor for bleeding gums, hematomas, increased bruising, GI distress, coffee ground emesis, tarry stool, pallor, monitor CBC, platelets, bleeding times --- With Reopro monitor VS and HR closely during infusion. (Given in ICU/Cath lab setting only) - Prolonged pressure needed to control bleeding at puncture sites (IV sites, venous punctures, arterial punctures) - Monitor for gastrointestinal upset with warfarin and ticlopidine (Ticlid) - May increase menstrual bleeding in females-tell patient to report increased bleeding

recognize the food group to treat pernicious anemia, IDA

- To increase VitB12-fish, meat, poultry, mil/milk products, fortified cereals - Folic acid-leafy green veggies, citrus fruits, dried beans & peas - Iron-meats, fish, poultry, lentils & beans

Teaching points: Hemostatic drugs

- To report symptoms of clotting or bleeding - Not to take aspirin

Explain why hematopoietic agents are often administered to patients following chemotherapy or organ transplant.

- Treating hematopoietic disorders-may need to replace the substance that is lacking to resolve the disorder - Examples-increasing iron or folic acid in diet or taking iron or folic acid supplements for iron deficiency anemia - Also hematopoietic drugs important adjunct for patients receiving chemotherapy

Misoprostol (Cytotec)

- Used in prevention of Peptic ulcers in those who require long term use of NSAIDs/corticosteroids - Stimulates mucus production in stomach, cause cramping - ***do not use in pregnant people - abortive action

Indication: Hemostatics

- Used to promote the formation of clots - Primary use: to promote formation of clots by preventing and treating excessive bleeding from surgical sites - Given after surgery to reduce post op bleeding. - Given to patients with hemophilia血友病 after dental procedures.

Nursing interventions: Adenosine (Adenocard)

- When given as a 1- to 2-second bolus IV injection, adenosine terminates serious atrial tachycardia by slowing conduction through the AV node and decreasing automaticity of the SA node. - Its primary indication is a specific dysrhythmia known as paroxysmal supraventricular tachycardia (PSVT), for which it is a preferred drug. - It is also used to assist in the diagnosis of coronary artery disease or dysrhythmias in patients who are unable to undergo an exercise stress test. - Although dyspnea is common, adverse effects are generally self-limiting because of its 10-second half-life.

Diarrhea

- When large intestine does no reabsorb enough water from fecal mass, stools become watery, - Increase in frequency and fluidity of bowel movements - Will lead to significant fluid loss, acid-base and F & E imbalance - Not a disease but a symptom of an underlying disorder - Treatment follows after assessment of cause: --- Out of country, bowel infection, certain medications

Nursing implications: Ondansetron (Zofran)

- Works much better as a prophyly actic method of preventing N&V than if you were to give it once they have started N&V. (e.g.: better to before chemotherapy than during or after once they're become nauseous) - 30-60 minute before starting the chemotherapy

Side effects/Adverse effects: cyanocobalamin (Nascobal)

- arthralgia, dizziness, HA, naso-pharyngitis, hypokalemia, rash, anaphylaxis - Can cause sodium retention use cautiously in patients with heart or lung disease

Nursing interventions: Atropine

- assess VS, heart rate. - Avoid with patients with glaucoma-too much fluid inside the eyeball. - runner, athletes usually have low heart rate who are health, we do not always to treat bradycardia - S/S of bradycardia- dizziness, fatigue, confusion, syncope. If the the bradycardia is systemic, we will treat it.

Side effects: diltiazem (Cardizem)

- bradycardia, - hypotension, - HA, dizziness, - peripheral edema, - constipation

Side Effects: Amiodarone (Cordarone)

- bradycardia, - hypotension, - blurred vision (halos), - N/V, anorexia, - fatigue, dizziness, ***Blue man syndrome

Nursing interventions: Epinephrine

- can given IV, subcu, IM, intracardiac - when systematic we treat it.

Nursing interventions: diltiazem (Cardizem)

- contraindication: renal and liver impairment, - drug interaction: digoxin-it will potentiate the effect of digoxin; increase risk of myopathy with statins (lower the level of cholesterol in the blood by reducing the production of cholesterol by the liver) - Calcium channel blockers are safe medications that are well tolerated by most patients. - avoid grapefruit juice, it can slow the metabolism

Thrombocytopenia

- decreased platelet production or increased platelet destruction. - Causes: Bone marrow suppression from chemotherapy and taking immunosuppressant meds. - Other causes: folic acid & vitamin B12 deficiency, and hepatic failure.

Opioids- slow peristalsis

- diphenoxylate or codeine with atropine (Lomotil) - Imodium (Loperamide)

Multiple Sclerosis

- do not know what cause it, and no cure - Demyelination of neurons in CNS resulting in progressive weakness, visual disturbances, mood alteration, and cognitive deficits --- Antibodies target and destroy oligodendrocytes, myelin, and axonal membranes, inflammation accompanies damage tissues, plaques (scleroses) form - Chronic inflammatory autoimmune disorder ???-unknown --- Diagnosed based on symptoms and ruling out other conditions - S & S: Fatigue, heat sensitivity, neuropathic pain, spasticity, disruption of balance and coordination, bowel and bladder symptoms, visual impairment, slurred speech.

Alzheimer's

- do not know what cause it, and no cure - Progressive loss of brain function, cause is unknown, amyloid plaques, neurofibrillary tangles混乱状态present - Impaired memory and judgment, confusion and disorientation, inability recognize family or friends, aggressive behavior, depression, psychoses, anxiety, - On autopsy - structural damage in brain - amyloid plagues and neurofibrillary tangles.

Side effects/Adverse effects: Atropine

- drowsiness, - blurred vision, - dry eyes, dry mouth, - constipation, - urinary hesitancy and retention, - - flushing

side effects: Imodium (Loperamide)

- drowsiness, sedation

Ondansetron (Zofran)

- drug of choice - Therapeutic: antiemetic - Pharmacologic: Serotonin (5-Ht3) antagonist - Mechanism of action: blocks the effects of serotonin at 5-HT3 - receptor sites located in the vagal nerve terminal, and chemoreceptor trigger zone in the CNS - Indication: decrease nausea and vomiting with chemo or surgery

Diazepam (Valium)

- emergency, IV - Therapeutic class: antiseizure - Pharmacologic class: benzodiazepine, GABA receptor agonist - Mechanism of action: binds to the GABA receptor -chloride channels throughout the CNS; suppresses abnormal neuronal foci - Indication: to suppress seizure activity, skeletal muscle relaxation, and decrease anxiety,

Side Effects: Propanolol (Inderal)

- fatigue, - hypotension, - bradycardia, - diminished libido, impotence, - mask signs of hypoglycemia

signs or symptoms that indicate diabetes

- fatigue, blurred vision, thirst, yeast infections, skin infections, UTIs, nocturia, unintentional weight loss, acanthosis nigricans (also associated with obesity)

Food groups to treat Iron Deficiency Anemia (IDA)

- fish, red meat, fortified cereals, whole grain breads - poultry, lentils扁豆, beans

OnabotulinumtoxinA (Botox)

- injected directly into the target muscle to cause the muscle relax - Therapeutic: direct - acting antispasmodic - Pharmacologic: neurotoxin - Mechanism of action: produces partial chemical denervation by inhibiting the release of acetylcholine. Results in decrease muscle activity - Indication: upper limb spasticity, cervical dystonia

what drugs decrease preload (volume)

- loop diuretics- drug of choice - thiazide diuretics - potassium spring diuretics - vasodilators

Mineral oil

- lubricates the stool and colon mucosa, (should be avoided - interferes with absorption of fat soluble vitamins)

which drugs can use for colonoscopy

- polyethylene glycol (MiraLax)

Symptoms of hypoglycemia

- rapid onset, cool, pale, clammy/sweaty skin, hunger, shakiness, irritability, headache, lightheadedness, tachycardia, confusion, drowsiness, coma, glucose less than 50, Can result in death. (In some patients a glucose less than 70 causes symptoms)

Nursing interventions: Digoxin (Lanoxin)

- very narrow therapeutic range, - dig-dip=digoxin toxicity - patients with low potassium are at higher risk for dig toxicity. Risk for injury - ECG changes-prolonged PR interval, decreased QT (thought to be related to increased calcium and increased inotropic of the heart), -Scooping on ECG (scooping of the ST-T complex in which the ST segments and T waves are fused together making it impossible to tell where one ends and the other begins. Scooping can occur even when digoxin is in the therapeutic range), T wave inversion (common ECG finding in digoxin use, even when the levels are within a therapeutic range) - Contraindicated in patients with heart block, pregnancy, acute MI, and hypokalemia (because digoxin normally competes with K+ ions for the same binding site on the Na+/K+/ATPase pump, hypokalemia can make toxicity present more quickly.) - Usually checked every 6 months along with lab values. - Although digoxin is primarily used to treat HF, it is also prescribed for certain types of atrial dysrhythmias due to its ability to decrease automaticity of the SA node and slow conduction through the AV node. Because excessive levels of digoxin can produce serious dysrhythmias, and interactions with other medications are common, patients must be carefully monitored during therapy.

polyethylene glycol (MiraLax)

- very small dose - Saline cathartics - Osmotic laxatives, pull water to create more watery stool, will deplete F & E, - Used in colonoscopy, bowel preps

side effects: diphenoxylate or codeine with atropine (Lomotil)

- watch for sedation, drowsiness, dry mouth - Pts with glaucoma should avoid anticholinergic b/c it can increase eye pressure

Sucralfate (Carafate)

- works by dissolving into a gel and adhering to the site of the ulcer. - Forms a barrier/coating - thick - liquid-this medication must be in an acid environment in order to form a protective barrier in the stomach, so sucralfate should not be taken with antacids or other medications that alter the pH of the stomach. - Indication: GI ulcer

etiology of Type 1 diabetes

- ~10% of all cases of diabetes - Caused by lack of insulin secretion, absolute insulin deficiency - Due to autoimmune destruction of pancreatic islet cells (genetic & environmental factors may contribute also). - Some no evidence of immune destruction of pancreatic cells-idiopathic Type 1. Some genetic susceptibility/ and or protection from the disease exist. Environmental triggers play a role in those susceptible. - Most common onset between age 5-15 (varies by study)

The nurse is caring for a patient with gastroesophageal reflux disease and would question an order for which of the following? 1. Amoxicillin (Amoxil) 2. Ranitidine (Zantac) 3. Pantoprazole (Protonix) 4. Calcium carbonate (Tums)

1 Rationale: Antibiotics such as amoxicillin (Amoxil) are used in the treatment of PUD caused by H. pylori. They are not indicated for the treatment of GERD. Options 2, 3, and 4 are incorrect. Antacids, H2 blockers, and PPIs are used in the treatment of GERD. Calcium carbonate, ranitidine, and pantoprazole would be appropriate drugs to use.

The physician prescribes cyclobenzaprine (Flexeril) for the patient. When doing medication education, what will the best information of the nurse include? 1. Increase the intake of fiber while taking this medication. 2. Restrict the intake of sodium while taking this medication. 3. Increase the intake of protein while taking this medication. 4. Do not drink any caffeine while taking this medication.

1 Rationale: Cyclobenzaprine (Flexeril) has anticholinergic properties and can cause constipation, so the patient should increase the intake of fiber while taking this medication. There is no need to limit sodium. There is no need to limit caffeine. There is no need to increase protein.

The nurse has completed medication education for the client who takes psyllium mucilloid (Metamucil). The nurse recognizes that additional teaching is indicated when the client makes which statement? 1. "I don't need to drink extra fluids while I take this medication." 2. "My cholesterol level will be reduced somewhat with this medication." 3. "This medication is a lot more natural than other laxatives." 4. "This medication takes several days to work."

1 Rationale: Fluids must be increased when clients use psyllium mucilloid (Metamucil). Psyllium mucilloid (Metamucil) does help to reduce cholesterol levels. Psyllium mucilloid (Metamucil) is more natural than other laxatives. Psyllium mucilloid (Metamucil) does take several days to work.

The nurse plans care for a patient with Parkinson's disease. What will the best plan by the nurse include? 1. Monitor the patient for the ability to chew and swallow. 2. Check peripheral circulation for thrombophlebitis. 3. Monitor the patient for psychotic symptoms. 4. Limit exercise to decrease the possibility of fractures.

1 Rationale: In Parkinson's disease, muscle function is lost, and the patient's ability to chew and swallow to prevent aspiration becomes a safety issue. Psychosis is possible; however, this is not the primary concern. Activity is important to maintain as much muscle tone as possible and should not be limited. Thrombophlebitis is not related to Parkinson's disease.

