Phar Ch 41-43 Antitubercular, Ch. 42, 43 ANTIFUNGAL, ANTIMALARIAL, ANTIPROTOZOAL, ANTIHELMINTIC (LILLEY

A patient who is prescribed isoniazid (INH) tells the nurse that green tea is a favorite drink. Which statement by the nurse would be appropriate?

"Green tea and INH can increase the risk for irregular heart rhythms." Green tea can increase the risk for cardiac dysrhythmias and severe hypertension when consumed concomitantly with INH.

Which statement made by Ms. Hope indicates an accurate understanding of patient teaching on isoniazid (INH)?

"I should not drink alcohol while on the drug." Alcohol can increase the risk for hepatotoxicity if consumed while on INH.

A patient with active tuberculosis (TB) is started on antitubercular drugs. Which statement made by the patient indicates an accurate understanding of the drug treatment?

"I will be taking the drugs for about 9 months." Active TB is treated with a two-phase regimen: intensive phase for 2 months, followed by the continuation phase for 4 to 7 months for a total of 9 months.

Which teachings would the nurse include for a patient who is prescribed isoniazid (INH)?

"You may need to take a vitamin B6 supplement. "INH can cause peripheral neuropathy. Vitamin B6 can reduce the severity. "Avoid alcohol. "INH is hepatotoxic, and alcohol can increase the risk for hepatotoxicity. "Wash your dishes separately from other family members. "The risk for exposing family members is reduced by washing dishes separately from other members of the family.

After learning that Ms. Hope has tuberculosis (TB), her family member with HIV has a tuberculin skin test performed with a positive reaction of 7 mm. Which dosage of isoniazid (INH) would the nurse anticipate in administering?

300 mg daily A prophylactic dosage of INH 300 mg daily is appropriate for Ms. Hope's family member who has HIV and a positive skin test.

A patient who weighs 75 kg is to receive isoniazid (INH) for active tuberculosis (TB). Which dose would the nurse administer based on the average adult daily dose?

375 mg The average adult daily dosage is 5 mg/kg. The patient's weight is 75 kg; therefore the patient will receive 375 mg.

During an intravenous (IV) infusion of amphotericin B, a patient develops tingling and numbness in his toes and fingers. What will the nurse do first? a. Discontinue the infusion immediately. b. Reduce the infusion rate gradually until the adverse effects subside. c. Administer the medication by rapid IV infusion to reduce these effects. d. Nothing; these are expected side effects of this medication.

A Once the intravenous infusion of amphotericin B has begun, vital signs must be monitored frequently to assess for adverse reactions such as cardiac dysrhythmias, visual disturbances, paresthesias (numbness or tingling of the hands or feet), respiratory difficulty, pain, fever, chills, and nausea. If these adverse effects or a severe reaction occur, the infusion must be discontinued (while the patient is closely monitored) and the prescriber contacted. The other options are incorrect.

A patient has an infestation with flukes. The nurse anticipates the use of which drug to treat this infestation? a. praziquantel (Biltricide) b. pyrantel (Pin-X) c. metronidazole (Flagyl) d. ivermectin (Stromectol)

A Praziquantel is an anthelmintic that is used to kill flukes. Metronidazole is used to treat protozoal infections. The other drugs listed are used for other helminthic infestations.

During therapy with amphotericin B, the nurse will monitor the patient for known adverse effects that would be reflected by which laboratory result? a. Serum potassium level of 2.7 mEq/L b. Serum potassium level of 5.8 mEq/L c. White blood cell count of 7000 cells/mm3 d. Platelet count of 300,000 per microliter

A The nurse needs to monitor for hypokalemia, a possible adverse effect of amphotericin B. The other options are incorrect.

A nurse is reviewing patients who will be receiving isoniazid (INH). Which patient would the nurse suspect is not a candidate for INH?

A patient with alcohol cirrhosis Contraindications include previous hepatic injury. Alcohol cirrhosis is a condition in which the liver is damaged due to alcoholism.

Bacille Calmette-Guérin (BCG)

A vaccine injection derived from an inactivated strain of Mycobacterium bovis Used in much of the world to vaccinate young children against TB Does not prevent infection Reduces active TB by 60% to 80% Effective at preventing more severe cases involving dissemination of infection throughout the body Can cause false-positive results on the tuberculin skin test

Hydroxychloroquine (Plaquenil) is prescribed as part of malaria prophylaxis for a patient who will be traveling. The nurse will discuss which potential adverse effects with the patient? (Select all that apply.) a. Diarrhea b. Constipation c. Insomnia d. Dizziness e. Rash f. Headache

A, D, E, F Diarrhea, anorexia, nausea, vomiting, dizziness, rash, and headache are potential adverse effects of hydroxychloroquine. See Table 43-1 for other common adverse effects. The other options are not adverse effects of this drug.

The nurse is reviewing the therapeutic effects of nonsteroidal antiinflammatory drugs (NSAIDs), which include which effect? a.Anxiolytic b.Sedative c.Antipyretic (antifever) d.Antimicrobial

ANS: C NSAIDs have antipyretic effects but not the other effects listed.

In which time frame would the nurse instruct the patient to take isoniazid (INH) with respect to eating?

At least 2 hours after eating Food reduces the absorption rate of INH. INH should be taken 1 hour before or 2 hours after eating.

A patient is being evaluated for a possible helminthic infection. The nurse knows that which statement about anthelmintic therapy is true? a. The drugs may cause severe drowsiness. b. Anthelmintics are very specific in their actions. c. Anthelmintics are effective against broad classes of infestations. d. The drugs are used to treat protozoal infections such as intestinal amebiasis.

B Anthelmintics are very specific in their actions, and it is important to identify the cause of the infestation before beginning treatment. They are not used to treat protozoal infections, and they do not cause severe drowsiness.

The nurse is assessing a patient who is about to receive antifungal drug therapy. Which condition, if found in the patient, would be of most concern? a. Diabetes mellitus b. Liver disease c. Pulmonary disease d. Bleeding disorders

B Liver failure, kidney failure, and porphyria (for griseofulvin) are the most common contraindications for antifungal drugs. The other options are not contraindications.

