Pharmacology Unit 4

CH. 49 Check your understanding Why are antibiotics used in the treatment of some acne conditions?

Antibiotics are sometimes used in combination with acne medications to lessen the severe redness and inflammation associated with the disorder, especially when the acne is inflammatory and results in cysts and pustules, and to reduce bacterial colonization.

CH. 34 Check your understanding What are the four different types of vaccination? Name an example of each.

Attenuated (live) vaccines contain microbes that are alive but weakened (attenuated) so they are unable to produce disease unless the patient is immunocompromised. An example is the measles, mumps, and rubella (MMR) vaccine. Inactivated (killed) vaccines contain microbes that have been inactivated by heat or chemicals and are unable to replicate or cause disease. Examples include the influenza and hepatitis A vaccines. Toxoid vaccines contain bacterial toxins that have been chemically modified to be incapable of causing disease. Examples include diphtheria and tetanus toxoids. Recombinant vaccines are those that contain partial organisms or bacterial proteins that are generated in the laboratory using biotechnology. An example is the hepatitis B vaccine.

CH. 48 Check your understanding Is the amount of calcium available in a calcium supplement always the same? What is the difference?

Calcium supplements consist of complexed calcium in salts such as carbonate, lactate, or phosphate. The amount of calcium in a tablet will differ depending upon its salt. The dose of calcium that a supplement will deliver depends upon the anion it is complexed with and how much is available for the body to use. The body is able to use ionized and complexed calcium. Bound calcium is not available for use. The calcium dose contained in a supplement is known as elemental calcium and is listed on the product label.

CH. 33 Check your understanding Many drug classifications may be used to reduce inflammation, including the NSAIDs, COX-2 inhibitors, and corticosteroids. Why are corticosteroids not routinely used for reducing inflammation?

Corticosteroids have a number of serious adverse effects that limit their therapeutic usefulness. These include suppression of the normal functions of the adrenal gland (adrenal insufficiency), hyperglycemia, mood changes, cataracts, peptic ulcers, electrolyte imbalances, and osteoporosis.

CH. 11 Check your understanding True or False? The most dangerous infectious diseases in the world are those potentially used as weapons of bioterrorism. Explain your answer.

False. The most dangerous diseases are those that are common throughout the world but potentially deadly when adequate prevention or treatment is not available. These diseases include influenza, malaria, AIDS, tuberculosis, SARS, and measles. While infectious agents may be used as weapons of bioterrorism, disease outbreaks caused by infectious agents cause more deaths in unprotected populations than they do through bioterrorism.

CH. 46 Check your understanding What instruction should be given to a woman who has missed a dose of her oral contraceptive?

If a dose is missed, the patient should take it as soon as it is remembered; otherwise, she should take two tablets the next day.

CH. 50 Check your understanding Patients are taught to put gentle pressure on the lacrimal duct for one minute after instilling eye drops. What is the purpose of this technique?

Patients should be taught to hold gentle pressure on the inner canthus of the eye over the tear duct for one full minute after instilling eyedrops to prevent drug leakage into the nasopharynx with possible systemic effects. It also allows for sufficient time for better absorption of the eyedrops.

CH. 50 Hazel Leonard is a 65-year-old African American woman who visits her ophthalmologist with reports of blurry vision and not being able to see well at night while driving. Her health history includes adult-onset diabetes for the past 10 years and osteoporosis since age 55. Her medical regimen includes diet control for the diabetes and Boniva monthly. She denies any injury to her eyes and last had an eye exam 1 year ago. Her provider diagnoses primary open-angle glaucoma. 1. What factors are present in Mrs. Leonard's health history that you identify as predisposing conditions for the development of primary open-angle glaucoma? 2. What would be possible effects from systemic absorption if the provider has prescribed beta-adrenergic drops (e.g., timolol, carteolol)? Prostaglandin drops (e.g., latanoprost, bimatoprost)? Cholinergic agonists (e.g., carbachol, pilocarpine)?

Predisposing factors that Mrs. Leonard has include the fact that she is an African American, and that she is an older adult with a history of diabetes. Other general pre-disposing factors that may not apply to Mrs. Leonard include Asian descent, genetic factors, congenital defects in infants and children, a history of eye trauma, infection, inflammation, hemorrhage, tumors, or cataracts. Long-term use of topical corticosteroids, some antihypertensives, antihistamines, and antidepressants may also contribute to the development or progression of glaucoma. Risk factors associated with glaucoma would include HTN, migraine headaches, refractive disorders with a high degree of nearsightedness or farsightedness, and the normal aging process. If eyedrops for glaucoma are given frequently or if the tear duct is not held after administering the drop and the solution is swallowed, systemic effects may be observed. Adverse effects from beta-adrenergic blocker drops include angina, anxiety, bronchoconstriction, hypotension, and dysrhythmias. Systemic adverse effects from prostaglandin drops include respiratory infection, angina, muscle or joint pain. Cholinergic agonist drops may cause systemic adverse effects, such as salivation, tachycardia, hypotension, bronchospasm, nausea, and vomiting.

CH. 44 Check your understanding What are three main uses of pharmacotherapy with endocrine hormones?

Three main uses for endocrine hormones include replacement therapy (e.g., insulin, thyroid), cancer treatment when used with other antineoplastic drugs, and to produce an exaggerated response (e.g., corticosteroids to suppress inflammation, oral contraceptives to prevent ovulation).

CH. 47 Check your understanding A 53-year-old man is prescribed sildenafil (Viagra) for treatment of ED. His medical history reveals no cardiovascular disease and no other medication use. His blood pressure is within normal range. Later that evening, he is admitted to the emergency department complaining of chest pain and dizziness, and his blood pressure is 80/48. The triage nurse notes in the electronic health record that the patient took two acetaminophen (Tylenol) tablets 4 hours before taking the sildenafil, and a dietary history reveals that he follows a gluten-free diet with 3 glasses of grapefruit juice daily. What is a potential cause of this patient's symptoms?

The patient's normal diet includes a significant amount of grapefruit juice. Grapefruit juice is known to increase the plasma concentrations of sildenafil. The nurse should explore with the patient other dietary options as replacements for grapefruit juice to avoid potential adverse reactions related to enhanced drug plasma levels in the future.

CH. 45 Check your understanding As type 2 DM progresses, supplemental insulin is often required. What is the pathophysiology associated with this progression?

Type 2 DM occurs as a result of insulin resistance. Target cells become unresponsive to insulin due to a defect in insulin receptor function. As cells become more resistant to insulin, blood glucose levels rise and the pancreas responds by secreting even more insulin. Eventually, the hypersecretion of insulin causes beta cell exhaustion and ultimately leads to beta cell death. As type 2 DM progresses, it becomes a disorder characterized by insufficient insulin levels as well as insulin resistance. At this point, supplemental insulin is usually required.

CH. 10 A 44-year-old breast cancer survivor is placed on tamoxifen (Nolvadex), a drug that may prevent recurrence of the cancer. Since receiving chemotherapy, the patient has not had a menstrual cycle. She is concerned about being menopausal and wonders about the possibility of using a soy-based product as a form of natural hormone replacement. How should the nurse advise the patient?

A natural soy product may interfere with the desired action of tamoxifen or other chemotherapy drugs. Her concern should be acknowledged, but she should be warned not to consume any herbal product without first consulting her healthcare provider. The nurse may also explore the patient's concerns by assessing for symptoms related to menopause and the effect they have on the patient. Chemotherapy may cause adverse effects on a wide range of body systems and follow-up with the healthcare provider may be advised.

CH. 44 A 5-year-old girl requires treatment for diabetes insipidus acquired following a case of meningitis. Her DI is being treated with intranasal desmopressin, and the child's mother has been asked to help evaluate the drug's effectiveness using urine volumes and urine specific gravity. Discuss the changes that would indicate that the drug is effective.

A patient with DI produces large amounts of pale or colorless urine with a low specific gravity of 1.001 to 1.005. Daily urine volume may be 4 to 10 L or more and result in excessive thirst and rapid dehydration. Desmopressin is a synthetic analog of ADH. It may be administered intranasally and therefore may be better tolerated by a child. With pharmacotherapy, there should be an immediate decrease in urine production and an increase in urine concentration. The child's mother or caregiver should be taught to use a urine dipstick to check specific gravity during the initiation of therapy. A normal specific gravity would range from 1.005 to 1.030 and would indicate that the kidneys are concentrating urine. The caregiver also should be taught to monitor urine volume, color, and odor until a dosing regimen is established.

CH. 11 Potassium iodide (KI) taken immediately following a nuclear incident can prevent 100% of radioactive iodine from entering which body organ? 1. Brain 2. Thyroid 3. Kidney 4. Liver

Answer: 2 Rationale: Potassium iodine (KI) protects the thyroid gland from I-131.

CH. 48 A young woman calls the triage nurse in her mother's healthcare provider's office with questions concerning her mother's medication. The mother, age 76, has been taking alendronate (Fosamax) after a bone density study revealed a decrease in bone mass. The daughter is worried that her mother may not be taking the drug correctly and asks for information to minimize the potential for drug adverse effects. What information should the triage nurse incorporate in a teaching plan regarding the oral administration of alendronate?