6. A patient who has been prescribed baclofen (Lioresal) returns to the health care provider after a week of drug therapy, complaining of continued muscle spasms of the lower back. What further assessment data will the nurse gather? 1. Whether the patient has been taking the medication consistently or only when the pain is severe 2. Whether the patient has been consuming alcohol during this time 3. Whether the patient has increased the dosage without consulting the health care provider 4. Whether the patient's log of symptoms indicates that the patient is telling the truth

1 Rationale: Muscle relaxers such as baclofen (Lioresal) work best when taken consistently and not prn. Noting consistency of dosing helps to determine the appropriateness of dose, frequency, and drug effects. Options 2, 3, and 4 are incorrect. Consumption of alcohol or increasing the dose of muscle relaxers will increase the risk of sedation and drowsiness. The patient's log of symptoms and drug dose and frequency may assist the provider in determining the therapeutic outcome of the medication. The patient's report of pain or continued spasms should be considered an accurate account.

The nurse has been conducting medication education for a patient with epilepsy. What is the best outcome for this patient? 1. The patient will recognize that the antiseizure medication must be continued indefinitely. 2. The patient will recognize the need to be on a tyramine-free diet while on antiseizure medications. 3. The patient will recognize the need to be on a ketogenic diet in combination with antiseizure medications. 4. The patient will recognize the need to be on antiseizure medication for 1 year after the last seizure.

1 Rationale: Once seizures have been controlled, patients are continued indefinitely on the antiseizure drug. A ketogenic diet is indicated when seizures cannot be controlled through pharmacotherapy or when there are unacceptable side effects to the medications. A tyramine-free diet is indicated for patients receiving monoamine oxidase inhibitor medications. It is unknown how long antiseizure drugs will be necessary, but many patients require a life-time regimen.

The nursing plan of care for a patient receiving oprelvekin (Neumega) should include careful monitoring for symptoms of which adverse effect? 1. Fluid retention 2. Severe hypotension 3. Impaired liver function 4. Severe diarrhea

1 Rationale: Oprelvekin (Neumega) may cause significant fluid retention, which may be particularly detrimental to a patient with cardiac or renal disease. Options 2, 3, and 4 are incorrect. Severe hypotension, impaired liver function, or severe diarrhea are not associated with oprelvekin therapy and other causes should be investigated if they occur.

Pharmacotherapy for Parkinson's disease is intended to 1. increase the amount of dopamine and reduce the amount of acetylcholine. 2. increase the amount of dopamine and acetylcholine. 3. reduce the amount of dopamine and increase the amount of acetylcholine. 4. reduce the amount of dopamine and acetylcholine.

1 Rationale: Parkinson's disease results in the death of neurons that produce dopamine. The balance is restored by increasing the levels of dopamine or by inhibiting the excitatory actions of acetylcholine.

The physician has ordered intravenous (IV) phenytoin (Dilantin). The nurse does not read the drug label and administers the medication intramuscularly (IM). What is the most likely response in the patient? 1. Local tissue damage following extravasation will most likely occur. 2. A phenomenon known as purple gluteus syndrome will most likely occur. 3. A marked decrease in serum glucose levels will most likely occur. 4. Nothing adverse, the medication may be administered intravenously (IV) or intramuscularly (IM).

1 Rationale: Phenytoin (Dilantin) injectable is a soft-tissue irritant that causes local tissue damage following extravasation. It should not be administered intramuscularly but should be given intravenously into a large vein or via a central catheter. There isn't any such thing as purple gluteus syndrome; purple glove syndrome occurs when phenytoin (Dilantin) is administered in a hand vein and causes a serious local vasoconstrictive response. Phenytoin (Dilantin) causes an increase in serum glucose.

Simethicone (Gas-X, Mylicon) may be added to some medications or given plain for what therapeutic effect? 1. Decrease the amount of gas associated with GI disorders. 2. Increase the acid-fighting ability of some medications. 3. Prevent constipation associated with gastrointestinal drugs. 4. Prevent diarrhea associated with gastrointestinal drugs.

1 Rationale: Simethicone is used along with other GI drugs or alone to decrease the amount of gas bubbles that accumulate with GI disorders or indigestion. Options 2, 3, and 4 are incorrect. Simethicone will not affect the acid-fighting ability of medications or prevent constipation or diarrhea from developing.

Which statement about skeletal muscle relaxants is correct? 1. They inhibit upper motor neuron activity within the central nervous system. 2. They work primarily by stimulating the peripheral nervous system. 3. They increase the amount of neurotransmitter within the muscles. 4. They stimulate motor activity within the brainstem.

1 Rationale: The exact mechanism by which skeletal muscle relaxants work is not fully understood. It is believed that they inhibit upper motor neuron activity, causing CNS depression. Stimulation of the peripheral nervous system is not the mechanism of action of muscle relaxants. Muscle relaxants do not increase the amount of neurotransmitter. Muscle relaxants do not stimulate motor activity in the brainstem.

The client had stomach cancer and a surgical removal of his stomach several years ago. The physician prescribed cyanocobalamin (Nascobal). The client stopped this drug several months ago. What will the nurse most likely assess in this client? 1. Memory loss, numbness in the limbs, and depression 2. A gradual decrease in red blood cell counts 3. Jaundice and tarry stools 4. Low hemoglobin and hematocrit counts

1 Rationale: The most common cause of vitamin B12 deficiency (pernicious anemia) is absence of intrinsic factor, a protein secreted by stomach cells. This protein is required for vitamin B12 to be absorbed from the intestine. Symptoms of pernicious anemia involve the nervous system and include memory loss, confusion, tingling or numbness in the limbs, and mood disturbances. A decrease in red blood cells, jaundice, tarry stools, and low H&H do not occur with pernicious anemia.

The nurse is providing education for a 12-year-old patient with partial seizures currently prescribed valproic acid (Depakene). The nurse will teach the patient and the parents to immediately report which symptom? 1. Increasing or severe abdominal pain 2. Decreased or foul taste in the mouth 3. Pruritus and dry skin 4. Bone and joint pain

1 Rationale: Valproic acid may cause life-threatening pancreatitis, and any severe or increasing abdominal pain should be reported immediately. Options 2, 3, and 4 are incorrect. The drug is not known to cause dysgeusia (altered sense of taste) or effects on bones or joints. Although pruritus is an adverse effect associated with valproic acid, it may be managed with simple therapies, and unless it progresses to a more serious rash, it does not need to be reported immediately.

The patient receives dantrolene (Dantrium). Which medication would the nurse evaluate as being contraindicated with dantrolene (Dantrium)? 1. Verapamil (Calan) 2. Insulin 3. Clarithromycin (Biaxin) 4. Methylphenidate (Concerta)

1 Rationale: Verapamil (Calan) is a calcium channel blocker; combining this with dantrolene (Dantrium) could lead to cardiovascular collapse. There isn't any contraindication to the use of dantrolene (Dantrium) and insulin. There isn't any contraindication to the use of dantrolene (Dantrium) and methylphenidate (Concerta). There isn't any contraindication to the use of dantrolene (Dantrium) and clarithromycin (Biaxin).

A patient has purchased capsaicin over-the-counter cream to use for muscle aches and pains. What education is most important to give this patient? 1. Apply with a gloved hand only to the site of pain. 2. Apply the medication liberally above and below the site of pain. 3. Apply to areas of redness and irritation only. 4. Apply liberally with a bare hand to the affected limb.

1 Rationale:Capsaicin should be applied to the site of pain with a gloved hand to avoid introducing the capsaicin to the eyes or other parts of the body not under treatment. Options 2, 3, and 4 are incorrect. Capsaicin should be applied only to the site of pain and never with the bare hand. It should not be applied to irritated or open skin areas and should be discontinued if irritation occurs.

A patient who has been diagnosed with GERD is reluctant to make suggested lifestyle changes. What information about GERD should the nurse provide? 1. "The damage to your esophagus may result in esophagitis." 2. "Long-term exposure to acid increases risk for esophageal cancer." 3. "Without lifestyle changes, the medications will be totally ineffective." 4. "The lifestyle changes are not so bad if you adopt them one at a time and institute them gradually." 5. "You will have trouble swallowing if you do not treat this condition."

1,2 Rationale: Esophagitis is a possible complication of GERD. Approximately 10% of those with GERD will develop Barrett's esophagus, which is associated with increased risk of cancer. Medications may be somewhat effective even if lifestyle changes are not made. The nurse should not determine if the patient will think the lifestyle changes are "not so bad." It is unknown what this particular patient will experience if treatment is not undertaken.

The nurse observes a patient with Parkinson's disease having difficulty controlling hand movements. What did the nurse observe in this patient? 1. Pill rolling 2. Tremor 3. Stooped posture 4. Lack of arm swing 5. Difficulty bending the arms

1,2 Rationale: Pill rolling is a common behavior in progressive Parkinson's disease in which the patient rubs the thumb and forefinger together in a circular motion resembling the motion of rolling a tablet between two fingers. The hands develop a palsy-like continuous motion or shaking when at rest. A stooped posture, lack of arm swing, and difficulty bending the arms would not influence the patient's ability to control hand movements.

The parents of an infant with recurrent seizures are interested in starting amino acid therapy for their child. The father says, "After all, amino acids are natural; it couldn't hurt to give this a try." The nurse should consider which complications of this therapy when formulating a response? 1. Allergic reactions to the product 2. Cardiac changes such as palpitations 3. Neurological effects such as dizziness and lack of coordination 4. Gastrointestinal effects such as decreased weight gain 5. Failure to thrive.

1,2,3 Rationale: Allergic reactions to amino acids are not uncommon. Irregular heartbeat may occur in response to this therapy. Neurological effects of amino acid therapy include drowsiness, dizziness, and problems with coordination. Decreased weight gain may occur but is not likely to be a direct result of amino acid therapy. There is no evidence that amino acid therapy results in failure to thrive.

A nurse would question a prescription for sulfasalazine (Azulfidine) if the client is also taking which medication? 1. Insulin 2. Digoxin 3. Warfarin 4. Penicillin 5. Vitamin C

1,2,3 Rationale: Clients with diabetes may experience hypoglycemia if sulfasalazine is taken concurrently. Absorption of digoxin may be decreased. Anticoagulation effects may be increased. There is no drug-drug interaction with penicillin. There is no drug-drug interaction with vitamin C.

The nurse providing medications to a patient with multiple sclerosis realizes that the goals of medication therapy for this patient include 1. modifying the progression of the disease. 2. treating acute exacerbations. 3. managing symptoms. 4. curing the disease. 5. remyelinating nerve fibers.

1,2,3 Rationale: Drugs can modify the progression of the disease, treat acute exacerbations, and manage symptoms. They cannot cure the disease or remyelinate nerve fibers.

The nurse is concerned that a patient is developing right heart failure. What did the nurse assess in this patient? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Ankle edema 2. Enlarged liver 3. Displaced apical heart rate 4. Shortness of breath 5. Cough

1,2,3 Rationale: In right heart failure, the blood backs up into veins, resulting in peripheral edema and engorgement of organs such as the liver. A displaced apical heart rate would indicate cardiac hypertrophy, which is associated with right heart failure. Shortness of breath is a manifestation of left heart failure. A cough is a manifestation of left heart failure.

An older adult patient diagnosed with iron-deficiency anemia will be taking ferrous sulfate (Feosol). The nurse will teach which of the required administration guidelines to the patient? (Select all that apply.) 1. Take the tablets on an empty stomach if possible. 2. Increase fluid intake and increase dietary fiber while taking this medication. 3. If liquid preparations are used, dilute with water or juice and sip through a straw placed in the back of the mouth. 4. Crush or dissolve sustained-release tablets in wa- ter if they are too big to swallow. 5. Take the drug at bedtime for best results.

1,2,3 Rationale: Iron preparations should be taken on an empty stomach, diluted, and taken through a straw if liquid preparations are used, and extra fluid and fiber will help prevent constipation. Options 4 and 5 are incorrect. Sustained-release medications are specially formulated to absorb slowly and should never be crushed or dissolved. Iron preparations do not need to be taken only at bedtime.

A patient with Parkinson's disease is experiencing an increase in bradykinesia. What will the patient demonstrate with this manifestation? 1. Slow speech 2. Difficulty chewing 3. Shuffling the feet when walking 4. Stooped posture 5. Lack of facial expression

1,2,3 Rationale: Slow speech, difficulty chewing, and a shuffling gait are manifestations of bradykinesia. Stooped posture and lack of facial expression are not manifestations of bradykinesia.

The nurse is educating a patient diagnosed with heart failure (HF). The nurse knows that instruction regarding compensatory mechanisms has been effective when the patient states 1. "My heart enlarged in order to compensate for the effects of heart failure." 2. "My nervous system kicks in to compensate for the effects of heart failure." 3. "My body will decrease blood flow to other organs in order to compensate for heart failure." 4. "My body will increase urine output in order to compensate for the effects of heart failure." 5. "My body will produce anti-inflammatory agents to compensate for heart failure."