A patient is taking nystatin (Mycostatin) oral lozenges to treat an oral candidiasis infection resulting from inhaled corticosteroid therapy for asthma. Which instruction by the nurse is appropriate? a. "Chew the lozenges until they are completely dissolved." b. "Let the lozenge dissolve slowly and completely in your mouth without chewing it." c. "Rinse your mouth with water before taking the inhaler." d. "Rinse your mouth with mouthwash after taking the inhaler."

B Nystatin may be given orally in the form of lozenges, or troches, which need to be slowly and completely dissolved in the mouth for optimal effects; tablets are not to be chewed or swallowed whole. The other options are incorrect. Patients taking an inhaled corticosteroid must rinse their mouths with water thoroughly after taking the inhaler.

A patient with late-stage HIV infection also has Pneumocystis jirovecii pneumonia. The nurse anticipates treatment with which medication for this pneumonia? a. ivermectin (Stromectol) b. atovaquone (Mepron) c. praziquantel (Biltricide) d. metronidazole (Flagyl)

B Pentamidine and atovaquone are used for the treatment of pneumonia caused by P. jirovecii. The other options are not used for this pneumonia.

If a patient is taking fluconazole (Diflucan) with an oral anticoagulant, the nurse will monitor for which possible interaction? a. Reduced action of oral anticoagulants, resulting in decreased prothrombin time/international normalized ratio (PT/INR) b. Increased effects of oral anticoagulants, resulting in increased PT/INR c. Increased change in renal impairment caused by the antifungal drug d. Decreased effectiveness of the antifungal drug

B Some antifungal drugs, including fluconazole and itraconazole, increase the effects of oral anticoagulants, which manifest as increases in PT/INR. As a result, increased bleeding may occur. The other options are incorrect.

A patient with an intestinal infection that is positive for the Giardia lamblia organism will be taking an antiprotozoal drug. The nurse will include which information in the teaching plan for this patient? a. The urine may become dilute and pale during therapy. b. Taking the medications with food reduces gastrointestinal upset. c. The medications should be taken on an empty stomach. d. The drugs may be discontinued once the diarrhea subsides.

B Taking these drugs with food reduces gastrointestinal upset. Antiprotozoal drugs may cause the urine to turn dark. These drugs should be administered for the prescribed length of time to ensure complete eradication of the infection.

A patient with a severe fungal infection has orders for voriconazole (Vfend). The nurse is reviewing the patient's medical record and would be concerned if which assessment finding is noted? a. Decreased breath sounds in the lower lobes b. History of cardiac dysrhythmias c. History of diabetes type II d. Potassium level of 4.0 mEq/L

B Voriconazole is contraindicated when coadministered with certain other drugs metabolized by the cytochrome P-450 enzyme 3A4 (e.g., quinidine) because of the risk for inducing serious cardiac dysrhythmias.

The nurse is administering an amphotericin B infusion. Which actions by the nurse are appropriate? (Select all that apply.) a. Administering the medication by rapid IV infusion b. Discontinuing the drug immediately if the patient develops tingling and numbness in the extremities c. If adverse effects occur, reducing the IV rate gradually until they subside d. Using an infusion pump for IV therapy e. Monitoring the IV site for signs of phlebitis and infiltration f. Administering premedication for fever and nausea g. Knowing that the intravenous solution for amphotericin B will be cloudy h. Knowing that muscle twitching may indicate hypokalemia

B, D, E, F If the patient develops tingling and numbness in the extremities (paresthesias), discontinue the drug immediately. An infusion pump is necessary for the infusion, and the nurse will monitor the IV site for signs of phlebitis and infiltration. Premedication to reduce the adverse effects of fever, malaise, and nausea may be ordered. The IV solution must be clear and without precipitates; and muscle weakness, not twitching, may indicate hypokalemia. The medication must be administered at the rate recommended and stopped, not slowed, if adverse reactions occur.

A patient, who has been taking isoniazid (INH), reports numbness and tingling to the hands and feet. Which action of INH would the nurse suspect is causing the reaction?

Blocking the effects of pyridoxine Pyridoxine is needed for intracellular enzyme production. When INH blocks the action of pyridoxine, peripheral neuropathy can occur, which is exhibited as numbness and tingling of the hands and feet.

A patient has received a prescription for a 2-week course of antifungal suppositories for a vaginal yeast infection. She asks the nurse if there is an alternative to this medication, saying, "I don't want to do this for 2 weeks!" Which is a possibility in this situation? a. A single dose of a vaginal antifungal cream b. A one-time infusion of amphotericin B c. A single dose of a fluconazole (Diflucan) oral tablet d. There is no better alternative to the suppositories.

C A single oral dose of fluconazole may be used to treat vaginal candidiasis. The other options are incorrect.

A patient is infected by invasive aspergillosis, and the medical history reveals that the patient has not been able to tolerate several antifungal drugs. The nurse anticipates an order for which medication to treat this infection? a. fluconazole (Diflucan) b. micafungin (Mycamine) c. caspofungin (Cancidas) d. nystatin (Mycostatin)

C Caspofungin is used for treating severe infection by Aspergillus species (invasive aspergillosis) in patients who are intolerant of or refractory to other drugs.

The nurse is reviewing antimalarial drug therapy with a patient and instructs the patient to watch for and report which potential adverse reactions? a. Drowsiness b. Insomnia c. Visual disturbances d. Constipation

C Encourage the patient to contact the prescriber if there is unresolved nausea, vomiting, profuse diarrhea, or abdominal pain and to report immediately any visual disturbances, dizziness, or respiratory difficulties.

A patient is receiving hydroxychloroquine therapy but tells the nurse that she has never traveled out of her city. The nurse knows that a possible reason for this drug therapy is which condition? a. Lyme disease b. Toxoplasmosis c. Systemic lupus erythematosus d. Intestinal tapeworms

C Hydroxychloroquine, which is used for malaria, also possesses antiinflammatory actions and has been used to treat rheumatoid arthritis and systemic lupus erythematosus. The other options are incorrect.

The nurse is administering one of the lipid formulations of amphotericin B. When giving this drug, which concept is important to remember? a. The lipid formulations may be given in oral form. b. The doses are much lower than the doses of the older drugs. c. The lipid formulations are associated with fewer adverse effects than the older drugs. d. There is no difference in cost between the newer and older forms.