Alendronate (Fosamax) is poorly absorbed after oral administration and can produce significant GI irritation. It is important that the patient or patient's daughter be educated regarding several elements of drug administration. To promote absorption, the drug should be taken first thing in the morning with 8 oz of water 30 minutes before food or beverages are ingested or any other medications are taken. It has been shown that certain beverages, such as orange juice and coffee, interfere with drug absorption. By delaying eating for 30 minutes or more, the patient is promoting absorption of the drug. Additionally, the patient should be taught to sit upright after taking the drug to reduce the risk of esophageal irritation. Alendronate must be used carefully in patients with esophagitis or gastric ulcer. If the patient misses a dose, she should be told to skip it and not to double the next dose. Alendronate has a long half-life, and missing an occasional dose will do little to interfere with the therapeutic effect of the drug.

CH. 50 To determine a patient's ability to administer glaucoma medications, the nurse asks an 82-year-old woman to instill her own medications prior to discharge. The nurse notes that the patient is happy to cooperate and watches as the she quickly bends her head back, opens her eyes, and drops the medication directly onto her cornea. The patient blinks several times, smiles at the nurse, and says, "There, it is no problem at all!" What correction should the nurse make in the patient's technique?

All ophthalmic agents should be administered in the conjunctival sac. The cornea is highly sensitive, and direct application of medication to the cornea may result in excessive burning and stinging. The conjunctival sac normally holds one or two drops of solution. The patient should be reminded to place pressure on the inner canthus of the eye following administration of the medication to prevent the medication from flowing into the nasolacrimal duct. This maneuver helps prevent systemic absorption of medication and decreases the risk of side effects commonly associated with anti-glaucoma drugs.

CH. 48 Which teaching point will the nurse provide to a patient with a new prescription for alendronate (Fosamax)? 1. Take the medication with a full glass of water 30 minutes before breakfast. 2. Take the medication with a small snack or meal containing dairy. 3. Take the medication immediately before bed. 4. Take the medication with a calcium supplement.

Answer: 1 Rationale: Alendronate (Fosamax) should be taken on an empty stomach with a full glass of water, and the patient should remain upright for a minimum of 30 minutes to prevent esophageal irritation.

CH. 33 A 24-year-old patient reports taking acetaminophen (Tylenol) fairly regularly for headaches. The nurse knows that a patient who consumes excessive acetaminophen per day or regularly consumes alcoholic beverages should be observed for what adverse effect? 1. Hepatotoxicity 2. Renal damage 3. Thrombotic effects 4. Pulmonary damage

Answer: 1 Rationale: Excessive doses of acetaminophen or regular consumption of alcohol may increase the risk of hepatotoxicity when acetaminophen is used.

CH. 49 The nurse evaluates the patient's understanding of the procedure for application of triamcinolone (Kenalog, Aristocort) cream for acute contact dermatitis of the neck, secondary to a reaction to perfume. The patient asks why she can't just use up some fluocinonide (Lidex) cream she has left over from a poison ivy dermatitis last month. The nurse's response will be based on which of the following? 1. High-potency corticosteroid creams should be avoided on the neck or face because of the possibility of additional adverse effects. 2. All creams should be discarded after the initial condition has resolved. 3. Fluocinonide cream is too low potency to use for contact dermatitis. 4. Contact dermatitis from perfume is harder to treat than poison ivy dermatitis.

Answer: 1 Rationale: High-potency corticosteroid creams such as fluocinonide (Lidex) should be avoided in the highly vascular neck and facial areas because of the possibility of adverse effects.

CH. 45 The patient is scheduled to receive 5 units of Humalog and 25 units of NPH (Isophane) insulin prior to breakfast. Which nursing intervention is most appropriate for this patient? 1. Make sure the patient's breakfast is available to eat before administering this insulin. 2. Offer the patient a high-carbohydrate snack in 6 hours. 3. Hold the insulin if the blood glucose level is greater than 100 mg/dL. 4. Administer the medications in two separate syringes.

Answer: 1 Rationale: Humalog is a rapid-acting insulin that is administered for elevated glucose levels. It should be given within 15 minutes before meals. Hypoglycemic reactions may occur rapidly if Humalog insulin is not supported by sufficient food intake.

CH. 46 A patient has started taking clomiphene (Clomid, Serophene) after an infertility workup and asks the nurse why she is not having in-vitro fertilization. Which statement would be most helpful in explaining the use of clomiphene to the patient? 1. The patient's diagnostic workup suggested that infrequent ovulation may be the cause for her infertility, and clomiphene increases ovulation. 2. In-vitro fertilization is expensive and because clomiphene is less expensive, it is always tried first. 3. There is less risk of multiple births with clomiphene. 4. The patient's past history of oral contraceptive use has prevented her from ovulating. Clomiphene is given to stimulate ovulation again in these conditions.

Answer: 1 Rationale: Infertility may result from physical obstruction, pelvic infections, or endocrine-related reasons resulting in lack of ovulation. If a fertility workup suggests that infrequent or lack of ovulation is a primary cause, clomiphene may be tried to increase ovulation and is approximately 80% effective for patients with ovulatory-related infertility.

CH. 50 The nurse is planning health teaching for a patient who has been prescribed latanoprost (Xalatan) drops for open-angle glaucoma. The nurse should include which of the following in the teaching plan? 1. The drops may cause darkening and thickening of the eyelashes and upper lid and darkening of the iris color. 2. The drops may cause a temporary loss of eyelashes that will regrow once the drug is stopped. 3. The drops will cause dilation of pupils, and darkened glasses should be worn in bright light. 4. The drops will cause a permanent bluish tint to the conjunctiva that is harmless.

Answer: 1 Rationale: Latanoprost (Xalatan) may cause darkening and thickening of the eyelashes and upper lid and darkening of the color of the iris.

CH. 47 The patient with erectile dysfunction is being evaluated for the use of sildenafil (Viagra). Which question should the nurse ask before initiating therapy with sildenafil? 1. "Are you currently taking medications for angina?" 2. "Do you have a history of diabetes?" 3. "Have you ever had an allergic reaction to dairy products?" 4. "Have you ever been treated for migraines?"

Answer: 1 Rationale: Life-threatening hypotension is an adverse effect in patients who are taking sildenafil (Viagra) along with organic nitrates for angina.

CH. 10 Appropriate teaching to provide safety for a patient who is planning to use herbal products should include which of the following? 1. Take the smallest amount possible when starting herbal therapy, even less than the recommended dose, to see if allergies or other adverse effects occur. 2. Read the labels to determine composition of the product. 3. Research the clinical trials before using the products. 4.Consult the internet or herbal store staff to determine the safest dose and length of time the dose should be taken.

Answer: 1 Rationale: Natural products contain many active ingredients, many of which have not been tested or identified. Patients with known allergies to food products or medicines should seek medical advice before using herbal supplements.

CH. 11 Patients who may have been exposed to nerve agents may be expected to display which of these symptoms? 1. Convulsions and loss of consciousness 2. Memory loss and fatigue 3. Malaise and hemorrhaging 4. Fever and headaches

Answer: 1 Rationale: Overstimulation of the neurotransmitter acetylcholine causes convulsions and loss of consciousness within seconds.

CH. 44 The nurse is talking with the parents of a child who will receive somatropin (Nutropin) about the drug therapy. Which important detail will the nurse include in the teaching for these parents? 1. The drug must be given by injection. 2. The drug must be given regularly throughout adolescence and young adulthood to achieve desired effects. 3. If the drug therapy is given throughout adolescence, it could add 6 (15 cm) to 8 inches (20 cm) to the child's height. 4. Daily laboratory monitoring will be required during the first weeks of therapy.

Answer: 1 Rationale: Somatropin (Nutropin) cannot be given PO; it must be given by subcutaneous injection.

CH. 45 A 63-year-old patient with type 2 diabetes is admitted to the nursing unit with an infected foot ulcer. Despite previous good control on glyburide (Dia-Beta), his blood glucose has been elevated the past several days and he requires sliding-scale insulin. What is the most likely reason for the elevated glucose levels? 1. It is a temporary condition related to the stress response with increased glucose release. 2. He is converting to a type 1 diabetic. 3. The oral antidiabetic drug is no longer working for him. 4. Patients with diabetes who are admitted to the hospital are switched to insulin for safety and tighter control.

Answer: 1 Rationale: The release of glucose may be in response to a stressful situation, such as hospitalization and infection. Blood glucose levels will continue to be monitored, and control may improve as the infection clears and the patient is discharged.

CH. 47 The nurse is teaching a patient who has a new prescription for testosterone gel. Which instruction should the nurse give to this patient? 1. "Avoid exposing women to the gel or to areas of skin where the gel has been applied." 2. "Report any weight gain over 2 kg (5 lb) in 1 month." 3. "Avoid showering or swimming for at least 12 hours after applying the gel." 4. "Apply the gel to the scrotal and perineal areas daily."

Answer: 1 Rationale: Women and children should avoid contact with the gel or areas of the skin where gel has been applied to avoid drug absorption.

CH. 45 What patient education should the nurse provide to the patient with diabetes who is planning an exercise program? (Select all that apply.) 1. Monitor blood glucose levels before and after exercise. 2. Eat a complex carbohydrate prior to strenuous exercise. 3. Exercise may increase insulin needs. 4. Withhold insulin prior to engaging in strenuous exercise. 5. Take extra insulin prior to exercise.

Answer: 1, 2 Rationale: Blood glucose levels should be monitored prior to starting and after ending exercise and should be addressed appropriately. A complex carbohydrate should be consumed prior to strenuous exercise.

CH. 49 After trying many other treatments, a 28-year-old female is started on isotretinoin for treatment of severe acne. While she is on this medication, what explicit instructions must be followed? (Select all that apply.) 1. She must use two forms of birth control and have pregnancy tests before beginning, during, and after she is on the therapy. 2. She must have vision checks performed every 6 months. 3. She must increase intake of vitamin A-rich foods. 4. She must return every 2 to 3 months for laboratory tests. 5. She must delay any future pregnancies for a period of 5 years.