1,2,3 Rationale: Ventricular hypertrophy occurs as a compensatory mechanism to heart failure. One of the fastest homeostatic responses to diminished cardiac output is activation of the sympathetic nervous system (SNS). The increased heart rate resulting from sympathetic activation is a normal compensatory mechanism that serves to increase cardiac output. When cardiac output in a patient with HF is diminished, blood flow to the kidneys is reduced. Vasopressin (antidiuretic hormone), which is elevated in HF patients, causes fluid retention and worsens this condition. Two pro-inflammatory substances, tumor necrosis factor (TNF) and interleukin, are found in high levels in patients with HF and are associated with a poor prognosis.

The nurse is caring for a patient who has been diagnosed with heart failure. The nurse knows that which conditions may have contributed to the development of heart failure in this patient? 1. Uncontrolled hypertension 2. Coronary artery disease (CAD) 3. Diabetes (DM) 4. HIV 5. Mitral stenosis

1,2,3,5 Rationale: Uncontrolled hypertension, CAD, DM, and mitral stenosis are all associated with the development of heart failure. There is not a direct relationship with HIV status.

Pancrelipase (Pancreaze) granules are ordered for a patient. Which of the following will the nurse complete before administering the drug? (Select all that apply.) 1. Sprinkle the granules on a nonacidic food. 2. Give the granules with or just before a meal. 3. Mix the granules with orange or grapefruit juice. 4. Ask the patient about an allergy to pork or pork products. 5. Administer the granules followed by an antacid.

1,2,4 Rationale: Before administering pancrelipase (Pancreaze) the nurse should assess for an allergy to pork or pork products. The granules may be sprinkled on nonacidic foods and should be given 30 minutes before a meal or with meals. Options 3 and 5 are incorrect. Pancrealipase should not be given with acidic foods or beverages because the drug will be inactivated. It should not be taken with an antacid because the effect of the pancrelipase will be decreased.

The nurse and a home health patient have established this expected outcome: "The patient will be free from adverse effects of administration of verapamil (Calan)." Which finding indicates this outcome has not been met? 1. The patient complains of headache at each visit by the nurse. 2. The patient has 3+ edema in the ankles and feet. 3. The patient says, "Everything I eat tastes like metal." 4. The patient says, "I got so dizzy yesterday that I had to lie down for a while." 5. The patient's face is flushed.

1,2,4 Rationale: Headache, edema of the ankles and feet, and dizziness are potential adverse effects of verapamil. Metallic taste and facial flushing are not expected adverse effects of verapamil.

Which of the following medications may be used to treat partial seizures? (Select all that apply.) 1. Phenytoin (Dilantin) 2. Valproic acid (Depakene) 3. Diazepam (Valium) 4. Carbamazepine (Tegretol) 5. Ethosuximide (Zarontin)

1,2,4 Rationale: The phenytoin-like drugs including phenytoin (Dilantin), valproic acid (Depakene), and carbamazepine (Tegretol) are used to treat partial seizures.

Lisinopril (Prinivil) is part of the treatment regimen for a patient with heart failure. The nurse monitors the patient for the development of which of the following adverse effects of this drug? (Select all that apply.) 1. Hyperkalemia 2. Hypocalcemia 3. Cough 4. Dizziness 5. Heartburn

1,3,4 Common adverse effects of lisinopril (Prinvil) and other ACE inhibitors include cough, headache, dizziness, change in sensation of taste, vomiting and diarrhea, and hypotension. Hyperkalemia may occur, especially when the drug is taken concurrently with potassium-sparing diuretics. Options 2 and 5 are incorrect. Hypercalcemia and heartburn are not adverse effects associated with the ACE inhibitors.

Cyclobenzaprine (Amrix, Flexeril) is prescribed for a patient with muscle spasms of the lower back. Appropriate nursing interventions would include which of the following? (Select all that apply.) 1. Assessing the heart rate for tachycardia 2. Assessing the home environment for patient safety concerns 3. Encouraging frequent ambulation 4. Providing oral suction for excessive oral secretions 5. Providing assistance with activities of daily living such as reading

1,2,5 Rationale:Adverse reactions to cyclobenzaprine include drowsiness, dizziness, dry mouth, rash, blurred vision, and tachycardia. Because the medication can cause drowsiness and dizziness, ensuring patient safety must be a priority. The patient may need assistance with reading or other activities requiring visual acuity if blurred vision occurs. Options 3 and 4 are incorrect. Patients who are experiencing back pain often have orders for limited ambulation until muscle spasms have subsided. Suctioning should not be required related to this drug.

A clinic nurse is developing a teaching handout for patients who are prescribed warfarin (Coumadin) therapy. Which statement should be included in this information? 1. "Tell your dentist you are taking warfarin prior to any procedures." 2. "Report to the lab for testing of activated partial thromboplastin time (APTT)." 3. "Avoid strenuous activities." 4. "Place ice at the injection site if stinging or burning occurs." 5. "Take nonsteroidal anti-inflammatories (NSAIDs) for minor pain relief."

1,3 Rational: Warfarin increases the risk of bleeding from dental procedures. Strenuous or risky activities place the patient at risk for injury and bleeding. APTT is not used to monitor warfarin. Warfarin is not administered by injection. NSAIDs can cause bleeding if taken concurrently with warfarin.

A client comes to the clinic with report of intermittent epigastric pain that is associated with meals. The nurse would review the client's medical record and assess for the presence of which risk factors for peptic ulcer disease (PUD)? 1. The client reports that his mother and grandfather both had ulcers. 2. The client has type AB blood. 3. The client reports drinking several cups of coffee every morning. 4. The client reports mild to moderate job and family stress. 5. The client tested positive for influenza A.

1,3 Rationale: A close family history of PUD increases the client's risk for developing the disease. Consumption of beverages that contain caffeine increases the risk for PUD. The risk for developing PUD is higher in those with type O. The presence of excessive psychological stress increases the risk for PUD. Infection with Helicobacter pylori increases the risk for PUD. Influenza A is not associated with increased risk.

A patient calls the clinic and asks for a refill for a prescription for cyclobenzaprine (Flexeril) that was written a year ago. Which information from the medical record would the nurse draw to the prescriber's attention? 1. The patient reported drinking wine each day with dinner. 2. The patient has been using nasal saline spray for allergies. 3. The patient was prescribed a MAO inhibitor last month. 4. The patient's blood glucose was elevated at the last visit. 5. The patient had a ulnar fracture repaired a year ago.

1,3 Rationale: Alcohol should not be consumed while taking cyclobenzaprine (Flexeril). Concurrent use of cyclobenzaprine (Flexeril) and MAOIs is contraindicated. There is no interaction between nasal saline spray and cyclobenzaprine (Flexeril). There is no contraindication for use of cyclobenzaprine (Flexeril) in a patient with elevated blood glucose. There is no relationship between use of cyclobenzaprine (Flexeril) and a fractured ulna.

The patient tells the nurse, "My doctor says I have atrial fibrillation. Is this serious and how is it treated?" What are the best responses by the nurse? 1. "This condition is best treated with what we call antidysrhythmic drugs." 2. "This is very common; your doctor will discuss the best treatment with you." 3. "Depending on your symptoms, your doctor may use an electrical shock." 4. "This is quite serious; did your doctor mention a heart transplant?" 5. "It is very serious, even more serious than a ventricular dysrhythmia."

1,3 Rationale: Atrial fibrillation is the most common type of dysrhythmia. The physician will determine whether to use nonpharmacologic techniques, such as cardioversion, an implantable cardioverter defibrillator (ICD), or medication. Medications can cause serious side effects and are normally reserved for patients with overt symptoms or for patients whose condition cannot be controlled by other means. Ventricular dysrhythmias are more serious than atrial dysrhythmias because they are more likely to interfere with the normal function of the heart. Heart transplants are not indicated for patients with dysrhythmias.

The nurse is writing a care plan for a patient who has been started on an antiarrhythmic drug for complaints of chest pain and palpitations. The patient says, "I can't do what I once did. I just do not have any energy." Which nursing diagnoses would the nurse likely include in this care plan? 1. Decreased Cardiac Output 2. Ineffective Breathing Pattern 3. Activity Intolerance 4. Ineffective Individual Coping 5. Impaired Gas Exchange

1,3 Rationale: Decreased cardiac output is a common occurrence in patients who have palpitations and may be the etiology of the patient's chest pain. The statement "I can't do what I once did" is an indicator that the patient is not tolerating normal amounts of activity. There is no evidence that this patient is not breathing effectively and not enough information to decide that the patient is at risk of developing problems breathing. There is no evidence that this patient is not coping with the illness. To support this nursing diagnosis, the patient must have alterations in arterial blood gases.

The nurse is collecting information from a patient who has history of peptic ulcer disease (PUD). The nurse will evaluate that the goals of therapy for PUD have been met when the patient makes which statements? 1. "I was surprised at how quickly my symptoms went away after I started taking the medications and following the lifestyle changes." 2. "My PUD comes back once in a while if I am under a lot of stress." 3. "My previous doctor said my ulcer was completely healed." 4. "I still have to be very careful about what I eat." 5. "As long as I do not lay down for a couple of hours after I eat, I have no problems."

1,3 Rationale: Relief of symptoms is a goal of PUD therapy. The goal is promoting healing of the ulcer. The goal is permanent cure. Symptoms should not recur.

The nurse would plan to most closely observe which patients for the development of liver toxicity after dantrolene (Dantrium) is initiated? 1. A 49-year-old woman who has a history of esophagitis. 2. A 60-year-old man with pneumonia. 3. A 38-year-old woman who has type 2 diabetes. 4. An 18-year-old who injured his leg playing soccer. 5. A 26-year-old woman who has an ostomy.

1,3 Rationale: Women over age 35 are at high risk for development of hepatotoxicity. While risk is present for all patients, there is nothing in the other scenarios that indicates risk is particularly high.

A nurse is providing discharge instruction for a patient who had onabotulinumtoxinA (Botox) injected to smooth the wrinkles across his forehead. The nurse would advise this patient to monitor for which changes? 1. Chest pain 2. Urinary retention 3. Heart palpitations 4. Difficulty swallowing 5. Eye spasm

1,3,4 Rationale: Angina is an adverse effect of this medication. Dysrhythmias may occur, as may difficulty swallowing. Loss of bladder control is the adverse effect associated with onabotulinumtoxinA (Botox). OnabotulinumtoxinA (Botox) is used to treat eye spasm.

A patient has been treated for mild phlebitis. Which discharge teaching should the nurse provide? 1. "You should stop smoking." 2. "Do not travel by air." 3. "Increase your fluid intake." 4. "When you travel, stop frequently and walk around." 5. "Adopt a low-fat diet."

1,3,4,5 Global Rationale: Smoking increases platelet aggregation and promotes the formation of thrombi. Increasing fluid intake helps to prevent dehydration, which increases risk for thrombi development. Prolonged sitting, as in a car, limits blood flow to the lower extremities and venous return, promoting the formation of emboli. Low-fat diets are recommended as part of a healthy lifestyle. Air travel is permitted as long as the patient takes precautions against prolonged immobility.

A client calls the clinic and says, "I have been taking Imodium (loperamide) for diarrhea, but it isn't helping." How should the nurse respond? 1. "Are you taking it after every episode of diarrhea?" 2. "Imodium is not effective against diarrhea." 3. "This medication may make you sleepy." 4. "You may have to take the maximum dose for 2 or 3 days before diarrhea slows." 5. "You should come in for assessment."

1,3,5 Rationale: Loperamide (Imodium) is taken as a 4 mg single dose, followed by 2 mg after each diarrhea episode up to 16 mg/day. Imodium has the adverse effect of drowsiness. If over-the-counter medications are not effective, prescription medications may be necessary. The client should be seen in the clinic. Imodium is indicated for diarrhea. Diarrhea should slow within a few hours of doses.

The nurse plans to teach a class about Alzheimer's disease to a caregiver's support group. What will the best plan by the nurse include? 1. Depression and aggressive behavior are common with the disease. 2. Alzheimer's disease accounts for about 50% of all dementias. 3. Glutamergic inhibitors are the most common class of drugs for treating Alzheimer's disease. 4. Chronic inflammation of the brain may be a cause of the disease. 5. Memory difficulties are an early symptom of the disease.

1,4,5 Rationale: Memory difficulties are an early symptom of Alzheimer's disease. It is suspected that chronic inflammation and excess free radicals may cause neuron damage and contribute to the disease. Depression and aggressive behavior are common symptoms of the disease. Alzheimer's disease accounts for about 70% of all dementias. The acetylcholinesterase inhibitors, not the glutamergic inhibitors, are the most widely used class of drugs for treating the disease.

