Pharmacological & Parental Therapies
Administering Chemotherapeutic Agents The nurse cares for a client receiving chemotherapy for leukemia. What actions should the nurse take when preparing and administering a vesicant agent? Select all that apply.
A central line or port should be used for intravenous chemotherapy as peripheral lines are easily damaged from the consistency of the chemotherapy. The nurse should verify patency by checking for blood return in the line prior to the administration of chemotherapeutic agents. If infiltration of an IV occurs during the delivery of a non-vesicant, it can irritate the surrounding tissue. Extravasation from the delivery of a vesicant agent can erode and cause permanent damage to tissues. The nurse should watch for signs of irritation and extravasation on the client's skin such as redness, streaking, bruising, and pus. A second qualified nurse should verify the medication just prior to administration. When administering the chemotherapy, a closed, needleless system is used, and there should be a dedicated line so no other medications are infused in that line. Nurses should protect themselves with double gloves, goggles, and a gown when handling chemotherapeutic agents. The nurse should keep a spill kit near the bedside. The nurse should discard items used during the infusion into a dedicated container for chemotherapy waste, and not in the regular trash.
Hyperglycemic Hyperosmolar Syndrome The nurse cares for a client admitted into the emergency room with a diagnosis of hyperglycemic hyperosmolar syndrome.
A client with hyperglycemic hyperosmolar syndrome (HHS) is profoundly dehydrated. The nurse must rapidly initiate the IV fluid bolus as rehydration is the key to stopping the cycle with HHS. The first prescription should be the fluid bolus, next the nurse will give the insulin bolus, and then they can initiate the insulin infusion following the hyperglycemia protocol. The nurse should question the prescription for ampicillin to gain clarification about its use. It is the nurse's responsibility to verify the right drug and, if the nurse does not see an indication for use, then clarification is needed from the prescriber. The client's temperature is elevated but this is from dehydration and hyperglycemia rather than an infectious process. A client with HHS does not develop acidosis as there is still some functional insulin left. Infections can precipitate HHS in clients, but the nurse needs more clarification on why the antibiotic is prescribed.
Case Study: Medication Administration Part 1 (2) Review the client's health information in the electronic health record (EHR) and then identify the condition, associated findings, and parameters to monitor for this client. Select the correct answers from the provided drop-down boxes.
Based on data collection, the client is experiencing diabetic ketoacidosis, which is associated with elevated blood glucose levels, ketones in the urine, and fruity/acetone breath. With the administration of insulin and intravenous fluids, the nurse will monitor blood glucose levels and potassium levels to ensure the safety of the client. Administration of insulin causes potassium to move inside the cell and can result in hypokalemia.
Administering Intravenous Push Medications The nurse prepares to administer an intravenous push (IVP) medication to a client via a saline locked (capped) peripheral IV site. Which actions should the nurse take to safely administer the IVP? Select all that apply.
Before administering any IV medication, the nurse should verify the medication prepared is the medication that was prescribed, assess the site for redness, pain, or swelling, and confirm two client identifiers. Because this is an intravenous push in a capped line, medication compatibility with fluid does not need to be checked as there is no fluid infusing when the client has a capped line. A gravity infusion bag is not required, and the rate of administration is mL per minute. The capped line (saline locked) means it is available for use and not running any medication or fluid. The nurse should flush the line prior to administering the medication but does not need to start a new IV line.
Assessment Findings The nurse admits a client into the emergency department with shortness of breath, chest tightness, and wheezing. The client is barely able to complete a sentence, but the nurse learns that the client has a history of asthma. The client tried a rescue inhaler but "it did not work." The client was coughing a lot but then struggled to cough. The nurse initiates the prescribed albuterol nebulizer. For each potential assessment finding, click to specify whether the finding indicates a potential improvement, signals a worsening condition, or is unrelated to the condition of the client after completion of the nebulizer treatment.