C Newer lipid formulations of amphotericin B have been developed in an attempt to decrease the incidence of its adverse effects and increase its efficacy. However, the lipid formulations are more costly.

3. Which patient statement indicates to the nurse that the patient understands the discharge teaching for ethambutol? A. "Constipation will be a problem, so I will increase the fiber in my diet." B. "Dizziness and drowsiness are common adverse effects with this drug." C. "I will need to have my vision checked periodically while I am taking this drug." D. "This medication may cause my bodily secretions to turn red-orange-brown."

C. "I will need to have my vision checked periodically while I am taking this drug." Ethambutol can cause optic neuritis. Ophthalmologic examinations should be performed periodically to assess visual acuity.

2. What information would the nurse provide to a patient prescribed rifampin? A. Oral contraception is the preferred method of birth control when using rifampin. B. The patient will only need to take this medication for the prescribed 14-day period. C. A nonharmful adverse effect of this medication is red-orange discoloration of urine, sweat, tears, skin, salvia, and feces. D. Peripheral neuropathy is an expected side effect, and the patient should report any numbness or tingling of the extremities.

C. A nonharmful adverse effect of this medication is red-orange discoloration of urine, sweat, tears, skin, salvia, and feces. Red-orange-brown discoloration of the skin, sweat, tears, urine, feces, sputum, saliva, and tongue is an adverse effect of the drug, but it is not harmful. Rifampin does not cause peripheral neuropathies (isoniazid does), but it does interfere with the effectiveness of oral contraceptives. All antitubercular drugs need to be taken long term to eradicate the slow-growing mycobacterium lying deep within the tissues.

A patient who has a helminthic infection has a prescription for pyrantel (Antiminth). Which is one of the common adverse effects that the patient may experience while on this therapy? a. Vertigo b. Seizures c. Diarrhea d. Insomnia

C. Diarrhea Diarrhea and abdominal pain are some of the possible gastrointestinal effects of pyrantel. See Table 43-11 for other adverse effects. The other options are incorrect.

A patient has been taking isoniazid (INH) for 3 months. Which test would the nurse anticipate will be ordered for this patient to determine effectiveness of therapy?

Chest x-ray A repeat chest x-ray should be obtained approximately 3 months after starting INH.

Mycobacterium (MTB)Infections

Common infection sites Lung (primary site) Brain (cerebral cortex) Bone (growing end) Liver Kidney Genitourinary tract Aerobic bacillus Passed from infected: Humans Cows (bovine) and birds (avian) Much less common Tubercle bacilli are conveyed by droplets. Droplets are expelled by coughing or sneezing, and they then gain entry into the body by inhalation. Tubercle bacilli then spread to other body organs via blood and lymphatic systems. Tubercle bacilli may become dormant, or walled off by calcified or fibrous tissue. MTB: very slow-growing organism More difficult to treat than most other bacterial infections First infectious episode: primary TB infection Reinfection: chronic form of the disease Dormancy: may test positive for exposure but are not necessarily infectious because of this dormancy process

A patient with TB has been taking antitubercular drugs. A sputum culture is ordered to test for acid-fast bacilli. When is the best time for the nurse to obtain the sputum culture? a. In the morning b. Noon c. 5 pm d. 10 pm

Correct answer: A Rationale: If the prescriber has ordered collection of a sputum specimen to test for acid-fast bacilli, it is best to obtain the sample early in the morning. The most common order is for three consecutive morning specimens, with a repeat specimen several weeks later.

A patient with a diagnosis of TB will be taking INH as part of the anti-TB therapy. When reviewing the patient's chart, the nurse finds documentation that the patient is a "slow acetylator." This means that: a. the dosage of INH may need to be lower to prevent INH accumulation. b. the dosage of INH may need to be higher because of the slow acetylation process. c. he should not take INH. d. he will need to take a combination of anti-TB drugs for successful therapy.

Correct answer: A Rationale: When INH is taken by slow acetylators, the INH accumulates because there are not enough liver enzymes to break down the INH. Therefore, the dosages of INH may need to be adjusted downward to prevent toxicity.

The patient's wife is taking rifampin to prevent her from developing a TB infection. Which statement by the wife indicates that further teaching is needed? a. "Because my oral contraceptives will not work while I am taking rifampin, I will use another form of birth control." b. "I will take the medication for 1 week and then stop." c. "I will avoid prolonged exposure to the sun." d. "My urine may turn a reddish color when taking rifampin."

Correct answer: B Rationale: Antitubercular therapy is taken for long periods of time, often 24 months. Although this patient does not have an active infection at this time and is taking the rifampin to prevent an infection, the nurse should further investigate the length of time the medication is ordered. All other statements are true.

A patient has an extremely severe infection with a Mycobacterium that is resistant to all but one antitubercular drug; however, the patient has had an allergic reaction to that drug in the past. What does the nurse anticipate as being ordered for this patient? a. A combination of antitubercular drugs will be chosen to fight the infection. b. The patient will receive the drug and supportive care to help him tolerate the antitubercular therapy. c. The patient will remain on isolation precautions until his cough clears. d. There is nothing that can be done for this patient.

Correct answer: B Rationale: It must be recognized that the urgency of treating a potentially fatal infection may have to be balanced against any prevailing contraindications. In extreme cases, patients are sometimes given a drug to which they have some degree of allergy with supportive care that enables them at least to tolerate the medication. Examples of such supportive care are treatment with antipyretics (e.g., acetaminophen), antihistamines (e.g., diphenhydramine), or even corticosteroids (e.g., prednisone, methylprednisolone).

A home care nurse is visiting a patient with a diagnosis of TB. The patient traveled abroad 2 months ago. He lives with his wife and 5-year-old son. The patient tells the nurse that he is concerned his son will also get TB, so he wants to share his pills with his son. What is the best response by the nurse? a. "That is a good idea. Children should not be exposed to TB." b. "You should give your son half of the dose you take." c. "Do not share any of your medications with anyone. Contact your son's health care provider to discuss your concerns." d. "Children have an immune system that makes them immune to TB."

Correct answer: C Rationale: Medications of any kind should never be shared with any other person. In particular, antitubercular drugs are age specific. Assessment of age is also important because the likelihood of adverse reactions and toxicity is increased in older patients because of age-related liver and kidney dysfunction. Additionally, the safety of these drugs in children 13 years of age and younger has not been established.

