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UWorld Pharmacology Nursing Test-Questions and Answers (Latest Update 2021).

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Pharmacology Nursing Test The community health nurse prepares a teaching plan for a client with latent tuberculosis who is prescribed oral isoniazid (INH). Which instructions should the nurse inclu... de? Select all that apply. Unordered Options Ordered Response 1. Avoid drinking alcohol 2. Expect body fluids to change color to red 3. Report yellowing of skin or sclera 4. Report numbness and tingling of extremities 5. Take with aluminum hydroxide to prevent gastric irritation Explanation Isoniazid (INH) is a first-line antitubercular drug prescribed as monotherapy to treat latent tuberculosis infection. Combined with other drugs, INH is also used for active tuberculosis treatment. Two serious adverse effects of INH use are hepatotoxicity and peripheral neuropathy. A teaching plan for a client prescribed INH includes the following: • Avoid intake of alcohol and limit use of other hepatotoxic agents (eg, acetaminophen) to reduce risk of hepatotoxicity (Option 1) • Take pyridoxine (vitamin B6) if prescribed to prevent neuropathy • Avoid aluminum-containing antacids (eg, aluminum hydroxide (Maalox)) within 1 hour of taking INH • Report changes in vision (eg, blurred vision, vision loss) • Report signs/symptoms of severe adverse effects such as: o Hepatoxicity (eg, scleral and skin jaundice, vomiting, dark urine, fatigue) (Option 3) o Peripheral neuropathy (eg, numbness, tingling of extremities) (Options 4) (Option 2) Rifampin, another antitubercular drug, often causes a red-orange discoloration of body fluids (ie, urine, sweat, saliva, tears). However, this effect is not associated with INH use. (Option 5) Concurrent use of antacids containing aluminum decreases INH absorption. The medication may be taken with food if gastric irritation is a concern. Educational objective: Common potential side effects of INH include hepatotoxicity (eg, jaundice, vomiting, dark urine, fatigue) and peripheral neuropathy (eg, numbness, tingling of extremities). Clients should avoid alcohol use and aluminum-containing antacids, and report any experienced side effects to the health care provider immediately. In which scenarios should the nurse hold the prescribed medication and question its administration? Select all that apply. Unordered Options Ordered Response 1. Client on IV heparin and the platelet count is 50,000/mm3 (50 x 109/L) 2. Client on newly prescribed lisinopril and is at 8 weeks gestation 3. Client on nitroglycerine patch for heart failure and blood pressure is 84/56 mm Hg 4. Client on phenytoin for epilepsy and the nurse notes gingival hyperplasia 5. Client on warfarin and prothrombin time/International Normalized Ratio is 1.5 times control value Explanation Heparin is a natural anticoagulant. Its risk is heparin-induced thrombocytopenia (HIT), also known as heparin-associated thrombocytopenia. Normal platelet range is 150,000-400,000/mm3 (150-400 x 109/L). A mild lowering of platelets may occur and resolve spontaneously around the 4th day of administration. The danger is type II HIT, a more severe form in which there is an acute drop in the number of platelets (more than 50% from baseline), which requires discontinuing heparin (Option 1). Angiotensin-converting enzyme (ACE) inhibitors such as lisinopril are teratogenic. Lisinopril can cause embryonic/fetal developmental abnormalities (cardiovascular and central nervous system) if taken during pregnancy, especially during the first 13 weeks of gestation. During the 2nd and 3rd trimesters, ACE inhibitors interfere with fetal renal hemodynamics, resulting in low fetal urine output (oligohydramnios) and fetal growth restriction (Option 2). Nitroglycerine causes vasodilation and can lower blood pressure. Systolic blood pressure should be >90 mm Hg to ensure renal perfusion (Option 3). (Option 4) Gingival hyperplasia or hypertrophy is a known side effect of phenytoin (Dilantin) and is not a reason to stop the drug. Vigorous dental hygiene beginning within 10 days of initiation of phenytoin therapy can help control it. Signs and symptoms that require discontinuation include toxic levels or phenytoin hypersensitivity syndrome (fever, skin rash, and lymphadenopathy). A client with gout who was started on allopurinol a week ago calls the health care provider's (HCP's) office with several concerns. The nurse should recognize which report by the client as being significant and requiring immediate follow-up? Unordered Options Ordered Response 1. Also takes ibuprofen for pain 2. Frequency of urination has increased 3. Mild red rash has developed over torso 4. Nausea occurs after each dose Explanation Allopurinol is a medication frequently used in the prevention of gout. Gout is a buildup of uric acid deposited in the joints that causes pain and inflammation. The medication helps to prevent uric acid deposits in the joints and the formation of uric acid kidney stones. Any rash in a client taking allopurinol, even if mild, should be reported immediately to the HCP. The nurse should direct the client to stop taking the medication immediately, schedule an appointment, and notify the HCP. A rash caused by allopurinol may be followed by more severe hypersensitivity reactions that can be fatal, including Stevens-Johnson syndrome and toxic epidermal necrolysis. (Option 1) Allopurinol can take several months to become effective. Its primary use is to prevent gout attacks; it is not effective in treating acute attacks. The client will need to continue to take anti-inflammatory drugs (eg, nonsteroidal anti-inflammatory drugs or colchicine) for acute attacks. (Option 2) Clients are directed to take allopurinol with a full glass of water and to increase daily fluid intake to prevent kidney stones. This will cause an increase in urination and is an expected outcome. (Option 4) Nausea can be prevented by instructing the client to take the medication with food or following a meal. Educational objective: The nurse should direct the client taking allopurinol for gout to immediately discontinue the medication and report to the HCP if any rash develops. Allopurinol-induced rashes can develop into severe and sometimes fatal hypersensitivity reactions, such as Stevens-Johnson syndrome. Similar instructions should be given to clients taking anticonvulsants (eg, carbamazepine, phenytoin, lamotrigine) and sulfa antibiotics. A client diagnosed with trichomonal vaginal infection (trichomoniasis) is prescribed metronidazole. Which of the following is essential for the nurse to teach? Select all that apply. Unordered Options Ordered Response 1. Avoid alcohol while taking this medication 2. Perform vaginal douche for 7-10 days 3. Use birth control pills to prevent recurrence of infection 4. Your partner(s) must be treated simultaneously 5. Your urine can change to a deep red-brown color Explanation Trichomoniasis is a sexually transmitted infection (STI). Many women with trichomoniasis are asymptomatic but can have profuse frothy gray or yellow-green vaginal discharge with a fishy odor. Small red lesions (strawberry) may be present in the vagina or cervix. Pruritus is common. Metronidazole (Flagyl) is the initial drug of choice. Clients should avoid alcohol while taking metronidazole and for 24 hours after completion of the therapy due to a reaction that includes flushing, nausea/vomiting, and abdominal pain. The medication can cause a metallic taste and turn the urine a deep red-brown color. It is essential to treat the partner(s) at the same time to avoid reinfection. Clients should abstain from sexual intercourse until the infection is cleared, usually about 1 week after treatment. (Option 2) Routine vaginal douching (with a mixture of water and vinegar) is not recommended as it increases the risk of infections such as bacterial vaginosis. (Option 3) Birth control pills do not protect against transmission of STIs. The use of condoms can help prevent the spread of infection. Educational objective: Trichomoniasis is an STI. Expected symptoms include yellow-green, frothy discharge with a fishy odor and an accompanying itch. Metronidazole is the initial drug of choice. Clients should avoid alcohol while on metronidazole, which can make the urine darker and cause a metallic taste. Partners must be treated simultaneously. A male client with hypertension was prescribed amlodipine. Which of these adverse effects is most important to teach the client to watch for? Unordered Options Ordered Response 1. Erectile dysfunction 2. Dizziness 3. Dry cough 4. Leg edema Explanation Calcium channel blockers (nifedipine, amlodipine, felodipine, nicardipine) are vasodilators used to treat hypertension and chronic stable angina. They promote relaxation of vascular smooth muscles leading to decreased systemic vascular resistance and arterial blood pressure. The most important adverse effects of calcium channel blockers include dizziness (Option 2), flushing, headache, peripheral edema (Option 4), and constipation. The reduced blood pressure may initially cause orthostatic hypotension. The client should be taught to change positions slowly to prevent falls. Leg elevation and compression can help to reduce the edema. Constipation should be prevented with daily exercise and increased intake of fluids, fruits/vegetables, and high-fiber foods. (Option 3) Angiotensin-converting enzyme (ACE) inhibitors prevent the breakdown of bradykinin, which may produce a nonproductive cough in susceptible individuals. Discontinuation of the medication stops the cough. (Option 1) Adverse effects of beta-blockers include bradycardia, bronchospasm, depression, and decreased libido with erectile dysfunction. Educational objective: Calcium channel blockers are utilized to treat hypertension and chronic stable angina. Adverse effects of these medications include dizziness, flushing, headache, peripheral edema, and constipation. During shift report it was noted that the off-going nurse had given the client a PRN dose of morphine 2 mg every 2 hours for incisional pain. What current client assessment would most likely affect the oncoming nurse's decision to discontinue the administration every 2 hours? Unordered Options Ordered Response 1. Client reports burning during injection into the IV line 2. Client reports dizziness when getting up to use the bathroom 3. Client's blood pressure is 106/68 mm Hg 4. Client's respiratory rate is 11/min Explanation Morphine is an opioid analgesic that can be given intravenously for moderate to severe pain. An adverse reaction to morphine administration is respiratory depression. A respiratory rate <12/min would be a reason to hold morphine administration. The nurse should perform a more in-depth assessment of the client's pain and causes. The morphine dose may need to be decreased or the time between administrations may need to be increased. The nurse should not administer additional doses until the respiratory rate increases. (Option 1) Morphine can cause burning during IV administration. This can be reduced by diluting the morphine with normal saline and administering it slowly over 4-5 minutes. (Option 2) The nurse should instruct the client to call for help before getting up to go to use the bathroom to avoid falls caused by dizziness from the morphine. (Option 3) Morphine can lower blood pressure, and clients receiving it should have blood pressure monitored. This blood pressure reading is not severely low and is not a priority over the respiratory depression. Educational objective: Morphine administration can cause respiratory depression. The nurse should hold a dose of morphine for a client whose respiratory rate is <12/min. A client with deep vein thrombosis (DVT) is receiving a continuous infusion of unfractionated heparin. The client asks the nurse what the heparin is for. How should the nurse respond? Unordered Options Ordered Response 1. "Heparin is a blood thinner that will help to dissolve the clot in your leg." 2. "Heparin will help stabilize the clot in your leg and prevent it from breaking off and traveling to your lungs." 3. "Heparin will keep the current clot from getting bigger and help prevent new clots from forming." 4. "I'm sorry. This is something that your health care provider (HCP) can answer better upon arriving." Explanation Venous thrombosis involves the formation of a thrombus (clot) and the inflammation of the vein. Anticoagulant therapy such as heparin does not dissolve the clot. The clot will be broken down by the body's intrinsic fibrinolytic system over time. The heparin slows the time it takes blood to clot, thereby keeping the current clot from growing bigger and preventing new clots from forming. (Option 1) Anticoagulants do not dissolve clots. Thrombolytic agents (fibrinolytics), such as tissue plasminogen activator (tPA), are used to break the clots, but they also carry the risk of serious intracranial hemorrhage and are used only for acute life-/organ- threatening conditions. The body will break down the clot over a period of time. (Option 2) Heparin does not prevent the clot from breaking off but will deter the clot from growing larger. (Option 4) The nurse should be able to answer client questions regarding medications being administered. The HCP can answer any further questions the client may have. Educational objective: The nurse should teach the client that the purpose of unfractionated heparin infusion in the treatment of DVT is to slow the time it takes blood to clot, thereby keeping the current clot from getting bigger and preventing new clots from forming. An elderly client is prescribed codeine for a severe cough. The home health nurse teaches the client how to prevent the common adverse effects associated with codeine. Which client statements indicate an understanding of how to prevent them? Select all that apply. Unordered Options Ordered Response 1. "I'll be sure to apply sunscreen if I go outside." 2. "I'll drink at least 8 glasses of water a day." 3. "I'll drink decaffeinated coffee so I can sleep at night." 4. "I'll sit on the side of my bed for a few minutes before getting up." 5. "I'll take my medicine with food." Explanation Codeine is an opioid drug prescribed as an analgesic to treat mild to moderate pain and as an antitussive to suppress the cough reflex. Although the antitussive dose (10- 20 mg orally every 4-6 hours) is lower than the analgesic dose, clients can still experience the common adverse effects (eg, constipation, nausea, vomiting, orthostatic hypotension, dizziness) associated with the drug. Codeine decreases gastric motility, resulting in constipation. Increasing fluid intake and fiber in the diet and taking laxatives are effective measures to prevent constipation (Option 2). Changing position slowly is effective in preventing the orthostatic hypotension associated with codeine, especially in the elderly (Option 4). Taking the medication with food is effective in preventing the gastrointestinal irritation (eg, nausea, vomiting) associated with codeine (Option 5). (Options 1 and 3) These statements are inaccurate as photosensitivity, insomnia, palpitations, and anxiety are not adverse effects associated with codeine. Educational objective: The common adverse effects of codeine, an opioid drug, include constipation, nausea, vomiting, orthostatic hypotension, and dizziness. Interventions to help prevent them include increasing fluid intake and bulk in the diet, laxatives, taking the medication with food, and changing position slowly. A client is being discharged after having a stent placed in the left anterior descending coronary artery. The client is prescribed clopidogrel. Which client data obtained by the nurse would be concerning in relation to this new medication? Select all that apply. Unordered Options Ordered Response 1. Blood pressure of 140/84 mm Hg 2. Heart rate of 98/min 3. Platelet count of 200,000/mm3 4. Report of Ginkgo biloba use 5. Report of peptic ulcer disease Explanation Antiplatelet agents (eg, clopidogrel, ticagrelor, or prasugrel) prevent platelet aggregation and are given to clients to prevent stent re-occlusion. They prolong bleeding time and should not be taken by clients with a bleeding peptic ulcer, active bleeding, or intracranial hemorrhage. Ginkgo biloba also interferes with platelet aggregation and can cause increased bleeding time. Antiplatelet agents and Ginkgo biloba should not be taken together. If this were to occur, this client would be at an increased risk for bleeding. This information should be reported to the prescribing health care provider (HCP) before the client is discharged. (Option 1) This blood pressure is slightly elevated, but is unaffected by antiplatelet agents. (Option 2) Normal heart rate is between 60/min-100/min. (Option 3) This is a normal platelet count (150,000/mm3-400,000/mm3). Educational objective: If a client is prescribed clopidogrel, the nurse should be concerned about a history of peptic ulcer disease and Ginkgo biloba use. In this situation, the client would be at increased risk for bleeding. This data should be reported to the prescribing HCP before the client is discharged. A client with a history of degenerative arthritis is being discharged home following exacerbation of chronic obstructive pulmonary disease (COPD). After reviewing the discharge medications, the nurse should educate the client about which topics? Select all that apply. Click on the exhibit button for additional information. Unordered Options Ordered Response 1. Dryness of the mouth and throat may occur 2. Notify the health care provider (HCP) if stools are black and tarry 3. Ringing in the ears may occur 4. The albuterol canister should not be shaken before use 5. Tiotropium capsules should not be swallowed Explanation A common side effect of tiotropium (Spiriva) and other anticholinergics (eg, ipratropium, benztropine) is xerostomia (dry mouth) due to the blockade of muscarinic receptors of the salivary glands that inhibits salivation. Sugar-free candies or gum may be used to alleviate dry mouth and throat (Option 1). Tiotropium capsules should not be swallowed. These capsules are placed inside the inhaler device and the capsule is pierced, allowing the client to inhale its contents (Option 5). Glucocorticoids such as prednisone, taken in combination with aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs), can increase the risk of gastrointestinal (GI) ulceration and bleeding. The client should report the presence of black, tarry stools (melena) to the HCP as this could indicate GI bleeding (Option 2). (Option 3) Ringing in the ears is more commonly seen with salicylates such as aspirin. (Option 4) The albuterol canister should be shaken prior to inhalation. Educational objective: The nurse should teach the client who has been prescribed glucocorticoids in combination with aspirin or NSAIDs about the potential risk for GI bleeding or ulceration. Xerostomia is a common side effect of anticholinergic drugs and can be alleviated with sugar-free gum or candies. Discharge medications Albuterol: 2 puffs, every 4-6 hours as needed Prednisone: 40 mg orally, daily Naproxen: 220 mg orally, twice daily Tiotropium: 1 capsule inhaled, daily A client has nausea, abdominal cramping, and persistent mucus-like, watery diarrhea that is positive for Clostridium difficile. The nurse anticipates the client will be prescribed which medication to treat this condition? Unordered Options Ordered Response 1. Ceftriaxone 2. Fluconazole 3. Metronidazole 4. Pantoprazole Explanation C difficile is often associated with antibiotic therapy but can also be a nosocomial hospital-acquired infection. Antibiotics, especially broad-spectrum, reduce normal bacteria in the body. This allows other bacteria, such as C difficile, to take over and cause a superinfection. It grows in the intestinal tract and causes antibiotic-associated diarrhea. Metronidazole (Flagyl) is an anti-infective drug commonly used to treat C difficile. For severe C difficile infection, oral vancomycin may be used; intravenous vancomycin is ineffective. (Option 1) Ceftriaxone (Rocephin) is a cephalosporin antibiotic; its use could cause C difficile infection. (Option 2) Fluconazole (Diflucan) is a broad-spectrum antifungal agent; it is not indicated to treat C difficile. (Option 4) Pantoprazole (Protonix) is a proton pump inhibitor agent; its use has been associated with development of C difficile infection. Educational objective: Antibiotics reduce normal bacteria in the body, allowing other bacteria or fungi, such as C difficile, to take over. C difficile is a toxin-producing microorganism that grows in the intestinal tract and causes antibiotic-associated diarrhea. Metronidazole (Flagyl) and oral vancomycin are commonly used to treat this condition. A client is receiving lithium carbonate 900 mg/day for a schizoaffective disorder. The laboratory notifies the nurse that the client's lithium level is 1.0 mEq/L (1.0 mmol/L). Based on this result, which prescription does the nurse anticipate receiving from the health care provider? Unordered Options Ordered Response 1. Continue at the current dosage 2. Decrease the dosage 3. Discontinue the medication 4. Increase the dosage Explanation Lithium carbonate is used as a mood stabilizer in clients with schizoaffective disorder (combination of schizophrenia and a mood disorder) and bipolar disorders. Lithium has a very narrow therapeutic index (0.6-1.2 mEq/L [0.6-1.2 mmol/L]); levels >1.5 mEq/L (1.5 mmol/L) are considered toxic. Lithium toxicity can be acute (eg, ingesting a bottle of lithium tablets in a suicide attempt) or chronic (eg, slow accumulation due to decreased renal function or drug-drug interactions). Acute or acute-on-chronic toxicity presents predominantly with gastrointestinal symptoms (eg, nausea, vomiting, diarrhea); neurologic manifestations occur later. However, neurologic manifestations occur early in chronic toxicity. Common neurologic manifestations include ataxia, confusion, or agitation, and neuromuscular excitability (eg, tremor, myoclonic jerks). Chronic toxicity also manifests as diabetes insipidus (eg, polyuria, polydipsia). (Options 2, 3, and 4) No dose adjustment is needed as this client's lithium level is therapeutic. Educational objective: Lithium levels should be checked frequently given the narrow therapeutic index (0.6-1.2 mEq/L [0.6-1.2 mmol/L]). A level >1.5 mEq/L (1.5 mmol/L) is considered toxic. Chronic toxicity manifests with neurologic symptoms (eg, confusion, tremor, ataxia) and/or diabetes insipidus (eg, polyuria, polydipsia). The health care provider (HCP) has prescribed spironolactone to be given in addition to hydrochlorothiazide to a client with hypertension. Which finding by the nurse would indicate that the new medication is having the desired effect? Unordered Options Ordered Response 1. Blood glucose of 95 mg/dL 2. Potassium level of 4.2 mEq/L 3. Reduction in dizziness 4. Sodium level of 138 mEq/L Explanation Spironolactone, amiloride, triamterene, and eplerenone are potassium-sparing diuretics. In general, these are very weak diuretics and antihypertensives and are used mainly in combination with thiazide diuretics to reduce potassium (K+) loss. The K+ level of 4.2 mEq/L would indicate that this medication has been effective in preventing hypokalemia in a client receiving a thiazide diuretic such as hydrochlorothiazide or chlorthalidone. (Option 1) Blood glucose levels can be increased by thiazide diuretics but are not affected by potassium-sparing diuretics. (Option 3) All diuretics, including spironolactone, have the potential to cause dizziness. (Option 4) Potassium-sparing diuretics exchange sodium for potassium in the kidneys; potassium is saved but sodium is lost. Therefore, a normal sodium level is not a desired side effect. Educational objective: Potassium-sparing diuretics (eg, spironolactone, amiloride, triamterene, eplerenone) are often combined with thiazide diuretics to reduce potassium loss during hypertension treatment. A child with cystic fibrosis is to receive a dose of pancrelipase at 12:00 PM. The client states that he is not hungry and will eat his lunch in an hour. Which action is appropriate for the nurse to take? Unordered Options Ordered Response 1. Administer the prescribed pancrelipase 2. Hold the pancrelipase until the client eats 3. Notify the health care provider 4. Skip this dose of the pancrelipase Explanation Cystic fibrosis affects the pancreatic excretion of digestive enzymes. Without these enzymes, the client is unable to absorb fats, starches, and some proteins from the diet. Pancrelipase provides these enzymes to the client and must be given with every snack and meal so that the client can digest and absorb the nutrients eaten. If the client is not eating when the medication is scheduled, there are no nutrients to digest. Therefore, the dose should be held until the client eats. Educational objective: Pancrelipase is a medication containing lipase, protease, and amylase. In cystic fibrosis, the client's pancreas does not excrete these necessary enzymes. To prevent malabsorption syndrome, the enzymes must be taken with every snack and every meal. A client with stable chronic obstructive pulmonary disease (COPD) has been prescribed extended-release oral theophylline for the past 2 years. The nurse reviews the serum laboratory results. Which value would the nurse report to the health care provider immediately? Unordered Options Ordered Response 1. Theophylline level 23.6 mcg/mL 2. Theophylline level 10.4 mcg/mL 3. Theophylline level 15.3 mcg/mL 4. Theophylline level 18.0 mcg/mL Explanation Theo-24 (theophylline) is a long-acting, slow-release methylxanthine bronchodilator that relaxes bronchial smooth muscles, improves contractility of the diaphragm, and facilitates mucus transport by the cilia. Methylxanthines (eg, aminophylline, theophylline) are sometimes administered in addition to first-line drugs (eg, beta agonists, anticholinergics, corticosteroids) to prevent and treat reversible bronchospasm in clients with long-standing COPD. Theophylline has a narrow therapeutic index, and toxicity can occur from accumulation by reduced clearance or decreased metabolism. Medications, diet, underlying disease, and smoking can affect plasma theophylline clearance. To provide the desired effect of the drug and limit side effects, serum theophylline levels are monitored periodically (every 6 months) to maintain a target blood level of 10–20 mcg/mL. In some cases, symptom management may be attained at a lower target range (8–15 mcg/mL). (Options 2, 3, and 4) All values are within the normal adult target range (10–20 mcg/mL). Educational objective: Theophylline relaxes bronchial smooth muscles, improves contractility of the diaphragm, and facilitates mucus transport by the cilia in clients with COPD. However, due to its narrow therapeutic index, theophylline levels are monitored periodically to maintain a target blood level of 10–20 mcg/mL. The nurse is preparing to administer medications to a client admitted with atrial fibrillation. The nurse notes the vital signs shown in the exhibit. Which medications due at this time are safe to administer? Select all that apply. Click on the exhibit button for additional information. Unordered Options Ordered Response 1. Albuterol inhaler 2. Diltiazem extended-release PO 3. Heparin subcutaneous injection 4. Lisinopril PO 5. Metoprolol PO 6. Timolol eye drops Explanation Clients with atrial fibrillation can have either bradycardia (slow ventricular response) or tachycardia (rapid ventricular response). This client's vital signs are significant for bradycardia (heart rate <60/min). Therefore, the medications that can decrease heart rate should be held and the health care provider (HCP) should be notified. The reason for holding the medication (heart rate 46/min) and an HCP contact note should be documented. Albuterol, a short-acting beta-adrenergic inhaler to control asthma, can increase the heart rate and is a safe choice (Option 1). Heparin is an anticoagulant; the subcutaneous injection is most commonly used to prevent deep venous thrombosis in hospitalized clients on bed rest. This medication will not affect the vital signs and so is also safe to administer (Option 3). Lisinopril, an ACE inhibitor, does not lower the heart rate and is not contraindicated in clients with bradycardia (Option 4). This client's blood pressure is considered normal and lisinopril is safe to administer. Withholding this medication could cause rebound hypertension. (Option 2) Diltiazem is a calcium channel blocker that can decrease the heart rate and so should be held. Verapamil, another calcium channel blocker, can also cause bradycardia. (Options 5 and 6) This client is on 2 beta blockers, oral metoprolol and timolol eye drops that can be absorbed systemically. All beta blockers can further decrease the heart rate and should be held until the prescriptions can be clarified by the HCP. Educational objective: Medications that decrease the heart rate should be held in clients with bradycardia. These include beta blockers such as metoprolol (including eye drops) and some types of calcium channel blockers (eg, diltiazem, verapamil). Vital signs Temperature 98.4 F (36.9 C) Blood pressure 116/70 mm Hg Heart rate 46/min and irregularly irregular Respirations 22/min The nurse admits a client to the unit who reports taking high doses of aspirin to ease the pain of chronic headaches. The nurse should monitor for which adverse effects? Select all that apply. Unordered Options Ordered Response 1. Black tarry stools 2. Bradycardia 3. Bruising 4. Hypertension 5. Ringing in the ears Explanation Aspirin is a nonsteroidal anti-inflammatory drug (NSAID). NSAIDs can cause gastrointestinal (GI) bleeding by decreasing the production of prostaglandins, which protect the lining of the stomach and intestines from digestive acids. NSAIDs (especially aspirin) also decrease platelet aggregation and thereby inhibit blood clotting. Coffee-ground emesis and black tarry stools (melena) are signs of GI bleeding. Bruising can occur due to the decreased platelet aggregation. Tinnitus (ringing in the ears) is the earliest sign of aspirin toxicity. (Options 2 and 4) An NSAID overdose will cause tachycardia (not bradycardia) and hypotension (not hypertension). However, tachycardia and hypotension occur later, secondary to blood loss and dehydration due to nausea and vomiting (common side effects). Educational objective: Aspirin and other NSAIDs inhibit platelet aggregation, resulting in GI bleeding complications. They also promote development of gastric ulcers with long-term use. Tinnitus (ringing in the ears) is the earliest sign of aspirin toxicity. The parent of a child diagnosed with attention-deficit hyperactivity disorder (ADHD), predominantly inattentive type, says to the nurse, "I hate the idea of my child taking a drug that's a stimulant. How will I know that the methylphenidate is even working?" Which is the best response by the nurse? Unordered Options Ordered Response 1. "Methylphenidate is generally a safe and effective drug for children with ADHD." 2. "Methylphenidate will increase the levels of neurotransmitters in your child's brain." 3. "You should see your child's school grades improve." 4. "Your child should be able to more easily complete school assignments and other tasks." Explanation Although methylphenidate (eg, Ritalin, Concerta) is classified as a stimulant, in children with ADHD it improves attention, decreases distractibility, helps maintain focus on an activity, and improves listening skills. For many years, the effects of methylphenidate in children were labeled as paradoxical. Now, research has shown that methylphenidate significantly increases levels of dopamine in the central nervous system (CNS) that lead to stimulation of the inhibitory system of the CNS. Methylphenidate works quickly; symptom relief is often seen after the first dose. (Option 1) This is a true statement; methylphenidate is generally safe for most children, adolescents, and adults. Methylphenidate can cause adverse reactions, but these affect a very small percentage of users. However, this response does not address the parent's question about how the drug works. (Option 2) This is a true statement but does not give the parent information about the benefits of methylphenidate. In addition, it contains language that most clients would not understand. (Option 3) A child's school grades may improve due to the benefits of methylphenidate. This would be seen over time as a secondary benefit; the immediate therapeutic effects are often observed with the first dose. Educational objective: The therapeutic effects of methylphenidate can be observed very quickly in children with ADHD. Methylphenidate improves attention, decreases distractibility, helps maintain focus on an activity, and improves listening skills. A client has just been prescribed allopurinol for chronic gout. Which instruction is most important for the nurse to emphasize to the client? Unordered Options Ordered Response 1. Report for periodic laboratory tests for kidney, liver, and blood functions 2. Store the medication in a cool, dry place away from direct heat and light 3. Take the medication after a meal to prevent gastric distress 4. Take the medication with a full glass of water and increase fluids during the day Explanation Allopurinol is prescribed to prevent gout attacks (pain and inflammation in joints caused by uric acid deposits). It inhibits uric acid production and improves solubility. Allopurinol should be taken with a full glass of water, and it is very important for the nurse to educate the client about fluid intake with this medication. The client should also increase daily fluid intake as this will help prevent the formation of renal stones and promote diuresis (increase drug and uric acid excretion). (Option 1) Biosynthesis of uric acid occurs in the liver, and antigout medications are excreted via the kidneys; therefore, liver and renal function should be checked periodically. In addition, blood counts should be monitored as some antigout medications can cause blood dyscrasias. This is important but does not have priority over the daily need for increased fluids. (Option 2) This is a common instruction given about the storage of many medications. It helps to ensure potency of the medication and prevent deterioration. (Option 3) Taking allopurinol with food or after a meal can help to prevent gastric upset. Educational objective: It is important for the nurse to educate the client taking allopurinol about drinking a full glass of water with each dose and increasing overall fluid intake. Increased fluids help to prevent renal stones and promote diuresis and uric acid excretion. A client with uncontrolled hypertension is prescribed clonidine. What instruction is most important for the clinic nurse to give this client? Unordered Options Ordered Response 1. Avoid consuming high-sodium foods 2. Change positions slowly to prevent dizziness 3. Don't stop taking this medication abruptly 4. Use an oral moisturizer to relieve dry mouth Explanation Central-acting alpha2 agonists (eg, clonidine, methyldopa) decrease the sympathetic response from the brainstem to the peripheral vessels, resulting in decreased peripheral vascular resistance and vasodilation. Clonidine is a highly potent antihypertensive. Abrupt discontinuation (including the patch) can result in serious rebound hypertension due to the rapid surge of catecholamine secretion that was suppressed during therapy. Clonidine should be tapered over 2-4 days. Abrupt withdrawal of beta blockers can also result in rebound hypertension and in precipitation of angina, myocardial infarction, or sudden death. (Option 1) Avoiding high-sodium foods is important for blood pressure control but is not the most important advice for this client as consumption of these is not immediately life- threatening. (Option 2) Dizziness is a side effect of clonidine. The nurse should teach the client to change positions slowly and sit for a few minutes before rising to prevent falls. Drowsiness is also quite common with clonidine. Clients should not use it with alcohol or central nervous system depressants. However, dizziness and drowsiness should diminish with continued use of the medication. (Option 4) Dry mouth is a side effect of clonidine. Use of over-the-counter mouth moisturizers, chewing gum, or hard candy may be helpful for clients with dry mouth. Educational objective: Clonidine is a very potent antihypertensive. Abrupt discontinuation can result in serious rebound hypertensive crisis. Other common side effects of clonidine include dizziness, drowsiness, and dry mouth (the 3 Ds). Beta blockers, another class of blood pressure medications, can result in withdrawal symptoms if discontinued suddenly. A client is in the cardiovascular clinic for a 3-month follow-up visit. At the first visit, the client was prescribed hydrochlorothiazide and amlodipine for hypertension. Which statement by the client would be concerning to the nurse and should be reported to the primary health care provider (PHCP)? Unordered Options Ordered Response 1. "I like to have a banana every morning with my breakfast." 2. "I occasionally experience slight dizziness when I get up in the morning." 3. "I started taking licorice root for my occasional heartburn." 4. "I usually take my hydrochlorothiazide first thing in the morning." Explanation Licorice root is an herbal remedy sometimes used for gastrointestinal disorders such as stomach ulcers, heartburn, colitis, and chronic gastritis. Clients with heart disease or hypertension should be cautious about using licorice root. When used in combination with a diuretic such as hydrochlorothiazide, it can increase potassium loss, leading to hypokalemia. Hypokalemia can cause dangerous cardiac dysrhythmias. Thiazide diuretics are considered "potassium-wasting" diuretics, so this client is already at risk for hypokalemia. The addition of licorice root could potentiate the potassium loss. The nurse should discourage the client from using this herbal remedy and report the client's use to the PHCP. (Option 1) Bananas are rich in potassium. Eating one each morning is beneficial. (Option 2) Diuretics and calcium channel blockers (eg, nifedipine, amlodipine, felodipine) commonly cause postural hypotension or dizziness on rising. The nurse should encourage the client to rise slowly and sit on the side of the bed for a few minutes before getting up. Persistent dizziness should be reported to the PHCP. (Option 4) Diuretics should be taken in the morning as nighttime dosing will cause nocturia and interrupted sleep. Educational objective: The nurse should discourage the client from using the herbal remedy licorice root when taking thiazide diuretics. Licorice root can potentiate potassium loss and increase the client's risk for hypokalemia. Use of licorice root should be reported to the PCHP. The home health nurse prepares to give benztropine to a 70-year-old client with Parkinson disease. Which client statement is most concerning and would warrant health care provider notification? Unordered Options Ordered Response 1. "I am going for repeat testing to confirm glaucoma." 2. "I am not able to exercise as much as I used to." 3. "I started taking esomeprazole for heartburn." 4. "My bowel movements are not regular." Explanation Parkinson disease (PD) is a progressive neurological disorder characterized by bradykinesia (loss of autonomic movements), rigidity, and tremors. Clients with PD have an imbalance between dopamine and acetylcholine in which dopamine is not produced in high enough quantities to inhibit acetylcholine. Anticholinergic medications (eg, benztropine, trihexyphenidyl) are commonly used to treat tremor in these clients. However, in clients with benign prostatic hyperplasia or glaucoma, caution must be taken as anticholinergic drugs can precipitate urinary retention and an acute glaucoma episode. As a result, such medications are contraindicated in these clients. (Option 2) Decreased ability to exercise is common in clients with PD due to tremors and bradykinesia, and they require physical and occupational therapy consultations. However, acute glaucoma can be sight threatening and is the priority. (Option 3) Esomeprazole is safe to take with benztropine and will not cause an adverse reaction. (Option 4) Constipation is a common side effect of benztropine. Due to the characteristic decreased mobility, PD can also cause constipation. The client should be instructed to increase dietary fiber intake and drink plenty of water. However, this is not the most concerning issue. Educational objective: Anticholinergic medications (eg, benztropine, trihexyphenidyl) are used to treat Parkinson disease tremor. However, they can precipitate acute glaucoma and urinary retention and are therefore contraindicated in susceptible clients (eg, those with glaucoma or benign prostatic hyperplasia). The nurse on the neurosurgery step-down unit is assigned to a stable client with a closed-head injury who is 1 day postoperative craniotomy. The nurse prepares to administer the 7:00 AM medications and reviews the client's medication administration record. Which prescription prompts the nurse to contact the prescribing health care provider (HCP) for prescription clarification? Click on the exhibit button for additional information. Unordered Options Ordered Response 1. Acetaminophen 1000 mg IV every 6 hours 2. Gabapentin 300 mg orally every 8 hours 3. Hydrocodone/acetaminophen (5 mg/325 mg) orally, every 4 hours PRN 4. Phenytoin 100 mg orally, every 12 hours Explanation The recommended dose for acetaminophen should not exceed 4 g in 24 hours, as it can lead to liver injury. The nurse should contact the HCP to question the prescription for the PRN opioid analgesic hydrocodone/acetaminophen (5 mg/325 mg) (Vicodin). The client is already receiving acetaminophen 1000 mg IV every 6 hours (4,000 mg). If the client needed and received the maximum possible dose of 6 tablets of hydrocodone/acetaminophen (5 mg/325 mg), the total dose of acetaminophen (4,000 mg + 1,950 mg [6 tablets] = 5,950 mg) would exceed the recommended daily dose. (Option 1) Acetaminophen is an antipyretic and nonopioid analgesic. The HCP may prescribe this drug to manage mild to moderate pain and fever in the initial postoperative period. The antipyretic effects of the drug can mask fever in clients medicated for postoperative pain. The nurse would not question this prescription. (Option 2) Gabapentin (Neurontin) is an analgesic adjunct and anticonvulsant drug prescribed to promote comfort and decrease the incidence of seizures. The nurse would not question this prescription. (Option 4) Phenytoin (Dilantin) is an anticonvulsant prescribed to prevent and/or treat post-traumatic seizure activity in clients following a head injury. The nurse would not question this prescription. Educational objective: Higher-than-recommended doses of acetaminophen can lead to hepatotoxicity. The nurse should monitor the total amount of acetaminophen administered to a client in a 24-hour period, including the amount combined with opioid drugs (eg, hydrocodone/acetaminophen [Vicodin]). The nurse would notify the HCP if the combined dose exceeds the recommended dose of 4 g in 24 hours. A client is being discharged on enoxaparin therapy following total knee replacement surgery. Which teaching instruction does the nurse include in the teaching plan? Unordered Options Ordered Response 1. "Eliminate green, leafy, vitamin K-rich vegetables from your diet." 2. "Mild bruising or redness may occur at the injection site." 3. "You can take over-the-counter drugs such as ibuprofen to relieve mild discomfort." 4. "You will need PT/INR assessments at regular intervals while on enoxaparin therapy." Explanation Enoxaparin (Lovenox) is a low molecular weight heparin (LMWH) that may be prescribed for up to 10-14 days following hip and knee surgery to prevent deep venous thrombosis. Discharge teaching for the client on enoxaparin therapy includes: 1. Pinch an inch of skin upwards and insert the needle at a 90-degree angle into the fold of skin. 2. Continue to hold the skin fold throughout the injection and then remove the needle at a 90-degree angle. 3. Mild pain, bruising, irritation, or redness of the skin at the injection site is common. Do NOT rub the site with the hand. Using an ice cube on the injection site can provide relief (Option 2). 4. Avoid taking aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), and herbal supplements (Ginkgo biloba, vitamin E) without health care provider approval as these can increase the risk of bleeding (Option 3). 5. Monitor complete blood count to assess for thrombocytopenia. (Option 1) Vitamin K-rich foods do not need to be eliminated from the diet during enoxaparin therapy; prothrombin time (PT) and international normalized ratio (INR) are not affected. However, PT and INR are decreased when a vitamin K antagonist (eg, warfarin [Coumadin]) is taken with vitamin K-rich foods. (Option 4) Routine coagulation studies (eg, PT, INR, partial thromboplastin time [PTT]) do not need to be monitored in a client who is taking enoxaparin. However, periodic assessment of complete blood count (CBC) is usually required to monitor for hidden bleeding and thrombocytopenia (especially in older clients with renal insufficiency). Educational objective: LMWH (Enoxaparin) requires monitoring of CBC (thrombocytopenia) but not coagulation studies. Administration of unfractionated heparin requires monitoring with PTT, whereas warfarin requires PT/INR monitoring. Clients on these medications should avoid aspirin and NSAIDs. A post-surgical client is unresponsive to painful stimuli and is given naloxone. Within 5 minutes, the client is arousable and responds to verbal commands. One hour later, the client is again difficult to arouse, with minimal response to physical stimuli. Which actions should the nurse take? Select all that apply. Unordered Options Ordered Response 1. Administer oxygen 2. Assess respiratory rate 3. Initiate rapid response or code team 4. Notify the health care provider 5. Prepare a second dose of naloxone Explanation A client in the post-operative period that is unresponsive to painful stimuli is likely still under the effects of medications used during anesthesia. Using the opioid antagonist naloxone (Narcan) will temporarily reverse the effects of any opioid medications. Unfortunately, the half-life of naloxone is much shorter than most opioid medications, wearing off in 1–2 hours. The nurse should make repeat assessments of the post- surgical client's respiratory rate and administer prescribed oxygen for respiratory support. The health care provider should be notified and a second dose of naloxone should be prepared and administered as prescribed (either as a one-time dose or a continuous drip, depending on the prescription). (Option 3) An overly sedated client is not an indication for a rapid response team. Although this intervention is unlikely to cause harm to the client, it is not necessary and may result in overuse of personnel resources. If additional information indicates a more serious situation (eg, respiratory rate <8 breaths/min, oxygen saturation <90%), it may be appropriate to initiate the emergency response system. Educational objective: Naloxone (Narcan) is usually prescribed as needed for post-surgical clients for over- sedation related to opioid use. The nurse should continue to monitor clients who are given naloxone with the understanding that the opioid antagonist has a shorter half-life than most of the opioids it is meant to counteract. As a result, a second dose of naloxone may be necessary. The nurse provides teaching about methotrexate to a 28-year-old client with rheumatoid arthritis (RA). Which client statement indicates the need for further instruction regarding this drug? Unordered Options Ordered Response 1. "I know my resistance to germs will be lower, so I should get a flu shot this year." 2. "I should not become pregnant while I take this medicine." 