A nurse has provided medication education for a patient just diagnosed with Parkinson's disease. The nurse would evaluate that this instruction is successful when the patient makes which statements? 1. "I guess I will have to give up eating my wife's banana pudding." 2. "I should add some wheat germ to my breakfast cereal." 3. "I should add olive oil to the salads I eat at noon each day." 4. "I have to become a vegetarian." 5. "I will take my medication on an empty stomach."

1,5 Rationale: Bananas are high in vitamin B6 and should be avoided when taking these medications. These medications should be taken on an empty stomach. Wheat germ and fortified cereals should be avoided when taking these medications. Olive oil is not prohibited, but green vegetables should be limited. The patient does not need to follow a vegetarian diet but should reduce meat intake.

The patient receives an appropriate dose of warfarin (Coumadin), but the international normalized ratio (INR) is in the high range. The patient denies taking any aspirin products. What is the best assessment question to ask the patient at this time? 1. "Have you been eating much garlic?" 2. "Have you been eating a lot of salads and vegetables?" 3. "Have you been drinking too much milk?" 4. "Are you restricting your fluids too much?"

1. "Have you been eating much garlic?" Rationale: Garlic has been shown to decrease the aggregation of platelets, thus producing an anticoagulant effect. Patients taking anticoagulant medications should limit their intake of garlic. Salads and vegetables contain vitamin K, which is an antidote for warfarin (Coumadin). This would not impact the international normalized ratio (INR). Milk does not impact the international normalized ratio (INR) when a patient receives warfarin (Coumadin). Dehydration does not impact the international normalized ratio (INR) when a patient receives warfarin (Coumadin).

The patient receives verapamil (Calan). The patient tells the nurse that he is nervous about taking this medicine. What is the best response by the nurse? 1. "This medicine is safe, and most patients do very well with it." 2. "This medicine increases your blood pressure, but we will be monitoring that." 3. "This medicine has many side effects, but you should be okay." 4. "This medicine is a potassium channel blocker and is considered safe."

1. "This medicine is safe, and most patients do very well with it." Rationale: Calcium channel blockers are safe medications that are well tolerated by most patients. All medications have side effects, but telling the patient that he should be okay is not very reassuring. Verapamil (Calan) is a calcium channel blocker, not a potassium channel blocker. Verapamil (Calan) lowers, not increases, blood pressure and decreases cardiac workload.

Common adverse effects of antidysrhythmic medications include which of the following? (Select all that apply.) 1. Hypotension 2. Hypertension 3. Dizziness 4. Weakness 5. Panic attacks

1. Hypotension 3. Dizziness 4. Weakness Rationale:Because antidysrhythmics can slow the heart rate, the patient may experience hypotension, dizziness, or weakness. Options 2 and 5 are incorrect. Some antidysrhythmic classes, such as beta blockers and CCBs, are used in the treatment of HTN, which is a therapeutic rather than adverse effect of the drug. Antidysrhythmics are not used in the treatment of panic disorder.

When monitoring for therapeutic effect of any anti-dysrhythmic drug, the nurse would be sure to assess which essential parameter? 1. Pulse 2. Blood pressure 3. Drug level 4. Hourly urine output

1. Pulse Rationale:In the absence of ECG monitoring, the nurse would assess the pulse for rate, regularity, quality, and volume, noting any changes. The nurse should also teach the patient to monitor the pulse for rate and regularity before sending the patient home. Options 2, 3, and 4 are incorrect. The nurse is monitoring for the therapeutic effects of anti-dysrhythmic therapy. Al- though BP and drug level may also be monitored, they do not evaluate the therapeutic effects of the drug. Urine output may change related to the type of drug given and any effects on cardiac output. However, frequent output monitoring is not indicated in routine anti-dysrhythmic therapy and will not assess for therapeutic drug effects.

An 8-year-old boy is evaluated and diagnosed with absence seizures. He is started on ethosuximide (Zarontin). Which information should the nurse provide the parents? 1. After-school sports activities will need to be stopped because they will increase the risk of seizures. 2. Monitor height and weight to assess that growth is progressing normally. 3. Fractures may occur, so increase the amount of vitamin D and calcium-rich foods in the diet. 4. Avoid dehydration with activities and increase fluid intake.

2 Rationale: Because adverse drug effects such as nausea, anorexia, or abdominal pain may occur with ethosuximide (Zarontin), the parents should monitor the child's height and weight to assess whether nutritional intake is sufficient for normal growth and development. Options 1, 3, and 4 are incorrect. Physical activity does not increase the risk of seizure activity or need to be curtailed, and the drug does not affect bone growth or require extra vitamin D or calcium in the diet. Dehydration is a condition to be avoided in all clients, although increasing fluid intake is not necessarily related to the use of ethosuximide.

The patient will receive an IV infusion of milrinone (Primacor) as treatment for acute heart failure. What is the priority plan by the nurse? 1. Plan to monitor for atrial fibrillation. 2. Plan to monitor the ECG continuously. 3. Plan to take vital signs every 15 minutes. 4. Plan to monitor for hypertension.

2 Rationale: Due to the risk of ventricular dysrhythmia, the patient's ECG is usually monitored continuously during the infusion of milrinone (Primacor). Vital signs should be assessed continuously, not every 15 minutes, while the patient receives milrinone (Primacor). Hypotension, not hypertension, is an adverse effect of milrinone (Primacor). Ventricular dysrhythmias, not atrial fibrillation, are an adverse effect of milrinone (Primacor).

A client is admitted for treatment of a duodenal ulcer. What will the nurse's admission assessment likely reveal? 1. Nausea and lower right quadrant abdominal pain 2. Burning pain several hours after eating a meal 3. Anorexia and weight loss 4. Low back pain radiating down the left leg

2 Rationale: Duodenal ulcers are associated with burning upper abdominal pain after a meal. Nausea and lower right quadrant abdominal pain are more likely associated with appendicitis. Anorexia and weight loss are more common with gastric, not duodenal, ulcers. Duodenal ulcers do not cause low back pain radiating down the left leg.

When planning to teach the patient about the use of epoetin alfa (Epogen, Procrit), the nurse would give which of the following instructions? 1. Eating raw fruits and vegetables must be avoided. 2. Frequent rest periods should be taken to avoid excessive fatigue. 3. Skin and mucous membranes should be protected from traumatic injury. 4. Exposure to direct sunlight must be minimized and sunscreen used when outdoors.

2 Rationale: Epoetin alfa (Epogen, Procrit) is ordered to treat anemia and the patient with anemia may experience periods of excessive fatigue and weakness related to the diminished oxygen-carrying capacity from low RBC counts. Adequate rest periods should be planned and patients taught to avoid overexertion until the epoetin alfa has had therapeutic effects and the RBC counts improve. Options 1, 3, and 4 are incorrect. Avoiding fresh fruits or vegetables is not necessary for a patient who is taking epoetin alfa but may be appropriate for a patient with low WBC counts. Patients with anemia do not necessarily have low platelet counts (thrombocytopenia) and do not need to routinely avoid activities that may cause direct tissue injury. Limiting direct sun exposure and wearing sunscreen are excel- lent health practices but are not required as part of epoetin alfa therapy.

The patient receives levodopa-carbidopa (Sinemet). The nurse has completed medication education and determines that learning has occurred when the patient makes which statement? 1. "I need to increase my daily intake of protein." 2. "I must increase the fiber in my diet." 3. "I need to check my pulse before taking the medication." 4. "I must avoid carbohydrates in my diet."

2 Rationale: Fiber will help prevent constipation, which is a side effect of levodopa-carbidopa (Sinemet). There isn't any need to check the pulse prior to the medication. There isn't any need to avoid carbohydrates. There isn't any need to increase the daily intake of protein.

The patient has a history of cardiac disease and receives digoxin (Lanoxin). The nurse determines that education about dietary needs with this medication has been effective when the patient makes which selection for lunch? 1. Cottage cheese, peach salad, and blueberry pie 2. Baked fish, sweet potatoes, and banana pudding 3. Green bean soup, whole-wheat bread, and an apple 4. Hamburger, French fries, and chocolate chip cookies

2 Rationale: Fish, sweet potatoes, and bananas are high in potassium, which will help prevent digoxin toxicity. The hamburger is high in potassium, but the French fries are not appropriate for a cardiac patient. Green bean soup, whole-wheat bread, and an apple are not significant sources of potassium needed to help prevent digoxin toxicity. Cottage cheese, peach salad, and blueberry pie are not significant sources of potassium needed to help prevent digoxin toxicity.

A patient has been started on a stool softener for constipation. Which information should the nurse provide regarding onset of action? 1. "Continue to take this medication until your stool is very loose and diarrhea-like." 2. "If your discomfort gets worse, return to the clinic." 3. "This medication will work in about 8 hours." 4. "If you do not have a bowel movement by tomorrow, return to the clinic."

2 Rationale: If the patient has increased discomfort, additional assessment is indicated. There is no reason to take this medication until loose stools occur. This medication may take 2 or 3 days to work. Tomorrow is too soon to evaluate that therapy is unsuccessful.

A client who has gastroesophageal reflux disease (GERD) has been taking proton pump inhibitors (PPIs) for many years. The nurse discusses which potential complication of this long-term therapy? 1. Increased risk of anemia 2. Increased risk of osteopenia 3. Increased risk of hypertension 4. Increased risk of intestinal irritation

2 Rationale: Long-term use of PPIs increases risk of osteopenia and osteoporosis. It does not increase risk of anemia, hypertension, or intestinal irritation.

A patient who has been taking diphenoxylate with atropine (Lomotil) is very drowsy and has a respiratory rate of 10 bpm. The roommate, who brought the patient to the emergency department, states that the patient took "a whole bottle" of the drug. Which nursing action is indicated? 1. Administer a beta blocker 2. Administer naloxone 3. Administer high volume intravenous fluids 4. Administer activated charcoal

2 Rationale: Naloxone is a narcotic antagonist to reverse the effects of opioid overdose. The patient will need intravenous access, but there is no information to suggest high volume IV fluids are necessary. Activated charcoal will not reverse the patient's respiratory depression. There is no indication that a beta blocker is needed.

A 24-year-old patient has been taking sulfasalazine (Azulfidine) for irritable bowel syndrome and complains to the nurse that he wants to stop taking the drug because of the nausea, headaches, and abdominal pain it causes. What would the nurse's best recommendation be for this patient? 1. The drug is absolutely necessary, even with the adverse effects. 2. Talk to the health care provider about dividing the doses throughout the day. 3. Stop taking the drug and see if the symptoms of the irritable bowel syndrome have resolved. 4. Take an antidiarrheal drug such as loperamide (Imodium) along with the sulfasalazine.

2 Rationale: Nausea, vomiting, diarrhea, dyspepsia, abdominal pain, and headache are common adverse effects of sulfasalazine (Azulfidine). Dividing the total daily dose evenly throughout the day and using the enteric-coated tablets may improve adherence. Options 1, 3, and 4 are incorrect. Patients who experience significant adverse effects of drug therapy are unlikely to comply with a drug regimen if the effects are severe. Suggesting that the patient take an antidiarrheal drug or that he stop drug therapy is not within the scope of a nurse's practice and should be items that he discusses with his health care provider.

A patient has been taking phenytoin (Dilantin) for control of generalized seizures, tonic-clonic type. The patient is admitted to the medical unit with symptoms of nystagmus, confusion, and ataxia. What change in the phenytoin dosage does the nurse anticipate will be made based on these symptoms? 1. The dosage will be increased. 2. The dosage will be decreased. 3. The dosage will remain unchanged; these are symptoms unrelated to the phenytoin. 4. The dosage will remain unchanged but an additional antiseizure medication may be added.

2 Rationale: Nystagmus, confusion, and ataxia may occur with phenytoin, particularly with higher dosages. The dosage is likely to be decreased. Options 1, 3, and 4 are incorrect. The dosage would not remain the same or be increased because these are adverse effects of phenytoin that are related to overdosage.

Which degenerative disease of the central nervous system is the most common? 1. Amyotrophic lateral sclerosis (ALS) 2. Alzheimer's 3. Multiple sclerosis (MS) 4. Huntington's chorea

2 Rationale: Parkinson's and Alzheimer's diseases are the most common degenerative diseases of the central nervous system. MS is not the most common disease.

2. The patient asks what can be expected from the levodopa/carbidopa (Sinemet) he is taking for treatment of Parkinson's Disease. What is the best response by the nurse? 1. "A cure can be expected within 6 months." 2. "Symptoms can be reduced and the ability to perform ADLs can be improved." 3. "Disease progression will be stopped." 4. "Extrapyramidal symptoms will be prevented."