Answer: 1, 2, 4 Rationale: Isotretinoin is teratogenic and pregnancy must be avoided while on this medication. To be eligible for treatment, female patients must agree to frequent pregnancy tests and commit to using two forms of birth control while on the drug. Because of adverse visual, hepatic, and lipid effects, periodic vision screening and laboratory work must be monitored.

CH. 34 The nurse would question an order for peginterferon alfa-2a (Pegasys) if the patient had which of the following conditions? (Select all that apply.) 1. Pregnancy 2. Kidney disease 3. Hepatitis 4. Liver disease 5. Malignant melanoma

Answer: 1, 2, 4 Rationale: Pregnancy and kidney or liver disease are contraindications to the use of immunostimulant drugs such as peginterferon alfa-2a (Pegasys).

CH. 50 The patient is prescribed timolol (Timoptic) for treatment of glaucoma. During the history and physical, the nurse assesses for which of the following medical disorders that may be a contraindication to the use of this drug? (Select all that apply.) 1. Heart block 2. Heart failure 3. Liver disease 4. Chronic obstructive pulmonary disease Renal disease

Answer: 1, 2, 4 Rationale: The nurse needs to notify the healthcare provider if the patient has a history of heart block, bradycardia, cardiac failure, heart failure, or COPD because timolol may be contraindicated for clients with these conditions. If the drug is absorbed systemically, it will worsen these conditions. Proper administration lessens the danger that the drug will be absorbed systemically.

CH. 11 What key roles does the nurse play in the event of a potential bioterrorist attack? (Select all that apply.) 1. Helping to plan for emergencies and develop emergency management plans 2. Recognizing and reporting signs and symptoms of chemical or biologic agent exposure and assisting with treatment 3. Storing antidotes, antibiotics, vaccines, and supplies in their homes 4. Keeping a list of resources, such as health and law enforcement agencies and other contacts who would assist in the event of a bioterrorist attack 5. Keeping up to date on emergency management protocols and volunteering to become members of a first-response team

Answer: 1, 2, 4, 5 Rationale: Nurses help to plan for emergencies and in developing emergency management plans. In the event of a bioterrorist attack, the nurse should be able to recognize and report signs and symptoms of chemical or biologic agent exposure and to assist with treatment. By keeping a list of resources, such as health and law enforcement agencies and other contacts that would assist in the event of a bioterrorist attack, the nurse can help to coordinate neighborhood and local emergency efforts. The nurse can also serve the community by keeping up to date on emergency management protocols and volunteering to become a member of a first-response team.

CH. 48 A patient with rheumatoid arthritis will begin treatment with adalimumab (Humira). Which statement related to this therapy is correct? Select all that apply. Adlimumab: 1. May lower immune response and increase the risk of infections and malignancies. 2. Is associated with osteoporosis and baseline and periodic DXA scans should be conducted. 3. May reactivate latent TB. 4. May cause local injection-site irritations such as pain and bruising. 5. Must be taken daily for up to 6 months.

Answer: 1, 3, 4 Rationale: DMARDs modify immune and inflammatory responses but may increase the risk of infections and malignancies, and may reactivate latent TB. Injection site reactions such as pain, swelling, and bruising are common adverse effects.

CH. 47 A patient is given a prescription for finasteride (Proscar) for treatment of benign prostatic hyperplasia. Essential teaching for this patient includes which of the following? (Select all that apply.) 1. Full therapeutic effects may take 3 to 6 months. 2. Hair loss or male-pattern baldness may be an adverse effect. 3. The drug should not be handled by pregnant women, especially if it is crushed. 4. Blood donation should not occur while taking this drug. Report any weight gain of over 2 kg (5 lb) in 1 week.

Answer: 1, 3, 4 Rationale: Enlarged prostatic tissue will decrease over a period of 3 to 6 months. The drug is teratogenic and should not be handled by pregnant women. Blood donation should not occur while taking finasteride because the blood may be given to a woman.

CH. 46 Which patients would have a higher risk for adverse effects from estradiol and norethindrone (Ortho-Novum)? (Select all that apply.) 1. An 18-year-old with a history of depression 2. A 16-year-old with chronic acne 3. A 33-year-old with obesity per her body mass index (BMI) 4. A 24-year-old who smokes one pack of cigarettes per day 5. A 41-year-old who has delivered two healthy children

Answer: 1, 4 Rationale: A previous history of depression is a relative contraindication because OCs may worsen depression in some women. The use of OCs should be evaluated by the healthcare provider in this situation. Women who smoke have a greater risk of adverse cardiovascular effects and the FDA has issued a black box warning about these effects.

CH. 49 A 15-year-old patient started using topical benzoyl peroxide (Benzaclin, Fostex) 1 week ago for treatment of acne and is discouraged that her acne is still visible. What is the nurse's best response? 1. "The cream should have started working by now. Check with your healthcare provider about switching to a different type." 2. "Some improvement will be noticed quickly, but full effects may take several weeks to a month or longer." 3. "Acne is very difficult to treat. It may be several months before you notice any effects." 4. "If your acne is not gone by now, you may need an antibiotic too. Ask your healthcare provider."

Answer: 2 Rationale: Initial drying of the skin caused by benzoyl peroxide will help begin to clear acne lesions in the early stages of treatment, but it may take several weeks before full effects are visible.

CH. 34 The nurse is evaluating drug effects in a patient who has been given interferon alfa-2b (Intron A) for hepatitis B and C. Which of the following is a common adverse effect? 1. Depression and thoughts of suicide 2. Flulike symptoms of fever, chills, or fatigue 3. Edema, hypotension, and tachycardia 4. Hypertension, renal or hepatic insufficiency

Answer: 2 Rationale: Interferon alfa-2b (Intron-A) commonly causes flulike symptoms in up to 50% of patients receiving the drug.

CH. 48 A postmenopausal woman is started on raloxifene (Evista) for prevention of osteoporosis. Because of the black box warning, what condition, noted in the patient's history, may indicate that this drug should not be given, or given with extreme caution? 1. A history of depression 2. A history of coronary artery disease or thrombophlebitis 3. A history of osteoarthritis 4. A history of using black cohosh to treat menopausal symptoms

Answer: 2 Rationale: Raloxifene carries a black box warning that the drug increases the risk of venous thromboembolism and death from strokes, especially in women with coronary artery disease. With a previous history, the drug may not be given, or the healthcare provider will evaluate risk-versus-benefit before beginning this drug.

CH. 10 The patient states that he has been using the herbal product saw palmetto. The nurse recognizes that this supplement is often used to treat which condition? 1. Insomnia 2. Urinary problems associated with prostate enlargement 3.Symptoms of menopause 4. Urinary tract infection

Answer: 2 Rationale: Saw palmetto is used to relieve urinary problems related to prostate enlargement.

CH. 46 A patient is interested in taking levonorgestrel and estradiol (Seasonique) and asks how it is taken. Which explanation by the nurse is correct? 1. "Seasonique is taken year-round without a break and without a period." 2. "Seasonique is taken for 84 days and then followed by 7 days of a lower dose contained in the same package." 3. "Seasonique is a vaginal ring that is inserted monthly." 4. "Seasonique is taken for 2 months then off for 1 month using regular oral contraceptives."

Answer: 2 Rationale: Seasonique is taken for 84 consecutive days, followed by 7 days of a lower dose that is contained in the same pill pack.

CH. 11 How does the Centers for Disease Control and Prevention categorize biologic threats? 1. Based on their potential adverse effects 2. Based on the potential impact on public health 3. Based on their potential cost of treatment 4. Based on the potential loss of life

Answer: 2 Rationale: The CDC has categorized biologic threats based on the potential impact on public health.

CH. 49 The patient is treated for head lice with permethrin (Nix). Following treatment, the nurse will reinforce which instruction? 1. Remain isolated for 48 hours. 2. Inspect the hair shafts, checking for nits daily for 1 week following treatment. 3. Shampoo with permethrin three times per day. 4. Wash linens with cold water and bleach.

Answer: 2 Rationale: To ensure the effectiveness of drug therapy, patients should inspect hair shafts after treatment, checking for nits by combing with a fine-toothed comb after the hair is dry. This procedure must be conducted daily for at least 1 week after treatment.

CH. 47 Which of the following nursing assessments would be appropriate for the patient who is receiving testosterone? (Select all that apply.) 1. Monitor for a decrease in hematocrit. 2. Assess for signs of fluid retention. 3. Assess for increased muscle mass and strength. 4. Check for blood dyscrasias. 5. Assess for muscle wasting.

Answer: 2, 3 Rationale: A side effect of testosterone therapy is fluid retention. Testosterone is also used to increase muscle mass and strength.

CH. 48 A 62-year-old female has received a prescription for alendronate (Fosamax) for treatment of osteoporosis. The nurse would be concerned about this order if the patient reported which condition? (Select all that apply.) 1. She enjoys milk, yogurt, and other dairy products and tries to consume some with each meal. 2. She is unable to sit upright for prolonged periods because of severe back pain. 3. She is lactose intolerant and rarely consumes dairy products. 4. She has had trouble swallowing and has been told she has "problems with her esophagus." 5. She has a cup of green tea every night before bed.

Answer: 2, 3, 4 Rationale: Bisphosphonates such as alendronate require the patient to take the drug on an empty stomach and remain upright for 30 minutes to 1 hour. Adequate serum calcium levels should be confirmed before starting bisphosphonates, and adequate calcium and vitamin D intake should be encouraged while on drug therapy. Any narrowing of the esophagus may place the patient at risk of increased adverse esophageal effects from the drug.