The patient tells the nurse, "I had a shot after I returned from my trip overseas. I thought that was supposed to stop me from getting a TB infection." What information regarding TB-related injections does the nurse identify as being true? a. BCG is used to prevent infection with TB for women of childbearing age. b. A positive result for a PPD test is indicated by redness at the site of injection. c. PPD is a diagnostic injection given intradermally to detect exposure to the TB organism. d. BCG is a vaccine injection derived from an activated strain of Mycobacterium bovis.

Correct answer: C Rationale: PPD is a diagnostic injection given intradermally in doses of 5 tuberculin units (0.1 mL) to detect exposure to the TB organism. A positive result is indicated by induration (not erythema) at the site of injection and is known as the Mantoux reaction, named for the physician who described it. BCG is used in much of the world to vaccinate young children against TB. Although it does not prevent infection, evidence indicates that it reduces active TB by 60% to 80% and is even more effective at preventing more severe cases involving dissemination of infection throughout the body.

Four weeks after beginning antitubercular drug therapy on an outpatient basis, the patient reports that he still experiences night sweats. What does the nurse identify as the main concern at this time? a. He is not taking his medication properly. b. More time is needed to see a therapeutic response. c. His infection may be resistant to the drug therapy ordered. d. He may have contracted a different strain of TB.

Correct answer: C Rationale: The nurse should not jump to conclusions that the patient is not taking his medication properly. An improvement should start to occur within 2 weeks of starting drug therapy, but this may not occur if the patient's TB is not sensitive to the prescribed drugs. An evaluation of the drug therapy will be needed.

A patient is receiving INH for the treatment of TB. Which vitamin does the nurse anticipate administering with the INH to prevent INH-precipitated peripheral neuropathies? a. Vitamin C b. Vitamin B12 c. Vitamin D d. Vitamin B6

Correct answer: D Rationale: Pyridoxine (vitamin B6) may be indicated to prevent INH-precipitated peripheral neuropathies and numbness, tingling, or burning of the extremities.

The nurse is preparing an infusion of amphotericin B for a patient who has a severe fungal infection. Which intervention is appropriate regarding the potential adverse effects of amphotericin B? a. Discontinuing the infusion immediately if fever, chills, or nausea occur b. Gradually increasing the infusion rate until the expected adverse effects occur c. If fever, chills, or nausea occur during the infusion, administering medications to treat the symptoms d. Before beginning the infusion, administering an antipyretic and an antiemetic drug

D Almost all patients given the drug intravenously experience fever, chills, hypotension, tachycardia, malaise, muscle and joint pain, anorexia, nausea and vomiting, and headache. For this reason, pretreatment with an antipyretic (acetaminophen), antihistamines, and antiemetics may be conducted to decrease the severity of the infusion-related reaction. The other options are incorrect.

The nurse is reviewing instructions for vaginal antifungal drugs with a patient. Which statement by the nurse is an appropriate instruction regarding these drugs? a. "The medication can be stopped when your symptoms are relieved." b. "Discontinue this medication if menstruation begins." c. "Daily douching is part of the treatment for vaginal fungal infections." d. "Abstain from sexual intercourse until the treatment has been completed and the infection has resolved."

D Female patients taking antifungal medications for the treatment of vaginal infections need to abstain from sexual intercourse until the treatment has been completed and the infection has resolved. The medication needs to be taken for as long as prescribed. Instruct patients to continue to take the medication even if they are actively menstruating. Douching is not an appropriate intervention.

A patient is experiencing the exoerythrocytic phase of malaria. The nurse expects which drug to be used for this patient? a. quinine b. chloroquine (Aralen) c. mefloquine (Lariam) d. primaquine

D Primaquine is one of the few antimalarial drugs that can destroy the malarial parasites while they are in their exoerythrocytic phase. The other drugs are effective during the erythrocytic, or blood, phase. DIF

A woman is traveling to a country where she will be at high risk for malarial infection. What will the nurse teach her regarding prophylactic therapy with hydroxychloroquine (Plaquenil)? a. Hydroxychloroquine is better absorbed and has fewer adverse effects if taken on an empty stomach. b. The drug is started 3 weeks before exposure but can be discontinued once she leaves the area. c. The medication is taken only when she observes mosquito bites, because it can have toxic effects if taken unnecessarily. d. The drug is usually started 1 to 2 weeks before traveling to endemic areas and is continued for 4 weeks after leaving the area.

D Prophylaxis of malaria with hydroxychloroquine is usually started 1 to 2 weeks before exposure and continued for 4 weeks after the person has left the area. The medication should be taken with food to decrease gastrointestinal upset.

A patient who is being treated for malaria has started therapy with quinine and tetracycline. He asks the nurse why he is on an antibiotic when malaria is caused by a parasite. Which response by the nurse is correct? a. "The tetracycline prevents reinfection by the malarial parasite." b. "The antibiotic is combined with quinine to reduce the side effects of the quinine." c. "An antibacterial drug prevents the occurrence of superinfection during antimalarial therapy." d. "The two drugs are more effective against malaria when given together."

D The combination of quinine and tetracycline takes advantage of their synergistic protozoacidal effects. The other responses are incorrect.

1. Before discharge, the nurse is reviewing a patient's prescribed medication regimen for tuberculosis (TB). The patient asks the nurse why pyridoxine has been prescribed while continuing to take isoniazid to treat TB. What is the nurse's appropriate response? A. "Multidrug therapy is necessary to prevent the occurrence of resistant bacteria." B. "You really should not be on that drug. I will check with the health care provider." C. "Pyridoxine is another antitubercular drug that will work synergistically with the isoniazid." D. "Pyridoxine will help prevent numbness, and tingling that can occur secondary to the isoniazid."

D. "Pyridoxine will help prevent numbness, and tingling that can occur secondary to the isoniazid." Isoniazid can cause neurotoxicity. Pyridoxine is the drug of choice to prevent this adverse reaction. It is not an antiinfective drug and thus will not work to destroy the mycobacterium or prevent drug resistance.