Click on image to get a larger view An albuterol nebulizer treatment is needed by some clients with asthma when they have an asthmatic attack that does not respond to the use of a rescue inhaler. A lower pitch to the wheeze means the airways are starting to open more, which means more air is moving through the airways. The client is not completely open since a wheeze is still present, but it does show an improvement. The client being able to cough some again and being able to complete sentences shows there is improvement after the treatment. Lack of audible breath sounds and restlessness are indications of a worsening condition as they indicate no air movement and hypoxia. Mist will stop coming from the nebulizer end when all the solution has been used up, which is about 5-15 minutes after starting the treatment. Gently tapping the sides of the nebulizer container will help ensure that all medication has been aerosolized before turning off the machine. The completion of the treatment does not indicate a change in the condition itself. Thirst after an asthma attack is not an indicator of improvement nor a sign of worsening of the attack. Open-mouth breathing can be the reason for the increased thirst.
Potential Nursing Actions A nurse is floated to a different medical-surgical unit for the day. Another nurse on the unit asks the floated nurse to witness a wasting of an opioid medication that is due for a client at 1200 today. The floated nurse is still involved in another client's room at 1200 but comes to the medication room at 1215. The other nurse tells the floated nurse, "You're too late. I already prepared the medication and wasted the excess. Just go into the chart and sign off that it was wasted. A pharmacy tech was here in the med room when I did it but left a few minutes ago." For each potential nursing action, click to specify whether the action is appropriate or not appropriate by the floated nurse at this time.
Excess opioid that is not administered to a client needs to be wasted with a witness. The floated nurse did not witness the waste, so should not sign off that it was witnessed. The floated nurse should calmly explain this to the other nurse. The floated nurse should not get more involved by calling the pharmacy but rather should notify the charge nurse. There is no reason for the floated nurse to call hospital security. It is a good idea for the floated nurse to review policies and procedures when uncertain about actions to take.
Immediate Nursing Actions The chemo-certified nurse is caring for clients in the outpatient infusion center. The client is a newly diagnosed cancer client who has not undergone a port placement yet. The nurse starts a new intravenous (IV) catheter on the client's forearm with an 18 gauge. The client had no complaints with flushing of normal saline, nor the initial normal saline fluids. The nurse starts the client on the dose of chemotherapy via intravenous catheter infusion. The client has no complaints with the initiation of this therapy. When the nurse checks on the client one hour later, the nurse notices that extravasation has occurred. After reviewing the client's information, determine what actions the nurse should complete immediately. Select all that apply.
Extravasation is considered an emergency. Immediately, the nurse should stop the infusion, disconnect the main line tubing, aspirate any remaining drug from the cannula, and notify the healthcare provider. Do not remove the existing IV line before notifying the healthcare provider. Administer drug-specific antidote based on provider prescription through the existing site. Failure to recognize and respond to this emergency could cause permanent issues for the client.
Question 2 / 2 Additional Education Required Current Date/Time: 6/12 at 1100 Review the client's health information in the electronic health record (EHR) and then identify the statements by the client that indicate a need for additional education. Select one option in each row.
Feeling shaky, dizzy, diaphoretic, or confused are manifestations of hypoglycemia. The client should be instructed to check a blood glucose level and consume a complex carbohydrate and protein to increase the level. Administering insulin will worsen hypoglycemia. Administering insulin is needed for individuals with type 1 diabetes mellitus due to the autoimmune response that causes the pancreas to stop producing insulin. Injections are given subcutaneously in the abdomen or back of the arm. Glucagon is prescribed for situations when the client is no longer able to safely ingest food to bring up the blood glucose level. The client should be instructed to use a needle once and discard it appropriately. Reuse of needles increases the risk of skin infection.
Acetaminophen Overdose The nurse reviews the electronic health record (EHR) of a 16-year-old client admitted to the pediatric unit for treatment following an overdose of acetaminophen. In what order should the nurse perform these prescriptions, from first to last?
First, the nurse should insert the peripheral venous access device. The normal saline bolus should be administered before N-acetylcysteine because that medication will be delivered continuously over a longer period. A clear liquid diet is the lowest priority after treatment of the client's condition has been initiated. The nurse should also obtain acetaminophen level now and every eight hours.
Administering Heparin After reviewing the electronic health record (EHR), for each potential nursing action, click to specify whether the action is appropriate or not appropriate when preparing and administering the prescribed heparin. The nurse has an IV pump that can be programmed to run rates in whole numbers. The available heparin from the pharmacy is shown in the image.