CH. 44 A nurse is preparing the teaching plan for a patient who will be discharged on methylprednisolone (Medrol Dosepak) after a significant response to poison ivy. The nurse will include instruction on reporting which adverse effects to the healthcare provider? (Select all that apply.) 1. Tinnitus 2. Edema 3. Eye pain or visual changes 4. Abdominal pain 5. Dizziness upon standing

Answer: 2, 3, 4 Rationale: Edema, eye pain or visual changes, and abdominal pain are symptoms of possible adverse effects from the methylprednisolone.

CH. 33 A patient with a history of hypertension is to start drug therapy for rheumatoid arthritis. Which drug(s) would be contraindicated, or used cautiously, for this patient? (Select all that apply.) 1. Aspirin 2. Ibuprofen (Advil, Motrin) 3. Acetaminophen (Tylenol) 4. Naproxen (Aleve) 5. Methylprednisolone (Medrol)

Answer: 2, 4, 5 Rationale: NSAIDs such as ibuprofen and naproxen have been shown to increase the risk of serious thrombotic events, MI, and stroke which can be fatal. These drugs should be used cautiously or avoided in patients with HTN. Corticosteroids such as methylprednisolone may cause fluid retention, which may increase the patient's blood pressure. Cautious and frequent monitoring will be required if the patient takes this drug.

CH. 10 Which patients may be most at risk for adverse effects related to specialty supplements? (Select all that apply.) 1. Adolescents 2. Pregnant women 3. School-age children 4. Older adult patients 5. Patients taking prescription medication

Answer: 2, 4, 5 Rationale: Pregnant women, older adult patients, and patients who are taking prescription medications, especially those with a narrow safety profile, are at greatest risk for adverse effects related to specialty supplements. Some supplements may cross the placenta with unknown effects on the developing fetus. Older adult patients may have concurrent disease conditions or a decline in organ function that would affect the safety of the supplement. Drug-supplement interactions may occur, especially with drugs with narrow safety profiles.

CH. 44 A patient will be started on desmopressin (DDAVP) for treatment of diabetes insipidus. Which instruction should the nurse include in the teaching plan? 1. Drink plenty of fluids, especially those high in calcium. 2. Avoid close contact with children or pregnant women for 1 week after administration of the drug. 3. Obtain and record your weight daily. 4. Wear a mask if around children and pregnant women.

Answer: 3 Rationale: Patients on DDAVP should obtain a daily weight and monitor for the presence of peripheral edema.

CH. 44 Which assessment findings would cause the nurse to withhold the patient's regularly scheduled dose of levothyroxine (Synthroid)? 1. A 1-kg (2-lb) weight gain 2. A blood pressure reading of 90/62 mmHg 3. A heart rate of 110 beats/minute 4. A temperature of 37.9°C (100.2°F)

Answer: 3 Rationale: A heart rate of 110 beats/min may indicate that the dosage may be too high. The nurse should withhold the dose and notify the healthcare provider.

CH. 45 The nurse is initiating discharge teaching with the newly diagnosed patient with diabetes. Which statement indicates that the patient needs additional teaching? 1. "If I am experiencing hypoglycemia, I should drink 1/2 cup of apple juice." 2. "My insulin needs may increase when I have an infection." 3. "I must draw the NPH insulin first if I am mixing it with regular insulin." 4. "If my blood glucose levels are less than 60 mg/dL, I should notify my healthcare provider."

Answer: 3 Rationale: Additional teaching is needed to ensure that the patient is mixing insulin correctly in the same syringe. The short-acting solution (regular insulin) should be drawn into the syringe first, followed by the longer-acting (intermediate) solution (NPH).

CH. 34 A nurse is preparing to administer a hepatitis B vaccination to a patient. Which condition would cause the nurse to withhold the vaccination and check with the healthcare provider? 1. The patient smokes cigarettes, one pack per day. 2. The patient is frightened by needles and injections. 3. The patient is allergic to yeast and yeast products. 4. The patient has hypertension.

Answer: 3 Rationale: An allergy to yeast or yeast products is a contraindication to the hepatitis B vaccination.

CH. 50 Timolol (Timoptic) drops have been ordered to treat glaucoma. Because of the possibility of systemic adverse effects, what essential instruction should the patient receive? 1. Monitor urine output and daily weight. Promptly report any edema. 2. Monitor blood glucose and alert the healthcare provider to any significant changes. 3. Hold slight pressure on the inner canthus of the eye for 1 minute after instilling the drop. 4. Monitor respiratory rate and for signs and symptoms of upper respiratory infection.

Answer: 3 Rationale: Beta-adrenergic drugs such as timolol (Timoptic) may reduce resting heart rate and blood pressure. The patient should hold slight pressure on the inner canthus of the eye to prevent the drug from entering the lacrimal duct with possible systemic absorption.

CH. 50 A patient with a history of glaucoma who has been taking latanoprost (Xalatan) eyedrops complains of severe pain in the eye, severe headache, and blurred vision. What should be the nurse's first response? 1. Document the occurrence; this symptom is expected. 2. Medicate the patient with a narcotic analgesic. 3. Notify the healthcare provider immediately. 4. Place the patient in a quiet, darkened environment.

Answer: 3 Rationale: Closed-angle glaucoma is an acute type of glaucoma that is caused by stress, impact injury, or medications. Pressure inside the anterior chamber increases suddenly because the iris is pushed over the area where the aqueous fluid normally drains. Signs and symptoms include intense headaches, difficulty concentrating, bloodshot eyes, blurred vision, and a bulging iris. Closed-angle glaucoma constitutes an emergency.

CH. 49 The biologic DMARDs such as adalimumab (Humira) are used for psoriasis and psoriatic arthritis when topical treatments have not achieved desirable results. What is a major clinical disadvantage of DMARD therapy when compared to conventional topical drugs? 1. They take months to be effective. 2. They only treat certain types of psoriasis. 3. They increase the risk of serious infections, including reactivation of TB. 4. They are expensive.

Answer: 3 Rationale: DMARDs such as adalimumab (Humira), secukinumab (Cosentyx), and ustekinumab (Stelara) decrease immune response and increase the risk of serious infections, including TB.

CH. 44 A patient is being treated with methimazole (Tapazole) for hyperthyroidism, pending thyroidectomy. While the patient is taking this drug, what symptoms will the nurse teach the patient to report to the healthcare provider? 1. Tinnitus, altered taste, thickened saliva 2. Insomnia, nightmares, night sweats 3. General weakness, muscle cramps, and dry skin 4. Dry eyes, decreased blinking, reddened conjunctiva

Answer: 3 Rationale: General weakness, muscle cramps, and dry skin are early signs of hypothyroidism and may indicate overtreatment with methimazole. Later signs include slurred speech, bradycardia, weight gain, decreased sense of taste and smell, and intolerance to cold environments.

CH. 48 The patient who is receiving allopurinol (Lopurin) for treatment of gout asks why he should avoid the consumption of alcohol. The nurse's response is based on the knowledge that the use of alcohol along with allopurinol may result in which of the following? 1. It significantly increases the drug levels of allopurinol. 2. It interferes with the absorption of antigout medications. 3. It raises uric acid levels. 4. It causes the urine to become more alkaline.

Answer: 3 Rationale: Gout is a metabolic disorder characterized by the accumulation of uric acid in the bloodstream or joint cavities. Alcohol increases uric acid levels.

CH. 33 The patient has been taking aspirin for several days for headache. During the assessment, the nurse discovers that the patient is experiencing ringing in the ears and dizziness. What is the most appropriate action by the nurse? 1. Question the patient about history of sinus infections. 2. Determine whether the patient has mixed the aspirin with other medications. 3. Tell the patient not to take any more aspirin. 4. Tell the patient to take the aspirin with food or milk.

Answer: 3 Rationale: High doses of aspirin can produce side effects of tinnitus, dizziness, headache, and sweating. These symptoms should be reported to the healthcare provider.

CH. 46 A woman consults the nurse about Plan B (levonorgestrel) after unprotected intercourse that occurred 2 days earlier. Which instruction will the nurse give to this patient? 1. "You must wait 7 days before taking the pills for Plan B to be effective." 2. "Plan B is effective only within 24 hours of unprotected intercourse." 3. "You will take one pill of Plan B at first, followed by another pill 12 hours later." 4. "You will need to obtain a prescription for Plan B."

Answer: 3 Rationale: Plan B (levonorgestrel) is administered by taking one pill, followed by another pill 12 hours later.

CH. 10 What is the difference between an herbal product and a specialty supplement? 1. An herbal product is safer to use than a specialty supplement. 2. A specialty supplement tends to be more expensive than an herbal product. 3. A specialty supplement is a nonherbal dietary product used to enhance a variety of body functions. 4. There are less adverse effects or risk of allergy with specialty supplements than there are with herbal products.

Answer: 3 Rationale: Specialty supplements are nonherbal dietary products used to enhance a wide variety of body functions. In general, specialty supplements have a legitimate rationale for their use. But the link between most specialty supplements and their claimed benefits is unclear and the body may already have sufficient quantities of the substance.

CH. 47 The nurse is teaching a patient about the use of tadalafil (Cialis). What will the nurse teach him about the effects of tadalafil? 1. It should always result in a penile erection within 10 minutes. 2. It may heighten female sexual response. 3. It is not effective if sexual dysfunction is caused by psychologic conditions. 4. It will result in less intense sensation with prolonged use.