4. Which instruction would the nurse include for a patient prescribed rifampin and isoniazid prophylactically secondary to TB exposure? A. Advise that these drugs will only need to be taken for 7 to 10 days. B. Remind that sunscreen is not needed during outdoor activities. C. Explain that isoniazid may decrease blood serum glucose in susceptible people. D. Emphasize that oral contraceptives become ineffective when given with rifampin.

D. Emphasize that oral contraceptives become ineffective when given with rifampin. Women taking oral contraceptives who are prescribed rifampin must be switched to another form of birth control because oral contraceptives become ineffective when given with rifampin. These medications must be taken long term because mycobacterium is slow growing. They can cause photosensitivity, necessitating the use of sunscreen. Finally, isoniazid may increase, not decrease, serum glucose levels.

6. When assessing for adverse effects to Rifamate (combination isoniazid and rifampin), the nurse would monitor which laboratory values? *(Select all that apply.)* A. Cholesterol B. Uric acid levels C. Sputum cultures D. Liver function tests E. Complete blood cell count

D. Liver function tests E. Complete blood cell count Rifamate can lead to impairment of liver function as well as hematologic disorders. Assessment of sputum cultures confirms the diagnosis but is not related to adverse effects. The drug does not affect uric acid levels or cholesterol.

5. The nurse anticipates a prescription for vitamin supplementation for a patient who is receiving isoniazid therapy. What vitamin supplement is usually prescribed with isoniazid? A. Folate B. Calcium C. Vitamin E D. Vitamin B6

D. Vitamin B6 Pyridoxine (vitamin B6) is often given concurrently with isoniazid to prevent the adverse effect of isoniazid induced peripheral neuropathy associated with neurotoxicity.

A patient with fever and cough has a positive purified protein derivative (PPD) skin test. Which action is most appropriate for the nurse?

Determine any history of receiving the BCG vaccine. The nurse must ascertain if the patient received BCG vaccine. Persons who have received the BCG vaccine will have a positive PPD skin test without having acute tuberculosis.

Isoniazid

Drug of choice for TB Resistant strains of Mycobacterium emerging Metabolized in the liver through acetylation—watch for "slow acetylators" Used alone or in combination with other drugs Contraindicated with liver disease

ELSEVIER NCLEX PREP (ONLINE)

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Antitubercular Therapy

Effectiveness depends on: Type of infection Adequate dosing Sufficient duration of treatment Adherence to drug regimen Selection of an effective drug combination Problems: Drug-resistant organisms Drug toxicity Patient nonadherence MDR-TB

Antitubercular Drugs First-line drugs

First-line drugs : INH: primary drug used rifapentine ethambutol rifabutin pyrazinamide (PZA) rifampin streptomycin

A patient who lives with a family member who has tuberculosis (TB) is concerned about contracting TB. Based on the recommendation by the Centers for Disease Control and Prevention (CDC), which prophylactic regimen would the nurse anticipate for this patient?

INH alone The CDC recommends starting prophylactic therapy, such as INH alone, to anyone in close contact with persons with active TB.

Adverse Effects

INH: peripheral neuropathy, hepatotoxicity Ethambutol: retrobulbar neuritis, blindness Rifampin: hepatitis; discoloration of urine, stools, and other body fluids

A patient who is on warfarin for atrial fibrillation is prescribed isoniazid (INH). Which drug-drug interaction would the nurse anticipate?

Increased level of warfarin INH can increase the level of warfarin, an anticoagulant. The patient will be at increased risk for warfarin toxicity.

To which drugs are extensively drug-resistant (XDR) strains resistant?

Isoniazid (INH)XDR strains are resistant to INH. Rifampin XDR strains are resistant to rifampin. Fluoroquinolone XDR strains are resistant to fluoroquinolone.

A patient with active tuberculosis (TB) is not responding to the initial drug regimen with the first-line drugs. Which drug would the nurse anticipate administering?

Kanamycin is an antibacterial that is used as a second-line therapy for tuberculosis that is not responding to the first-line drugs.

Antitubercular Drug TherapyConsiderations

Major effects of drug therapy: reduction of cough and, therefore, reduction of the infectiousness of the patient Normally occurs within 2 weeks of the initiation of drug therapy if TB strain is drug sensitive Most cases of TB can be cured. Successful treatment: several antibiotic drugs for at least 6 months and sometimes for as long as 12 months Perform drug-susceptibility testing on the first Mycobacterium spp. that is isolated from a patient specimen to prevent the development of MDR-TB. Even before the results of susceptibility tests are known, begin a regimen with multiple antitubercular drugs (to reduce the chances of development of resistance). Adjust drug regimen after the results of susceptibility testing are known. Monitor patient compliance closely during therapy. Problems with successful therapy occur because of patient nonadherence to drug therapy and the increased incidence of drug-resistant organisms.

The patient has been admitted with cultures confirming presence of tubercle bacilli (MTB). What precautions will the nurse take when entering the room?

N95, gown, and gloves Tubercle bacilli are conveyed in droplets expelled by infected people or animals during coughing or sneezing, and then inhaled by the new host. Pg. 652

Nursing Implications

Obtain a thorough medical history and assessment. Perform liver function studies in patients who are to receive INH or rifampin (especially in older patients and those who use alcohol daily). Assess for contraindications to the various drugs, conditions for cautious use, and potential drug interactions. Patient education is critical. Therapy may last for up to 24 months. Take medications exactly as ordered at the same time every day. Emphasize the importance of strict adherence to regimen for improvement of condition or cure. Patient education is critical. (Cont.) Remind patients that they are contagious during the initial period of their illness—instruct in proper hygiene and prevention of the spread of infected droplets. Teach patients to take care of themselves, including getting adequate nutrition and rest. Patients should not consume alcohol while taking these medications or take other medications, including over-the-counter medications, unless they check with their prescribers. Rifampin causes oral contraceptives to become ineffective; another form of birth control is needed. Patients who are taking rifampin should be told that their urine, stool, saliva, sputum, sweat, or tears may become reddish orange; even contact lenses may be stained. Pyridoxine may be needed to combat neurologic adverse effects associated with INH therapy. Oral preparations may be given with meals to reduce gastrointestinal upset even though recommendations are to take them 1 hour before or 2 hours after meals. Monitor for adverse effects. Instruct patients on the adverse effects that should be reported to the prescriber immediately. These include fatigue, nausea, vomiting, numbness and tingling of the extremities, fever, loss of appetite, depression, and jaundice. Monitor for therapeutic effects. Decrease in symptoms of TB, such as cough and fever Laboratory study results (culture and sensitivity tests) and chest radiographs should confirm clinical findings. Watch for lack of clinical response to therapy, indicating possible drug resistance.