High-risk medications can fit into the high alert category in which the medications have a high likelihood of causing harm to the client even when they are used as prescribed. Heparin is a high-risk medication that requires careful preparation and administration techniques. The nurse needs to verify the safety of the medication by verifying the client's identity, weight, allergies, and health history. Two nurses need to verify both heparin doses. A direct IV push is outside the scope of practice for the LPN/LVN, so the nurse needs an RN to complete the verification steps. The tubing should be labeled as heparin and should not be mixed with other agents. The bolus is given via IV push and is not a part of what is programmed into the IV pump. The IV pump needs to be set to run at 34 mL/hr. The client weighs 93.2 kg, so the client is getting 1677.6 units of heparin per hour (93.2 x 18). The available solution is heparin 25,000 units/500 mL so the pump should be set for 34 mL/hr. [(1677.6 x 500) / 25,000)]. The nurse needs to check the anti-Xa in 6 hours so the volume to be infused is not the entire bag of heparin, but rather the amount that will be infused over 6 hours (34 x 6 = 204 mL). Heparin has a short half-life so, in many cases, if the client is showing signs of toxicity, discontinuing the infusion is sufficient. However, having the antidote, protamine sulfate, available on the unit is important so that it is ready if needed.
Case Study: Medication Administration Part 1 (1) Review the client's health information in the electronic medical record (EHR) and then complete the sentences using the drop-down choices. The nurse completing the medication reconciliation recognizes that a medication attributing to the client's current problem is insulinlevofloxacinprednisone and was prescribed for glycemic controlbacterial load reductionreducing inflammation.
Medication reconciliation is completed to ensure safety with medication administration and appropriate dosing during admission. Prednisone is an agent used for acute lung problems to reduce inflammation.
Priority Medications The nurse reviews discharge medications with a client. While explaining the new medications, the client asks if they can have one glass of wine at a wedding in the coming week. After reviewing the client's information, highlight the priority medication in the electronic health record (EHR) that indicates the client needs to avoid alcohol consumption.
Metronidazole is an antibiotic used to treat certain types of bacterial and parasitic infections. Drinking alcohol with metronidazole is known to cause abdominal cramping, headache, vomiting, and seizures. Alcohol will not stop amoxicillin or fluticasone from working if taken in moderation.
Reviewing Provider Prescriptions The nurse receives a client as a new admission. The client is experiencing a sickle cell crisis. After reviewing the provider's prescriptions, select the row from the provider's prescription that indicates the need to contact the healthcare provider for clarification.
Pain is the most prominent feature when a client is admitted with a sickle cell crisis. Nurses must ensure that these clients receive adequate pain relief and nurses need to advocate for the client with the provider. The nurse should contact the provider to clarify the dose and frequency of the morphine as a client with a sickle cell crisis will need greater pain control. The recommendation is that these clients receive a continuous intravenous analgesic along with an analgesic scheduled on an as-needed basis for breakthrough pain. This client is only prescribed a small dose of an as-needed medication given orally which will not manage the client's pain when in a sickle cell crisis. The nurse should remain professional in communication with the provider and collaborate to ensure adequate pain control measures are in place. The other prescriptions are expected for a client in a sickle cell crisis.
Case Study: Medication Administration Part 2 (1) Review the client's health information in the electronic health record (EHR) and then highlight the prescriptions that should be clarified by the nurse. Select to highligh
Rights of medication administration include ensuring that the right client, medication, dosage, route, time, and documentation are being used. The insulin infusion does not have an associated diluent solution that it is to be mixed with. The ondansetron, morphine, potassium chloride, and normal saline prescriptions have all the required aspects of medication rights fulfilled. It is appropriate for the healthcare provider to be notified of a blood glucose higher than 400. With the client's hyperglycemic state and need for intravenous insulin, routine labs should be drawn and the blood glucose monitored frequently.
Assessment Findings Requiring Follow-Up Review the client information in the electronic health record (EHR) and then answer the question. The nurse checks on the client at 1030 and notes the client is sleeping soundly. The client does not arouse to name but arouses to touch. Indicate whether each client finding requires follow-up by the nurse or if no action is needed. Each row should include a single choice.