Answer: 3 Rationale: Tadalafil (Cialis) and other similar drugs are not effective if the ED is psychologic in nature.

CH. 11 Which medication is primarily used as a treatment for anthrax? 1. Diphtheria vaccine 2. Amoxicillin (Amoxil) 3. Ciprofloxacin (Cipro) 4. Smallpox vaccine

Answer: 3 Rationale: The antibiotic ciprofloxacin (Cipro) has been used for both prophylaxis and treatment of anthrax.

CH. 48 Which assessment findings in a patient who is receiving calcitriol (Calcijex, Rocaltrol) should the nurse immediately report to the healthcare provider? 1. Muscle aches, fever, dry mouth 2. Tremor, abdominal cramping, hyperactive bowel sounds 3. Bone pain, lethargy, anorexia 4. Muscle twitching, numbness, and tingling of the extremities

Answer: 3 Rationale: Toxicity from calcitriol (Calcijex, Rocaltrol) includes symptoms of hypercalcemia and bone pain, anorexia, nausea and vomiting, increased urination, hallucinations, and dysrhythmias.

CH. 11 The nurse recognizes which of the following to be initial symptoms of inhaled anthrax? (Select all that apply.) 1. Cramping and diarrhea 2. Skin lesions that develop into black scabs 3. Fever 4. Headache 5. Cough and dyspnea

Answer: 3, 5 Rationale: Inhaled anthrax affects the respiratory system. Fever, persistent cough, and dyspnea are all initial symptoms of inhaled anthrax.

CH. 49 The nurse is planning teaching for a patient prescribed desoximetasone (Topicort) for atopic dermatitis. The nurse will teach the patient to anticipate which possible adverse effects? 1. Localized pruritus and hives 2. Hair loss in the application area 3. Worsening of acne 4. Burning and stinging of the skin in the affected area

Answer: 4 Rationale: Topical reactions such as burning or stinging in the area where topical corticosteroids such as desoximetasone (Topicort) are applied are common.

CH. 33 The nurse is counseling a mother regarding antipyretic choices for her 8-year-old daughter. When asked why aspirin is not a good drug to use, what should the nurse tell the mother? 1. It is not as good an antipyretic as is acetaminophen. 2. It may increase fever in children under age 10. 3. It may produce nausea and vomiting. 4. It increases the risk of Reye's syndrome in children under 19 with viral infections.

Answer: 4 Rationale: Aspirin and salicylates are associated with an increased risk of Reye's syndrome in children under 19, especially in the presence of viral infections.

CH. 50 Appropriate administration is key for patients who are taking eyedrops for the treatment of glaucoma to optimize therapeutic effects and reduce adverse effects. The nurse would be concerned if the patient reports administering the drops in which manner? 1. Into the conjunctival sac 2. Holding slight pressure on the tear duct (lacrimal duct) for 1 minute after instilling the eyedrops 3. Avoiding direct contact with the eye dropper tip and the eye 4. Leaving contact lenses in to be sure the eyedrop is maintained in the eye

Answer: 4 Rationale: Contact lenses should be removed before instilling eyedrops and remain out for a minimum of 15 minutes after instilling eyedrops.

CH. 34 A 55-year-old female patient is receiving cyclosporine (Neoral, Sandimmune) after a heart transplant. The patient exhibits a white blood cell count of 12,000 cells/mm3, a sore throat, fatigue, and a low-grade fever. Which condition does the nurse suspect? 1. Transplant rejection 2. Heart failure 3. Dehydration 4. Infection

Answer: 4 Rationale: Due to immune system suppression by the cyclosporine (Neoral, Sandimmune), infections are common. While the WBC count is slightly elevated, this drug suppresses the function of the immune cells (T cells) and does not suppress bone marrow production of WBCs.

CH. 47 A patient with a history of benign prostatic hyperplasia is complaining of feeling like he "cannot empty his bladder." He has been taking finasteride (Proscar) for the past 9 months. What should the nurse advise this patient to do? 1. Continue to take the drug to achieve full therapeutic effects. 2. Discuss the use of a low-dose diuretic with the healthcare provider. 3. Decrease the intake of coffee, tea, and alcohol. 4. Return to the healthcare provider for laboratory studies and a prostate exam.

Answer: 4 Rationale: Finasteride promotes shrinking of enlarged prostates and helps restore urinary function with full therapeutic effects obtained within 6 to 12 months. Because this patient reports a sudden increase in urinary symptoms after taking the drug for 9 months, he should be evaluated by the healthcare provider for prostate cancer screening.

CH. 34 Which statement by a patient who is taking cyclosporine (Neoral, Sandimmune) would indicate the need for more teaching by the nurse? 1. "I will report any reduction in urine output to my healthcare provider." 2. "I will wash my hands frequently." 3. "I will take my blood pressure at home every day." 4. "I will take my cyclosporine at breakfast with a glass of grapefruit juice."

Answer: 4 Rationale: Grapefruit juice increases cyclosporine levels 50% to 200%, resulting in drug toxicity.

CH. 45 A patient receives NPH and regular insulin every morning. The nurse is verifying that the patient understands that there are 2 different peak times to be aware of for this insulin regimen. Why is this an important concept for the nurse to stress? 1. The patient needs to plan the next insulin injection around the peak times. 2. Additional insulin may be needed at peak times to avoid hyperglycemia. 3. It is best to plan exercise or other activities around peak insulin activity. 4. The risk for hypoglycemia is greatest around the peak of insulin activity.

Answer: 4 Rationale: Insulin peak times are the periods of maximum insulin utilization with the greatest risk of hypoglycemia.

CH. 34 A 5-year-old child is due for prekindergarten immunizations. After interviewing her mother, which response may indicate a possible contraindication for giving this preschooler a live vaccine (e.g., measles, mumps, and rubella [MMR]) at this visit and would require further exploration by the nurse? 1. Her cousin has the flu. 2. The mother has just finished her series of hepatitis B vaccines. 3. Her arm became very sore after her last tetanus shot. 4. They are caring for her grandmother who has just finished her second chemotherapy treatment for breast cancer.

Answer: 4 Rationale: Live vaccines may be contraindicated when patients present an exposure risk of the infectious agent to immunocompromised people such as those on chemotherapy or immunosuppressant therapy.

CH. 46 A 43-year-old patient is receiving medroxyprogesterone (Depo-Provera) for treatment of dysfunctional uterine bleeding. Because of related adverse effects, which condition may indicate a potential adverse effect? 1. Breakthrough bleeding between periods 2. Insomnia or difficulty falling asleep 3. Eye, mouth, or vaginal dryness 4. Joint pain or pain on ambulation

Answer: 4 Rationale: Medroxyprogesterone (Depo-Provera) carries a black box warning about the risk of decreased bone density that may occur over time. Joint or bone pain, or pain on ambulation, should be assessed as a sign of this potential adverse effect.

CH. 44 The nurse is assisting a patient with chronic adrenal insufficiency to plan for medication consistency while on a family vacation trip. He is taking hydrocortisone (Cortef) and fludrocortisones (Florinef) as replacement therapy. What essential detail does this patient need to remember to do? 1. Take his blood pressure once or twice daily. 2. Avoid crowded indoor areas to avoid infections. 3. Have his vision checked before he leaves. 4. Carry an oral and injectable form of both drugs with him on his trip.

Answer: 4 Rationale: Patients who are taking replacement therapy for adrenal insufficiency must carry emergency supplies of both oral and injectable forms of the drugs they are prescribed in case of emergencies where the drug may not be readily available.

CH. 50 The nurse emphasizes to the patient with glaucoma the importance of notifying the healthcare provider performing an eye examination of a glaucoma diagnosis because of potential adverse reactions to which drugs? 1. Antibiotic drops 2. Cycloplegic drops 3. Anti-inflammatory drops 4. Anticholinergic mydriatic drops

Answer: 4 Rationale: Patients with glaucoma must be especially careful with anticholinergic mydriatics because these drugs can worsen glaucoma by impairing aqueous humor outflow and thereby increasing intraocular pressure.

CH. 33 While educating the patient about hydrocortisone (Cortef), the nurse would instruct the patient to contact the healthcare provider immediately if which of the following occurs? 1. There is a decrease of 1 kg (2 lb) in weight. 2. There is an increase in appetite. 3. There is tearing of the eyes. 4. There is any difficulty breathing.

Answer: 4 Rationale: Side effects that need to be reported immediately include difficulty breathing; heartburn; chest, abdomen, joint, or bone pain; nosebleed; blood in sputum when coughing, vomitus, urine, or stools; fever; chills or signs of infection; increased thirst or urination; fruity breath odor; falls; or mood swings.

CH. 33 The nurse is admitting a patient with rheumatoid arthritis. The patient has been taking prednisone for an extended time. During the assessment, the nurse observes that the patient has a very round moon-shaped face, bruising, and an abnormal contour of the shoulders. What does the nurse conclude based on these findings? 1. These are normal reactions with the illness. 2. These are probably birth defects. 3. These are symptoms of myasthenia gravis. 4. These are symptoms of adverse drug effects from the prednisone.

Answer: 4 Rationale: Signs and symptoms of bruising and a characteristic pattern of fat deposits in the cheeks (moon face), shoulders, and abdomen are common adverse effects associated with long-term prednisone use.