The nurse would anticipate administering pyridoxine to decrease which common side effect of isoniazid (INH)?

Peripheral neuropathy Pyridoxine (vitamin B6) is administered concomitantly with INH to reduce the severity of peripheral neuropathy caused by INH.

For which individuals is prophylactic antitubercular therapy appropriate?

Persons in close contact with individuals with active tuberculosis (TB) Persons in close contact with individuals with active TB should be started on prophylactic antitubercular therapy. Persons with a latent TB infection Persons with a latent TB infection should be started on prophylactic antitubercular therapy. Recent immigrants with a positive skin test reaction of ≥10 mm Recent immigrants with a positive skin test reaction of ≥10 mm should be started on prophylactic antitubercular therapy.

A patient presents to the ER with decreased appetite, night sweats, unintentional weight loss, nausea and vomiting, and a persistent cough that for the last three weeks. What is the most likely diagnosis?

Primary TB infection pg 652

Tuberculosis-Related Injections

Purified protein derivative (PPD) (Mantoux) A diagnostic injection given intradermally in doses of 5 tuberculin units (0.1 mL) to detect exposure to the TB organism Positive result is indicated by induration (not erythema) at the site of injection

Which drugs are considered first-line antitubercular drugs?

Pyrazinamide is a first-line anti-tuberculosis (anti-TB) drug. Rifampin Rifampin is a first-line anti-TB drug. Rifapentine Rifapentine is a first-line anti-TB drug.

Antitubercular Drugs Second-line drugs

Second-line drugs: capreomycin cycloserine levofloxacin ethionamide ofloxacin kanamycin para-aminosalicyclic acid (PAS)

Before starting prophylactic antitubercular treatment, which test result would the nurse anticipate obtaining?

Sputum culture and sensitivity Persons exposed to tuberculosis (TB) must be evaluated for active TB. A sputum culture and sensitivity and assessment for immunocompetency are necessary to prevent emergence of resistant TB strains.

Multidrug-Resistant Tuberculosis (MDR-TB)

TB infects one third of the world's population. MDR-TB that is resistant to both isoniazid (INH) and rifampin Extensively drug-resistant tuberculosis (XDR-TB): relatively rare type of MDR-TB, resistant to almost all drugs used to treat TB, including the two best first-line drugs, INH and rifampin, as well as to the best second-line medications XDR-TB is of special concern for patients who have AIDS or are otherwise immunocompromised. Bedaquiline (Sirturo) 2013: Food and Drug Administration granted accelerated approval for bedaquiline (Sirturo) for the treatment of MDR-TB Inhibits mycobacterial adenosine triphosphate (ATP) synthase First drug in 40 years to treat TB with a new mechanism of action Side effects: headache, chest pain, nausea, QT prolongation

Mechanism of Action

Three groups: Protein wall synthesis inhibitors: streptomycin, kanamycin, capreomycin, rifampin, rifabutin, others Cell wall synthesis inhibitors: cycloserine, ethionamide, INH Other mechanisms of action: ethambutol, INH, PAS, ethionamide

Antitubercular Drugs

Tuberculosis (TB) Caused by Mycobacterium tuberculosis Antitubercular drugs treat all forms of Mycobacterium (MTB) TB is most commonly characterized by granulomas in the lungs: nodular accumulations of inflammatory cells (e.g., macrophages, lymphocytes) that are delimited ("walled off" with clear boundaries) and have a center that has a cheesy or caseated consistency

Which additional drug is usually taken concomitantly with isoniazid (INH) to reduce peripheral neuropathy?

Vitamin B6 Pyridoxine, or B6, is often taken concomitantly with INH to reduce peripheral neuropathy.

A chronic hypertensive patient on antihypertensive medications for years develops malaria. The HCP orders chloroquine. A few days pass with no reduction in symptoms of malaria. What does the nurse know to be the issue? a. coadministration of beta-blockers b. resistance to the antimalarial drug c. high virulence of the malarial parasite d. low prescribed dosage of antimalarial drug

a. coadministration of beta blockers Chloroquine interacts with many drugs. Given with beta-blockers may cause failure of the therapeutic action of the drug.

A patient with TB has been taking antitubercular drugs. A suputum culture is ordered to test for acid fast bacilli. When is the best time for the nurse to obtain the suputum culture? a. in the morning b. Noon c. 1700 d. 2200

a. in the morning If the prescriber has ordered collection of a suputm specimen for acid fast bacilli, it is best to obtain the specimen in the early morning. The most common order is for three consecutive morning specimens, with a repeat specimen several weeks later.

Question 1 of 6 Before discharge, the nurse is reviewing a client's prescribed medication regimen for tuberculosis (TB). The client asks the nurse why pyridoxine (vitamin B6) has been prescribed while continuing to take isoniazid (Nydrazid) to treat TB. What is the nurse's best response? a. "Pyridoxine will help prevent numbness, and tingling that can occur secondary to the isoniazid." b. "Pyridoxine is another antitubercular drug that will work synergistically with the isoniazid." c. "You really should not be on that drug. I will check with the health care provider." d. "Multidrug therapy is necessary to prevent the occurrence of resistant bacteria."

answer: a Isoniazid can cause neurotoxicity. Pyridoxine, vitamin B6, is the drug of choice to prevent this adverse reaction. It is not an antiinfective drug and thus will not work to destroy the mycobacterium or prevent drug resistance.

Question 6 of 6 When assessing for adverse effects to Rifamate (combination isoniazid and rifampin), the nurse would monitor which laboratory values? (Select all that apply.) Select all that apply. Liver function tests Complete blood cell count Sputum cultures Uric acid levels Cholesterol

answer: a, b Rifamate can lead to impairment of liver function as well as hematologic disorders. Assessment of sputum cultures confirms the diagnosis but is not related to adverse effects. The drug does not affect uric acid levels or cholesterol.