The notable adverse effects of opioid medications are seen in the central nervous system, the gastrointestinal system, and the genitourinary system. Opioids can cause depression of the respiratory centers in the brain, and the client's change in respiratory rate requires follow-up. Opioids can also cause orthostatic hypotension, and the low blood pressure requires review. Agitation, anxiety, and fear can also occur due to opioid activity in the nervous system. Somnolence can indicate sedation is occurring and requires review. The oxygen saturation dropped from 99% to 89% and requires follow-up. The pain level of 4/10 on the Numerical Rating Scale has decreased from the previous level of 8/10. This is a therapeutic outcome and no action is needed. The heart rate is within expected limits.
Case Study: Medication Administration Part 2 (2) Review the client's health information in the electronic health record (EHR) and then identify the correct nursing actions. Select all that apply.
The nurse is responsible for ensuring the safety of the client receiving intravenous therapy. The client is on an insulin drip, which requires hourly blood glucose monitoring. This can be safely delegated to the UAP. However, the task of titration falls within the scope of the registered nurse. The client's blood glucose level at 0900 is 363, indicating that the insulin drip should be titrated to 6 units/hr. This should be verified with another nurse to ensure safety. The rate of infusion for potassium chloride is 100 mL/hr. The client's potassium may be safely infused into the existing IV site and should be run with other IV fluids to reduce irritation to the vessel.
Managing Heparin Administration The nurse cares for a client with pulmonary emboli receiving intravenous (IV) heparin therapy per the facility's heparin protocol. The client weighs 100 kg. The infusion was initiated at a starting rate of 18 units/kg/hr and has been running for 6 hours. The hanging heparin bag is 25,000 units in 250 mL D5W. The nurse receives the client's current anti-Xa value and finds it is 0.8 units/milliliter. Before answering this question, review the heparin titration protocol.
The nurse must recognize that the high anti-Xa level means that the client is getting too much heparin and the infusion rate needs to be slowed down according to the protocol. The protocol for 0.8 units/mL indicates that there is no bolus, the IV infusion is not stopped, and the running infusion needs to be decreased by 1 unit/kg/hour. The current rate is running at 18 units/kg/hour (18 mL/hr), so it needs to be changed to 17 units/kg/hr (17 mL/hr). The protocol dictates that after the rate change the nurse should schedule another anti-Xa lab to be drawn in 6 hours. Additionally, the nurse must understand that heparin is an anticoagulant; therefore, when heparin is having an increased effect, the nurse should be alert to signs/symptoms of bleeding in the client. The nurse should check the client for petechiae and new bruises as well as check if there is bleeding around the IV site. Determining the presence of unilateral leg pain is not as high a priority as the client is at risk of bleeding more than new clot formation currently. Assessment of the anti-Xa labs provides a more accurate assessment of the heparin activity within the body and requires fewer dosage adjustments to achieve and maintain a therapeutic range as compared with the previous aPTT test that was used in heparin titration. The typical goal is to maintain anti-Xa levels between 0.3-0.7 units/mL, but this is based on client need and indication for use.
Nursing Actions The nurse receives a hand-off report for a client scheduled for dialysis in two hours. After reviewing the electronic health record (EHR), which actions should the nurse take? Select all that apply.
The nurse should hold the blood pressure medication, antibiotics, and sodium polystyrene sulfonate, since dialysis is scheduled in 2 hours and the medications will be removed during the process. Potassium will be reduced during dialysis, so getting the client dialyzed is a priority over polystyrene administration. It is safe for the nurse to deliver the insulin as the client can eat before and during dialysis. The blood is best given during dialysis so that the client does not experience fluid overload.
Pain Management The nurse cares for the client in the surgical unit. Review the electronic health record (EHR) and complete the sentence using the drop-down lists. Based on the client's reported pain and request for pain medication at 1530, the nurse will suggest
The nurse would suggest the client take oral oxycodone based on the client's pain rating. The client's pain rating is 9/10 on Numerical Rating Scale, which indicates the client has severe pain. Oxycodone is an opioid analgesic that may be used for moderate to severe pain. Acetaminophen has indications for mild to moderate pain associated with headaches, body aches, and arthritis. It is also indicated for fever reduction due to infection/inflammation due to its antipyretic properties. Ketorolac is a prescription non-steroidal anti-inflammatory drug (NSAID) used short-term due to the risk of bleeding for indications like post-operative pain. The client did receive the scheduled dose of ketorolac at 1030, and this medication is scheduled to be given every 8 hours. The client may not have another dose of ketorolac at 1530 and must wait until 1830.