3. "I will make sure to have my eyes checked every 6 months." 4. "It will be hard for me not to have wine with my dinner!" Explanation Methotrexate (Rheumatrex) is classified as a folate antimetabolite, antineoplastic, immunosuppressant drug to treat various malignancies and as a nonbiologic disease- modifying antirheumatic drug (DMARD) to treat RA and psoriasis. The statement in option 3 indicates that further teaching is necessary as eye examinations every 6 months are not indicated for clients prescribed methotrexate. They are indicated for those prescribed the nonbiological DMARD antimalarial drug hydroxychloroquine (Plaquenil) as it can cause retinal damage. (Option 1) Methotrexate is an immunosuppressant and can cause bone marrow suppression. Clients are at risk for infection. They should avoid crowded places and individuals with known infection. They should receive appropriate killed (inactivated) vaccines (eg, influenza, pneumococcal). Live vaccines (eg, herpes zoster) are contraindicated. (Option 2) The client should not become pregnant while taking methotrexate or for at least 3 months after it is discontinued as the drug is teratogenic. (Option 4) Clients taking methotrexate should avoid alcohol as the drug is hepatotoxic, and drinking alcohol increases the risk for hepatotoxicity. Educational objective: Methotrexate is a DMARD used to treat RA. The major adverse effects associated with methotrexate include bone marrow suppression, hepatotoxicity, and congenital abnormalities and fetal death A client with a brain tumor is admitted for surgery. The health care provider prescribes levetiracetam. The client asks why. What is the nurse's response? Unordered Options Ordered Response 1. "It destroys tumor cells and helps shrink the tumor." 2. "It prevents seizure development." 3. "It prevents blood clots in legs." 4. "It reduces swelling around the tumor." Explanation Levetiracetam (Keppra) is a medication often used to treat seizures in various settings. It has minimal drug-drug interactions compared to phenytoin and is often the preferred antiepileptic medication. (Option 1) Chemotherapy and radiation therapy would kill tumor cells and reduce tumor size. (Option 3) Hospitalized clients and clients with malignancy are at higher risk for venous thromboembolism. These clients would benefit from anticoagulation (eg, heparin, enoxaparin, rivaroxaban, apixaban). (Option 4) Dexamethasone, a corticosteroid, is used to treat cerebral edema associated with a brain injury/tumor by decreasing inflammation. Educational objective: Levetiracetam (Keppra) is a medication often used to treat seizures in various settings. Corticosteroids are used to reduce inflammation and cerebral edema in clients with brain injury and tumors. A newly admitted client describes symptoms of dizziness and feeling faint on standing. The client has a history of type 2 diabetes, coronary artery disease, and bipolar disorder. Which medications may be contributing to the client's symptoms? Select all that apply. Unordered Options Ordered Response 1. Atorvastatin 2. Metformin 3. Metoprolol 4. Olanzapine 5. Omeprazole Explanation Drugs commonly associated with orthostatic hypotension include: 1. Most antihypertensive medications, particularly sympathetic blockers such as beta blockers (eg, metoprolol) and alpha blockers (eg, terazosin) (Option 3) 2. Antipsychotic medications (eg, olanzapine, risperidone) and antidepressants (eg, selective serotonin reuptake inhibitors) (Option 4) 3. Volume-depleting medications such as diuretics (eg, furosemide, hydrochlorothiazide) 4. Vasodilator medications (eg, nitroglycerine, hydralazine) 5. Narcotics (eg, morphine) Clients at risk for developing orthostatic hypotension should be instructed to: 1. Take medications at bedtime, if approved by the health care provider 2. Rise slowly from a supine to standing position, in stages (especially in the morning) 3. Avoid activities that reduce venous return and worsen orthostatic hypotension (eg, straining, coughing, walking in hot weather) 4. Maintain adequate hydration (Option 1) Muscle cramps and liver injury, not orthostatic hypotension, are the major adverse effects of statin medications (eg, atorvastatin). (Option 2) Major side effects of metformin are lactic acidosis and gastrointestinal disturbances (metallic taste in the mouth, nausea, and diarrhea). Unlike insulin, metformin does not usually cause hypoglycemia. Orthostatic hypotension is not a common side effect. (Option 5) Proton pump inhibitors (eg, omeprazole) are associated with increased risk of pneumonia, Clostridium difficile diarrhea, and calcium malabsorption (osteoporosis), but not orthostatic hypotension. Educational objective: Medications commonly associated with orthostatic hypotension include most antihypertensives, most antipsychotics and antidepressants, and volume-depleting agents. Clients are instructed to rise slowly when standing to prevent a drop in blood pressure. The nurse is preparing to administer IV cefazolin to a client who is newly admitted with cellulitis. The client's allergies include amoxicillin, ciprofloxacin, and sulfa drugs. What should the nurse do first? Unordered Options Ordered Response 1. Administer the medication as ordered 2. Clarify the order with the health care provider (HCP) 3. Get more information from the client about the client's allergies 4. Notify the pharmacy that the drug is inappropriate for this client Explanation The nurse should find out more about this client's allergies before giving the medication. Specifically, the nurse must learn what type of reaction the client had to amoxicillin, a penicillin antibiotic. With a history of anaphylaxis to penicillin, cephalosporins (eg, cefazolin) are contraindicated. Penicillin-cephalosporin cross- sensitivity occurs due to the structural similarity between the cephalosporin and penicillin molecules. If this client's reaction to amoxicillin was only a rash or other mild reaction that was not life-threatening, the cephalosporin can be safely administered. However, if the client had an anaphylactic reaction to penicillin, the HCP will need to prescribe a different antibiotic. (Option 1) The nurse should hold the medication until more is known about the client's reaction to amoxicillin. (Option 2) The nurse does not have enough information to determine whether the HCP needs to be called. (Option 4) The nurse does not have enough information to determine whether the medication is appropriate. Educational objective: A client with a penicillin allergy may be allergic to cephalosporin antibiotics. Cephalosporins may be safely administered to clients with a history of mild allergic reaction, such as rash, but they are contraindicated in clients with a history of penicillin anaphylaxis. A parent calls the after-hours triage nurse about a 3-year-old who is sick with the flu. Which report by the parent would necessitate intervention by the nurse? Unordered Options Ordered Response 1. Acetaminophen being given every 4 hours for fever 2. Bismuth subsalicylate being used for nausea 3. Ibuprofen being given every 6 hours for body aches 4. Popsicles and gelatin desserts being used for hydration Explanation The nurse should tell the parent to discontinue the use of bismuth subsalicylate (Pepto-Bismol) as it contains a salicylate (same class as aspirin) and could possibly cause Reye syndrome. Reye syndrome can develop in children with a recent viral illness such as varicella or influenza. It can cause acute encephalopathy and hepatic dysfunction. Children with viral infections should not be given aspirin or products containing salicylates. (Options 1 and 3) Acetaminophen and ibuprofen are being used appropriately. (Option 4) Sufficient fluids are important to maintain hydration in the child with influenza. Water and fluids should be offered frequently; popsicles and gelatin desserts (eg, Jell-O) provide a palatable means of getting children to ingest fluids. Educational objective: The nurse should tell the parent not to administer any product containing aspirin or salicylates to a child with a viral infection (eg, influenza, varicella) to prevent Reye syndrome. The nurse is providing discharge teaching to several clients with new prescriptions. Which instructions by the nurse are correct in regards to medication administration? Select all that apply. Unordered Options Ordered Response 1. Avoid salt substitutes when taking valsartan for hypertension 2. Take levofloxacin with an aluminum antacid to avoid gastric irritation 3. Take sucralfate (for a gastric ulcer) PC to minimize gastric irritation 4. When taking ethambutol, notify the health care provider (HCP) for changes in vision. 5. When taking rifampin, notify the HCP if the urine turns red- orange in color Explanation Both ACE inhibitors ("prils" – captopril, enalapril, lisinopril, ramipril) and angiotensin receptor blockers ("sartans" – valsartan, losartan, telmisartan) cause hyperkalemia. Salt substitutes contain high potassium and must not be taken without consulting the HCP (Option 1). Ethambutol (Myambutol) is used to treat tuberculosis but can result in an ocular toxicity that causes vision loss and loss of red-green color discrimination. Vision acuity and color discrimination must be monitored regularly (Option 4). (Option 2) Levofloxacin (Levaquin) is a quinolone antibiotic. For this class of antibiotics, 2 hours should pass between the drug ingestion and taking aluminum/magnesium antacids, iron supplements, multivitamins with zinc, or sucralfate. In addition, these substances can bind up to 98% of the drug and make it ineffective. (Option 3) Sucralfate (Carafate, Sulcrate) should be administered before meals (AC) to coat the mucosa to prevent irritation from the acid during the meal. It should also be administered at least 30 minutes to 2 hours before or after other medications to prevent binding with them and rendering them less effective. (Option 5) Rifampin (Rifadin) normally causes red-orange discoloration of all body fluids. The client should be alerted to expect this change, but it does not require HCP notification. In addition, most antituberculosis medications (eg, rifampin, isoniazid, pyrazinamide) can cause hepatitis. Educational objective: Watch for vision changes with ethambutol. Do not give potassium supplements or salt substitutes to a client taking an ACE inhibitor or angiotensin receptor blocker. Sucralfate must be given AC to coat the gastric ulcer mucosa. Quinolone antibiotics should not be given with antacids or supplements that will bind with the drug. The nurse is discharging a client who has been prescribed warfarin for chronic atrial fibrillation. The nurse should instruct the client to avoid excess or inconsistent intake of which foods? Select all that apply. Unordered Options Ordered Response 1. Bananas 2. Broccoli 3. Grapefruit juice 4. Red meat 5. Spinach Explanation Large amounts of vitamin K-rich foods can decrease the anticoagulant effects of warfarin therapy. Clients are not instructed to remove those foods from their diet but are encouraged to be consistent in the intake of foods high in vitamin K, including leafy green vegetables, asparagus, broccoli, kale, Brussels sprout, and spinach. Several beverages also affect warfarin therapy. Green tea, grapefruit juice, and cranberry juice may alter its anticoagulant effects. (Option 1) Certain fruits (eg, bananas, oranges) are rich in potassium and may increase the risk for hyperkalemia with the use of potassium-sparing diuretics (eg, spironolactone, triamterene, eplerenone). However, bananas and oranges are low in vitamin K and are not known to interact with warfarin. (Option 4) Eating less red meat and reducing sodium intake are part of a heart-healthy diet but are not specific to a warfarin regimen. Educational objective: The nurse should teach the client receiving warfarin therapy to be consistent with intake of foods high in vitamin K. Clients do not need to restrict vitamin K-rich foods completely. Leafy green vegetables and grapefruit juice are the most important to teach. A nurse is caring for a client with an exacerbation of chronic obstructive pulmonary disease (COPD) and a history of type 2 diabetes mellitus requiring insulin. The client has been prescribed prednisone. The nurse anticipates which need? Unordered Options Ordered Response 1. Close monitoring for hypotension 2. Gradually increasing the prednisone dose 3. Increasing the insulin dose 4. Monitoring and recording intake and output Explanation Corticosteroids (eg, methylprednisolone, prednisone, dexamethasone) are given to combat inflammation in the lungs in clients with COPD exacerbation. All glucocorticoids can cause an increase in blood sugar. This may lead to the need for a higher dose of insulin based on the client's blood sugar level. (Option 1) Most glucocorticoids have some mineralocorticoid activity, causing fluid retention and worsening hypertension. (Option 2) Prednisone is started at a higher dose and then gradually decreased for COPD exacerbation and most other conditions. A slow taper will prevent adrenal crisis. (Option 4) Intake and output are not affected by corticosteroids. Educational objective: Corticosteroids commonly cause hyperglycemia and worsen hypertension. When taken in combination with NSAIDs, they can increase the risk of peptic ulcer disease. Corticosteroids in general are started at high doses and slowly tapered to reduce the risk of sudden adrenal crisis. A client in the intensive care unit is receiving IV vancomycin and gentamicin. The nurse should monitor for which potential complication with the administration of these medications? Unordered Options Ordered Response 1. Blood in nasogastric tube drainage 2. Decrease in red blood cell (RBC) count 3. Increase in serum creatinine level 4. Onset of muscle aches and cramping Explanation Vancomycin and aminoglycosides (eg, gentamicin, amikacin, tobramycin) are strong antibiotics that can cause nephrotoxicity and ototoxicity. The client receiving these medications simultaneously would be at an even higher risk for these adverse reactions. The nurse should monitor the client's renal function by assessing blood urea nitrogen (BUN) and creatinine levels and measuring urinary output. Increased levels of BUN and creatinine may indicate kidney damage. The health care provider should be notified before continuing these medications. (Option 1) Blood in the nasogastric tube could be a complication of peptic ulcer disease and the use of nonsteroidal anti-inflammatory drugs and corticosteroids. (Option 2) A decrease in the RBC count may be evidence of bone marrow suppression that can occur with use of certain cancer drugs (eg, methotrexate). (Option 4) Muscle cramping can occur occasionally with use of gentamicin but is not an indication to stop the infusion. Muscle aching and cramping that may signify a complication occur with the use of statins (eg, atorvastatin, rosuvastatin) and fibrates (eg, gemfibrozil, fenofibrate). Educational objective: The nurse should recognize that the risk of nephrotoxicity and ototoxicity is potentiated when vancomycin and aminoglycosides (eg, gentamicin) are administered together. Kidney and hearing functions should be closely monitored in these clients. A client with stable angina is being discharged home with a prescription for a transdermal nitroglycerin patch. The nurse has reviewed discharge instructions on the medication with the client. Which statement by the client indicates that teaching has been effective? Unordered Options Ordered Response 1. "I can continue to take my prescription of sildenafil." 2. "I should take the patch off when I shower." 3. "I will remove the patch if I develop a headache." 4. "I will rotate the site where I apply the patch." Explanation Nitroglycerin patches are transdermal patches used to prevent angina in clients with coronary artery disease. They are usually applied once a day (not as needed) and worn for 12–14 hours and then removed. Continuous use of patches without removal can result in tolerance. No more than one patch at a time should be worn. The patch should be applied to the upper body or upper arms. Clean, dry, hairless skin that is not irritated, scarred, burned, broken, or calloused should be used. A different location should be chosen each day to prevent skin irritation. (Option 1) Phosphodiesterase inhibitors used in erectile dysfunction (eg, tadalafil, sildenafil, vardenafil) are contraindicated with the use of nitrates. Both have similar mechanisms and cause vascular smooth muscle dilation. Combined use can result in severe hypotension. (Option 2) Patches may be worn in the shower. (Option 3) Headaches are common with the use of nitrates. The client may need to take an analgesic. Educational objective: Nursing education about transdermal nitroglycerin includes application of the patch to the upper arms or body, rotating the sites daily, removing the patch at night, taking no erectile dysfunction medications, and informing clients that headaches are common. Patches do not need to be removed for bathing. A nurse is assessing a client with type 2 diabetes mellitus who was recently started on pioglitazone. Which client data obtained by the nurse is most important to bring to the attention of the health care provider? Unordered Options Ordered Response 1. Bilateral pitting edema in ankles 2. Blood pressure is 140/88 mm Hg 3. Most recent HbA1c is 6.7% 4. Retinal photocoagulation in right eye Explanation Thiazolidinediones (rosiglitazone [Avandia] and pioglitazone [Actos]) are used to treat type 2 diabetes mellitus. These agents improve insulin sensitivity but do not release excess insulin, leading to a low risk for hypoglycemia (similar to metformin). These drugs can worsen heart failure by causing fluid retention and increase the risk of bladder cancer. Heart failure or volume overload is a contraindication to thiazolidinedione use. These medications also increase the risk of cardiovascular events such as myocardial infarction. (Option 2) The target blood pressure for a client with diabetes is <140/90 mm Hg. (Option 3) The goal HbA1c for diabetic clients is <7%. (Option 4) Diabetic retinopathy, a condition treated with retinal photocoagulation, is unrelated to thiazolidinedione use. If the client has a history of bladder cancer, then it should be reported. Educational objective: Thiazolidinediones (rosiglitazone [Avandia] and pioglitazone [Actos]) increase the risk of cardiovascular events (eg, mycoardial infarction, heart failure) and bladder cancer. Thiazolidinedione use increase insulin sensitivity but carries a low risk for hypoglycemia (similar to metformin). A client has received the PRN prescription 5 mg hydrocodone/500 mg acetaminophen 2 tablets every 4 hours for moderate postoperative pain for a total of 4 doses since 0700. The nurse assesses the vital signs and pain level prior to each medication administration. Based on the vital signs at 2300, which interventions would the nurse implement? Select all that apply. Click on the exhibit button for additional information. Unordered Options Ordered Response 1. Administer the requested medication 2. Check the chart for a naloxone order 3. Contact the health care provider (HCP) 4. Decrease the dose to 1 tablet 5. Hold the requested dose of medication Explanation The nurse closely monitors clients receiving opiate and acetaminophen combination products for sedation and pain levels to determine the effectiveness of pain management strategies. Hepatotoxicity is a possible complication in clients exceeding the recommended acetaminophen dose of 4 g/day. This client will exceed the recommended acetaminophen dose for a 24-hour period; therefore, the nurse should hold the next dose and contact the HCP. The client's verbal report indicates a consistent pain level of 6/10 over 16 hours; therefore, the HCP should be consulted for further pain management strategies. (Options 1 and 4) Additional medication should not be given as the client will exceed the recommended acetaminophen dose for a 24-hour period. (Option 2) The vital signs and sedation level do not show that naloxone is indicated at this time. If the client's respirations are ≤12/min, the nurse should hold the medication and contact the HCP. Educational objective: Clients receiving opiate and acetaminophen combination products are monitored for sedation and pain levels to determine the effectiveness of pain management strategies. Hepatotoxicity may develop in clients receiving combination products when acetaminophen dosage is >4 g/day. The health care provider prescribes amoxicillin/clavulanate (liquid) twice a day for a child with acute sinusitis. What instructions are most important for the parents? Select all that apply. Unordered Options Ordered Response 1. Administer it with food if nausea or diarrhea develops 2. Complete the medication course even if the child is better 3. Expect a rash, which is normal, as a side effect 4. Shake the medicine well before use 5. Use a household spoon to measure the dose Explanation Amoxicillin/clavulanate belongs to aminopenicillin group and is often used to treat respiratory infections. Instructions for parents about amoxicillin include: • The medication may be taken with or without food as food does not affect absorption • The most common side effects of this medication are nausea, vomiting, and diarrhea. If nausea or diarrhea develops, the medicine may be administered with food to decrease the gastrointestinal side effects (Option 1). • Shake the liquid well prior to administration. Administer at evenly spaced intervals throughout the day to maintain therapeutic blood levels (Option 4). • Ensure that the child receives the full course of therapy; do not discontinue the medication if the child is feeling better or symptoms have resolved (Option 2). (Option 3) Rash, itching, dyspnea, or facial/laryngeal edema may indicate an allergic reaction, and the medication should be discontinued. (Option 5) Pediatric liquid medications are often dispensed with a measuring device designed to administer the exact dose prescribed. The following calibrated devices may be included: dropper, oral syringe, plastic measuring cup, or measuring spoon. Educational objective: Amoxicillin/clavulanate in liquid form should be shaken well prior to administration; the correct dose is administered using a calibrated measuring device. It is taken with or without food, at evenly spaced intervals, and until all the medication is consumed. If nausea or diarrhea develops, the medication may be administered with food. The nurse completes the following drug administrations. Which would require an incident report? Unordered Options Ordered Response 1. Client with chronic stable angina and blood pressure of 84/52 mm Hg; isosorbide mononitrate held 2. Client with depression stopped phenelzine yesterday; escitalopram given today 3. Client with diabetes and morning glucose of 90 mg/dL (5.0 mmol/L); the daily NPH insulin 20 units given at 8:00 AM 4. Client with pulmonary embolism and International Normalized Ratio (INR) of 2.5; warfarin given Explanation Selective serotonin reuptake inhibitors (SSRIs) (eg, escitalopram) cannot be combined with monoamine oxidase inhibitors (MAOIs) (eg, phenelzine) as there is a risk of serotonin syndrome. MAOI effects persist long after dosing stops. An MAOI should be withdrawn at least 14 days before starting an SSRI. (Option 1) The isosorbide has actions identical to nitroglycerin and can cause hypotension from vasodilation. It should be held when the systolic blood pressure is <90 mm Hg. Perfusion to the kidneys is inadequate if the systolic blood pressure is <80 mm Hg. Because the pressure is so low, the nurse does not want to lower it further by giving the drug. (Option 3) Insulin is given to control diabetes. A "normal" fasting glucose level (70-99 mg/dL [3.9-5.5 mmol/L]) indicates that the dosing is correct and should be given to continue control of blood glucose. (Option 4) The effect of warfarin (Coumadin) is monitored by the INR. The therapeutic range of INR is 2-3. This result indicates that the current dosing is achieving the desired effect. Educational objective: There must be a minimum of 14 days between the administration of MAOIs and SSRIs to avoid serotonin syndrome; these medications cannot be administered concurrently. A client is having a severe asthma attack lasting over 4 hours after exposure to animal dander. On arrival, the pulse is 128/min, respirations are 36/min, pulse oximetry is 86% on room air, and the client is using accessory muscles to breathe. Lung sounds are diminished and high-pitched wheezes are present on expiration. Based on this assessment, the nurse anticipates the administration of which of the following medications? Select all that apply. Unordered Options Ordered Response 1. Inhaled albuterol nebulizer every 20 minutes 2. Inhaled ipratropium nebulizer every 20 minutes 3. Intravenous methylprednisolone 4. Montelukast 10 mg by mouth STAT 5. Salmeterol metered-dose inhaler every 20 minutes Explanation Clinical manifestations characteristic of moderate to severe asthma exacerbations include tachycardia (>120/min), tachypnea (>30/min), saturation <90% on room air, use of accessory muscles to breathe, and peak expiratory flow (PEF) <40% of predicted or best (<150 L/min). Pharmacologic treatment modalities recommended by the Global initiative for Asthma (2014) to correct hypoxemia, improve ventilation, and promote bronchodilation include the following: 1. Oxygen to maintain saturation >90% 2. High-dose inhaled short-acting beta agonist (SABA) (albuterol) and anticholinergic agent (ipratropium) nebulizer treatments every 20 minutes 3. Systemic corticosteroids (Solu-Medrol) (Option 4) Montelukast (Singulair) is a leukotriene receptor blocker with both bronchodilator and anti-inflammatory effects; it is used to prevent asthma attacks but is not recommended as an emergency rescue drug in asthma. (Option 5) A long-acting beta agonist (Salmeterol) is administered with an inhaled corticosteroid for long-term control of moderate to severe asthma; it is not used as an emergency rescue drug in asthma. Educational objective: Clinical manifestations characteristic of moderate to severe asthma exacerbations include tachycardia, tachypnea, saturation <90% on room air, use of accessory muscles of respiration, and PEF <40% predicted. Management includes the administration of high-dose inhaled SABA and ipratropium nebulizer, systemic corticosteroids, and oxygen to maintain saturation >90%. An unresponsive client is brought to the emergency department after a party. Friends report that the client drank beer, may have taken some kind of pills, and then passed out. Blood pressure is 90/62 mm Hg, pulse is 64/min, and respirations are 8/min. Which priority action is expected to be taken following the initial assessment? Unordered Options Ordered Response 1. Administer IV naloxone 2. Administer Ringer's lactate at 125 mL/hr 3. Collect a urine sample for a urine drug screen 4. Draw blood for a blood alcohol content test Explanation The characteristic clinical features of opioid intoxication include the following: • Depressed mental status • Decreased respiratory rate (<12/min) (most notable) • Constricted (miotic) pupils (may not be present in every client) • Decreased/absent bowel sounds Mild hypotension from histamine release and bradycardia from central nervous system (CNS) depression may also be present. Concurrent intake of other CNS depressants (eg, alcohol) can worsen the respiratory depression. Naloxone (Narcan) is a potent narcotic antagonist that can reverse symptoms (respiratory depression, sedation, hypotension) associated with suspected opioid overdose without producing any opioid-like effects. The usual dose is 0.4 mg IV (in non- opioid dependent clients), typically given via IV push. The therapeutic effect is rapid, within 1-2 minutes, and dosing may be repeated in 2-3 minutes. It is the priority action to reverse CNS and respiratory depression (Option 1). (Option 2) IV fluids will be administered, but the priority action is to address the client's respiratory depression. (Option 3) A urine sample will be obtained for a urine drug screen and toxicology tests. It is not necessary to wait for the results before administering naloxone as delaying care could result in further CNS or respiratory depression and subsequent death. (Option 4) Blood for a blood alcohol content test will be drawn, but this is not the priority action. Educational objective: The administration of IV naloxone (Narcan), a potent narcotic antagonist, is a priority action to reverse depression of the respiratory and central nervous systems in a client with suspected opioid overdose. A respiratory rate <12/min is the most notable feature of opioid overdose The nurse is providing discharge instructions to a client receiving oxybutynin for overactive bladder. Which client statement indicates that further teaching is required? Unordered Options Ordered Response 1. "I am looking forward to our summer vacation at the beach." 2. "I plan to eat more fruits and vegetables to prevent constipation." 3. "I should not drive until I know how this drug affects me." 4. "I will drink at least 6-8 glasses of water daily." Explanation Oxybutynin (Ditropan) is an anticholinergic medication that is frequently used to treat overactive bladder. Common side effects include: • New-onset constipation • Dry mouth • Flushing • Heat intolerance • Blurred vision • Drowsiness Decreased sweat production may lead to hyperthermia. The nurse should instruct the client to be cautious in hot weather and during physical activity (Option 1). (Options 2 and 4) Increasing dietary intake of fluids and bulk-forming foods (eg, fruits, vegetables) promotes normal bowel function and prevents constipation. (Option 3) Sedation is a common side effect of anticholinergic drugs. Clients should be taught not to drive or operate heavy machinery until they know how the drug affects them. Educational objective: Anticholinergic medications are commonly associated with constipation, urinary retention, flushing, dry mouth, and heat intolerance. Clients should be taught to prevent these side effects by increasing intake of fluids and bulk-forming foods (prevents dry mouth and constipation) and by avoiding locations or activities that may lead to hyperthermia. A 64-year-old client is prescribed ciprofloxacin for a urinary tract infection (UTI). The nurse instructs the client to observe for and notify the health care provider (HCP) immediately about which of the following? Unordered Options Ordered Response 1. Brown-colored urine 2. Hearing and balance problems 3. Pain in the Achilles tendon area 4. Sunburn Explanation Use of fluoroquinolones (ciprofloxacin, levofloxacin, moxifloxacin, norfloxacin, ofloxacin), especially ciprofloxacin, places clients at increased risk for tendinitis and tendon rupture that most often occur in the Achilles tendon. This class of antibiotics carries a black box warning about this risk. The Food and Drug Administration recommends that at the first sign of tendon pain or swelling, clients should stop taking the fluoroquinolone, abstain from moving the affected area, and contact their HCP promptly for further evaluation and a change of antibiotic. (Option 1) Turning urine into a harmless brown color is a common side effect of nitrofurantoin, another antibiotic commonly used for UTI treatment. (Option 2) Hearing and balance problems (vertigo) result from aminoglycoside ototoxicity (eg, gentamicin). (Option 4) Ciprofloxacin can cause photosensitivity. The client should be instructed to avoid sun exposure and use sunscreen while taking the medication. Educational objective: Fluoroquinolones (ciprofloxacin) carry a black box warning citing an increased risk of tendinitis and rupture, especially of the Achilles tendon. The nurse is administering a pink pill to a hospitalized medical-surgical client. The alert, oriented client says, "This is a pill I haven't seen before." What follow-up action should the nurse take next? Unordered Options Ordered Response 1. Check the health care provider's prescription in the medical record 2. Explain that the health care provider has prescribed the medication 3. Look up the medication in the pharmacology reference 4. Teach the client about the purpose of the medication Explanation Safe medication administration is conducted according to 6 rights: • Right client using 2 identifiers • Right medication • Right dose • Right route • Right time • Right documentation When a mentally competent client questions a drug administration, the safest option is to first check the prescription to verify the 6 rights of medication administration (Option 1). If an error is ruled out (eg, different brand, new order) the nurse should follow up with appropriate teaching. (Option 2) The nurse must first verify all aspects of proper medication administration. If they are correct, the nurse should provide appropriate teaching on why the health care provider prescribed the medication. Explaining that the nurse is just following orders is rarely the correct answer. (Option 3) A pharmacology reference can verify information about the medication but will not confirm that the client is the correct recipient. Acceptable identifiers include first and last name, medical record number, and birth date. (Option 4) The nurse can teach the client about the purpose of the medication after the 6 rights have been verified. Educational objective: When a competent client questions a new medication, the nurse should first verify the 6 rights of safe medication administration: right client, medication, dose, route, time, and documentation. If safe administration has been confirmed, the nurse should then provide appropriate teaching to the client An 80-year-old client with hypertension and type 2 diabetes has recently started taking chlorthalidone. Which report by the client is most concerning to the office nurse? Unordered Options Ordered Response 1. Dizziness on standing 2. Fasting blood sugar of 160 mg/dL 3. Presence of muscle cramps 4. Sunburn Explanation Hydrochlorothiazide and chlorthalidone are the most commonly used thiazide diuretics for treating hypertension. The major side effects of thiazide diuretics include: • Hypokalemia (manifests as muscle cramps) • Hyponatremia (manifests as altered mental status and seizures) • Hyperuricemia (may worsen gout attacks) • Hyperglycemia (requires adjustment of diabetic medications) Of the above side effects, hypokalemia is the most serious as it can lead to life- threatening cardiac arrhythmias. (Option 1) Orthostatic hypotension may be a side effect of many diuretics. The nurse should teach the client to rise slowly and sit for a few minutes before standing. The elderly client may need to use a cane or walker to prevent falls. Additionally, the nurse should check that the client's blood pressure is not too low. (Option 2) Mild to moderate hyperglycemia is common with thiazides and needs to be addressed. However, it is not life-threatening and therefore not a priority. (Option 4) Most thiazide diuretics are sulfa derivatives. Therefore, they can cause photosensitivity. The nurse should encourage the client to use sunscreen and wear protective clothing. Educational objective: The nurse should suspect hypokalemia in the presence of muscle cramps in a client taking diuretics. Hypokalemia can lead to dangerous ventricular dysrhythmias. The client is brought to the emergency department in handcuffs by the police. Witnesses said that the client became violent and confused after consuming large amounts of alcohol at a party. The client is placed in 4-point restraints, and ziprasidone hydrochloride is administered. The client is sleeping 30 minutes later. What is a priority action for the nurse at this time? Unordered Options Ordered Response 1. Check for a history of bipolar disease 2. Determine if restraints can now be removed 3. Monitor for widened QT intervals and hypotension 4. Obtain blood for the current blood alcohol level Explanation Ziprasidone hydrochloride (Geodon) is an atypical antipsychotic drug that is used for acute bipolar mania, acute psychosis, and agitation. Its use carries a risk for QT prolongation leading to torsade de pointes. A baseline electrocardiogram and potassium are usually checked. At a minimum, the client should be placed on a cardiac monitor. The client should also be monitored for hypotension and seizures, especially if the previous medical history is not known or obtainable. The risk for adverse effects is increased with the interaction of alcohol. (Option 1) Although knowing past psychiatric history will assist in determining the cause of this episode, this knowledge is not essential when caring for this client's current needs. Any physical reasons for the behavior should be ruled out before focusing on psychiatric history. Risk for suicide also needs to be assessed after the client is alert and sober. (Option 2) This should be reassessed after the drug is wearing off, not before the medication is peaking. The client could suddenly wake up and become violent again. Also, it is a priority to perform restraint monitoring per protocol, including checks on circulation and hydration/elimination needs. The client's physiological response is priority. (Option 4) It would be beneficial to know the current alcohol (ethanol) level in order to estimate the client's level of intoxication and when the client will be sober. The body normally clears alcohol at a rate of 25-50 mg/dL per hour. However, there is a reliable history that the client had been drinking, and the presence of alcohol in the blood carries a risk for drug interaction. Therefore, it is more important to monitor the client for any negative effects (adverse physiological responses) from the drug than to quantify the current alcohol level. Educational objective: After ziprasidone hydrochloride administration, clients should be monitored for cardiac effects (including prolonged QT interval), hypotension, and/or seizure activity. Alcohol interacts with ziprasidone and increases the potential for an adverse effect from the drug. The home health nurse reviews the laboratory results for 4 clients. Which laboratory value is most important for the nurse to report to the health care provider? Unordered Options Ordered Response 1. Client with Clostridium difficile infection receiving metronidazole has a white blood cell count of 15,000/mm3 (15.0 x 109/L) 2. Client with liver cirrhosis has an International Normalized Ratio of 1.5 3. Client with mild asthma exacerbation receiving prednisone has a blood glucose of 250 mg/dL (13.9 mmol/L) 4. Client with rheumatoid arthritis taking adalimumab has a white blood cell count of 14,000/mm3 (14.0 x 109/L) Last Updated: 10/7/2015 Explanation Adalimumab (Humira) is a tumor necrosis factor (TNF) inhibitor, a biologic disease- modifying antirheumatic drug (DMARD) classified as a monoclonal antibody. Its major adverse effects are similar to those of other TNF inhibitor drugs (eg, etanercept [Enbrel], infliximab [Remicade]) and include immunosuppression and infection (eg, current, reactivated). An elevated white blood cell count in this client can indicate underlying infection and should be reported immediately. (Option 1) This client with Clostridium difficile infection will have an elevated white blood cell count. The client is receiving appropriate therapy (eg, metronidazole, oral vancomycin). The nurse will need to monitor the white cell count and, if it keeps increasing, report it. (Option 2) The liver produces most blood clotting factors. Clients with liver cirrhosis will lose this ability and are at risk for bleeding. This client's International Normalized Ratio is mildly elevated (normal 0.75-1.25), which is expected with cirrhosis. (Option 3) Corticosteroids increase blood glucose. This is expected, and the client may need treatment if the glucose levels are markedly increased for a prolonged period. Most clients with asthma exacerbation are expected to take a 5- to 7-day course of steroids. Educational objective: Adalimumab (Humira), etanercept (Enbrel), and infliximab (Remicade) are common tumor necrosis factor inhibitor, biologic disease-modifying antirheumatic drugs. Major adverse effects include immunosuppression and infection. A client with schizophrenia that is resistant to other antipsychotic medications is about to start on a course of clozapine. Which of these periodic measurements has the highest priority in this client? Unordered Options Ordered Response 1. Complete blood count (CBC) and absolute neutrophil count (ANC) 2. Electrocardiogram 3. Fasting blood sugar and fasting lipids 4. Height, weight, and waist circumference Explanation Clozapine is an atypical antipsychotic medication used to treat schizophrenia that has not responded to standard, more traditional treatment. Clozapine is associated with a risk for agranulocytosis and is therefore used only in clients with treatment-resistant schizophrenia. A client must have a white blood cell (WBC) count of ≥3500/mm3 and an ANC of ≥2000/mm3 before starting clozapine treatment, and so it is most important to first obtain a baseline CBC and ANC. Agranulocytosis is reversible if caught early. Therefore, clients taking clozapine must have their WBC and ANC monitored regularly throughout the course of therapy (initially once every week). Clients should also contact the health care provider (HCP) immediately if fever or a sore throat develops, as this may indicate an underlying infection from neutropenia. Other potential adverse effects of clozapine requiring baseline assessment prior to treatment and ongoing monitoring include: • Weight gain—a baseline height, weight, and waist circumference should be obtained, and a BMI can be calculated • Hyperglycemia—symptoms of hyperglycemia (eg, increased thirst and urination, weakness, increased blood glucose) should be monitored • Dyslipidemia—a lipid profile should be obtained (Options 2, 3, and 4) These are important but not priority actions. Educational objective: Agranulocytosis is the most serious adverse effect of clozapine. Pretreatment assessment and ongoing monitoring of WBC and ANC are necessary. Clients are advised to contact their HCP if fever or a sore throat develops. Clozapine can also cause metabolic syndrome (weight gain, hyperlipidemia, insulin resistance/diabetes) and seizures. A client who has been on long-term omeprazole therapy for gastroesophageal reflux disease is admitted to the hospital for a urinary tract infection. The nurse recognizes that this client is at highest risk for which complication due to omeprazole use? Unordered Options Ordered Response 1. Clostridium difficile infection 2. Gait disturbance 3. Jaw necrosis 4. Tremor Explanation Long-term use of proton pump inhibitors (PPIs) is common as these medications are available over the counter. PPIs impair intestinal calcium absorption and therefore are associated with decreased bone density, which increases the possibility of fractures of the spine, hip, and wrist. PPIs cause acid suppression that otherwise would have prevented pathogens from more easily colonizing the upper gastrointestinal tract. This leads to increased risk of pneumonias. PPI use may also increase the risk for clostridium difficile-associated diarrhea (CDAD); currently the cause is unclear. A safety alert has been issued by the US Food and Drug Administration (FDA) advising health care providers to consider CDAD for unresolved diarrhea in PPI users. This client would be receiving antibiotics for a urinary tract infection, further increasing the risk for C difficile infection (Option 1). (Option 2) Gait disturbance (ataxia) is commonly seen with phenytoin toxicity. (Option 3) Jaw necrosis is associated with long-term bisphosphonate (eg, alendronate, risedronate) therapy. (Option 4) Tremor is seen with lithium toxicity and albuterol (short-acting beta agonist) use. Educational objective: Long-term use of PPIs (Prazoles – omeprazole, lansoprazole, pantoprazole, rebeprazole) has been associated with decreased bone density (calcium malabsorption) and increased risk for C difficile-associated diarrhea and pneumonia. The health care provider prescribes phenazopyridine hydrochloride for a client with a urinary tract infection. What would the office nurse teach the client to expect while taking this medication? Unordered Options Ordered Response 1. Constipation 2. Difficulty sleeping 3. Discoloration of urine 4. Dry mouth Explanation Phenazopyridine hydrochloride (Pyridium) is a urinary analgesic prescribed to relieve the pain and burning associated with a urinary tract infection. The urine will turn bright red-orange while on this medication; other body fluids can be discolored as well. Because staining of underwear, clothing, bedding, and contact lenses can occur, the nurse should suggest that the client use sanitary napkins and wear eyeglasses while taking the medication. Phenazopyridine hydrochloride provides symptomatic relief but no antibiotic action, and so it is important that the client take a full course of antibiotics. (Options 1, 2, and 4) Constipation, difficulty sleeping, and dry mouth are not common adverse effects of phenazopyridine hydrochloride. Educational objective: Phenazopyridine hydrochloride (Pyridium) is a urinary analgesic prescribed to relieve symptoms of dysuria associated with a urinary tract infection. An expected side effect of the drug is orange-red discoloration of urine. The nurse working on the inpatient psychiatric unit is preparing to administer 9:00 AM medications to a client. The medication administration record is shown in the exhibit. On assessment, the client is tremulous, exhibits muscle rigidity, and has a temperature of 101.1 F (38.4 C). Which action should the nurse take? Click on the exhibit button for additional information. Unordered Options Ordered Response 1. Give all medications, including acetaminophen, and reassess in 30 minutes 2. Hold the haloperidol, give acetaminophen, and reassess in 30 minutes 3. Hold the haloperidol and notify the health care provider (HCP) immediately 4. Hold the hydrochlorothiazide and notify the HCP immediately Last Updated: 1/14/2016 Explanation This client is exhibiting signs and symptoms of neuroleptic malignant syndrome (NMS), a rare but potentially life-threatening reaction. NMS is most often seen with the "typical" antipsychotics (eg, haloperidol, fluphenazine). However, even the newer "atypical" antipsychotic drugs (eg, clozapine, risperidone, olanzapine) can cause the syndrome. NMS is characterized by fever, muscular rigidity, altered mental status, and autonomic dysfunction (eg, sweating, hypertension, tachycardia). Treatment is supportive and is directed at reducing fever and muscle rigidity and preventing complications. Treatment in an intensive care unit (ICU) may be required. The most important intervention is to immediately discontinue the antipsychotic medication and notify the HCP for further assessment. (Option 1) Administering acetaminophen may be appropriate, but it is more important to discontinue the haloperidol and notify the HCP immediately. (Option 2) Due to the life-threatening nature of NMS, the HCP should be informed immediately. The HCP may order muscle enzymes, administer IV fluids/medications, and move the client for close monitoring (eg, to the ICU). (Option 4) Hydrochlorothiazide is a diuretic commonly used for hypertension. It does not cause NMS symptoms. Educational objective: NMS is characterized by fever, muscle rigidity, altered mental status, and autonomic dysfunction. The most important intervention is to discontinue the antipsychotic medication. The nurse working on the inpatient psychiatric unit is preparing to administer 9:00 AM medications to a client. The medication administration record is shown in the exhibit. On assessment, the client is tremulous, exhibits muscle rigidity, and has a temperature of 101.1 F (38.4 C). Which action should the nurse take? Click on the exhibit button for additional information. Unordered Options Ordered Response 1. Give all medications, including acetaminophen, and reassess in 30 minutes 