Question 5 of 6 The nurse anticipates a prescription for vitamin supplementation for a client who is receiving isoniazid (Nydrazid) therapy. What vitamin supplement is usually prescribed with isoniazid? a. Vitamin E b. Calcium c. Vitamin B6 d. Folate

answer: c Pyridoxine (vitamin B6) is often given concurrently with isoniazid to prevent the adverse effect of isoniazid induced peripheral neuropathy associated with neurotoxicity.

Question 2 of 6 What information should the nurse provide to a client prescribed rifampin (Rifadin)? a. Peripheral neuropathy is an expected side effect, and the patient should report any numbness or tingling of the extremities. b. Oral contraception is the preferred method of birth control when using rifampin. c. A nonharmful adverse effect of this medication is red-orange discoloration of urine, sweat, tears, skin, salvia, and feces. d. The patient will only need to take this medication for the prescribed 14-day period.

answer: c Red-orange-brown discoloration of the skin, sweat, tears, urine, feces, sputum, saliva, and tongue as an adverse effect of the drug, but it is not harmful. Rifampin does not cause peripheral neuropathies (isoniazid does), but it does interfere with the effectiveness of oral contraceptives. All antitubercular drugs need to be taken long term to eradicate the slow-growing mycobacterium lying deep within the tissues.

Question 4 of 6 What instruction should the nurse include for a client prescribed rifampin (Rifadin) and isoniazid (Nydrazid) prophylactically secondary to TB exposure? a. Remind that sunscreen is not needed during outdoor activities. b. Explain that isoniazid may decrease blood serum glucose in susceptible people. c. Emphasize that oral contraceptives become ineffective when given with rifampin. d. Advise that these drugs will only need to be taken for 7 to 10 days.

answer: c Women taking oral contraceptives who are prescribed rifampin must be switched to another form of birth control because oral contraceptives become ineffective when given with rifampin. These medications must be taken long term because mycobacterium is slow growing. They can cause photosensitivity, necessitating the use of sunscreen. Finally, isoniazid may increase, not decrease, serum glucose levels.

Question 3 of 6 Which client statement indicates to the nurse that the client understands the discharge teaching for ethambutol (Myambutol)? a. "Constipation will be a problem, so I will increase the fiber in my diet." b. "This medication may cause my bodily secretions to turn red-orange-brown." c. "Dizziness and drowsiness are common adverse effects with this drug." d. "I will need to have my vision checked periodically while I am taking this drug."

answer: d Ethambutol can cause optic neuritis. Ophthalmologic examinations should be performed periodically to assess visual acuity.

1. The nurse is providing patient teaching for a patient who is starting antitubercular drug therapy. Which of these statements should be included? *(Select all that apply.)* a. "Take the medications until the symptoms disappear." b. "Take the medications at the same time every day." c. "You will be considered contagious during most of the illness and must take precautions to avoid spreading the disease." d. "Stop taking the medications if you have severe adverse effects." e. "Avoid alcoholic beverages while on this therapy." f. "If you notice reddish-brown or reddish-orange urine, stop taking the drug and contact your doctor right away." g. "If you experience a burning or tingling in your fingers or toes, report it to your prescriber immediately." h. "Oral contraceptives may not work while you are taking these drugs, so you will have to use another form of birth control

b. "Take the medications at the same time every day." e. "Avoid alcoholic beverages while on this therapy." g. "If you experience a burning or tingling in your fingers or toes, report it to your prescriber immediately." h. "Oral contraceptives may not work while you are taking these drugs, so you will have to use another form of birth control Medications for tuberculosis must be taken on a consistent schedule to maintain blood levels. Medication therapy for tuberculosis may last up to 24 months, long after symptoms disappear, and patients are infectious during the early part of the treatment. Compliance with antitubercular drug therapy is key, so if symptoms become severe, the prescriber should be contacted for an adjustment of the drug therapy. The medication must not be stopped. Because of potential liver toxicity, patients on this drug therapy must not drink alcohol. Discoloration of the urine is an expected adverse effect, and patients need to be warned about it beforehand. Burning or tingling in the fingers or toes may indicate that peripheral neuropathy is developing, and the prescriber needs to be notified immediately. A second form of birth control must be used because antitubercular drug therapy makes oral contraceptives ineffective.

9. The nurse is preparing to administer morning medications to a patient who has been newly diagnosed with tuberculosis. The patient asks, "Why do I have to take so many different drugs?" Which response by the nurse is correct? a. "Your prescriber hopes that at least one of these drugs will work to fight the tuberculosis." b. "Taking multiple drugs is recommended because of the increasing presence of resistance to TB drug therapy. c. "Using more than one drug can help to reduce side effects." d. "Using multiple drugs enhances the effect of each drug."

b. "Taking multiple drugs is recommended because of the increasing presence of resistance to TB drug therapy. The 2016 American Thoracic Society/CDC treatment guidelines recommend the use of multiple medications because of the increasing presence of resistance. The other options are incorrect.

8. A patient who has started drug therapy for tuberculosis wants to know how long he will be on the medications. Which response by the nurse is correct? a. "Drug therapy will last until the symptoms have stopped." b. "Drug therapy will continue until the tuberculosis develops resistance." c. "You should expect to take these drugs for as long as 24 months." d. "You will be on this drug therapy for the rest of your life."

c. "You should expect to take these drugs for as long as 24 months." Drug therapy commonly lasts for 24 months if consistent drug therapy has been maintained. The other options are incorrect.

4. When monitoring patients on antitubercular drug therapy, the nurse knows that which drug may cause a decrease in visual acuity? a. Rifampin (Rifadin) b. Isoniazid (INH) c. Ethambutol (Myambutol) d. Streptomycin

c. Ethambutol (Myambutol) Ethambutol may cause a decrease in visual acuity or even blindness resulting from retrobulbar neuritis. The other options are incorrect.

6. The nurse is counseling a woman who will be starting rifampin (Rifadin) as part of antitubercular therapy. The patient is currently taking oral contraceptives. Which statement is true regarding rifampin therapy for this patient? a. Women have a high risk for thrombophlebitis while on this drug. b. A higher dose of rifampin will be necessary because of the contraceptive. c. Oral contraceptives are less effective while the patient is taking rifampin. d. The incidence of adverse effects is greater if the two drugs are taken together.

c. Oral contraceptives are less effective while the patient is taking rifampin. Women taking oral contraceptives and rifampin need to be counseled about other forms of birth control because of the impaired effectiveness of the oral contraceptives during concurrent use of rifampin.