2 Rationale: Pharmacotherapy does not cure or stop the disease process but does improve the patient's ability to perform ADLs such as eating, bathing, and walking. Options 1, 3, and 4 are incorrect. Drug therapy for PD does not cure or halt progression of the disease. Depending on the drug therapy, EPS may be an adverse effect.

The physician has prescribed phenytoin (Dilantin) for a patient with type 1 diabetes mellitus. What does the nurse include in the plan of care for this patient? 1. Plan to discuss with the physician the need to decrease the patient's insulin based on serum glucose levels. 2. Plan to discuss with the physician the need to increase the patient's insulin based on serum glucose levels. 3. Plan to assess the patient for petechiae, epistaxis, and hematuria. 4. Plan to institute safety precautions, as the patient is at risk for dizziness and ataxia.

2 Rationale: Phenytoin (Dilantin) can increase serum glucose levels, and the patient may need additional insulin. All patients receiving phenytoin (Dilantin) are at risk for dizziness and ataxia; this is not specific to the patient with type 1 diabetes mellitus. All patients receiving phenytoin (Dilantin) are at risk for petechiae, epistaxis, and hematuria; this is not specific to the patient with type 1 diabetes mellitus. Phenytoin (Dilantin) can increase serum glucose levels, not decrease them.

The nurse has administered prochlorperazine (Compazine) to a patient for postoperative nausea. Before administering this medication, it is essential that the nurse check which of the following? 1. Pain level 2. Blood pressure 3. Breath sounds 4. Temperature

2 Rationale: Prochlorperazine (Compazine) may cause decreased blood pressure or hypotension as an adverse effect. The blood pressure should be taken before administering and the drug held if the BP is below 90/60 mmHg or is below parameters as ordered by the provider. Options 1, 3, and 4 are incorrect. Although it is important to assess pain level, breath sounds, and temperature in the postoperative patient, prochlorperazine does not directly affect these parameters.

The nurse completes medication education for the client receiving sucralfate (Carafate). The nurse evaluates that learning has occurred when the client makes which statement? 1. "This works by inhibiting bacterial growth in my stomach." 2. "This works by dissolving into a jelly and sticking to my ulcer." 3. "This works by decreasing the amount of acid in my stomach." 4. "This works by neutralizing the acid in my stomach."

2 Rationale: Sucralfate (Carafate) works by dissolving into a gel and adhering to the site of the ulcer. It does not inhibit bacterial growth, decrease the amount of acid in the stomach, or neutralize stomach acid.

In a person with a sinus rhythm, the primary purpose of the AV node is to 1. pace the heart at 40-60 bpm. 2. delay the impulse from the SA node. 3. pace the heart at 60-100 bpm. 4. enhance the impulse from the SA node.

2 Rationale: The AV node delays the impulse as it travels from the atria to the ventricles. The AV junction does pace the heart at 40-60 bpm, but not when the SA node is pacing the heart.

A client has been prescribed sulfasalazine (Azulfidine) for treatment of ulcerative colitis. Which nursing assessment question is essential? 1. "How long have you had ulcerative colitis?" 2. "What are you allergic to?" 3. "Are you lactose intolerant?" 4. "Do you have to stand in one place for long periods of time at your work?"

2 Rationale: The client who is allergic to sulfa drugs should not take sulfasalazine. How long the ulcerative colitis has existed is not the most important data. Lactose intolerance is not a significant assessment finding for this client. Standing in one spot for long periods of time is not a significant issue with sulfasalazine.

The patient receives digoxin (Lanoxin). Which assessment findings would indicate adverse effects to this medication? 1. Tachycardia and hypotension 2. Blurred vision and tachycardia 3. Anorexia and nausea 4. Anorexia and constipation

3 Rationale: Anorexia and nausea are common adverse effects of digoxin (Lanoxin). Hypotension can occur, but bradycardia occurs, not tachycardia. Blurred vision can occur, but bradycardia occurs, not tachycardia. Anorexia can occur, but diarrhea is more likely than constipation.

The nurse is preparing to administer chemotherapy to an oncology patient who also has an order for ondansetron (Zofran). When should the nurse administer the odansetron? 1. Every time the patient complains of nausea 2. 30 to 60 minutes before starting the chemotherapy 3. Only if the patient complains of nausea 4. When the patient begins to experience vomiting during the chemotherapy

2 Rationale: To be most effective, ondansetron (Zofran) or other antiemetics should be administered 30 to 60 minutes before initiating the chemotherapy drugs. Options 1, 3, and 4 are incorrect. Almost all chemotherapy drugs have emetic potential and the nurse should not wait until the patient complains of nausea or experiences vomiting before giving the drug. The patient may complain of nausea more frequently than is possible to give the drug. Other nondrug relief strategies such as diversion techniques or ginger ale should also be tried.

To best monitor for therapeutic effects from filgrastim (Granix, Neupogen), the nurse will assess which laboratory finding? 1. Hemoglobin and hematocrit 2. White blood cell or absolute neutrophil counts 3. Serum electrolytes 4. Red blood cell count

2 Rationale:Filgrastim stimulates granulocytes (WBCs). Options 1, 3, and 4 are incorrect. Filgrastim does not stimulate RBC production, affect Hgb or Hct, or have a direct effect on serum electrolytes.

While a nurse is collecting medical history, the client says, "I was diagnosed with a spastic colon." How should the nurse interpret this statement? 1. The client has ulcerative colitis. 2. The client has had recurrent abdominal pain for at least 3 months. 3. The client has irritable bowel syndrome. 4. The client's disease is psychosomatic. 5. The client has Crohn's disease.

2,3 Rationale: Irritable bowel syndrome is also known as spastic colon. The diagnostic criterion for this disorder is recurrent abdominal pain for at least 3 days per month during the previous 3 months. Typically, the diagnosis of spastic colon is not the same as ulcerative colitis. While there is often no organic disease found in this disorder, the pain and other findings are real. Irritable bowel syndrome is not the same as Crohn's disease.

The patient tells the nurse, "This educational video you gave me shows normal electrical conduction through the heart, but I still don't understand it. Can you explain it to me?" What are the nurse's best responses? 1. "Conduction through the bundle of His is the slowest in the heart." 2. "Conduction begins in the sinoatrial (SA) node and travels to the atrioventricular (AV) node." 3. "Conduction continues through the bundle branches to the Purkinje fibers." 4. "Conduction travels from the atrioventricular (AV) node through the bundle of His." 5. "The sinoatrial (SA) node is located in the left atrium."

2,3,4 Rationale: Conduction through the heart originates in the sinoatrial (SA) node and travels through the atrioventricular (AV) node through the bundle of His to the right and left bundle branches to the Purkinje fibers. Conduction through the atrioventricular (AV) node is the slowest in the heart. The sinoatrial (SA) node is located in the right atrium.

5. A female patient is prescribed dantrolene (Dantrium) for painful muscle spasms associated with multiple sclerosis. The nurse is writing the discharge plan for the patient and will include which of the following teaching points? (Select all that apply.) 1. If muscle spasms are severe, supplement the medication with hot baths or showers three times per day. 2. Inform the health care provider if she is taking estrogen products. 3. Sip water, ice, or hard candy to relieve dry mouth. 4. Return periodically for required laboratory work. 5. Obtain at least 20 minutes of sun exposure per day to boost vitamin D levels.

2,3,4 Rationale: Dantrolene (Dantrium) may cause hepatotoxicity with the greatest risk occurring for women over age 35, and periodic laboratory tests will be required for monitoring. Estrogen taken concurrently with dantrolene may increase this risk. The drug may cause dry mouth and sucking on hard candy, sucking ice chips, or sipping water may help relieve the dryness. Options 1 and 5 are incorrect. Dantrolene may cause erratic blood pressure, including hypotension, and hot baths or showers cause vasodilation, increasing the risk for syncope and falls. The drug may cause photosensitivity and direct exposure to the sun should be avoided.

A patient has been started on clopidogrel (Plavix) after a myocardial infarction and stent placement. How should the nurse explain the action of this medication to the patient? 1. "Plavix will dissolve any clots that might form in your stent." 2. "Plavix will make the platelets in your blood less sticky." 3. "Plavix will change the way your platelets work their entire lives." 4. "Plavix decreases your blood's ability to clot." 5. "Plavix works just like the heparin you have been on in the hospital."

2,3,4 Rationale: Plavix is an adenosine diphosphate (ADP) receptor blocker that acts to make platelets unable to aggregate, thus rendering them less "sticky." Plavix causes irreversible changes in platelet plasma membranes. Plavix does decrease the blood's ability to clot. Plavix does not act to dissolve clots. The mechanisms of action of Plavix and heparin are not alike.

The nurse knows that which of the following are major disadvantages for the use of donepezil (Aricept) to treat the symptoms of early Alzheimer's disease? (Select all that apply.) 1. It must be administered four times per day. 2. It may causes significant weight loss. 3. It may cause potentially fatal cardiac dysrhythmias. 4. It may cause serious hepatic damage. 5. It results in only modest cognitive improvement and results do not last.

2,3,4,5 Rationale: Donepezil (Aricept) may cause serious liver damage and potentially fatal dysrhythmias including severe bradycardia and heart block. It may also cause significant weight loss, and the patient's weight should be monitored. While cognitive improvement may be observed in as few as 1 to 4 weeks, patients should receive pharmacotherapy for at least 6 months prior to assessing maximum benefits of drug therapy. Unfortunately, cognitive improvement is only modest and short-term. Option 1 is incorrect. Donepezil is taken once per day usually at bedtime.

Which statement best explains why structural changes occur within the brains of people with Alzheimer's disease? 1. Increased acetylcholine levels 2. Increases in blood pressure and cholesterol levels 3. Chronic inflammation and oxidative cellular damage 4. Cerebral bleeding and associated hypoxia

3 Rationale: Alzheimer's disease is characterized by amyloid plaques and neurofibrillary tangles that most likely occur from chronic inflammation or oxidative cellular damage. There is no increase of acetylcholine levels. Blood pressure and cholesterol levels are not implicated. Cerebral bleeding and associated hypoxia are not implicated.

It is suspected that a client has developed peptic ulcer disease (PUD). Which information should the nurse provide this client regarding projected course of treatment? 1. You will be started on an antibiotic. 2. You will be tested for the presence of H. pylori. 3. You may be directed to take Pepto-Bismol along with your other medications. 4. You should plan on taking medication for 4 to 8 weeks. 5. There are some lifestyle changes you can take to make therapy more successful.

2,3,4,5 Rationale: The client should be tested for the presence of H. pylori before antibiotic therapy is started. If the client is positive for H. pylori, bismuth-containing medications are sometimes prescribed for concurrent use. It takes time to heal a peptic ulcer, so therapy may continue for several weeks. Some lifestyle changes such as changing dietary habits and smoking cessation can help therapy be more successful. The client may or may not be started on an antibiotic.

The parents of a 2-year-old who has cerebral palsy are only now beginning to accept that their child will have a permanent disability. The nurse has been instructing the parents about the treatment for the spasticity their child is experiencing. Which statements by the parents indicate that the nurse should plan additional teaching sessions? 1. "At some point, our child may require surgery to correct this spasticity." 2. "As long as we continue our child's medications, the spasticity can be controlled." 3. "Our physical therapy sessions should focus on flexing our child's muscles." 4. "We should repeat the exercises several times with each muscle group." 5. "It is best to give our child a rest from physical therapy by skipping 1 week a month."

2,3,5 Rationale: Medication alone is generally not enough to control spasticity in these children. The parents need additional teaching. The physical therapy sessions for spasticity focus on muscle stretching, not flexion. The parents need additional teaching. Physical therapy should be routine and consistent in order to reduce or control spasticity. These parents need additional teaching. Surgery is sometimes necessary in these cases, so this statement reflects accurate knowledge. Repetitive motion exercises are beneficial in reducing and controlling spasticity. The parents have expressed accurate knowledge.

The nurse is discharging a 72-year-old man who was hospitalized after a muscle strain injury to his back. One of the discharge prescriptions for this patient is cyclobenzaprine (Flexeril) 10 mg three times per day with food. The prescription is written for 90 tablets and there are three refills available. Which information from this situation would alert the nurse for the need to collaborate with the patient's health care provider? 1. The dosage amount is too low for the type of injury this patient sustained. 2. Cyclobenzaprine should be used with great caution in those over 65. 3. If taken as directed, the patient would be able to take the medication for 120 days. 4. Cyclobenzaprine is not effective for back pain. 5. Cyclobenzaprine should not be taken with food.

2,3,5 Rationale: The adverse reactions from cyclobenzaprine include confusion, hallucinations, and cardiac events, which are more common in patients over 65. The manufacturer recommends that treatment not extend beyond 3 weeks or 21 days. The drug may be taken with food or milk if gastric upset occurs. The dosage of 10 mg three times daily is standard. Cyclobenzaprine is not effective for muscle spasm due to spinal cord injury but is useful in the treatment of back pain from muscle strain.