2. Hold the haloperidol, give acetaminophen, and reassess in 30 minutes 3. Hold the haloperidol and notify the health care provider (HCP) immediately 4. Hold the hydrochlorothiazide and notify the HCP immediately You answered this question incorrectly. Explanation This client is exhibiting signs and symptoms of neuroleptic malignant syndrome (NMS), a rare but potentially life-threatening reaction. NMS is most often seen with the "typical" antipsychotics (eg, haloperidol, fluphenazine). However, even the newer "atypical" antipsychotic drugs (eg, clozapine, risperidone, olanzapine) can cause the syndrome. NMS is characterized by fever, muscular rigidity, altered mental status, and autonomic dysfunction (eg, sweating, hypertension, tachycardia). Treatment is supportive and is directed at reducing fever and muscle rigidity and preventing complications. Treatment in an intensive care unit (ICU) may be required. The most important intervention is to immediately discontinue the antipsychotic medication and notify the HCP for further assessment. (Option 1) Administering acetaminophen may be appropriate, but it is more important to discontinue the haloperidol and notify the HCP immediately. (Option 2) Due to the life-threatening nature of NMS, the HCP should be informed immediately. The HCP may order muscle enzymes, administer IV fluids/medications, and move the client for close monitoring (eg, to the ICU). (Option 4) Hydrochlorothiazide is a diuretic commonly used for hypertension. It does not cause NMS symptoms. Educational objective: NMS is characterized by fever, muscle rigidity, altered mental status, and autonomic dysfunction. The most important intervention is to discontinue the antipsychotic medication. Which medication prescriptions should the nurse question? Select all that apply. Unordered Options Ordered Response 1. Cephalexin for a client with severe allergy to penicillin 2. Fexofenadine for a client with hives 3. Ibuprofen for a client with asthma and nasal polyps 4. Lisinopril for a client with diabetes mellitus 5. Propranolol for a client with asthma Last Updated: 12/24/2015 Explanation Cephalexin is a cephalosporin, which is chemically similar to penicillin. If a client has had a severe allergic reaction to penicillin, there is a 1%-4% chance of an allergic reaction (cross-sensitivity) to a cephalosporin (Option 1). Clients with nasal polyps often have sensitivity to nonsteroidal anti-inflammatory drugs (NSAIDS), including aspirin. In addition, NSAIDs can exacerbate asthma symptoms. Therefore, acetaminophen may be a better choice for these clients (Option 3). The selective beta blockers (eg, metoprolol, atenolol, bisoprolol) are generally given for heart failure and hypertension control due to their beta1-blocking effect. The nonselective beta blockers (eg, propranolol, nadolol), in addition, have a beta2-blocking effect that results in bronchial smooth muscle constriction. Therefore, nonselective beta blockers are generally contraindicated in clients with asthma (Option 5). (Option 2) H1 receptor antagonists (eg, fexofenadine, cetirizine, levocetirizine, loratadine) decrease the inflammatory response by blocking histamine receptors. Histamine is released from mast cells during a type I (immediate) hypersensitivity reaction (ie, allergic rhinitis, allergic conjunctivitis, and hives). (Option 4) Angiotensin-converting (ACE) inhibitors (ending in "pril") are the drugs of choice in diabetic clients with hypertension or proteinuria. This would be an appropriate administration. Educational objective: Clients with asthma and nasal polyps can have sensitivity to NSAIDs; those with an allergy to penicillin can have a cross-sensitivity to cephalosporins. Nonselective beta blockers are contraindicated in clients with asthma. H1 receptor antagonists block histamine in an allergic reaction. ACE inhibitors are protective for diabetic nephropathy. A client was prescribed phenytoin 100 mg orally 3 times a day a month ago. The serum phenytoin level is 32 mcg/mL and the nurse notifies the health care provider (HCP). Which action is anticipated from the HCP? Unordered Options Ordered Response 1. Administer phenytoin as prescribed 2. Decrease phenytoin daily dose 3. Increase phenytoin daily dose 4. Repeat serum phenytoin level in 2 hours Explanation Phenytoin (Dilantin), an anticonvulsant drug, is used to treat generalized tonic-clonic seizures. The therapeutic serum phenytoin reference range is 10-20 mcg/mL. In the presence of an elevated reference range (32 mcg/mL), if no seizure activity is observed, the nurse would anticipate the HCP to prescribe a decreased daily dose. The nurse will continue to monitor for signs of toxicity (eg, ataxia, nystagmus, slurred speech, decreased mentation). (Options 1 and 3) The serum phenytoin level is elevated, so administering the prescribed dose or increasing the dose can raise the level and further increase the risk for drug-induced toxicity. (Option 4) Repeating the serum phenytoin level in 2 hours will not result in a significant change as the average half-life of the drug is 22 hours. Educational objective: Phenytoin (Dilantin) is used to treat generalized tonic-clonic seizures. Common symptoms of phenytoin-induced toxicity involve the central nervous system (eg, nystagmus, ataxia, slurred speech, decreased mentation) and can occur when phenytoin plasma levels exceed the therapeutic reference range (10-20 mcg/mL). A client is receiving chemotherapy for acute myeloid leukemia. The health care provider prescribes allopurinol to prevent tumor lysis syndrome (TLS). Which laboratory value indicates a therapeutic response to the medication? Unordered Options Ordered Response 1. Serum calcium 9.5 mg/dL (2.38 mmol/L) 2. Serum phosphate 4.0 mg/dL (1.29 mmol/L) 3. Serum potassium 4.5 mEq/L (4.5 mmol/L) 4. Serum uric acid level 6.0 mg/dL (357 µmol/L) Explanation A potential complication of chemotherapy is acute tumor lysis syndrome (TLS), a rapid release of intracellular components into the bloodstream. Massive cell lysis releases intracellular ions (potassium and phosphorus) and nucleic acids into the bloodstream. Catabolism of the nucleic acids produces uric acid, resulting in severe hyperuricemia. Released phosphorus binds calcium, producing calcium phosphate mixture but lowering serum calcium levels. Both calcium phosphate and uric acid are deposited into the kidneys, causing renal injury. Allopurinol (Zyloprim) blocks the nucleic acid catabolism and prevents hyperuricemia but would not affect potassium, phosphate, and calcium levels. Chronic gout and uric acid calculi also require the administration of allopurinol to decrease uric acid accumulation. A normal blood uric acid level for an adult male is 4.4–7.6 mg/dL (262– 452 µmol/L) and female is 2.3-6.6 mg/dL (137-393 µmol/L). (Option 1) The normal calcium level for adults is 8.6–10.2 mg/dL (2.15–2.55 mmol/L). The client with this complication would experience hypocalcemia. (Option 2) The normal phosphate level for adults is 2.4–4.4 mg/dL (0.78–1.42 mmol/L). In this condition, the phosphate level would show hyperphosphatemia. (Option 3) The normal potassium level for adults is 3.5–5.0 mEq/L (3.5–5.0 mmol/L). Hyperkalemia is usually present in a client with this chemotherapy-induced complication. Educational objective: The therapeutic effect of allopurinol (Zyloprim) is to decrease hyperuricemia caused by TLS. Laboratory values of significance in TLS include rising blood uric acid, potassium, and phosphate levels, with decreasing calcium levels. A client with ulcerative colitis is prescribed the drug sulfasalazine. Which information should the nurse discuss with the client concerning this drug? Select all that apply. Unordered Options Ordered Response 1. Drinking 8 glasses of water daily 2. Stopping the medicine if blood is present in stool 3. Stopping the medicine if urine turns an orange-yellow color 4. Taking folic acid supplements 5. Wearing sunscreen when outdoors Explanation Sulfasalazine (Azulfidine) is a sulfonamide (salicylate and sulfa antibiotic) and nonbiologic disease-modifying antirheumatic drug (DMARD) used for mild to moderate chronic inflammatory rheumatoid arthritis (RA) and inflammatory bowel disease (eg, ulcerative colitis). It inhibits the production of prostaglandin, a mediator in the body's inflammatory response. Most "sulfa" medications (eg, trimethoprim, sulfamethoxazole) share common side effects, including: 1. Crystalluria causing kidney injury – client should drink 8 glasses of water daily to maintain adequate urine output (eg, 1200-1500 mL/day) 2. Photosensitivity and risk for sunburn – client should avoid sun exposure and apply sunscreen 3. Folic acid deficiency (megaloblastic anemia and stomatitis) – client should eat folate-rich foods and take 1 mg/day folic acid supplement 4. Rarely life-threatening agranulocytosis (leukopenia) – client should be monitored for complete blood count at the start of therapy and report fever or sore throat immediately 5. Stevens-Johnson syndrome – client should stop the medicine if rash develops (Option 2) Ulcerative colitis is characterized by bloody diarrhea, and the medication is taken to reduce this effect. (Option 3) Urine and skin can turn an orange-yellow color but will return to normal when the drug is discontinued. This is an expected finding. Educational objective: Sulfasalazine (Azulfidine) is used for mild to moderate chronic inflammatory RA and inflammatory bowel disease. Important adverse effects include crystalluria with kidney injury, yellow-orange skin and urine discoloration, folic acid deficiency, and photosensitivity. A nurse has completed teaching a client who is being discharged on lithium for a bipolar disorder. Which statement by the client indicates a need for further teaching? Unordered Options Ordered Response 1. "I need to drink 1-2 liters of fluid daily." 2. "I need to have my blood levels checked periodically." 3. "I should not limit my sodium intake." 4. "I should use ibuprofen for pain relief." Explanation Lithium is a mood stabilizer most often used to treat bipolar affective disorders. It has a very narrow therapeutic serum range of 0.6-1.2 mEq/L (0.6-1.2 mmol/L). Levels >1.5 mEq/L (1.5 mmol/L) are considered toxic. Lithium toxicity usually occurs with the following: 1. Dehydration 2. Decreased renal function (eg, elderly clients) 3. Diet low in sodium 4. Drug-drug interactions (nonsteroidal anti-inflammatory drugs [NSAIDs] and thiazide diuretics) Lithium is cleared renally. Even a mild change in kidney function (as seen in elderly clients) can cause serious lithium toxicity. Therefore, drugs that decrease renal blood flow (eg, NSAIDs) should be avoided. Acetaminophen would be a better choice for pain relief (Option 4). (Options 1 and 3) Sodium, water, and lithium are normally filtered by the kidneys. Restriction of dietary sodium/water or dehydration signals renal sodium and water reabsorption which will also increase lithium absorption, resulting in toxicity. Therefore, clients should never restrict their sodium or water intake while taking lithium; instead, they should maintain a consistent sodium intake. (Option 2) Blood should be drawn frequently to monitor for therapeutic lithium levels and toxicity. Educational objective: Dehydration, decreased renal function, diet low in sodium, and drug-drug interactions (eg, NSAIDs and thiazide diuretics) can cause lithium toxicity. The nurse provides instructions to a client discharged on warfarin, after being treated for a pulmonary embolism (PE) following surgery. Which statements made by the client indicate the need for further teaching? Select all that apply. Unordered Options Ordered Response 1. "I will need to take my blood thinner for about 3-6 months." 2. "I will place small rugs on my wood floors to cushion a fall." 3. "I will take a baby aspirin if I have mild chest pain." 4. "I will use a soft-bristled toothbrush to clean my teeth." 5. "I will wear a blood thinner MedicAlert tag." Explanation Clients discharged on warfarin (Coumadin) are taught interventions to prevent injury, such as removing scatter rugs in the home to reduce the risk of tripping and falling (especially in elderly) (Option 2). Clients are educated to avoid aspirin, drugs containing aspirin, nonsteroidal anti- inflammatory drugs (NSAIDs), and alcohol when taking warfarin due to an increased risk for bleeding (Option 3). (Option 1) Warfarin is usually administered for 3-6 months following PE to prevent further thrombus formation. A longer duration (lifelong) of anticoagulation is recommended in clients with recurrent PE. Prothrombin time and INR must be monitored regularly to adjust the dose and maintain a therapeutic anticoagulant level. (Option 4) Clients should be taught to avoid trauma or injury to decrease the risk for bleeding. Preventive measures include gently brushing teeth with a soft-bristled toothbrush, avoiding use of alcohol-based mouthwash, avoiding contact sports or rollerblading, and using a straight razor. Flossing should also be avoided in general, but waxed dental floss may be used with care in some clients. (Option 5) Clients are instructed to wear a MedicAlert tag (eg, necklace, bracelet) when taking anticoagulants (eg, warfarin, heparin). Educational objective: Clients on warfarin or heparin should avoid using aspirin or nonsteroidal anti- inflammatory drugs, wear a MedicAlert device, avoid activities that increase the risk for bleeding, and limit alcohol intake. A diabetic client is prescribed metoclopramide. Which of the following side effects must the nurse teach the client to report immediately to the health care provider? Select all that apply. Unordered Options Ordered Response 1. Excess blinking of eyes 2. Dry mouth 3. Dull headache 4. Lip smacking 5. Puffing of cheeks Explanation Metoclopramide (Reglan) is prescribed for the treatment of delayed gastric emptying, gastroesophageal reflux (GERD), and as an antiemetic. Similar to antipsychotic drugs, metoclopramide use is associated with extrapyramidal adverse effects, including tardive dyskinesia (TD). This is especially common in older adults with long-term use. The client should call the health care provider immediately if TD symptoms develop, including uncontrollable movements such as: • Protruding and twisting of the tongue • Lip smacking • Puffing of cheeks • Chewing movements • Frowning or blinking of eyes • Twisting fingers • Twisted or rotated neck (torticollis) (Options 2 and 3) Common side effects of metoclopramide such as sedation, fatigue, restlessness, headache, sleeplessness, dry mouth, constipation, and diarrhea need not be reported to the health care provider. Educational objective: Both antipsychotic medication and metoclopramide use can be associated with significant extrapyramidal side effects (eg, tardive dyskinesia). The nurse should teach the client the importance of immediately communicating these to the health care provider. A client is receiving a continuous heparin infusion and the most recent aPTT is 140 seconds. The nurse notices blood oozing at the surgical incision and IV insertion sites. What interventions should the nurse implement? Select all that apply. Unordered Options Ordered Response 1. Continue heparin infusion and recheck aPTT in 6 hours 2. Prepare to administer vitamin K 3. Redraw blood for laboratory tests 4. Review guidelines for administration of protamine 5. Stop infusion of heparin and notify the health care provider (HCP) Explanation Depending on the institution and HCP, a therapeutic aPTT level for a client being heparinized is somewhere between 46-70 seconds (1.5-2.0 times the baseline value). An aPTT of 140 seconds is too long and this client is showing signs of bleeding. The nurse should stop the heparin infusion, notify the HCP, and review administration guidelines for possible administration of protamine (reversal agent for heparin). (Option 1) Continuing the heparin infusion will put the client at risk for a severe bleeding episode. (Option 2) Vitamin K is the reversal agent for warfarin. (Option 3) There is no reason to redraw blood for laboratory workup at this time as the abnormal aPTT result is consistent with the client’s bleeding. Laboratory studies may need to be redone within 1 hour of stopping the infusion or giving a reversal agent. Educational objective: The nurse should stop the infusion of heparin when there is evidence of bleeding. The HCP should be notified immediately and the nurse should be prepared to give protamine if ordered. The emergency department nurse prepares a male client for surgery. The client was admitted with a traumatic open fracture of the femur, hematocrit of 36%, and hemoglobin of 12 g/dL. Which prescription should the nurse validate with the health care provider (HCP) before administration? Unordered Options Ordered Response 1. Cefazolin 2. Enoxaparin 3. Morphine 4. Tetanus toxoid Explanation The Joint Commission Surgical Improvement Project CORE measure set has shown that preventives (eg, heparin, enoxaparin, aspirin) in select surgical procedures, given 24 hours before and after surgery, reduce the risk of venous thromboembolism. However, the estimated blood loss in a client with a fracture can be significant depending on the site (eg, 250-1200 mL). Although this client's admission hematocrit (36%) and hemoglobin (12 g/dL) are only slightly low for an adult male (normal: 39%- 50%, 13.2-17.3 g/dL), the blood loss may not yet be evident. Therefore, the nurse would validate the prescription for enoxaparin (Lovenox) with the HCP before administration. Medications commonly prescribed for a client with an open fracture include: • Cefazolin (Ancef), a bone-penetrating cephalosporin antibiotic that is active against skin flora (Staphylococcus aureus); it is given prophylactically before and after surgery to prevent infection (Option 1) • Cyclobenzaprine (Flexeril), a central and peripheral muscle relaxant given to treat pain associated with muscle spasm; carisoprodol (Soma) or methocarbamol (Robaxin) can also be prescribed • Tetanus and diphtheria toxoid, an immunization given prophylactically to prevent infection (Clostridium tetani) if immunizations are not up to date (>10 years), unavailable, or unknown (Option 4) • Ketorolac (Toradol), a nonsteroidal anti-inflammatory drug given to decrease inflammation and pain • Opioids (eg, morphine, hydrocodone [Vicodin]), given for analgesia (Option 3) Educational objective: Medications commonly prescribed for a client with an open fracture to prevent infection and treat pain and muscle spasm include cefazolin (Ancef), tetanus toxoid, ketorolac (Toradol), opioids, and cyclobenzaprine (Flexeril). The nurse is assessing a client with hypertension and essential tremor 2 hours after receiving a first dose of propranolol. Which assessment is most concerning to the nurse? Unordered Options Ordered Response 1. Client reports a headache 2. Current blood pressure is 160/88 mm Hg 3. Heart rate has dropped from 70/min to 60/min 4. Slight wheezes auscultated during inspiration Explanation Propranolol is a nonselective beta-blocker that inhibits beta1 (heart) and beta2 (bronchial) receptors. It is used for many indications (eg, essential tremor) in addition to blood pressure control. Blood pressure decreases secondary to a decrease in heart rate. Bronchoconstriction may occur due to the effect on the beta2 receptors. The presence of wheezing in a client taking propranolol may indicate that bronchoconstriction or bronchospasm is occurring. The nurse should assess for any history of asthma or respiratory problems with this client and notify the health care provider (HCP). (Option 1) A headache is a common occurrence with hypertension. The nurse may administer an analgesic as needed. (Option 2) This is the first dose of propranolol that the client has received. It may take several days of treatment for the blood pressure to reduce to a more normal reading. (Option 3) A reduction in heart rate is expected with a beta-blocker. The nurse should continue to monitor it for further reduction. Educational objective: The nurse should be concerned about the presence of wheezing in a client taking a nonselective beta-blocker like propranolol. Wheezing may indicate bronchoconstriction or bronchospasm. The nurse should assess for any history of asthma or other respiratory problems and report to the HCP The nurse has provided education for a client newly prescribed alprazolam for generalized anxiety disorder. Which client statement indicates that teaching has been effective? Unordered Options Ordered Response 1. "Eliminating aged cheeses and processed meats from my diet is essential." 2. "I can skip doses on days that I am not feeling anxious." 3. "I will take my daily dose at bedtime." 4. "Using sunscreen is important as this drug will make me sensitive to sunlight." Explanation Benzodiazepines (eg, alprazolam [Xanax], lorazepam [Ativan], clonazepam, diazepam) are commonly used antianxiety drugs. They work by potentiating endogenous GABA, a neurotransmitter that decreases excitability of nerve cells, particularly in the limbic system of the brain, which controls emotions. Benzodiazepines may cause sedation, which can interfere with daytime activities. Giving the dose at bedtime will help the client sleep. (Option 1) Eliminating aged cheeses and processed meats, which contain tyramine, is necessary with monoamine oxidase inhibitors (eg, tranylcypromine, phenelzine), which are used for depressive disorders. It is not necessary with benzodiazepines. (Option 2) A benzodiazepine should never be stopped abruptly. Instead, it should be tapered gradually to prevent rebound anxiety and a withdrawal reaction characterized by increased anxiety, confusion, and more. (Option 4) Photosensitivity is a problem with most antipsychotics and many antidepressants, but not with benzodiazepines. Educational objective: Benzodiazepines have a sedative effect and should be administered at bedtime when possible. Benzodiazepines should never be stopped abruptly in long-term users as this can precipitate withdrawal symptoms. A client diagnosed with stable angina is being discharged home on the cholesterol- lowering drug rosuvastatin. The nurse should teach the client to report which side effect to the health care provider (HCP) immediately? Unordered Options Ordered Response 1. Abdominal discomfort 2. Insomnia 3. Morning headache 4. Muscle aches or weakness Explanation Rosuvastatin (Crestor) is a strong statin drug that can cut LDL drastically and reduce total cholesterol and triglycerides. It also increases HDL. A serious complication associated with statin medication is rhabdomyolysis. Rhabdomyolysis is the breakdown of muscle tissue that leads to the release of muscle fiber contents into the blood. These substances can be harmful to the kidney and often cause kidney damage. The client should immediately report any signs of muscle aches or weakness to the HCP. These could be early signs of rhabdomyolysis, which can be fatal. (Options 1, 2, and 3) These can also be considered side effects of rosuvastatin calcium, but they are minor and do not need to be reported to the HCP immediately. If they persist, the client should consider reporting them. Educational objective: The nurse should teach all clients taking statin drugs (eg, atorvastatin, rosuvastatin) to immediately report any muscle aches or weakness, as these can lead to rhabdomyolysis, a muscle disintegration that can cause serious kidney injury. Which herbal supplements pose an increased risk for bleeding in surgical clients and should be discontinued prior to major surgery? Select all that apply. Unordered Options Ordered Response 1. Black cohosh 2. Garlic 3. Ginger 4. Ginkgo biloba 5. Hawthorne Explanation Clients are often aware of the need to discontinue prescription medications such as aspirin and anticoagulants prior to elective surgery, but they may not know that some herbal supplements can increase bleeding risk. The nurse should question the client specifically about the use of herbal supplements. Herbal supplements that can increase risk for bleeding include: • Gingko biloba • Garlic • Ginseng • Ginger • Feverfew (Option 1) Black cohosh is used for treatment of menopausal symptoms. The main side effect is liver injury. (Option 5) Hawthorne extract is used to control hypertension and mild to moderate heart failure. Hawthorne use does not increase the risk of bleeding. Educational objective: Use of herbal supplements such as ginkgo biloba, garlic, ginseng, ginger, and feverfew should be reported to the health care provider before surgery as they may increase the risk of bleeding. A client has a deep vein thrombosis and is receiving a heparin drip. The client's activated partial thromboplastin time (aPTT) has been in the therapeutic range for the past 24 hours. The most recent laboratory value shows that the current aPTT equals the control value. What explanation should the nurse consider? Unordered Options Ordered Response 1. The client became tolerant to heparin 2. The client consumed spinach 3. The client developed thrombocytopenia 4. The client's intravenous (IV) line is infiltrated Explanation With a heparin drip infusion, the goal is to reach the therapeutic range of the drug's effect and not the "normal" or "control value." Once the therapeutic effect range has been reached (usually 1.5-2.0 times the control value), it usually remains within this range without titrating the heparin infusion rate. Heparin has a short duration (approximately 2-6 hours IV). Therefore, if it is not being infused, the aPTT level will go back to the control value (aPTT level without administration of anticoagulants). In addition, the volume of heparin being infused is small (because the standard concentration is 100 units/mL) so it is possible to miss an infiltration. (Option 1) Clients do not develop tolerance to heparin. However, tolerance is typically seen with other medications such as nitroglycerine and opioids. (Option 2) Consumption of dark-green leafy vegetables is an issue related to therapeutic levels of warfarin (Coumadin). These foods have vitamin K, the antagonist for warfarin. However, this is not an issue related to heparin administration. (Option 3) Low platelets (heparin-induced thrombocytopenia) are a risk for clients on heparin; this can typically result in clot formation rather than bleeding (paradoxic effect) but has no effect on aPTT. Educational objective: PTT is used to measure the therapeutic effect of heparin IV infusion (should be 1.5-2.0 times the control value). Due to the short half-life, the possibility of infiltration should be assessed if the PTT level suddenly drops despite heparin administration. The nurse reviews a client's medical record and notes the following PRN medication prescriptions: acetaminophen, haloperidol, and benztropine. The nurse would administer a dose of benztropine on assessing which client behavior? Unordered Options Ordered Response 1. Muscle rigidity and shuffling gait 2. Nihilistic delusions 3. Tangentiality 4. Waxy flexibility Explanation Benztropine (Cogentin) is an anticholinergic medication used to treat some extrapyramidal symptoms, which are side effects of some antipsychotic medications. These side effects include: • Pseudoparkinsonism: Symptoms that resemble parkinsonism (eg, masklike face, shuffling gait, rigidity, resting tremor, psychomotor retardation [bradykinesia]) • Dystonia: Abnormal muscle movements of the face, neck, and trunk caused by sustained muscular contractions (eg, torticollis, oculogyric crisis, opisthotonos) (Options 2, 3, and 4) Delusions are a symptom of schizophrenia. Tangentiality (deviating from the original topic of discussion) is an abnormal thought process seen in schizophrenia. Waxy flexibility (tendency to remain in an immobile posture) is a motor disturbance seen in schizophrenia. All are treated with antipsychotic medications. Educational objective: Benztropine (Cogentin) is an anticholinergic drug used to treat extrapyramidal symptoms, which are side effects of some antipsychotic medications. A client with methicillin-resistant Staphylococcus aureus (MRSA) bacteremia has been receiving IV vancomycin for the last 3 days. Which blood test trend is most important for the nurse to review when preparing to administer this medication? Unordered Options Ordered Response 1. Blood cultures 2. Creatinine levels 3. Magnesium levels 4. White blood cell (WBC) count Explanation Vancomycin can cause nephrotoxicity, which occurs most often in clients who already have some degree of renal impairment. Serum creatinine levels should be monitored daily during IV vancomycin treatment to look for an increase in level over a few days. If an increasing trend is identified, the nurse should consult with the health care provider (HCP) and/or pharmacist before administering the dose. (Option 1) Blood cultures may be checked periodically during vancomycin therapy, but they are not likely to change this quickly. (Option 3) Magnesium levels are typically not affected by vancomycin therapy. (Option 4) The WBC count may be helpful in determining the effectiveness of vancomycin therapy in treating infection. However, this laboratory result is unlikely to influence the nurse's decision on whether to administer the dose. Therefore, it is not the highest priority. Educational objective: Creatinine levels should be closely monitored for signs of nephrotoxicity in the client receiving IV vancomycin. If increasing creatinine is identified, the nurse should hold the dose and consult with the HCP and/or pharmacist before administration. Copyright © UWorld. All rights reserved. The nurse is preparing to administer a sodium polystyrene sulfonate retention enema. Which explanation by the nurse best describes the purpose of this type of enema? Unordered Options Ordered Response 1. "A contrast medium is administered rectally to visualize the colon via x-ray." 2. "Bedridden clients receive this enema to stimulate defecation and relieve constipation." 3. "This enema assists the large intestines in removing excess potassium from the body." 4. "This enema is administered before bowel surgery to decrease bacteria in the colon." Explanation Sodium polystyrene sulfonate (Kayexalate) retention enema is a medicated enema administered to clients with high serum potassium levels. The resin in Kayexalate replaces sodium ions for potassium ions in the large intestine and promotes evacuation of potassium-rich waste from the body, thereby lowering the serum potassium level. Kayexalate can also be given orally and is much more effective. Kayexalate can rarely be associated with intestinal necrosis. (Option 1) A barium enema uses contrast medium (barium) administered rectally to visualize the colon using fluoroscopic x-ray. (Option 2) A fleet enema relieves constipation by infusing a hypertonic solution into the bowel, pulling fluid into the colon and causing distension and then defecation. (Option 4) A neomycin enema is a medicated enema that reduces the number of bacteria in the intestine in preparation for colon surgery. Educational objective: Kayexalate retention enemas are medicated enemas administered to clients with high serum potassium levels. The resin in Kayexalate replaces sodium ions for potassium ions in the large intestine and promotes evacuation of potassium-rich waste from the body, thereby lowering the serum potassium level The health care provider (HCP) has told a client to take over-the-counter (OTC) supplemental calcium carbonate 1000 mg/day for treatment of osteoporosis. Which instruction should the clinic nurse give the client? Unordered Options Ordered Response 1. Monthly calcium levels will need to be drawn 2. Stop vitamin D supplements when taking calcium 3. Take calcium at bedtime 4. Take calcium in divided doses with food Explanation Calcium and vitamin D are essential for bone strength. Calcium carbonate (Caltrate) has the most available elementalcalcium of OTC products and is inexpensive; it is therefore the preferred calcium supplement for most clients with osteoporosis. Calcium absorption is impaired when taken in excess of 500 mg per dose. Therefore, most clients should take supplements in divided doses (<500 mg per dose). These should be taken within an hour of meals as food increases calcium absorption. Constipation is a frequent side effect of calcium supplements, so clients should be advised to take appropriate precautions. Calcium carbonate and calcium acetate (PhosLo) are used to reduce serum phosphorous levels in clients with chronic kidney disease. In such cases, calcium should remain in the intestine and bind the phosphorous present in food; the calcium phosphorus product would then be excreted in stool. Therefore, these clients should take calcium supplements before meals. (Option 1) Calcium levels may need to be checked periodically, but it is not necessary to do so monthly. (Option 2) Vitamin D also increases calcium absorption and is important for treatment of osteoporosis. There is no need to stop it. (Option 3) Calcium does not need to be taken at any particular time of day. Educational objective: The nurse should encourage the client with osteoporosis to take supplemental calcium with food to increase its absorption. Vitamin D will also enhance absorption. Multiple daily doses are recommended as calcium absorption is impaired when taken in excess of 500 mg per dose. Constipation is a frequent side effect of calcium supplementation. A nurse is preparing an educational presentation on herbal supplements for the local community center. Saw palmetto is one herbal medicine being discussed. Which audience participants would find this information beneficial? Unordered Options Ordered Response 1. Clients diagnosed with heart failure 2. Clients experiencing major depressive disorder 3. Elderly clients with benign prostatic hyperplasia 4. Perimenopausal clients experiencing hot flashes Explanation Herbal preparations are not regulated by governmental agencies and are generally classified as food or dietary supplements. Manufacturers are therefore able to avoid the scientific scrutiny exercised when prescription drugs are readied for the market. Saw palmetto is one such herbal preparation, and clients most often use it to treat benign prostatic hyperplasia. (Option 1) Hawthorn extract is used to treat heart failure and in some countries (eg, Germany) is an approved treatment for this purpose. (Option 2) St John's wort has been used for centuries to treat depression. It may cause hypertension and serotonin syndrome when used with other antidepressants. (Option 4) Black cohosh is an herbal supplement often used by perimenopausal clients experiencing hot flashes. Educational objective: Saw palmetto, a herbal preparation, is often used to treat benign prostatic hyperplasia. St John's wort has been used for centuries to treat depression The home health nurse visits a client with hypertension whose blood pressure has been well controlled on oral valsartan 320 mg daily. The client's blood pressure is 190/88 mm Hg, significantly higher than it was 2 weeks ago. The client reports a cold, stuffy nose and sneezing for 3 days. Which of the following questions is most appropriate for the nurse to ask? Unordered Options Ordered Response 1. "Are you taking any over-the-counter (OTC) medicines for your cold?" 2. "Are you taking extra vitamin C?" 3. "Did you babysit your granddaughter this past week?" 4. "Did you get a flu shot in the past week?" Explanation Clients with hypertension should be instructed not to take potentially high-risk OTC medications such as high-sodium antacids, appetite suppressants, and cold and sinus preparations. It is appropriate to ask a client with hypertension about taking OTC cold medications as many cold and sinus medications contain phenylephrine or pseudoephedrine. These sympathomimetic decongestants activate alpha-1 adrenergic receptors, producing vasoconstriction. The resulting decreased nasal blood flow relieves nasal congestion. These agents have both oral and topical forms. With systemic absorption, these agents can cause dangerous hypertensive crisis. (Option 2) Taking extra vitamin C may offer some protection for the immune system, but it does not cause an increase in blood pressure. (Option 3) Exposure to young children increases the risk for contracting a contagious respiratory illness, but it does not directly increase blood pressure. (Option 4) A flu shot would not offer protection against the flu within a week and does not cause an increase in blood pressure. Educational objective: Clients with hypertension should be instructed not to take potentially high-risk OTC medications, including high-sodium antacids, appetite suppressants, and cold and sinus preparations, as they can increase blood pressure. A client with a history of heart failure calls the clinic and reports a 3-lb (1.4-kg) weight gain over the past 2 days and increased ankle swelling. The nurse reviews the client's medications and anticipates the immediate need for dosage adjustment of which medication? Unordered Options Ordered Response 1. Bumetanide 2. Candesartan 3. Carvedilol 4. Isosorbide Explanation Most clients with heart failure are prescribed a loop diuretic (eg, furosemide, torsemide, bumetanide) to reduce fluid retention. If the client has signs and symptoms of excessive fluid accumulation, the nurse will need to assess the situation by asking the client about dietary and fluid intake, adherence to prescribed medications, and the presence of any other associated symptoms (eg, shortness of breath). If the client is stable, the nurse may anticipate the need to increase the dosage of the prescribed loop diuretic (eg, bumetanide). (Option 2) Losartan, valsartan, and candesartan (sartans) are the commonly used angiotensin II receptor blockers. They are used in clients who cannot take ACE inhibitors (eg, lisinopril, ramipril). They block the renin-angiotensin-aldosterone system but will not affect the fluid status of the client with acute heart failure. (Option 3) Metoprolol, bisoprolol, and carvedilol (lols) are the commonly used beta blockers for treatment of chronic heart failure. They block the negative effects of the sympathetic nervous system (increased heart rate) and reduce the cardiac workload. However, they can worsen heart failure if used in the acute setting of this condition. (Option 4) Isosorbide (nitrate) and hydralazine are used in African American clients with heart failure; this combination decreases cardiac workload by reducing preload and afterload. However, it does not decrease excess fluid. Educational objective: A client who reports weight gain and edema requires evaluation for additional symptoms of fluid volume overload (eg, shortness of breath) and adherence to the current treatment plan. If the client is stable, an increase in the dosage of loop diuretic (eg, furosemide, torsemide, bumetanide) is anticipated. The nurse in an outpatient clinic cares for a client with primary adrenal insufficiency (Addison's disease) who has been taking hydrocortisone 20 mg/day for the last 8 years. Which client data is most important to report to the primary healthcare provider (PHCP)? Unordered Options Ordered Response 1. Development of moon face 2. Heart rate increase from 75 to 84/min 3. Low-grade fever of 100 F (37.7 C) 4. Weight gain of 6 lb (2.7 kg) in 3 months Explanation Corticosteroid therapy is the primary classification of drugs used to treat Addison's disease, an adrenocortical insufficiency. Signs and symptoms of infection should be reported to the PHCP immediately. Use of corticosteroids can cause immunosuppression. Infection can develop quickly and spread rapidly. Its anti- inflammatory effects may also mask signs of infection such as inflammation, redness, tenderness, heat, fever, and edema. In addition, physiological stress such as infection can trigger addisonian crisis, a life-threatening complication of Addison's disease. (Options 1, 2, and 4) Tachycardia, moon face, and weight gain are also side effects of long-term corticosteroid therapy; however, they are not as life-threatening as infection. Educational objective: In a client taking corticosteroids, it is imperative to notify the PHCP if signs and symptoms of infection, even a low-grade fever, occur. This is because the anti- inflammatory properties of these drugs can mask infection that can spread quickly in this type of immunocompromised client. The nurse is preparing to administer 160 mg of furosemide via IV piggyback to a client with chronic kidney disease and fluid overload. The nurse plans to give the dose slowly over 40 minutes to prevent which adverse effect? Unordered Options Ordered Response 1. Bradycardia 2. Hypokalemia 3. Nephrotoxicity 4. Ototoxicity Explanation IV furosemide may cause ototoxicity, particularly when high doses are administered in clients with compromised renal function. The rate of administration should not exceed 4 mg/min in doses >120 mg. To determine the correct rate of administration for the dose above, use the following formula: (160 mg) / (4 mg/min) = 40 min (Option 1) Bradycardia is an adverse effect of beta blockers (eg, metoprolol, atenolol), calcium channel blockers (eg, verapamil), and digoxin. It is not an adverse effect of furosemide. (Option 2) Hypokalemia is common with furosemide administration due to the potassium-wasting effects of this loop diuretic. However, slower infusion is unlikely to prevent this adverse effect. (Option 3) Although nephrotoxicity can occur with IV furosemide administration, it is dependent on the dose, not the rate of administration. Educational objective: High doses of IV furosemide should be administered slowly to prevent ototoxicity. A client with chronic heart failure is being discharged home on furosemide and supplementary potassium chloride tablets. Which instructions related to the potassium supplement should the nurse give to the client? Unordered Options Ordered Response 1. "A diet rich in protein and vitamin D will help with absorption." 2. "If the tablet is too large to swallow, crush and take it in applesauce or pudding." 3. "Potassium tablets should be taken on an empty stomach." 4. "Take it with plenty of water and sit upright for a period of time afterward." Explanation Furosemide is considered a "potassium-wasting" diuretic, meaning that a client could experience loss of potassium. A low potassium level in a client with heart failure could be dangerous due to possible life-threatening dysrhythmias and increased susceptibility to toxicity from digoxin (if taken). Therefore, potassium supplementation is needed for this client. Potassium should be taken with plenty of water (at least 4 ounces), and the client should sit upright for a period of time after ingestion. This prevents the tablet from lodging in the esophagus, which can cause erosion and pill-induced esophagitis. Pill-induced esophagitis is also common with tetracyclines (eg, doxycycline) and bisphosphonates ("dronates": alendronate, ibandronate, pamidronate, risedronate), and clients taking these medications should be given similar instructions. (Option 1) A diet rich in protein and vitamin D will help with calcium supplement absorption. (Option 2) Some potassium tablets are sustained-release and should not be crushed. The nurse would need to verify the type of tablet the client is taking before giving this instruction. (Option 3) Potassium should be taken with a meal or immediately following a meal to prevent gastric upset. Educational objective: The nurse should teach the client to take potassium tablets with plenty of water (at least 4 ounces) and to sit upright after ingestion to prevent pill-induced esophagitis. Potassium should also be taken with meals or immediately after a meal to prevent gastric upset. Sustained-release tablets should not be crushed. The nurse administers 8 units of regular insulin subcutaneously at 11:30 AM to a client with type I diabetes mellitus and serves the client lunch 30 minutes later. The client eats a few bites, becomes nauseated, and is unable to finish the meal. When is the client at highest risk for experiencing an insulin-related hypoglycemic reaction? Unordered Options Ordered Response 1. 12:30 PM 2. 2:00 PM 3. 4:00 PM 4. 6:00 PM Explanation The client is at highest risk for experiencing an insulin-related hypoglycemic reaction when the drug peaks. The peak indicates the time during which insulin works at its maximum strength to lower the blood glucose. Regular insulin is short-acting and peaks 2-4 hours after administration. The onset of regular insulin is 30 minutes-1 hour with duration of 3-6 hours. (Option 1) 12:30 PM is 1 hour after insulin administration. Rapid-acting insulins (lispro, aspart, glulisine) reach peak effect in 45-75 minutes. (Option 3) 4:00 PM is 4.5 hours after insulin administration. Neutral protamine Hagedorn (NPH) is an intermediate-acting insulin that reaches peak effect in 4 hours. (Option 4) 6:00 PM is 6.5 hours after insulin administration. Detemir reaches peak around this time (varies from 4-9 hours). Educational objective: The client is at highest risk for experiencing an insulin-related hypoglycemic reaction when the drug peaks. Regular insulin is short-acting and peaks 2-4 hours after administration A client with bronchial asthma and sinusitis has increased wheezing and decreased peak flow readings. During the admission interview, the nurse reconciles the medications and notes that which of the following over-the-counter medications taken by the client could be contributing to increased asthma symptoms? Unordered Options Ordered Response 1. Guaifenesin 600 mg orally twice a day as needed 2. Ibuprofen 400 mg orally every 6 hours for pain as needed 3. Loratadine 1 tablet orally every day as needed 4. Vitamin D 2,000 units orally every day Explanation Two groups of commonly used drugs, nonsteroidal anti-inflammatory drugs and beta-adrenergic antagonists (beta blockers), have the potential to cause problems for clients with asthma. Ibuprofen (Motrin) and aspirin are common over-the-counter anti-inflammatory drugs that are effective in relieving pain, discomfort, and fever. About 10%-20% of asthmatics are sensitive to these medications and can experience severe bronchospasm after ingestion. This is prevalent in clients with nasal polyposis. (Option 1) Guaifenesin (Mucinex) is an expectorant used to facilitate mobilization of mucus and should not have the potential to exacerbate asthma or cause an attack. (Option 3) Loratadine (Claritin) is an antihistamine and should not have the potential to exacerbate asthma or cause an attack. (Option 4) Vitamin D is used to help maintain bone density and should not have the potential to exacerbate asthma or cause an attack. Educational objective: Ibuprofen and aspirin are common over-the-counter anti-inflammatory drugs that can cause bronchospasm in some clients with asthma. A client with cancer pain is prescribed oxycodone. Which teaching is most essential to help prevent long-term complications? Unordered Options Ordered Response 1. Teach the client how to assess blood pressure daily 2. Teach the client how to prevent constipation 3. Teach the client how to prevent itching 4. Teach the client how to prevent nausea Explanation Oxycodone is a morphine-like opioid medication. Opioid medications bind to opioid receptors in the intestine, which slows peristalsis and increases water absorption, leading to constipation. Constipation is an almost universally expected side effect from opioid medications. Clients will not develop tolerance to this side effect. Although clients with idiopathic chronic constipation are not commonly advised to take laxatives, opioid-induced constipation is treated with simultaneous use of senna (stimulant) and docusate (stool softener). (Options 1 and 3) Opioids cause the release of histamine, a vasodilator, which is responsible for pruritus and flushing. Opioids can also cause peripheral vasodilation and nervous system depression; both can lead to hypotension. These develop in some clients when the treatment is initiated but usually resolve over time. Antihistamines (eg, diphenhydramine) can prevent the pruritus. Lifestyle changes (eg, rising slowly from a seated position) and adequate hydration can prevent hypotension. (Option 4) Opioids stimulate the opioid receptors in the gastrointestinal tract and the chemoreceptor trigger zone in the brain, producing nausea. This is also not seen with long-term use. Antiemetics (eg, ondansetron) can be helpful. Educational objective: Constipation is an expected long-term side effect of opioid use; clients will not develop tolerance to this side effect. It is important to teach aggressive preventive measures (eg, defecate when the urge is felt, drink 2-3 L of fluid/day, high-fiber diet, exercise) and simultaneous use of a stool softener and a stimulant. A client with long-term hypertension and hypercholesterolemia comes to the clinic for an annual checkup. The client takes nifedipine, simvastatin, and spironolactone and reports some occasional dizziness. Which statement by the client would warrant intervention by the nurse? Unordered Options Ordered Response 1. "I've been better about walking for 20 minutes 3 days a week on my treadmill." 