2. A patient who has been taking isoniazid (INH) has a new prescription for pyridoxine. She is wondering why she needs this medication. The nurse explains that pyridoxine is often given concurrently with the isoniazid to prevent which condition? a. Hair loss b. Renal failure c. Peripheral neuropathy d. Heart failure

c. Peripheral neuropathy Pyridoxine (vitamin B6) may be beneficial for isoniazid-induced peripheral neuropathy. The other options are incorrect.

7. The nurse is reviewing the medication administration record of a patient who is taking isoniazid (INH). Which drug or drug class has a significant drug interaction with isoniazid? a. Pyridoxine (vitamin B6) b. Penicillins c. Phenytoin (Dilantin) d. Benzodiazepines

c. Phenytoin (Dilantin) ANS: C Taking INH with phenytoin will cause decreased metabolism of the phenytoin, leading to increased drug effects. Pyridoxine is often given with isoniazid to prevent peripheral neuropathy. The other options are incorrect

Which medication is indicated for a Plasmodium falciparum infection, which causes a type of malaria that affects the brain? a. Malarone b. chlorquine c. quinine d. pyrimethamine

c. quinine Indications pg 673 Quinine is indicated for infection with chloroquine-resistant P. falciparum, which can cause a type of malaria that affects the brain. Quinine is often given in combination with pyrimethamine, a sulfonamide, or a tetracycline (such as doxycycline).

10. A patient newly diagnosed with tuberculosis (TB) has been taking antitubercular drugs for 1 week calls the clinic and is very upset. He says, "My urine is dark orange! What's wrong with me?" Which response by the nurse is correct? a. "You will need to stop the medication, and it will go away." b. "It's possible that the TB is worse. Please come in to the clinic to be checked." c. "This is not what we usually see with these drugs. Please come in to the clinic to be checked." d. "This is an expected side effect of the medicine. Let's review what to expect."

d. "This is an expected side effect of the medicine. Let's review what to expect." Rifampin, one of the first-line drugs for TB, causes a red-orange-brown discoloration of urine, tears, sweat, and sputum. Patients need to be warned about this side effect. The other options are incorrect.

3. The nurse will assess the patient for which potential contraindication to antitubercular therapy? a. Glaucoma b. Anemia c. Heart failure d. Hepatic impairment

d. Hepatic impairment Results of liver function studies (e.g., bilirubin level, liver enzyme levels) need to be assessed because isoniazid and rifampin may cause hepatic impairment; severe liver dysfunction is a contraindication to these drugs. In addition, the patient's history of alcohol use needs to be assessed.

1. The nurse is discussing adverse effects of antitubercular drugs with a patient who has active tuberculosis. Which potential adverse effect of antitubercular drug therapy should the patient report to the prescriber? a. Gastrointestinal upset b. Headache and nervousness c. Reddish-orange urine and stool d. Numbness and tingling of extremities

d. Numbness and tingling of extremities Patients on antitubercular therapy should report experiencing numbness and tingling of extremities, which may indicate peripheral neuropathy. Some drugs may color the urine, stool, and other body secretions reddish-orange, but this is not an effect that needs to be reported. Patients need to be informed of this expected effect. The other options are incorrect.

5. A patient has been taking antitubercular therapy for 3 months. The nurse will assess for what findings that indicate a therapeutic response to the drug therapy? a. The chronic cough is gone. b. There are two consecutive negative purified protein derivative (PPD) results over 2 months. c. There is increased tolerance to the medication therapy, and there are fewer reports of adverse effects. d. There is a decrease in symptoms of tuberculosis along with improved chest radiographs and sputum cultures.

d. There is a decrease in symptoms of tuberculosis along with improved chest radiographs and sputum cultures. A therapeutic response to antitubercular therapy is manifested by a decrease in the symptoms of tuberculosis, such as cough and fever, and by weight gain. The results of laboratory studies (culture and sensitivity tests) and the chest radiographic findings will be used to confirm the clinical findings of resolution of the infection.

Which condition would be the result of a drug-drug interaction between mefloquine and a beta-blockers in a patient with malaria? a. potential toxicity b. treatment failure c. muscle weakness d. cardiac dysrhythmia

d. cardiac dysrhythmia See table 43.2

Which action does the nurse take to ensure effective treatment for a patient with giardiasis who has been prescribed metronidazole (antiprotozoal drug)? a. advise the patient's family to use meronidazole for prophylaxis b. administer drug to the patient on an empty stomach c. administers the drug as an IV bolus for rapid absorption d. immediately obtains prescribed specimens before administering medication

d. immediately obtains prescribed specimens before administering medication Assessment: pg 681 Metronidazole requires assessment for allergy to any of the nitroimidazole derivatives as well as to parabens (for the topical dosage forms). Obtain appropriate specimens for analysis before treatment. Assess blood counts, presence of central nervous system disorders or abnormalities, and bladder function before use of metronidazole. This is important because of the adverse effects of dysuria, cystitis, headache, dizziness, confusion, and fatigue

What antiprotozoal drug is effective for the treatment of trichomoniasis? a. iodoquinol b. atovaquone c. pentamidine d. metronidazole

d. metronidazole pg 676

Which group of helminths is comprised of flatworms that are parasitic in humans? a. cestodes b. nematodes c. trematodes d. platyhelminthes

d. platyhelminthes The most prevalent helminthic infection in the United States is enterobiasis, caused by one genus of roundworm, Enterobius. Helminths that are parasitic in humans are classified in the following way: • Platyhelminthes (flatworms) • Cestodes (tapeworms) • Trematodes (flukes) • Nematodes (roundworms)

Which opportunistic infection complicates HIV and AIDS? a. giardiasis b. toxoplasmosis c. trichomoniasis d. pneumocystosis

d. pneumocystosis Pneumocystosis is a pulmonary infection caused by Pneumocystis jirovecii.

Which anthelmintic medication can be prescribed for the treatment of cutaneous larva migrans (creeping eruption)? a. pyrantel b. ivermectin c. praziquantel d. thiabendazole

d. thiabendazole