The patient's health care provider prescribed cyclobenzaprine (Flexeril) for the treatment of neck spasms. The patient reports that the medication is "not working," even though it has been a week since the medication was started. What changes in this patient's plan of care would the nurse anticipate? 1. Increase in the dosage frequency 2. Discontinuation of the medication 3. Waiting a few more days for full medication effect 4. Change to a different medication

2,4 Rationale: Full effects of this medication may take two weeks. Increasing the dosage frequency is not indicated. It is not yet time to discontinue the medication or to change the medication.

The nurse is teaching a class for patients who have been recently diagnosed with epilepsy. The nurse determines that learning has occurred when the patients make which statements? 1. "Excessive stress levels cause disruptions in how the brain receives oxygen, leading to epilepsy." 2. "Epilepsy may be caused by a head injury." 3. "Eating disorders, like anorexia nervosa, increase the risk for developing epilepsy." 4. "A stroke, or brain attack, could increase the risk for developing epilepsy." 5. "With some cases of epilepsy, the cause is never determined."

2,4,5 Rationale: Epilepsy is a disorder where seizures occur on a chronic basis. Head trauma is a known cause of seizures. In some cases, the exact etiology may not be identified. Changes in cerebral perfusion such as hypotension; strokes, or brain attacks; and shock may be causes of seizures. There is no known correlation with anorexia nervosa and the development of epilepsy. Excessive levels of stress cannot disrupt cerebral oxygen to the extent that epilepsy would occur.

A 35-year-old male patient has been prescribed omeprazole (Prilosec) for treatment of gastroesophageal reflux disease. Which of the following assessment findings would assist the nurse to determine whether drug therapy has been effective? (Select all that apply.) 1. Decreased "gnawing" upper abdominal pain on an empty stomach 2. Decreased belching 3. Decreased appetite 4. Decreased nausea 5. Decreased dysphagia

2,4,5 Rationale:Symptoms of GERD include dysphagia, dyspepsia, nausea, belching, and chest pain. Therapeutic effects of omeprazole (Prilosec) would include relief of these symptoms. Options 1 and 3 are incorrect. Gnawing or burning upper abdominal pain is symptomatic of PUD, not GERD. A decreased appetite should not occur with omeprazole.

A patient diagnosed with pernicious anemia is to start cyanocobalamin (Nascobal) injections. Which of the following patient statements demonstrates an understanding of the nurse's teaching? (Select all that apply.) 1. "I need to be careful to avoid infections." 2. "I will need to take this drug for the rest of my life." 3. "I should increase my intake of foods that contain vitamin B12." 4. "I need to take the liquid preparation through a straw." 5. "I may be able to switch over to nasal sprays once my vitamin B12 levels are normal."

2,5 Rationale: The patient with pernicious anemia is unable to absorb vitamin B12 from the stomach and must take lifelong supplements of the vitamin. Once vitamin levels reach normal, a weekly nasal spray may be ordered. Options 1, 3, and 4 are incorrect. Because patients with pernicious anemia lack a factor (intrinsic factor) that allows gastric absorption of vitamin B12, oral use is not effective and increasing the amount of foods containing the vitamin will not be effective. Patients with pernicious anemia have a decrease in RBCs, not WBCs, and are not at increased risk for infections.

A patient is given a prescription for propranolol (Inderal) 40 mg bid. What is the most important instruction the nurse should give to this patient? 1. Take this medication on an empty stomach, as food interferes with its absorption. 2. Do not stop taking this medication abruptly; the dosage must be decreased gradually if it is discontinued. 3. If the patient experiences any disturbances in hearing, the patient should notify the health care provider immediately. 4. The patient may become very sleepy while taking this medication; do not drive.

2. Do not stop taking this medication abruptly; the dosage must be decreased gradually if it is discontinued. Rationale: Beta blockers such as propranolol should never be stopped abruptly because of the possible rebound HTN and increased dysrhythmias that may occur. Options 1, 3, and 4 are incorrect. The nurse may teach the patient to take the medication on an empty stomach and to be cautious with drowsiness while taking beta blockers. However, these are not as significant as the HTN or dysrhythmias that may occur from abrupt cessation and would be considered secondary teaching points. Hearing loss is not a common side effect of beta blockers.

Which change is a common adverse effect of cyclobenzaprine (Flexeril)? 1. Alopecia 2. Tongue swelling 3. Drowsiness 4. Hypotension

3 Rationale: All centrally acting agents have the potential to cause sedation. Tongue swelling is serious, but rare. Tachycardia is possible but would likely lead to hypertension, not hypotension. Alopecia is not an associated adverse effect.

Depolarization occurs when which two electrolytes rush into the cell? 1. Sodium and potassium 2. Calcium and magnesium 3. Calcium and sodium 4. Chloride and potassium

3 Rationale: An action potential begins when sodium and calcium flow into the cell, resulting in depolarization.

A female patient reports using OTC aluminum hydroxide (AlternaGEL) for relief of gastric upset. She is on renal dialysis three times a week. What should the nurse teach this patient? 1. Continue using the antacids but if she needs to continue them beyond a few months, she should consult the health care provider about different therapies. 2. Take the antacid no longer than for two weeks; if it has not worked by then, it will not be effective. 3. Consult with the health care provider about the appropriate amount and type of antacid. 4. Continue to take the antacid; it is OTC and safe.

3 Rationale: Antacids are generally combinations of aluminum hydroxide, calcium, and/or magnesium hydroxide. Hypermagnesemia, hypercalcemia, or hypophosphatemia can develop with use of OTC antacids. Because this patient is on renal dialysis, her kidneys are unable to adequately control the excretion of electrolytes. The nephrologist should be contacted about whether an antacid is appropriate for this patient. Options 1, 2, and 4 are incorrect. Because of concerns about electrolyte imbalance, taking the antacid for limited periods may not be advisable. Because a drug is OTC does not guarantee its safety and it may produce adverse effects in patients.

A client who was diagnosed with Clostridium difficile calls the clinic and says, "I'm still having diarrhea so I started taking an over-the-counter medication to stop it." How should the nurse respond? 1. "Which antidiarrheal are you taking?" 2. "How many doses have you taken?" 3. "Stop taking the medicine and come to the clinic." 4. "Is it stopping your diarrhea?"

3 Rationale: Antidiarrheal use is contraindicated in cases of Clostridium difficile. The identity of the antidiarrheal and the number of doses taken are not the priority. The effectiveness of the antidiarrheal is not the priority.

1. Which of the following patient statements indicates that the levodopa/carbidopa (Sinemet) is effective? 1. "I'm sleeping a lot more, especially during the day." 2. "My appetite has improved." 3. "I'm able to shower by myself." 4. "My skin doesn't itch anymore."

3 Rationale: Becoming more independent in ADLs shows an improvement in physical abilities. Options 1, 2, and 4 are incorrect. Drowsiness is a common adverse effect of medications for PD. Anorexia or loss of appetite is also a common adverse effect and skin itch- ing is not related to medication use.

An early sign(s) of levodopa toxicity is (are) which of the following? 1. Orthostatic hypotension 2. Drooling 3. Spasmodic eye winking and muscle twitching 4. Nausea, vomiting, and diarrhea

3 Rationale: Blepharospasm (spasmodic eye winking) and muscle twitching are early signs of poten- tial overdose or toxicity. Options 1, 2, and 4 are incorrect. Orthostatic hypotension is a common adverse effect of both PD and many drugs used to treat the condition but is not a symptom of overdosage or toxicity. Drooling, nausea, vomiting, and diarrhea are also not symptoms of overdose or toxicity.

Which statement describes the primary difference between centrally acting muscle relaxants and direct-acting antispasmodics? 1. Centrally acting agents inhibit neurons of the central nervous system, while direct-acting agents stimulate neurons of the central nervous system. 2. Centrally acting agents stimulate neurons of the central nervous system, while direct-acting agents stimulate neurons of the peripheral nervous system. 3. Centrally acting agents inhibit neurons of the central nervous system, while direct-acting agents work at the level of the neuromuscular junction and skeletal muscles. 4. Centrally acting agents stimulate the central nervous system, while direct-acting agents inhibit neuronal conduction of the central nervous system.

3 Rationale: Centrally acting agents inhibit neurons of the central nervous system, while direct-acting agents work at the level of the neuromuscular junction and skeletal muscles.

A patient has been prescribed clonazepam (Klonopin) for muscle spasms and stiffness secondary to an automobile accident. While the patient is taking this drug, what is the nurse's primary concern? 1. Monitoring hepatic laboratory work 2. Encouraging fluid intake to prevent dehydration 3. Assessing for drowsiness and implementing safety measures 4. Providing social services referral for patient concerns about the cost of the drug

3 Rationale: Clonazepam (Klonopin) is a benzodiazepine; because it works on the CNS, it may cause significant drowsiness and dizziness. Safety measures should be implemented to prevent falls and injury. Options 1, 2, and 4 are incorrect. Benzodiazepines may cause hepatotoxicity in patients with existing hepatic insufficiency and may be needed for long-term monitoring. This drug was prescribed after a health care provider's assessment and is currently given to treat a potential short-term condition. The drug should not cause dehydration and is available in generic form. If cost is a concern, social service aid may be needed, but the primary concern for the nurse is safety.

Darbepoetin (Aranesp) is ordered for each of the following patients. The nurse would question the order for which condition? 1. A patient with chronic renal failure 2. A patient with AIDS who is receiving anti-AIDS drug therapy 3. A patient with hypertension 4. A patient on chemotherapy for cancer

3 Rationale: Darbepoetin (Aranesp) and other similar drugs should not be used or are used cautiously in the patient with HTN because they may increase the blood pressure. Options 1, 2, and 4 are incorrect. Chronic renal failure, AIDS, and cancer chemotherapy are all indications for the use of darbepoetin.

Which of the following adverse effects would most likely be associated with the use of phenytoin (Dilantin)? 1. Vitamin B deficiency 2. Leg edema 3. Bleeding 4. Hypoglycemia

3 Rationale: Dilantin affects the metabolism of vitamin K, which can lead to blood dyscrasias. Hyperglycemia is more common than hypoglycemia, and leg edema is not generally experienced as an adverse effect. Vitamin B deficiency is not the most common complication.

Which statement is accurate regarding the physiological changes associated with heart failure? 1. Blood backs up into the lungs due to right ventricular hypertrophy. 2. The walls of the heart shrink, leading to lower cardiac output. 3. Cardiac remodeling occurs after prolonged ventricular hypertrophy. 4. Blood pressure increases, resulting in lowered afterload.

3 Rationale: Heart walls thicken and enlarge with heart failure. These changes occur over time and are referred to as cardiac remodeling. Blood can back up into the lungs, but this would be a result of left ventricular hypertrophy, not right. Blood pressure can go up but would result in a higher, not lower, afterload.

The patient receives levodopa and carbidopa (Sinemet). What will the best teaching by the nurse include as relates to this medication? 1. Avoid drinking caffeinated beverages. 2. Take the medication with meals. 3. Take the medication on an empty stomach. 4. Take the medication with a protein food.

3 Rationale: Levodopa and carbidopa (Sinemet) should be taken on an empty stomach for better absorption. Levodopa and carbidopa (Sinemet) should not be taken with meals; this will decrease absorption. Levodopa and carbidopa (Sinemet) should not be taken with a protein food; this will decrease absorption. There isn't any significant relationship between caffeine and Levodopa and carbidopa (Sinemet).

Levodopa is prescribed for a patient with Parkinson's disease. At discharge, which of the following teaching points should the nurse include? 1. Monitor blood pressure every 2 hours for the first 2 weeks. 2. Report the development of diarrhea. 3. Take the pill on an empty stomach or 2 hours after a meal containing protein. 4. If tremors seem to worsen, take a double dose for two doses and call the provider.

3 Rationale: Taking dopamine replacement drugs such as levodopa with meals containing protein significantly impairs absorption. The drug should be taken on an empty stomach or 2 or more hours after a meal containing protein. Options 1, 2, and 4 are incorrect. Although the patient should be taught to rise gradually from lying or sitting to standing, the patient does not need to monitor blood pressure every 2 hours. Diarrhea should be reported but is unrelated to the effects of levodopa, and other causes should be explored. An increase in tremors should be evaluated, and the dose of the drug should not be independently increased.

An older adult client comes to the emergency department with his wife. He has a history of peptic ulcer disease (PUD) and is currently experiencing confusion and severe headaches. What does the best plan by the nurse include? 1. Ask the client if he has experienced any head injuries recently. 2. Obtain a complete blood count (CBC), chemistry profile, and urine drug screen. 3. Ask the client's wife for a list of medications that the client has taken. 4. Obtain a magnetic resonance imaging (MRI) exam to assess if the client has experienced a stroke.