CH. 10 The nurse obtains information during the admission interview that the patient is taking dietary supplements in addition to prescribed medications. What is the nurse's primary concern for this patient? 1. Dietary supplements are natural and pose no risk to the patient but may be costly. 2. Dietary supplements are a welcome addition to conventional medications but do not always come with instructions. 3. The patient may be at risk for allergic reactions. 4. Dietary supplements may interact with prescribed medications and affect drug action.

Answer: 4 Rationale: Some dietary supplements contain ingredients that may serve as agonists or antagonists to prescription drugs. Dietary supplements should not be taken without discussing their use with the healthcare provider.

CH. 46 The nurse completes an assessment of a patient in labor who is receiving an intravenous infusion of oxytocin. Which assessment indicates the need for prompt intervention? 1. There is no vaginal bleeding noted. 2. The patient is managing her pain through breathing techniques. 3. Fetal heart rate remains at baseline parameters. 4. Contractions are sustained for 2 minutes in duration.

Answer: 4 Rationale: Sustained contractions increase the risk of uterine rupture and adverse effects to the fetus. They should be reported immediately and prompt and appropriate intervention started, including stopping the oxytocin drip and starting oxygen therapy for the patient.

CH. 45 A patient with type 2 diabetes has been nothing by mouth (NPO) since midnight for surgery in the morning. He has been on a combination of oral type 2 anti-diabetic drugs. What would be the best action for the nurse to take concerning the administration of his medications? 1. Hold all medications as per the NPO order. 2. Give him the medications with a sip of water. 3. Give him half the original dose. 4. Contact the healthcare provider for further orders.

Answer: 4 Rationale: The healthcare provider should be contacted for further orders. The need for oral hypoglycemic medication may have been overlooked, or other measures, such as insulin, to treat hyperglycemia during the surgery may be planned. Contacting the healthcare provider ensures that the provider is aware that the patient has diabetes and that no medications for diabetes were ordered.

CH. 10 An older adult patient tells the nurse that she has been using several herbal products recommended by a friend. Why would the nurse be concerned with this statement, given the patient's age? 1. The older adult patient may have difficulty reading labels and opening bottles and may confuse medications. 2. The older adult patient may have difficulty paying for additional medications and may stop using prescribed drugs. 3. The older adult patient may be more prone to allergic reactions from herbal products. 4. The older adult patient may have other disease conditions that could increase the risk for a drug reaction.

Answer: 4 Rationale: The older adult patient is more likely to have chronic ailments such as kidney, cardiac, or liver disease that could increase the risk for a drug-herb interaction.

CH. 47 A 16-year-old adolescent tries out for the football team. He is immediately impressed with the size of several junior and senior linemen. One older student offers to "hook him up" with a source for androstenedione (Andro). From a developmental perspective, explain why this young man may be susceptible to anabolic steroid abuse. Can anabolic steroid abuse affect his stature?

At this age, peer groups are often more important than the family, and fitting in is important to many adolescents. This young man's desire to be accepted as an athlete and a team member may produce a willingness to do what it takes to fit in. In addition, the young man may have aspirations of a career in sports and recognize the need to be in optimal physical condition. He may not be aware that testosterone can produce premature epiphyseal closure, potentially affecting his adult height. Other risks include hypertension and long-term organ damage. He should be referred to his healthcare provider for a discussion on appropriate options to help build muscle mass such as moderate weight-lifting.

CH. 45 A patient with type 2 diabetes on metformin (Glucophage) reports that he takes propranolol (Inderal) for his hypertension. What concerns would the nurse have about this combination of medications? What would the nurse teach the patient?

Beta-blocking drugs such as propranolol have the potential to alter the way hypoglycemia is perceived and the normal "alarm" symptoms may be subtle. Diaphoresis is a common symptom when blood glucose decreases among those patients on beta blockers along with their oral antidiabetic drug. The nurse should teach the patient to be aware that should his blood glucose begin to decrease, symptoms normally felt (e.g., nervousness, tremors, agitation) may be perceived differently, and that if sweating occurs, he should check his blood sugar immediately.

CH. 49 A 36-year-old woman is seen by her healthcare provider for scaling patches on her forearms, elbows, and lower legs. She is diagnosed with psoriasis vulgaris and the provider prescribes betamethasone cream (Diprosone). After 6 months of therapy, her psoriasis has not been responsive to betamethasone and she is prescribed calcipotriene (Dovonex). What effect does betamethasone have in the treatment of psoriasis? What teaching should the patient receive about this new prescription for calcipotriene?

Betamethasone is used to reduce the inflammation that occurs with psoriasis. Calcipotriene is a derivative of vitamin D that is applied topically to the skin to decrease cell turnover. It is applied in thin layers and is not recommended for use over large surface areas because hypocalcemia may result. Excessive sun exposure to the areas should be avoided while using calcipotriene, and it may take 2 to 3 weeks to see improvement. Because this woman is within child-bearing age, she should be taught to consult with the healthcare provider if she plans to be or is pregnant. The drug is pregnancy category C.

CH. 10 A 62-year-old male patient is recuperating from a myocardial infarction. He is on the anticoagulant warfarin (Coumadin) and antidysrhythmic digoxin (Lanoxin). He talks to his wife about starting to take garlic, to help lower his blood lipid levels, and ginseng, because he has heard it helps in coronary artery disease. Discuss the potential concerns about the use of garlic and ginseng by this patient.

Both garlic and ginseng have a potential drug interaction with the anticoagulant warfarin (Coumadin). It is known that ginseng is capable of inhibiting platelet activity. When taken in combination with an anticoagulant, these herbal products are capable of producing increased bleeding potential. The use of ginseng with digoxin (Lanoxin) may increase the risk of toxicity.

CH. 44 Brandon Folleck is a 17-year-old adolescent with a history of severe asthma who has been admitted to the intensive care unit. He is comatose, appears much younger than his listed age, and has short stature. The nurse notes that the asthma had been managed with prednisone for 15 days until 3 days ago. The patient's father is extremely anxious and says that he was unable to refill his son's prescription for medicine until he got his paycheck. 1. What is a potential cause of Brandon's condition? 2. As the nurse, what will you discuss with, or teach, the father?

Brandon has been on prednisone for 15 days and may be experiencing adrenal insufficiency. Abruptly discontinuing a corticosteroid after long-term therapy (more than 10 days) can produce cardiovascular collapse. Brandon's father is in emotional distress, and as the nurse, you should empathize with him and allow him to express his concerns. He may feel guilty about contributing to his son's current health crisis. Once the patient's condition begins to improve, you should assess the father's understanding of the asthma regimen. The father and the patient should receive instruction about the adverse effects of corticosteroid therapy and that the drug should not be discontinued abruptly. The father needs to be instructed about the dosage regimen for prednisone, which may include an incremental decrease in the dosage when discontinuing the drug. It would also be appropriate to respectfully assess for concerns the father has about the economic needs of his family. Referrals to a resource providing financial support for medication may be appropriate.

CH. 46 A 22-year-old patient has been taking ethinyl estradiol with drospirenone (Yasmin) but has just started penicillin for a recurrent throat infection. She asks the nurse if she should stop taking the Yasmin. What instructions should the nurse give to this patient?

Broad-spectrum antibiotics such as tetracyclines and penicillin can alter the effectiveness of OCs, resulting in an increased risk of pregnancy. The patient should not stop her use of Yasmin but should use additional precautions during intercourse such as condoms and spermicidal agents until she starts her next monthly cycle of pills.

CH. 46 Yolanda Clerik is 22 years old and has been taking estradiol and norethindrone (Ortho-Novum) for contraception. She has been seen by her healthcare provider today for a recurrent throat infection and has been given a prescription for penicillin. 1. As the nurse, what instructions will you give Yolanda about her new prescription and the effect it may have on her estradiol and norethindrone (Ortho-Novum)? 2. While Yolanda is in the office, what additional education will you give her to minimize the risk of adverse effects from her estradiol and norethindrone (Ortho-Novum)?

Broad-spectrum antibiotics such as tetracyclines and penicillin can alter the effectiveness of OCs, resulting in an increased risk of pregnancy. The patient should not stop using Ortho-Novum but should use additional precautions during intercourse, such as condoms and spermicidal agents, until she starts her next monthly cycle of pills. Each patient encounter provides the opportunity for a nurse to provide or reinforce education. As the nurse, you would evaluate Yolanda's understanding of her OC, assess for smoking, and provide education about smoking cessation programs if needed. You would also reinforce the need for her to immediately report any signs of thromboembolic conditions, such as dyspnea, chest pain, or blood in sputum (possible pulmonary embolism); a sensation of heaviness in the chest or chest pain, or overwhelming fatigue or weakness accompanied by nausea and diaphoresis (possible MI); sudden, severe headache, especially if associated with dizziness; difficulty with speech, numbness in the arm or leg, difficulty with vision (possible stroke); or warmth, redness, swelling, or tenderness in the calf or pain on walking (possible thrombophlebitis).

CH. 46 A 28-year-old woman has tried for over a year to become pregnant. Her husband has a 4-year-old child from a previous marriage and a physical workup suggests that clomiphene (Clomid) may be useful in promoting pregnancy. What information should be included in a teaching plan for a patient who is receiving this drug?

Clomiphene (Clomid) is used when lack of ovulation is a potential cause for infertility after mechanical causes have been ruled out (e.g., obstruction of the Fallopian tubes or pelvic inflammatory disease). Before administration of clomiphene the nurse would complete a medical history and physical examination. The pregnancy rate of persons taking this drug is about 80% and twins occur in about 5% of treated patients. She should discontinue the drug immediately if pregnancy is suspected.