2. "I've been trying to eat more fruits and vegetables. I discovered that I really like grapefruit." 3. "I've heard that having a glass of red wine with dinner every night is good for my heart." 4. "We no longer add salt when preparing meals. It has really been hard to get used to that." Explanation The nurse should intervene when the client talks about eating grapefruit. Grapefruit inhibits enzyme CYP3A4. The drugs that are metabolized by the same pathway would not be metabolized, resulting in higher drug levels and serious side effects. Calcium channel blocker (eg, nifedipine) use with grapefruit juice can cause severe hypotension; some statins (eg, simvastatin) may result in myopathy. (Option 1) The nurse should praise and encourage the client to continue exercising and possibly increase the amount. This is a positive lifestyle change. The client should engage in moderate-intensity aerobic exercise for at least 30 minutes most days of the week or vigorous-intensity aerobic exercise for 20 minutes 3 days a week. (Option 3) It is thought that red wine in moderation has some beneficial effects on the heart. The nurse would not encourage a client to start drinking red wine if the client didn't already. Excessive alcohol consumption is strongly associated with hypertension. The nurse should encourage the client to discuss alcohol consumption with the health care provider (HCP). (Option 4) Sodium restriction is important in the management of hypertension. This teaching should be reinforced and the client should be encouraged to restrict the use of salt. Educational objective: The nurse should tell the client not to eat grapefruit or drink grapefruit juice while taking calcium channel blockers due to the possible development of severe hypotension. The nurse should report this client's statement to the HCP. The client has increased intracranial pressure with cerebral edema, and mannitol is administered. Which assessment should the nurse make to evaluate if a complication from the mannitol is occurring? Unordered Options Ordered Response 1. Auscultate breath sounds to assess for crackles 2. Monitor for >50 mL/hr urine output 3. Monitor Glasgow Coma Scale increasing from 8/15 to 9/15 4. Press over the tibia to assess for pitting edema You answered this question incorrectly. Explanation Mannitol (Osmitrol) is an osmotic diuretic used to treat cerebral edema (increased intracranial pressure) and acute glaucoma. When administered, mannitol causes an increase in plasma oncotic pressure (similar to excess glucose) that draws free water from the extravascular space into the intravascular space, creating a volume expansion. This fluid, along with the drug, is excreted through the kidneys, thereby reducing cerebral edema and intracranial pressure. However, if a higher dose of mannitol is given or it accumulates (as in kidney disease), fluid overload that may cause life-threatening pulmonary edema results. An early sensitive indicator of fluid overload is new onset of crackles auscultated in the lungs. To prevent these complications, clients require frequent monitoring of serum osmolarity, input and output, serum electrolytes, and kidney function. (Option 2) Urine output would be expected to increase from the diuretic effect of mannitol. This is not a complication. (Option 3) Glasgow Coma Scale scores range from 3-15. Improved mental status (orientation, alertness) is a desired effect of treatment. (Option 4) The presence of crackles is a more sensitive sign of fluid overload than pedal edema. Furthermore, in a bedridden client, the assessment should take place at a dependent part of the body, usually the sacral area. Educational objective: Mannitol is an osmotic diuretic used to treat cerebral edema and acute glaucoma. Normal kidney function and adequate urine output are crucial while administering this medication as mannitol accumulation can result in significant volume expansion, dilutional hyponatremia, and pulmonary edema. A nurse is discharging a client who is receiving lithium for treatment of a bipolar disorder. It is most important for the nurse to provide which instruction to the client? Unordered Options Ordered Response 1. Avoid a high-potassium diet 2. Exercise regularly and maintain a high-fiber diet 3. Maintain oral hygiene 4. Report excessive urination and increased thirst Explanation Lithium is a mood stabilizer most often used to treat bipolar affective disorders. It has a narrow therapeutic index (0.6-1.2 mEq/L [0.6-1.2 mmol/L]). Risk factors for lithium toxicity include dehydration, decreased renal function (in the elderly), diet low in sodium, and drug-drug interactions (eg, nonsteroidal anti-inflammatory drugs [NSAIDS] and thiazide diuretics). Chronic toxicity can result in: 1. Neurologic manifestations – ataxia, confusion or agitation, and neuromuscular excitability (tremor, myoclonic jerks) 2. Nephrogenic diabetes insipidus – polyuria and polydipsia (increased thirst) (Option 4) Clients should be educated about monitoring for these symptoms and obtaining serum lithium levels at regular intervals. (Option 1) Dietary potassium should be avoided when taking drugs such as potassium- sparing diuretics (eg, spironolactone, triamterene, amiloride) and angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. (Option 2) Regular exercise and a high-fiber diet can prevent constipation, which is not a known side effect of lithium. Opioids, anticholinergics, and iron supplements are medications that cause constipation. (Option 3) Good oral hygiene is ideal for every client but is not specially indicated for those taking lithium. Clients taking phenytoin should maintain oral hygiene to prevent gingival hyperplasia. Educational objective: Risk factors for lithium toxicity include dehydration, decreased renal function, low- sodium diet, and drug-drug interactions (eg, NSAIDs and thiazide diuretics). Chronic toxicity manifests with neurologic symptoms (ataxia, confusion or agitation, and neuromuscular excitability) and/or diabetes insipidus (polyuria and polydipsia). The nurse is conducting intake interviews at the clinic. Which client situations would require the nurse to intervene? Select all that apply. Unordered Options Ordered Response 1. Client with iron deficiency anemia takes iron supplements with milk 2. Client takes levothyroxine early in the morning on an empty stomach 3. Client taking phenazopyridine for urine infection states that the urine has turned orange 4. Client taking metronidazole mentions going to a wine-tasting party tonight 5. Client with closed-angle glaucoma takes over-the-counter diphenhydramine for a cold Explanation Iron is absorbed better on an empty stomach; ascorbic acid (vitamin C), such as found in citrus fruits and juices, increases the absorption of iron. However, milk products decrease iron absorption and should be avoided (Option 1). Metronidazole (Flagyl) is used to treat trichomoniasis and amebiasis. Consuming alcohol while taking the medication may elicit a disulfiram (Antabuse)-like reaction. Alcohol should be avoided for at least 48 hours after treatment is completed (Option 4). Many antihistamines also have anticholinergic effects. Anticholinergics have an antimuscarinic effect that can increase intraocular pressure and are therefore contraindicated in closed-angle glaucoma. Other contraindications include urinary retention (benign prostatic hyperplasia) and bowel obstruction related to the anticholinergic drug's effect on the smooth muscle in the urinary and gastrointestinal tract (Option 5). (Option 2) Enteral nutrition decreases levothyroxine absorption; as a result, it should be taken early in the morning on an empty stomach (at least 30 minutes before food intake). (Option 3) Phenazopyridine (Pyridium) is used as a local anesthetic in the treatment of urinary tract infection. The azo dye turns the urine an orange-red color. The client needs to be reassured that this is an expected result and could stain clothing. Educational objective: Clients taking metronidazole (Flagyl) should avoid alcohol. Those with glaucoma or urinary retention should avoid anticholinergic drugs. Oral iron is better absorbed on an empty stomach and with vitamin C. Phenazopyridine (Pyridium) will turn urine an orange-red color. A hospitalized client has been treated for the past 48 hours with a continuous heparin infusion for a deep vein thrombosis (DVT). When the nurse prepares to administer the evening dose of warfarin, the client's spouse says "Wait! My spouse can't have that! My spouse is already getting heparin for DVT." How should the nurse respond? Unordered Options Ordered Response 1. "Both medications will be given for several days until the warfarin has time to take effect." 2. "I will be discontinuing the heparin infusion as soon as I give this dose of warfarin." 3. "The two medications work synergistically to help break down the clot in your spouse's leg." 4. "We will hold the medication until I can call the health care provider (HCP) for clarification." Explanation Warfarin begins to take effect in 48-72 hours and then takes several more days to achieve a maximum effect. Therefore, an overlap of a parenteral anticoagulant like heparin with warfarin is required. The typical overlap is 5 days or until the INR reaches the therapeutic level. The nurse will need to explain this overlap of the 2 medications to the client and the spouse. (Option 2) The nurse should not discontinue the heparin infusion until the INR is at the therapeutic level. (Option 3) Anticoagulants like heparin and warfarin will not break down or dissolve clots. However, they inhibit any further clot formation and keep the current clot from getting larger. Thrombolytics, such as tissue plasminogen activator, do break down clots. (Option 4) Clarification from the HCP is not needed. The warfarin should be administered to the client after explaining the reasons for its use to the client and the spouse. Educational objective: Warfarin requires an overlap of therapy with unfractionated heparin infusion or low- molecular-weight heparin (eg, enoxaparin, dalteparin) for several days until the INR is in the therapeutic range for the client's condition. The health care provider (HCP) has prescribed amitriptyline 25 mg orally every morning for an elderly client with recent herpes zoster infection (shingles) and severe postherpetic neuralgia. What is the priority nursing action? Unordered Options Ordered Response 1. Encourage increased fluid intake 2. Provide frequent rest periods 3. Teach the client to get up slowly from the bed or a sitting position 4. Tell the client to wear sunglasses when outdoors Explanation Tricyclic antidepressants (eg, amitriptyline, nortriptyline, desipramine, imipramine) are commonly used for neuropathic pain. Side effects are especially common in elderly clients. Due to the increased risk of falling, the priority nursing action is to teach the client to get up slowly from the bed or a sitting position. (Options 1, 2, and 4) These are important instructions but not priority ones. Educational objective: The most common side effects experienced by clients taking tricyclic antidepressants include dizziness, drowsiness, dry mouth, constipation, photosensitivity, urinary retention, and blurred vision. The priority nursing action is to teach caution in changing positions due to the increased risk for falls from dizziness and orthostatic hypotension, especially in elderly clients. The hospice nurse is caring for an actively dying client who is unresponsive and has developed a loud rattling sound with breathing ("death rattle") that distresses family members. Which prescription would be most appropriate to treat this symptom? Unordered Options Ordered Response 1. Atropine sublingual drops 2. Lorazepam sublingual tablet 3. Morphine sublingual liquid 4. Ondansetron sublingual tablet Explanation The "death rattle" is a loud rattling sound with breathing that occurs in a client who is actively dying. When the client cannot manage airway secretions, the movement of these secretions during breathing causes a noisy rattling sound. This can distress family and friends at the bedside of the dying client. The "death rattle" can be treated using anticholinergic medications to dry the client's secretions. Medications include atropine drops administered sublingually or a transdermal scopolamine patch. (Option 2) Lorazepam is a benzodiazepine that is used to treat anxiety and restlessness in terminally ill clients. It can be effective for alleviating dyspnea exacerbated by anxiety, but it is ineffective for controlling secretions (the cause of the "death rattle"). (Option 3) Morphine is an opioid analgesic that is effective for pain treatment as well as terminal dyspnea. The client is not exhibiting these symptoms, so morphine would be inappropriate. (Option 4) Ondansetron will help the nausea and vomiting but is not very effective for treating the "death rattle." Educational objective: The "death rattle" a noisy rattling sound with breathing commonly seen in a dying client who is unresponsive and no longer able to manage airway secretions. Anticholinergic medications such as transdermal scopolamine or atropine sublingual drops effectively treat this symptom by drying up the excess secretions. A client with seizure disorder is prescribed a moderately high dose of phenytoin. Which teaching topic should the nurse discuss with this client? Unordered Options Ordered Response 1. Diet high in iron 2. Good oral care and dental follow-up 3. Shaving with an electric razor 4. Use of sunglasses for eye protection Explanation The nurse should discuss the need to perform good oral hygiene with a soft-bristle toothbrush and to visit the dentist regularly as phenytoin can cause gingival hyperplasia (overgrowth of the gum tissues or reddened gums that bleed easily), especially in high doses. Folic acid supplementation can also reduce this side effect. The other major side effects of phenytoin use are an increase in body hair, rash, folic acid depletion, and decreased bone density (osteoporosis). (Option 1) Long-term use of phenytoin can cause folic acid deficiency and decreased bone density. Therefore, a diet high in folic acid and calcium should be recommended. (Option 3) Clients who use anticoagulants (eg, warfarin, rivaroxaban, apixaban) should avoid cuts and preferably use an electric razor for shaving. (Option 4) Exposure of the eyes to ultraviolet light and use of corticosteroids are risk factors for cataract development. Educational objective: The nurse should encourage the client taking phenytoin to perform good oral hygiene and visit the dentist regularly to prevent gingival hyperplasia. The other major side effects of phenytoin use are an increase in body hair, rash, folic acid depletion, and decreased bone density (osteoporosis). A client has been on long-term therapy with esomeprazole. What is essential for the nurse to ask the client? Unordered Options Ordered Response 1. "Are you drinking plenty of water with the medication?" 2. "Are you taking the medication after meals?" 3. "Have you had a bone density test recently?" 4. "Have you had your blood pressure taken regularly?" Explanation Long-term therapy with a proton pump inhibitor (PPI) (eg, omeprazole, pantoprazole, esomeprazole) may decrease the absorption of calcium and promote osteoporosis. A bone density test can assess if the client already has osteoporosis. Hospitalized clients also have an increased risk of diarrhea caused by Clostridium difficile. PPIs cause suppression of acid that otherwise would have prevented pathogens from more easily colonizing the upper gastrointestinal tract. This leads to increased risk of pneumonias. (Option 1) Drinking extra water and being upright for 30 minutes after taking bisphosphonates (eg, risedronate, alendronate) is necessary to prevent esophagitis. However, this is not necessary with PPI use. (Option 2) The medication should be taken prior to meals. (Option 4) PPIs do not affect blood pressure. Educational objective: Long-term use of PPIs (eg, omeprazole, pantoprazole, esomeprazole) is associated with osteoporosis, C difficile infection, and pneumonias. Clients should be encouraged to increase calcium and vitamin D intake to help prevent osteoporosis The nurse evaluating a 52-year-old diabetic male client's therapeutic response to rosuvastatin would notice changes in which laboratory values? Select all that apply. Unordered Options Ordered Response 1. Alanine aminotransferase (ALT) from 20 U/L to 80 U/L 2. High-density lipoprotein (HDL) cholesterol from 48 mg/dL to 30 mg/dL 3. Low-density lipoprotein (LDL) cholesterol from 176 mg/dL to 98 mg/dL 4. Total cholesterol from 250 mg/dL to 180 mg/dL 5. Triglycerides from 180 mg/dL to 149 mg/dL Explanation Statins (rosuvastatin, atorvastatin, simvastatin, atorvastatin) are the most preferred agents to reduce LDL cholesterol, total cholesterol, and triglyceride levels. This client's LDL level has decreased to a target range (diabetic client <100 mg/dL), total cholesterol has decreased to a normal range (adult <200 mg/dL), and triglyceride level has decreased to a normal range (adult <150 mg/dL); all these changes indicate a therapeutic response (Options 3, 4, and 5). (Option 1) The adult therapeutic range of ALT is 10-40 U/L. Increased aspartate aminotransferase (AST) and ALT may indicate hepatic dysfunction, a potential adverse effect of statin medication. (Option 2) The therapeutic range of HDL cholesterol for adult men is >40 mg/dL. HDL is good cholesterol. This client's HDL level is below the therapeutic range, indicating a nontherapeutic response. Educational objective: A therapeutic response to statin medication includes a decrease in a client's LDL cholesterol, total cholesterol, and triglyceride levels to within normal range. An increase in HDL cholesterol to within normal range is also an expected outcome. Potential adverse effects include hepatic dysfunction and muscle injury. A client diagnosed with trigeminal neuralgia is given a prescription of carbamazepine by the health care provider. Which intervention does the nurse add to this client's care plan? Unordered Options Ordered Response 1. Encourage client to drink cold beverages 2. Encourage client to eat a high-fiber diet 3. Encourage client to perform facial massage 4. Encourage client to report any fever or sore throat Explanation Trigeminal neuralgia is sudden, sharp pain along the distribution of the trigeminal nerve. The symptoms are usually unilateral and primarily in the maxillary and mandibular branches. Clients may experience chronic pain with periods of less severe pain, or "cluster attacks" of pain between long periods without pain. Triggers can include washing the face, chewing food, brushing teeth, yawning, or talking. Pain is severe, intense, burning, or electric shock-like. The primary intervention for trigeminal neuralgia is consistent pain control with medications and lifestyle changes. The drug of choice is carbamazepine. It is a seizure medication but is highly effective for neuropathic pain. Carbamazepine is associated with agranulocytosis (leukopenia) and infection risk. Clients should be advised to report any fever or sore throat. Behavioral interventions include the following: 1. Oral care – use a small, soft-bristled toothbrush or a warm mouth wash 2. Use lukewarm water; avoid beverages or food that are too hot or cold (Option 1) 3. Room should be kept at an even and moderate temperature 4. Avoid rubbing or facial massage. Use cotton pads to wash the face if necessary. 5. Have a soft diet with high calorie content; avoid foods that are difficult to chew. Chew on the unaffected side of the mouth. (Option 2) A high-fiber diet is not required for a client with trigeminal neuralgia, and the additional chewing with higher-fiber foods may serve as a pain trigger. (Option 3) Clients with trigeminal neuralgia are encouraged not to massage the face as this can trigger pain. Educational objective: The primary intervention for trigeminal neuralgia includes pain control and limiting pain triggers. The drug of choice is carbamazepine. Triggers can include washing the face, chewing food, brushing teeth, yawning, or talking. Carbamazepine is associated with agranulocytosis (leukopenia) and infection risk. Clients should be advised to report any fever or sore throat. A client with type I diabetes mellitus is prescribed an insulin pump. The nurse reinforces the diabetic educator's teaching regarding transitioning from multiple daily injections to continuous subcutaneous insulin infusion (CSII) therapy. Which statement indicates that the client understands the advantages of using this therapy? Unordered Options Ordered Response 1. "I won't need a bolus dose of insulin before my meals anymore." 2. "I'm glad my blood sugars won’t go way up and way down, like they did before." 3. "I'm so glad I don’t have to stick my finger 4 times a day to test my sugar anymore." 4. "It'll finally be easier for me to lose some weight." Explanation An insulin pump is a small, battery-operated device about the size of a pager. The infusion set holds a syringe (reservoir) filled with rapid-acting insulin (175-315 units) and delivers the drug from the pump to the client through a needle or catheter that is usually secured to the abdomen with an adhesive patch. The pump delivers insulin in 2 ways: • As a steady, measured, and continuous dose (basal rate) 24 hours a day • As an intermittent dose (bolus) administered manually at mealtime to cover carbohydrate intake and as a supplemental dose to correct pre- or postprandial hyperglycemia. CSII therapy delivers the insulin more accurately than injections, so the client experiences fewer swings in blood glucose levels and hypoglycemic episodes, as compared with the administration of insulin using a needle and syringe, or pen. (Option 1) Although the pump can calculate and deliver a more precise dose to regulate blood glucose levels more effectively, a bolus dose must be administered manually at mealtime to cover carbohydrate intake. (Option 3) Pumps used most commonly (open-loop) cannot respond to changes in the client's glucose levels. The American Diabetes Association recommends that clients using CSII check their blood glucose levels 4-8 times a day: fasting, pre-meal, 2-hours postprandial, bedtime, at 3:00 AM weekly, when experiencing symptoms of hypoglycemia, after treating low blood sugar, and before exercise. Some insulin pumps (closed-loop system) are equipped with continuous blood glucose monitoring (CBGM) systems, which can detect blood glucose levels without a fingerstick. However, CBGM does not completely eliminate the need to test blood sugar because some machines must be calibrated every day to validate accuracy. (Option 4) Use of the insulin pump facilitates tighter glucose control, leading to more normal metabolism. However, if the client continues to take in more calories than needed for a given amount of activity or exercise, glucose that is not used by the cells accumulates as fat and results in weight gain. Educational objective: A client prescribed CSII is taught how to self-manage the insulin pump. Key points include the importance of checking blood glucose levels at least 4 times a day, how to administer a bolus dose at mealtime to cover carbohydrate intake, how to administer a supplemental bolus dose to correct pre- and postprandial hyperglycemia, and the importance of balancing diet and exercise to avoid excess weight gain. The nurse teaches the client taking atorvastatin to call the health care provider (HCP) if experiencing which symptom associated with a serious adverse effect of atorvastatin? Unordered Options Ordered Response 1. Diarrhea 2. Headache 3. Muscle aches 4. Numbness in the feet Explanation Atorvastatin (Lipitor) is a statin drug, or HMG-CoA reductase inhibitor, prescribed to lower cholesterol and reduce the risk of atherosclerosis and coronary artery disease. A serious adverse effect of statins, including atorvastatin and rosuvastatin (Crestor), is myopathy with ongoing generalized muscle aches and weakness. A client who develops muscle aches while on a statin drug should call the HCP who will then obtain a blood sample to assess the creatinine kinase (CK) level. If myopathy is present, CK will be significantly elevated (≥10x normal), and the drug will then be discontinued. (Option 1) Diarrhea is not a side effect of statin drugs. Colchicine used for gout and acute pericarditis commonly leads to diarrhea. Many antibiotics can induce diarrhea, and some may cause Clostridium difficile infection. (Option 2) Headache is not a serious side effect of statin drugs. It is often a bothersome side effect of nitrates and calcium channel blockers as they dilate intracranial vessels; however, tolerance usually develops over time. (Option 4) Numbness in the feet (neuropathy) is not a common side effect of statin drugs. It is commonly associated with isoniazid, amiodarone, and chemotherapy agents (eg, vincristine, cisplatin). Educational objective: The client taking a statin such as atorvastatin or rosuvastatin should be taught to call the HCP if generalized muscle aches develop as this may be a symptom of myopathy, a serious adverse effect of this type of medication. An elderly client with depression, diabetes mellitus, and heart failure has received a new digoxin prescription for daily use. Which client assessment indicates that the nurse should follow up on serum digoxin levels frequently? Unordered Options Ordered Response 1. Apical heart rate is 62/min 2. Blood sugar level is 240 mg/dL (13.3 mmol/L) 3. Client is taking 20 mg fluoxetine daily 4. Serum creatinine is 2.3 mg/dL (203 µmol/L) Explanation Digoxin (Lanoxin) is a cardiac glycoside that increases cardiac contractility but slows the heart rate and conduction. It is used in heart failure (to increase cardiac output) and atrial fibrillation (to reduce the heart rate). The drug is excreted almost exclusively by the kidney. BUN and creatinine levels are measurements of kidney function. The normal range for creatinine is 0.6-1.3 mg/dL (53- 115 µmol/L). Elderly clients tend to develop age-related decrease in glomerular filtration rate (GFR). These clients and those with obvious kidney injury (possibly due to diabetes in this client) can accumulate digoxin. The early symptoms of toxicity are nausea and vomiting. Later signs of toxicity are arrhythmias, including heart blocks. Therefore, clients at risk for digoxin toxicity require frequent drug level monitoring and dose adjustment. (Option 1) An apical heart rate is taken for a full minute prior to administration. It is safe to administer the drug when the apical heart rate is ≥60/min. (Option 2) An elevated blood sugar level requires attention but is unrelated to digoxin toxicity. However, hypokalemia can increase the risk of digoxin toxicity. (Option 3) Fluoxetine (Prozac) is an antidepressant drug that is a selective serotonin reuptake inhibitor. It does not usually interact with digoxin and its use is unaltered by cardiac disease. This is a normal dose. Educational objective: Digoxin (Lanoxin) is excreted almost exclusively by the kidneys. Decreased kidney function usually requires decreased digoxin dosage and frequent drug level monitoring. BUN and creatinine are measurements of kidney function A client presents to the emergency department with alcohol intoxication. Assessment shows nystagmus, ataxia, and confusion. The client's breath smells of alcohol. Which prescription from the health care provider should the nurse implement first? Unordered Options Ordered Response 1. Blood draw for liver function tests 2. D5 1/2 normal saline 3. Folic acid, IV 4. Thiamine, IV Explanation Clients with alcoholism can have hypoglycemia. They can also have thiamine (vitamin B1) deficiency related to poor nutrient intake (a healthy diet contains enough thiamine) and alcohol-induced suppression of thiamine absorption. Thiamine deficiency can result in Wernicke encephalopathy (WE). Untreated WE can lead to death or neurologic morbidity (Korsakoff psychosis). In the setting of alcoholism, administered glucose is oxidized by using all the existing thiamine in the body; this can worsen thiamine deficiency, which in turn can precipitate the development of WE in a previously unaffected individual. Because the signs of alcohol intoxication and WE are similar, all intoxicated clients should be given IV thiamine before or with IV glucose (Options 2 and 4). (Option 1) A blood draw for liver functions tests to rule out alcoholic hepatitis is important but not a priority. (Option 3) Clients with alcoholism usually have additional nutritional deficiencies (eg, folic acid, magnesium). Magnesium and multiple vitamins should also be given to these clients. However, thiamine is the essential vitamin to administer before or with IV glucose in a client with suspected alcoholism. Educational objective: IV thiamine is given before or with IV glucose to a client with alcohol intoxication to prevent Wernicke encephalopathy. Clients with alcoholism often have thiamine deficiency. The nurse is preparing to administer medications due at 1800 to a client who had an aortic valve replacement 5 days ago. The client also has a urinary tract infection and hypercholesterolemia. Which action should the nurse implement first? Click on the exhibit button for additional information. Unordered Options Ordered Response 1. Assess the client's complete blood count and potassium (K+) level 2. Check the client's international normalized ratio (INR) 3. Measure the client's vital signs 4. Verify the client's name and date of birth Explanation Warfarin is given as an anticoagulant to the client with a mechanical valve replacement. INR should be checked regularly to determine proper dosage and adequacy of therapy. An INR of 2.5-3.5 is considered therapeutic for a client with a mechanical valve. The nurse should not administer warfarin without checking the INR first. Warfarin should be administered if the INR is ≤3.5. If the INR is >3.5, the nurse should hold the dose and contact the health care provider (HCP) for further direction. (Option 1) The CBC and K+ level should have been checked during administration of the 0900 doses of levofloxacin and potassium chloride. (Option 3) The client's vital signs should be measured routinely, but administration of warfarin and simvastatin are not contingent on the results. (Option 4) Verification of the client's name and date of birth should be done at the bedside, immediately before medication administration. Educational objective: The nurse should check the client's most recent INR level prior to administering warfarin. Therapeutic level is 2.5-3.5 for clients with mechanical heart valves. The nurse should hold the dose and contact the HCP if INR is >3.5. A client with coronary artery disease and atrial fibrillation is being discharged home following coronary artery stent placement. Discharge medications are shown in the exhibit. The nurse identifies which educational topic as the highest priority for this client? Click on the exhibit button for additional information. Unordered Options Ordered Response 1. Bleeding risk 2. Bronchospasm 3. Muscle injury 4. Tinnitus Explanation This client is on 3 different medications that affect bleeding risk (aspirin, clopidogrel, and rivaroxaban); this drug combination places the client at increased risk for bleeding. Teaching the client about the signs and symptoms of bleeding and risk reduction is the highest priority. The nurse should instruct the client to monitor for black, tarry stools, bleeding gums, and excessive bruising. The client should also use a soft bristle toothbrush, shave with an electric razor, and refrain from playing contact sports. (Option 2) Bronchospasm rarely occurs with high doses of aspirin and metoprolol. This client is on low-dose aspirin and metoprolol. Although this should be a teaching topic for the client, bleeding is more likely to occur than this adverse reaction. (Option 3) Muscle cramps can be common with statins (eg, rosuvastatin, atorvastatin, simvastatin). However, muscle injury is rare and not as high in priority as bleeding risk. (Option 4) Tinnitus may occur with aspirin toxicity. However, this client is on baby aspirin (81 mg) and is very unlikely to experience adverse effects. Educational objective: Clients taking a combination of antiplatelet agents (eg, aspirin, clopidogrel, ticagrelor, prasugrel) and anticoagulants (eg, warfarin, rivaroxaban, apixaban) are at very high risk for life-threatening bleeding complications. The nurse should teach the client how to recognize and prevent signs and symptoms of increased bleeding. Which client is at greatest risk for respiratory depression when receiving opioids for pain control? Unordered Options Ordered Response 1. 20-year-old client with bronchitis receiving inhaled bronchodilator therapy every 4 hours 2. 30-year-old client with heroin addiction with rotator cuff repair surgery this morning 3. 50-year-old client with sleep apnea and left foot cellulitis and scheduled for a bone scan 4. 70-year-old client with chronic obstructive pulmonary disease (COPD) with knee replacement this morning Explanation The following are at greatest risk for respiratory depression related to opioid use for analgesia: the elderly; those with underlying pulmonary disease, history of snoring (with or without apnea), obesity, or smoking (more than 20-pack-year history); the opiate naïve, especially if treated for acute pain; and post surgery (first 24 hours). The 70-year old client has 3 significant risk factors: advanced age, COPD, and surgery within 24 hours. COPD clients who have hypercarbia and hypoxemia are at even greater risk for respiratory depression when receiving opioids. (Option 1) This client has 1 risk factor, pulmonary disease. (Option 2) This client has 1 risk factor, surgery within 24 hours. His addiction to heroin gives him a higher tolerance for opioids. (Option 3) This client has 1 risk factor, sleep apnea. Educational objective: Factors that increase risk for respiratory depression related to opioid use for pain control include advanced age, underlying pulmonary disease, snoring, obesity, smoking, opiate naïve, and surgery. The nurse has received 4 prescriptions from the health care provider (HCP). Which should the nurse clarify with the HCP prior to administering? Unordered Options Ordered Response 1. Hydrocodone/acetaminophen 10/325 mg orally every 4 hours as needed for pain 2. Ketorolac 15 mg IV every 6 hours as needed for pain x 5 days only 3. Levofloxacin 500 mg/100 mL IVPB over 90 minutes every 24 hours 4. Promethazine 25 mg IV every 6 hours as needed for nausea/vomiting Explanation Promethazine (Phenergan) is a commonly used antiemetic. It may be given intramuscularly, orally, rectally, or, in some cases, intravenously. The deep intramuscular route is strongly preferred over the IV route as severe adverse reactions have occurred with IV administration. Extravasation of the drug can cause chemical irritation and damage to tissues, including necrosis and gangrene. Some clients have had to undergo surgical intervention such as fasciotomy, skin graft, and/or amputation. Therefore, the U.S. Food and Drug Administration (FDA) has issued a Black Box warning to avoid the IV route; the subcutaneous route is absolutely contraindicated. (Option 1) Oral hydrocodone/acetaminophen (eg, Norco, Percocet) is a commonly prescribed medication to treat mild to moderate pain. Total acetaminophen dose per 24 hours should not exceed 4 g (to avoid liver toxicity). The FDA also recommends that health care providers prescribe tablets that contain no more than 325 mg of acetaminophen per dose. (Option 2) Ketorolac (Toradol) is also a commonly used parenteral nonsteroidal anti- inflammatory agent for moderate to severe (opioid level) pain. It should be administered for only 5 days or less due to a reported increase in severe adverse effects such as bleeding, kidney injury, and cardiovascular events (infarctions and stroke). (Option 3) Levofloxacin is an antibiotic. This is an appropriate dose and time of administration. Educational objective: Promethazine is a commonly used antiemetic. Intramuscular (IM) administration is strongly preferred over the IV route due to an increased incidence of severe tissue injury and gangrene with extravasation. Promethazine should be given through the deep IM route. The health care provider has just prescribed tetracycline for an adolescent with acne vulgaris. The client takes oral contraceptive pills. The clinic nurse should educate the teen about which topics? Select all that apply. Unordered Options Ordered Response 1. Not taking tetracycline with dairy products 2. Taking tetracycline at bedtime 3. Taking tetracycline with food 4. Using additional contraceptive techniques 5. Using sunblock Explanation The following should be taught to clients taking tetracyclines (eg, tetracycline, doxycycline, minocycline): 1. Take on an empty stomach – for optimum absorption, tetracyclines should be taken 1 hour before or 2 hours after meals (Option 3) 2. Avoid antacids or dairy products – tetracyclines should not be taken with iron supplements, antacids, or dairy products as they bind with the drug and decrease its absorption (Option 1) 3. Take with a full glass of water – tetracyclines can cause pill-induced esophagitis and gastritis; the risk can be reduced by taking with a full glass of water and remaining upright after pill ingestion 4. Photosensitivity – severe sunburn can occur with tetracycline. The client should use sunblock (Option 5). Medications such as tetracycline and rifampin can decrease the effectiveness of oral contraceptives; additional contraceptive techniques will be needed (Option 4). (Option 2) Tetracycline taken at bedtime has been associated with esophageal irritation and stricture development as it increases reflux of the gastric contents into the esophagus. This can be prevented by taking the medicine with plenty of water and during the day when upright. Educational objective: Tetracyclines should be taken 1 hour before or 2 hours after meals with plenty of water. They should not be taken with dairy products or within 2 hours of taking antacids. Clients should use sunblock due to photosensitivity and plan to use additional contraceptive techniques. The nurse is teaching a client with advanced chronic obstructive pulmonary disease who was prescribed oral theophylline. Which client statement indicates that additional teaching is required? Unordered Options Ordered Response 1. "I need to avoid caffeinated products." 2. "I need to get my blood drug levels checked periodically." 3. "I need to report anorexia and sleeplessness." 4. "I take cimetidine rather than omeprazole for heartburn." Last Updated: 11/12/2015 Explanation Theophylline is a bronchodilator with a low therapeutic index and a narrow therapeutic range (10-20 mcg/mL). The serum level should be monitored frequently to avoid severe adverse effects. Toxicity is likely to occur at levels >20 mcg/mL. Individual titration is based on peak serum theophylline levels, so it is necessary to draw a blood level 30 minutes after dosing. Theophylline can cause seizures and life-threatening arrhythmias. Toxicity is usually due to intentional overdose or concurrent intake of medications that increase serum theophylline levels. Cimetidine and ciprofloxacin can dramatically increase serum theophylline levels (>80%). Therefore, they should not be used in these clients. (Option 1) Caffeinated products (eg, coffee, cola, chocolate) should be avoided as they would intensify the adverse effects (eg, tachycardia, insomnia, restlessness) of theophylline. (Option 2) The best way to prevent toxicity is to monitor drug levels periodically and adjust the dose. (Option 3) The signs of toxicity that should be reported are anorexia, nausea, vomiting, restlessness, and insomnia. Educational objective: Theophylline can cause seizures and life-threatening arrhythmias due to its narrow therapeutic range (10-20 mcg/mL). The dose is adjusted based on peak drug levels, obtained 30 minutes after the dose is given. Clients should avoid caffeinated products and medications that increase serum theophylline levels (eg, cimetidine, ciprofloxacin). The nurse precepts a nursing student caring for a client with glaucoma and observes the student administer timolol maleate, an ophthalmic medication. Which student action indicates that further instruction is needed? Unordered Options Ordered Response 1. Instructs client to close eyelid and move eye around; applies pressure to the lacrimal duct for 30-60 seconds 2. Pulls lower eyelid down gently with thumb or forefinger against bony orbit to expose the conjunctival sac 3. Removes dried secretions with moistened sterile gauze pads by wiping from the outer to inner canthus 4. Rests hand on client's forehead and holds dropper 1-2 cm (1/2-3/4 in) above the conjunctival sac Explanation If applicable, the nurse requests that the client remove contact lenses. The nurse then dons clean gloves and uses aseptic technique to administer ophthalmic medications (eg, eye drops, lubricant) that lubricate the eye and treat eye conditions (eg, glaucoma, infection). The Joint Commission disallows the use of abbreviations for right eye (OD), left eye (OS), and both eyes (OU). The nurse must verify the prescription if the health care provider (HCP) uses these abbreviations. The general procedure for the administration of ophthalmic medications includes the following steps in sequence: 1. Remove dried secretions with moistened (warm water or normal saline) sterile gauze pads by wiping from the inner to outer canthus to keep eyelid and eyelash debris from entering the eye and to prevent transfer of debris into the lacrimal (tear) duct (Option 3) 2. Place client in the supine or sitting position with head tilted back toward side of the affected eye to prevent excess medication from flowing into the lacrimal duct and minimize systemic absorption through the nasal mucosa 3. Rest hand on client's forehead and hold dropper 1-2 cm (1/2-3/4 in) above the conjunctival sac, which keeps the dropper away from the eye globe and avoids contamination (Option 4) 4. Pull lower eyelid down gently with thumb or forefinger against bony orbit to expose the conjunctival sac (Option 2) 5. Instruct client to look upward and then instill drops of medication into the conjunctival sac. This minimizes the blink reflex and retracts the cornea up and away from the conjunctival sac to avoid instillation onto the cornea 6. Instruct client to close the eyelid and move the eye around (if able). Then apply pressure to the lacrimal duct for 30-60 seconds if medication has systemic effects (eg, beta blocker, timolol maleate [Timoptic]). This will distribute the medication, prevent overflow into the lacrimal duct, and reduce possible systemic absorption (Option 1) 7. Remove excess medication from each eye with a new tissue or gauze pad to prevent cross-contamination 8. Wait 5 minutes before instilling a different medication into the same eye Educational objective: To administer ophthalmic medications, follow these steps: (1) Remove secretions from the eyelid by wiping from the inner to outer canthus; (2) pull lower eyelid downward, have client look upward, and instill drops into the conjunctival sac; and (3) apply pressure to the lacrimal duct if medication has systemic effects (eg, beta blocker, timolol maleate). A pediatric client is diagnosed with an acute asthma attack. Which immediate-acting medications should the nurse prepare to administer to this client? Select all that apply. Unordered Options Ordered Response 1. Albuterol 2. Ibuprofen 3. Ipratropium 4. Montelukast 5. Tobramycin Explanation Asthma is an inflammatory condition in which the smaller airways constrict and become filled with mucus. Breathing, especially on expiration, becomes more difficult. Pharmacologic treatment for acute asthma includes the following: 1. Oxygen to maintain saturation >90% 2. High-dose inhaled short-acting beta agonist (albuterol or levalbuterol) and anticholinergic agent (ipratropium) nebulizer treatments every 20 minutes 3. Systemic corticosteroids (Solu-Medrol) to control the underlying inflammation. These will take some time to show an effect. (Option 2) Nonsteroidal anti-inflammatory agents (eg, ibuprofen, naproxen, indomethacin) and aspirin can worsen asthma symptoms in some clients and are not indicated unless necessary. (Option 4) Montelukast (Singulair) is a leukotriene (chemical mediator of inflammation) inhibitor and is not used to treat acute episodes. It is given orally in combination with beta agonists and corticosteroid inhalers (eg, fluticasone, budesonide) to provide long- term asthma control. (Option 5) Tobramycin is an aminoglycoside antibiotic. It is used in aerosolized form to treat cystic fibrosis exacerbation when Pseudomonas is the predominant organism causing lung infection. Educational objective: Inhaled corticosteroids and leukotriene inhibitors are typically used to achieve and maintain control of inflammation for long-term management of asthma. Quick-relief medications (eg, albuterol, ipratropium) are used to treat acute symptoms and exacerbations. The nurse develops a teaching plan for a client prescribed isoniazid, rifampin, ethambutol, and pyrazinamide to treat active tuberculosis (TB). Which of the following instructions associated with the adverse effects of rifampin is most important for the nurse to include? Unordered Options Ordered Response 1. Notify the health care provider if your urine is red 2. Take acetaminophen every 6 hours for drug-associated joint pain while taking this medication 3. Wear eyeglasses instead of soft contact lenses while taking this medication 4. You can stop taking the medications as soon as one sputum culture comes back normal Explanation Active TB is treated with combination drug therapy. Isoniazid causes hepatotoxicity and peripheral neuropathy. Rifampin (Rifadin) also causes hepatotoxicity. Therefore, baseline liver function tests should be obtained. Clients should be advised to watch for signs and symptoms of hepatotoxicity (eg, jaundice, anorexia). Ethambutol causes ocular toxicity, and clients will need frequent eye examinations. A teaching plan for a client prescribed rifampin includes these additional instructions: • Rifampin changes the color of body fluids (eg, urine, sweat) due to its body-wide distribution. Tears can turn red, making contact lenses appear discolored. Client should wear eyeglasses instead of soft contact lenses while taking this medication. • Women should use nonhormonal birth control methods while taking this drug as it can decrease the effectiveness of oral contraceptives. (Option 1) Red urine is an expected finding with rifampin use; clients should not be concerned. (Option 2) Clients should be advised to not consume alcohol and drugs that can increase the risk for hepatotoxicity (eg, acetaminophen) during long-term use of this drug. (Option 4) The effectiveness of treatment for active TB is determined by 3 negative sputum cultures and chest x-ray. If the