3 Rationale: There is a known correlation between H2-receptor antagonists and confusion and headaches in the older adult population; the nurse should ascertain what medications the client is taking. Since the client has PUD, it would be logical to ask about medication prior to asking about injury. A complete blood count (CBC), chemistry profile, and urine drug screen are worthwhile tests, but the first priority for a client with a history of peptic ulcer disease (PUD) should be to find out what medications he has been taking. It is premature to obtain a magnetic resonance imaging (MRI) exam until other causes have been ruled out.

A patient is being treated for a thromboembolic disorder. If the goal is to prevent clot formation, the nurse anticipates the patient will be treated with which classification of drug? 1. Hemostatics 2. Thrombolytics 3. Anticoagulants 4. Antiplatelet agents 5. Clotting factor concentrates

3,4 Rationale: Anticoagulants inhibit specific clotting factors, thereby preventing clot formation. Antiplatelet agents inhibit the action of platelets, thereby preventing clot formation. Hemostatic drugs are given to inhibit fibrin destruction, thereby promoting clot formation. Thrombolytic drugs are given to remove existing clots by dissolving them. Clotting factor concentrates replace missing clotting factors, thereby promoting clot formation.

The patient who is prescribed valproic acid (Depakene) for seizure control would like to have a baby. Which statements should the nurse include in a discussion with this patient? 1. "Since your epilepsy may flare up during pregnancy, your doctor will likely have you take a second antiepileptic medication." 2. "Thankfully, most modern antiepileptic medications will not interfere with you getting pregnant." 3. "Your current antiepileptic medication should not be used when you are pregnant." 4. "Folic acid supplementation is important for you." 5. "You should consider adopting a baby instead since there are so many problems associated with epilepsy and pregnancy."

3,4 Rationale: Valproic acid (Depakene) is Pregnancy Category D. Folic acid supplementation is important for all women who are, or wish to become, pregnant. This is especially true of women who are epileptic because many antiepileptic medications cause folic acid deficiency. Since there are many side effects to antiepileptic medications, single drug therapy is the goal for pregnant patients. Women who have epilepsy have a reduced fertility rate, and some do not ovulate. Women who are epileptic can and do conceive and deliver healthy babies. The nurse should not discourage this patient but should provide information to the patient and then support the patient's choice.

A client has been prescribed aluminum hydroxide (AlternaGEL) for the treatment of heartburn. Which information should the nurse plan to teach this client? 1. You should expect this medication to take up to 2 days to start taking effect. 2. Take this medication with a glass of milk. 3. You may notice constipation as an effect of this drug. 4. Take this medication at least 2 hours before or after any other medication you are taking. 5. This medication will reduce the acid your stomach produces.

3,4,5 Rationale: Constipation may be a side effect of this antacid. Absorption may be affected if taken within 2 hours of any other drug. This medication's onset of action is within 20-40 minutes. There is no reason for the client to drink milk with this medication. This medication acts to neutralize acid, not to reduce its production.

Verapamil (Calan, Covera-HS, Verelan) should be used with extra caution or is contraindicated in patients with which cardiovascular condition? 1. Hypertension 2. Tachycardia 3. Heart failure 4. Angina

3. Heart failure CCBs such as verapamil (Calan) are used cautiously or are contraindicated in patients with HF because they may cause decreased contractility, which may precipitate or worsen HF. Options 1, 2, and 4 are incorrect. Verapamil and CCBs are often prescribed to treat HTN, tachycardia, and angina.

The patient tells the nurse, "The doctor is going to start me on Botox for the muscle spasms in my neck. I've always wanted to try that. It will make my face look younger." What information should the nurse provide to this patient regarding onabotulinumtoxinA (Botox)? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. "Once you start on the medication, it may take a week or so before you notice a change in your skin." 2. "Be certain you take the medication with a full glass of water because it can be hard on your kidneys." 3. "There are many different uses for that drug, depending on how it is administered." 4. "You may need additional treatments with the medication in a few months." 5. "You should be aware that side effects of the medication can occur hours or weeks after your treatment."

3,4,5 Rationale: OnabotulinumtoxinA (Botox) has many clinical indications. Repeated doses of onabotulinumtoxinA (Botox) are often required. Side effects of onabotulinumtoxinA (Botox) may not occur immediately upon administration, and the patient should watch for their development for several hours to weeks later. Action depends on the area where the medication is administered. OnabotulinumtoxinA (Botox) in this patient's case will not change the skin. OnabotulinumtoxinA (Botox) is administered by injection into the muscle.

The nurse is providing discharge teaching regarding anticoagulant therapy. Which statements by the patient would the nurse evaluate as indicating the need for further instruction? 1. "I'll ask for an electric razor for my birthday next week." 2. "I guess my trip to the amusement park is off for now." 3. "I won't be able to cook anymore." 4. "I'll get one of those new electric toothbrushes with the firm bristles." 5. "I should make an appointment for a B12 injection monthly."

3,4,5 Rationale: The patient should be cautious when cutting food for preparation, but cooking is not prohibited. The patient should use a soft-bristle toothbrush. IM injections should be avoided. Use of an electric razor is preferred for patients on anticoagulant therapy. The patient should avoid situations in which jostling or violent bumping could occur.

The nurse is talking with a patient who was just prescribed ethosuximide (Zarontin). Which patient statement should the nurse immediately discuss with the patient's health care provider? 1. "Did I mention that I used to take phenobarbital for my seizures?" 2. "I forgot to tell the doctor that I am allergic to penicillin." 3. "I take ginkgo to help improve my memory." 4. "My husband and I plan to have a baby in a couple of years." 5. "My husband and I are leading a 20-mile bicycle tour next weekend for the company we have just started."

3,5 Rationale: Ginkgo may reduce the therapeutic effects of ethosuximide (Zarontin). The most common adverse effects of ethosuximide (Zarontin) include dizziness, ataxia, and fatigue. These effects may be problematic for the owner of a company that promotes bicycle touring. There is no indication that previous phenobarbital use is problematic with the use of ethosuximide (Zarontin). There is no indication of cross sensitivity with penicillin. Ethosuximide (Zarontin) is Pregnancy Category C.

The patient comes to the emergency department complaining of coughing and difficulty breathing. The patient's diagnosis is heart failure. He asks the nurse how difficulty breathing could be a heart problem. What is the best response by the nurse? 1. "The right side of your heart has weakened and blood has entered your lungs." 2. "The right side of your heart has enlarged and cannot effectively pump blood." 3. "What you have is called congestive heart failure." 4. "The left side of your heart is weak and pumps blood too quickly." 5. "The left side of your heart has weakened and blood has entered your lungs."

3,5 Rationale: When the left ventricle cannot compensate for increased preload, blood backs up into the lungs resulting in cough and shortness of breath. Left heart failure is sometimes called congestive heart failure. Left-sided, not right-sided, heart failure is associated with pulmonary congestion. Right-sided heart failure results in peripheral edema, not pulmonary congestion. Heart failure results from the inability of the left ventricle to pump blood, not pumping blood too quickly.

The patient is prescribed digoxin (Lanoxin) for treatment of HF. Which of the following statements by the patient indicates the need for further teaching? 1. "I may notice my heart rate decrease." 2. "I may feel tired during early treatment." 3. "This drug should cure my heart failure." 4. "My energy level should gradually improve."

3. "This drug should cure my heart failure." Rationale: Digoxin helps increase the contractility of the heart, thus increasing cardiac output. But it is not a cure for HF, only a treatment option. Options 1, 2, and 4 are incorrect. The patient is correct that the heart rate will decrease with the use of digoxin, tiredness may be noted in early therapy until the HF has improved, and energy levels will gradually improve.

A patient with heart failure has an order for lisinopril (Prinivil, Zestril). Which of the following conditions in the patient's history would lead the nurse to confirm the order with the provider? 1. A history of hypertension previously treated with diuretic therapy 2. A history of seasonal allergies currently treated with antihistamines 3. A history of angioedema after taking enalapril (Vasotec) 4. A history of alcoholism, currently abstaining

3. A history of angioedema after taking enalapril (Vasotec) Rationale: Angioedema is a rare but potentially serious adverse effect of ACE inhibitors; because this patient has had a previous reaction to another drug within the same group (enalapril/Vasotec), the nurse should confirm the order with the provider. Options 1, 2, and 4 are incorrect. The use of diuretics along with ACE inhibitors must be closely monitored, but this patient was previously on diuretic therapy and it may be assumed that the patient is no longer taking it. The use of antihistamines concurrently with lisinopril may help to relieve any dry cough that occurs with the lisinopril. While a history of alcoholism may suggest more frequent hepatic monitoring, the patient is currently abstaining.

The patient who has not responded well to other therapies has been prescribed milrinone (Primacor) for treatment of his heart failure. What essential assessment must the nurse make before starting this drug? 1. Weight and presence of edema 2. Dietary intake of sodium 3. Electrolytes, especially potassium 4. History of sleep patterns and presence of sleep apnea

3. Electrolytes, especially potassium Rationale: Electrolytes, especially potassium for the presence of hypokalemia, should be assessed before beginning milrinone (Primacor) or any phosphodiesterase inhibitory. Hypokalemia should be corrected before administering phosphodiesterase inhibitors because this can increase the likelihood of dysrhythmias. Options 1, 2, and 4 are incorrect. Weight, presence of edema, and dietary intake of sodium will be monitored because of their relationship to HF and for therapeutic improvement, but they are not crucial to assess before beginning therapy. The patient's sleep patterns or presence of sleep apnea have no direct relationship to the drug; however, monitoring may be ordered for other reasons.

The nurse is caring for a 72-year-old patient taking gabapentin (Gralise, Horizant, Neurontin) for a seizure disorder. Because of this patient's age, the nurse would establish which nursing diagnosis related to the drug's common adverse effects? 1. Risk for Deficient Fluid Volume 2. Risk for Impaired Verbal Communication 3. Risk for Constipation 4. Risk for Falls

4 Rationale: CNS depression including dizziness and drowsiness is a common adverse effect of gabapentin (Gralise, Horizant, Neurontin). Because of this patient's age, these effects may increase the risk of falls. Options 1, 2, and 3 are incorrect. The drug is not known to cause dehydration (fluid volume deficit) or constipation or impair the ability to communicate.

Teaching for a patient receiving carbamazepine (Tegretol) should include instructions that the patient should immediately report which symptom? 1. Leg cramping 2. Blurred vision 3. Lethargy 4. Blister-like rash

4 Rationale: Carbamazepine (Tegretol) is associated with Stevens-Johnson syndrome and exfoliative dermatitis. A blister-like skin rash may indicate that these conditions are developing. Options 1, 2, and 3 are incorrect. Blurred vision, leg cramping, and drowsiness or lethargy are adverse effects of carbamazepine but do not require immediate reporting and may diminish over time.

The client takes a stool softener on a regular basis and now reports a change in bowel patterns. Which assessment finding is the priority for the nurse to discuss with the physician? 1. Stools that are smaller in size 2. An increase in bowel frequency 3. A decrease in bowel frequency 4. Cramping with each stool passed

4 Rationale: Cramping could indicate a serious condition that should be reported to the physician. Stools that are smaller in size are a concern but are not the priority concern. Changes in bowel frequency does not need to be reported at this time.

The patient receives dantrolene (Dantrium) for muscle spasticity. Which lab result is a priority for the nurse to assess? 1. Creatinine clearance 2. Serum amylase 3. Hemoglobin and hematocrit 4. Aspartate aminotransferase (AST) and alanine aminotransferase (ALT)

4 Rationale: Dantrolene (Dantrium) can cause hepatitis; the aspartate aminotransferase (AST) and alanine aminotransferase (ALT) are the priority laboratory tests for the nurse to assess. Dantrolene (Dantrium) does not affect hemoglobin or hematocrit; these laboratory tests are not a priority to assess. Dantrolene (Dantrium) does not significantly affect renal function; the creatinine clearance test isn't a priority laboratory test to assess. Dantrolene (Dantrium) does not affect pancreatic function; the serum amylase isn't a priority laboratory test to assess.

Which situation would lead to an increase in cardiac output? 1. Reduced cardiac contractility 2. Hypovolemia 3. Peripheral vascular resistance 4. Increase in preload

4 Rationale: Increased preload results in a more forceful contraction and increases cardiac output. A reduction in cardiac contractility results in lower preload and subsequent cardiac output. Hypovolemia is a lower blood volume and will result in lower cardiac output. Peripheral vascular resistance increases afterload and increases the workload on the heart.