CH. 50 A 3-year-old girl is playing nurse with her dolls. She picks up her mother's flexible metal necklace and places the tips of the necklace in her ears for her "stethoscope." A few hours later, she cries to her mother that her "ears hurt." The child's mother takes her to see the healthcare provider at an after-hours clinic. An examination reveals abrasions in the outer ear canal and some dried blood. The healthcare provider prescribes Cortisporin otic drops. What does the nurse need to teach the mother about instillation of this medication?

Cortisporin otic is a combination of neomycin, polymyxin B, and 1% hydrocortisone. The technique for instilling this drug applies to most eardrops. The nurse needs to instruct the mother to position her daughter in a side-lying position with the affected ear facing up. The mother needs to inspect the outer (visible) ear canal for the presence of drainage or cerumen and, if present, gently remove it with a cotton-tipped applicator. Any unusual odor or drainage could indicate a ruptured tympanic membrane and should be reported to the healthcare provider. Next, the mother should be taught to straighten the child's external ear canal by pulling down and back on the auricle to promote distribution of the medication to deeper external ear structures. After the drops are instilled, the mother can further promote medication distribution by gently pressing on the tragus of the ear. The mother should be taught to keep her daughter in a side-lying position for 3 to 5 minutes after the drops are instilled. If a cotton ball has been prescribed, it should be placed in the ear without applying pressure. The cotton ball can be removed in 15 minutes.

CH. 34 Genoa Brown, 43 years old, experienced chronic kidney disease secondary to polycystic kidney disease and underwent a kidney transplant 6 months ago. She has been taking cyclosporine (Neoral, Sandimmune) daily. 1. What is the purpose of the cyclosporine? 2. As the nurse, what three precautions will you review with Genoa concerning her cyclosporine treatment?

Cyclosporine (Neoral, Sandimmune) is a calcineurin inhibitor given for immunosuppressant effects. It is given to prevent transplant rejection, and in the treatment of psoriasis and exophthalmia, an eye condition of diminished tear production caused by ocular inflammation. An IV form is available for transplant rejection and for severe cases of ulcerative colitis or Crohn's disease. Cyclosporine is a medication with many serious adverse effects. Because the drug cannot be given with grapefruit juice due to a significant increase in serum drug level, you should review Genoa's diet and ask whether she eats grapefruit or drinks grapefruit juice. Non-juice flavored beverages are acceptable. Her kidney function will be assessed by laboratory tests (e.g., creatinine), and you would also ask her about her urine output because cyclosporine may reduce urine output and to assess her kidney function following the transplant. You would also review the need for vigilant observation for signs and symptoms of infection, such as low-grade fever or sore throat, and indicate that these should be reported promptly. Her WBC counts may remain normal because cyclosporine does not tend to cause bone marrow suppression.

CH. 47 Michael Galvin is a 68-year-old who has been diagnosed with BPH. He has been given a prescription for finasteride (Proscar), but he says that he has been hearing about the benefits of saw palmetto and is curious about it. 1. What is the action of finasteride (Proscar), and how will it be beneficial in treating Mr. Galvin's BPH? 2. How do the effects of saw palmetto compare to finasteride?

Finasteride (Proscar), an androgen inhibitor, is used to shrink the prostate and relieve symptoms associated with BPH. Finasteride inhibits 5-alpha reductase, an enzyme that converts testosterone to the potent androgen 5-alpha dihydrotestosterone (DHT). The prostate gland depends on this androgen for its development, but excessive levels can cause prostate cells to increase in size and divide. A regimen of 6 to 12 months may be necessary to determine Mr. Galvin's response. Saw palmetto is an herbal preparation derived from a shrub-like palm tree that is native to the southeastern United States. This herbal medication compares pharmacologically with finasteride in that it is an antiandrogen. The mechanism of action is virtually the same in these two agents. There have been no serious adverse effects noted with saw palmetto extract and no known drug-drug interactions. Just as with finasteride, long-term use is required.

CH. 45 Jorge Esperanza is a 35-year-old who has been on insulin therapy since he was diagnosed with type 1 diabetes at age 14. He had been taking twice daily doses of a combination of NPH and regular insulin. However, his healthcare provider has recently switched him to insulin glargine (Lantus) and regular insulin ordered for every morning. 1. How is insulin glargine (Lantus) different from other types of insulin? 2. As the nurse, how will you explain to Jorge the technique of administering these two types of insulin?

Insulin glargine (Lantus) is a modified form of insulin known as an insulin analog. It has a gradual onset of action (approximately one hour) and no peak but, rather, a constant duration of action of approximately 24 hours. It is often given at bedtime so that the hours of peak duration occur during waking hours and when food consumption occurs, although this differs by provider. As the nurse, you would check the order for a morning dose of this insulin. Lantus must not be mixed in the syringe with any other insulin and Jorge should be taught that he will require two injections as long as the regular insulin is required. Like regular insulin, Lantus must be administered subcutaneously.

CH. 11 Why would the medical community be opposed to the mass vaccination of the general public for potential bioterrorist threats such as anthrax and smallpox?

Mass vaccination of the general public for anthrax, smallpox, and other potential biohazardous infections is not recommended until issues of the safety and effectiveness of these vaccines have been resolved. With any vaccination, there is always the potential for serious adverse effects to occur related to the vaccinations given. Vaccinating when there has not been a public health emergency needlessly exposes the general public to these known adverse effects.

CH. 48 A woman calls the healthcare provider's office, worried about her 82-year-old mother, Basanthi Singh. Mrs. Singh had a stroke 6 years ago and requires help with most ADLs. Since her husband's death 18 months ago, she rarely leaves home. She has lost 11 kg (25 lb) because she "just can't get interested" in her meals. She has never liked milk and now refuses to drink milk or eat dairy products. Mrs. Singh's daughter has been prescribed bisphosphonates, and wonders if her mother should also be on them. 1. What risk factors does Mrs. Singh have for osteoporosis and hypocalcemia? 2. What other factors should be considered before making a recommendation for an appointment to discuss a bisphosphonate prescription?

Mrs. Singh is a frail older patient who is postmenopausal and with, potentially, a significantly limited calcium intake. Her diet may lack sufficient quantities of vitamin D, and she has decreased physical activity and lack of exposure to sunshine. Her daughter reports that Mrs. Singh is uninterested in eating, has physical limitations, and is not able to get out of the house into the sunshine without assistance. As the nurse, you would want to take a thorough dietary history, including whether any calcium and vitamin D supplements are used. You would also consider the physical limitations that Mrs. Singh has as a result of her stroke: Is she able to prepare her own meals, or does she have to rely on her daughter and others? Does she have favorite foods that are rich in the nutrients necessary? You may also consult with the healthcare provider about the need for depression screening for Mrs. Singh. Her lack of interest in her meals and remaining at home since her husband's death may indicate depression that is interfering with ADLs and nutrition. Mrs. Singh should be evaluated by the provider. Bisphosphonates may be required, but if other risk factors such as depression are present, additional treatment may be needed.

CH. 11 Why do nurses play such a central role in emergency preparedness and treatment of poisonings?

Nurses play a key role in preparing for an emergency of any kind, natural or human-made, by educating patients and their communities, serving as volunteers for emergency medical corps, and maintaining current knowledge of resources. Nurses also play a key role in the early detection of possible emergency conditions. Through educating their patients, families, and communities, they are also a primary source of information in the prevention of poisonings or for early treatment.

CH. 46 A nurse is assessing a 32-year-old postpartum patient and notes 2+ pitting edema of the ankles and pretibial area. The patient denies having "swelling" prior to delivery. The nurse reviews the patient's chart and notes that she was induced with oxytocin (Pitocin) over a 23-hour period. What is the relationship between this drug regimen and the patient's current presentation? What additional assessments should be made?

Oxytocin exerts an antidiuretic effect when administered in doses of 20 milliunits/min or greater. Urine output decreases, and fluid retention increases. Most patients begin to have a postpartum diuresis and are able to balance fluid volumes relatively quickly. However, the nurse should evaluate the patient for signs of excess fluid volume, which include drowsiness, listlessness, headache, and oliguria. The patient's breath sounds, blood pressure, and pulse should be carefully monitored for adverse effects related to excess fluid volume.

CH. 33 As the nurse in the neighborhood, your neighbors turn to you for medication advice. Carlos Alvera, your new next-door neighbor, is requesting advice for medication to take for occasional headache pain. He asks you about acetaminophen (Tylenol) because he knows that the drug is available OTC. 1. What advice will you provide Mr. Alvera about his choice of acetaminophen? 2. What additional information will you gather from Mr. Alvera that will be important to cover when teaching him about acetaminophen?

Patients sometimes consider OTC medications to be safer than prescription drugs. You would teach Mr. Alvera to take the recommended dose of acetaminophen (Tylenol) and not exceed the amount or frequency recommended. You should also caution him about the use of additional cough and cold medications because they often contain acetaminophen and may lead to an overdose. If an additional product is needed, he should read the labels and either choose one without acetaminophen, or stop taking his usual acetaminophen and take the cough-cold medication alone. You would also assess Mr. Alvera for a history of liver conditions such as hepatitis and discuss whether he drinks alcoholic beverages and the amount. Acetaminophen can be hepatotoxic and a history of liver disease may represent a contraindication to the use of the drug. Drinking more than two alcoholic beverages per day for men, one for women, increases the risk of hepatotoxicity from the acetaminophen, and another OTC medication may be preferable to the acetaminophen if the patient drinks more than the recommended limit.