entire course of therapy (6-9 months) is not completed, reinfection, spread to others, and development of resistant strains of TB bacteria can result. Educational objective: Common potential side effects of rifampin include hepatotoxicity, red-orange discoloration of body fluids, and increased metabolism of some drugs (eg, oral contraceptives, hypoglycemics, warfarin). The nurse is caring for a client receiving IVPB azithromycin. Which client data obtained by the nurse should be reported to the health care provider (HCP) prior to administering any additional doses? Unordered Options Ordered Response 1. Currently nauseated and vomited once 2. Decreased white blood cell (WBC) count 3. Prolonged QT interval 4. Temperature of 101.4 F (38.6 C) Explanation All macrolide antibiotics (eg, azithromycin, erythromycin, clarithromycin) can cause a prolonged QT interval, which may lead to sudden cardiac death due to torsades de pointes. Therefore, an electrocardiogram (ECG) should be monitored. Concurrent use of macrolide antibiotics with other drugs that prolong QT interval (eg, amiodarone, sotalol, haloperidol, ziprasidone, azole antifungals) will further increase this risk. Macrolides can also cause hepatotoxicity when taken in high doses or in combination with other hepatotoxic medications such as acetaminophen, phenothiazines, and sulfonamides. Elevation of aspartate transaminase and alanine transaminase levels (liver enzymes) may indicate that hepatotoxicity is occurring, and the nurse should report these results to the HCP. (Option 1) Nausea and vomiting can be side effects of azithromycin. They are not as concerning as the adverse reaction of prolonged QT interval. (Option 2) A decrease in the WBC count would be expected as infection is resolving. (Option 4) Fever may be present in a client with an infection. The nurse should use as-needed acetaminophen cautiously in a client also receiving azithromycin due to the risk of hepatotoxicity. Educational objective: Macrolide antibiotics (eg, erythromycin, azithromycin, clarithromycin) can cause QT prolongation, which can lead to life-threatening arrhythmias (eg, torsades de pointes). They can also be hepatotoxic; therefore, the nurse should monitor liver function tests and an ECG and report significant results to the HCP. A client just diagnosed with methicillin-resistant Staphylococcus aureus septic arthritis is receiving the first dose of IV vancomycin. Which finding is most concerning to the nurse? Unordered Options Ordered Response 1. Diffuse muscle pain 2. Flushing and pruritus 3. Low blood pressure 4. Wheezing and hives Explanation Red man syndrome (RMS) is a condition that can occur with rapid IV vancomycin administration. It is characterized by flushing, erythema, and pruritus, typically on the face, neck, and chest. Muscle pain, spasms, dyspnea, and hypotension may also occur. RMS is usually a rate-related infusion reaction and not an allergic reaction. It can be reduced by infusing vancomycin over a minimum of 60 minutes. It can be difficult to differentiate severe RMS from anaphylaxis as flushing and hypotension can occur in both conditions. However, hives, angioedema (lip swelling), wheezing, and respiratory distress are more suggestive of anaphylaxis. The client exhibiting signs and symptoms suggestive of anaphylaxis should have the vancomycin infusion stopped immediately and be treated with intramuscular (IM) epinephrine. The infusion must not be restarted if anaphylaxis is suspected. A slowed infusion rate or pre-medications will not prevent a future anaphylactic response. (Option 1) Muscle pain and spasms may be symptoms of RMS. The nurse should also assess for other medications the client may be taking that could cause these symptoms (ie, statins). (Option 2) Flushing and pruritus may also be symptoms of RMS. The nurse should further assess the client's airway for possible anaphylaxis. (Option 3) Low blood pressure (BP) can have many causes, RMS being one of them. If low BP is due to RMS, stopping or reducing the rate of vancomycin (depending on severity) would solve this. If low BP is due to anaphylaxis, IM epinephrine must be given in addition to stopping the vancomycin infusion. Educational objective: The development of hives, angioedema, wheezing, and respiratory distress in a client receiving IV vancomycin indicates anaphylaxis. The infusion must be stopped immediately and IM epinephrine administered. RMS is a rate-related infusion reaction to IV vancomycin that is characterized by flushing, erythema, and pruritus, typically on the face, neck, and chest. A client with generalized anxiety disorder has received a new prescription for sertraline. The nurse should teach this client about which possible side effect? Unordered Options Ordered Response 1. Constipation 2. Sedation 3. Sexual dysfunction 4. Weight loss Explanation Selective serotonin reuptake inhibitors (SSRIs) are commonly used to treat major depression and anxiety disorders. SSRIs (eg, fluoxetine, paroxetine, citalopram, escitalopram, sertraline) are generally well tolerated except for sexual dysfunction. Clients often underreport this side effect. However, when asked specifically, over 50% of clients taking SSRIs may be experiencing some type of sexual dysfunction. This can be a decrease in sexual desire, arousal, or orgasm and may vary by gender. The nurse should discuss this with the client. The side effect may decrease or cease after a 2- to 4-week waiting period for the therapeutic effect, or the client may be able to switch to a different antidepressant medication (eg, bupropion). (Option 1) Constipation is uncommon with SSRIs. Drugs with anticholinergic activity (eg, tricyclic antidepressants such as amitriptyline) may result in constipation or urinary retention. (Option 2) Sedation is a common side effect of benzodiazepines (eg, alprazolam, lorazepam, diazepam, and chlordiazepoxide), first generation antihistamines, and narcotic medications. SSRIs may cause insomnia. (Option 4) Weight gain is a common side effect of most SSRIs, especially with long- term therapy. Educational objective: SSRIs (eg, fluoxetine, paroxetine, citalopram, escitalopram, sertraline) can cause sexual dysfunction. The client should be encouraged to report this to the health care provider if they are still present 2-4 weeks after treatment initiation A client with chronic rheumatoid arthritis (RA) says, "I am so frustrated, tired, and stiff. I just can't keep up with my young children anymore." The client is prescribed adalimumab, a tumor necrosis factor (TNF) inhibitor. What is the priority nursing diagnosis (ND) for this client regarding the new prescription? Unordered Options Ordered Response 1. Disturbed body image 2. Hopelessness 3. Impaired physical mobility 4. Risk for infection Explanation Infection is a major adverse effect of TNF inhibitors (eg, etanercept [Enbrel], infliximab [Remicade], adalimumab [Humira]) as these drugs interfere with the body's normal immune response and cause immunosuppression. This increases the risk for a new infection or reactivation of a previous infection (eg, latent tuberculosis, hepatitis B virus). Nursing interventions should focus on preventing infection (eg, reducing risk factors, promoting wellness) as it can be life-threatening in the setting of immunosuppression. This ND poses the greatest threat to the client's survival and is therefore the priority diagnosis (Option 4). (Option 1) Disturbed body image related to physical and psychological changes secondary to chronic RA is an appropriate ND. Nursing interventions should focus on client adaptation and acceptance of changes due to the illness. However, this does not pose the greatest risk to the client's survival and is not the priority ND. (Option 2) Hopelessness related to activity restriction and worsening physiological status secondary to chronic RA is an appropriate ND. Interventions should focus on setting short-term goals to change behaviors and promoting a more positive attitude. However, this is not the priority ND. (Option 3) Impaired physical mobility related to decreased physical endurance and joint stiffness secondary to chronic RA is an appropriate ND. Interventions should focus on improving joint function and resuming the client's usual activities. However, this is not the priority ND. Educational objective: TNF inhibitors (eg, etanercept, infliximab, adalimumab) interfere with the body's normal immune response and cause immunosuppression. This increases the risk for a new infection or reactivation of a previous infection (eg, latent tuberculosis, hepatitis B virus). The nurse administers the prescribed dose of hydromorphone 2 mg to a client who is 2 days postoperative from a colostomy. Which assessment finding is most important for the nurse to follow-up? Unordered Options Ordered Response 1. Client has 1 emesis of green fluid 2. Client has had no bowel movement for 2 days 3. Client falls asleep while talking to the nurse 4. Client reports experiencing pruritus Explanation Respiratory depression is the most serious side effect of narcotic medication. Sedation precedes respiratory depression. Falling asleep during a conversation scores "3" on the Pasero Opioid-Induced Sedation Scale (POSS); no additional narcotics should be given to the client. Other classes of drugs (eg, non-steroidal anti- inflammatory medications) can be given if the client is still in pain. The client will also be at increased risk for respiratory depression if the pain is completely relieved and/or it is night time. No additional narcotics should be given until the client is at level 2 sedation on POSS (eg, slightly drowsy, easily aroused). (Option 1) Nausea or vomiting is a typical side-effect of narcotic administration, especially when it is given in a larger dose or to the opioid-naïve client. It usually lessens with time and repeat administration. Nausea or vomiting would not be a concern unless it is excessive or severe. The nurse should ensure that the client receives adequate hydration (eg, intravenous fluids, clear liquids, antiemetics). (Option 2) Constipation is a known side effect of opioid administration and does not lessen with long-term administration. Proactive measures are needed as long as the client is on narcotics. However, large intestine peristalsis does not usually start until 2-3 days after surgery. (Option 4) Pruritus (itching) is a known side effect of narcotic administration. It is usually treated with diphenhydramine (Benadryl) or some other antihistamine. Educational objective: Sedation precedes respiratory depression in narcotic administration. A client (especially if on high doses) should be assessed for sedation level. Level 3 sedation on POSS requires that no additional narcotics be administered to the client. The nurse is caring for a client admitted with serotonin syndrome after taking citalopram and tramadol. Which assessment findings does the nurse expect to find? Select all that apply. Unordered Options Ordered Response 1. Absent deep tendon reflexes 2. Cold, clammy skin 3. Muscle rigidity 4. Restlessness and agitation 5. Sinus tachycardia Explanation Serotonin syndrome, a potentially life-threatening condition, develops when drugs affecting the body's serotonin levels are administered simultaneously or in overdose. Drugs, which may trigger this reaction, include selective serotonin reuptake inhibitors (SSRIs), monoamine oxidase inhibitors (MAOIs), dextromethorphan, ondansetron, St. John's wort, and tramadol. The diagnosis is primarily clinical and based on medication history and clinical findings. Symptoms may include mental status changes (eg, anxiety, agitation, disorientation), autonomic dysregulation (eg, hyperthermia, diaphoresis, tachycardia/hypertension), and neuromuscular hyperactivity (eg, tremor, muscle rigidity, clonus, hyperreflexia). (Option 1) The client experiencing serotonin syndrome would exhibit hyperreflexia. (Option 2) The client experiencing serotonin syndrome would exhibit warm moist skin and a fever. Educational objective: Clinical manifestations of serotonin syndrome include mental status changes (eg, anxiety, agitation, disorientation), autonomic dysregulation (eg, hyperthermia, diaphoresis, tachycardia/hypertension), and neuromuscular hyperactivity (eg, tremor, muscle rigidity, clonus, hyperreflexia). The nurse reviews an elderly client's medication administration record and identifies which prescriptions as having the potential for injury in the elderly? Select all that apply. Unordered Options Ordered Response 1. Amitriptyline 2. Chlorpheniramine 3. Docusate 4. Donepezil 5. Lorazepam Last Updated: 12/7/2015 Explanation Polypharmacy and physiologic changes associated with aging (eg, decreased renal and hepatic function, orthostatic hypotension, decreased visual acuity, balance and gait problems) place the elderly at increased risk of adverse drug effects. The Beers criteria provide a list that classifies potentially harmful drugs to avoid or administer with caution in the elderly due to the high incidence of drug-induced toxicity, cognitive dysfunction, and falls. Some commonly used medications in this list include antipsychotics, anticholinergics, antihistamines, antihypertensives, benzodiazepines, diuretics, opioids, and sliding insulin scales. Amitriptyline (Elavil) is a tricyclic antidepressant used to treat depression and neuropathic pain; its anticholinergic properties may cause dry mouth, constipation, blurred vision, and dysrhythmias (Option 1). Chlorpheniramine (ChlorTrimeton) is a sedating histamine H1 antagonist used to treat allergy symptoms. Increased central nervous system effects (eg, drowsiness, dizziness) may occur due to its reduced clearance in the elderly (Option 2). Lorazepam (Ativan) is a benzodiazepine with a long half-life (10-17 hours). Side effects include drowsiness, dizziness, ataxia, and confusion (Option 5). (Option 3) Docusate is a stool softener and does not increase risk of injury in the elderly. (Option 4) Donepezil (Aricept) is an acetylcholinesterase inhibitor used to treat Alzheimer dementia. It does not place the elderly at increased risk of adverse effects. Educational objective: The Beers criteria provide a list that classifies potentially harmful drugs to avoid or administer with caution in the elderly due to the high incidence of adverse effects and potential for injury. The list includes antipsychotics, anticholinergics, antihistamines, antihypertensives, benzodiazepines, diuretics, opioids, and sliding insulin scales A nurse is giving medications to a client who is being evaluated for a brain malignancy. The health care provider (HCP) has ordered a computed tomography (CT) scan with intravenous (IV) iodinated contrast for the next morning. Which medication should the nurse plan to withhold from this client? Unordered Options Ordered Response 1. Amlodipine 2. Gabapentin 3. Metformin 4. Phenytoin Explanation IV iodinated contrast used for CT scan or cardiac catheterization can cause kidney injury (contrast-induced nephropathy). The side effect of metformin (Glucophage) is lactic acidosis. If the client takes metformin and develops kidney injury from contrast, then the lactic acidosis will worsen. As a result, most HCPs discontinue metformin on the day of IV iodine contrast exposure (regardless of baseline creatinine) and restart the drug at least 48 hours later, after stable renal function has been documented. (Options 1, 2, and 4) Amlodipine (Norvasc) is a calcium channel blocker commonly used to treat hypertension. Gabapentin (Neurontin) is commonly used for neuropathic pain. Phenytoin (Dilantin) is an antiseizure medication. None of these medications interact with the iodinated contrast or worsen kidney injury. Therefore, these can be safely administered. Educational objective: Iodinated contrast used for CT scan or cardiac catheterization can cause kidney injury. Metformin (Glucophage) can worsen lactic acidosis in the presence of kidney injury. Metformin should be withheld prior to the contrast exposure and can be resumed when kidney function is within normal limits. An elderly client with depression is given trazodone. Which statement by the client indicates that additional teaching is needed? Unordered Options Ordered Response 1. "I will call the health care provider if I develop a prolonged erection." 2. "I will get up slowly, in stages, from supine to standing." 3. "I will take this medication at night to avoid daytime drowsiness." 4. "It is okay to drink 2 glasses of wine at night." Explanation Trazodone (Oleptro), a serotonin modulator, is used to treat major depressive disorders. In addition to affecting serotonin levels, the drug blocks alpha and histamine (H1) receptors. Blockade of alpha receptors can cause orthostatic hypotension similar to that from other alpha blockers (eg, terazosin, tamsulosin) used to treat benign prostatic hyperplasia. Blockade of H1 receptors leads to sedation. Therefore, this drug is particularly effective in treating insomnia associated with depression. However, concurrent intake of other medications or substances that cause sedation can be detrimental; these include benzodiazepines (eg, alprazolam, lorazepam, diazepam), sedating antihistamines (eg, chlorpheniramine, hydroxyzine), and alcohol (Option 4). (Option 1) Priapism is a known serious side effect of trazodone. A client with an erection lasting several hours should go to the hospital. (Option 2) Clients should be advised to rise from supine to standing slowly, in stages, due to the risk of orthostatic hypotension. (Option 3) The drug should be taken at bedtime to avoid daytime sedation. Educational objective: Trazodone modulates serotonin levels in the brain. In addition, it blocks alpha and H1 receptors, leading to orthostatic hypotension and sedation, respectively. Priapism is another serious side effect, though rare. The nurse is caring for a postoperative client who has D5W/0.45% NS with 20 mEq potassium chloride infusing through a peripheral IV catheter. Which of the following would be appropriate reasons for the nurse to change the site? Select all that apply. Unordered Options Ordered Response 1. Client reports mild arm discomfort since infusion was started 2. Edema observed on the dependent side of the involved arm 3. Intraoperative peripheral IV catheter was placed in the left antecubital region 4. Serous fluid is leaking from the site despite secure connections 5. Small ecchymotic area noted lateral from the insertion site Explanation Peripheral IV (PIV) catheter sites should be changed based on hospital policy (often every 72 hours) or if signs of complications develop. The Infusion Nurses Society also suggests that PIV sites be changed if the client requests a new site. To prevent complications, the nurse should frequently assess the site for early signs of infiltration, phlebitis, or infection (eg, erythema, edema, warmth, pain). The nurse should monitor for infiltration not only at the insertion site, but also underneath the involved limb. Infiltrated fluid may leak into loose skin and accumulate in dependent areas with no obvious signs of infiltration at the PIV site, particularly in the elderly (Option 2). If a PIV site is leaking fluid, the tubing and catheter connections should be assessed. If all connections are intact, possible problems include infiltration/extravasation, presence of a thrombus at the catheter tip, or damage to the catheter; all of these require a site change (Option 4). (Option 1) Potassium is a known irritant to veins. Discomfort in the vein during potassium infusion is not a sign of infiltration, although the nurse should regularly monitor the site for pain, redness, and coolness to the touch, which might indicate a complication. (Option 3) Locations where flexion occurs (eg, bend of the elbow) are generally avoided. However, the large antecubital veins may be needed for certain medications or situations. Unless a problem develops, PIV sites are not routinely changed based solely on location. (Option 5) Bruising not located directly at the site likely occurred from a separate event (eg, inadvertent minor trauma to the arm) or previous IV insertion attempt. However, it should be monitored to ensure that it does not enlarge. Educational objective: Peripheral IV catheter sites should be changed every 72 hours, if signs of complications (eg, erythema, coolness to the touch, pain, palpable venous cord) develop, or if the client requests a different site. The nurse should check for signs of infiltration by also assessing the area dependent from the insertion site (eg, for edema). The clinic nurse evaluates a client's response to levothyroxine after 6 weeks of treatment. The nurse will note which therapeutic responses to the medication. Select all that apply. Unordered Options Ordered Response 1. Apical heart rate of 88/min 2. Elevation of mood 3. Improved energy levels 4. Skin is cool and dry 5. Slight weight gain Explanation The client's therapeutic response to levothyroxine (Synthroid) is evaluated by resolution of hypothyroidism symptoms. The expected response includes improved well-being with elevated mood (Option 2), higher energy levels (Option 3), and a heart rate that is within normal limits (Option 1). The nurse should consult the health care provider if the heart rate is >100/min, or if the client reports chest pain, nervousness, or tremors; this may indicate that the dose is higher than necessary. Pharmacological therapy manages the symptoms of hypothyroidism, but it takes up to 6 weeks after initiation to see the full therapeutic effect. (Option 4) In hypothyroidism, the skin is cool, pale, and rough (due to dryness). These characteristics result from decreased blood flow. A therapeutic response to levothyroxine would be skin that is normal. (Option 5) The client experiencing a therapeutic response to levothyroxine would experience weight loss due to the increased metabolic rate. However, the client with untreated hypothyroidism would experience weight gain. Educational objective: The expected therapeutic response to levothyroxine (Synthroid) includes an increased sense of well-being with elevated mood, greater energy levels, and a heart rate within normal limits. It takes up to 6 weeks to see the full effect of pharmacological therapy. A home health nurse visits a client 2 weeks after discharge from the hospital. The client experienced an acute myocardial infarction and subsequent heart failure. Home medications are listed in the exhibit. Which symptom reported by the client is most concerning to the nurse? Click on the exhibit button for additional information. Unordered Options Ordered Response 1. Bruising easily, especially on arms 2. Fatigue 3. Feeling depressed 4. Muscle cramps in legs Explanation The nurse would be most concerned with the client's report of muscle cramps in the legs. This could be a sign of hypokalemia caused by use of the diuretic furosemide or possibly a reaction from the statin medication atorvastatin. Hypokalemia may manifest as muscle cramps, weakness, or paralysis and typically starts with the leg muscles. Hypokalemia could be dangerous in this client due to possible arrhythmias in the presence of existing cardiac dysfunction. The client may need to be started on supplemental potassium and a high-potassium diet if the serum potassium level is low. If the potassium level is normal, atorvastatin may be responsible for muscle cramps. (Option 1) Bruising, especially on the upper extremities, is common with the use of antiplatelet agents such as aspirin and clopidogrel. The nurse should teach the client to monitor for other, more severe signs of bleeding, such as blood in the stool. (Option 2) The myocardial infarction and heart failure have most likely reduced the client's functional capacity and can cause fatigue. Beta blockers such as metoprolol can also cause fatigue. This will improve with time, and the nurse should talk to the client about possible cardiac rehabilitation. (Option 3) Feeling depressed is common after an acute health-related event such as a myocardial infarction. The client needs to be evaluated further and may need an antidepressant. However, feelings of depression are not immediately life-threatening unless the client exhibits suicidal ideation. Educational objective: The nurse should recognize muscle cramps in the legs as a possible sign of hypokalemia in the client taking diuretics. Muscle cramps should be reported to the health care provider in anticipation of checking a potassium level, adding a potassium supplement, and instructing the client to eat potassium-rich foods The nurse is caring for a client with an inflammatory bowel disease exacerbation. The client is prescribed sulfasalazine. Which finding would require a priority follow-up by the nurse? Unordered Options Ordered Response 1. Elevated erythrocyte sedimentation rate 2. Hemoglobin 10.5 g/dL (105 g/L) 3. Urine with yellow-orange discoloration 4. Urine specific gravity 1.035 Explanation Sulfasalazine (Azulfidine) contains sulfapyridine and aspirin (5-ASA) and is used as a topical gastrointestinal anti-inflammatory and immunomodulatory agent in inflammatory bowel disease (IBD). When the 5-ASA is combined with the sulfa preparation, the drug does not become absorbed until it reaches the colon. Dehydration is a risk with IBD as the client can have up to 20 diarrheal stools a day. The client usually does not feel thirsty until after there is a fluid volume deficit. Sulfa can crystallize in the kidney if the client is dehydrated. Normal urine specific gravity is 1.003-1.030. Elevated specific gravity can indicate concentrated urine and be a sign of dehydration (Option 4). (Option 1) Due to the inflammatory nature of IBD, erythrocyte sedimentation rate, C- reactive protein, and white blood cells can be elevated. This is an expected finding during an exacerbation. (Option 2) Mild to moderate anemia (normal hemoglobin 13.2-17.3 g/dL [132-173 g/L] for males, 11.7-15.5 g/dL [117-155 g/L] for females) is common with most chronic inflammatory conditions (eg, rheumatoid arthritis, IBD) as the body cannot use the available iron in bone marrow with active inflammation. In addition, IBD exacerbation usually includes bloody stools, resulting in blood loss iron deficiency anemia. This needs follow-up but is not a priority. (Option 3) Yellow-orange discoloration of the client's skin and urine is an expected side effect from the drug. Educational objective: Dehydration is a concern with sulfasalazine and most other "sulfa" medications due to the risk of crystal formation in the kidney. It is also a potential complication of inflammatory bowel disease. The nurse is preparing 7:00 AM medications for a client with a urinary tract infection and a history of heart failure and type 2 diabetes. Based on the information from the medical and medication records, which prescription should the nurse question before administering? Click on the exhibit for more information. Unordered Options Ordered Response 1. Furosemide 2. Glipizide 3. Levofloxacin 4. Potassium chloride Explanation The nurse should question the prescription for furosemide (Lasix), a potent loop diuretic, before administering the medication. The client has a significant decrease in systolic blood pressure (50 mm Hg), a negative fluid balance of 2000 mL for 24 hours, hypernatremia (normal sodium, 135-145 mg/dL [135-145 mmol/L]), and a potassium level that is trending downward. These parameters indicate hypotonic dehydration, which is often caused by diuretic use. If the diuretic were administered, the fluid volume deficit would increase further. (Option 2) Glipizide, an oral sulfonylurea drug used to control blood sugar, is prescribed once or twice a day 30 minutes before meals. The client's blood sugar is within normal limits (70-99 mg/dL [3.9-5.5 mmol/L]), so there is no need for the nurse to question the prescription. (Option 3) Antibiotic therapy with levofloxacin (Levaquin) is appropriate for a client with a urinary tract infection, so there is no need for the nurse to question the prescription. (Option 4) Potassium chloride is usually prescribed with a diuretic to prevent hypokalemia. The potassium is within normal limits (normal, 3.5-5.0 mEq/L [3.5-5.0 mmol/L]) but is trending downward. A further decrease in potassium from the diuretic would increase the risk for cardiac dysrhythmias associated with hypokalemia. Most clients need a potassium level of around 4.0 mEq/L (4.0 mmol/L) to prevent arrhythmias. If the furosemide is discontinued, the health care provider and nurse should check serum potassium levels the next day to determine whether further dosing is necessary. Educational objective: Decrease in blood pressure, increase in pulse rate, output greater than intake, hypernatremia, and decrease in serum potassium are manifestations that can indicate hypotonic dehydration in a client receiving diuretic therapy. The nurse is caring for a client who started receiving chemotherapy 10 days ago. Today, the health care provider prescribes filgrastim. Which of the following is an expected outcome of this medication? Unordered Options Ordered Response 1. Decrease in serum uric acid 2. Increase in hemoglobin level 3. Increase in neutrophil count 4. Increase in platelet count Explanation Chemotherapy can cause suppression of rapidly reproducing cells, including bone marrow suppression. This can result in decreased red blood cells, white blood cells, and platelets, all manufactured in the bone marrow. It is most likely to be seen with chemotherapy (versus radiation), with the lowest counts (the nadir) usually at 7-10 days after therapy initiation. Leukopenia is a decrease in total circulating white blood cell count (<4,000/mm3) and neutropenia is a decrease in circulating neutrophils (usually <1500/mm3). Filgrastim (Neupogen) and pegfilgrastim (Neulasta) stimulate neutrophil production and are given prophylactically or if the client has an infection and more neutrophils are needed to fight it (Option 3). (Option 1) Cancer chemotherapy causes cell lysis, which results in tumor lysis syndrome due to massive release of nucleic acid and its metabolic product, uric acid. Uric acid deposition leads to acute kidney injury. Medications such as allopurinol or rasburicase and aggressive IV hydration are used to prevent this complication. (Option 2) Anemia is also common with chemotherapy. Epoetin (Procrit), a form of erythropoietin, stimulates the body to make additional red blood cells. (Option 4) Low platelet count is not considered an urgent need until it is at <50,000/mm3. Usually, platelet transfusions are given. Educational objective: Bone marrow suppression from chemotherapy can cause decreased red blood cells, white blood cells, and platelets. Erythropoietin is used to increase red blood cell production, and filgrastim is administered to stimulate neutrophil production A 24-year-old female client has been prescribed isotretinoin for severe nodulocystic acne that has been resistant to other therapies. Which instruction is most important for the nurse to reinforce with this client? Unordered Options Ordered Response 1. "Apply lubricating eye drops when wearing contacts." 2. "Swallow capsules whole." 3. "Use sunscreen routinely." 4. "Use 2 forms of contraception." Explanation Isotretinoin (Accutane) decreases sebum secretion and is prescribed for severe, disfiguring nodular acne that has been unresponsive to other therapies, including antibiotics. It is a pregnancy category X drug and is known to cause serious birth defects if taken during pregnancy. Females prescribed isotretinoin must have 2 negative pregnancy tests before taking the medication. Also, 2 forms of contraception must have been in place for at least 1 month prior to starting isotretinoin, and these must be continued both during treatment and for 1 month after the medication is discontinued. Before refills can be obtained, enrollment in a risk management program is required to verify that pregnancy tests are negative and 2 forms of contraception are being used. Blood donation is also discouraged while on therapy and for 1 month afterward to ensure that pregnant women do not receive any donated blood. (Option 1) Dryness of the eyes, mouth, and skin are common side effects. Lubricating eye drops may be needed to wear contacts. Some clients are unable to wear contacts while taking this medication. Good oral hygiene and skin care are needed. (Option 2) Capsules should be swallowed whole with at least 8 oz of water or other fluid. Capsules should not be broken, crushed, or chewed as contents of opened capsules could irritate esophagus. (Option 3) This medication causes photosensitivity. The nurse should teach the client to use sunscreen routinely. Educational objective: Isotretinoin is a pregnancy category X drug and will cause birth defects if taken during pregnancy. The client must use 2 forms of birth control for 1 month prior to taking the medication as well as during treatment and 1 month afterward. The client must also be enrolled in a risk management program prior to receiving refills. The nurse is caring for a client hospitalized for an acute exacerbation of heart failure. The client receives digoxin 0.5 mg orally once daily, furosemide 40 mg orally twice daily, and potassium chloride 20 mEq orally twice daily. The client's daughter tells the nurse that the client has not been eating or drinking well and has had trouble swallowing the large potassium pill. The client's K+ level is 3.7 mEq/L. How should the nurse handle this situation? Unordered Options Ordered Response 1. Call the pharmacy to see if other forms of potassium chloride are available 2. Crush the potassium chloride pill and mix it with applesauce or pudding 3. Hold the potassium chloride until the health care provider (HCP) makes rounds 4. Instruct the client to tuck the chin to the chest when swallowing the pill Explanation Potassium chloride is available in tablets or capsules, oral liquid, or diluted in intravenous fluids. Pills should be taken with plenty of water, no less than 4 oz or half a glass due to the risk of pill-induced esophagitis. The nurse should consult the pharmacist, who is part of the interdisciplinary team, to see if another form of potassium chloride is available. An oral liquid may be a better alternative for this client, or the pharmacist may be able to verify if the medication is safe to crush. (Option 2) Some pills or capsules are sustained-release formulations and should not be crushed. Crushing an extended release capsule may cause an overdose of the medication. (Option 3) The client's K+ is at the lower end of normal. The client is also taking digoxin and furosemide. Digoxin toxicity may be potentiated with hypokalemia, and furosemide is a potassium-wasting diuretic that may further reduce the K+ level. The nurse may not know when the HCP will be making rounds. (Option 4) Tucking the chin to the chest during swallowing is a technique to prevent aspiration. This most likely will not help the client swallow the large pill. Educational objective: Potassium chloride comes in 3 forms: tablet or capsule, oral liquid, or intravenous infusion. Some tablets or pills are sustained-release formulations and should not be crushed. Interdisciplinary team members, such as the pharmacist, can assist the nurse with decisions related to medication availability. The nurse is performing discharge teaching for the parents of a 4-year-old with heart failure. Which statement by the parents indicates the need for further teaching related to the administration of digoxin? Unordered Options Ordered Response 1. "If our child vomits after a dose, we won't give a second one." 2. "Symptoms of nausea and vomiting should be reported to our health care provider (HCP)." 3. "We will hold the dose if our child's heart rate is above 90/min." 4. "We will not mix the medication with other foods or liquids." Explanation Digoxin is a cardiac glycoside given to infants and children in heart failure. It is given to increase myocardial contraction, which increases cardiac output and improves circulation and tissue perfusion. Digoxin is a potentially dangerous drug due to its narrow margin of safety in dosage. Parents should receive thorough education and in return demonstrate appropriate administration procedures for this medication. Parent teaching for administration of digoxin includes the following: • Inform parents of the pulse rate at which to hold the medication based on HCP prescription. In general, digoxin is held if pulse <90-110/min for infants and young children or <70/min for an older child. • Administer oral liquid in the side and back of the mouth • Do not mix the drug with food or liquids as the refusal to take these would result in inaccurate intake of medication (Option 4) • If a dose is missed, do not give an extra dose or increase the dose. Stay on the same schedule. • If more than 2 doses are missed, notify the HCP • If the child vomits, do not give a second dose (Option 1). Nausea, vomiting, or slow pulse rate could indicate toxicity. Notify the HCP (Option 2). • Give water or brush the client's teeth after administration to remove the sweetened liquid Educational objective: Nausea, vomiting, or slow pulse rate can indicate digoxin toxicity. General guidelines are to hold digoxin for pulse <90-110/min in infants and young children and <70/min in older children. The nurse teaches a parent how to administer an oral liquid medication to a 2-month-old client. The nurse knows that the parent understands the teaching when the parent does which of the following? Unordered Options Ordered Response 1. Allows the client to sip the medication from a cup 2. Expels the medication from a dropper onto the back of the tongue 3. Mixes the medication in the infant's bottle of formula 4. Using a syringe, administers the medication in small amounts into the back of the cheek Explanation Using a syringe to measure the medication is the most accurate technique to ensure that the proper amount of medication is being administered. The correct procedure for administering oral medication to an infant is to place small amounts of the medication at the back of the cheek, allowing time for the infant to swallow each amount. This technique decreases the risk for choking and ensures that all the medication is consumed. (Option 1) Although cup feeding may be a method used to feed infants in specific cases, medication administration requires a more accurate measurement. A syringe can provide an accurate measurement and decrease the risk of waste due to the infant's spitting or drooling. (Option 2) Infants have a decreased gag reflex. Dispensing medication onto the back of the tongue would increase the risk for aspiration of the medication. (Option 3) It is very important for the infant to receive the entire dose of the medication. Medication should never be mixed in a bottle of formula as the infant may not consume the entire amount. Educational objective: The extrusion reflex and a decreased gag reflex in infants less than 4 months old increase the risk for choking and aspiration. Instilling the medication using a syringe at the back of the cheek decreases the risk for choking and ensures that the correct amount of medication is consumed. The nurse provides teaching about methotrexate to a client with rheumatoid arthritis. It is most important to address which topic regarding this drug? Unordered Options Ordered Response 1. Need for an eye examination 2. Need for sunblock 3. Risk for infection 4. Risk for kidney injury Explanation Methotrexate (Rheumatrex) is classified as a folate antimetabolite, antineoplastic, immunosuppressant drug used to treat various malignancies and as a nonbiologic disease-modifying antirheumatic drug (DMARD) used to treat rheumatoid arthritis and psoriasis. Methotrexate can cause bone marrow suppression resulting in anemia, leukopenia, and thrombocytopenia. Leukopenia and its immunosuppressant effects can increase susceptibility to infection. Clients should be educated about obtaining routine killed (inactivated) vaccines (eg, influenza, pneumococcal) and avoiding crowds and persons with known infections. Live vaccines (eg, herpes zoster) are contraindicated in clients receiving immunosuppressants, such as methotrexate. Alcohol should be avoided in clients taking methotrexate as it is hepatotoxic and drinking alcohol increases the client's risk for hepatotoxicity. (Option 1) Regular eye examinations every 6 months are indicated for clients prescribed the nonbiological DMARD antimalarial hydroxychloroquine (Plaquenil) as it can cause retinal damage. Ethambutol, used to treat tuberculosis, also requires frequent eye examinations. (Options 2 and 4) Photosensitivity (common with tetracycline, thiazide diuretics, and sulfonamides) and nephrotoxicity (common with aminoglycosides, vancomycin, and nonsteroidal anti-inflammatory drugs) can occur, but immunosuppression is more likely and potentially fatal. The emergency department nurse is caring for a client who has been recently prescribed methadone for chronic severe back pain. The client ingested extra tablets tonight because the pain returned. Which assessment findings during discharge require the client to be monitored longer in the hospital setting? Select all that apply. Unordered Options Ordered Response 1. Falls asleep when the nurse is talking 2. Frequently scratches due to pruritus 3. Has third emesis since taking medication 4. Monitor shows occasional premature ventricular contractions 5. Pulse oximetry reading is 92% Explanation Methadone is a potent and unique narcotic with a long half-life (up to 50+ hours) due to its lipophilic properties. There is a risk of overdose as the analgesic effect only lasts 6-8 hours. As a result, a client can inadvertently take too many tablets for additional pain relief even though fat cells continue to release a high amount of the drug in the circulation. Early signs of toxicity are nausea/vomiting and lethargy. A client who falls asleep with stimulation is described as obtunded and requires additional observation/monitoring. Sedation precedes respiratory depression, which is a life-threatening complication of severe toxicity (Options 1 and 3). A normal, healthy nonsmoking adult should have a pulse oximetry reading of 97%- 100%. A value of 95%-100% is considered acceptable, but a reading of 92% is low and indicates inadequate depth or rate of respiration (Option 5). (Option 2) Itching sensation (pruritus) is an expected finding with narcotic use, especially in opiate naïve clients. It can be managed with an antihistamine. (Option 4) Occasional premature ventricular contractions are a common, non- significant finding in most adults. The client should have cardiac monitoring in the setting of methadone use as there is a risk of QT interval prolongation (normal 0.34- 0.43 sec or less than half the RR interval). However, it is safe to discharge the client if this prolongation is absent. Educational objective: Methadone is a potent narcotic with a long half-life. Early signs of toxicity are nausea/vomiting and lethargy. The nurse should monitor the client's respiratory rate, pulse oximetry, and ECG tracing. QT interval prolongation and torsades de pointes are life-threatening complications. The nurse is caring for a client with asthma exacerbation. Blood pressure is 146/86 mm Hg, pulse is 110/min, and respirations are 32/min. The respiratory therapist administers nebulized albuterol as prescribed. One hour after the treatment, the nurse assesses which finding that indicates the drug is producing the therapeutic effect? Unordered Options Ordered Response 1. Constricted pupils 2. Heart rate of 120/min 3. Respirations of 24/min 4. Tremor Explanation Albuterol (Proventil) is a short-acting inhaled beta-2 agonist used to control airway obstruction caused by chronic obstructive pulmonary disease, asthma, or bronchitis. It also is used to prevent exercise-induced asthma. The therapeutic effect is relaxation of the smooth muscles of the airways, which results in immediate bronchodilation. Bronchodilation decreases airway resistance, facilitates mucus drainage (expectorates mucus plugs), decreases the work of breathing, and increases oxygenation. As a result of these actions, the respiratory rate will decrease and peak flow will be increased (if tested). However, short-acting beta-2 agonists are associated with the following side effects (not therapeutic effects): tremor (most frequent), tachycardia and palpitations, restlessness, and hypokalemia. These side effects are due to the oral deposition of medication (subsequent systemic absorption) and can be reduced with the use of a spacer or chamber device. (Option 1) The presence of constricted pupils is neither a side effect nor therapeutic effect of the drug. Constricted pupils are often seen with opioid medications (eg, morphine, oxycodone). Educational objective: Albuterol (Proventil) is a short-acting beta-2 agonist that produces immediate bronchodilation by relaxing smooth muscles. Bronchodilation decreases airway resistance, facilitates mucus drainage, decreases the work of breathing, and increases oxygenation. Peak flow will improve. The most frequent side effects are tremor, tachycardia, restlessness, and hypokalemia A child with attention-deficit hyperactivity disorder (ADHD) has been taking methylphenidate for a year. What are the priority nursing assessments when the client comes to the clinic for a well-child visit? Unordered Options Ordered Response 1. Attention span and activity level 2. Dental health and mouth dryness 3. Height/weight and blood pressure 4. Progress with schoolwork and in making friends Explanation Methylphenidate (Ritalin, Concerta) is a central nervous system stimulant used to treat ADHD and narcolepsy. It affects neurotransmitters (dopamine and norepinephrine) in the brain that contribute to hyperactivity and lack of impulse control. A common side effect of methylphenidate is loss of appetite with resulting weight loss. Parents and caregivers should be instructed to weigh the child with ADHD at least weekly due to the risk of temporary interruption of growth and development. It is very important to compare weight/height measures from one well-child checkup to the next. If weight loss becomes a serious problem, methylphenidate can be given after meals; however, before meals is preferable. Another side effect of methylphenidate is increased blood pressure and tachycardia. These should be monitored before and after starting treatment with stimulants. (Option 1) Therapeutic effects of methylphenidate include increased attention span and improvement in hyperactivity. These would be important components of a well-child assessment, but not the priority. (Option 2) Evaluating dental health is part of any well-child assessment. Dry mouth is not a common side effect of methylphenidate. (Option 4) Expected outcomes of methylphenidate therapy include improvement in schoolwork and social relationships. These would be important components of a well- child assessment, but not the priority. Educational objective: Side effects of methylphenidate therapy that require on-going monitoring are delayed growth and development and increased blood pressure. Children with ADHD should be weighed regularly at home or school; weight loss trends should be reported and discussed with the health care provider. Blood pressure and cardiac function also should be monitored on an on-going basis. After receiving shift report, the nurse is assessing a client started on trimethoprim- sulfamethoxazole 2 days ago for treatment of a urinary tract infection. The client reports itching, and the nurse notices a diffuse maculopapular rash on the client's face. What should the nurse do first? Unordered Options Ordered Response 1. Administer diphenhydramine 2. Administer injectable epinephrine 3. Examine the client's trunk and limbs 4. Reassess the client's allergy history Explanation Clients may not know the signs and symptoms of allergies or not remember a past history of allergies, which causes underreporting of allergies. Therefore, reassessing client allergies is the first and oftentimes the quickest action (Option 4). To ensure that the client report is accurate, the nurse should ask about specific signs and symptoms that would indicate an allergy (eg, hives, rash, diarrhea) as the client may not be aware of these indicators. A diffuse maculopapular rash is a typical manifestation of an allergic medication reaction that develops within the first 3 days of starting a new medication. Therefore, the nurse should also ask the client about any signs and symptoms of anaphylaxis. The health care provider (HCP) should be notified to assess, diagnose, and treat the rash. If a medication allergy is diagnosed, the client’s record should be updated and the pharmacist should be notified. (Option 1) Diphenhydramine is an antihistamine used to treat mild allergic reactions. This would be appropriate to administer after an allergic reaction is confirmed by the HCP. Corticosteroids (eg, prednisone) have an anti-inflammatory action and may also be used to prevent or treat a mild allergic reaction. (Option 2) A drug rash is a mild allergic reaction. Injectable epinephrine (Epi-pen) would only be used when the client is having a severe anaphylactic reaction, with swelling of the airway and/or cardiovascular collapse. (Option 3) A drug rash is usually a systemic type of reaction with diffuse rash evident on the face, trunk, and limbs. Therefore, assessment of the client's trunk and limbs would be the second nursing action after reassessing allergy history. Educational objective: A client with signs of a potential allergic reaction should be assessed quickly, including allergy history and physical assessment (face, trunk, and limbs) with attention to signs of anaphylaxis. The health care provider should then be notified to assess the client, and the client's allergies should be updated in the medical record. A client with coronary artery disease and stable angina is being discharged home on sublingual nitroglycerin (NTG). The nurse has completed discharge teaching related to this medication. Which statement by the client indicates that the teaching has been effective? Unordered Options Ordered Response 1. "I can keep a few pills in a plastic bag in my pocket in case I need them while I'm out." 2. "I can still take this with my vardenafil prescription." 