The patient is started on a medication to treat a neuromuscular disorder. What does the nurse teach as the primary therapeutic goal of the medication? 1. To stop the patient's muscle spasms 2. To improve the patient's appearance 3. To promote exercise in the patient 4. To allow the patient increased independence

4 Rationale: The therapeutic goals of pharmacotherapy include minimizing pain and discomfort, increasing range of motion, and improving the patient's ability to function independently. Stopping muscle spasms can be achieved, but this is not the primary goal. Promoting exercise is not a goal. Improving the patient's appearance is not a goal.

The client takes diphenoxylate with atropine (Lomotil) for diarrhea. The client asks the nurse why he does not experience pain relief since this drug is an opioid. What is the best response by the nurse? 1. "This drug is not an opioid; did your doctor tell you that?" 2. "You would really have to take a lot to experience pain relief." 3. "It does provide some relief from the pain associated with diarrhea." 4. "Because this opioid does not have analgesic properties."

4 Rationale: Unlike most opioids, diphenoxylate with atropine (Lomotil) does not have analgesic properties. The amount of diphenoxylate with atropine (Lomotil) is not the issue; this opioid does not have analgesic properties.

The patient who is prescribed furosemide (Lasix) and digoxin (Lanoxin) reports using an over-the-counter antacid for recurrent heartburn. The nurse would assess for which result? 1. Hyponatremia 2. Hypermagnesemia 3. Increased effectiveness of furosemide (Lanoxin) 4. Decreased effectiveness of digoxin (Lanoxin)

4 Rationale: Use of antacids may decrease the effectiveness of digoxin (Lanoxin). Use of furosemide (Lasix), digoxin (Lanoxin) and antacid does not increase the effectiveness of furosemide. Hyponatremia and hypermagnesemia do not result from an interaction with furosemide (Lasix), digoxin (Lanoxin), and antacids.

In taking a new patient's history, the nurse notices that he has been taking omeprazole (Prilosec) consistently over the past 6 months for treatment of epigastric pain. Which recommendation would be the best for the nurse to give this patient? 1. Try switching to a different form of the drug. 2. Try a drug like cimetidine (Tagamet) or famotidine (Pepcid). 3. Try taking the drug after meals instead of before meals. 4. Check with his health care provider about his continued discomfort.

4 Rationale:PPIs such as omeprazole(Prilosec) are recommended for short-term therapy, approximately 4 to 8 weeks in length. If symptoms of epigastric pain and discomfort continue, other therapies and screening for H. pylori may be indicated. Options 1, 2, and 3 are incorrect. Switching to another PPI still exceeds the recommended time of use for this category of drugs. H2- receptor blockers such as cimetidine (Tagamet) and famotidine (Pepcid) may be indicated but their use should be evaluated by a health care provider because more definitive treatment (e.g., for H. pylori) may be required. PPIs should be taken 30 minutes before meals.

A patient with constipation is prescribed psyllium (Metamucil) by his health care provider. What essential teaching will the nurse provide to the patient? 1. Take the drug with meals and at bedtime. 2. Take the drug with minimal water so that it will not be diluted in the GI tract. 3. Avoid caffeine and chocolate while taking this drug. 4. Mix the product in a full glass of water and drink another glassful after taking the drug.

4 Rationale:To avoid esophagealorgastric obstruction, psyllium (Metamucil) should be mixed with a full glass of water or juice and followed by another full glass of liquid. Options 1, 2, and 3 are incorrect. The drug should not be taken directly with meals because nutrients in the food may be bound into the psyllium and not absorbed. Psyllium should not be taken dry and should be taken with plenty of fluids. Caffeine and chocolate do not need to be avoided while on this medication.

The teaching plan for a patient receiving hydralazine (Apresoline) should include which of the following points? 1. Returning for monthly urinalysis testing 2. Including citrus fruits, melons, and vegetables in the diet 3. Decreasing potassium-rich food in the diet 4. Rising slowly to standing from a lying or sitting position

4. Rising slowly to standing from a lying or sitting position Rationale:Hydralazine (Apresoline) commonly causes orthostatic hypotension, and the patient should be taught to rise slowly from a lying or sitting position to standing. Options 1, 2, and 3 are incorrect. Hydralazine does not require monthly urinalysis testing. Potassium levels will be monitored along with other electrolytes, but the patient does not need to decrease the amount of potassium-rich foods in the diet, and a healthy balance of all foods is encouraged.

A patient was admitted from the emergency department after receiving treatment for dysrhythmias. He will be started on amiodarone (Cordarone, Pacerone) due to the lack of therapeutic effects from his other antidysrhythmic therapy. When the nurse checks with him in the afternoon, he complains of feeling light-headed and dizzy. What will the nurse assess first? 1. Whether there is the possibility of sleep deprivation from the stress of admission to the hospital 2. Whether an allergic reaction is occurring with anticholinergic-like symptoms 3. Whether the amiodarone level is not yet therapeutic enough to treat the dysrhythmias 4. Whether the patient's pulse and blood pressure are within normal limits

4. Whether the patient's pulse and blood pressure are within normal limits Rationale: Potassium channel blockers such as amiodarone, like other antidysrhythmics, may cause significant bradycardia and hypotension. The light headedness and dizziness may be associated with a drop in cardiac output due to bradycardia and hypotension. Options 1, 2, and 3 are incorrect. The significant finding of dizziness would first be assessed in relation to the known adverse effects of the drug. If pulse and blood pressure are within normal limits, the nurse could then consider sleep deprivation, allergies, and drug level as causes of these symptoms.

What patient education should be included for a patient receiving enoxaparin (Lovenox)? (Select all that apply.) 1. Teach the patient or family to give subcutaneous injections at home. 2. Teach the patient or family not to take any over- the-counter drugs without first consulting with the health care provider. 3. Teach the patient to observe for unexplained bleeding such as pink, red, or dark brown urine or bloody gums. 4. Teach the patient to monitor for the development of deep vein thrombosis. 5. Teach the patient about the importance of drinking grapefruit juice daily.

Answer: 1, 2, 3, 4 Rationale: Enoxaparin is an LMWH. Patients and family can be taught to give subcutaneous injections at home. Teaching should include instructions to not take any other medications without first consulting the health care provider and recognizing the signs and symptoms of bleeding. Enoxaparin is given to prevent development of DVT. Patients should be taught signs and symptoms of DVT to observe for and should contact their health care provider immediately if these develop or worsen while on enoxaparin therapy. Option 5 is incorrect. Grapefruit juice is known to alter the metabolism of many drugs in the liver. Even though the enoxaparin is given parenterally, it is metabolized in the liver and may be affected by compounds in the grapefruit juice.

A patient with a congenital coagulation disorder is given aminocaproic acid (Amicar) to stop bleeding following surgery. The nurse will carefully monitor this patient for development of which of the following adverse effects? (Select all that apply.) 1. Anaphylaxis 2. Hypertension 3. Hemorrhage 4. Headache 5. Hypotension

Answer: 1, 4, 5 Rationale: Adverse effects of aminocaproic acid (Amicar) include headache, anaphylaxis, and hypo- tension. Options 2 and 3 are incorrect. Aminocaproic acid is given to prevent excessive bleeding and hemorrhage in patients with clotting disorders. It may cause hypotension, not HTN.

A patient is receiving a thrombolytic drug, alteplase (Activase), following an acute myocardial infarction. Which of the following effects is most likely attributed to this drug? 1. Skin rash with urticaria 2. Wheezing with labored respirations 3. Bruising and epistaxis 4. Temperature elevation of 38.2°C (100.8°F)

Answer: 3 Rationale: Thrombolytic agents such as alteplase (Activase) dissolve existing clots rapidly and continue to have effects for 2 to 4 days. All forms of bleeding must be monitored and reported immediately. Options 1, 2, and 4 are incorrect. Skin rash, urticaria, labored respirations with wheezing, or temperature elevation are not directly associated with alteplase, and other causes should be investigated.

signs and symptoms of Type 2 diabetes (HHS)

BG>600, dehydration, electrolyte imbalance, flushed dry skin, coma. 20-40% mortality. Treated with fluid replacement, electrolyte replacement, and slow IV regular insulin infusion to lower BG.

Angiotensin Receptor-Neprilysin Inhibitor (ARNI)

Entresto-sacubitril/valsartan-FDA approval -July 2015 - Reduces the risk of cardiovascular death and hospitalization for heart failure in patients with chronic heart failure (NYHA Class II-IV) and reduced ejection fraction - Given in conjunction with other heart failure treatments-in place of an ACE or other ARB - Study showed better improvement than with ACE - 20% reduction in hospitalization or death

Loop Diuretics

Furosemide (25-50% absorbed orally), Bumetanide, Torsemide (80-90% absorbed orally) First diuretic choice - Quick onset, especially IV - Increase loss of sodium and free water better than other diuretics - The only drugs to control fluid retention - Play an important role in the success of treatment with other drugs - Should usually be used with an ACE inhibitor, beta blocker, and aldosterone antagonist - ADHERE Trial noted higher mortality with increased diuretic use, but results uncertain - NSAIDS-cause Na and H2O retention, limit diuretic affects, can increase morbidity and mortality

what bacteria is the primary cause of peptic ulcers?

H. pylori

Vasodilators

Hydralazine with isosorbide dinitrate (BiDil), Nesiritide - Decrease workload by dilating vessels and reducing preload and afterload - Side Effects limit their use - Some combinations such hydralazine and isosorbide dinitrate (BiDil) is recommended to: --- reduce morbidity and mortality African Americans with NYHA class III-IV HF with reduced EF receiving optimal therapy with ACE inhibitors and beta blockers, unless contraindicated --- Use in non African Americans still under investigation

Thiazide Diuretics

Hydrochlorothiazide, Indapamide, Metolazone, Chlorothiazide - Less effective in HF - Distal portion of the tubule - Can be combined with a loop diuretic - May be more appropriate if patient also has HTN - Increase urinary excretion of Na and H2O by inhibiting sodium reabsorption - May increase attacks of gout -hyperuricemia

Pharmacotherapy for multiple sclerosis

Immunomodulators - Interferon beta-1a (Avonex) - Glatiramer (Capaxone) --- Dizziness, HA, confusion, neutropenia, flulike symptoms Immunosuppressants - Mitoxantreone (Novantrone) --- N & V, fever, diarrhea, increased susceptibility to infection - Meds are very individualized based on type of MS...might be on steroids, may be on meds for spasticity, cholinergic agents, meds for fatigue, antidepressants, may need bowel and bladder training

Nausea and Vomiting

Reflex primarily controlled by vomiting center of the medulla of the brain receives signals from - Digestive tract - Inner ear - Chemoreceptor trigger zone (CTZ) Treatment based on cause - GI infections, food poisoning, motion sickness, pain, general anesthetics, migraines, head trauma, pregnancy - Medications work by inhibiting serotonin or dopamine receptors in brain Concerns - Results in dehydration, significant weight loss, metabolic alkalosis, severe acid-base disturbances

Aldosterone Antagonists

Spironolactone - Antagonize aldosterone and also a K+ sparing diuretic - Patients with NYHA class II-IV and who have LVEF of 35% or less, unless contraindicated - Reduce morbidity and mortality --- 30% reduction in SCD and hospitalizations - Slows the progression of HF

Identify thromboembolic disorders that are indications for coagulation modifiers.

Thromboembolic disorders- occur in arteries and veins-caused by thrombi, emboli - Stationary clot is referred to as a thrombus, traveling clot referred to as an embolus - Thrombi in an artery leads to tissue ischemia (angina), can result in tissue death (infarction) (i.e.-MI, CVA) - Thrombi in the venous system can form especially in the legs due to trauma, sluggish blood flow, stasis (DVT) - Thrombi also form in the heart in the atrium due to atrial fibrillation - Emboli in right atrium can lead to PE, thrombi in left atrium can lead to CVA or arterial occlusion in systemic circulation leading to tissue ischemia elsewhere such as lower extremity/foot/toe - Risk for arterial thrombi/emboli after surgical procedures and arterial punctures (angiograms) - Also increased risk for thrombi with indwelling catheters, mechanical heart valves, malignancy

Phosphodiesterase inhibitor

milrinone (Primacor)-IV mcg/kg IV bolus and mcg/kg/min infusion - Increases calcium for contraction - Positive inotropic effect and vasodilation - Increased CO and decreases afterload - Limited use-serious toxicity - Acute decompensated HF - Limited to 2-3 days - Not as common any longer-only briefly mentioned in the 2013 AHA HF Guidelines

therapeutic goals of pharmacotherapy to treat a neuromuscular disorder

minimizing pain and discomfort, increasing range of motion, and improving the patient's ability to function independently.

Liver function tests

to assess for liver impairment

therapeutic goals of MS pharmacotherapy

to provide symptom relief

S/S of gout

warmth, redness, painful swelling of joint