CH. 49 Ryan Keogh is an 18-year-old high school student in his senior year and a catcher for the varsity baseball team. He has had acne for several years, but lately it has worsened. He has been using topical benzoyl peroxide but is becoming discouraged at the increase in breakouts. He feels it has started to affect his social life and his parents make an appointment for him with a dermatologist. The dermatologist diagnoses Ryan's skin condition as acne vulgaris and prescribes tretinoin (Retin-A). 1. What are some potential reasons why Ryan's acne outbreaks may have increased at this time? 2. As the nurse, what will you teach Ryan about the application of tretinoin and adverse effects that may occur?

Ryan's increase in acne at this time may be linked to rising androgen levels as he progresses through puberty. Because he is active in outdoor sports activities, the use of sunscreen, and sweat, dust, and dirt from athletic fields may be aggravating the condition. Ryan should wash his face gently with a mild soap and water, especially after participating in sports practices or games. He should apply a thin layer of the tretinoin to the acne areas, avoiding the eye area. He should discontinue any benzoyl peroxide or other topical drugs while he is using the tretinoin to avoid excessive dryness. Tretinoin often causes local skin effects such as redness, peeling, or a temporary hyperpigmentation. Ryan should limit sun exposure to the treated areas and should consult with his healthcare provider about the use of sunscreens.

CH. 34 A patient is taking sirolimus (Rapamune) following a liver transplant. On the most recent CBC, the nurse notes a marked 50% decrease in platelets and leukocytes. During the physical assessment, what signs and symptoms should the nurse look for? What are appropriate nursing interventions?

Sirolimus (Rapamune) is an immunosuppressant. The nurse should assess for any signs and symptoms of bleeding infection, such as an increase in bruising, pete-chiae, low-grade fever, or sore throat. The nurse may use the opportunity during the assessment to teach the patient about avoiding activities that may increase the risk of bleeding or infection.

CH. 10 The patient has been taking St. John's wort for symptoms of depression. He is now scheduled for an elective surgery. What important preoperative teaching should be included?

St. John's wort interacts with multiple drugs. It is important that the patient stop taking St. John's wort at least 3 weeks prior to the surgery because it can potentiate sedation when combined with CNS depressants and opiate analgesics. St. John's wort can also decrease the effects of anticoagulants.

CH. 11 What is the purpose of the Strategic National Stockpile (SNS)? What is the difference between a push package and a vendor-managed inventory (VMI) package? How might the nurse be called to assist with these supplies?

The Strategic National Stockpile (SNS) is designed to ensure immediate deployment of essential medical supplies to a community in the event of a large-scale chemical or biologic attack. Push packages of preassembled medical supplies and pharmaceuticals in the SNS are designed to meet the needs of an unknown biologic or chemical attack. They are strategically located around the United States, can be deployed rapidly, and can reach any affected community within 12 hours of an attack. Vendor-managed inventory (VMI) packages are shipped if necessary and require identification of the type of chemical or biologic attack. They contain supplies more specific to the type of attack and can reach an affected community within 24 to 36 hours. The nurse may be called upon to help distribute supplies to the appropriate healthcare treatment area or may be needed to use the supplies to treat injured patients.

CH. 34 A patient has been exposed to hepatitis A and has been referred for an injection of gamma globulin. The patient is hesitant to get a "shot" and says that his immune system is fine. How should the nurse respond?

The gamma globulin will act as a protective mechanism after exposure to hepatitis A. This drug does not stimulate the patient's own immune system but will help protect the patient from developing the disease through passive immunity. The nurse should work with the patient to determine strategies that will decrease his fear of the injection (e.g., ice or numbing cream to the area prior to giving the injection). The nurse should also teach the patient about hepatitis A, how it is transmitted, symptoms to observe for, and when to seek treatment.

CH. 33 The mother of a 7-year-old child calls the healthcare provider's office stating that her daughter has a temperature of 38.3°C (101°F). She states that the child is also complaining of being tired and "achy" all over. The mother asks how much aspirin she can give her daughter for her temperature. How should the nurse respond?

The nurse should educate the mother that aspirin and aspirin-containing products should not be given to children younger than age 18. These drugs have been associated with an increased risk of Reye's syndrome, a potentially fatal adverse reaction. Acetaminophen (Tylenol) is the antipyretic of choice for treating most fevers. The nurse should also question the mother regarding the length and severity of symptoms for possible referral to the healthcare provider.

CH. 45 A 28-year-old woman who is pregnant with her first child is diagnosed with gestational DM. She is concerned about the fact that she might have to take "shots." She tells the nurse at the public health clinic that she does not think she can self-administer an injection and asks if there is a pill that will control her blood sugar. She has heard her grandfather talk about his pills to control his "sugar." What should the nurse explain to this patient?

The nurse should explain that management of gestational diabetes includes appropriate dietary management, regular exercise, and home blood glucose monitoring. Based on her glucose levels, insulin may be required but not all patients require insulin throughout the entire pregnancy. Recent research suggests that some oral antidiabetic drugs may be used safely during pregnancy. Her obstetrician, healthcare provider, or endocrinologist will work with her to determine the most appropriate treatment. Should insulin injections be required, she will be given multiple opportunities for practice, and discomfort during an injection is usually minimal.

CH. 44 A 42-year-old mother of two children is assessed by her healthcare provider after complaining of extreme fatigue, weight gain, and feelings of cold regardless of room temperature. Based on laboratory studies, she is diagnosed with hypothyroidism and started on levothyroxine (Synthroid). What teaching will she need about this drug?

The patient should take the levothyroxine (Synthroid) in the morning on awakening and as close to the same time each morning as possible to mimic the body's own natural thyroid hormone rhythm. If she forgets to take a dose, she should take it as soon as she remembers it. If she is unable to take the drug for more than one day because of illness, she should contact the provider for further instructions. Because replacing a hormone exogenously does not precisely mimic the body's own hormone levels, there may be times when she experiences symptoms of hyperthyroidism or return of symptoms similar to the ones she experienced from hypothyroidism. Symptoms similar to what she experienced before do not need to be immediately reported to the provider unless they are significantly worse than previously experienced. If they continue for longer than a few days, she should inform the provider because a dosage adjustment may be required. Symptoms she should immediately report to her provider are those similar to hyperthyroidism. These include rapid heart rate, palpitations, headache, shortness of breath, anxiety, and intolerance to heat.

CH. 33 A 64-year-old patient with diabetes is on prednisone for rheumatoid arthritis. The patient has recently been admitted to the hospital for stabilization of hyperglycemia. What are the nurse's primary concerns when caring for this patient?

The primary current concern is the hyperglycemia—an adverse effect of the prednisone that can become serious when the patient has diabetes. Glucose levels should be monitored and a potential change in antidiabetes medication may be required while the patient is taking the prednisone. Blood pressure must be monitored for potential HTN, which is related to sodium and fluid retention, and the client is also at high risk for infection while on prednisone because of suppression of the immune system.

CH. 48 A 36-year-old man comes to the emergency department complaining of severe pain in the first joint of his right big toe. The triage nurse inspects the toe and notes that the joint is red, swollen, and extremely tender. Recognizing this as a typical presentation for acute gouty arthritis, what historical data should the nurse obtain relevant to this disease process?

The triage nurse should obtain information about the onset of symptoms, degree of discomfort, and frequency of attacks. A familial history of gout can be predictive because primary gout is inherited as an X-linked trait. A past medical history of renal calculi may also be predictive of acute gouty arthritis. The nurse should ask the patient questions about his diet and fluid intake. An attack of gout can be precipitated by alcohol intake (particularly beer and wine), starvation diets, and insufficient fluid intake. In addition, the nurse should obtain information about prescribed drugs and the use of OTC drugs containing salicylates. Thiazide diuretics and salicylates can precipitate an attack. The nurse should also ask about recent lifestyle events. Stress, illness, trauma, or strenuous exercise can precipitate an attack of gouty arthritis.

CH. 47 A 78-year-old widower has come to see his healthcare provider. The nurse practitioner interviews the patient about his past medical history and current health concerns. The patient states that he is planning to marry "a very nice lady" but is concerned about his sexual performance. He asks about a prescription for sildenafil (Viagra). What additional assessment data does the nurse need to collect given this patient's age?

This patient's age puts him at risk for a variety of health problems. Conditions such as kidney dysfunction may alter the manner in which sildenafil (Viagra) is metabolized or excreted, increasing the risk of adverse effects. The nurse should ensure that the history includes the following data: sexual dysfunction, cardiovascular disease and use of organic nitrates, severe hypotension, kidney or liver impairment, sexual history, and history of sexually transmitted infections.

CH. 49 A senior nursing student is participating in well-baby screenings at a public health clinic. While examining a 4-month-old infant, the student notes an extensive, confluent diaper rash. The baby's mother is upset and asks the student nurse about the use of OTC corticosteroid ointment and wonders how she should apply the cream. How should the student nurse respond?

To establish a rapport with the baby's mother, the nurse should first respond to the mother's anxiety. She should validate that the baby's condition is cause for concern and commend the mother for seeking medical guidance. The nursing student should recognize that the availability of OTC preparations may be a temptation to a young mother who only wants to see her infant more comfortable and relieved of symptoms. The use of topical corticosteroid ointments can be potentially harmful, especially for young children. Corticosteroids, when absorbed by the skin in large enough quantities over a long period, can result in adrenal suppression and skin atrophy. Children have an increased risk of toxicity from topically applied drugs because of their greater ratio of skin surface area to weight compared with that of adults. The healthcare provider at the public health clinic should assess this patient, and once a drug treatment modality is prescribed, the student nurse should make sure that the baby's mother understands the correct method of administering the drug.