3. "I can take up to 3 pills in a 15-minute period if I am experiencing chest pain." 4. "I should stop taking the pills if I experience a headache." Explanation Current evidence shows that up to 50% of clients lack knowledge about NTG administration procedures, storage, and side effects. Proper teaching can prevent many hospital visits for chest pain due to stable angina. Instructions for proper NTG administration include: • Tablets are heat and light sensitive: They should be kept in a dark bottle and capped tightly. An opened bottle should be discarded after 6 months (Option 1). • Take up to 3 pills in a 15-minute period: Take 1 pill every 5 minutes (up to 3 doses). Emergency medical services (EMS) should be called if pain does not improve or worsens 5 minutes after the first tablet has been taken. Previously, clients were taught to call after the third dose was taken, but newer studies suggest this causes a significant delay in treatment (Option 3). • Avoid fatal drug interactions: Concurrent use of erectile dysfunction drugs (sildenafil, tadalafil, vardenafil) or alpha blockers (terazosin, tamsulosin) is contraindicated due to potentially fatal hypotension (Option 2). • Headache may occur: Headache and flushing are common side effects of NTG due to systemic vasodilation and do not warrant medication discontinuation (Option 4). Educational objective: The nurse should instruct the client who is taking sublingual NTG to keep the tablets in a tightly capped, dark bottle away from heat and light. The client should be taught to take 1 tablet every 5 minutes (up to 3 tablets), but notify EMS if the pain does not improve or worsens 5 minutes after the first pill has been taken. These instructions should be reinforced at each appointment During shift change, the night nurse notices that the graduate nurse administered IV dopamine instead of the prescribed norepinephrine for a client with sepsis. What should the night nurse do first? Unordered Options Ordered Response 1. Administer the correct medication and obtain current vital signs 2. Alert the graduate nurse and complete an incident report 3. Assess the client and notify the health care provider 4. Discontinue the dopamine and inform the nursing supervisor Explanation When a medication error occurs, client safety is the nurse's first priority. The nurse should assess the client immediately for any adverse effects and inform the healthcare provider (HCP) (Option 3). Before taking any other actions, the nurse must ensure that the client is stable. Following client stabilization, the error should be reported to the appropriate nursing authority (eg, supervisor, manager), and an incident or occurrence report should be filed within 24 hours. (Option 1) Prior to administering the correct medication, the HCP should be informed to ensure that the original medication is appropriate in light of the medication error. Additional medications or therapies may be necessary to reverse the effects of the medication given in error. (Option 2) Although it is important that the graduate nurse has a chance to learn from the mistake, ensuring client safety is the first priority. An incident report can be filed after the client is stable. (Option 4) Discontinuing dopamine without providing another medication for hemodynamic stabilization may harm the client. The nursing supervisor should be informed after client stabilization. Educational objective: Client safety is the first priority when a medication error occurs. The nurse should assess the client and inform the HCP about the error before reporting to nursing management and completing an incident report The nurse is caring for a client on IV heparin infusion and oral warfarin. Current laboratory values indicate that the client's aPTT is 5 times the control value and the PT/INR is 2 times the control value. What action does the nurse anticipate? Unordered Options Ordered Response 1. Clarify vegetable consumption with client 2. Decrease the heparin rate 3. Decrease the warfarin dose 4. Obtain an order for vitamin K injection Explanation The anticoagulant heparin has to be administered intravenously or subcutaneously. The duration is 2-6 hours intravenously and 8-12 hours subcutaneously. It is measured by the aPTT (activated partial thromboplastin time) laboratory value. Warfarin (Coumadin) is taken orally, with onset/therapeutic effects reached after 2-7 days. It is measured by prothrombin time (PT) or International Normalized Ratio (INR). The therapeutic range for aPTT or PT/INR is generally 1.5-2.0 times the control value (up to 3 times the control value at times). An aPTT value above the therapeutic range places the client at risk for excess bleeding. The heparin administration would need to be stopped or decreased. (Option 1) Clients on warfarin must eat the same amount of dark green leafy vegetables because these foods contain vitamin K and will alter the effects of warfarin. The PT/INR is at therapeutic level so there is no concern related to this client's diet. (Option 3) The warfarin dose has achieved the therapeutic range for PT/INR and does not need adjustment. (Option 4) Vitamin K is the antidote for warfarin; the antidote for heparin is protamine sulfate. However, due to the short half-life of heparin, usually the dose is just held instead of administering an antidote when the values are too high. Educational objective: The therapeutic effect from heparin or warfarin (Coumadin) is 1.5-2.0 times the control value. Heparin is measured with aPTT and warfarin is measured with PT/INR. Vitamin K is the antidote for warfarin; protamine sulfate is the antidote for heparin An 80-year-old client is receiving amikacin, an aminoglycoside antibiotic, IVPB every 12 hours. Which data obtained by the nurse is most important to report to the health care provider before hanging the next dose? Unordered Options Ordered Response 1. Blood pressure 104/62 mm Hg 2. Blood urea nitrogen 20 mg/dL (7.1 mmol/L) 3. Client report of tinnitus 4. Urine output of 400 mL since last dose Explanation Serious adverse reactions to aminoglycosides (eg, gentamicin, tobramycin, amikacin) include ototoxicity and nephrotoxicity. Age, renal function, and drug dose affect the occurrence of these adverse reactions. Careful dosing is especially important for older clients. Tinnitus and vertigo are early signs of ototoxicity. The nurse should carefully assess for changes in the client's hearing, balance, and urinary output. (Option 1) The blood pressure is low, but the nurse should compare it to previous readings. Blood pressure is not generally affected by IV antibiotics. The client may be taking antibiotics for sepsis. (Option 2) The blood urea nitrogen (BUN) is within normal range (6-20 mg/dL [2.1-7.1 mmol/L]), but is at the high end of normal and should continue to be monitored. (Option 4) Urine output is adequate (>30 mL/hr) but should be closely monitored. Educational objective: The nurse should closely monitor renal function and assess for any changes in hearing or balance in a client receiving aminoglycoside antibiotics. Ototoxicity and nephrotoxicity are serious adverse reactions related to this type of medication. A client is 6 hours postoperative from hip surgery after receiving regional anesthesia and has epidural continuous anesthesia in place. Which is the most important reason for the nurse to contact the health care provider? Unordered Options Ordered Response 1. Client reports paresthesia bilaterally since the surgery 2. Fondaparinux is prescribed for STAT administration 3. Lower-extremity muscle strength is 3/5 bilaterally 4. Postoperative laboratory results show hemoglobin of 9.9 g/dL Explanation Fondaparinux, unfractionated heparin, and low molecular weight heparin (eg, enoxaparin, dalteparin) are anticoagulants commonly used for deep vein thrombosis and pulmonary embolism prophylaxis after hip/knee replacement or abdominal surgery. However, fondaparinux is not administered until more than 6 hours after any surgery, and anticoagulants are not given while an epidural catheter is in place (Option 2). Fondaparinux is associated with epidural hematoma. Any bleeding in the tight epidural space, which does not expand, could result in spinal cord compression. Signs of epidural spinal hematoma can include severe back pain and paralysis. (Option 1) Paresthesia is an expected finding from postoperative analgesia for 2-24 hours after surgery, depending on the agent and location. Continuously administered analgesia usually results in some paresthesia until approximately 4-6 hours after discontinuance. As long as the level remains relatively stable or improves, it is an acceptable finding. However, paresthesia or motor weakness is a concern when the sensory or motor block outlasts the expected duration. (Option 3) Client response to operative analgesia and postoperative continued analgesia can range from minimal to significant. As long as the analgesic is infusing and findings remain stable, reduced muscle strength is expected. (Option 4) Major orthopedic surgery can result in significant blood loss, and it is not unusual for the client to have hemoglobin drop of 1-2 g/dL. Blood loss should be monitored over time; transfusion usually is not indicated unless hemoglobin is <7-8 g/dL. Educational objective: Residual paresthesia and motor weakness for several hours are expected findings after regional anesthesia. Anticoagulants are not given while an epidural catheter is in place. A client has received a new prescription for nystatin to treat oral candidiasis. Which instructions should the nurse give this client? Unordered Options Ordered Response 1. Apply the ointment inside the mouth with a cotton-tipped applicator 2. Chew, then swallow the lozenge 3. Swish liquid in mouth for as long as possible, then spit it out 4. Swish liquid in mouth for several minutes, then swallow it Explanation Nystatin is used to treat oral candidiasis, or thrush, that can be caused by medications such as antibiotics, corticosteroids, or oral contraceptive pills. Medical conditions that make oral candidiasis more likely include HIV, immunosuppression, uncontrolled diabetes, denture use, and hormonal changes during pregnancy. Nystatin is available in the form of powders, suspensions, creams, ointments, and lozenges. Oral suspensions are the more common form of nystatin used for oral candidiasis. The client should be directed to swish the solution within the mouth, making contact with all the mucous membranes, and then swallow the solution after several minutes. Swallowing would help to clear any unseen esophageal candidiasis. (Option 1) Ointments are used on Candida infections of the skin. (Option 2) Lozenges are available for oral candidiasis but should be allowed to dissolve in the mouth. (Option 3) The liquid should be swallowed, not spit out. Educational objective: The nurse should teach the client taking nystatin solution for oral candidiasis to swish it in the mouth for several minutes and then swallow the solution. Swallowing would help to clear any unseen esophageal candidiasis. The nurse administers 15 units of aspart insulin subcutaneously to a hospitalized client with type I diabetes mellitus at 7:00 AM for a fasting blood glucose of 180 mg/dL. Which nursing action is a priority? Unordered Options Ordered Response 1. Ensure that the client continues to fast for at least 30 more minutes 2. Give the client breakfast within 15 minutes 3. Recheck the blood glucose in 1 hour 4. Teach the client about the signs and symptoms of hyperglycemia Explanation Aspart (NovoLOG) is a rapid-acting insulin with an onset of 10-15 minutes. Onset is the time it takes for the insulin to enter the circulation and begin to lower blood glucose. The peak effect takes 45-75 minutes and the duration of action is 2-4 hours. It is important for the nurse to ensure that the client eats within 15 minutes of administration of aspart/lispro/glulisine to prevent an insulin-related hypoglycemic reaction. (Option 1) The client is at risk for a hypoglycemic reaction if breakfast is delayed for 30 minutes. (Option 3) Rechecking the blood glucose in 1 hour is not indicated unless hypoglycemia is suspected. (Option 4) Teaching is vital, but it is most important to ensure that the client eats breakfast to prevent a hypoglycemic reaction at drug onset. Educational objective: It is important for the nurse to ensure that the client eats within 15 minutes of administration of rapid-acting insulins such as aspart (NovoLOG), lispro (HumaLOG), and glulisine (Apidra) to prevent an insulin- related hypoglycemic reaction. The nurse assesses a client who is receiving methotrexate to treat rheumatoid arthritis (RA). Which assessment finding associated with this drug is most important for the nurse to report to the heath care provider (HCP)? Unordered Options Ordered Response 1. Hair loss 2. Nausea 3. Petechiae 4. Stomatitis Explanation Methotrexate (Rheumatrex) is a nonbiologic disease-modifying antirheumatic drug (DMARD) prescribed to treat RA. Adverse effects associated with this medication include bone marrow suppression, hepatotoxicity, and gastrointestinal irritation (eg, nausea, vomiting, diarrhea). Bone marrow suppression can lead to anemia, leukopenia, and thrombocytopenia. Anemia manifests as fatigue, dyspnea on exertion, and pallor. Leukopenia increases the risk for infection. Thrombocytopenia presents as petechiae, purpura, or bleeding. Petechiae are small, purplish hemorrhagic skin spots that occur when the platelet count is <150,000/mm3(Option 3). Bone marrow suppression is managed with dose reduction or discontinuation of the medication. (Option 1) Although not common, mild temporary alopecia is an expected adverse effect of methotrexate. It does not require intermediate intervention and is not the most important finding to report. (Option 2) Nausea and vomiting are the most common side effects (25%-60%) associated with methotrexate. Although the nurse should notify the HCP and request a prescription for an antiemetic, nausea is not the most important finding to report. (Option 4) Stomatitis (inflammation of the mouth, oral ulcers) is a common side effect associated with methotrexate. It can be prevented with folic acid supplementation. Although the condition is uncomfortable, it would not require immediate intervention and is not the most important finding to report. Educational objective: Methotrexate (Rheumatrex) is a nonbiologic DMARD prescribed to treat RA. Major adverse effects include bone marrow suppression and hepatotoxicity. Most common side effects can be prevented by folic acid supplementation. A client with chronic heart failure developed an intractable cough and an incident of angioedema after starting enalapril. Which prescription does the nurse anticipate for this client? Unordered Options Ordered Response 1. Alprazolam 2. Dextromethorphan 3. Lisinopril 4. Valsartan Explanation Major side effects of angiotensin-converting enzyme (ACE) inhibitors include: • Symptomatic hypotension • Intractable cough • Hyperkalemia • Angioedema (allergic reaction involving edema of the face and airways) • Temporary increase in serum creatinine For clients unable to tolerate ACE inhibitors, angiotensin II receptor blockers (ARBs) such as valsartan or losartan are recommended. ARBs prevent the vasoconstrictor and aldosterone-secreting effects of angiotensin II by binding to the angiotensin II receptor sites. (Option 1) Alprazolam is an anxiolytic. It is not used in the treatment of heart failure. (Option 2) Dextromethorphan is a cough suppressant. A cough caused by an ACE inhibitor will not be improved by a cough suppressant. (Option 3) Lisinopril is an ACE inhibitor. This client has been unable to tolerate this class of drug. Educational objective: ARBs are recommended for clients unable to tolerate ACE inhibitors The nurse teaches a client about the use of regular and neutral protamine Hagedorn (NPH) insulin. Which statement by the client indicates that further teaching is needed? Unordered Options Ordered Response 1. "I will always check my blood glucose prior to using the sliding scale." 2. "I will eat breakfast 30 minutes after taking my morning NPH and regular insulin." 3. "I will use a new insulin syringe each time I give myself an injection." 4. "I will use the sliding scale to determine my NPH dose 4 times a day." Explanation The Institute for Safe Medication Practices has labeled insulin a high-alert medication. These types of medication can be safe and effective when administered or taken according to recommendations. However, errors in administration may cause death or serious illness. NPH is an intermediate-acting insulin with a duration of 12-18 hours; it is generally prescribed 2 times daily (morning and evening). Regular insulin and other rapid-acting insulins (lispro, aspart, glulisine) are typically used with a sliding scale for tighter control of blood glucose throughout the day. These are generally taken before meals and at bedtime. (Options 1, 2, and 3) These are correct statements and indicate the teaching objective was completed successfully. Educational objective: NPH is an intermediate-acting insulin with a duration of 12-18 hours and typically prescribed twice a day The nurse is conducting a hospital admission history and assessment. The client informs the nurse of taking the herb black cohosh (Actaea racemosa) daily. What is the best nursing response? Unordered Options Ordered Response 1. Ask the client about menopausal symptoms 2. Ask the health care provider to write a prescription for use of the herb during hospitalization 3. Contact the pharmacy to see if the herb interacts with the client's medications 4. Tell the client to stop taking it Explanation The nurse should follow up regarding the quantity of the herb and how it is used. Black cohosh is used by some clients for menopausal hot flashes. The main side effects are thickening of the uterine lining and potential liver toxicity. Herbs can cause harmful reactions when taken in combination with other drugs. It is most important to determine that an herb does not interfere with other medications. Herbal therapy is usually stopped 2-3 weeks before any surgery. (Option 1) Although black cohosh is typically used for menopausal symptoms, this is not the most important issue. (Option 2) Herbs are not routinely continued during a short hospitalization, especially when used for comfort symptomatic relief. (Option 4) There is no established contraindication at this point. Some herbs, such as those starting with "g" (eg, garlic, ginger, gingko, ginseng) lead to an increased bleeding risk. St. John's wort interferes with the metabolism of other drugs. It is important to know about potential interactions and the necessary response (eg, delay surgery, change medication or dosing). Educational objective: Contact the pharmacy to determine possible drug-drug interaction in a client using herbal therapy. A client with asthma was recently prescribed fluticasone/salmeterol. After the client has received instructions about this medication, which statement would require further teaching by the nurse? Unordered Options Ordered Response 1. "After taking this medication, I will rinse my mouth with water." 2. "At the first sign of an asthma attack, I will take this medication." 3. "I have been smoking for 12 years, but I just quit a month ago." 4. "I received the pneumococcal vaccine about a month ago." Explanation Fluticasone/salmeterol (Advair) is a combination drug containing a corticosteroid (fluticasone) and a bronchodilator (salmeterol). Salmeterol is a long-acting inhaled β2-adrenergic agonist that promotes relaxation of the bronchial smooth muscles over 12 hours. Fluticasone decreases inflammation. This medication is used as part of the treatment plan for prevention and long-term control of asthma. Client instructions include: • After inhalation, rinse the mouth with water without swallowing to reduce the risk of oral/esophageal candidiasis • Avoid smoking and using tobacco products • Receive the pneumococcal and influenza vaccines if there is a risk for infection (Option 2) Fluticasone/salmeterol is not a rescue inhaler and does not treat acute exacerbations of asthma. The client should always have a rescue inhaler (eg, albuterol [short-acting β2-adrenergic agonist] or ipratropium [Atrovent]) for sudden changes in breathing and call 911 if the rescue inhaler does not relieve the breathing problem. Educational objective: Fluticasone/salmeterol (Advair) is a long-acting inhaled β2-adrenergic agonist combination drug containing a corticosteroid (fluticasone) and a bronchodilator (salmeterol). It is used for long-term control of asthma but not for acute attacks A nurse in the cardiac intermediate care unit is caring for a client with acute decompensated heart failure (ADHF). The client also has a history of coronary artery disease and peripheral vascular disease. The nurse is preparing to administer medications. Based on the assessment data, the nurse should question which medication? Click on the exhibit button for additional information. Unordered Options Ordered Response 1. Aspirin 2. Atorvastatin 3. Furosemide 4. Metoprolol You answered this question correctly. Explanation Beta blockers, or "lols" (metoprolol, carvedilol, bisoprolol, atenolol), are the mainstay of therapy for clients with chronic heart failure as these improve survival rates for both systolic and diastolic heart failure. However, in certain situations beta blockers can worsen heart failure symptoms by decreasing normal compensatory sympathetic nervous system responses and myocardial contractility. In this client with acute decompensated heart failure (ADHF), marginally low blood pressure (BP), crackles in the lungs, low oxygen saturation, jugular venous distension (JVD), and peripheral edema, the administration of beta blockers can cause the client to further deteriorate. Beta blockers at low doses may be able to be restarted after this client has stabilized and exacerbation of ADHF has resolved with diuresis. (Options 1 and 2) Aspirin is contraindicated if the client has evidence of bleeding. Statins are contraindicated if there is evidence of severe liver or muscle injury. It is appropriate to administer both of these medications to this client who has coronary artery disease and peripheral vascular disease. (Option 3) This client has crackles, JVD, and peripheral edema, indicating the need for furosemide (Lasix). Therefore, the nurse should continue to monitor the client's BP with the administration of furosemide as it can lower BP. When excess fluid is removed through diuresis, the heart will be able to pump more effectively, which will increase cardiac output and BP. Educational objective: The nurse should question administration of beta blockers in a client with symptoms of acute ADHF due to the possibility of further clinical deterioration. Beta blockers are most useful for chronic heart failure The clinic nurse reviews the medical record of a client who was prescribed etanercept, a tumor necrosis factor (TNF) inhibitor. Which test result is most important for the nurse to check before initiating this treatment? Unordered Options Ordered Response 1. C-reactive protein (CRP) 2. Prothrombin time (PT) 3. Serum LDL cholesterol 4. Tuberculin skin test (TST) Explanation TNF inhibitor drugs (eg, etanercept [Enbrel], infliximab [Remicade], adalimumab [Humira]) block the action of TNF, a mediator that triggers a cell-mediated inflammatory response in the body. These drugs reduce the manifestations of rheumatoid arthritis (RA) and slow the progression of joint damage by inhibiting the inflammatory response. The medication causes immunosuppression and increased susceptibility for infection and malignancies. Clients should have a baseline TST before initiating therapy and yearly skin tests thereafter. Those with latent tuberculosis (TB) must be treated with antitubercular agents before initiating treatment with these drugs. Otherwise, TB reactivation would occur (Option 4). (Option 1) CRP is a non-specific test used to detect acute or chronic inflammation in the body. CRP can be used to evaluate the effectiveness of medications that decrease inflammation. An elevation would be expected in clients with RA, especially during a flare, but it is not the most important test result to check before initiating therapy. (Options 2 and 3) LDL cholesterol and PT are unrelated to the administration of these medications. Educational objective: Major adverse effects of biologic disease-modifying TNF inhibitor drugs (eg, etanercept, infliximab, adalimumab) include severe infections and bone marrow suppression. TB reactivation is a major concern. Therefore, all clients must receive a TST to rule out latent TB. A client has a follow-up checkup in the urology clinic. Six months ago, the client started taking tolterodine. What data collected from the client should the nurse report to the health care provider? Unordered Options Ordered Response 1. Client excitedly reports being able to go an entire work day without having to urinate 2. Client is using an over-the-counter artificial saliva product for dry mouth 3. Client reports occasional dizziness in the morning and when changing positions 4. Client reports symptoms of constipation Explanation Tolterodine (Detrol LA), oxybutynin (Ditropan), and solifenacin (Vesicare) are antimuscarinic/anticholinergic medications used for overactive bladder and urge urinary incontinence. They decrease urinary urgency and frequency. The most common side effects are anticholinergic (eg, dry mouth, constipation, cognitive dysfunction). The client's report of not urinating the entire day while at work may indicate that the dosage is too high and is causing urinary retention. Urinary retention can lead to bladder infections and distension. This information should be reported to the health care provider (HCP). (Option 2) Artificial saliva products and sugar-free hard candy and gum are acceptable ways to manage dry mouth caused by anticholinergic medications. (Option 3) Occasional dizziness is a side effect of tolterodine. The client should rise and change positions slowly. However, if this client is receiving too high a dose, reduction of the dose may alleviate the dizziness. Severe dizziness should be reported to the HCP. (Option 4) Constipation can be managed with increased fiber in the diet, fluids, stool softeners, or laxatives. Educational objective: Anticholinergic medications (eg, tolterodine, oxybutynin, solifenacin) are commonly used for overactive bladder. The client should experience a reduction in the number of times needed to urinate, but the number should not decrease below typical urination frequency. The nurse should also teach the client how to manage the common side effects of dry mouth, constipation, and mild dizziness. The clinic nurse is assessing the client’s understanding of the tiotropium that has been prescribed for chronic obstructive pulmonary disease (COPD). Which statement indicates that the client has a correct understanding of this medication? Unordered Options Ordered Response 1. "A capsule holds the powdered medication that I have to put in a special inhaler." 2. "I have been taking tiotropium every time I have difficulty breathing." 3. "I need to rinse my mouth out with water after taking tiotropium." 4. "Tiotropium helps control my COPD by reducing inflammation in my airway." Explanation Tiotropium (Spiriva) is a long-acting, 24-hour, anticholinergic inhaled medication used to control COPD and is administered most commonly using a capsule-inhaler system called the HandiHaler. The powdered medication dose is contained in a capsule. The client places the capsule in the inhaler device and pushes a button on the side of the device, which pokes a hole in the capsule. As the client inhales, the powder is dispersed through the hole. Unlike most inhaled medications, tiotropium looks like an oral medication because it comes in capsules and preparation for dispersion is unique. Therefore, it is important to teach the client how to administer the medication prior to the first dose, emphasizing that the capsules should not be swallowed and that the button on the inhaler must be pushed to allow for medication dispersion. During future appointments, the nurse should assess/reassess the client's ability to use this medication correctly. (Option 2) Tiotropium is a controller medication for COPD, and the peak effect takes about one week; therefore, it should not be used as a rescue medication. Instead, short-acting bronchodilators such as albuterol and/or ipratropium should be used for symptom rescue. Clients must discontinue ipratropium before taking tiotropium as both are anticholinergic. (Option 3) Rinsing the mouth is not required with tiotropium use. It is necessary only with inhaled steroids (eg, beclomethasone, budesonide, fluticasone), which can cause thrush if the medication remains in the mouth. (Option 4) Anticholinergic inhaled medications (eg, ipratropium, tiotropium, umeclidinium) do not reduce inflammation in the airway. Instead, they relax the airway by blocking parasympathetic bronchoconstriction. They also help to dry up airway secretions. Educational objective: Tiotropium and umeclidinium are long-acting, 24-hour, anticholinergic medications. Ipratropium is a short-acting anticholinergic used as a rescue medication for COPD and asthma. Tiotropium is typically administered as a powder via a special inhaler The nurse should call the primary health care provider (PHCP) to obtain a new prescription prior to administering which medication to a client with type I diabetes mellitus? Unordered Options Ordered Response 1. 10 units regular insulin intravenous (IV) push for blood glucose >250 mg/dL 2. 14 units glargine insulin subcutaneous injection every night at 8:00 PM 3. 18 units aspart insulin subcutaneous injection 15 minutes before breakfast 4. 20 units NPH insulin IV push administered every morning at 7:00 AM Explanation Subcutaneous injection is the indicated route for NPH insulin administration; it should never be administered via IV push. Regular insulin is the only insulin that can be administered via IV push; this is typically performed only in an acute care facility under close observation by the nurse. (Option 1) Administration of 10 units regular insulin IV push for blood glucose >250 mg/dL is appropriate and a new prescription is not required. (Option 2) Administration of 14 units glargine insulin subcutaneous injection every night at 8:00 PM is appropriate and a new prescription is not required. (Option 3) Administration of 18 units aspart insulin subcutaneous injection 15 minutes before breakfast is appropriate and a new prescription is not required. Educational objective: Subcutaneous injection is the indicated route for NPH insulin administration; it should never be administered IV push. Regular insulin is the only insulin that can be administered IV push. A 45-year-old client with atrial fibrillation has been prescribed diltiazem. Which client outcome would best indicate that the medication has had its intended effect? Unordered Options Ordered Response 1. Atrial fibrillation is converted to sinus rhythm 2. Blood pressure is 126/78 mm Hg 3. No signs or symptoms of stroke 4. Ventricular rate decreased from 158/min to 88/min Explanation Atrial fibrillation is characterized by disorganized electrical activity in the atria due to multiple ectopic foci. It leads to loss of effective atrial contraction and places the client at risk for embolic stroke as a result of the thrombi formed in the atria. During atrial fibrillation, the atrial rate may be increased to 350-600/min. The ventricular response can vary. The higher the ventricular rate, the more likely the client will have symptoms of decreased cardiac output (ie, hypotension). The treatment goals are to reduce the ventricular rate to <100/min and prevent stroke. Ventricular rate control is the priority. Medications used for rate control include calcium channel blockers (ie, diltiazem), beta blockers (ie, metoprolol), and digoxin. (Option 1) Diltiazem is unlikely to convert atrial fibrillation to sinus rhythm. Antiarrhythmic medications such as amiodarone or ibutilide will be used for conversion of the rhythm. (Option 2) Calcium channel blockers such as diltiazem may reduce blood pressure, but the nurse is not evaluating this client in atrial fibrillation for this outcome. In this case, diltiazem is being used for ventricular rate reduction. (Option 3) Having no signs or symptom of stroke is a positive outcome in this client; however, it is not a specific outcome of diltiazem. Anticoagulants (eg, warfarin, dabigatran, rivaroxaban, apixaban) are used for this purpose. Educational objective: The nurse should monitor for a reduction in ventricular rate in the client with atrial fibrillation who is receiving diltiazem, metoprolol, or digoxin. Anticoagulants are used to prevent embolic complications. A client with coronary artery disease was discharged home with a prescription for sublingual nitroglycerin (NTG) to treat angina. Which statement by the client indicates that further teaching is required? Unordered Options Ordered Response 1. "I may experience flushing but will continue to take the medication as prescribed." 2. "I should lie down before taking the medication." 3. "I should not swallow the tablet." 4. "I will wait to call 911 if I don't experience relief after the third tablet." Explanation Current evidence indicates that up to 50% of clients lack knowledge about administration procedures, storage, and side effects of NTG. Proper teaching can prevent many hospital visits for chest pain from stable angina. The client should be instructed to take 1 pill (or 1 spray) every 5 minutes for up to 3 doses, but emergency medical services (EMS) should be called if pain is unimproved or worsening 5 minutes after the first tablet. Previously, clients were taught to call EMS after the third dose, but newer studies suggest that this causes a significant delay in treatment (Option 4). NTG should cause a slight tingling sensation under the tongue if it is potent; otherwise, the medication is likely outdated. The oral mucosa needs to be moist for adequate absorption of NTG, and clients should be instructed to take a drink of water before administration if needed for dry mouth. Sublingual tablets should never be swallowed (Option 3). If using a spray, the client should not inhale it but direct it onto/under the tongue instead. (Option 1) Headache and flushing are common side effects of NTG due to systemic vasodilation. (Option 2) The client should lie down before taking the pill as it can cause dizziness from possible orthostatic hypotension. Educational objective: The nurse should instruct clients taking sublingual NTG that they should call EMS if their chest pain is unrelieved or worsening 5 minutes after the first tablet. The tablet should be allowed to dissolve under the tongue to allow for adequate absorption and should never be swallowed. The registered nurse is counseling the parent of a child who was diagnosed with attention-deficit hyperactivity disorder (ADHD) and received a prescription of methylphenidate. Which statement by the parent best demonstrates that teaching has been effective? Unordered Options Ordered Response 1. "An additive-free, low-sugar diet will reduce my child's symptoms." 2. "I can now manage my child's condition on my own." 3. "My child should take the last daily dose of methylphenidate before 6:00 PM." 4. "Once the medication is started, I will not have to monitor my child anymore." Explanation Stimulants (eg, methylphenidate, dextroamphetamine, lisdexamfetamine) are first-line agents in the treatment of ADHD. Methylphenidate (Ritalin) is administered in divided doses 2 or 3 times daily, usually 30-45 minutes before meals. As a stimulant, methylphenidate may interfere with sleep and should be given no later than around 6:00 PM. The sustained-release preparation should be given in the morning. The dosage in children is usually started low and titrated to the desired response. Children should be monitored closely during initial treatment for development of tics and continuously for adherence and response to therapy (Option 4). (Option 1) Contrary to popular myth, sugar does not increase hyperactivity; although an additive-free diet may be a healthy approach for children, eliminating additives or food colorings does not decrease the symptoms of ADHD. (Option 2) A team approach (parents, teachers, and health care providers) is the most effective way to help a child with ADHD. School-based interventions may include specific classroom modifications or accommodations to be incorporated into the treatment plan. Educational objective: Methylphenidate is a stimulant drug with the potential to cause insomnia. Parents are instructed to administer the last dose no later than 6:00 PM to prevent sleep disruption. Which client finding would be a contraindication for the nurse to administer dicyclomine hydrochloride for irritable bowel syndrome? Unordered Options Ordered Response 1. Bladder scan showing 500 mL urine 2. Hemoglobin of 11 g/dL 3. History of cataracts 4. Reporting frequent diarrhea today Explanation Dicyclomine hydrochloride (Bentyl) is an anticholinergic medication. Anticholinergics are used to relax smooth muscle and dry secretions. Anticholinergic side effects include pupillary dilation, dry mouth, urinary retention, and constipation. Therefore, the classic contraindications are closed-angle glaucoma, bowel ileus, and urinary retention. The urge to urinate is normally present at 300 mL; pain is usually felt around 500 mL. This client has urinary retention and should not have the bladder smooth muscle further relaxed. (Option 2) Anticholinergic drugs do not affect the blood count. The normal reference range for hemoglobin is 11.7-15.5 g/dL for females and 13.2-17.3 g/dL for males. (Option 3) The common eye contraindication is narrow-angle glaucoma as it could worsen the condition. Cataracts are a clouding of the lens and are not related to drainage flow. (Option 4) Diarrhea is an expected finding with irritable bowel syndrome or other increased peristalsis and is a common reason for the drug to be prescribed. Anticholinergic drugs are contraindicated in the presence of a bowel ileus or atony as constipation is a side effect and further relaxation of the intestines could worsen these conditions. Educational objective: Anticholinergic drugs are contraindicated when smooth muscle relaxation is already a concern. Commonly cited contraindications include narrow-angle glaucoma, urinary retention (including benign prostatic hyperplasia), and bowel ileus/obstruction. A client has a serum potassium level of 2.8 mEq/L, and the health care provider (HCP) prescribes intravenous (IV) potassium chloride (KCL). The nurse administers 10 mEq KCL/100 mL 5% dextrose in water at 100 mL/hr through the client's peripheral IV line using an infusion pump. Shortly after initiation of the infusion, the client reports feeling burning and discomfort at the IV site. What is the nurse's priority action? Unordered Options Ordered Response 1. Notify HCP to request a peripherally inserted central catheter (PICC) 2. Notify HCP to request an oral preparation of KCL 3. Slow the rate of the KCL infusion 4. Stop the infusion of KCL immediately Explanation KCL, an electrolyte replacement to correct hypokalemia, is a high-alert drug that is never administered by the IV push, intramuscular, or subcutaneous routes. The recommended peripheral infusion rate is 5-10 mEq/hr. However, the nurse should always follow institution IV guidelines and policy and procedure for administering KCL. The nurse's priority action is to slow the infusion rate if the client feels a burning discomfort at the IV site shortly after initiation of the infusion. KCL irritates the vein, and irritation and discomfort at the site is expected. Slowing the infusion rate is effective in alleviating discomfort. (Option 1) KCL in concentrations 20-40 mEq/100 mL at a maximum rate of 40 mEq/hr should be administered through a central venous access device (CVAD) (eg, PICC, centrally inserted catheter) to prevent postinfusion phlebitis. A concentration of 10 mEq KCL/100 mL can be administered through a peripheral vein at the recommended infusion rate. (Option 2) The IV infusion is preferred over the oral preparation to decrease the risk for dysrhythmias when hypokalemia must be corrected quickly. Some clients may need both oral and IV forms if the serum potassium levels are markedly low. However, this action is not a priority. (Option 4) Rapid correction of this client's hypokalemia (2.8 mEq/L) is necessary due to risk for hypokalemia-associated dysrhythmias. Stopping the infusion when not necessary further increases risk. The nurse assesses the site at least every hour for adverse reactions (eg, redness, pain, swelling, phlebitis, thrombosis, extravasation or infiltration), and stops the infusion if any occur. Educational objective: Potassium chloride (KCL) administered by the IV route is prescribed for rapid correction of hypokalemia (<3.5 mEq/L). It is irritating to the vein but can be administered slowly through a peripheral vein at recommended infusion rates (5-10 mEq/hr). KCL concentrations 20-40 mEq/100 mL at a maximum rate of 40 mEq/hr should be administered through a CVAD to prevent postinfusion phlebitis or infiltration. The nurse reviews the medication administration record and daily laboratory report of a client with atrial fibrillation. Which laboratory results should the nurse monitor when giving these medications? Select all that apply. Click the exhibit button for more information. Unordered Options Ordered Response 1. Complete blood count 2. Digoxin level 3. Glucose 4. International Normalized Ratio 5. Serum potassium Explanation The complete blood count (CBC) should be assessed periodically with the administration of enoxaparin, an anticoagulant. The nurse would want to assess the hemoglobin, hematocrit, and platelet count levels. If these levels are low, the client will be at risk for increased bleeding. Digoxin levels are not often prescribed unless there is suspicion of digoxin toxicity. However, if this value is available, the nurse should assess it. Digoxin toxicity can be seen with levels >2 ng/mL. Potassium levels should also be monitored in the client receiving digoxin. Hypokalemia can potentiate digoxin toxicity. Prednisone is a glucocorticoid that can increase glucose levels. Glucose levels should be monitored periodically for clients receiving this medication. (Option 4) Low-molecular-weight heparins, such as enoxaparin, produce a stable response at recommended dosages and negate the need for frequent monitoring of activated partial thromboplastin time (aPTT) or International Normalized Ratio (INR) levels. aPTT is monitored when administering unfractionated heparin. INR is monitored if the client is receiving warfarin. Educational objective: The nurse should routinely monitor laboratory values prior to administering medications. A CBC should be assessed periodically in the client receiving enoxaparin. Digoxin and potassium levels should be assessed with the administration of digoxin. Glucose levels should be monitored in the client receiving glucocorticoids. A client is admitted to the ambulatory care unit for an endoscopic procedure. The gastroenterologist administers midazolam 1 mg intravenously for sedation and titrates the dosage upward to 3.5 mg. The client becomes hypotensive (86/60 mm Hg), develops severe respiratory depression (SpO2 86%), and has periods of apnea. The nurse anticipates the administration of which antidote drug? Unordered Options Ordered Response 1. Benztropine 2. Flumazenil 3. Naloxone 4. Phentolamine Explanation Midazolam (Versed) is a benzodiazepine commonly used to induce conscious sedation in clients undergoing endoscopic procedures. The initial dose is 1 mg and is titrated up slowly (eg, 2 minutes before each 1-mg increment) until speech becomes slurred. Usually no more than 3.5 mg is necessary to induce conscious sedation. It is commonly administered with an opioid analgesic (eg, morphine, Fentanyl) because of their synergistic effects. Side effects can include airway occlusion, apnea, hypotension (especially in the presence of an opioid), and oxygen desaturation with resultant respiratory arrest. Flumazenil (Romazicon) is the antidote drug used to reverse the sedative effects of benzodiazepines. (Option 1) Benztropine (Cogentin) is used in the treatment of extrapyramidal side effects associated with antipsychotic medications or metoclopramide. (Option 3) Naloxone (Narcan) is the antidote drug to reverse the effects of opioids. (Option 4) Phentolamine (Regitine) is the antidote drug used to treat a norepinephrine (Levophed) extravasation. Educational objective: Flumazenil is a drug used to reverse the sedative effects of benzodiazepines such as midazolam. Copyright © UWorld. All rights reserved. A nurse teaches a client who is being discharged on warfarin for atrial fibrillation. Which client statements indicate that teaching has been effective? Select all that apply. Unordered Options Ordered Response 1. "Antibiotics can affect my INR value." 2. "I am going to eat more leafy greens." 3. "I will shoot for my INR value to be between 4 and 5." 4. "I will take warfarin at the same time daily." 5. "If I miss a dose, I can double it on the following day." Explanation A therapeutic INR for most conditions is 2-3 but can be up to 3.5 for heart valve disease. However, it is never between 4 and 5 (Option 3). Intestinal bacteria produce vitamin K; most antibiotics kill these bacteria, leading to vitamin K deficiency. Warfarin is a vitamin K antagonist; therefore, INR would overshoot in the setting of vitamin K deficiency, placing the client at risk for bleeding (Option 1). Leafy-green vegetables contain a high amount of vitamin K, which may lower a client's INR and make it difficult to maintain a therapeutic INR. Clients do not have to avoid consumption of leafy-green vegetables, but they should eat a consistent quantity and have their INR checked periodically (Option 2). (Option 4) It is important to take warfarin at the same time daily to maintain a consistent therapeutic drug level. (Option 5) Clients should call their health care provider if they miss or forget to take a warfarin dose. Double dosing is contraindicated. Educational objective: Warfarin must be taken at the same time daily to reach a therapeutic INR of 2-3. A diet high in vitamin K may decrease warfarin's anticoagulant effect. Most antibiotics will increase INR by causing a vitamin K deficiency. The nurse is working in the emergency department. Which client should the nurse see first? Unordered Options Ordered Response 1. 12-year-old with severe neck muscle spasms who is taking haloperidol for Tourette syndrome 2. 80-year-old with irritability and agitation who has taken alprazolam for 2 weeks 3. Client taking clozapine who has sudden onset of high fever, diaphoresis, and change in mental status 4. Client taking olanzapine who has dry mouth, blurry vision, and constipation Explanation The client taking clozapine is exhibiting classic signs of neuroleptic malignant syndrome (NMS), an uncommon but life-threatening adverse reaction to anti-psychotic medications. NMS is characterized by high fever, muscular rigidity, altered mental status, and autonomic dysfunction. Treatment includes supportive care (eg, rehydration, cooling body temperature) and immediate discontinuation of the medication. Due to the life-threatening nature of NMS, this client needs to be seen first to assess for generalized muscle rigidity. (Option 1) Severe neck spasms in an individual taking haloperidol (and other psychotropic medications) indicate a dystonic reaction. This client is in no immediate danger but needs treatment with IV benztropine (Cogentin) as soon as possible. The client should be seen second. (Option 2) Benzodiazepines can cause paradoxical worsening of agitation in elderly clients. This client needs a change in medication but does not need to be seen immediately. (Option 4) Dry mouth, blurry vision, and constipation are common anti-cholinergic side effects of olanzapine (and other psychotropic medications). These symptoms usually resolve after the client has taken the medication for a few weeks; treatment is symptomatic (eg, increased fluids, sugar-free chewing gum, high-fiber foods, avoidance of driving). This client can be seen last. Educational objective: Neuroleptic malignant syndrome (NMS) usually presents with mental status changes, fever, muscle rigidity, and autonomic instability after starting antipsychotic medications. Treatment involves discontinuation of the medication and supportive care (eg, rehydration, cooling body temperature). NMS is a life-threatening condition. A client recently diagnosed with heart failure is being discharged on the angiotensin- converting enzyme (ACE) inhibitor lisinopril. Which client teaching related to this new medication is important to review at discharge? Unordered Options Ordered Response 1. Instruct client to report for monthly blood work to monitor drug levels 2. Review foods high in potassium that client should include in diet 3. Teach client to count own pulse for 1 minute; hold medication if pulse <60/min 4. Teach client to rise slowly and sit on side of bed for several minutes before rising Explanation ACE inhibitors prevent the pathological enlargement of the left ventricle of the heart. They work by blocking a crucial step in the renin-angiotensin-aldosterone system, the main hormonal mechanism involved in blood pressure regulation. Interrupting this step of the renin-angiotensin-aldosterone system has following effects: 1. A shortage of angiotensin II results in an absence of the vasoconstrictive responses (orthostatic reflex, renal blood flow regulation) causing orthostatic hypotension. Clients may be more prone to experiencing orthostatic hypotension early in treatment with ACE inhibitors and should be taught ways to prevent it. 2. A shortage of aldosterone causes hyperkalemia. Aldosterone Saves Sodium and Pushes Potassium out of the body. 3. ACE inhibitors are contraindicated in pregnancy due to teratogenic affects on the fetus (eg, oligohydramnios, fetal kidney injury). The other important side effects of ACE inhibitors, cough and angioedema, are thought to be due to the accumulation of bradykinin. (Option 1) Renal function (blood urea nitrogen, creatinine) is commonly checked during the first week of treatment. Regular measurements to ensure therapeutic drug levels are required for lithium, phenytoin, and digoxin. (Option 2) A common side effect of ACE inhibitor is mild hyperkalemia, which may require a lower intake of foods high in potassium. Clients taking loop diuretics (eg, furosemide) will need to increase their intake of foods high in potassium. (Option 3) ACE inhibitors do not directly affect the heart rate. Clients prescribed digoxin are taught to take their pulse and hold their medication if the heart rate is <60/min. Educational objective: Client education after initiation of an ACE inhibitor (eg captopril, lisinopril) includes a discussion on development of a dry cough, taking several minutes to get out of bed, possible allergic reactions (rash, angioedema), and the teratogenic effects of the drug A client with seizure activity is receiving a continuous tube feeding via a small-bore enteral tube. The nurse prepares to administer phenytoin oral suspension via the enteral route. What is the nurse's priority action before administering this medication? Unordered Options Ordered Response 1. Check renal function laboratory results 2. Flush tube with normal saline, not water 3. Stop the feeding for 1 to 2 hours 4. Take the blood pressure (BP) Explanation Phenytoin (Dilantin) is an anticonvulsant drug commonly used to treat seizure disorders. Steady absorption is necessary to maintain a therapeutic dosage range and drug level to control seizure activity. The nurse's priority action is to stop the feeding for 1 to 2 hours before and after administering phenytoin as products containing calcium (eg, antacids, calcium supplements) and/or nutritional enteral tube feedings can decrease the absorption and the serum level of this drug. (Option 1) Unless clients have renal insufficiency, renal function tests are not routinely monitored during prescribed phenytoin therapy. Phenytoin is metabolized in the liver and can cause liver damage. Monitoring of liver function test during therapy is recommended. (Option 2) Flushing the tube with 30-50 mL of water before and after administering phenytoin is recommended to minimize drug loss and drug-drug incompatibility. Flushing with normal saline before and after drug administration is recommended in clients receiving intravenous (IV) phenytoin. (Option 4) BP is not usually affected in clients prescribed oral phenytoin therapy for seizure disorders. However, IV phenytoin can cause hypotension and arrhythmias. Educational objective: Phenytoin is an anticonvulsant drug commonly used to treat seizure disorders. Steady absorption is necessary to maintain a therapeutic dosage range and drug level to control seizure activity. Administration of phenytoin concurrent with certain drugs (eg, antacids, calcium) and/or enteral feedings can affect the absorption of phenytoin. The home health nurse reviews the serum laboratory test results for a client with seizures. The phenytoin level is 27 mcg/mL. The client makes which statement that may indicate the presence of dose-related drug toxicity and prompt the nurse to notify the health care provider? Unordered Options Ordered Response 1. "I am feeling unsteady when I walk." 2. "I am getting up to urinate about 4 times during the night." 3. "I have a metallic taste in my mouth when I eat." 4. "My gums are getting so puffy and red." Explanation Phenytoin (Dilantin) is an anticonvulsant drug used to treat generalized tonic-clonic seizures. The therapeutic serum phenytoin reference range is between 10-20 mcg/mL. Levels are measured when therapy is initiated, periodically throughout treatment to guide dosing until a steady state is attained (3-12 months), and if seizure activity increases. Early signs of toxicity include horizontal nystagmus and gait unsteadiness. These may be followed by slurred speech, lethargy, confusion, and even coma. Bradyarrhythmias and hypotension are usually seen with intravenous phenytoin. (Option 2) Nocturia is an expected side effect of diuretics but not phenytoin. Nocturia is also seen with diabetes mellitus and benign prostatic hyperplasia. (Option 3) Metallic taste in the mouth is often seen with metronidazole but not with phenytoin. (Option 4) Gingival hyperplasia is a common expected side effect of phenytoin and does not indicate drug toxicity. It occurs more often in clients <23 years of age who are prescribed >500 mg/day. Good oral hygiene can limit symptoms. Educational objective: Phenytoin, an anticonvulsant drug, is used to treat generalized tonic-clonic seizures. Common symptoms of phenytoin drug-induced toxicity involve the central nervous system and include ataxia, nystagmus, slurred speech, and decreased alertness. Copyright © UWorld. All rights reserved. A client with a chronic kidney disease has blood laboratory values as shown in the exhibit. The nurse administers sodium polystyrene sulfonate by mouth per the health care provider's prescription. The nurse evaluates that the therapy is effective when which value is noted on the follow-up results? Click on the exhibit button for additional information. Unordered Options Ordered Response 1. Calcium 7.4 mg/dL (1.85 mmol/L) 2. Creatinine 4.0 mg/dL (353 µmol/L) 3. Phosphorus 3.9 mg/dL (1.26 mmol/L) 4. Potassium 4.9 mEq/L (4.9 mmol/L) Explanation The client with kidney disease is at risk for both hyperkalemia (normal potassium 3.5- 5.0 mEq/L [3.5-5.0 mmol/L]) and hyperphosphatemia due to reduced glomerular filtration rate. Untreated hyperkalemia may cause life-threatening cardiac arrhythmias. Sodium polystyrene sulfonate (Kayexalate) can be used to treat hyperkalemia. It works in the gastrointestinal tract to trade sodium for potassium, thereby eliminating excess potassium through the stool and reducing the serum potassium level. (Option 1) Serum calcium levels (normal 8.6-10.2 mg/dL [2.15-2.55 mmol/L]) may decrease with diminished renal function due to lower activation of vitamin D and subsequent impaired gut absorption of calcium. Calcium supplements are used to increase the serum calcium level. Sodium polystyrene sulfonate does not affect the serum calcium level. (Option 2) Sodium polystyrene sulfonate does not affect serum creatinine levels. Creatinine levels may decrease after dialysis. (Option 3) Phosphorus is also not filtered with kidney injury and the levels increase in serum (normal 2.4-4.4 mg/dL [0.78-1.42 mmol/L]). Phosphate binders (calcium acetate/carbonate) administered orally eliminate phosphorous through stool. Sodium polystyrene sulfonate does not bind phosphorous. Educational objective: Clients with kidney disease are at risk for hyperkalemia. Sodium polystyrene sulfonate (Kayexalate) works in the gastrointestinal tract to trade sodium for potassium, thereby eliminating excess potassium through the stool and reducing the serum potassium level. A client has been on lithium carbonate therapy for 7 days. Which of the following findings would be most important to report to the health care provider (HCP)? Unordered Options Ordered Response 1. Diarrhea, vomiting, and mild tremor 2. Dry mouth and mild thirst 3. Hyperactivity and auditory hallucinations 4. Lithium level of 1.3 mEq/L Explanation Lithium carbonate is used for the initial and maintenance treatment of bipolar mania. Typical symptoms of mania include extreme hyperactivity, delusions and hallucinations, grandiosity, elation, poor judgment, aggressiveness, impulsivity, pressure of speech, insomnia, flight of ideas, and sometimes hostility. There is a very narrow range between therapeutic and toxic serum lithium levels; the usual ranges of therapeutic levels are 1.0–1.5 mEq/L for the treatment of acute mania and 0.6–1.2 mEq/L for maintenance therapy (Option 4). Acute lithium toxicity presents primarily with gastrointestinal side effects such as persistent nausea and vomiting and diarrhea. Neurologic symptoms typically manifest later and include tremor, confusion, ataxia, and sluggishness. Severe toxicity results in seizures and encephalopathy. Serum lithium levels and clinical condition must be monitored before medication administration. Serum levels ≥1.5 mEq/L and/or even the mildest symptoms of lithium toxicity must be reported to the HCP. (Option 2) Dry mouth and thirst are common and expected side effects of lithium carbonate when treatment is initiated. They will resolve spontaneously and lithium need not be discontinued. (Option 3) Hyperactivity and auditory hallucinations are clinical findings associated with bipolar mania. Because lithium may take up to 3 weeks to become effective, it would not be unusual for a client to experience these symptoms after only 7 days of treatment. Educational objective: Acute lithium toxicity (>1.5 mEq/L) presents primarily with gastrointestinal side effects such as persistent nausea and vomiting and diarrhea. Neurological symptoms typically manifest later and include tremor, confusion, ataxia, and sluggishness. The HCP must be notified at the earliest indication of lithium toxicity. The nurse in an ambulatory care center is teaching a client with a diagnosis of persistent depressive disorder (dysthymia) about the appropriate use of bupropion hydrochloride SR. Which statement made by the client indicates a need for further teaching? Unordered Options Ordered Response 1. "If I have a sudden change in my mood, I should call my physician immediately." 2. "If I have trouble swallowing the tablet, I can cut it in half." 3. "If I miss a dose, I should not double the next dose to catch up." 4. "It may take several weeks before I get better." Explanation Bupropion hydrochloride (Wellbutrin) is an atypical antidepressant used to treat depressive disorders, including major depressive disorder, seasonal affective disorder, and persistent depressive disorder (dysthymia). Preparations of bupropion hydrochloride include immediate-release, sustained release (SR), and extended-release (XL) tablets. Any medication marked SR or XL should not be chewed, cut, or crushed due to the risk of adverse effects from too rapid absorption of the drug. No form of bupropion hydrochloride should be altered; tablets should be swallowed whole, with or without food. Seizures are of particular concern if a client takes a high or toxic dose of bupropion hydrochloride. Clients on any kind of antidepressant need to be monitored closely for worsening depression, sudden or unusual behavior or mood changes, and the emergence of suicidal thoughts and behaviors. Clients with a diagnosis of depression and/or their family members need education and information on the increased risk of suicide (Option 1). Additional instructions to a client about the use of bupropion hydrochloride include the following: • Limit alcohol; inform the health care provider if you are used to consuming large amounts of alcohol • Do not double up on the medication if a scheduled dose is missed (Option 3) • Take the medication at the same time each day • It may take several weeks to feel the effects of bupropion hydrochloride (Option 4) • Weight loss may occur when taking this medication Educational objective: No form of bupropion hydrochloride should be crushed, chewed, or cut due to the risk of seizures and other adverse effects caused by the more rapid absorption and resulting higher serum levels of the drug. No medications labeled SR or XL should be altered before they are administered. This type of medication preparation should be swallowed whole. The home health nurse visits a client with atrial fibrillation who is newly prescribed digoxin 0.25 mg orally on even-numbered days. Which client statement would require further teaching about digoxin? Unordered Options Ordered Response 1. "I will call the health care provider (HCP) if I don't feel like eating." 2. "I will call the HCP if I feel dizzy and lightheaded." 3. "I will call the HCP if I have trouble reading." 4. "I will take my blood pressure before taking my medicine." Explanation Digoxin (Lanoxin) is a cardiac glycoside with positive inotropic and negative chronotropic effects. It is used to treat atrial fibrillation because at therapeutic levels (0.5-2.0 ng/mL) it decreases conduction through the sinoatrial node (SA) and ventricular heart rate. However, drug toxicity is common due to digoxin's narrow therapeutic range. Clients are instructed to recognize and report signs and symptoms of digoxin toxicity. These include the following: 1. Gastrointestinal symptoms, including anorexia, nausea, vomiting, and abdominal pain, are frequently the earliest symptoms (Option 1) 2. Neurologic manifestations - lethargy, fatigue, weakness, and confusion 3. Visual symptoms are characteristic and include alterations in color vision, scotomas, or blindness (Option 3) 4. Cardiac arrhythmias are the most dangerous symptoms. Digoxin toxicity can result in bradycardia and heart block, which can cause dizziness or lightheadedness. Clients are instructed to check their pulse and tell the HCP if it is low or has skipped beats (Option 2). (Option 4) There is no need to routinely check blood pressure before taking the medicine. Clients should check their pulse. Educational objective: Clients receiving digoxin are instructed to measure their pulse before taking the medication and withhold digoxin if the heart rate is <60/min. Clients should also be taught to recognize and report gastrointestinal (eg, anorexia, nausea, diarrhea), neurologic, and cardiac symptoms and visual changes (eg, altered color vision, scotomas) that suggest toxicity. A client with active pulmonary tuberculosis is prescribed 4-drug therapy with ethambutol. The community health nurse instructs the client to notify the health care provider immediately if which adverse effect associated with ethambutol occurs? Unordered Options Ordered Response 1. Blurred vision 2. Dark-colored urine 3. Difficulty hearing 4. Yellow skin Explanation Ethambutol (Myambutol) is used in combination with other antitubercular drugs (eg, isoniazid, rifampin, pyrazinamide) to treat active tuberculosis. The client must have baseline and periodic eye examinations during therapy as optic neuritis is a potentially reversible adverse effect. The client is instructed to report signs of decreased visual acuity and loss of color (red-green) discrimination. (Options 2 and 4) Dark-colored urine and yellow skin can indicate the presence of hepatotoxicity, which is associated with many drugs used to treat tuberculosis (eg, isoniazid, pyrazinamide, rifampin). However, hepatotoxicity is not common with ethambutol. (Option 3) Difficulty hearing (tinnitus, subjective hearing loss) is an adverse reaction to streptomycin. Streptomycin, an aminoglycoside antibiotic, is a second-line drug sometimes used to treat multi-drug-resistant tuberculosis, with ototoxic and nephrotoxic adverse effects. Educational objective: Clients taking ethambutol must have baseline and periodic eye examinations during therapy as optic neuritis is a potentially reversible adverse effect. A client with latent tuberculosis has been taking oral isoniazid (INH) 300 mg daily for 2 months. The client tells the nurse that for the past week she has had numbness, a burning sensation, and tingling in her hands and feet. Additional intake of which of the following would most likely have prevented this? Unordered Options Ordered Response 1. Folic acid 2. Vitamin B6 3. Vitamin B12 4. Vitamin D Explanation INH interferes with the action of vitamin B6 (pyridoxine), resulting in peripheral neuropathy; it manifests as ataxia and paresthesia. Individuals who are most predisposed to becoming neurotoxic from taking INH include older adults, those who are malnourished, diabetic clients, pregnant or breastfeeding clients, alcoholics, children, those with liver or renal disease, and HIV-positive individuals. To prevent these complications, a vitamin B6 supplement at a dose of 25–50 mg/day is recommended for those at high risk. (Option 1) Folic acid deficiency does not cause peripheral neuropathy. It is associated with macrocytic anemia and neural tube defects in children. (Option 3) Vitamin B12 deficiency can cause peripheral neuropathy; however, it is not seen with INH therapy. (Option 4) Vitamin D deficiency causes osteomalacia but not peripheral neuropathy. Educational objective: High-risk clients on isoniazid therapy for treatment of tuberculosis may experience neurological side effects due to a decrease in the body's ability to utilize vitamin B6 (pyridoxine). A vitamin B supplement will prevent these effects. The clinic nurse evaluates a client who was prescribed lithium therapy a month ago for bipolar disorder. Which client statement would cause the most concern? Unordered Options Ordered Response 1. "Everyone in my family has had the stomach flu; I will probably get it too." 2. "I've felt the need for an afternoon nap most days this week." 3. "I've gained 3 pounds since I began taking this medication." 4. "My mouth seems to be dry all the time." Explanation Lithium is often used in the treatment of bipolar disorder. It has expected, mild side effects as well as potentially serious ones related to drug toxicity. Drowsiness, weight gain, dry mouth, and gastrointestinal upset are expected, mild side effects. Lithium toxicity occurs with dehydration, low-sodium diet, decreased renal function, and drug-drug interactions (eg, NSAIDs, thiazidediuretics). Lithium and sodium are closely related in the body. Clients with vomiting and diarrhea are at risk of developing dehydration and/or low serum sodium. (Option 2) Drowsiness is an expected side effect. The nurse should advise the client to avoid hazardous activities and driving until the drug's effects are known or this side effect subsides. (Option 3) Weight gain is an expected side effect. The nurse should provide client education about healthy food choices and proper exercise and/or provide for a dietary consult. (Option 4) Dry mouth is an expected side effect. The nurse should provide client teaching about measures to counteract this side effect (eg, ice chips, sugarless gum or candy, drinking plenty of water). However, excess urination and polydipsia indicate nephrogenic diabetes insipidus from lithium toxicity. Educational objective: Dehydration and sodium loss from vomiting and diarrhea can lead to toxic lithium levels in clients receiving lithium therapy The nurse reviews the medication administration records and laboratory results for assigned clients. Which medication requires that the health care provider be notified before administration? Unordered Options Ordered Response 1. Calcium acetate for a client with a phosphate level of 8.5 mg/dL (2.75 mmol/L) 2. Clopidogrel for a client with a platelet count of 70,000/mm3 (70 × 109/L) 3. Magnesium sulfate for a client with a magnesium level of 1.0 mEq/L (0.5 mmol/L) 4. Metformin for a client with a glycosylated hemoglobin level of 11% Explanation Clopidogrel (Plavix) is a platelet aggregation inhibitor used to prevent blood clot formation in clients with recent myocardial infarction, acute coronary syndrome, cardiac stents, stroke, or peripheral vascular disease. Because it can cause thrombocytopenia and increase the risk for bleeding, the nurse should notify the health care provider (HCP) of the low platelet count (normal: 150,000-400,000/mm3 [150-400 × 109/L]) before administering clopidogrel. (Option 1) Calcium acetate (PhosLo) is used to control hyperphosphatemia in clients with end-stage kidney disease by binding to phosphate in the intestines and excreting it in the stool. Because the phosphate level is high (normal adult: 2.4-4.4 mg/dL [0.78- 1.42 mmol/L]), it is not necessary to notify the HCP. (Option 3) Magnesium sulfate is used to correct hypomagnesemia and treat torsades de pointes and seizures associated with eclampsia. Because the magnesium level is low (normal adult: 1.5-2.5 mEq/L [0.75-1.25 mmol/L]), it is not necessary to notify the HCP. (Option 4) Metformin (Glucophage) is a first-line drug for the control of blood sugar in clients with type 2 diabetes mellitus. Glycosylated hemoglobin (A1C) measures the total hemoglobin that has glucose attached to it, expressed as a percentage. Glucose remains attached to the red blood cell for the life of the cell (about 120 days) and reflects glycemic control over an extended period. The recommended A1C level for a client with diabetes is <7%. Although the A1C level is elevated, the medication would be administered regardless of the result (unless the client is hypoglycemic), so it is not necessary to notify the HCP. Educational objective: Clopidogrel (Plavix) can cause thrombocytopenia (platelet count <150,000/mm3 [150 × 109/L]) and increase a client's risk for bleeding. The nurse is passing the prescribed medications to the assigned clients. Which scheduled administrations should the nurse hold and seek clarification from the health care provider (HCP)? Select all that apply. Unordered Options Ordered Response 1. Client diagnosed with cirrhosis had 2 stools today; laxative lactulose prescribed daily 2. Client is scheduled for abdominal surgery tomorrow; vitamin E PO prescribed daily 3. Client is receiving IV vancomycin infusion; mild facial flushing noted after 30 minutes 4. Client with diabetes has insulin glargine and aspart prescribed; AM glucose is 100 mg/dL 5. Lisinopril PO is prescribed daily; serum potassium level is 5.6 mEq/L Explanation ACE inhibitors ("-prils") and angiotensin II receptor blockers (ARBs) ("-sartans") create a risk for hyperkalemia. ACE inhibitors decrease the excretion of aldosterone. Ordinarily, aldosterone would increase sodium and decrease potassium. However, when the ACE inhibitor suppresses aldosterone, potassium rises, placing clients at risk for hyperkalemia, especially in the presence of impaired renal function. The nurse should question the administration of an ACE inhibitor in a client who is hyperkalemic (Option 5). In general, certain herbs (garlic, gingko), vitamin E, and anticoagulation medications (eg, warfarin) are held prior to surgery as they can increase bleeding (Option 2). (Option 1) Lactulose is administered to excrete ammonia in cirrhosis with hepatic encephalopathy and not for the sole purpose of treating constipation. The dose is adjusted to achieve 2-3 soft stools each day. (Option 3) Vancomycin should be infused over at least 60 minutes (100 minutes if infusing ≥1 gram). When it is given too fast, the client may develop red man syndrome, which is characterized by facial and upper body flushing. If this occurs, the infusion needs to be slowed or stopped and restarted after a certain amount of time elapses, depending on flushing severity. However, it is not an anaphylactic rash and not a true allergy. This client is experiencing only a mild reaction; therefore, by slowing the infusion rate, the nurse can manage this side effect independently and does not need to contact the HCP. (Option 4) Basal insulin glargine (Lantus) and the rapid-acting insulin aspart (NovoLOG) are used for glucose control in diabetic clients. The insulin is given at mealtime to prevent postprandial hyperglycemia. The client should receive the prescribed insulin prior to eating the meal even if blood glucose is within normal limits. Educational objective: • Clients receiving ACE inhibitors should be monitored for hyperkalemia, especially in the presence of renal insufficiency. • Certain herbs (garlic, gingko) and vitamin E can increase the risk for bleeding. • A scheduled insulin regimen is given to maintain glycemic control even if the blood glucose is within normal limits The nurse is caring for a client with cirrhosis who has hepatic encephalopathy. The client is prescribed lactulose. Which assessment by the nurse will most likely indicate that the medication has achieved the desired therapeutic effect? Unordered Options Ordered Response 1. Higher potassium level 2. Improved mental status 3. Looser stool consistency 4. Reduced abdominal distension Explanation Hepatic encephalopathy in cirrhosis results from higher serum ammonia levels that cause neurotoxic effects, including mental confusion. Oral lactulose is given to reduce the ammonia by trapping it in the gut and then expelling it with a laxative effect. Improved mental status implies reduction of ammonia levels. (Option 1) Clients with cirrhosis typically have hypokalemia due to hyperaldosteronism (as aldosterone is not metabolized by the damaged liver). Hypokalemia can also result from diuretics used to treat the fluid retention and ascites. Lactulose is not intended to treat this pathology. (Option 3) Lactulose is a laxative. In cirrhosis, constipation (which allows more ammonia to be absorbed) and hard stool (which irritates hemorrhoids) are to be avoided. However, the main purpose of lactulose is expelling the ammonia, with resulting benefits. (Option 4) Abdominal distension (ascites) in cirrhosis is treated with diuretics (eg, furosemide, spironolactone) and paracentesis. Lactulose does not influence this pathology or symptom. Educational objective: Lactulose is a laxative used to trap and expel ammonia in clients with cirrhosis who have hepatic encephalopathy. Elevated ammonia levels cause mental confusion. The nurse provides discharge teaching for the parent of a child newly prescribed methylphenidate for attention-deficit hyperactivity disorder (ADHD). The nurse advises the parent that the child might experience which side effects? Unordered Options Ordered Response 1. Decreased blood pressure and growth delays 2. Heart palpitations and weight gain 3. Loss of appetite and restlessness 4. Trouble sleeping and a dry cough Explanation Stimulant medications are commonly used to treat ADHD in children and adults. Methylphenidate (Ritalin) and amphetamines (eg, dextroamphetamine, lisdexamfetamine) are the most commonly used stimulants. The major problems with stimulant medications include: 1. Decreased appetite and weight loss – can lead to growth delays 2. Cardiovascular effects – hypertension and tachycardia (particularly in adults) 3. Appearance of new or exacerbation of vocal/motor tics 4. Excess brain stimulation – restlessness, insomnia 5. Abuse potential – misuse, diversion, addiction (Option 1) Growth delays are a common side effect. The medications may cause hypertension, not hypotension. (Option 2) Heart palpitations are a common side effect; weight loss, not weight gain, can be a problem. (Option 4) Trouble sleeping is a common side effect, but the medications do not cause a dry cough. Educational objective: Methylphenidate (Ritalin) is a central nervous system stimulant with the following potential side effects: anorexia and weight loss/growth delays, restlessness and insomnia, hypertension and tachycardia, vocal or motor tics, and abuse potential A client with a history of atrial fibrillation has experienced a cardiac arrest episode with torsades de pointes. The client was successfully resuscitated. Which data collected by the nurse should be reported immediately to the health care provider? Unordered Options Ordered Response 1. Client has a dose of sotalol due this evening 2. Client took rivaroxaban this morning 3. Client's magnesium level is 2.0 mEq/L (1.0 mmol/L) 4. Client's potassium level is 5.0 mEq/L (5.0 mmol/L) Explanation Torsades de pointes (TdP) is a form of polymorphic ventricular tachycardia. It means "twisting of the points" around the isoelectric line of the recording. TdP is typically caused by a prolongation of the QT interval (measured from the beginning of the Q wave to the end of the T wave). This results primarily from the following 2 causes: 1 Medications: Antiarrhythmics (eg, sotalol, ibutilide, dofetilide), macrolide antibiotics (erythromycin, azithromycin), methadone, and psychotropic medications (eg, haloperidol [Haldol], ziprasidone [Geodon]) are the most commonly implicated ones. 1 Electrolyte abnormalities: Hypokalemia and hypomagnesemia can also precipitate TdP. TdP may reoccur until the underlying cause is identified and corrected. If the TdP is drug-induced, that drug should be discontinued immediately. Treatment may require defibrillation and the administration of magnesium. (Option 2) Dabigatran, rivaroxaban, apixaban, and warfarin are the commonly used anticoagulant medications in atrial fibrillation to prevent clot formation. These drugs do not prolong QT interval or cause TdP. (Option 3) This is a normal magnesium level (1.5-2.5 mEq/L [0.75-1.25 mmol/L]). If this were low, it could be a contributing factor to the occurrence of TdP. (Option 4) This is a normal potassium level (3.5-5 mEq/L [3.5-5.0 mmol/L]). If this were low, it could be a contributing factor to the occurrence of TdP. Educational objective: Antiarrhythmics (eg, sotalol, ibutilide, dofetilide), macrolide antibiotics (erythromycin, azithromycin), methadone, and psychotropic medications (eg, haloperidol [Haldol], ziprasidone [Geodon]) are the most common causes of drug-induced torsades de pointes (TdP). Hypomagnesemia and hypokalemia can also contribute to the occurrence of TdP. An African American client comes to the clinic for a follow-up visit 2 months after starting enalapril for hypertension. Which data collected during the health history should be reported to the health care provider (HCP) immediately? Unordered Options Ordered Response 1. Blood pressure taken in the clinic is 158/84 mm Hg 2. Client has a dry hacking cough 3. Client has noticed that the tongue is swelling slightly 4. Client has occasional dizziness upon rising in the morning Explanation Swelling of the tongue can be a sign of angioedema. Angioedema is swelling that can occur in the eyelids, lips, tongue, larynx, hands, feet, gastrointestinal tract, and genitalia. It often starts in the face and then progresses to the airways, which can be life-threatening. This can be an adverse effect of an angiotensin-converting-enzyme (ACE) inhibitor and African Americans are at a higher risk for its occurrence. Unlike other typical drug allergies, this side effect can occur any time after starting the medication (eg, sometimes after 1 year). The nurse should carefully monitor the client and report this immediately to the HCP. (Option 1) The nurse should review the client's log of recorded blood pressure readings over the past month since starting enalapril. The client may need a dosage change or an additional medication. This should be reported, but it is not the priority in this situation. (Option 2) A dry hacking cough is a common side effect of ACE inhibitors. It is not life- threatening, but the medication should be discontinued to resolve the cough. (Option 4) Occasional dizziness upon rising is a common side effect of most antihypertensives. The client should be taught to rise slowly and sit on the side of the bed for a few minutes before rising. Educational objective: Swelling of the tongue can be a sign of angioedema in the client taking ACE inhibitors; this can be potentially life-threatening if the airway becomes compromised. The nurse should report this immediately to the HCP. Angioedema can be a more common occurrence in African Americans. A client is receiving scheduled doses of carbidopa-levodopa. The nurse evaluates the medication as having the intended effect if which finding is noted? Unordered Options Ordered Response 1. Improvement in short-term memory 2. Improvement in spontaneous activity 3. Reduction in number of visual hallucinations 4. Reduction of dizziness with standing Explanation Parkinson disease is caused by low levels of dopamine in the brain. Levodopa is converted to dopamine in the brain, but much of this drug is metabolized before reaching the brain. Carbidopa helps prevent the breakdown of levodopa before it can reach the brain and take effect. This combination medication is particularly effective in treating bradykinesia (generalized slowing of movement). Tremor and rigidity may also improve to some extent. Carbidopa-levodopa (Sinemet) once started should never be stopped suddenly as this can lead to akinetic crisis (complete loss of movement). However, prolonged use can also result in dyskinesias (spontaneous involuntary movements) and on/off periods when the medication will start or stop working unpredictably. (Option 1) Carbidopa-levodopa does not improve memory. Medications for the treatment of Alzheimer disease, such as donepezil and rivastigmine, are used to improve cognition and memory. (Options 3 and 4) Orthostatic hypotension and neuropsychiatric disturbances (eg, confusion, hallucinations, delusions, agitation, psychosis) are serious and important adverse effects of carbidopa-levodopa. Health care providers usually start the medications at low doses and gradually increase them to prevent these effects. Educational objective: The combination medication carbidopa-levodopa is most helpful for treating bradykinesia in Parkinson disease and can also improve tremor and rigidity to some extent. It is started in low doses to prevent orthostatic hypotension and neuropsychiatric adverse effects. Carbidopa-levodopa once started should never be stopped suddenly as doing so can lead to akinetic crisis (complete loss of movement). A client taking morphine sulfate for acute pain has not voided in 6 hours. The nurse suspects the client has developed urinary retention. What is the priority nursing intervention? Unordered Options Ordered Response 1. Ask if the client needs to use the bedpan 2. Assess the client's fluid intake 3. Assess the client's skin turgor 4. Palpate the client's suprapubic area Explanation Opioids (eg, morphine sulfate), anticholinergic medications, and tricyclic antidepressants can cause urinary retention; they increase bladder sphincter tone and/or relax bladder muscle. The nurse should assess the client's suprapubic area to determine if the client has urinary retention. If the area is distended and dull to percussion, the nurse should proceed with interventions. (Option 1) While asking if a bedpan is needed is an important nursing intervention, it does not aid in the assessment of urinary retention. (Option 2) Gathering assessment data indicating the presence of urinary retention is necessary prior to other interventions. The nurse should assess for fluid intake after assessing bladder distension. (Option 3) The client's skin turgor is assessed after the nurse checks for urinary retention and fluid intake. There is no need to assess skin turgor until other indicators of adequate fluid intake are reviewed. Educational objective: Assessing the client's suprapubic area is the priority nursing action when urinary retention is suspected. Interventions are performed after a problem is identified and its cause is determined. Urinary retention is an expected side effect of opioid medications. A client with cancer is to receive a third dose of cisplatin. The client's laboratory results are shown in the exhibit. Which factor would be important for the nurse to assess before confirming the dose with the health care provider (HCP)? Click on the exhibit button for additional information. Unordered Options Ordered Response 1. Blood pressure 2. Capillary refill 3. Skin turgor 4. Urine output Explanation Urine output is a good indicator of renal function. Cisplatin is an antineoplastic medication that can cause renal toxicity. The client's elevated BUN may be due to dehydration (prerenal disease) or decreased kidney function. The creatinine is also elevated, an indication of kidney injury. In addition to laboratory results, the HCP will also need to know urine output. The medication dosage may then be adjusted or discontinued. (Option 1) Blood pressure may be part of the assessment of kidney function, but multiple disorders can cause changes in blood pressure. Urine output is a better indicator of renal function. (Option 2) Capillary refill is used to assess the circulatory system and is not a good indicator of a decrease in renal function. (Option 3) Skin turgor is important in assessing hydration status. However, this client's laboratory results indicate the possibility of renal toxicity from the cisplatin. Urine output is a better indicator of renal function. Educational objective: Cisplatin is an antineoplastic drug that may cause kidney injury. Assessment of renal function includes laboratory values and urine output. The nurse is preparing to administer the fourth dose of vancomycin IVPB to a client with infective endocarditis. Which intervention does the nurse anticipate? Unordered Options Ordered Response 1. Administering PRN antiemetic prior to the infusion 2. Administering via an infusion pump over at least 30 minutes 3. Drawing a trough level just prior to administration of the vancomycin 4. Starting a new IV line before administration Explanation Vancomycin is a very potent antibiotic that can cause nephrotoxicity and ototoxicity. Measuring for serum concentrations is a way to monitor for risk of nephrotoxicity as well as for therapeutic response. Trough serum vancomycin concentrations are the most accurate and practical method for monitoring efficacy. A trough should be obtained just prior (about 15-30 minutes) to administration of the next dose. (Option 1) Unlike some chemotherapy medications, vancomycin does not commonly cause nausea or vomiting. Premedication with antiemetics is not required. However, premedication with antihistamines (diphenhydramine) is recommended if the client had developed red man syndrome, also known as red neck syndrome, with prior vancomycin infusion. This syndrome is characterized by red blotching of the face, neck, and chest due to too rapid administration. (Option 2) Vancomycin should be administered over a minimum of 60 minutes. Too rapid administration can cause red man syndrome, considered a toxic effect rather than an allergic reaction. (Option 4) The nurse would want to verify patency of the IV line prior to administration as thrombophlebitis is a possibility with vancomycin; however, a new IV line is not necessarily required. Educational objective: To measure for efficacy and risk of nephrotoxicity with vancomycin, the nurse should draw periodic trough levels just prior to administration of the next IV dose. A client with primary hypothyroidism has been taking levothyroxine for 1 year. Laboratory results today show high levels of thyroid stimulating hormone (TSH). Which teaching should the nurse plan to implement? Unordered Options Your Response/Correct Response 1. "A new prescription will be issued for a decreased dose of levothyroxine." 2. "Discontinue levothyroxine immediately; we will reassess TSH levels in 3 months." 3. "Start taking your levothyroxine with dietary fiber or calcium to increase its effectiveness." 4. "You will need to get this new prescription filled for an increased dose of levothyroxine." Explanation Levothyroxine (Synthroid) is a thyroid hormone replacement drug that is the most common treatment for hypothyroidism, a condition in which thyroid hormone deficit slows the metabolic rate. In primary hypothyroidism, the deficit occurs due to a problem in thyroid gland tissue or hormone synthesis. TSH is released from the pituitary and stimulates the thyroid gland to secrete thyroid hormones (T3, T4). In primary hypothyroidism, when the thyroid does not synthesize enough T3 or T4, the pituitary releases additional TSH to compensate. This results in high levels of circulating TSH. Clients are prescribed levothyroxine (or their dose is augmented) to increase T3 and T4; this lowers TSH and leads to a euthyroid (normal) state (Options 1 and 2). (Option 3) For best results, levothyroxine should be taken on a consistent morning schedule before food ingestion. Foods containing certain ingredients (eg, cottonseed meal, walnuts, soybean flower, dietary fiber, calcium) can affect drug absorption. Educational objective: In primary hypothyroidism, the deficit occurs due to a problem in thyroid gland tissue or hormone synthesis. When the thyroid does not synthesize enough T3 or T4, the pituitary releases additional TSH to compensate. This results in high levels of circulating TSH. Levothyroxine is usually started/increased to lead to a euthyroid (normal) state The clinic nurse is teaching a client about levothyroxine, which the health care provider has prescribed for newly diagnosed hypothyroidism. Which statement made by the client indicates that further teaching is needed? Unordered Options Your Response/Correct Response 1. "I will need to get my blood drawn to see if I'm taking the right dose." 2. "I will probably need to take this the rest of my life." 3. "I will take this once a day in the morning." 4. "If this makes my stomach upset, I will take it with an antacid." Last Updated: 11/23/2015 Explanation Several medications impair the absorption of levothyroxine (Synthroid). Common offenders are antacids, calcium, and iron preparations. Some of these could be present in several over-the-counter multivitamin and mineral tablets. Therefore, clients with hypothyroidism should be instructed to take levothyroxine on an empty stomach, preferably in the morning, separately from other medications. The most common reason for inadequately treated hypothyroidism is deficient knowledge related to the medication regimen (eg, not taking daily, taking with other medications). (Option 1) Levothyroxine dosing is adjusted based on blood tests for thyroid- stimulating hormone or other thyroid hormone levels. The dose is not the same for each client. (Option 2) Thyroid supplementation with levothyroxine usually requires lifelong therapy. (Option 3) Levothyroxine has a long half-life, so dosing is once daily. Educational objective: Levothyroxine should be taken on an empty stomach, preferably in the morning, separately from other medications. During a routine office visit, the nurse documents the list of current medications of a client with a history of hypertension. Which statement by the client would cause the most concern? Unordered Options Your Response/Correct Response 1. "I periodically take docusate sodium for constipation." 2. "I regularly take ibuprofen for chronic low back pain." 3. "I take hydrochlorothiazide to prevent swelling around my ankles." 4. "I take omeprazole daily to prevent heartburn." Explanation Over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen can cause cardiovascular side effects, including heart attack, stroke, high blood pressure, and heart failure from fluid retention. These drugs also decrease the effectiveness of diuretics and other blood pressure medications. The risks can be even higher in the client who already has cardiovascular disease or takes NSAIDs routinely or for a long time. In addition, long-term use of NSAIDs is associated with peptic ulcers and chronic kidney disease. These clients should use NSAIDs cautiously, at the lowest dose necessary and for a short time. The nurse should notify the health care provider that this client is routinely taking ibuprofen. (Option 1) Taking docusate sodium occasionally for constipation is appropriate. (Option 3) Hydrochlorothiazide is a weak diuretic and is commonly used to treat hypertension. (Option 4) Omeprazole for heartburn is appropriate for this client. Educational objective: NSAIDs may cause heart attack, stroke, high blood pressure, and possible heart failure after long-term use. NSAIDs decrease the effectiveness of diuretic and blood pressure medications. Long-term use is also associated with chronic kidney disease and peptic ulcers. The nurse provides medication teaching to a client with primary adrenal insufficiency (Addison's disease) who is prescribed hydrocortisone 10 mg by mouth 3 times a day. Which instructions should be included in the client's teaching plan? Select all that apply. Unordered Options Your Response/Correct Response 1. "Discontinue hydrocortisone if you note mood changes or disruptions in behavior." 2. "Make an appointment with an optometrist yearly to assess for cataracts." 3. "Report even a low-grade fever to the health care provider (HCP) immediately." 4. "Report signs of hyperglycemia, including increased urine, hunger, and thirst." 5. "Take the medication on an empty stomach." 6. "The dose of hydrocortisone may need to be decreased during times of stress." Explanation Clients taking long-term corticosteroid replacement should be taught the following: 1. Do not discontinue glucocorticoid therapy abruptly. Abrupt discontinuation could lead to addisonian crisis, a life-threatening complication (Option 1). 2. Report any signs and symptoms of infection to the HCP immediately. Corticosteroid use can cause immunosuppression, and infection can develop quickly and spread rapidly. Corticosteroids' anti-inflammatory effects may also mask signs of infection such as inflammation, redness, tenderness, heat, fever, and edema (Option 3). 3. Stay attuned to signs and symptoms of stress and increase dose of corticosteroid during times of stress. A stress response (surgery, trauma) can cause a sudden decrease in cortisol levels, triggering addisonian crisis (Option 6). 4. A side effect of corticosteroid therapy is hyperglycemia. Report signs of hyperglycemia, including increased urine, hunger, and thirst. Clients with diabetes mellitus must be vigilant in checking blood glucose levels (Option 4). 5. Corticosteroids are catabolic to bone (osteoporosis) and muscle (muscle weakness). A diet high in calcium (at least 1500 mg/day) and protein (1.5 g/kg/day) but low in fat and simple carbohydrates is recommended. 6. Cataracts are a side effect of corticosteroids, particularly glucocorticoid therapy. Make an appointment with an optometrist yearly to assess for cataracts (Option 2). 7. Corticosteroid medications can cause gastric irritation and should not be taken on an empty stomach (Option 5). 8. Recognize signs and symptoms of Cushing syndrome and report to the PHCP. 9. Develop a regular HCP-approved exercise program. Educational objective: Corticosteroids are the primary drugs used to treat Addison's disease. It is imperative that the nurse teach the client about this medication, including points such as never to stop it abruptly, notify the HCP of signs and symptoms of infection, and monitor blood glucose closely if diabetes is a comorbid condition. The health care provider (HCP) prescribes naproxen for a client who has degenerative joint disease. What instructions regarding this drug does the nurse include in the client's discharge plan? Select all that apply. Unordered Options Your Response/Correct Response 1. Avoid driving while taking this medicine 2. Change positions slowly 3. Discontinue immediately if suicidal thoughts occur 4. Notify the HCP of tarry stools 5. Take the medicine with food Explanation Naproxen is a nonsteroidal anti-inflammatory drug (NSAID) commonly prescribed to decrease joint pain and inflammation. All NSAIDs (eg, indomethacin, ibuprofen) are associated with the following: 1. Gastrointestinal (GI) toxicity - symptoms of GI bleeding such as black tarry stools should be reported. Gastrointestinal upset (eg, dyspepsia, pain) can be reduced if the medicine is taken with food. 2. Kidney injury - long-term use is associated with kidney injury 3. Hypertension and heart failure - NSAIDs can cause fluid retention, which can exacerbate conditions such as heart failure, cirrhosis/ascites, and hypertension 4. Bleeding risk - clients should notify the HCP if taking concurrently with aspirin, other NSAIDs, or anticoagulant or antiplatelet drugs as they can increase the risk of GI bleeding. (Option 1) Clients should not drive when taking sedating medications (eg, antihistamines, benzodiazepines). However, sedation is not associated with NSAID use. (Option 2) Orthostatic hypotension is common with blood pressure medications (eg, ACE inhibitors, alpha blockers) but not with NSAIDs. (Option 3) Suicidal thoughts are commonly associated with selective serotonin reuptake inhibitors (antidepressants) and varenicline (Chantix), a smoking cessation medication. Educational objective: All NSAIDs (eg, indomethacin, ibuprofen, naproxen) are associated with gastrointestinal toxicity, kidney injury, exacerbation of fluid overload/hypertension, and bleeding risk. They should be used at the lowest dose and for the shortest period possible. Copyright © UWorld. All rights reserved. The nurse reviews assigned clients' medical and medication administration records. Which prescription should the nurse validate with the health care provider before administering? Unordered Options Your Response/Correct Response 1. Acetaminophen IV for a postoperative client with temperature of 101 F (38.3 C) who reports incisional pain of 6 on a 0-10 scale 2. Azathioprine for a client with Crohn disease who reports fatigue and nausea and has leukopenia 3. Baclofen for a client with multiple sclerosis and muscle spasms who reports dizziness when changing positions 4. Colchicine for a client with an acute gout attack who reports burning pain in the great toe of 10 on a 0-10 scale Explanation Azathioprine (Imuran) is an immunosuppressant drug that can cause bone marrow depression and increase the risk for infection. It is prescribed to treat autoimmune conditions such as inflammatory bowel disease and to prevent organ transplant rejection. Fatigue and nausea can be expected as minor adverse effects or may be associated with the disease. Leukopenia (white blood cell count <4,000/mm3 [4.0 × 109/L]) can be a severe adverse effect of the drug and should be reported to the health care provider before administering the medication. (Option 1) Acetaminophen IV (Ofirmev) blocks the production of prostaglandins and has both antipyretic and analgesic properties. It is effective in relieving mild to moderate pain and can be prescribed in combination with opioid analgesia to relieve moderate to severe pain. (Option 3) Baclofen (Lioresal) is an antispasmodic drug that promotes skeletal muscle relaxation by interfering with the transmission of impulses that cause muscle spasticity. It is effective in decreasing pain and cramping associated with muscle tightness and spasticity in clients with multiple sclerosis and in those with spinal cord injury. Orthostatic hypotension is an expected adverse effect. (Option 4) Colchicine is prescribed for clients with an acute attack of gout as it decreases the inflammation and pain associated with deposition of uric acid crystals in the joints. Educational objective: Azathioprine (Imuran) is an immunosuppressant drug that can cause bone marrow suppression and increase the risk for infection. Leukopenia, a severe adverse effect of azathioprine, should be reported to the health care provider before the medication is administered. A client with chronic kidney disease has received a continuous intravenous infusion of heparin for 5 days. The nurse reviews the coagulation studies and the medication administration record. Which prescription would the nurse question? Click on the exhibit button for additional information. Unordered Options Your Response/Correct Response 1. Epoetin 2. Sodium polystyrene sulfonate 3. Vitamin K 4. Warfarin Explanation Vitamin K (phytonadione) is a fat-soluble vitamin that is administered as an antidote for warfarin-related bleeding. This medication prescription should be questioned as vitamin K reverses the anticoagulant effect of warfarin, and the client's coagulation studies are in the therapeutic range (aPTT 46-70 sec, INR 2-3). (Option 1) Epoetin (Procrit) is a synthetic hormone that stimulates the production of erythropoietin and is used to treat anemia associated with chronic kidney disease. This is an appropriate prescription. (Option 2) Sodium polystyrene sulfonate (Kayexalate) is a sodium exchange resin administered to reduce elevated serum potassium levels in clients with chronic kidney disease and hyperkalemia. This is an appropriate prescription for this client. (Option 4) Warfarin (Coumadin) is a vitamin K antagonist used for long-term anticoagulation that is started about 5 days before a continuous heparin infusion is discontinued. An overlap of the parenteral and oral anticoagulant is required for about 5 days as this is the time it takes warfarin to reach therapeutic level. This is an appropriate prescription for this client. Educational objective: Anticoagulants stop thrombus formation by interfering with the coagulation cascade. Parenteral heparin and oral warfarin affect the clotting cascade differently; therefore, a 5-day overlap for the 2 drugs is required. This allows warfarin to reach a therapeutic level before the continuous heparin infusion is stopped. The health care provider is starting an elderly client on terazosin to treat benign prostatic hyperplasia (BPH). Which information should be included when teaching this client about the new medication? Unordered Options Your Response/Correct Response 1. Change positions slowly when going from lying to standing 2. Do not drink grapefruit juice when taking this drug 3. Take this medication first thing in the morning, before breakfast 4. Your stool may become darker and that's normal Explanation Terazosin is an alpha-adrenergic blocker that can relieve urinary retention in clients with BPH. It relaxes the smooth muscle in the bladder neck and prostate gland; however, it also relaxes smooth muscle in the peripheral vasculature, which can cause orthostatic hypotension, syncope (blacking out), and falls. This is particularly common when the drug is started (first-dose hypotension) or when the dosage is increased. The serious effects can be avoided by instructing the client to take the medication at bedtime, change positions slowly when going from lying to standing, and avoid any medications that also increase smooth muscle relaxation (eg, phosphodiesterase-5 inhibitors [sildenafil or vardenafil] used to treat erectile dysfunction). Some clients may also experience ejaculatory dysfunction (decreased or absent ejaculation). (Option 2) Grapefruit juice can cause significant interactions with drugs such as calcium channel blockers and sildenafil. However, it does not appear to interact with alpha blockers such as terazosin. (Option 3) Alpha-1-adrenergic antagonists (eg, terazosin, doxazosin, tamsulosin, alfuzosin) should be taken at bedtime, not in the morning, to avoid orthostatic hypotension. (Option 4) Oral iron tablets and bismuth salts (Pepto-Bismol) can turn stools dark, an expected side effect. This can be confused with upper gastrointestinal bleeding, which can also cause melena. Educational objective: Alpha blockers are commonly used to treat symptoms of urinary retention in clients with BPH. Orthostatic hypotension is a common side effect that can be avoided by teaching the client to take the medication at bedtime, avoid abrupt position changes, and avoid medications for erectile dysfunction, which can worsen hypotension. A client recovering from femoral-popliteal bypass surgery performed yesterday reports a pain level of 5 on a 0-10 scale. At 2400, the night shift nurse reviews the client's medication administration record, shown in the exhibit. Which medication should the nurse administer? Click on the exhibit button for additional information. Unordered Options Your Response/Correct Response 1. Acetaminophen 2. Alprazolam 3. Hydrocodone/acetaminophen 4. Morphine Explanation The client is reporting a moderate level of pain. The medication administration record indicates that the client last received hydrocodone/acetaminophen 5 hours ago. It is reasonable for the nurse to choose the oral pain medication for moderate-level pain as the client last received it and then did not require IV pain medication after that administration. (Option 1) The pain level is too high for acetaminophen alone. (Option 2) Alprazolam is typically used for the treatment of anxiety. (Option 4) Morphine is indicated for severe pain. Educational objective: The nurse should administer an opioid analgesic to a client who is experiencing moderate-level postoperative pain. Oral medication is an appropriate choice when it has been effective previously Test Id: 52331097 Question Id: 30770 (729561) A client suffering from chronic kidney disease is scheduled to receive recombinant human erythropoietin and iron sucrose. An assessment of lab work shows hemoglobin of 9.7 g/dL and hematocrit of 29%. What is the best nursing action? Unordered Options Ordered Response 1. Administer the erythropoietin in the client's abdominal area 2. Check the client's blood pressure prior to administering the erythropoietin 3. Hold the client's next scheduled iron sucrose dose 4. Hold the erythropoietin dose and inform the health care provider Explanation Anemia associated with chronic kidney disease is treated with recombinant human erythropoietin (Epogen/Procrit, epoetin). Therapy is initiated to achieve a target hemoglobin of 10-11.5 g/dL and to alleviate the symptoms of anemia (eg, fatigue) and the need for blood transfusions. However, higher hemoglobin concentrations, especially >13 g/dL, are associated with venous thromboembolism and adverse cardiovascular outcomes. Hypertension is a major adverse effect of erythropoietin administration. Therefore, uncontrolled hypertension is a contraindication to recombinant erythropoietin therapy. Blood pressure should be well controlled prior to administration of erythropoietin. (Option 1) Erythropoietin is administered intravenously or in any area subcutaneous area. However, checking the client's blood pressure must be done prior to administering. (Option 3) Iron in the form of iron sucrose (Venofer) or ferric gluconate (Ferrlecit) may be prescribed to promote an adequate response to erythropoietin. Adequate stores of iron, vitamin B-12, and folic acid are required for the erythropoietin to work. There is no reason to hold iron therapy at this time. (Option 4) The dose is held if the client has higher target hemoglobin or uncontrolled hypertension. Educational objective: The kidneys release erythropoietin to stimulate the production of red blood cells. Anemia of chronic kidney disease is treated with recombinant erythropoietin for a target hemoglobin of 10-11.5 g/dL. Hemoglobin levels >13 g/dL are associated with thromboembolic and cardiovascular events. Uncontrolled hypertension is a contraindication to recombinant erythropoietin therapy. Test Id: 52331097 Question Id: 31769 (729561) The nurse is preparing medications for the medical-surgical clients. The administration of an anticholinergic drug, such as atropine, is prohibited in which client condition? Unordered Options Ordered Response 1. Bladder scan revealing 450 mL residual 2. Double vision 3. Frequent, loose stools 4. Streptococcal throat infection Explanation An anticholinergic drug blocks neurotransmitter acetylcholine in the central and peripheral nervous systems. Therapeutically, these drugs are used to relax muscles and dry secretions; some common indications include the following: • Dicyclomine (Bentyl) for symptomatic relief of gastrointestinal hypermobility or irritable bowel syndrome • Oxybutynin (Ditropan) for overactive bladder • Atropine as a mydriatic eye drop to cause dilation for refraction testing • Atropine to dry respiratory secretions in end-of-life care The side effects are dry mouth and constipation. These drugs are contraindicated in glaucoma (where it would affect intraocular pressure), bladder retention (including benign prostatic hyperplasia where bladder force is required to overcome increased resistance), and bowel ileus/obstruction. Normally, a client feels the urge to void when the bladder contains 300 mL of urine. After voiding, the residual should be 50 mL or less. The client currently has urinary retention, which is a contraindication. (Option 2) Diplopia, or double vision, is not a result of excessive intraocular pressure but more likely related to dysfunction of the extraocular muscles. It would not be a contraindication. (Option 3) Contraindications for anticholinergic medications include bowel ileus/obstruction which leads to constipation (not diarrhea). (Option 4) There is no contraindication for an anticholinergic medication with throat infection. Educational objective: Anticholinergic medications are used therapeutically for muscle relaxation and to dry secretions. They are contraindicated with glaucoma, benign prostatic hyperplasia, urinary retention, and bowel ileus/obstruction. This is sometimes summarized as "can't pee, can't see, can't spit, can't shit." Test Id: 52331097 Question Id: 30083 (729561) The nurse caring for a client in the intensive care unit reports a critical laboratory value of 120,000/mm3 (120 x 109/L) platelets, decreased from 300,000/mm3 (300 x 109/L) on admission. The health care provider says this is normal. The client is receiving heparin injections. Which nursing action would be the most appropriate? Unordered Options Ordered Response 1. Contact the appropriate certification and licensing board 2. Document the exchange in the chart 3. Report the incident to the hospital's legal team 4. Report the incident to the state medical board Explanation There are 2 forms of heparin-induced thrombocytopenia. The first form (platelets >100,000/mm3 [100 x 109/L]) normalizes within a few days. The second form (platelets <40,000/mm3 [40 x 109/L]) is a life-threatening autoimmune process that requires immediate heparin discontinuation. When in doubt of a clinician's judgment, the nurse should document these objections and report to the nursing supervisor. (Options 1, 3, and 4) It is important to first refer up the nursing hierarchy. Educational objective: The nurse should document and then report objections about a clinician's judgment to the nursing supervisor. Test Id: 52331097 Question Id: 30994 (729561) Which prescriptions for these clients does the nurse question? Select all that apply. Unordered Options Ordered Response 1. Client with Clostridium difficile colitis, prescribed vancomycin 125 mg PO 2. Client with diabetes and elevated mealtime glucose, prescribed lispro insulin scale 6 units subcutaneously 3. Client with gastrointestinal bleed and nasogastric tube, prescribed pantoprazole 40 mg intravenous 4. Client with hypertension and blood pressure (BP) 94/40 mm Hg, prescribed metoprolol succinate SR 50 mg PO 5. Client with otitis media and penicillin allergy, prescribed ampicillin 500 mg PO Explanation The nurse would question the prescriptions for the following clients: • Client with hypertension and BP 94/40 mm Hg, prescribed metoprolol succinate SR (Toprol-XL) 50 mg PO: This client's mean arterial pressure (MAP) is only 58 mm Hg ({[2x diastolic] + systolic} ÷ 3). A MAP >60-65 mm Hg is necessary to perfuse the vital organs (eg, brain, coronary arteries, kidneys). Toprol-XL is a long-acting beta blocker and will continue to drop the client's BP over a 24-hour period. • Client with otitis media and penicillin allergy prescribed ampicillin 500 mg PO: Ampicillin is classified as a penicillin antibiotic and is contraindicated in clients with a penicillin allergy. (Option 1) C difficile colitis is treated with metronidazole or vancomycin, depending on severity and number of relapses. Vancomycin is typically given orally in this situation, unlike other nonintestinal infections in which IV is the standard route. There is no reason to question this prescription. (Option 2) A sliding insulin (correction) scale is used to prescribe rapid-acting lispro (Humalog) to control postprandial hyperglycemia. The nurse would not question this prescription. (Option 3) Proton pump inhibitors (eg, pantoprazole, omeprazole) are prescribed for gastroesophageal reflux disease, and ulcer treatment and prophylaxis. The IV preparation is administered when the oral route is contraindicated. The nurse would not question this prescription. Educational objective: IV proton pump inhibitors are used for gastric ulcer bleeding. Oral vancomycin can be used for C difficile colitis. Ampicillin or amoxicillin are contraindicated in clients with a penicillin allergy. Antihypertensives are held if the client has borderline low BP Test Id: 52331097 Question Id: 30461 (729561) The nurse is discharging a client hospitalized for a new diagnosis of heart failure. The discharge medications include lisinopril 10 mg and spironolactone 25 mg. The client has also been started on a 2000 mg low-sodium diet. Which statement by the client indicates teaching on discharge instructions has been effective? Unordered Options Ordered Response 1. "I will be sure to take my medications before bedtime." 2. "I will eat more fresh fruits like bananas and oranges." 3. "I will limit my intake of cheeses, breads, and canned foods." 4. "I will use a salt substitute to season my food." Explanation Poor adherence to a low-sodium diet (Choice 3) and failure to take prescribed medications as directed (Choice 1) are the most common reasons for readmission of heart failure clients to the hospital setting. The edema associated with heart failure is often treated by dietary restriction of sodium. The nurse or dietician should assess the client's diet history, teach how to read food labels and plan for dining out, and develop an overall diet plan. Diet recommendations should be individualized and culturally sensitive for the client to make the needed changes successfully. The Dietary Approaches to Stop Hypertension (DASH) diet is widely used for clients with heart failure. All foods high in sodium (>400 mg/serving) should be avoided. General principles of a low-sodium diet are as follows: • Do not add salt or seasonings containing sodium when preparing meals • Do not use salt at the table • Avoid high-sodium foods (eg, canned soups, processed meats, cheese, frozen meals) • Limit milk products to 2 cups daily (Option 1) Medications such as spironolactone are diuretics. Taking them at bedtime would cause the client to have nocturia. Spironolactone should be taken in the morning. (Option 2) Hyperkalemia is a side effect of angiotensin-converting enzyme (ACE) inhibitors such as lisinopril. Spironolactone is a potassium-sparing diuretic. Although fresh fruit is a good option for a low-sodium diet, bananas and oranges are high in potassium, which could put this client at increased risk for hyperkalemia. (Option 4) Many salt substitutes are high in potassium. This client is already at risk for hyperkalemia due to the ACE inhibitor lisinopril and the potassium-sparing diuretic spironolactone. The nurse should encourage the client to substitute lemon juice or other spices for salt or a salt substitute. Educational objective: The client in heart failure on a low-sodium diet should be encouraged to limit the intake of such foods as processed meats, cheese, canned soups and vegetables, frozen meals, breads, and milk products. Test Id: 52331097 Question Id: 31882 (729561) The health care provider prescribes simvastatin for a client with hyperlipidemia. The nurse instructs the client to take this medication in which manner? Unordered Options Ordered Response 1. At noon with a meal 2. In the morning on an empty stomach 3. In the morning with breakfast 4. With the evening meal Explanation Statin drugs (eg, simvastatin, atorvastatin, rosuvastatin) are prescribed to lower cholesterol and reduce the risk of atherosclerosis and coronary artery disease. Most of the cholesterol in the body is synthesized by the liver during the fasting state, at night. Trials have found greater reductions in total and LDL cholesterol when statins (especially those that are short-acting; eg, simvastatin) are taken in the evening or at bedtime as opposed to during the day. (Options 1 and 3) Medications that can cause stomach upset (eg, NSAIDs) should be taken with food. (Option 2) Medications such as levothyroxine should be taken on an empty stomach in the morning. Acid-suppressing medications (eg, proton pump inhibitors, H2 blockers) should also be taken 30 minutes before the meal. Educational objective: The client taking a statin drug such as simvastatin should be taught to take the medication with the evening meal or at bedtime to promote maximal effectiveness. Test Id: 52331097 Question Id: 30302 (729561) The nurse is providing discharge instructions on the proper use of prescribed short- acting beta agonist (SABA) and inhaled corticosteroid (ICS) metered-dose inhalers (MDIs) to a client with newly diagnosed asthma. Which instructions should the nurse include? Select all that apply. Unordered Options Ordered Response 1. "Omit the beclomethasone if the albuterol is effective." 2. "Rinse your mouth well after using the beclomethasone inhaler and do not swallow the water." 3. "Take the albuterol inhaler apart and wash it after every use." 4. "Use the albuterol inhaler first if needed, then the beclomethasone inhaler." 5. "Use the beclomethasone inhaler first, then the albuterol, if needed." Explanation Asthma is a disorder of the lungs characterized by reversible airway hyper-reactivity and chronic inflammation of the airways. Albuterol (Proventil) is a SABA administered as a quick-relief, rescue drug to relieve symptoms (eg, wheezing, breathlessness, chest tightness) associated with intermittent or persistent asthma. Beclomethasone (Beconase) is an ICS normally used as a long-term, first-line drug to control chronic airway inflammation. When using an ICS MDI, small particles of the medication are deposited and can impact the tongue and mouth. Rinsing the mouth and throat well after using the MDI and not swallowing the water are recommended to help prevent a Candida infection (thrush) (white spots on tongue, buccal mucosa, and throat), a common side effect of ICSs. The use of a spacer with the inhaler can also decrease the risk of developing thrush. When both MDIs are to be taken at the same time, clients are instructed to take the SABA first to open the airways and then the ICS to provide better delivery of the medication. It is important for the nurse to clarify indications and sequencing as the SABA is a rescue drug taken on an as-needed basis and is not always taken with the ICS (Option 5). (Option 1) Inhaled corticosteroids (eg, fluticasone, beclomethasone) are not rescue drugs. They are prescribed to be taken on a regular schedule (eg, morning, bedtime) on a long-term basis to prevent exacerbations and should not be omitted even if the SABA is effective. (Option 3) Taking the albuterol (Proventil) inhaler apart, washing the mouthpiece (not canister) under warm running water, and letting it air dry at least 1–2 times a week is recommended. Medication particles can deposit in the mouthpiece and prevent a full dose of medication from being dispensed. Taking the ICS inhaler apart and cleaning it every day is recommended. Educational objective: Proper use of the SABA inhaler includes taking it apart and rinsing the mouthpiece with warm water 1–2 times a week. Proper use of the ICS inhaler includes taking it apart and rinsing the mouthpiece with warm water daily and rinsing the mouth and throat after each use to prevent a Candida infection (thrush). When these medications are administered together, the sequence is SABA first to open the airways and ICS second. Test Id: 52331097 Question Id: 31519 (729561) A nurse is preparing for a medical relief trip to West Africa and is concerned about a disruption in circadian rhythm from traveling across several time zones. Which herbal supplement might help synchronize the body to environmental time? Unordered Options Ordered Response 1. Evening primrose 2. Ginseng 3. Melatonin 4. St. John's wort Explanation Melatonin supplements are thought to help the body adjust quickly to new surroundings and time zones (jet lag). Most practitioners agree that the lowest possible dose should be used and should be taken only for a short time. There are no long-term studies on the safety of melatonin. Higher doses may cause side effects such as vivid dreams and nightmares. Research suggests that taking melatonin once a person has reached the travel destination is sufficient and that starting it prior to or during air travel may actually slow the recovery of jet lag, energy, and alertness. (Option 1) Evening primrose may be used for eczema or skin irritations. (Option 2) Ginseng is used to promote mental alertness and enhance the immune system. (Option 4) St. John's wort is used for treatment of depression. It has many interactions with other prescription medications. Educational objective: Short-term use of low-dose melatonin may be considered to treat jet lag and fatigue from traveling across time zones. Copyright © UWorld. All rights reserved. Test Id: 52331097 Question Id: 31867 (729561) A client with fibromyalgia refuses to take the prescribed drug duloxetine. When the nurse asks, why, the client responds, "Because I'm not depressed!" What is the nurse's most appropriate response? Unordered Options Ordered Response 1. "Depression is common with fibromyalgia, but a low dose of this drug can prevent it." 2. "It can relieve your chronic pain and help you sleep better at night." 3. "It helps to relieve the adverse effects of your other prescribed drugs." 4. "You have the right to refuse. I will notify your health care provider (HCP)." Explanation Fibromyalgia (FM) results from abnormal central nervous system pain transmission and processing. It is characterized by chronic, bilateral musculoskeletal axial pain (above and below the waist), multiple tender points, fatigue, and sleep/cognitive disturbances. Duloxetine (Cymbalta) is a serotonin-norepinephrine reuptake inhibitor that has both antidepressant and pain-relieving effects. It is used to relieve chronic pain that interferes with normal sleep patterns in clients with FM. With the restoration of normal sleep patterns, fatigue often improves as well (Option 2). Other effective drugs to treat the chronic pain associated with FM include pregabalin and amitriptyline (Elavil), an older tricyclic antidepressant drug. (Option 1) Although depression often accompanies chronic pain, duloxetine can be prescribed specifically to treat the chronic pain associated with FM. (Option 3) Duloxetine is prescribed for major depressive disorder and to relieve pain associated with diabetic neuropathy and FM. It is not given to relieve the adverse effects of other drugs. (Option 4) A client has the right to refuse any drug. However, the nurse should first explain the purpose of the drug to the client before notifying the HCP. Educational objective: Medications such as duloxetine, pregabalin, and amitriptyline have neuropathic pain- relieving effects. They are commonly used for treating pain associated with diabetic neuropathy and FM. Duloxetine is particularly effective for treating both depression and pain. Test Id: 52331097 Question Id: 32044 (729561) A 65-year-old client has been hospitalized for 2 weeks with diabetic gastroparesis. While preparing to administer the daily dose of IV metoclopramide to this client, the nurse assesses for which symptom that may indicate a serious adverse effect of this medication? Unordered Options Ordered Response 1. Bradycardia 2. Diarrhea 3. Frequent burping 4. Unusual movements Explanation Metoclopramide is an antiemetic and/or prokinetic agent that promotes gastrointestinal motility and gastric emptying. It is commonly used to treat nausea/vomiting and gastroparesis. This medication can cause tardive dyskinesia (TD), a condition characterized by unusual uncontrollable movements of the arms, legs, head, face, or entire body. Examples include protruding and twisting tongue movements, lip smacking, torticollis, and "piano-playing" finger movements. TD is irreversible in many cases, and the risk for developing metoclopramide-induced TD is greater with advanced age, long-term therapy, and high drug doses. (Options 1 and 3) Metoclopramide does not affect the heart rate or cause burping. (Option 2) Although metoclopramide can cause diarrhea, particularly with high doses, this is not as serious as TD. Educational objective: A serious adverse effect of metoclopramide is TD, which can cause unusual uncontrollable movements. Risk factors for developing TD with metoclopramide use include advanced age, high dosage, and long-term use. Test Id: 52331097 Question Id: 30546 (729561) The nurse has just completed discharge teaching about sublingual nitroglycerin (NTG) tablets to a client with stable angina. Which statement by the client indicates the need for further teaching? Unordered Options Ordered Response 1. "I will call 911 if my chest pain isn't relieved by NTG." 2. "If I have chest pain, I can take up to 3 pills 5 minutes apart." 3. "I'll call my doctor if I start having chest pain at night." 4. "I'll keep one bottle in the house and one in the car." Explanation NTG is a vasodilator used to treat stable angina. It is a sublingual tablet or spray that is placed under the client's tongue. It usually relieves pain in about 3 minutes and lasts 30-40 minutes. The recommended dose is 1 tablet or 1 spray taken sublingually for angina every 5 minutes for a maximum of 3 doses (Option 2). If symptoms are unchanged or worse 5 minutes after the first dose, emergency medical services (EMS) should be contacted (Option 1). Previously, clients were taught to call EMS after the third dose was taken, but newer studies suggest that this leads to a significant delay in treatment. The NTG should be easily accessible at all times. Tablets are packaged in a light- resistant bottle with a metal cap. They should be stored away from light and heat sources, including body heat, to protect from degradation. Clients should be instructed to keep the tablets in the original container. Once opened, the tablets lose potency and should be replaced every 6 months. The car is not a good place to store NTG due to heat (Option 4). (Option 3) Waking up at night with chest pain can signify that angina is occurring at rest and is no longer considered stable angina. This should be reported to the health care provider. Educational objective: Education about sublingual NTG should include placing the tablet or spray under the tongue; repeating the dose every 5 minutes, with up to 3 total doses if angina is not relieved; notifying EMS if the first dose does not improve the symptoms; keeping the tablets in the original container away from light and heat; and replacing the bottle every 6 months once opened Test Id: 52331097 Question Id: 30192 (729561) A hospitalized client with thyrotoxicosis receives atenolol 50 mg PO daily. Which statement by the nurse accurately reinforces the client's understanding of this medication's purpose? Unordered Options Ordered Response 1. "Atenolol is an iodine-based medication that blocks the release of thyroid hormones." 2. "It is used to treat some of the symptoms of hyperthyroidism, such as increased heart rate." 3. "This drug is radioactive and damages or destroys the thyroid tissue." 4. "This first-line antithyroid drug inhibits the synthesis of thyroid hormones." Explanation Beta-adrenergic blockers (atenolol, metoprolol, and propranolol) are used to relieve some of the symptoms of thyrotoxicosis (thyroid storm), a complication of hyperthyroidism in which excessive thyroid hormones are released into the circulation. Beta blockers block the effects of the sympathetic nervous system and treat symptoms such as tachycardia, hypertension, irritability, tremors, and nervousness in hyperthyroidism. (Option 1) Atenolol is not iodine based. Iodine is used to treat thyrotoxicosis or to prepare the client for a thyroidectomy. In large doses, iodine quickly blocks the release of T4 and T3 from the gland within hours. In addition, iodine decreases thyroid gland vascularity and is helpful when preparing the client for a thyroidectomy. (Option 3) Atenolol does not contain radioactive iodine, the primary treatment for hyperthyroidism. It damages or destroys the thyroid tissue, therefore limiting thyroid secretion and eventually making the client hypothyroid. (Option 4) Propylthiouracil and methimazole (Tapazole) are first-line antithyroid drugs used to inhibit thyroid hormone synthesis. Educational objective: Beta-adrenergic blockers (atenolol, metoprolol, and propranolol) are given to relieve some of the symptoms of thyrotoxicosis. They block the effects of the sympathetic nervous system and treat symptoms such as tachycardia, hypertension, irritability, tremors, and nervousness in hyperthyroidism. Test Id: 52331097 Question Id: 30319 (729561) A client with a diagnosis of atrial fibrillation has just been placed on warfarin therapy. The registered nurse (RN) overhears a student nurse teaching the client about potential food-drug interactions. Which statement made by the student nurse requires an intervention by the RN? Unordered Options Ordered Response 1. "Do you take any nutritional supplements?" 2. "You will need to monitor your intake of foods containing vitamin K." 3. "You will not be able to eat green, leafy vegetables while taking this medication." 4. "Your blood will be tested at regular intervals." Explanation Warfarin (Coumadin) works by blocking the availability of vitamin K, which is essential for blood clotting. As a result, the clotting mechanism is disrupted, reducing the risk of a stroke, venous thrombosis, or pulmonary embolism. Sudden increases or decreases in the consumption of vitamin K-rich foods could inversely alter the effectiveness of warfarin. An increase in vitamin K could decrease the effectiveness of warfarin, placing the client at increased risk of blood clot formation; a decrease could increase the effectiveness of warfarin, placing the client at increased risk for bleeding. (Option 1) Many medications can interfere with warfarin metabolism. Nutritional supplements may contain vitamin K, and so any new medication or nutritional supplement should be approved by the health care provider. Cranberry juice, grapefruit, green tea, and alcohol may also interfere with the effectiveness of warfarin. (Option 2) Rather than avoid vitamin K-rich foods, the client needs to keep vitamin K intake consistent from day to day to keep International Normalized Ratio (INR)/prothrombin time (PT) stable and within the recommended therapeutic range. If the client enjoys vitamin K-rich foods (eg, kale, broccoli, spinach, Brussels sprouts, cabbage, green leafy vegetables), these may be consumed in the same amounts, consistently on a daily basis. There is some evidence that a very low intake of vitamin K could decrease the overall effectiveness of warfarin. (Option 4) INR/PT will be monitored on an ongoing basis to determine the safest, most therapeutic warfarin dosage. Educational objective: Sudden increases or decreases in the consumption of vitamin K-rich foods could inversely alter the effectiveness of warfarin. Rather than avoid vitamin K-rich foods, the client needs to keep vitamin K intake consistent from day to day to keep INR/PT stable and within the recommended therapeutic range. INR/PT is monitored at regular intervals. Pharmacy personnel and dieticians can provide additional teaching Test Id: 52331097 Question Id: 32140 (729561) A client receives an injection of botulinum toxin type A for facial and neck rejuvenation. What complications of this procedure should the nurse be aware of for monitoring and teaching? Unordered Options Ordered Response 1. Abdominal rigidity and diarrhea 2. Back pain and urge incontinence 3. Difficulty swallowing and breathing 4. Difficulty walking and hand tremor Explanation Botulinum toxin type A (Botox) blocks neuromuscular transmission by inhibiting acetylcholine release from nerve endings. The drug is used for treating wrinkles, blepharospasm, and cervical dystonia. Complications are uncommon when Botox is used for cosmetic purposes but can be life-threatening if they occur. The toxin can also relax the muscles used for swallowing and breathing, resulting in dysphagia (aspiration risk) and respiratory paralysis. (Options 1 and 2) Botulism can be associated with constipation and urinary retention due to relaxation of smooth muscle. Unlike in Clostridium tetani infection (tetanus), painful rigidity and spasms of the neck, back, and abdominal muscles are absent. (Option 4) Ataxia and hand tremor usually indicate drug toxicity (eg, phenytoin, lithium). Educational objective: Botulinum toxin type A (Botox) inhibits the release of acetylcholine from nerve endings and causes relaxation of skeletal/smooth muscles. On occasion, surrounding muscle weakness can lead to dysphagia and respiratory paralysis Test Id: 52331097 Question Id: 31856 (729561) The health care provider (HCP) prescribes paroxetine to a client with depression. What statement by the client indicates proper understanding of the medication? Unordered Options Ordered Response 1. "I can discontinue the medication if my symptoms improve." 2. "I need a healthy diet and regular exercise to combat weight gain." 3. "If I don't feel better in 1-2 weeks, then the medication is not working." 4. "This medication might increase my sexual performance." Explanation Paroxetine (Paxil) is a selective serotonin reuptake inhibitor (SSRI) often prescribed for major depression and anxiety disorders. Other SSRIs include citalopram (Celexa), escitalopram (Lexapro), fluoxetine (Prozac), and sertraline (Zoloft). Weight gain is a common side effect of long-term SSRI use. The nurse should teach the client to eat a healthy diet and engage in regular exercise to combat the weight gain. Other major side effects of SSRIs include increased suicide risk (at the beginning of therapy), sexual dysfunction, and serotonin syndrome when taken in excess doses. (Option 1) SSRIs should not be stopped abruptly without discussion with the HCP. Dosages should be gradually tapered before discontinuation to avoid withdrawal symptoms. (Option 3) Most clients will start to see symptom improvement in 1-2 weeks. However, some may take several weeks and require dose adjustments. Clients should continue to take the medication and discuss it with the HCP. (Option 4) SSRIs can cause sexual dysfunction. Clients should notify the HCP for a change of medication or to add medications to increase sexual performance. Educational objective: The major side effects of SSRIs include increased suicide risk (at the beginning of therapy), sexual dysfunction, weight gain, and serotonin syndrome (excess doses). It may take several weeks for the therapeutic effects of SSRIs to begin; they should never be discontinued abruptly. Test Id: 52331097 Question Id: 31773 (729561) The postoperative client on hydromorphone becomes hypoxic, and naloxone is administered per protocol. What is most important for the nurse to consider in the follow-up care of this client? Unordered Options Ordered Response 1. Client's respiratory status 60 minutes later 2. Documenting the client's hypoxic event 3. Obtaining an order for a different analgesic 4. Potential for drug-drug interaction now Explanation Hydromorphone duration of action is 3-4 hours. The effects of naloxone (Narcan) start to wane at 20-40 minutes after administration, and its duration of action is approximately 90 minutes. Therefore, depending on the hydromorphone dose, its duration of action can continue beyond the duration of the naloxone. Repeat naloxone doses may be necessary. (Option 2) Documentation is essential, but client care is more important than paperwork. (Option 3) Naloxone will reverse the effects of the narcotic in the body and, as long as it is in the body, will reverse the effects of any additional narcotic administered. This client will need a different class of analgesic at this time. However, adequate respiration/oxygenation as the naloxone wears off is more important. (Option 4) Naloxone is the reversal agent for narcotics, and a drug-drug interaction is not a concern. Educational objective: The half-life of naloxone (Narcan) is shorter than most narcotics. When naloxone is used to reverse the effects of narcotics, the nurse must monitor the client to ensure that the client does not fall again into excessive sedation and/or respiratory depression Test Id: 52331097 Question Id: 31655 (729561) A parent rushes a 4-year-old child to the emergency department after finding the child sitting on the kitchen floor holding an empty bottle of aspirin. The parent has no idea how many tablets were left in the container. The child is sniffling and quietly crying. The nurse anticipates initially implementing which treatment? Unordered Options Ordered Response 1. Activated charcoal 2. Gastric lavage 3. Sodium bicarbonate 4. Syrup of ipecac Explanation Activated charcoal is an important treatment in early acetylsalicylic acid (ASA) toxicity; it is recommended for gastrointestinal decontamination in clients with clinical signs of ASA poisoning (disorientation, vomiting, hyperpnea, diaphoresis, restlessness) as well as in those who are asymptomatic. Activated charcoal binds to available salicylates, thus limiting further absorption in the small intestine and enhancing elimination. (Option 2) Similar to syrup of ipecac, gastric lavage is associated with risk of aspiration. In addition, there is no convincing evidence that it decreases morbidity. It is not routinely recommended but may be performed for the ingestion of a massive or life- threatening amount of drug. If necessary, it should be administered within 1 hour of ingestion and requires a protected airway and possible sedation. (Option 3) IV sodium bicarbonate is an appropriate treatment for aspirin toxicity after the administration of activated charcoal. It is given to make the blood and urine more alkaline, therefore promoting urinary excretion of salicylate. (Option 4) Syrup of ipecac has been shown to have minimal benefit in treating aspirin overdose; in addition, it is not recommended due to the risk of aspiration pneumonia secondary to induced vomiting. Educational objective: Activated charcoal is used as the initial treatment for aspirin overdose in clients with clinical signs of salicylate toxicity as well as in those who are asymptomatic. Activated charcoal binds with salicylate and therefore inhibits absorption by the small intestine. IV sodium bicarbonate is also used for treating aspirin overdose after treatment with activated charcoal has been initiated. Test Id: 52331097 Question Id: 32043 (729561) The nurse is caring for a client who had surgery yesterday. When administering omeprazole, the client asks "What is that for? I don't take it at home." Which reply by the nurse is most appropriate? Unordered Options Ordered Response 1. "Omeprazole helps prevent nausea by making your stomach empty faster." 2. "Omeprazole helps prevent you from developing an ulcer due to the stress of surgery." 3. "Omeprazole protects you from getting an infection while on antibiotics." 4. "This medication will treat your gastroesophageal reflux disease (GERD)." Explanation Omeprazole is a proton pump inhibitor (PPI) that suppresses the production of gastric acid by inhibiting the proton pump in the parietal cells of the stomach. In most hospitalized clients without a history of GERD or ulcers, PPIs are prescribed to prevent stress ulcers from developing during surgery or a major illness. Although evidence has shown that two-thirds of clients who receive PPIs do not need them, these medications are still widely prescribed in hospitalized clients. PPIs can be identified by their "-prazole" ending (eg, pantoprazole, lansoprazole, esomeprazole). (Option 1) Metoclopramide (Reglan) is not a PPI. It decreases postoperative nausea by promoting gastric emptying. (Option 3) PPIs may be associated with an increased risk of Clostridium difficile infection with antibiotic use. (Option 4) The client does not take this medication at home. The nurse is assuming that the client has a history of GERD rather than assessing for this condition first. Educational objective: PPIs such as omeprazole are often prescribed to hospitalized clients without GERD or ulcers to prevent stress ulcers from developing during surgery or a major illness. [Show More]

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